So-called key populations – sex workers and their clients, gay men and other men who have sex with men, people who inject drugs, transgender people and their sexual partners – accounted for 70% of new HIV infections globally in 2021, according to UNAids.

As became clear at the recent Aids 2022 conference in Montreal, Canada, helping people in these groups to stay HIV-free has become an area of particular interest in the global HIV response.

One way to prevent new HIV infections in key populations and other groups is for people who are not living with HIV to take antiretroviral medicines to prevent infection. Such pre-exposure prophylaxis (PrEP) can come in the form of pills, a vaginal ring, or an injection administered every two months. The pills (oral PrEP) are already available in South Africa’s public sector, the ring has been approved by the South African Health Products Regulatory Authority but is not yet available in the public sector, and the injection is yet to be approved.

Oral PrEP is estimated to be more than 99% effective when taken as prescribed. In reality, people can’t always take them as prescribed, which can result in lower protection. This problem can, to some extent, be addressed by the injection that protects people for two months.

Having prevention products that work, however, is only part of the solution. Making people aware of the products and making it easy for them to access and use them presents more challenges, particularly for marginalised groups such as sex workers or transgender people.

Oral PrEP at 68% of facilities

South Africa’s initial roll-out of oral PrEP focused exclusively on key populations such as sex workers. It is only over the past two years that it has become more widely available at public-sector facilities. The extent to which programmes focusing on key populations will be maintained amid this broader roll-out is still unclear. 

By April 2022, oral PrEP was available at 2,359 (just over 68%) of the 3,456 primary healthcare facilities in the country, says Health Department spokesperson Foster Mohale: “The department aimed to have all PHC facilities offering oral PrEP, [but] due to the challenges faced during the Covid-19 pandemic, the scale-up to all primary healthcare facilities progressed slower than expected.”

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Mohale says that from July 2016 to April 2022, more than 560,000 people in South Africa were started on oral PrEP. Most were in KwaZulu-Natal (more than 195,000), followed by Gauteng (more than 136,000) and Mpumalanga (just more than 83,000).

Differentiated prevention

Professor Linda-Gail Bekker, director of the Desmond Tutu HIV Foundation who chaired one of the sessions at the Aids conference, tells Spotlight they now believe prevention should be differentiated in its delivery. 

“A bit like we have been doing for treatment. That means tailoring it to the population.” For example, people who use and inject drugs would need harm reduction and PrEP, men who have sex with men might need sexually transmitted infection screening, lube and PrEP, while young women and adolescent girls might need sexual and reproductive health rights support and PrEP.

The current one-size-fits-all delivery of PrEP is not working, says Bekker. “Where and when we offer the services may also be determined by the population we are hoping to reach. We know adolescents don’t always come to our services – can we go out to them? We want more people to adopt prevention and use it. It’s going to need to be more tailored to their lifestyles and where they are at.”

Dr Jenny Coetzee, principal researcher in the Perinatal HIV Research Unit at the University of the Witwatersrand, agrees that no one-size-fits-all method is going to work for HIV prevention. “Globally it appears to me that we have not made the kinds of inroads on PrEP roll-out that we would ideally like to see. 

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“We are many decades into this epidemic and we are still offering many of the same interventions, wondering why they are not effective. We cannot continue to make women responsible for decisions their male partners make in terms of sexual behaviours or condom use.

“Likewise, we also need to start considering changes in behaviours that will bring new populations into the risk space. For example, there is the increase in anal sex among cis-females that will see their risk profile change. I’m yet to hear this being discussed, or a really meaningful understanding of male clients of sex workers, and we are only now starting to acknowledge that we have feminised the epidemic in Africa. So, there are challenges and constantly new data,” she says.

Engage the community

Coetzee says the big thing when it comes to packaging PrEP for key populations is meaningful community engagement. “Sex workers or LGBTI+ need to be actively involved throughout the process of bringing HIV prevention packages into any country. They know what their needs are, what their priorities as human beings are, and they will be able to provide a strong foundation upon which an intervention can be tailored that, while being geared to HIV prevention, is underpinned by and supports community priorities,” she says. 

Community members could be included as researchers, data collectors, interviewers or counsellors. “Include them on boards or in workshops and privilege their voices by ensuring they are given the time to speak, and that their intimate knowledge of their community is really considered. Allow them to suggest what interventions should look like, and tailor your interventions to community suggestions,” she says. 

Bekker says some peer-led programmes in South East Asia have been amazing – using people from the particular population group. “For example, transgender women mobilising and administering PrEP to other transgender women. PrEP being offered to commercial sex workers at a time and venue that suits their working hours and also linking these to other social services that the sex worker may need for their well-being.”

According to Eugene van Rooyen, the Western Cape area manager at Sweat, programmes implemented through dedicated facilities for gay men or other key populations are successful because they are mainly staffed by members of the group the facility is aiming to reach. “This automatically results in a welcoming and understanding environment without stigma or discrimination.”

Van Rooyen argues that HIV-related services should be integrated into the normal services provided to the general population at community health facilities, since the separation of key populations and HIV services promotes further marginalisation and stigmatisation. “It would be preferable to employ members of key populations to act as ‘navigators’ and promoters who can facilitate access to services and provide information at health facilities.”

Special vs general provision

Coetzee says South Africa’s PrEP programme is enabling people to cycle on and off PrEP based on their risk perception. “So, when you are engaging in high-risk activities, then you are on PrEP. These programmes are having some success. But they require very specialised support, marketing and implementation. This means they need to be positioned within verticalised programmes. It will be challenging to move PrEP into the general population outside of specialist programmes.

“One of the biggest errors made in the initial PrEP roll-out was the announcement that it was for sex workers. So, the potential backlash was big and made it hard to get sex workers to initiate PrEP for fear of violent discrimination by partners.”

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South Africa’s shift from a key population-first model of PrEP access to general availability at all or most clinics seems to be widely supported, but with reservations.

Coetzee thinks the shift is a nice idea but not practical. “The roll-out of PrEP has required specialists and a huge investment of time and effort to make it work in the country. I am not convinced that we have the infrastructure or resources to add PrEP to the package for the general population without a lot more care and consideration for how this will be achieved.”

We need to be realistic about what we can and cannot do, she says. 

“I think more focused approaches are likely to yield a better uptake. That said, anyone who wants to take PrEP should be able to do so without having to identify as belonging to a specific subpopulation. It’s complicated.”

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Bekker tells Spotlight that “we hope that by offering PrEP to all and anyone who may feel they have a risk of HIV exposure, we will be able to offer protection to more individuals and reduce HIV transmission more broadly”. 

“But this shouldn’t mean that we don’t at the same time try to bring differentiated prevention services that are tailored to people’s needs.” DM/MC

This article was published by Spotlight – health journalism in the public interest.