About 940,000 people died of Aids in 2017 alone. According to UNAIDS, 77.3 million people have been infected with HIV that causes Aids since the start of the epidemic, while 1.8 million people got infected with the virus in 2017. To reduce the spread of the disease, Kenya launched Pre-exposure prophylaxis (PrEP) treatment in May 2017 in a bid to protect HIV-negative people from contracting the virus in cases of sexual encounter with HIV-positive partners. The drug is also recommended for people who are at high risk of sexual violence.
A walk into Nairobi’s Kibera slums presents one with a myriad of options to access various drugs over the counter. On a Saturday afternoon, I visit a pharmacy in the area to buy a dose of PrEP. In utter shock, the pharmacist tells me she has no idea of the drug I requested. But she quickly consults her colleague and gets back to me: “I am sorry, we do not stock such,” the colleague replies. A visit to a different pharmacy, a branch of a popular chain in Nairobi paints a different picture. Here, the pharmacist shows me adequate stock of Truvada, PrEP medicine. “We have enough stock of this, but it is hardly bought.
I think the high cost and its unpopularity could be the reason,” says Morgan Milimo, the pharmacist. He says a customer will be required to take a HIV test or come with the test results showing that they are HIV-negative. This, he explains, is to avert cases of misuse of the drug. The importance of the clinical assessment is to rule out any contraindications (pre-existing conditions) that may prevent one from using PrEP drugs due to the risks involved. These days, there are many innovations around HIV testing for individuals who may be reluctant to do it at a health facility. HIV self-testing kits are available in pharmacies, where anyone can walk in, purchase and test themselves in the privacy of their homes or wherever they are comfortable. Nonetheless, they are advised to visit a health facility for further confirmatory testing.
“Age, of course, is key to us, just like any other pharmacy. We do not sell drugs to people under the age of 18,” says Milimo. Abuse of the drug especially by young people, as has been suspected in some social quarters, he says, may not be possible, owing to its high cost. In this particular chemist, PrEP costs Sh5,000, an amount Milimo says is relatively high to allow abuse by the said group, majority of whom, either students or starting out in their careers, are in the low-income bracket.
Daniel Were, Project Director of Jilinde project by health NGO Jhpiego, however, says the cost of PrEP shouldn’t prevent those at high risk of contracting the HIV virus from seeking the treatment, because the government is providing PrEP free of charge. Were adds that there still exists gaps on the information the public has regarding the drug. “We have noted information gaps at the community level, such as assuming PrEP should be used the same way as Post Exposure Prophylaxis (PEP). This is why we continue to invest in creating wide scale awareness about PrEP and addressing some of these misconceptions,” he says.
According to Nascop, Kenya will need Sh3.1 billion to finance PrEP implementation within the 2018/19 financial year. Between now and 2021/22 financial year, the country will require Sh30.6 billion in order to ensure planning, advocacy and service delivery of the drug. The ‘Framework for the Implementation of Pre-Exposure Prophylaxis of HIV in Kenya’ estimates Kenya’s financial gap in PrEP implementation at $314,298,668 (Sh32.2 billion) over the five years. The plan by Nascop estimates the total cost of implementation of PrEP in Kenya between 2017 and 2022 to be $328,262,179 (Sh33.7 billion) against $13,3963,511 (Sh13.7 billion) available resources.
Laura Fitch, programme coordinator, Production Introduction & Access at AIDS Vaccine Advocacy Coalition (AVAC), says that although majority of PrEP users in sub-Saharan Africa are young girls and women, the region still records the highest gap between the target and actual uptake of PrEP. According to Were, the huge gap between eligibility and uptake is due to the fact that not necessarily everyone who presents themselves wants PrEP as a choice. “It is a matter of preference. There is also stigma in the community, as well as myths and misconceptions around PrEP. If these are addressed, then we are likely to see change in trends and an increased uptake of PrEP,” said Were during the recent HIV Research for Prevention conference held in Madrid, Spain.
KENYANS ON PrEP
Currently, there are about 25,000 to 26,000 Kenyans on PrEP in Kenya. The fight against HIV, Were opines, needs unhindered access to HIV prevention products such as PrEP among individuals who need them most. He emphasizes on the need to increase awareness of the products, addressing stigma of the same, as well as countering myths and misconceptions and making it widely available in many health facilities. To date, Jhpiego has over 18,000 clients who have been enrolled on PrEP through 86 clinics supported by the Jilinde project in partnership with the national and county government (10 counties) and collaboration with other partners.
The right to choice among potential and existing PrEP users ought to be respected, he notes. “I also want to emphasize that PrEP is coming in as an additional prevention option, which means that we don’t necessarily expect miraculous uptake overnight. There are individuals for instance who are using condoms correctly and consistently and they are comfortable with the method, and that is fine, we don’t expect them to switch to PrEP, unless it is their preferred method,” says Were, adding that it is about choice and presenting available technologies to those who prefer and can use them well.
“That is why we talk about presenting individuals who are vulnerable to HIV infection a basket of combination prevention tools to choose from based on what suits them most. We need to be patient with PrEP since it is less than two years since the product was launched, and rather than decry slow uptake, focus on how we can get the message to those who haven’t heard about the product and support those who are interested in using it. We have a long way to go and we have just made the initial steps,” explains Were, lauding the notable strides the country has made, seeing as there is progressive PrEP uptake.
To ensure adherence to PrEP use, Jhpiego is now using SMS and phone call prompts, since learning that users require ongoing support to address issues and challenges they face, as well as reminders for their clinic appointments. “Community support has also emerged as essential and therefore, we are focusing on community wide awareness of PrEP and engaging key stakeholders to create a favourable environment and support for user groups to effectively adhere to PrEP,” the project director explains.
PrEP gives me peace of mind
Cynthia is a 25-year-old sex worker born and raised in Nairobi. She was introduced to sex work as a teen, after the birth of her daughter. “My father deserted us and my mother struggled to take care of my siblings and I,” she explains. At 15, she dropped out of school to look for a job so she could feed her baby. When no opportunities arose, her cousin, a sex worker, told her how she could earn between Sh2,000-3,000 per night and Sh5,000 on weekends. Most of the clients are men 35 and older, from wealthy neighbourhoods surrounding Kangemi.
Conventional protection isn’t always easy or even possible, Cynthia says. “Sometimes, clients pay extra for condom-less sex and sometimes a condom bursts,” she explains. Cynthia has also been forced to have sex with policemen to buy her freedom when arrested. When she first heard about PrEP from a Jilinde-trained peer educator, it sounded like a scam, too good to be true. “My first thought was, there is no cure for HIV, so how could there then be a pill that prevents HIV?” Only when she saw PrEP in the media did she begin to believe it was a real drug and seek more information.
The Jilinde project is scaling up the use of PrEP in Kenya within existing combination prevention services to people like Cynthia who are at high risk of HIV. More than two million people acquire HIV infection globally every year. In Kenya, in 2015, 71,034 people aged above 15 years and 6,613 aged 0-14 years got infected with HIV. This translates to 77,648 Kenyans requiring lifelong antiretroviral treatment to keep them alive and prevent further transmission of HIV. The project is set to demonstrate the incredible potential of PrEP by generating evidence that population-level PrEP interventions are feasible and effective in low-and middle-income countries, which bear the brunt of the world’s HIV burden.
For Cynthia and many others like her, the time for PrEP is now. “I don’t like sex work and hope that one day I can start my own food business,” she says. “But for now, PrEP gives me peace of mind because I know that I can keep HIV at bay.”
Courtesy of Jhpiego
Photo: Juozas Cernius