Ensuring adolescent girls and young women in sub-Saharan Africa have access to a combination of HIV prevention methods will be crucial to reducing new infections. Tony Kirby reports.
In HIV prevention, the evidence is now irrefutable regarding the efficacy of both treatment as prevention and pre-exposure prophylaxis (PrEP). But while prevention has entered an exciting new era, substantial challenges remain in making sure that prevention efforts reach those who are most vulnerable—a group that includes adolescent girls and young women (AGYW) in sub-Saharan Africa; an estimated 7000 new HIV infections are occurring every week in this group alone.
“It's essential that a full range of prevention options are offered to AGYW, including PrEP, and that we learn more about how to reach them in a real world setting”, says Julie Pulerwitz, director of social and operations research, HIV/AIDS at the Population Council, Washington, DC, USA. The Population Council is a key partner in the DREAMS initiative—a multi-stakeholder project that stands for Determined, Resilient, Empowered, AIDS-free, Mentored, and Safe young women, which aims to respond to the heightened vulnerability of AGYW to HIV. DREAMS operates in ten countries that account for around half of the world's new HIV infections: Kenya, Lesotho, Malawi, Mozambique, South Africa, Swaziland, Tanzania, Uganda, Zambia, and Zimbabwe.
“The work the Population Council is doing takes into account the complex issues that girls and young women face”, says Pulerwitz. “We are working on questions such as: what is the right package of services that will reduce HIV risk among AGYW? How do we keep girls in school, which reduces their HIV risk? How do we identify the most vulnerable, such as young mothers, orphans, and those experiencing intimate partner violence, and provide safe spaces for them to talk freely about HIV prevention and access services?”
Data are currently being collected from Kenya and Zambia on the crucial question of whether the DREAMS project is recruiting and reaching the right AGYW, and retaining them. “We are also looking at whether the programme leads to better outcomes, like increased condom use and more HIV prevention knowledge”, explains Pulerwitz. A second strand of the work is not about the women themselves, but focuses on their male sexual partners—an obviously crucial link in the chain of HIV infection. “We need to get men engaged in testing, and then if positive treat them to bring down their viral loads”, she adds. “Also vital is understanding the relationships between men and young women, including their power dynamics.”
The final strand of the Population Council's DREAMS work focuses on PrEP, and learning more about how to make it available to AGYW. Among the ten DREAMS target countries, only South Africa and Kenya have guidelines authorising use of the PrEP drug Truvada (tenofovir disoproxil fumarate and emtricitabine; manufactured by Gilead) for HIV prevention. Zimbabwe and Uganda are considering the use of oral PrEP for young women, but politicians and other decision makers in those countries are asking how they can balance the cost and demand for PrEP against the demands for treatment of those already infected. “Added to this is the stigma around sexual activity experienced by girls and young women, and how to foster community support for AGYW to access PrEP”, says Pulerwitz, who adds that “PrEP is pretty new for everyone but we currently know a lot less about PrEP use for young women than in other groups such as MSM [men who have sex with men]”.
One factor that has helped garner support for PrEP is the expansion of WHO guidelines (released in September, 2015) to recommend PrEP use among all populations at substantial risk for HIV, including young women. “The President's Emergency Fund for AIDS Relief (PEPFAR), which initiated and funds the DREAMS programme activities, has been actively encouraging the DREAMS countries to consider PrEP as part of their prevention efforts”, explains Pulerwitz. “In our work in Tanzania, for example, we are collecting perspectives from young women themselves, their partners, and community stakeholders like health providers and local policy makers. We hope our results will contribute to making PrEP available and effective in these locations.”
Other projects on HIV prevention in young people include the All In initiative by UNAIDS and UNICEF, which aims to reach adolescents with HIV services designed for their specific needs and to fast-track progress to advance global efforts to end the AIDS epidemic by 2030. UNAIDS has also set fast-track targets to be achieved by 2020 for adolescents that include reducing new HIV infections by at least 75%.
“Realising the global goal for reduction in new HIV infections to under 500 000 per year by 2020 will require bold steps to martial and deploy every primary prevention tool we have in the tool box to the populations most affected by HIV”, says Linda-Gail Bekker, president of the International AIDS Society, Geneva, Switzerland. “Without doubt, young women and adolescent girls in southern and eastern Africa must be a top priority.”