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African women could really benefit from greater access to Pre-Exposure Prophylaxis
GFO Issue 409

African women could really benefit from greater access to Pre-Exposure Prophylaxis

Author:

Adeline Demoncy

Article Type:
FROM THE FIELD

Article Number: 5

ABSTRACT The effectiveness of pre-exposure prophylaxis (PrEP) is well known but its availability has reached a turning point. Access to PrEP, previously solely targeted at men who have sex with men, is now being offered to women, primarily in Western countries. Some pioneering African countries are now offering PrEP to female sex workers, transgender people and the sexual partners of people who inject drugs. Three organizations in Mali, Mauritius and Morocco have developed a community project offering PrEP to HIV-exposed women. It provides women with tailored, sustainable services, combining research, advocacy and implementation. It shows real promise of success and has potential for scale up and replication.

Pre-exposure prophylaxis (PrEP) is an HIV prevention method whereby HIV-negative people take antiretroviral drugs to reduce the risk of HIV infection.

Since September 2015, the World Health Organization (WHO) has recommended that ‘people at substantial risk of HIV infection should be offered PrEP as an additional prevention choice, as part of comprehensive prevention’. PrEP has become a key tool in the implementation of the Joint United Nations Programme for HIV/AIDS (UNAIDS) roadmap, which aimed to reduce the number of new infections by 75% by 2020 for key populations (KPs) in particular.

“Thanks to PrEP, I have a better sex life and I feel more fulfilled. I feel and I know that I am protected from HIV”

 

Sophie, Mauritius

 

 

PrEP is a prevention approach that complements other methods already recommended as part of a combination prevention approach to HIV infection, which includes all existing prevention approaches: behavior-based approaches, condom use, HIV testing, and antiretroviral therapy (ART) for people living with HIV (PLHIV).

PrEP’s effectiveness has been widely proven through numerous clinical trials, such as ANRS IPERGAY or the SEARCH study (2020) which focused on African women. When PrEP is used properly under optimal compliance conditions, it is 97% effective.

By the end of 2020, 928,750 people had initiated PrEP worldwide, mainly in Kenya, South Africa and the United States, announced during the virtual HIV Research for Prevention conference by AVAC, an American research agency focused on HIV. PrEP is now available in 78 countries. However, this number is nowhere near the target set by UNAIDS of three million people on PrEP by 2020.

Why it is important not to forget women

Current data show that 47% of new HIV infections worldwide relate to women and adolescent girls, yet until now PrEP has been overwhelmingly used by men. In Africa, women

“…PrEP provides effective protection…it ensures there is ongoing medical monitoring […] something that is not always accessible to people at risk…”
Community stakeholder, Agadir

aged 15 to 24 are twice as likely to be infected as men. In 2020, women and girls accounted for 63% of all new HIV infections in Sub-Saharan Africa.

Women are more vulnerable to HIV infection for many reasons: biological, cultural and/or social. When women also belong to a KP group, such as female sex workers (FSWs), transgender women (TG) or women with a partner who injects drugs (PWID), the risks are multiplied.

The increasing incidence of HIV infection among women clearly demonstrates that current available prevention methods are not enough.

Focusing on PrEP for women

Until now, PrEP media coverage has been centered on men who have sex with men (MSM). No female-targeted awareness-raising work or dedicated information is available to counter the misconception that PrEP is only available for MSM. Governments are finally becoming increasingly aware of this, although less so in developing countries.

The PrEP Femmes project: Access to PrEP for women: this project is developing and implementing a community intervention that can be modelled and adapted to women exposed to HIV in Mali, Mauritius and Morocco

This multi-country project was launched in 2020 and is co-financed by Coalition PLUS and L’Initiative, with a budget of just over €1 million for three years. It aims to understand and remove barriers to women accessing PrEP.

Three organizations working on HIV in Sub-Saharan Africa have taken on the challenge of helping women to access PrEP. They are Association de lutte contre le Sida (ALCS) Morocco, with its partners ARCAD Santé Plus in Mali and Prevention, Information et la lutte contre le Sida (PILS) in Mauritius. ALCS is building on the earlier PrePare Morocco project, the first study on PrEP acceptability to MSM and SWs in North Africa.

PrEP Women targets FSWs in Morocco and Mali and TG women with partners who are PWID in Mauritius. It aims to integrate PrEP in a sustainable way, adapted to country context, KP and community, within the combination prevention package already provided by the three organizations.

A project designed by and for women

Despite PrEP’s benefits, it is struggling to find its place within the prevention package available to women. Overall, PrEP distribution is proving to be slower than expected. By 2020, nearly one million people worldwide had started taking PrEP, only a third of the target set by UNAIDS.

And women seem to be lagging behind. In Europe and Central Asia, for example, available data suggest that only 10% of people taking PrEP are women. Amal Ben Moussa, Community Research Manager at ALCS, confirms this: “Although PrEP is available free of charge in our country, including for women, they very rarely use it. At the end of December 2020, there were 201 women on PrEP in Morocco.”

The project needs to position PrEP as a tool to enable women to take control of their sexual health, to improve self-esteem and simultaneously continuing to protect oneself. WHO also confirms that ‘PrEP programs can be a gateway to offer comprehensive sexual health care.’

Women’s sexual health services must therefore be redesigned to be accessible, adapted to their needs and using tools that enable them to strengthen risk reduction.

