When HIV first tore its way through communities in the early 1980s, activists argued that the retrovirus wasn’t just a medical emergency: it was a political crisis which exposed the inequalities that define societies across the world. Of the 35million people known to have died from HIV-related causes, the vast majority have been drug users, sex workers, LGBTQ people and the global poor.
Four decades on, there is still no cure, but new medication can effectively eliminate the chance of contracting the virus. In 2012, the US Federal Drugs Administration gave formal approval to a drug cocktail known as pre-exposure prophylaxis (PrEP): a single pill, taken daily, which is more than 90% effective at preventing HIV transmission.
But in the last seven years, use of PrEP has been patchy. Nowhere is it offered as a matter of course in universal healthcare systems. And its spread has been especially limited in the region where some 66% of people living with HIV reside: sub-Saharan Africa.
That’s about to change. Kenya and South Africa began rolling out the drug in 2016, with tens of thousands now receiving it. But despite PrEP’s proven effectiveness, the Kenyan and South African experiences underline the limits of science’s ability to end the epidemic. Without political action to quash stigma and careful policy to ensure safe and sustainable distribution of the drug, its potential will remain dormant.
“PrEP is quite astonishing,” said Peter Godfrey-Faussett, a scientific advisor to UNAIDS.
“The fact that we have a new tool that’s a pill-a-day [and] means that you remove the chance of catching HIV is really extraordinary. It’s the first thing we have since condoms that truly makes a difference to the risk of transmission.”
In some parts of the world, PrEP is already contributing to dramatic reductions in new transmissions. In London, new infections fell by 44% between 2015 and 2017.
The exact impact of the drug is hard to gauge — more sophisticated treatments and better awareness campaigns are also likely quelling new HIV transmissions.
But these sharp falls in the rate of infection coincided with PrEP becoming more readily available, suggesting its role is significant.
In the global north, PrEP has been most transformative among men who have sex with men.
“I think PrEP is partly responsible for the fantastic reductions in HIV in liberated gay cultures of Amsterdam, New York, London and San Francisco,” he said. “Because those communities talk about PrEP, they understand it well, and they’ve brought it into their approach [to sexual health].”.
But the existence of the pill alone, Godfrey-Faussett explained, isn’t enough to cut the number of transmissions. Instead, its potential can only be unlocked where PrEP use is accepted, encouraged, and seen as normal.
“PrEP is not a magic bullet. It needs to fit [into existing infrastructure],” he said, “and it’s not going to solve HIV alone.”
As they undertake their massive expansions in PrEP availability, Kenya and South Africa are learning that the existence of PrEP alone means little.
Both countries are looking to make the drug available, for free, to the people who most need it. But as they work toward their goals, both are encountering challenges that are as much political as technocratic.
PrEP costs around $1,500 per month if purchased in its branded form, Truvada. But generic drugs — identical in their ingredients but without the hefty price tag set by Gilead, Truvada’s developer — cost around $100 per year.
For the economic benefits that stopping HIV could entail, that’s a minor amount. But for African healthcare systems struggling against the tightest of resources, it’s still a significant challenge.
Making PrEP universally available when only a minority of people are at significant risk of contracting HIV is an expense to which some governments can’t stretch. So the first challenge was working out who should receive the drug.
Irene Mukui has supervised government programs that brought antiretrovirals to almost one million Kenyans and, more recently, made PrEP available to some 25,000.
Determining who should receive PrEP meant first understanding who was most at risk based on where they lived and the groups they belonged to.
Mukui calls the process “granulating your epidemic” — understanding the infection and its spread at the level of each province and community. Those most at risk, as elsewhere, include sex workers, men who have sex with men, drug users, and people with multiple partners.
In South Africa, identifying at-risk groups also defined the PrEP program.
The government made PrEP available to sex workers first, in June 2016. Then, in April 2017, PrEP was offered to men who have sex with men, and from May 2018, to adolescent girls and young women.
Avoiding social stigma also defined the strategy.
LGBT people or sex workers can face stigma if they attend some hospitals and clinics. Instead, South Africa integrated PrEP into specialist services, such as sex worker support centres, which offer advice on human rights protections and staying safe, as well as HIV treatment and prevention services.
In Kenya, a different approach to combating stigma was established.
While its PrEP program has in effect targeted similar groups of people, public messaging campaigns have eschewed overt references to the identities of people most at risk in favour of lists of behaviours that can increase risk.
Rather than stating that PrEP is needed by gay men or sex workers, policy documents instead emphasise the number of sexual partners each person has, and what kinds of sex can increase the risk of contracting HIV.
Mukui believes that approach has removed some of the stigma associated with accessing HIV services, particularly for groups that are already marginalised.
It isn’t just the cost of PrEP that is hindering its uptake across the world, however. As some countries turn inwards, many fear that the political will to end the HIV pandemic is in decline, and without it, PrEP’s potential will go unfulfilled.
One sticking point is the belief that PrEP could increase transmission rates for other sexually transmitted infections by encouraging sex without condoms.
According to Godfrey-Faussett, that’s something of a straw man.
“If somebody says they want to use a condom in a couple in Africa, it raises questions of fidelity, trust, intimacy and pleasure. Regardless of PrEP people aren’t using them,” he said, noting falling rates of condom use in numerous contexts globally.
“STIs in Africa are out of control as it is. We, as policymakers and governments, need to acknowledge that. For a long time in the global south, the strategy for dealing with STIs has simply not been fit for purpose,” Godfrey-Faussett added.
In addition, most PrEP programs also mandate regular STI testing and checkups, which can help bring populations into more sustained contact with health services than they had without PrEP.
The strength of political will behind any PrEP campaign is crucial: not only to ensure that there is enough money to buy the drugs at affordable prices for citizens, but also the longer-term challenge of normalising PrEP use among those who need it.
Precisely because PrEP depends on taking daily medication, investment in long-term strategies to ensure people don’t drop off it is vital, as Kenya is now finding out.
“Our biggest challenge right now is the high dropout rate among people who initiate PrEP. We have quite a good number of good initiations, but three months later, a significant proportion have dropped off treatment,” said Irene Mukui.
Sticking to long-term treatment plans is challenging in any context. But without it, PrEP won’t work.
Kenya and South Africa are still in the early stages of investing in prevention, with results and comprehensive evaluations expected in the next few years. If the benefits — economic as much as humanitarian — can be proved, both countries hope to scale up PrEP availability and take handle of their epidemics.
Other countries have their hands tied, however. While Kenya and South Africa qualify for access to cheaper, non-branded drugs thanks to UN-backed programs that loosen patent laws, regions such as South America do not. For the many countries too rich to qualify for cheap drugs, but too poor to invest in PrEP at scale, the future of the drug seems uncertain.
As ever in the history of HIV, the promise of PrEP will depend on factors far beyond research laboratories, but on the inequalities that determine access to healthcare. — Edward Siddons