Anti-HIV treatment – let’s get the facts right.

Yesterday – 4th May was the national roll out of the oral HIV Pre-exposure Prohylaxis (PrEP) by the Ministry of Health in Kenya. HIV PrEP is provision of medication to HIV negative people at high risk of HIV acquisition. They would need to use it regularly in order to prevent infections. This HIV prevention pill has generated a lot of excitement.

PrEP targets high risk groups and in Africa, this includes in some circumstances, teenage girls. A well written article in the Daily Nation raised the issue of rising numbers of new infections in young girls …….

Media article on anti-HIV treatment

However, there were still a lot of questions left answered.

I raised the questions with Dr Kimani Makobu who is a medical doctor and PhD student. Dr Kimani’s research is investigating the use of PrEP among men who have sex with men and female commercial sex workers in Malindi.

What is the different between post-exposure prophylaxis and pre-exposure prophylaxis (PrEP)?

I can think of two similar analogues. If a woman does not want to be pregnant – she will use birth control pills in anticipation of regular sexual encounters with risk of pregnancy. However, in the event of unplanned sexual activity – then she would be given the morning after pill. Both protect against pregnancy – one is used regularly in preparation – while the other is an emergency measure in case of an assault.

PrEP is the regular medication given to HIV-negative people in anticipation of regular sexual encounters with HIV infection risk while post-exposure prophylaxis is medication given in an emergency as a result of an unplanned sexual activity or assault.

HIV post-exposure prophylaxis is given to anyone in need, while PrEP is given to people at high risk of HIV acquisition.

The medication approved for use worldwide for PrEP, is a combination of two drugs and is known as Truvada. For Post-exposure prophylaxis, a 3-drug combination is used.

Why are girls being targeted? Are our girls so promiscuous, they need PrEP?

Oh no – girls are not being targeted for this reason and it is not being rolled out to just anybody. The roll out of PrEP will be among girls and women from 15 years and above, who are in exceptional circumstances and are at highest risk of getting infected with HIV. This roll out will also not just be about popping pills. Through the project DREAMS, girls will receive a number of interventions to enable them stay in school or find some other means of achieving their life goals. Staying HIV negative will enable them get further in life.

DREAMS project in Kenya

The Kenyan government through the National AIDS and STI control Program (NASCOP) unveiled Guidelines on Use of Antiretroviral Drugs for Treating and Preventing HIV Infection in Kenya. These guidelines are very clear about who should go on PrEP.

Ministry of Health guidelines on PrEP use

The girls that will be enrolled must be at high risk of acquiring HIV and a lot of ground work will be done to access their risk before enrolling them for PrEP. Women and girls already engaged in risky sexual behaviour for whatever reasons will be the target group. Many will be women and girls from very poor backgrounds who are not commercial sex workers but have to engage in sex for small gains. Many of their partners are older men with money, who have other sexual partners, putting these girls at risk of exposure to HIV.

PrEP has been through various pilot studies where it has proved its value in high risk populations such a men who have sex with men and female commercial sex workers

At the moment, PrEP is only available by prescription but it is likely that avenues for dispensing may in future, be varied, including pharmacies.

How often will the pills be taken?

Daily for the duration in which a person feels they are at risk of HIV exposure. The girls and women can stop taking the pills when they are no longer at risk of contracting HIV, upon consultation with a health care provider.

Why daily – why not just pop the pills after a sexual encounter?

To explain this – I need to remind you how the HIV virus causes disease. The HIV virus cannot multiply freely on its own and needs to get into CD4 cells – which are found in all human body tissues. The HIV virus integrate with parts of the CD4 cell which enables them to multiply and infect even more cells and therefore multiply and start to cause disease.

PrEP drugs stop the virus integrating with CD4 cells. The virus will not multiply and spread and therefore, there will be no infection.

For the PrEP drugs to be able to stop the virus– it needs to accumulate in adequate amounts in all CD4 cells in the body. For that accumulation to happen, scientists have worked out that PrEP needs to be taken continuously for a minimum of 7 days. So if you start PrEP today, you will gain protection in a week.

The drug accumulates in every single organ in the body and that is why it offers protection from any sexual act that could result in disease. Scientists have found that you can actually determine if someone is adhering to treatment by measuring the amount of PrEP in the hair!

Are there any risks to taking PrEP?

PrEP has the potential of causing kidney problems. One of the requirements for starting PrEP is that tests must be done to show that the kidneys are in good working order. In fact, every 3 months, a kidney function test is performed for those who are taking PrEP.

How strong is the protection from PrEP? Does this mean, those using PrEP don’t need to use condoms?

If you took the pill daily – PrEP has been shown to have just over 90% protection. This is good, but there is also the 8 to 10 people out of 100 who despite 100% adherence could still get HIV infection. PrEP is not the magic bullet and people still have to ensure that they use of condoms and adhere to other HIV preventative measures.

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