It's been slow and somewhat piecemeal -- but around sub-Saharan Africa, countries are beginning to explore PrEP using daily oral TDF/FTC for HIV prevention for women, gay men and other men who have sex with men and other vulnerable groups. In the first of a series of visits to PrEP programs in action or soon to be underway, AVAC's Policy Director, Kevin Fisher, visited a program underway in Senegal. Here is his update.
In October 2015, I visited a PrEP demonstration project focused on female sex workers which began earlier in the year in four suburban communities ringing Dakar. One of my hosts, Daouda Gueye, from the site explained that Senegal has a nationwide prevalence below 1 percent, but approximately one in four sex workers in Dakar are women living with HIV.
Gueye, whose serves as a project manager, said that the demonstration project will provide PrEP to female sex workers recruited through Senegalese health department clinics and hospitals. The demonstration project was fully enrolled with 273 women by November 2015. In Senegal, the official policy is that all women who exchange sex for money have to register with the Institute d'Hygiene Sociale or other government-run designated clinics where they are issued a health card and required to visit for bi-monthly checkups for STIs and HIV testing. Registered sex workers are given free condoms and, if they are positive, antiretroviral therapy. This PrEP project will include both government registered and unregistered sex workers who do not receive services.
Registered sex workers have lower HIV incidence than unregistered sex workers, according to Gueye. If the program is successful, Senegal will consider integrating PrEP into its suite of prevention services for registered sex workers, if support can be found to fund the program, said Dr. Moussa Sarr, one of the principal investigators.
Across Africa, many programs piloting PrEP for women are reaching out to sex workers. Some, especially through the PEPFAR-funded DREAMS program, are also exploring delivery to adolescent girls and young women.
These programs are happening in dialogue with policy makers, advocates and, in some cases, potential users. UNAIDS released in 2014 recommendations on community-based PrEP services for sex workers developed in consultation with sex workers from India and South Africa in November 2013 in Johannesburg. Sex workers have begun to explore the potential benefits of PrEP for HIV prevention in the U.S., too. One issue that is consistently raised is how to ensure that individuals at high risk get access to needed services -- without stigmatizing the intervention -- leading it to be seen as something that is only used by certain types of people. There are also concerns among some sex workers about PrEP not destabilizing their use of other prevention tools, such as condom negotiation.
This certainly isn't the intention of the WHO's Recommendation On Oral Pre- Exposure Prophylaxis Of HIV Infection released in September 2015. This document addresses both when to start antiretroviral therapy as well as the offer of PrEP to those at substantial risk. The Guideline recognizes that some people at substantial risk may fall into the categories of "key populations" (like sex workers or men who have sex with men) but that others, like young married women, may not.
This is a promising move -- as long as programs for all people, including those specifically marginalized and discriminated against due to who they have sex with, are rolled out. We don't want a world without sex work-specific PrEP programs (designed with the community as full partners), but we also don't want a world where these are the only PrEP programs around.
By including both registered and unregistered sex workers, after consultations with both, the Senegalese demonstration project will hopefully provide insights into how to reach women who have different identities or have made different choices about formally adopting the label of "sex worker."
The challenge in implementing PrEP will be to find those at substantial risk without sweeping in all sex workers or MSM or IDUs. The PrEP study in Senegal may provide one path.