Africa: ‘Why Are We Taking a Pill Every Day to Prevent Taking Another Pill Every Day?’ #Aids2024

More people living with HIV have access to life-saving treatment with antiretroviral therapy (ART). However, even if you take ART drugs regularly as prescribed, there are still dormant forms of the virus within groups of cells in your body which are called HIV reservoirs. If ART is discontinued, the virus in these reservoirs might reactivate, possibly causing AIDS. There is no universal cure for HIV, however, a few people have been declared HIV-free following high-risk stem cell transplants. However, scientists remain optimistic that 40 years without a cure for HIV infection could potentially come to an end.

“We need to address HIV using a multifaceted approach,” said Dr. Joram Sunguti Luke, a medical doctor and public health professional who works in HIV and AIDS & Sexual and Reproductive Health and Rights (SRHR), and is Senior Technical Advisor at Pathfinder International.

“Success with an HIV vaccine has been elusive due to various factors,” he said. “Even if we develop an effective vaccine, we will still require treatment or a cure for those already infected, as vaccines cannot eliminate the virus. For instance, while we have a malaria vaccine, we still prescribe drugs for treatment.”

According to Dr. Sunguti, ART should be used to support those living with HIV while improving the vaccine to protect those who haven’t been infected. However, ART does not offer a functional cure. “One promising avenue is the stem cell transplant, which has cured three individuals – known as the Berlin patient, the London patient, and the Dusseldorf patient.

“In addition to stem cell transplants, we should explore genetic approaches such as DNA-related cures and broadly neutralizing antibodies, while maintaining our efforts in HIV prevention, ARVs, and vaccination.”

PEPFAR’s push for equitable PrEP access

PEPFAR, through its implementing partners and country structures, integrated pre-exposure prophylaxis (PrEP) into existing health services using community-based delivery models, training providers, addressing structural barriers, and supporting innovative models. Examples include peer-led demand creation and PrEP distribution through village pharmacies in select sub-Saharan African countries.

“Previously, PrEP was overly medicalized,” said Dr. Sunguti. “People viewed it strictly through a clinical lens, focusing on how to prescribe and dispense medications like Truvada, cabotegravir, and lenacapavir. This biomedical approach meant that individuals would visit a doctor, express their risk of HIV infection, and receive a month’s supply of pills. Once finished, they would return for more to continue preventing HIV.”

“Why are we taking a pill every day to prevent taking another pill every day?”

Dr. Sunguti told of an encounter with university students taking PrEP who asked: “Why are we taking a pill every day to prevent taking another pill every day?”

“This question underscored the shift PEPFAR is making toward community-focused, client-centered PrEP access,” he said. “Essentially, PEPFAR is integrating PrEP into existing services. This means that if you visit a maternal newborn clinic or a prevention of mother-to-child transmission (PMTCT) clinic, you can access PrEP there.”

Similarly, STI clinics and HIV clinics are also providing PrEP, and some pharmacies in Kenya and South Africa have begun dispensing it.”

“These are community-based initiatives. PEPFAR supports community pharmacies and integrates PrEP provision within health facilities. Funds are allocated to train providers to overcome structural barriers. For example, if a young girl approaches a nurse asking for PrEP, the nurse may have biases, questioning her decision and suggesting she should be in school, be a committed Christian, or abstain from sex. Through PEPFAR funding, we are working to address these provider biases and ensure access to necessary medications.”

Companies such as Gilead and Viiv are manufacturing PrEP and working closely with PEPFAR, the Global Fund, and other entities to ensure these medications are available and distributed to communities in need.

PEPFAR also invests in monitoring and evaluation (M&E) for health focusing on mobile and online demand creation to enhance PrEP access. For instance, funds have been allocated to several implementing partners, who have developed mobile applications to create demand and increase access to PrEP. Users can install or access the app online to find nearby PrEP providers, linking them to free PrEP. They can then either call for delivery or pick it up.

“These investments, along with funding for implementation science, are crucial. Research on user experience and feasibility helps us understand how people perceive PrEP and the challenges they face,” he said.

Key gaps in HIV prevention and treatment

Unfortunately, those with HIV still have to deal with stigma and discrimination, which “manifests in three ways”.

“First, there is stigma against oneself, where individuals living with HIV harbor negative feelings about their condition. Second, stigma from others – friends, family, and healthcare providers – further compounds the issue. Lastly, institutional stigma and discrimination present significant barriers.

“The current approach is often vertical and not integrated with other programs. Those working within the HIV environment will often have their own technical working groups, guidelines, offices, and commodity procurement systems, among others. As a result, HIV is often perceived as a standalone issue.”

He said that clinics focusing on non-communicable diseases like hypertension or diabetes may not ask patients about HIV testing because it’s seen as unrelated. “This separation is a significant barrier, and we need to dismantle this siloed approach to integrate HIV into all health services.” However, the USAID is working on and supporting models that integrate HIV into primary health care.

Sustainable funding remains another challenge.

