Notes From the Field: Implementing PrEP in Resource Constrained Settings

Abstract

Introduction: Unequivocal evidence from landmark clinical trials has demonstrated that oral tenofovir disoproxil fumarate-based Pre-Exposure Prophylaxis (PrEP) is a highly effective biomedical intervention for preventing acquisition of HIV-1 infection. For the first time we have a much sought HIV prevention tool for vulnerable HIV-uninfected individuals without requiring negotiation of safe sex with partners. We currently have a robust toolbox of evidence-based biomedical and behavioural HIV prevention strategies that can be used in combination to effectively combat the HIV/AIDS epidemic. However, clinical trial efficacy is only the first step towards public health effectiveness. For high impact public health implementation, we require a delivery package that is both acceptable and accessible to the populations that most need it. The use of antiretroviral medications both as treatment and prophylaxis in combination with other interventions has shifted the goals of prevention of mother to child HIV transmission towards elimination; similarly, current evidence of PrEP and treatment as prevention in combination with each other and other preventative strategies can shift the goals of prevention of sexual HIV transmission towards zero new infections. From clinical trial efficacy to public health effectiveness, PrEP requires innovative implementation strategies and unrelenting demand creation. In the absence of these efforts a highly effective and needed HIV prevention intervention will join the pile of effective and underutilized public health interventions as the pool of newly infected individuals continues to rise. This presentation will discuss current on going activities in resource restrained settings that will inform both science and policy makers on PrEP implementation such as the current on-going ‘demonstration projects’ and options for successful PrEP delivery. Conclusion: PrEP implementation is not only possible, but it is required in resource-constrained settings.