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Review
. 2016 Jan;11(1):80-6.
doi: 10.1097/COH.0000000000000224.

The preexposure prophylaxis revolution; from clinical trials to programmatic implementation

Nelly R Mugo  1 , Kenneth Ngure, Michael Kiragu, Elizabeth Irungu, Nduku Kilonzo
Affiliations
Review

The preexposure prophylaxis revolution; from clinical trials to programmatic implementation

Nelly R Mugo et al. Curr Opin HIV AIDS. 2016 Jan.

Abstract

Purpose of review: An investment in preexposure prophylaxis (PrEP) delivery must have public health impact in reducing HIV infections. Sustainable delivery of PrEP requires policy, integration of services, and synergy with other existing HIV prevention programs. This review discusses key policy and programmatic considerations for implementation and scale up of PrEP in Africa.

Recent findings: PrEP delivery has been delayed by concerns about adherence and delivery in 'real world' settings. Demonstration projects and clinical service delivery models are providing evidence of PrEP effectiveness with an impact much higher than that found in randomized clinical trials. Data confirm that PrEP uptake, adherence, and retention has been high, more so by persons who perceive themselves at high risk for HIV infection, and PrEP is well tolerated. PrEP delivery is more than dispensation of a pill and programs should address other risk drivers, which differ by population. In Africa, barriers to PrEP uptake and adherence include stigma among MSM and low HIV risk perception among young women. Additional data have provided insight into optimal points of service delivery, provider training requirements and quality assurance needs. Of the 2 million new HIV infections in 2014, 70% were in Africa. PrEP use is not lifelong, and use limited to periods of risk may be both effective and cost-effective for the continent.

Summary: HIV prevention programs should determine strategies to identify those at substantial risk for HIV infection, formulate and deliver PrEP in combination with interventions that target social drivers of HIV vulnerability specific to each population. Policy guidance for optimal combination of interventions and service delivery avenues, clinical protocols, health infrastructure requirements are required. Cost-effectiveness and efficiency data are essential for policy guidance to navigate ethical questions over use of antiretroviral therapy for HIV-negative individuals when treatment coverage has not been attained in many parts of Africa. Countries need to invest in purposeful advocacy at both local and global forums. Failure to implement PrEP will be a failure to protect future generations.

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Conflict of interest statement

Conflict of Interest: The authors have all participated in research studies related to PrEP. They have no other conflicts of interest.

References

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    1. Baeten JM, Heffron R, Kidoguchi L, Mugo N, Katabira E, et al. CROI. Seattle, Washington: 2015. Near Elimination of HIV Transmission in a Demonstration Project of PrEP and ART. This study evaluated delivery of PrEP to HIV serodiscordant couples using a model, where PrEP was initiated to the HIV-uninfected partner and continued until 6 months after the HIV-infected partner initiated ART. The preliminary results presented at 48% follow up person time reported 96% reduction in incident HIV infections. It presents a practical model that can be implemented at HIV care facilities to deliver PrEP, complimenting ART initiation for the HIV-negative partner.

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