A community project developed and implemented through South-to-South collaboration

“PrEP Women clearly demonstrates the added value of Coalition PLUS Although our contexts and our target populations differ from one country to another, the coordination structure established by the project steering committee has enabled us to pool our knowledge and best practices”
Rime Barrakad, ALCS Project Coordinator

The three organizations have been working together for several years on PrEP, in particular through the PrEParons un monde sans sida (PrEParing for a world without AIDS) campaign led by Coalition PLUS.

This multi-country project embodies a South-to-South capacity building approach between peer community organizations. This is a prerequisite for implementing an innovative, tailor-made community approach that is a distinctive feature of this project, above all ensuring efficiency and sustainability.

A project combining research, advocacy and intervention: synergy and interdependency

The research phase provided crucial data on women’s interest in PrEP and the barriers that exist. These data are used as the basis for advocacy on the need for PrEP conducted with decision-makers and healthcare staff. The project focuses on highlighting the feasibility of PrEP provision and establishing and/or strengthening it.

Research to identify the right approach for rolling out PrEP

“PrEP is available in Morocco, but women are not accessing it much. So, we have started a campaign to understand more about the barriers to accessing PrEP for women, particularly those that are most exposed to HIV risk.” 

 

Amal Ben Moussa, Research Manager At ALCS Morocco

Quantitative and qualitative surveys among women at risk of HIV infection have provided a clearer understanding of the factors hindering PrEP roll-out and were used to develop advocacy and implementation strategies

A quantitative survey with 1,000 women across the three countries confirmed the key obstacles: lack of PrEP knowledge, fear of stigmatization and association with PLHIV, difficulty accessing PrEP sites, and laws criminalizing sex work, drug use and homosexuality.

The qualitative survey among 100+ people focused on political decision-makers, healthcare staff and community leaders. It provided a clearer understanding of the obstacles and potential catalysts to ensure strong and efficient advocacy interventions.

There is still reluctance concerning PrEP: more advocacy is needed

In addition to the usual obstacles in relation to HIV prevention for KPs, there is still a high level of reluctance to implement PrEP, even among doctors and pharmacists.

In all social groups, PrEP provision faces prejudices, which are unfortunately common when it comes to harm reduction measures: “Isn’t this a way of encouraging prostitution? What if using PrEP discourages people from protecting themselves and using condoms?” And so on.

Training plays a key role in fighting these attitudes. Political and community decision-makers, healthcare providers and the media all need to be sensitized and trained. PrEP Women focuses on prevention issues, but also on respecting the human rights and dignity of those most exposed to HIV.

“Thanks to PrEP, I have a better sex life and I feel more fulfilled. I feel and I know that I am protected from HIV”

Sophie, Mauritius

PrEP is a prevention approach that complements other methods already recommended as part of a combination prevention approach to HIV infection, which includes all existing prevention approaches: behavior-based approaches, condom use, HIV testing, and antiretroviral therapy (ART) for people living with HIV (PLHIV).

PrEP Women has been able to adapt its advocacy strategy to each country context and level of acceptance within government. In Morocco, PrEP is already included in the National Strategic Plan for AIDS and ALCS is recognized as a key implementing partner. Nevertheless, collaboration with the Ministry of Health (MOH) must continue to enable the PrEP program to be expanded. In Mauritius, PrEP has been included in HIV service packages for all vulnerable populations since 2018. In particular, the MOH trained 1,000 staff and oversaw training of PILS awareness officers. In Mali, on the other hand, although PrEP is part of the National Strategic Plan for HIV, it is currently only available for MSM.

Practical expectations and needs must be met

The three organizations’ intervention component’s focus comprises effective access to PrEP: treatment, follow-up and support.

Effective PrEP use by women depends largely on their perception of their HIV risk, on the PrEP knowledge of health care personnel and women themselves and on the provider: In Mauritius, trans women have indicated that they would prefer to access PrEP from an organization (50%) rather than a public hospital (18%). Furthermore, a recent meta-analysis highlights the need to increase adherence to PrEP among women in their daily lives. Service provision at community level, where services can be adapted in line with the needs of specific groups, has a key role to play.

Community organizations have begun training their teams and providing the tools necessary to implement a combination prevention package integrating PrEP.

When feasibility and acceptability meet

How to promote KPs’ access to PrEP if women are not aware of its existence AND convinced about its benefits?

We have proof of PrEP effectiveness. The objective of PrEP Women is therefore not to test the effectiveness of the treatment, but rather to verify technical and logistical feasibility and acceptability among women. It therefore involves assessing women’s behavior when they have the right level of information and see PrEP is form of empowerment in terms of their prevention choices.

In terms of acceptability, testimonies from users clearly demonstrate their needs and demands.

 

Fairer access to care, not simply access to care?

The success of this project requires political leadership, financing and quality health services.

Offering women PrEP is not a guarantee that they will start and continue to use it. In the background, stigma associated with HIV and KP ‘status’ remains. PrEP is a promising tool to introduce into a standardized package of HIV prevention services. It must be integrated into women’s comprehensive sexual health management.

Countries have a responsibility to increase funds available for PrEP to improve access and care. Particularly as new methods, such as injections, implants and vaginal rings, are starting to demonstrate their effectiveness. These different forms of PrEP could provide new options for women to enabling them to make informed choices about their sexual health.

 

“As sex workers, we are very interested in PrEP. It can protect us from HIV”

Alima, Mali

“PrEP helps me to focus on my sexual health with doctors from the Halles clinic. It’s one of the rare places that I can be myself without being discriminated.”

Alicia, Mali

 “The ALCS survey was the first step in a wider project, which helped me to both inform and sensitize my peers about using PrEP and make our demands to the authorities through Global Fund coordination bodies.”

Hayat – Community Counsellor at ALCS Morocco

 

 

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