By the end of May this year, more than 1m public healthcare users – 1 033 805 – had started using the HIV prevention pill, more than half doing so in the past two years, bringing SA closer to its goal of making the pill available at all 3 506 government primary healthcare clinics countrywide.
The pill, comprising two antiretrovirals – emtricitabine and tenofovir – reduces the chances of contracting HIV through sex to almost zero, write Mia Malan and Laura Grant for Bhekisisa.
ARVs prevent the virus from making copies of itself in the body, but with HIV treatment (as opposed to HIV prevention), two ARVs instead of the standard three are used (SA’s entry-level treatment is a three-in-one tablet with tenofovir, lamivudine and dolutegravir).
Pre-exposure prophylaxis (PrEP) pills were introduced in June 2016 to vulnerable groups (like sex workers and men who have sex with men), and in 2020, became available to anyone who wanted them, as long as the clinic they visited had stocks.
Today, 3 700 government clinics stock oral PrEP, most of them in KwaZulu-Natal.
But the daily HIV prevention pill is no longer the only medication – or most efficacious – available to stop infection.
The two-monthly antiretroviral injection, CAB-LA (the long-acting ARV drug cabotegravir), was registered in South Africa in 2022, and works even better than the pill, virtually eliminating a user’s chances of getting HIV.
However, it costs much more, and is currently sold in the United States for R54 000 a pop; a monthly supply of the HIV prevention pill in South Africa costs about R60.
For the past 18 months, donors like the US Government’s President’s Emergency Plan for Aids Relief, Pepfar, and the Global Fund for Aids, TB and Malaria, have been negotiating with CAB-LA’s manufacturer, ViiV Healthcare, for a non-profit price.
Although an official price hasn’t yet been announced, R4 500 for a year’s supply (six injections) has been mentioned by various organisations, which Mitchell Warren of the New York-based advocacy organisation, Avac, says is probably accurate.
As demand increases, the price could very well drop, he said, but that was still much more than the cost of the pill.
Avac hosts a coalition that looks at how to make long-acting PrEP available as fast as possible.
Cheaper, generic versions of CAB-LA are likely to become available in about three to seven years, Warren added.
CAB-LA will be rolled out in implementation trials in South Africa from late this year or early 2024. Rather than testing how well a drug works, implementation studies look into potential roll-out problems and ways to get people to use them.
And that, said Linda-Gail Bekker, who is running an implementation trial at the Desmond Tutu Health Foundation at the University of Cape Town, is the most important thing to focus on right now: how to make PrEP appealing and easy to get.
“Like the provision of fast food, where you have different ways, such as drive-throughs, home deliveries, or pickup points, to choose from … we need to offer people choices for how to get PrEP.”
The country is well on its way to offering those choices: in August, pharmacists, for instance, got permission to prescribe the HIV prevention pill, adding one more way (apart from clinics) to access the medication.
In March 2002, another type of PrEP, the vaginal ring, was registered, and is being rolled out in implementation trials countrywide.
So where is the country, currently, with the mass roll-out of the daily HIV prevention pill?
Update
Over the past two years, many more South Africans have started using it.
At the end of May, more than a million people (1 033 805) were taking the pill – more than half (576 000) of them started on the medication in the past two years.
When it was introduced in June 2016, it was initially only offered to key populations, who have a higher chance than the general population to contract HIV: sex workers, men who have sex with men, teens and young African women, people who inject drugs and transgender people.
Four years later, anyone who needed it could ask for it, if it were stocked by their clinic.
The goal is to make the tablets available at all public primary healthcare clinics.
In 2020, however, Covid-19 hit South Africa, slowing down the pill’s wider roll-out. But after the pandemic uptake improved.
Where are we now?
By the end of May this year, the pill was freely available at 79% (2 782 out of 3 506) of primary healthcare clinics. But it was also free at 960 other facilities, like clinics at universities, correctional facilities, hospitals, etc.
The Health Department’s goal for the 2023/24 financial year (1 March 2023-29 February 2024) is for the pill to be available at every one of the country’s 3 506 government primary healthcare clinics.
In May, Gauteng, KZN, Mpumalanga and the Free State were close to this goal – at least 98% of primary healthcare clinics stocked the pill. But the Western Cape (43%), Limpopo (29%) and Northern Cape (46%) were still far behind.
In the 2022/2023 financial year (1 March 2022-28 February 2023), the department’s goal was to get 461 372 people to start using the HIV prevention pill: it reached 91% of the target (421 236 people).
Most of the clinics stocking the pill are in KZN, which has the highest proportion of people with HIV in SA, and Gauteng.
Women aged 15 to 24 are the largest group using the pill, comprising 53% of those who started using it in the 2022/23 financial year. This is also the group among whom new HIV infections are increasing the fastest, highlighting the need for them to be reached by PrEP.
Bhekisisa article – Over a million SAs have used the HIV prevention pill (Creative Commons Licence)
See more from MedicalBrief archives:
Generics green-light for new HIV drug, but Africa peeved
HIV game-change with SAHPRA approval and vaccine trial breakthrough
Top HIV experts call for PrEP to be prescribed by all nurses and midwives
Cipla to produce anti-HIV injection in Benoni, Durban
Why SA pilots of HIV prevention shots and vaginal rings have been delayed