The more recent article, published by Sinead Delany-Moretlwe
and colleagues in Current Opinion in HIV
& AIDS, draws on some of the more recent history, especially in lower
and middle income countries.
They note that increasing choice by introducing new
contraceptive products has been seen as key to increasing the use of
contraception. In places where a wide range of delivery systems are available,
both short-acting (e.g. pills and diaphragms) and long-acting (e.g. implants
and injections), usage tends to be higher.
This suggests that adding PrEP to the range of HIV prevention
options that are already available will increase the number of people who are
protected in some way from HIV. Moreover, the option of non-daily dosing of
PrEP, and the possible future development of PrEP as a long-acting injection or
a vaginal ring, would increase usage.
Despite such innovations, adherence may remain imperfect. Even among women using contraceptive injections, discontinuation
rates are high, users often switch between methods and are frequently late for
their next injection. In some cases, this is due to failings in health services.
For example services may be difficult or costly to access, or staff may not
have warned users about the potential for side-effects.
Delany-Moretlwe warns that if health services are unable or
unwilling to deliver new health technologies with good quality care then the
potential of the new products may not be realised. “Too often, the focus on
product development leads to a focus on a single technology, and not on
investing in the larger programmatic and policy initiatives that are essential
to product uptake and use,” she says.
The first-generation of oral PrEP products have complex
requirements, including monitoring for side-effects and drug resistance. While
this may suggest delivery by providers with experience of antiretrovirals, they
may not reach those needing PrEP.
“The channels through which products reach users are
important for ensuring access,” the authors say. Programmes which attempt to
integrate PrEP into existing HIV prevention programmes or health services –
such as reproductive health services for women – will need to be carefully
evaluated. The experience with contraception shows that institutional changes
to health services are difficult to achieve and to maintain, for example when
the results from pilot projects are transferred to larger settings.
In contraception, medical barriers to access have been
removed as increasing evidence of safety has emerged. Products may be available
over the counter or through community-based distribution agents. Although this
expanded access has occasionally been at the cost of lower-quality provision
and monitoring, similar efforts will need to be made for PrEP. “All possible mechanisms
for providing access to PrEP will need to be explored to ensure that PrEP is
accessible to those with the greatest need,” Delany-Moretlwe argues.
Both contraception and PrEP draw attention to the broader
social, economic, and political context in which sexual relationships occur. Although
they both have the potential to be empowering technologies, uptake may be
limited where gender inequalities are strong. Adolescents may be
prevented from accessing contraception by official policies or due to
healthcare providers’ personal views about young people’s sexual activity. Marginalised
‘key populations’ such as sex workers and men who have sex with men may have
particular barriers to accessing health services.
But the authors say that if PrEP is primarily offered to
specific groups, such as sex workers, then this risks undermining wider
acceptance of the product. This has sometimes occurred with female condoms, but
has in other countries been avoided by providing female condoms in family
planning clinics. If PrEP is to be successfully introduced, the needs and views
of all users will need to be carefully considered.
The authors warn against expectations that PrEP will be an
overnight success. Several different contraceptive methods have taken decades
to be widely used, showing that slow initial uptake of a product should not be
interpreted as a fundamental problem with acceptability. Products which require different
practices from users, communities or healthcare providers may take some time to
get off the ground.