It is feasible to offer pre-exposure prophylaxis (PrEP) as part of community-wide HIV testing campaigns in East Africa, with a fifth of adults who were identified as eligible for PrEP starting it within 30 days, researchers from the SEARCH collaboration report in Clinical Infectious Diseases. Early adopters were more likely to be male, older, in a serodiscordant relationship or in a polygamous marriage.
The authors suggest that understanding the characteristics of early adopters is important – they may be opinion leaders and PrEP champions who could promote further uptake in their communities.
At the same time, identifying people less likely to start PrEP is critical to developing programmes to support them. The researchers found that fewer than a third of community members identified as being at higher risk of acquiring HIV made the same assessment of their risk. Just one in ten of this group took up the offer of PrEP within 30 days.
Until now, there have been very little data from African countries on the uptake of PrEP outside of clinical trials. Moreover, studies have tended to concentrate on targeted populations, such as serodiscordant couples or sex workers.
SEARCH is a large study of a test-and-treat approach in Kenya and Uganda. In rural communities, health campaigns offer testing for HIV, diabetes and hypertension, with linkage to care and antiretroviral therapy for anyone who needs it.
Based on data on new HIV infections in the first two years of SEARCH, the researchers developed a risk score that can identify at least half of people in these communities who will go on to acquire HIV. It is based on demographic data that are easy to collect, with no need to ask questions about sexual behaviour or to test for sexually transmitted infections. The risk score includes age, sex, marital status, polygamy, education, circumcision, occupation, and alcohol use.
In 2016, a PrEP intervention was added in five of the communities taking part in SEARCH. One month of community mobilisation activities on PrEP – including meetings with health workers, religious leaders, young people and workers in the fishing and transport sectors – preceded the testing campaign. Counsellors gave information about PrEP and engaged participants in discussions about their risk of acquiring HIV, as part of the HIV testing process.
For individuals who were assessed as being at higher risk by the risk score, counsellors explained, “From what we have learned from your community, and what you shared at the beginning of the campaign, we think that you would benefit from taking PrEP.” In addition, any individual who decided for themselves that they might benefit from PrEP was offered it, in line with World Health Organization guidance, which recommends offering PrEP to those who request it in the context of a generalised epidemic.
Most people were tested as part of the health campaign at community sites. Individuals who did not come forward for testing were then approached at home, with a further opportunity for testing there. In four of the five communities, a same-day PrEP start was possible at the community testing site (but not at home). Transport was also offered to PrEP clinics, usually on the same day. Read more via AIDSmap