Since the introduction of oral pre-exposure prophylaxis (PrEP) in South Africa in 2016, there has been a steady increase in its popularity. More and more people understand the value and safety of oral PrEP as part of combination HIV prevention. As of June 2019, approximately 29, 000 people in South Africa have started using oral pre-exposure prophylaxis (PrEP) to prevent HIV infection, but little is known about the opinions and attitudes of health providers. As the face of public health service delivery, their perspectives are important.
A little bit of background
In 2018, the Wits Reproductive Health and HIV Institute (Wits RHI), a leading partner of the OPTIONS Consortium*, in partnership with the National Department of Health and the Clinton Health Access Initiative, developed a research approach to understand exactly why people choose to use this fairly new HIV prevention method, what motivated them to continue using it and if they did stop, why they decide to do so.
The study also documented the perspectives of over 192 health providers (pharmacists, nurses, counsellors and peer educators) at 17 health facilities in Gauteng, Limpopo, KwaZulu-Natal and the Western Cape. We aimed to try and understand how much health providers know about oral PrEP, get insights into their opinions and their experiences providing oral PrEP to their clients. Of the health providers we spoke to, over 80% were female and 20% were male, all aged between 18 and 71.
How much do health providers know about oral PrEP?
We spoke to health providers who had experience working with a variety of people accessing services including adolescent girls and young women aged between 18 – 24 years. More than half (54%) of the health providers we spoke to were familiar with oral PrEP. Of these who were familiar with oral PrEP, 47% had been trained on how to provide oral PrEP. Of the providers trained to provide oral PrEP, 34% had experience with providing it.
When we asked health providers questions about oral PrEP, we found that they were generally well informed and were able to answer most of the questions correctly. One of the questions that they were not able to answer correctly was around viral-load suppression and risk for the HIV-negative partner. The question asked whether an HIV negative partner can stop taking oral PrEP if their HIV-positive partner, on antiretroviral therapy (ART), is virally suppressed. This question is really about the ability to navigate risk levels with a client. We know that the U=U campaign has been successful in building knowledge that if an HIV positive person adheres to their ART, and brings their viral load down to under 40 copies/ml, then their risk of infecting their sexual partner is eliminated. From a PrEP user’s perspective, if the client knows their partner’s viral load, and if it is suppressed and routinely monitored, then it is safe for them to cycle off PrEP. It’s important to remind healthcare workers that clients must be informed that they must assess their own risk profiles before making this decision, including whether this is their only sexual partner.
In addition, future training needs to have more content on what it means to be virally suppressed and how consistently taking one’s ART leads to an undetectable viral load and ultimately stops HIV transmission. Read more about viral suppression here.
Although a lot of the health providers felt they were adequately skilled and experienced to provide oral PrEP, many (58%) still felt that they needed more training on topics such as monitoring and evaluation, resistance risk, and clinical monitoring and management.
What were the health providers’ thoughts and concerns about oral PrEP?
Health providers were asked what they thought the benefits of providing oral PrEP were. It was encouraging to see that nearly all health providers (93%) believed that oral PrEP would add to the already existing HIV prevention options. About 60% of health providers felt that oral PrEP would give their clients peace of mind with the knowledge that they had an additional HIV prevention option to condoms or post-exposure prophylaxis (PEP), for instance. There was general agreement among the health providers that oral PrEP would empower their clients and give them a sense of control over their own health, sexual freedom, discretion and privacy.
When health providers were asked if they had any concerns about dispensing oral PrEP, many felt their clients should rather try alternative HIV prevention options such as condoms before trying oral PrEP.
What sort of challenges did health providers think their clients would face when trying to get oral PrEP?
We asked health providers what they thought would stop their clients from getting PrEP. More than half (58%) stated that the lack of access could be a barrier. Some spoke of how their clients would rather get oral PrEP from a mobile facility instead of going to the clinic. Other health providers noted that some clients found it difficult to take time off work to go the facility. In some cases this was because managers would not allow them to take leave, or they were not willing to miss hours of work and wages.
When it comes to offering accessible health care, perseverance is the mother of success. One of the health providers shared an experience in which clients had been banned by their manager to go to the drop-in centre for oral PrEP. This particular health provider decided to take oral PrEP to their clients’ place of work instead and help them from there.
Other challenges and barriers to getting oral PrEP included disapproval from sexual partners, families and friends. 30% of health providers felt that clients would fear judgement by their families and friends, while 27% believed side effects would discourage clients from taking oral PrEP.
Side effects or the fear of side effects were also seen as a key barrier to oral PrEP uptake. In order to reduce the fear of side effects and empower their clients, health providers reported counselling their clients and reassuring them that the side effects would not last. In some cases, however, clients still stopped taking their medication and gave side effects as the reason why.
Gender-based violence was highlighted as an important barrier to oral PrEP uptake and continuation because some male partners felt the women who were taking PrEP were participating in sex work.
Health providers also expressed concern over their clients not being able to consistently take their oral PrEP pill every day. They felt that their clients need to understand that oral PrEP does not work immediately after it is taken. In one example, a client would not regularly take their oral PrEP because they felt that they only needed to take the pill before having sex with someone.
We are the generation that will end HIV…
There’s no doubt about it, oral PrEP has the potential to reduce the alarmingly high numbers of new HIV infections, particularly among adolescent girls and young women in South Africa. Oral PrEP brings us one step closer to putting a stop to new HIV infections… FULL STOP! Although so much work has gone into making oral PrEP a reality, we still have a way to go to ensure it is delivered to those who need it most, from suitable delivery points – clinic, mobile facility, or a combination – so that is acceptable and easily accessible.
It was evident from this study that the thoughts, opinions and experiences of health providers play an important role in the way services are delivered, so that they can share this knowledge with oral PrEP initiates, with friendly and non-judgemental attitudes. This study found that adequate counselling, the realisation of personal risk and access to accurate, evidence-guided information are vital to empowering and helping PrEP oral users to people continue their PrEP journey.
Have more questions? Visit myprep.co.za to get more in-depth information about PrEP. Want even more interaction? Visit the South Africa MyPrEP Facebook and Twitter pages and join a community of people who believe that We Are The Generation That Will End HIV!
Want oral PrEP? Find your closest clinic in South Africa that is providing oral PrEP free of charge here. Want to know if PrEP is right for you? Try doing this online journey to find out: PrEP Roadmap.
Other blogs in this series:
ACCESS PrEP blog series: Oral PrEP – The pill with a big heart
ACCESS PrEP blog series: Slaying side effects - it’s all about managing the menace
ACCESS PrEP blog series: Wrapping it up - PrEP as part of combination prevention
*The OPTIONS Consortium is one of five microbicide projects funded by the U.S. Agency for International Development (USAID), in partnership with the U.S. President’s Emergency Plan for AIDS Relief (PEPFAR), working to accelerate and sustain access to oral PrEP.
Disclaimer: Oral PrEP is more than 90% effective at preventing HIV infection for HIV negative people only. It does not protect against other STIs or unintended pregnancy.