Current pre-exposure prophylaxis (PrEP) strategies can slow roll-out and contribute to stigma surrounding PrEP use, found a study in The Lancet. The authors propose adoping modern marketing strategies that are attractive to healthy clients and might promote an inclusive and holistic vision of biomedical prevention.
Dr K Rivet Amico at the School of Public Health, University of Michigan – Ann Arbor and Professor Linda-Gail Bekker at the Desmond Tutu HIV Centre, department of medicine, University of Cape Town, note that the roll-out of PrEP has lagged in many settings – including most generalised epidemic settings.
However, there are successes which can be learned from and the authors call for PrEP programmes to change in three ways:
Focus on protection, not risk – guidelines focus on identifying individuals who are at risk, but messaging about risks is essentially negative. Messaging that focuses on protection and health is more positive. People should be asked how confident they feel in maintaining their HIV-negative status, rather than how 'at risk' they feel, the authors say. Framing PrEP in terms of protection, wellbeing and feeling safe from HIV is more empowering. The approach is especially likely to be effective with people who do not already have elevated perceptions of personal risk, such as women and young people.
Promote PrEP as available to everyone – targeting PrEP programmes to particular risk groups has unintended consequences, Amico and Bekker believe. When PrEP is primarily offered to sex workers, the intervention is seen to only be appropriate for sex workers. When PrEP is promoted primarily to gay men, it feels less relevant to women and others who could benefit. “We strongly recommend the adoption of universal PrEP access, meaning all people should know about PrEP and be able to access it if appropriate,” they write.
Integrate PrEP with other valued health services – programmes which focus on PrEP and do not provide other services that people want are more likely to have large numbers of clients dropping out of care. If PrEP is the only reason people come to a clinic, it is not surprising that when people are no longer interested in PrEP they simply stop attending.
PrEP should be considered one part of a broader health package. Initial interest in PrEP might be enough to get people through the door, but comprehensive and engaged care that offers services of relevance and value to clients will help maintain long-term engagement.
The editors of The Lancet HIV contrast Amico and Bekker's recommendations with the current state of PrEP policy in England. PrEP is only available through the Impact trial, which has been oversubscribed by gay and bisexual men, with capacity reached in many clinics and potential participants turned away.
The trial numbers have since been doubled.
Abstract
Pre-exposure prophylaxis (PrEP) is being adopted and rolled out in diverse regions, communities, and groups. Although it has been shown to be effective, in some settings PrEP roll-out has lagged, in part due to flawed messaging. Lessons can be learned and principles applied from marketing to highlight the potential pitfalls of current roll-out strategies focused on selective and siloed service provision. After exploration of the way PrEP is promoted in awareness messaging (the sell), marketed to select and often stigmatised groups (the brand), and offered as a special or non-integrated service (product placement), we propose that current strategies can ultimately slow roll-out and contribute to stigma surrounding PrEP use. We propose alternatives for programmes and ministries to consider as they develop long-term plans for HIV prevention. We propose that the sell should focus on protection or wellness framing, the branding should convey PrEP as appropriate for anyone in need, and the provision of PrEP should be placed in the context of other relevant and valued health services. As has been shown in some PrEP programmes, it is possible for programmes to adopt modern marketing strategies that are attractive to healthy clients and might promote an inclusive and holistic vision of biomedical prevention.
Authors
K Rivet Amico, Linda-Gail Bekker
Around 25,000 people are taking PrEP in Kenya, making it Africa’s largest PrEP programme, ahead of South Africa (9,000 people), Uganda (4,000) and Zimbabwe (4,000). The roll-out was recently described by officials from Kenya’s Ministry of Health at October's HIV Research for Prevention conference.
Overall 5.6% of Kenya’s approximately 50m citizens are living with HIV, but HIV risk is not evenly distributed. A third of all new infections are in adolescent girls and young women, aged 15 to 24. Another third of new infections are in ‘key populations’ – sex workers, men who have sex with men and people who inject drugs.
With funding from the Global Fund, PEPFAR and other donors, the programme has been led by the country’s government and PrEP is being rolled out in the public sector. Government leadership and co-ordination has helped create synergies and a national approach.
In July 2016, revised antiretroviral therapy guidelines included a recommendation for oral PrEP to be offered to HIV negative individuals at substantial ongoing risk of HIV infection. A working group then gathered evidence from demonstration projects (several of which were already underway in the country) and sought input from stakeholders, leading to the launch of a implementation framework in May 2017.
PrEP has been targeted to 19 of the country’s 47 counties. Counties with very high incidence were selected for a large-scale roll out of PrEP, in almost all health facilities. Counties with lower incidence but significant numbers of key populations have had a more targeted approach.
While communications have presented PrEP as being appropriate for anybody, the implementation framework does target particular communities. The aim is for PrEP to be primarily accessed by female sex workers (39%), people in serodiscordant couples (34%), adolescents and young people (10%), people in the general population with multiple sexual partners or other risk situations (8%), men who have sex with men (8%) and people who inject drugs (1%).
