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New Vision
Opinion: Uganda Needs HIV Prevention Pill As Additional Strategy

<p>Richard Hasunira and Lydia Mulwanyi-Mukombe</p>


September 20, 2013

On August 26, 2013, the New Vision published a headline article, "Government rejects HIV prevention drug", in reference to the anti-retroviral drug (ARV) Truvada, which research has proven can significantly reduce the risk of HIV infection in HIV-negative men and women when taken daily.

Dr Alex Ario of the Ministry of Health (MoH) reportedly said the ministry had "conducted several studies" and decided not to adopt Truvada for HIV prevention because it is too expensive and could encourage reckless sex.

It is difficult to believe that this is the position of MoH on this new strategy of using ARVs in HIV-negative people to reduce chances of infection, known as pre-exposure prophylaxis (PrEP). Research on PrEP has been conducted in Uganda and follow-up studies are ongoing.

A trial conducted in Uganda and Kenya found Truvada to reduce infections among discordant couples (where one partner is HIV-positive and the other negative) by between 73% and 85% depending on how adherent to the daily dosing schedule a person is.

And at the moment, demonstration studies have started in Kasangati in Wakiso District and Kabwohe in Bushenyi District to test how PrEP would work in the real world, outside of a clinical trial.

The demonstration studies are expected to generate data on feasibility, which can then inform decision-making on policy and programming. It is, therefore, unbelievable that MoH can take a unilateral decision on PrEP without undertaking adequate consultations and when important studies are still ongoing.

We hope that the reported government rejection of PrEP is not the official position of MoH. It is important that the Government comes out to clarify their position on PrEP.

What we know about PrEP so far is that it cannot be for all people and it cannot be for all the time. We also know that implementing PrEP programmes will be challenging. But PrEP may also be able to play an important role in reducing HIV infection rates.

Scientific models have shown that PrEP will likely be most helpful when targeted at people who are most at risk of HIV infection, and for many people, this risk may not remain high for a life time.

PrEP could provide protection for an HIV-negative partner while the HIV-positive partner is initiating ART and/or if he or she is not on effective ART. PrEP will not replace other prevention methods, such as condom use and limiting the number of sexual partners.

The World Health Organisation has suggested that countries conduct demonstration projects to learn more about how PrEP could be used in given contexts. Uganda is currently supporting one such project. Until the results from this and other demonstration studies are known, the government's reported rejection of PrEP is not based on evidence.

It is important to note that Truvada is available in Uganda as a treatment drug, and there are people who may try to access it for prevention purposes on the basis of research findings. In the absence of guidance from MoH, health workers will not know what to do with clients seeking PrEP, which may lead to self-medication and irrational use of Truvada or tenofovir, another ARV that has also proven effective in HIV prevention.

What the MoH needs to do now is to develop interim guidance to service providers and prospective PrEP users who may wish to access Truvada for HIV prevention outside of government programmes. This has already happened in the United States and South Africa.

Rates of new HIV infections are rising in Uganda. This worrisome trend sets us apart from every other country in the region. We need to do more with the existing prevention strategies, while also utilising emerging ones.

In order to achieve this, Uganda must maximise benefits from each proven strategy, including HIV counselling and testing, abstinence, faithfulness/partner reduction, condom use, prevention of mother-to-child transmission, ART, and safe male circumcision, while also laying ground for PrEP and other emerging strategies.

The writers work with HEPS-Uganda and ICW East Africa respectively.



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