Adolescent girls and young women aged 15 to 24 account for 23% of all new HIV infections in sub-Saharan Africa. Females are much more vulnerable to HIV than their male peers. Whereas 0.7% of adolescent boys aged 15 to 19 have HIV in South Africa, the equivalent figure for girls is 5.6%. In the 20 to 24 age group, 5.1% of men and 17.4% of women have HIV. In some parts of the country, prevalence is even higher.
New prevention options that are acceptable to young people, and especially to young women, are urgently needed in southern Africa. Pre-exposure prophylaxis (PrEP) for young people is being considered in several countries as a potential option.
One of the first studies to explore the acceptability, safety and use of PrEP with adolescents in an African context has found that PrEP was safe and tolerable, although PrEP usage and adherence did tail off during the 12 months of the programme.
Presenting the findings of the PlusPills project to the 9th International AIDS Society Conference on HIV Science (IAS 2017) in Paris this week, Katherine Gill of the Desmond Tutu HIV Foundation said that South African adolescents need access to PrEP with tailored adherence support and more frequent clinic visits. Less frequent dosing schedules, if validated, could be of interest to this population, she suggested.
Yogan Pillay of South Africa’s National Department of Health said that five demonstration studies had already provided preliminary data on how to target and deliver PrEP to adolescent girls and young women.
The uptake of PrEP varies considerably between different studies and in different social contexts, ranging from 36 to 98% of those approached. Retention and adherence also varies considerably, with between 40 and 70% of participants either reporting continued PrEP use or having sufficient levels of the drug in their blood.
The experience so far has underscored the need for flexibility and adaptability in providing oral PrEP to young women in South Africa. The diversity of settings in which young women live means that PrEP cannot be a one-size-fits-all prevention tool.
Concern about side-effects has been a recurrent challenge and a frequent reason for young people to discontinue PrEP. Other reasons for opting out of PrEP include dislike of the pill’s size or taste, and difficulties remembering to take it every day.
Pillay said that community education is critical to uptake and adherence. It needs to try to reduce the stigma of young people’s sexual activity and to legitimise PrEP as a form of prevention. Parents and caregivers are extremely influential in adolescent girls’ decision-making about PrEP.
The South African government is hoping to deliver PrEP through clinics in tertiary and vocational education colleges and universities, as well as in family planning services. Work is needed to ensure that staff are sensitive and do not stigmatise PrEP users, Pillay said.