Engagement so far has been most successful among serodiscordant couples and female sex workers, but recruitment of adolescents and young people has been very slow.
Communication and social marketing activities have helped deal with myths and misconceptions. The first phase of communications targeted the general population and influential figures such as religious leaders, politicians and the media. The second phase focused on the healthcare sector and key population networks, before a third phase that attempted to reach potential PrEP users. The slogan ‘Jipende JiPrEP’ (love yourself, PrEP yourself) was created and used in channels including community radio, YouTube and social media. Specific materials for female sex workers and gay and bisexual men have been created.
Integrating PrEP into existing processes and services has been key to its rapid scale-up. PrEP can be provided at a wide range of services, including HIV testing centres, drop-in centres for key populations and maternal health clinics. Over 900 different health facilities currently offer PrEP.
Similarly, PrEP modules have been added to existing training programmes on HIV testing and antiretroviral therapy for healthcare workers. Training is based on case studies, with role plays and practical exercises.
A supply chain for PrEP medications has been integrated into the existing system for antiretroviral treatment, which supplies over 3000 health clinics. Facilities that supply PrEP but not HIV treatment have been integrated into this system. For monitoring and evaluation, officials identified a series of key indicators (such as the number of people eligible for, starting and discontinuing PrEP) and developed a number of data collection tools to track them.
Dr Irene Mukui of the Ministry of Health said that challenges remain, including user discontinuation: only half of PrEP users are still in follow up. Demand creation activities need to be sustained and re-invigorated so as to reach different sub-populations. The scale-up needs to be more thoroughly evaluated, with a focus on who is not accessing PrEP. Most of all, health officials need to better understand the perceptions, preferences and misconceptions of potential PrEP users and then develop strategies to address these.
Abstract
Background: While advances have been made in HIV prevention and treatment, new HIV infections continue to occur. The introduction of pre-exposure prophylaxis (PrEP) as an additional HIV prevention option for those at high risk of HIV may change the landscape of the HIV epidemic, especially in sub-Saharan Africa, which bears the greatest HIV burden.
Methods: This paper details Kenya’s experience of PrEP rollout as a national public sector program. The process of a national rollout of PrEP guidance, partnerships, challenges, lessons learnt and progress related to national scale up of PrEP in Kenya, as of 2018, is described. National rollout of PrEP was strongly lead by the government, and work was executed through a multidisciplinary, multi-organisation dedicated team. This required reviewing available evidence, providing guidance to health providers, integration into existing logistic and health information systems, robust communication and community engagement. Mapping of the response showed that subnational levels had existing infrastructure but required targeted resources to catalyse PrEP provision. Rollout scenarios were developed and adopted, with prioritisation of 19 counties focusing on high incidence area and high potential PrEP users to maximise impact and minimise costs.
Results: PrEP is now offered in over 900 facilities countrywide. There are currently over 14 000 PrEP users 1 year after launching PrEP.
Conclusions: Kenya becomes the first African country to rollout PrEP as a national program, in the public sector. This case study will provide guidance for low- and middle-income countries planning the rollout of PrEP in response to both generalised and concentrated epidemics.
Authors
Sarah Masyuko, Irene Mukui , Olivia Njathi, Maureen Kimani, Patricia Oluoch, Joyce Wamicwe, Jane Mutegi, Susan Njogo, Micah Anyona, Phillip Muchiri, Lucy Maikweki, Helgar Musyoki, Prince Bahati, Jordan Kyongo, Tom Marwa, Elizabeth Irungu, Michael Kiragu, Urbanus Kioko, Justus Ogando, Dan Were, Kigen Bartilol, Martin Sirengo, Nelly Mugo, Jared M Baeten, Peter Cherutich
A link has been provided below to a South Africa Department of Health site that provides extensive information on PrEP for users and providers.
Also, the Desmond Tutu HIV Foundaiton (DTHF) website (link below) is an informative guide for the medical profession and researchers on the use and provision of PrEP.
[link url="http://www.aidsmap.com/page/3425930/"]Aidsmap material[/link]
[link url="https://www.thelancet.com/journals/lanhiv/article/PIIS2352-3018(19)30002-5/fulltext"]The Lancet HIV abstract[/link]
[link url="https://www.thelancet.com/journals/lanhiv/article/PIIS2352-3018(19)30006-2/fulltext?rss=yes"]The Lancet HIV editorial[/link]
[link url="http://www.aidsmap.com/How-did-Kenya-build-Africas-largest-PrEP-programme/page/3422606/"]Aidsmap material[/link]
[link url="https://www.publish.csiro.au/SH/SH18090"]Sexual Health abstract[/link]
[link url="https://www.myprep.co.za/"]Department of Health material[/link]
[link url="http://desmondtutuhivfoundation.org.za/blog_post/prep-your-guide-to-this-hiv-prevention-drug/"]DTHF material[/link]