The U.S. government invested over $100 billion in the global HIV/AIDS response since PEPFAR’s inception in 2003, saving more than 25 million lives, preventing millions of new infections, and assisting numerous countries in combating the epidemic while strengthening global health and economic security. In addition to this big investment, countries should continue to explore ways to raise domestic funding for HIV prevention and control.

Aside from sustainable funding, several challenges persist. Many recipients of care struggle to adhere to HIV treatment and prevention measures due to various underlying structural, socioeconomic, and personal factors.

“I visited a clinic where a mother said, ‘If I don’t eat, I might die of hunger sooner, than HIV would kill me,'” Dr. Sunguti said. “This proved the necessity of strong social support, access to food, and education for people living with HIV. These are structural determinants that significantly impact their well-being.”

“Insufficient testing remains an issue,” he said. “We are not reaching everyone where they are, including children, adolescents, and key populations. Stigma drives people to hide, creating significant gaps in our efforts.”

Another aspect is addressing the issue of identifying cases among children who are being left behind in the global HIV response.

“First, we must prevent HIV infection among children while still in the womb. This means testing pregnant mothers for HIV and ensuring that those who are positive receive ARVs during pregnancy. They should deliver under recommended conditions, following proper protocols for both delivery and postnatal care. After delivery, infants should receive prophylaxis to prevent HIV transmission, as per national guidelines.

If we don’t initiate ARVs early for those who test positive, they tend to die quickly – often within one year (20-30%) or by their fifth birthday (50%).”

“Secondly, we must train healthcare providers in HIV care for children. Many providers fear prescribing ARVs to children due to a lack of knowledge or concerns about dose adjustments as the child grows. It’s essential to provide mentorship and conventional training for these providers. Lastly, we need to integrate pediatric HIV into existing programs, such as maternal and child health services. For instance, at child welfare clinics where children are monitored for growth and development, we can also conduct HIV screening and testing. This integration will help reduce the siloed nature of programming.”

He said caregivers of children living with HIV, whether HIV-positive or negative, also need support as they often face significant challenges. “Providing caregiver support packages that focus on mental health and overall well-being is essential. We must invest in programs that address the social and structural determinants impacting these families,” Dr. Sunguti said.

Pathfinder’s Impact on HIV

Dr. Sunguti said the countries supported by Pathfinder International – such as Mozambique, and Nigeria – new HIV cases have significantly declined since 2010, which is a major achievement. However, in some countries where implementing partners have had limited presence, such as South Sudan, Madagascar, and Congo-Brazzaville (not DRC), they are witnessing an increase in new HIV cases. This rise can be attributed to a lack of sufficient support from donors and development partners.

“For over 25 years, Pathfinder has continued to contribute to the global response to the HIV pandemic, but we don’t focus solely on HIV. We integrate HIV into primary healthcare, cervical cancer screening, family planning, and women’s health initiatives, including climate resilience and gender rights. Our programming is comprehensive and interconnected.”

Pathfinder extends their focus beyond medical issues, also engaging in advocacy. “In Mozambique, for example, we work with civil society organizations representing female sex workers, transgender people, and men who have sex with men to report cases of gender-based violence (GBV). We collaborate with the police on this initiative.”

The program includes training officers on how to handle these cases, and a reporting system was established for reporting GBV cases. “Police can access these reports online and we provide contact numbers for immediate assistance,” said Dr. Sunguti.

The importance of integrating HIV care into various health services is also addressed: “We are incorporating HIV into family planning, cervical cancer screening, STI clinics, and maternal and newborn health services.” He said promising practices such as Operation Triple Zero, which aims for ” zero missed appointments, zero missed medication, and zero viral loads among adolescents and young people” foster peer support for young people in Nigeria and Mozambique.

Dr. Sunguti also spoke about the OVC-clinical interface, where clinical and OVC partners jointly support families of orphaned and vulnerable children to receive comprehensive care, including education, vocational training, and agricultural assistance while connecting HIV-positive children and adolescents to these programs. Dr. Sunguti said using granular data to identify hotspots for new infections enables targeted community-based interventions. He described the mother-baby clinic, which promotes family-centered care by allowing mothers, fathers, and babies to attend appointments together.

He identified several key challenges facing the fight against HIV: “We’re still fighting stigma and discrimination, and HIV is often viewed as a donor-funded program with uncertain funding.” He said there’s a need to focus on the “last mile”, which includes the populations left behind in HIV prevention efforts, particularly key populations who fear victimization. He said in sub-Saharan Africa, women and girls of all ages accounted for “62% of all new HIV infections.

There is also the geographical shift of new infections, with a notable increase in cases in Central and West Africa. Over one quarter (26%) of all children living with HIV globally are in this region, and 4 in every 10 new infections in children occur there.

The campaign to end HIV/AIDS is a “victim of its own success”, Dr. Sunguti said, as many people now take antiretroviral medications and appear healthy, leading to a decrease in perceived risk and, consequently, potential risk of reduced prioritization and funding for HIV programs.