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Providing Oral PrEP: Getting women in the door
Starting the Journey of HIV Prevention Through Oral PrEP
By Alfred Itunga, Technical Communications Officer, LVCT Health
Imagine taking drugs every day even if you are not sick. Women who use daily oral PrEP, a medication that protects users from HIV, face this dilemma and must come to terms with it.
As oral PrEP rolled out in Kenya, women who chose to participate in LVCT health’s program,
Introducing Oral PrEP into HIV Combination Prevention (IPCP), said they understood the factors that put them at risk. IPCP was designed to bring oral PrEP to populations who are especially at risk of exposure, particularly adolescent girls and young women. But taking daily drugs when you are well, that was hard to imagine. LVCT Health met this reluctance with facts about oral PrEP.
To reach women eligible for oral PrEP in the community and get them to join the project, staff at LVCT Health used a number of strategies to explain oral PrEP and foster trust.
After a slow start to enrollment, service providers found HIV testing outside the clinic gave them a chance to talk about oral PrEP and allowed potential participants to manage their anxiety about testing in the comfort of their home.
“We realized the girls really wanted the test in the community. They are really willing to get tested, but they're not willing to walk into the health facility. Most girls felt it was better for them to be tested [in] their homes. Once they were sure of their HIV status, then they would be confident and happy to visit the facility for further tests and initiation into the project. Through this method we were able to get them to test and take that noble step of ensuring that they remained negative.”
—Maryanne Ajwang, clinical nurse at LVCT Health
Community health workers also played a role as effective messengers. As well-known figures in their communities, women trusted their information and advice.
“When the PrEP came, I was very happy and I worked very hard to look for young girls, to talk to them, to counsel them.”
—Grace Akinyi, community health worker
Since this was a demonstration project, the participants had to go through a number of assessments. As service providers screened for risk and conducted medical checks, they answered questions and explained how oral PrEP works.
Having an integrated clinic also allowed providers who handle family planning or other health issues to discuss oral PrEP with those at risk and connect them to IPCP. This brought a wave of early adopters into the program, who drew on already established trust with their referring providers.
With time, the early adopters reached many other young women, reassuring and modelling the benefits of participating in the project. The early adopters acted as peer educators and gave the participants the confirmation that the drugs were helpful and not harmful.
“I knew about PrEP from my friend who is a peer educator. She told me about PrEP and I was happy with what I heard, so I felt I should also try [it] as I considered [that] I was at high risk of being infected.”
—Millicent, project participant
Identifying or creating safe spaces—environments where they feel more comfortable— also gives girls and young women an opportunity to interact with the service providers and seek more information before starting oral PrEP. LVCT Health is implementing the PEPFAR-led DREAMS Initiative at a site outside of Homa Bay, using safe spaces to reach girls with oral PrEP.
“Safe spaces are accessible to the girls themselves. They are nearer to their homes. So it is the service provider going to seek or call out the girl to take up PrEP. And a safe space is not a clinic, a safe space is somewhere they can relax. A place they can unwind, and in the process of unwinding they are told about PrEP.”
—Matilda Abwok, LVCT Health researcher
As Kenya and other countries in sub Saharan Africa continue to approve and scale up oral PrEP, program’s that plan for robust yet flexible strategies for engaging communities will see far greater success when it’s time to ‘get people into the door’ for oral PrEP uptake. IPCP learnt that different communities prefer different strategies and to make oral PrEP a success these strategies have to be employed. The service providers should also be willing to support the users through the initial phases of the journey of initiation into oral PrEP.
There’s no question that a simple regimen of a single daily pill can slash HIV infections in people at risk. But although millions of people around the world could benefit, only 200,000 are prescribed PrEP, and 75 percent of them are in the United States. The disparity was the focus of anguished discussions this week at the largest annual US HIV/AIDS conference.
The Center for AIDS Research at Emory University's Rollins School of Public Health produces interactive online maps with visualized data on different aspects of the US HIV epidemic, and its prevention and treatment response, at AIDSVu.org. This set of maps and statistics focuses on PrEP use nationally and by state from 2012-2016.
The International Treatment Preparedness Coalition (ITPC) has released the Key Population Activist Toolkit on PrEP, developed to equip community activists to demand pre-exposure prophylaxis (PrEP). The toolkit includes step by step guidance for activists to develop an advocacy agenda to bring effective PrEP programs to their communities.