How are PEPFAR Countries Implementing PrEP?

The US Centers for Disease Control and Prevention (CDC) Morbidity and Mortality Weekly Report (MMWR) periodically features reviews on the HIV prevention and control efforts in countries supported by the US President’s Emergency Plan for AIDS Relief (PEPFAR).

In December 2019, an article in the MMWR highlighted challenges to implementing case-based HIV surveillance in countries supported by PEPFAR. Among the 39 countries which responded to CDC inquiry, 20 had implemented case-based surveillance, 15 were planning implementation, and 4 were not planning implementation.

An article in the February 28, 2020 edition of the MMWR concerns the expansion of pre-exposure prophylaxis (PrEP) into the 35 PEPFAR supported early program adopters from October 2016 to September 2018.

A key pillar of prevention efforts globally is the expansion of PrEP uptake in populations that are most risk for HIV.

PEPFAR “supports implementation of PrEP to reduce HIV incidence among persons at substantial risk for infection, including female sex workers, men who have sex with men (MSM), and transgender women,” the authors from the Division of Global HIV and TB at the CDC’s Center for Global Health wrote.

In 2018, for example, 54% of new HIV transmission around the world occurred among key populations and their partners.

Implementation of PrEP programs across the 35 PEPFAR supported countries examined in the analysis was assessed through the number of programs which reported new PrEP users quarterly from October 2016 through September 2018.

By September 2018, only 15 of the PEPFAR supported countries had PrEP programs. However, among these 15 countries, the client volume had increased by a substantial 3351% during the analysis period.

“Scale-up of PrEP among general population clients was nearly 3 times that of key population clients,” the authors pointed out.

Programs with more than 150 new key population clients were labeled early adopters of PrEP among key populations. Critical factors and scale up accelerators were identified among the PrEP programs which experienced rapid growth, with feedback provided by implementing partners in the programs.

“Among all PEPFAR-supported programs, 6 (Asia Region, Kenya, South Africa, Uganda, Vietnam, and Zimbabwe) were classified as early adopters of PrEP for key populations. Implementing partners in 5 of these programs (all except Vietnam) identified critical factors for early adoption of PrEP , including national and regional stakeholder meetings with strong ongoing engagement and advocacy from ministries of health, community advocates, and multilateral partners such as the World Health Organization and the Joint United Nations Programme on HIV/AIDS (UNAIDS),” the authors wrote.

Of these programs, 5 included PrEP programs in national treatment and prevention guidelines despite unfavorable national legal environments to protect key populations from stigma and violence.

Other factors which accelerated scale-up included active government ownership of the national PrEP program, developing training criteria for medical personnel, and the collection of PrEP data. Key accelerators also included promotion of HIV prevention outside the clinic on social media, at gay bars, and in the community via peer outreach.

The authors pointed out that because regular PrEP use is key to maintaining protection from HIV, these programs should monitor adherence.

Implementing PrEP into existing services may help as well. In sub-Saharan Africa, clinics have begun implementing PrEP use among pregnant and postpartum women.

To expand on their findings, the authors of the analysis suggested cost-effectiveness and mathematical modeling studies on PrEP implementation among PEPFAR supported countries. Such studies could help identify populations in which PrEP delivery would have the greatest HIV prevention impact in the context of limited resources.