An evidence review has identified the main gaps in health systems in sub-Saharan Africa that need to be addressed to boost PrEP (pre-exposure prophylaxis) scale-up.
Countries in sub-Saharan Africa began offering PrEP in 2015 after the World Health Organization recommended it, but scale-up has been slow. As of December 2020, only 18 countries had national PrEP programmes or policies.
Some countries only offered PrEP to specific groups, such as sex workers, when they first introduced it. As a result, many people associate PrEP with sex work, promiscuity or homosexuality, and stigma relating to these things has affected PrEP uptake.
To address this, there is a need for general PrEP awareness campaigns alongside targeted demand creation.
Successful general awareness campaigns should aim to ‘normalise’ PrEP by promoting it as an option for anyone at risk of HIV. These campaigns should be positive and highlight PrEP’s emotional and health benefits.
At the same time, targeted demand creation should be carried out to ensure PrEP reaches those people who need it the most. Successful strategies to boost take up include running targeted social media campaigns for specific groups and working with peer educators.
Access to treatment
Where people can get PrEP from is also an issue. PrEP is often provided in antiretroviral treatment (ART) clinics. But many people are reluctant to go to ART clinics to get PrEP due to HIV-related stigma.
To address this, PrEP should be available in settings that work for different groups. This includes antenatal clinics for pregnant women and family planning clinics for young men and women.
As people who are marginalised rarely use public health facilities, there is also a need to provide PrEP in drop-in centres, hotspots, at home and in community pharmacies.
Innovative delivery approaches are also needed. These include multi-month PrEP prescriptions and offering PrEP to people who self-test for HIV. Many of these innovations have already come about in response to COVID-19 restrictions and should now remain.
Addressing health workers training needs
The review also found that providing PrEP has added to health workers’ already heavy workloads. Group-based delivery and task-shifting could help address this, as it did with the rollout of HIV treatment.
As all staff who provide PrEP need training, particularly to address discriminatory attitudes, staggered training and online courses could prevent too many staff from being away from facilities at the same time.
Centralising data and supplies
The review assessed how best to manage PrEP data. It found that including PrEP data in existing health information management systems supports its integration into other services and makes scale-up more sustainable.
Centralising the supply of PrEP commodities and medicines is another way to quicken rollout. In Kenya, for example, PrEP commodities from different donors are centrally managed by the National AIDS and STI Control Programme and Kenya’s Medical Supplies Authority.
Advocating for change
Successful PrEP scale-up also requires effective leadership to coordinate various functions and stakeholders. Advocacy is essential to ensure policy-makers translate WHO guidance on PrEP into national policy and to convince them to address health system challenges.
Technical working groups are also important for sharing ideas and experiences, standardising approaches, pooling resources and avoiding duplication.
Financing is also an issue. Domestic resources for HIV programmes mainly fund HIV treatment rather than prevention. When investments from donor countries decrease this leaves a funding gap for HIV prevention, including PrEP. One way to address this is to integrate PrEP into other services to share costs. Progressive scale-up and increasing demand is likely to reduce the cost of PrEP delivery in the long term.