Access to PrEP has been slow and mostly limited to high income countries. Some countries, like Kenya, Uganda, South Africa, Zambia, and Nigeria, have been more proactive than others, but it is still hard for many to get PrEP. Credit: Shutterstock

By External Source
Nov 30 2022 (IPS)

While the world has focused on the COVID pandemic for nearly three years, less and less attention is being paid to HIV. However, HIV is still a global problem. In 2021, according to the United Nations, 38.4 million people were living with HIV, over 650,000 died from AIDS-related illnesses, and 1.5 million became newly infected.

Nearly 70% of infections occur in key groups: sex workers and their clients, men who have sex with men, people who inject drugs, and transgender people and their sexual partners. Adolescent girls and young women in sub-Saharan Africa are another important group, with nearly 5,000 getting HIV every week.

For many years, options for HIV prevention were quite limited. Early campaigns consisted of the ABCs – abstinence, being faithful, and condoms. In the early 2000s, male circumcision was added, but multiple attempts at developing a vaccine have been disappointing.

When taken regularly, PrEP is highly effective in preventing HIV infection and very safe. PrEP was seen as a game-changer by enabling people to take charge of their sexual health, particularly for those who could not necessarily control when or how they had sex

In 2012, however, much excitement surrounded the introduction of HIV pre-exposure prophylaxis, or PrEP. The initial form of PrEP was a combination oral pill consisting of two medications used to treat HIV – emtricitabine and tenofovir. When taken regularly, PrEP is highly effective in preventing HIV infection and very safe. PrEP was seen as a game-changer by enabling people to take charge of their sexual health, particularly for those who could not necessarily control when or how they had sex.

Oral PrEP has worked well for many, particularly for men who have sex with men in high income settings and for serodifferent couples (couples in which one person has HIV and the other does not).

For others – like young people – it’s hard to take a pill consistently during periods of risk for getting HIV. The interest is there, but lots of things get in the way. Some relate to the person, like forgetfulness, transport to a clinic, and alternative priorities. Other factors relate to stigma and lack of support.

PrEP administered via a vaginal ring is another safe option that’s been developed. It’s not yet clear how many people will want to use it as it becomes more widely available.

Access to PrEP has been slow and mostly limited to high income countries. Some countries, like Kenya, Uganda, South Africa, Zambia, and Nigeria, have been more proactive than others, but it is still hard for many to get PrEP.

Now that injectable PrEP is an option, it’s poised to make a huge difference in HIV prevention – as long as some key issues can be overcome.

Benefits of injectable PrEP

The latest version of PrEP is an injection of another HIV drug – cabotegravir (called CAB-LA for cabotegravir-long acting). It is given in the buttocks and lasts for two months. It is even more effective than oral PrEP and it’s safe.

Another injectable drug – lenacapavir – would only need to be given once every six months, and would be easier to inject because it only needs to go into the skin; but it is still in clinical trials.

In many ways, injectable PrEP seems like a perfect solution. It’s discreet, there’s no burden of frequent pill taking, and it can be combined with other services and injections, like contraception for women. People in the CAB-LA trials in many parts of the world, including sub-Saharan Africa, South America, and the US, really liked it. Although some public health officials and healthcare workers have worried about the pain and any swelling due to the injection itself, most people do very well.

Drawbacks of injectable PrEP

Several issues, however, may get in the way of injectable PrEP revolutionising HIV prevention.

First, most people can’t get it. The United States was the first country to approve CAB-LA in December 2021. The next was Zimbabwe in October 2022. The necessary paperwork is being processed in other countries in sub-Saharan Africa, but regulatory processes are slow and access is likely be to a challenge for some time.

Second, it’s expensive. CAB-LA is priced at over $22,000 per person per year in the US. It could be covered to some extent by health insurance companies, but not everyone has health insurance. The drug manufacturer will lower the price for the markets in low- and middle-income countries, but the exact cost is not yet known. Some estimates are around $250 per person per year. That’s still about five times as much as oral PrEP costs. The increased effectiveness may be worth it for people at high risk of getting HIV, but getting it to those people will be challenging for ministries of health.

