By Priyanka Rajendram (MSc Public Health Candidate)
The International Women’s Day, currently celebrated in many countries around the world on the 8th March, first emerged at the end of the nineteenth century in North America and Europe. Currently there is a strong global momentum striving for gender parity, with global activism for women’s equality, fuelled by movements like #MeToo and #TimesUp.
To celebrate the date, we spoke to Mitzy Gafos, Associate Professor at LSHTM, about HIV amongst women, the STRIVE study and challenges that women face in adhering to PrEP. Mitzy is Co-Research Director of STRIVE, an international research consortium dedicated to studying the structural drivers of HIV, including gender inequalities, stigma and criminalization, lack of livelihood options and alcohol use and harmful drinking norms.
Could you explain what STRIVE is?
STRIVE is a research consortium funded by the UK government to tackle the structural drivers of HIV. STRIVE is led by LSHTM in the UK and works with partners in South Africa, Tanzania, India, and USA. The consortium aims to describe the ways in which structural drivers increase vulnerability to HIV and evaluate interventions to address structural drivers of HIV. A core part of our research is to evaluate the ways in which structural factors, including gender inequality, stigma and gender based violence (GBV), impact on the uptake and sustained use of biomedical HIV prevention and treatment. As such, STRIVE partners in South Africa and Tanzania are conducting the EMPOWER trial to assess whether it is feasible, acceptable and safe to offer oral pre-exposure prophylaxis (PrEP) as part of a combination HIV prevention package that addresses GBV, stigma and HIV in adolescent girls and young women aged 16-24 years. Results of the study will be released later this year.
What PrEP is and how does it work?
PrEP stands for pre-exposure prophylaxis. The currently available form of PrEP is a combination of two anti-retroviral drugs (tenofovir disoproxil fumarate (TDF) and emtricitabine (FTC)) which have been used in HIV treatment for many years. When taken regularly by HIV negative individuals, PrEP prevents the virus from being able to replicate in the cells and prevents HIV infection.
PrEP is as effective for both cis and trans women as it is for men. However, we know that more drug is needed to ensure sufficient protection in vaginal tissue than is needed in rectal tissue. As such, the prescribing of PrEP is different for women and men.
Women (cis and trans): need to take PrEP for 7 days before they are protected from HIV. They then need to take it daily to maintain sufficient levels of protection. This is true for both cis and trans women having vaginal sex.
Men who have sex with women (cis and trans): need to take PrEP for 7 days before they are protected from HIV. They then need to take it daily to maintain sufficient levels of protection.
Men who have sex with men (cis and trans): need to take a double dose of PrEP between 2 to 24 hours before sex, followed by a third dose 24 hours later and a fourth 48 hours later. This is called ‘event-based dosing’. However, some MSM at regular risk of HIV choose to take PrEP daily. This dosing option is also considered to be effective for trans women whose main route of exposure is through receptive anal sex.
An important advantage of PrEP for both women and men, is that people can take PrEP only during times in their lives when they think they may be at increased risk of HIV – there is no need to take it forever.
How effective is PrEP?
When taken as prescribed, PrEP reduces the risk of getting HIV from sex by between 92% to 99%. While PrEP is as effective as condoms at preventing HIV, it does not reduce the risk of other STIs or pregnancy. Among people who inject drugs, PrEP reduces the risk by more than 70%. However, we already know that clean needles are the best way to prevent HIV among injecting drug users and should be available to people who need them.
Have all the PrEP trial results been consistent?
There have been seven randomised placebo controlled trials of oral PrEP and one deferred start randomised controlled trial – obviously the RCT design is considered the gold standard for evaluating the benefit of a new drug. Three of the trials enrolled men who have sex with men and trans women having anal sex with men. Another three trials enrolled heterosexual women and men. All six of these trials reported high levels of effectiveness.
However, two other trials which only enrolled heterosexual women did not show any effect of offering PrEP. The results were explained by the very low levels of adherence with less than a third of women taking PrEP regularly. These trials highlighted the structural and social challenges that women face in adhering to PrEP. A number of trials and demonstration studies are ongoing, such as EMPOWER, to find ways to support women overcome these challenges and be able to adhere to PrEP during periods when they are at risk of HIV.
What were the main reasons for low adherence of women?
The reasons for low adherence were often complex but they included women not being motivated to use an unproven or placebo product, low levels of perceived risk among women joining trials primarily for the additional health care benefits available, or lack of trust in researchers. Other reasons have implications for PrEP use beyond clinical trial settings as some women found adherence challenging in shared households or in the context of insecure living arrangements, or because of lack of partner support or even knowledge of their PrEP use, or even a lack of parental support especially for young women, or due to stigma associated to ARV products and the use of prevention products thereby inferring sexual risk taking. We also know that gender norms, the dynamics of transaction sex, alcohol use, and the risk of intimate partner violence can all serve as barriers to the uptake and adherence to a range of sexual and reproductive health products and services. There is no doubt that any PrEP delivery programme has to attend to the structural barriers that women face in their every day lives.
Is PrEP available for women in the UK?
Yes, it is available in GUM clinics via the IMPACT trial and women can find out more at the study website: https://www.prepimpacttrial.org.uk/join-the-trial
Before joining STRIVE, I led the social science component of the PROUD study which evaluated the offer of PrEP to MSM and trans women in England. Now, Public Health England and the St Stephens AIDS trust are running the IMPACT PrEP trial which has expanded the offer of PrEP to all people at risk regardless of gender or sexuality. The trial will enrol 10,000 people over the next three years in GUM clinics across England.
The community advisory board advocated for at least 1,000 places to be reserved for heterosexual women and men (cis and trans) as awareness about PrEP is still limited in these groups. As such, community organisations are working hard to raise awareness about PrEP especially among women who are at risk of HIV in England. So far, very few cis and trans women have joined the trial but we think this is because they just don’t know enough about PrEP.
PrEP is licensed and available on the NHS in Scotland and there is a separate trial ongoing in Wales.
Is PrEP available in other countries?
Yes, PrEP is available is almost 30 countries globally. PrEP was first licenced in the USA in 2012 and the latest data suggests that over 120,000 people are using PrEP, although less than 15% are women. In many countries, such as South Africa and Kenya, there are concerted efforts to offer PrEP to women most at risk of HIV.
Are there health promotion activities to raise awareness among women in England?
United4PrEP is a collaboration of community based organisations, clinicians, researchers and other interested individuals, who work together to raise awareness about PrEP. A number of organisations have developed specific information for cis and trans women – these include the Sophia Forum, cliniQ (a trans health service), prepster and iwantprepnow. I have listed their websites below.
In addition, a number of community based organisations are offering training on PrEP to health and social care providers who deliver services to women who may be at risk of HIV. While the IMPACT trial is only enrolling participants in GUM clinics, it is important that staff in other sexual and reproductive health, mental health, addiction and social care services, are aware of PrEP and can sign post women who may benefit from PrEP to the IMPACT trial. We are looking for any opportunities to raise awareness about PrEP among women.
Mitzy Gafos and myself are currently collaborating to raise awareness about PrEP among women and the existence of the trial, through an online entertainment-education drama. If you would like to learn more about our collaborative work please e-mail me at: Priyanka.firstname.lastname@example.org.
You can find out more about PrEP in the below websites: