By Marcus Low
The Department of Health aims to make a pill to prevent HIV infection available at all community health centres and primary healthcare clinics in South Africa by the end of September 2020.
Yogan Pillay, Deputy Director for Communicable and Non-Communicable Diseases at the National Department of Health, says that by the end of March 2020 the department aims to have an HIV prevention pill available in at least one health facility in each sub-district in the country.
According to Pillay, more than 50,000 people were initiated on the pill over the past four years. It seems likely that these numbers will increase dramatically as the pill becomes available more widely.
“The PrEP targets in the National Strategic Plan (NSP) for HIV, TB and STIs 2017-2022 is 85 000,” Pillay said. “We do however estimate based on the uptake trend at the current PrEP sites that approximately 10.5% of HIV negative persons offered PrEP will take up PrEP.
What is PrEP?
The pill in question is a form of so-called pre-exposure prophylaxis, or PrEP. It is meant to be taken by people who are not living with HIV in order to protect them from becoming HIV positive. The pill is a combination of two antiretroviral medicines, tenofovir disoproxil fumarate and emtricitabine (TDF/FTC).
TDF/FTC is highly effective at preventing HIV infection when taken as prescribed.
According to the Department of Health’s PrEP guidelines, seven consecutive days of TDF/FTC are needed before achieving full protection from HIV infection. Thereafter people need to take the pill once a day in order to maintain protection. It should be continued for 28 days after the last potential HIV exposure in those wanting to come off the pill.
Most people will not experience any side-effects on the pill. A minority may however experience minor side-effects such as diarrhoea, headache, abdominal pain and nausea in the first month of taking the pill. A very small percentage of people taking the pill may experience some kidney problems, but tests will be conducted to manage this risk.
The TDF/FTC pill can be taken at any time of day and taking alcohol will not reduce its effectiveness. It can be taken with any kind of contraception and sex hormones. It is also considered safe for pregnant and breastfeeding women. In couples where one partner is living with HIV and the other not, it can be used by the HIV negative partner for safe conception.
Who can get the pill and how?
According to Pillay any HIV negative persons who are at substantial risk for contracting HIV that are willing to take a pill a day and have a healthy kidney will be eligible to receive the TDF/FTC pill through the public sector. This is a wide definition and should, at least in theory, include most people in South Africa who consider themselves to be at risk of becoming HIV positive.
Pillay said the TDF/FTC pill can be prescribed by professional nurses that are NIMART trained (Nurse Initiated Management of Antiretroviral Therapy). For the time being, no other nurses or clinical associates will be able to prescribe the pill, nor will it be made available outside of healthcare facilities.
Pillay did, however, say that for people who want to continue taking the TDF/FTC pill on a long-term basis, distribution through CCMDD will be considered in the future. (CCMDD is an initiative that allows people dependent on the public healthcare system to collect their medicines in places other than healthcare facilities, such as private sector pharmacies.)
According to the guidelines, once started on the pill, people will be expected to return to the healthcare facility a month later, and then every three months after that for HIV testing and other tests. People will be given prescriptions for three months, but they will have to collect the pills at the clinic every month. Kidney function will be tested after one month, after seven months, and then once a year after that.
Will the pill reach young women and girls?
Young women and girls aged 15 to 24 have very high HIV infection rates (roughly four times that of boys and young men of the same age) and have rightly been identified as a key population in South Africa’s HIV response. For many sexually active young women and girls, especially those who are not in a position to negotiate correct condom use during sex, access to the TDF/FTC pill may well make the difference between contracting HIV and not contracting it.
Spotlight asked Pillay what steps are being taken to ensure young women and girls at risk of contracting HIV have access to the pill.
He explained that a tool was developed to estimate priorities for different healthcare facilities. “The targets for each clinic are disaggregated by age and gender to ensure that the facility focuses on populations that are at highest risk,” he said. “Through this process adolescent girls and young women aged 15-24 years are prioritised at most facilities.”
Pillay said that all primary healthcare facilities are encouraged to establish youth friendly services and more specifically to establish dedicated times when young people can easily access these facilities through the establishment of “Youth Zones” during which time youth are welcomed to the clinic.
“Special youth-focused social mobilisation and IEC (information, education and communication) materials for HIV prevention and sexual reproductive health services are made available to primary healthcare facilities,” Pillay said.
“Ward based outreach teams, school health nurses and community based organisations will also be utilised by the health facilities for demand creation, [to] educate and screen youth and assist with linking youth to health and other services.” MC