TODD MALONE: Why we need to put choice at the centre of HIV prevention

I recently returned from the 24th International Aids Conference in Montreal, Canada, and I’ve been reflecting on the plethora of ideas and innovations discussed during the thought-provoking and energising sessions. I left the conference with renewed optimism that we can end HIV in our lifetime.  

One of the topics that particularly got me thinking is the issue of choice — how do we create an environment where people have the right mix of options to enable the right health-seeking behaviour for themselves? I was inspired by a session where Annah Sango, advocacy officer at the Global Network of People Living with HIV, shared recent innovations and research around new treatments that give people wider prevention options. Previously the primary prevention options were condoms or daily pre-exposure prophylaxis (PrEP) in pill form. This is finally starting to change.  

First, long-lasting injectable PrEP (taken initially as two injections one month apart and then after every two months afterwards) is becoming available in many countries for HIV prevention. It’s not yet available in SA, but is an exciting prospect. The second innovation is a vaginal ring, also a form of PrEP, which lasts 28 days. The PrEP ring has been approved by the SA Health Products Regulatory Authority (Sahpra) and is likely to be made available in public and private health facilities soon.  

The Aids Vaccine Advocacy Coalition, which monitors PrEP rollouts around the world via PrEP Watch, reports that three projects to launch PrEP rings and five projects to launch injectable PrEP are under way in SA. It’s exciting to hear that Sahpra is reviewing new long-lasting HIV preventions. The more options available the more likely it is that each person finds the right prevention method for their situation, ensuring more opportunities for positive health seeking behaviour. 

Different needs

It should go without saying, but is still important to highlight, that people have different needs based on their social and medical considerations. This is why differentiated service delivery in public healthcare is so important. We don’t talk about this enough, but it’s vital to serve everyone effectively.  

We already see customised options for women being used effectively with birth control. We can see from the data that women are receptive to being given choices that work for them and their bodies — whether it be the pill, injections or insertable intrauterine devices (IUDs). These options are available in public clinics in SA, and this differentiated model of care is already making a positive impact on millions of women’s lives.  

PrEP in daily pill form (oral PrEP) has been available for a few years to effectively reduce people’s chances of contracting HIV from unprotected sex or injection drug use, and according to the department of health, oral PrEP is available at 68% of state facilities. Oral PrEP is great, but we know from lessons learnt from family planning and other public health focus areas that daily pills aren’t always the best option for every patient.

We must move away from putting people in boxes. We can’t assume the same approaches will work for everyone, from adolescent girls and young women to “key populations” (the incredibly diverse grouping, including transgender people, sex workers and their clients, men who have sex with men, people who inject drugs, and people in prisons). People have individual needs based on their life circumstances, personal preferences, work schedules, access to transport, bodily autonomy and far more. 

We know, for instance, that some sex workers prefer not to have injections that could cause bruising, while some adolescent girls feel they need to hide their daily contraception or PrEP pills from parents and caregivers. This means a monthly injectable may or may not be the best option for everyone.  

There are drawbacks to providing a wider range of choices: different options come with different costs and different implications for delivery. For instance, injectable PrEP is about 20% more expensive than oral PrEP, according to researchers from the University of the Witwatersrand, who presented their findings at Aids 2022. Certainly, offering these choices will demand operational changes in our public health systems, yet I believe they will also improve the health outcomes.

For now we need to be cognisant of the existing barriers to HIV prevention and develop and expand differentiated models of care to give people choice, as this is the best way to reach everyone effectively. 

• Malone is MD of Cape Town-based international healthtech company BroadReach Health Development.