Third, logistical issues complicate delivery of injectable PrEP, including the need for refrigerators to store the drug and nurses to give the injections. Clinics may not be set up to provide many injections in a given day, and limited availability may mean people can’t get the shots when they need them.

Finally, continuing to get injections over time is still likely to be a problem. The experience with injectable contraception has taught us that up to half of people who select that form of family planning stop it within a year. Injectable PrEP does not solve the other barriers people face, like transport to clinic and prioritisation of HIV prevention.

The lack of access raises important ethical concerns. Most of the thousands of people in the CAB-LA trials live in countries without access to it, including Botswana, Eswatini, Kenya, Malawi, South Africa, Uganda, and Zimbabwe among others. Processes to enable access are unacceptably slow, although the drug is available in the US (and just recently Zimbabwe).

Where to go from here?

Despite these challenges, injectable PrEP is a huge advantage for the HIV prevention toolbox. Choice is critical for most interventions to work, and HIV prevention is no different. PrEP use increases when people are given effective options and can choose what works best for them.

PrEP needs to be easier for people to take, for instance by making it more convenient and less medical. Programmes are starting to do this through community delivery. That approach may be more challenging with injections, but it may get easier with time and with injections in the skin, like lenacapavir.

Advocacy will be critical for expediting the regulatory process and negotiating with pharmaceutical companies to license other companies to produce more affordable generics.

Jessica Haberer, Director of Research, Massachusetts General Hospital Center for Global Health and Professor of Medicine, Harvard Medical School, Harvard University

This article is republished from The Conversation under a Creative Commons license. Read the original article.

Elisha Arunga Odoyo, a clinical officer within the PMTCT program at the Homabay County Referral Hospital. There is increasing fear that adolescents will be left behind in the efforts to reduce HIV infections. Credit: Joyce Chimbi/IPS

By Joyce Chimbi
Nairobi, Kenya, Jan 18 2022 (IPS)

The ominous warning came in 2019 through an anonymous message on her mobile phone to stay away from a man she met on social media.

At 18 years and freshly out of high school, *Nicole Kisi was in a relationship with a 45-year-old businessman.

“The message was clear. It said to be careful because of a rumour that the man’s wife died of HIV/Aids. I was shocked. I forwarded the message to my boyfriend, and he told me the person was jealous of him because he is successful,” she tells IPS.

“He looked healthy to me, and I believed that the message came from one of those jealous people.”

One year into the relationship, Kisi was in and out of hospitals. At first, she was treated for severe malaria, but her condition only worsened. Eventually, her HIV positive status was discovered.

As with other sub-Saharan Africa countries, government data shows AIDS is the leading cause of death and morbidity among adolescents and young people in Kenya.

Over the past decade, Africa’s fight to combat HIV has seen new HIV infections reduced by 43 percent and nearly halving AIDS-related deaths.

However, the Joint United Nations Programme on HIV/AIDS (UNAIDS) shows the continent is not on track to end AIDS by 2030 because key elimination milestones have not been met.

“There are 18,004 new infections and 2,797 deaths among adolescents 10-19 years annually in Kenya. Overall, 40 percent of new HIV infections in the country are among adolescents and young people 15 to 24 years,” says Damaris Owuor, an HIV activist based in Nairobi.

“The Prevention of Mother to Child Transmission (PMTCT) of HIV is extremely successful, and so we are greatly concerned about the HIV risk that our young people now face from cross-generational sex.”

More than 90 percent of HIV infections in children result from mother-to-child-transmission, says Elisha Arunga Odoyo, a clinical offer within the PMTCT program at the Homabay County Referral Hospital.

UNAIDS data shows that East and Southern Africa has significantly reduced this risk. Between 2010 and 2018, new HIV infections among children 0 to 14 years declined from 1.1 million to 84,000 across the region.

Odoyo points to Kenya’s Homabay County. Despite having the highest HIV prevalence in Kenya at 20.7 percent, over four times the national prevalence of 4.8 percent, mother-to-child transmission of HIV reduced from 16.8 percent in 2015 to 9.1 percent in 2019.

Owuor says poor sex and reproductive health education and, lack of access to adolescent-friendly reproductive health services is primarily to blame.

Further, UNICEF research shows transactional and age-disparate sex, peer pressure, stigma and discrimination, harmful social and gender norms, and unequal power dynamics contribute significantly to the bulging number of adolescents living with HIV.

