South Africa: Stigma, domestic violence hampering lifesaving PrEP

Pilot PrEP projects have been underway in some African countries for several years. But it was only in the late 2017 that some countries – notably Kenya and South Africa, as well as eSwatini started serious PrEP availability programmes for wider populations.

In South Africa, roughly 25 000 to 30 000 people have started taking PrEP; Kenya has initiated PrEP in about 25,000 people; Zimbabwe in about 5 000 and the 2 250 in eSwatini who have been assessed for PrEP will, if all of them start it, be about three times the number per head of population compared with the much larger Kenya.

Truvada for PrEP provides 92%-99% reduction in HIV risk for HIV-negative individuals who take the pills everyday as directed. If a daily dose is missed, the level of HIV protection may decrease. For people who have taken seven PrEP pills per week, their estimated level of protection is 99%.

Despite these encouraging statistics, fewer women are taking PrEP, while those who initiate are likely to abandon this life-saving programme.

The most common reasons given for not taking PrEP were the perception that one was at high risk of HIV.

A study among women and men of all ages in Zimbabwe also found that women felt that they needed to consult with their partners first.

This project, sponsored by the Clinton HIV and Aids Initiative, offered PrEP at two pilot HIV testing centres, in a Family Planning Council clinic in the capital, Harare and the other in a youth centre in Chimanimani, a rural district near the Mozambican border.

These centres offered PrEP to every person taking an HIV test there (the Harare centre performs 300 a month and there are 175 a month at the Chimanimani centre), but only got a very small proportion agreeing to try it. Between January and May this year, 151 out of 3158 people started PrEP (4.8%: it was 9% at Chimanimani and 2.7% in Harare).

According to researchers, one woman aged 20 said: “What made me decline PrEP is that my husband would accuse me of having another sexual partner while he is away. So I think it is best for me to ask for the permission to take PrEP and if he agrees, then I will come.”

Other reasons for declining PrEP were that people were happy with condoms and were afraid of side-effects. However, as in the Kenyan study, PrEP was seized on by those with the highest risk indicators, such as women in abusive relationships: “I will take PrEP for life because I can no longer be infected by HIV. To add on, my husband was cruel as he could tear the condoms sometimes and he could pretend as if it had burst. I was really happy that I now have a backup,” said one such woman.

Or another whose husband’s unfaithfulness had resulted in her being infected with STIs: “I saw a lot of messages from different girls on my husband’s phone and I spoke to him about it, but I was surprised to be diagnosed of an STI twice, so I realised that I was talking to myself. I, therefore, decided to take PrEP.”

In short people, including young women, will take PrEP if they are in situations of imminent risk, especially if they feel they have no control over that risk.

A second factor was that the most frequent reason given for not continuing with PrEP was the experience of side-effects during the first month. 

Diantha Pillay of South Africa’s Wits Reproductive Health and HIV Institute presented in-depth qualitative findings from Female Sex Workers (FSW) and Men who have Sex with Men (MSM) who took PrEP up till June 2017 at nine of the 16 PrEP implementation sites that were open at the time.

Among these past users, 83% said side-effects had affected their daily lives and even among current users, 59% said they had experienced them and 31% said they affected their daily lives.

Real side-effects reinforced and imaginary ones might be induced by community beliefs about PrEP, such as it causing impotence or sterility or being a population-control measure.

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