Q&A with Saiqa Mullick, Director of Implementation Science at Wits RHI

Contributed by Neeraja Bhavaraju and Daniela Uribe from FSG, a member of the OPTIONS Consortium.

Dr. Saiqa Mullick Dr. Saiqa Mullick is on the frontlines of PrEP introduction in South Africa. In her role as the Director of Implementation Science at Wits RHI and Deputy Director of the OPTIONS Consortium, Dr. Mullick has been deeply involved in the emergent strategy to bring PrEP to South Africans as an effective and game-changing prevention option. In the conversation below, she outlines the key catalysts, challenges, and remaining questions in the continued effort to make PrEP widely available and effectively used.

What factors have accelerated or supported the progress made with PrEP in South Africa?

Dr. Mullick: The first is the release of the WHO guidelines in September 2015. I think the second has been the political leadership. The National Department of Health (NDoH) called the first meeting of the technical working group (TWG) to consider how South Africa was going to move forward on PrEP weeks after the WHO guidance was released. That has been a very critical factor. The third thing is the wealth of expertise available in the country. The TWG was formed to bring together a number of partners with varying expertise in terms of reaching and providing services to key populations, those who were engaged with research and demonstration projects on PrEP and those with experience with monitoring and evaluation, training, and other areas of expertise that would be valuable in terms of developing the guidelines moving forward. The other issue that has been catalytic has been having flexible support available to the NDoH because there has been a need to adapt the approach and learn as we go along. Needs have evolved, so I think it’s important to have partners who are able to respond to those needs and support the department in its plan and its activities rolling out PrEP in the country.

Another lesson leaned has been the value of coordinating the various stakeholders that have been engaged in the PrEP demonstration projects. One of the key tools that has been developed is a PrEP demonstration project landscape, which shows things like timelines for the studies, the kinds of service delivery platforms that are being tested, the eligibility criteria, and other factors. This has been a really important tool not only to show which questions are being answered by whom, but also to identify key gaps in the existing projects that will help us to think about an implementation science agenda moving forward. We have been able to highlight a couple of areas where none of the demonstration projects are going to be answering questions and have been able to prioritize additional implementation science research to address those gaps.

What has been the most valuable lesson learned to-date?

Dr. Mullick: There have been a number of really valuable lessons that we have learned through this process. One has been the unpredictability of the timeline, and, related to that, having the TWG as a coordination mechanism able to draw on various partners with different expertise in order to support the NDoH to quickly rollout PrEP for sex workers. I think the other lesson learned is the need to be flexible and adaptable to the needs in the country. That is really a critical factor and sometimes as much as we plan things, we have to respond very quickly and do things and then learn as we do rather than getting everything perfect upfront.

Finally, understanding what expertise different partners bring to the table and being able to coordinate and allow different partners to bring their expertise so that we can catalyze implementation but also catalyze learning from the various demonstration projects and other experience that partners bring.

What have been the major challenges?

Dr. Mullick: One of the strengths is that there are many partners working with the NDoH on learning more about how to roll out PrEP and on implementation of services for populations at significant risk. But I think that having many partners brings a challenge of coordination. How do we make sure that we are collectively going in the right direction, learning from each other’s work, and that we are leveraging resources to make sure that we have the ability to address needs as we move forward with the NDoH? The other challenge is that we are in an environment where there are budget constraints and other competing priorities. The government is also trying to rollout Universal Test and Treat, there is currently a national campaign that has been launched targeting HIV prevention care and treatment for AGYW as well as other aspects around education, reducing teen pregnancy rates, sexual and gender based violence, and unemployment, so there are big needs and competing needs, with the NDOH also rolling out PrEP and learning how best to roll out PrEP to AGYW.

How have the discussions around PrEP evolved in the last 6-12 months?

Dr. Mullick: The discussions around PrEP have evolved since the release of the WHO guidelines. The initial issue was how to interpret the 2-3 percent incidence of HIV amongst populations considered at “significant risk” and how to reach those populations. Initially, the TWG was thinking of a broader range of key populations which were going to potentially access PrEP. However, over time with the launch of the National Sex Worker rollout plan, it was decided that PrEP should first be made available to sex workers as a population at significantly higher risk of HIV.

We’ve learned a lot, but we also need to learn some more. What would you see are the biggest questions that still remain?

Dr. Mullick: The biggest questions that remain are in a couple of categories. One is that we are very early in terms of our rollout and so there are a set of questions around monitoring and evaluating and learning from the experience of rollout in the sex worker population, which is a specific high-risk population.

The second large question remains around how best to identify adolescent girls and young women at highest risk and how to provide PrEP to these populations at highest risk. We have a number of PrEP demonstration projects that are currently going on in the country, many of those are at quite early stages, and so there is a challenge around being able to learn from those projects as they implement PrEP. Questions also remain around how to create demand around PrEP, how to encourage uptake for those who really need PrEP and how to support adherence.

There are additional questions around providing PrEP to pregnant women and providing PrEP to younger adolescent girls. Many of the trials have not included very young adolescent girls so we still have some questions around how to best provide PrEP to younger adolescents. The final question is around how we are going to get the resources to be able to support the rollout of services for adolescent girls and young women. I think we still have a long way to go in terms of answering some of these questions.