The most recent Kenya Demographic and Health Survey shows three out of 10 girls have sex before age 15 and that one in every five girls, 15 and 19 years is either pregnant or already a mother.

Still, Owuor tells IPS that significant strides are needed to address the adolescents’ risk of acquiring HIV. Girls account for six in every seven new HIV infections among adolescents in sub-Saharan Africa.

“My friends and I worried more about getting pregnant than HIV. When you are young, you think about HIV as something that happens to older people. None of my friends has ever bought a condom, but we have bought P2 (morning after pill) so many times for fear of getting pregnant,” she tells IPS.

UNAIDS research shows adolescents and mothers are still disproportionately affected by HIV and left behind the global AIDS response.

Within this context, Owuor cautions that the youth bulge could significantly increase new HIV infections without a targeted approach to increase access to HIV prevention, HIV testing, care and treatment among adolescents and young people.

To achieve the 2030 global target to end AIDS, an analysis by the World Health Organization (WHO) indicates that by 2025, 95 percent of all people living with HIV know their status, 95 percent of those who know their status are on treatment, and 95 percent of those on treatment have a suppressed viral load.

In Africa, 87 percent of people living with HIV knew their status. Of those, 77 percent were on treatment, and 68 percent had a low viral load, according to statistics released in December 2021.

Only nine countries, including Kenya, Botswana, Cabo Verde, Lesotho, Malawi, Nigeria, Rwanda, Uganda, and Zimbabwe, were on track to reach the 95-95-95 fast track target to end AIDS.

Nonetheless, Owuor says while progress has been commendable, the ambitious target will not be achieved if crucial HIV/AIDS elimination milestones among adolescents are missed.

According to Kenya’s ministry of health, access to and uptake of HIV testing and counselling by adolescents is significantly low, as is antiretroviral therapy coverage compared to any other age group of persons living with HIV.

UNICEF research finds while there is increased awareness of HIV in general, adolescents still lack comprehensive knowledge of HIV and condom use remains low in the age group.

“Young people are among the least tested, and without targeted intervention, they also do not adhere to treatment and are often virally unsuppressed. A high viral load, or the amount of HIV in the blood, increases the risk of an adolescent transmitting the virus, so we have to break this cycle,” Owuor says.

Kisi agrees, adding that an adolescent’s journey to accepting a positive HIV result is a long road marred with denial, anger, and bitterness.

“Seeing your friends living a carefree life as you die inside is very painful. The biggest problem is that you lose hope and start to believe that there is no future,” she says.

“Even today, I struggle with accepting my status. I recently joined a peer support group, and I am smiling again. I feel more hopeful than I have ever before.”

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Community support workers are key in raising awareness about TB and promoting diagnosis and treatment. Credit, Busani Bafana/IPS

By Busani Bafana
BULAWAYO, Zimbabwe, Jan 7 2022 (IPS)

Global efforts to end tuberculosis (TB) are futile without dedicated investment in research into the debilitating disease that is killing 4000 people a day, Stop TB Partnership warns.

“TB is a disease that is not a darling of donors and investors,” Lucica Ditiu, the Executive Director of the Stop TB Partnership, told IPS in an interview from Geneva.

“We do not have a Bill Gates that can support TB research, yet TB remains a disease of concern with deaths increasing for the first time in over a decade,” she added.

TB, a bacterial disease mainly affecting the lungs, has been around for over millennia and remains one of the top killer diseases globally. But it is preventable and curable with the right investment in diagnosis and treatment.

Ditiu attributed the rise in TB incidents to several factors; many people diagnosed and on treatment for TB have defaulted owing to the disruption of health services in the wake of the COVID-19 pandemic and global lockdown. Furthermore, many people remain undiagnosed because they have not been reached.

Dr Lucica Ditiu, Executive Director of the Stop TB Partnership. Credit: Stop TB Partnership

“Southern Africa has done a good job in respect of Zambia, Zimbabwe and South Africa as well as Rwanda in trying to disrupt as little as possible the treatment and diagnosis of people with TB,” Ditiu said. She commended awareness programmes in the media and community door-to-door campaigns to promote diagnosis and treatment.

