The recent launch of the guidelines for pre-exposure prophylaxis (PreP) for HIV by the Kenya Ministry of Health presents an excellent opportunity to rewrite the HIV prevention landscape in Kenya. PreP, currently available as a daily pill, and hopefully as a long acting injection in the near future, is highly effective if used in combination with other options to reduce the risk of getting HIV from an HIV-infected sex partner.
As a life-saving intervention, it’s been long in coming mainly due to the rigorous research that was required to make sure that it was effective and safe to use. Part of this research was done in Kenya, and our own Kenyan scientists have made history through their contribution in generating the necessary evidence to enable the Kenya government to embrace this new initiative. As part of the Kenya Prevention Revolution Roadmap, PreP is a game changer and is good news for the HIV prevention community.
Kenya is a country burdened by a high number of new infections mainly among sex workers, injecting drug users, men who have sex with other men and young women. These would be the populations that would benefit most from PreP. As we initiate the implementation of this novel intervention, it would be desirable that we prioritise these key populations to ensure one hundred percent access among them.
Unless these populations have unhindered access to PreP, it would be near impossible to achieve the dream of zero new infections by the year 2030. Further to this, current efforts to enhance access to HIV treatment among these populations would enhance effectiveness of PreP by further limiting transmissions and reducing the pool of potentially infectious persons.
Of particular interest are couples in sero-discordant relationships and for the first time, they would have the ability to make choices on their HIV prevention options. Providing PreP to the HIV-negative partner before the HIV-positive partner’s viral load reaches undetectable levels is now a distinct possibility.
This approach reinforces the HIV-negative partner’s right to remain uninfected while removing the guilt from the HIV-positive partner regarding the potential for transmitting HIV to a loved one.
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On this matter alone, there has never been an HIV prevention intervention that balances human rights concerns of HIV-negative people and the public health imperative to halt transmissions. Further to this, sero-discordant couples now and tangibly so, are able to decide to have a safe pregnancy and deliver a healthy baby. This is a major victory for HIV prevention and for human fertility!
As a country, we should implement PreP with sufficient safeguards. First, we should remove potential barriers to access including cost. PreP will only succeed if the drugs, HIV testing and the related screening tests are provided at no cost to the client. As it were people may not feel sufficiently at risk to be motivated to be on PreP and coupled with unaffordability, this may be a threat to the PreP programme.
Fundamentally, there is potential that with widespread access to PreP, a significant proportion of the population may feel well protected on PreP alone and stop using condoms. This may lead to a new epidemic of bacterial sexually transmitted diseases (STDs) and erode all the gains we have made on STD prevention in the last twenty years. Consequently, we need to reinforce the message that “PreP without a condom in not PreP at all!”
As a country we should keep our fingers on the STD pulse through renewed investments in STD surveillance.
As the programme is rolled out, front line health workers should be on the look-out for clients who don’t take PreP regularly for several reasons. First, it should be made clear that unless one takes it regularly and for the prescribed duration they will not be protected from HIV. For policy makers, this should be of concern because of the attendant wastages that would be occasioned from poor adherence to PreP medication.
PreP is expensive and the country cannot afford to throw good money after the bad by having whole populations who may have taken several millions’ worth of PreP drugs but due to inconsistent use, are under-protected from HIV. This would be a high price to pay for any country and a disservice to all scientists who worked hard to demonstrate that PreP works.
Dr Cherutich, PhD, OGW
Chairman, Public Health Society of [email protected]