Countries need to invest more in finding people with TB and putting them on treatment. Until you find people, you cannot put them on treatment, and this is where we are very much lagging, she said.

Ditiu fears the worst should the world fail to change the current TB transmission trend. An estimated 5.8 million people received treatment for TB in 2020; a drop of 21 percent from 2019, and more than 4 million people worldwide remain untreated. According to Stop TB Partnership, half of those untreated are likely to die from the disease.

Admitting that funding for TB has always been insufficient, Ditiu said TB was the poor cousin compared to the deep pockets for HIV and AIDS.

“In general, we have available only 30 percent of the funding needed globally. We have places that have done well in preventing TB in people living with HIV. Prevention of TB in people living with HIV is going well, especially in African countries because HIV has resources.”

According to the Stop TB Partnership, a network of international organisations established in 1998 to help end TB as a public health problem, funding for TB research and development (R&D) has remained flat since 2018.

Global funding for tuberculosis (TB) research totalled 915 million US dollars in 2020 – less than half the goal of 2 billion US dollars set forth by participating country governments at the 2018 United Nations High-Level Meeting on TB.

In 2021, TB had a funding gap of 13 billion US dollars globally, with only 5,3 billion US dollars available for its programmes. It experienced a drop in funding amounting to 500 000 US dollars in 2020 as many countries took money away from TB to respond to COVID-19.

A new report, Tuberculosis Research Funding Trends, 2005–2020 by Treatment Action Group (TAG) and the Stop TB Partnership, found that TB received less than 1 percent of the amount invested in COVID-19 Research and Development over the first 11 months of the pandemic.

“The mobilisation of over 100 billion US dollars for COVID-19 research and development in the first 11 months of the pandemic shows us just how powerful a coordinated effort against a disease can be,” noted Ditiu.

While the pandemic has shown that effective vaccines can save lives, the world is still banking on a 100-year-old vaccine, Bacillus Calmette-Guérin or BCG. However, a more effective vaccine could have higher efficacy rates, especially for adults. Why has it taken so long to develop a new, more effective TB vaccine when the health burden of TB is increasing?

“This is the drama,” Ditiu commented. “We have a vaccine for a hundred years that we know for the last 40 years does not work (effectively) except for newly-born babies, and yet we have not done much about it.”

While ongoing research on new vaccines had been slow because of poor funding, Ditiu said several potential vaccines were in the pipeline, and a vaccine could be expected by 2027.

“It takes a long time to get a vaccine. But because of COVID (we realised), it is possible to have a vaccine much quicker, and we hope to use the learnings from COVID-19 to get a TB vaccine,” Ditiu told IPS.

Tuberculosis vaccine research has been slowed by chronic underfunding with only one moderately effective century-old TB vaccine, compared to over 20 COVID-19 vaccines.

“What’s enabled the development of dozens of COVID-19 vaccines in less than a year has essentially been money,” noted Austin Aurinze Obiefuna, Executive Director of the Afro Global Health Alliance and incoming Vice-Chair of the Stop TB Partnership Board.

“I think that the same enormous amount of funding should be applied with equal vigour to the development of TB vaccines. But that simply doesn’t seem to be happening.”

According to the Stop TB Partnership, making much-needed progress against TB demands investment that matches the threat of the disease around the world. This includes a commitment to rectify the inadequate funding of the past. Over the next two years, 10 billion US dollars are needed to close the tuberculosis R&D funding gap.

“Wealthy countries need to step up and put more money into correcting global health inequalities, which COVID-19 vaccine allocation inequities laid bare,” urged Mark Harrington, Executive Director of TAG, an independent activist, and community-based research and policy think tank.

“COVID-19 made more people around the world aware of the importance of R&D spending than ever before. Now is the time to finally start making investments ambitious enough to end TB for good.”

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COVID-19 lockdowns and restrictions meant that many informal sector traders lost their jobs. Not eligible for compensation, some have turned to sex work. Credit: Marko Phiri/IPS

By Marko Phiri
Bulawayo, ZIMBABWE , Nov 4 2021 (IPS)

Thirty-six-year-old Thandiwe Mtshali* watched helplessly as her informal cross-border trading (ICBT) enterprise came to a grinding halt when the Zimbabwean authorities closed the border with South Africa as part of global efforts to stem the spread of the deadly novel coronavirus.

“That was last year, and I had no idea what to do next,” Mtshali told IPS.

Before the lockdown, she made up to four trips each month to Musina and Johannesburg in neighbouring South Africa to buy goods ranging from clothes to electrical appliances for resale in Bulawayo, Zimbabwe’s second city.

And by her account, the money was good.

“I could rent a full house in the suburbs, and my long-term plans have always been to build my own home,” she said.

After months of being idle in Bulawayo, a colleague tipped her about what appeared to be an easy route out of her money troubles: truckers had not been banned from transporting goods between South Africa and Zimbabwe.

As truckers got stuck at the Beitbridge border post for weeks waiting to get their consignments processed by port authorities, it presented a new venture for informal cross-border traders such as Mtshali: sex work.

Today, Mtshali, who has two young children back in Bulawayo, rents a small shack in the border town where she “entertains” truckers and other men willing to pay for sex.

Commercial sex work is illegal in Zimbabwe, but COVID-19 has turned the sector into a necessity for many women who were made redundant by lockdown measures imposed by the government because of public health concerns.

“I do not want to do this, but it is better than sitting and waiting,” Mtshali said.

“My kids are with my mother, and all they know is that I am working in Beitbridge. As long as I send them money and groceries, they don’t need to know anything else,” she told IPS.

Local residents, however, complain that despite the lockdown restrictions that banned travel across cities, there appeared to be an influx of sex workers to the border town, each seeking to make a living.

“We have always had a problem here with sex workers, young and old competing for clients. But now we see even more after borders closed,” said Dumisani Tlou, a resident and taxi driver.

“Every tenant knows they can rent any available backroom to the women who entertain truckers and other illegal dealers, but no one seems to be doing anything about it,” he told IPS.

While the Zimbabwean authorities have made efforts to provide bailout stipends for informal traders, this has been criticised for being too little to improve the lives of millions on the fringes of official economic activity.

Many more, like Mtshali, missed out on the bailouts because they are not registered with any informal traders’ association.

“There is a need to consider special exemptions that will allow cross-border traders to import goods during the lockdown and border closures,” said Fadzai Nyamande-Pangeti, International Organisation for Migration – Zimbabwe spokesperson.

“It is also important for women cross-border traders to formalise their businesses, to make them less likely to be impacted by shocks caused by the pandemic,” she told IPS.

However, for many here at the border town, sex work comes with challenges.

While borders were closed in line with public health safety measures, this has exposed sex workers to concerns about HIV/Aids.

“These women have no social protection or insurance or any other mitigation measures to cushion them in times of disasters such as the current pandemic,” said Mary Mulenga, a representative of the Southern Africa Cross-border Traders Association (SACBTA).

In a submission to the UN Special Rapporteur on Health ahead of the UN General Assembly in October, the Global Network of Sex Work Projects (GNSWP), which brings together sex worker-led organisations across ninety-six countries, says, “during the pandemic, there has been a (global) drop in the availability of HIV treatment services due to the prioritisation of treating and stopping the spread of COVID-19.”

“As a result, sex workers living with HIV have experienced even greater challenges in accessing HIV treatments, further endangering their health and ability to work,” the network says in its brief to the UN.

Truckers have for years been identified as an HIV/Aids high-risk group in southern Africa, raising concerns among campaigners, such as the GNSWP, that while resources are being directed toward addressing the spread of COVID-19, both old and new entrants into the sex trade such as Mtshali are being left out.

According to the UN’s International Organisation for Migration (IOM), informal cross-border trade accounts for up to 40 percent of southern Africa’s intra-trade estimated USD17 billion annually. Still, border closures have upended this due to COVID-19.

Despite these disruptions brought by the novel coronavirus, the once-thriving informal cross-border trade could present more public health concerns: an increase in those living with HIV/Aids.

In recent months, Zimbabwe’s First Lady Auxillia Mnangagwa launched countrywide self-sufficiency projects for sex workers. Still, with the industry continuing to take in new entrants such as Mtshali, it could be a race against daunting odds as global health experts see no easy end to COVID-19.

• The Pulitzer Centre supported this story.
• Name changed to protect identity.

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