Awareness and Acceptability of PrEP Among Men Who Have Sex with Men in Kazakhstan

Oral pre-exposure prophylaxis (PrEP) is an antiretroviral method of HIV prevention recommended to men who have sex with men (MSM) at high risk of infection. In Kazakhstan, which has one of the fastest growing HIV epidemics globally, PrEP is not currently available. The aim of this study is to explore the possibilities for PrEP initiatives in Kazakhstan by investigating awareness and acceptability of this prevention method among MSM. This mixedmethods study employs an online survey and qualitative interviews to describe PrEP awareness and acceptability. Less than half (39.8%) of survey participants had heard of PrEP.

However, a majority (85.2%) of MSM would possibly or defi nitely use PrEP if it was available. Awareness of PrEP was positively associated with willingness to use PrEP. The main reason to be interested in PrEP was an increased feeling of protection, whereas barriers were related to the idea of taking daily medication and the potential for side effects. PrEP is an essential component of HIV combination prevention. Our findings suggest potential for PrEP programmes among MSM in Kazakhstan and possibly in other Central Asian nations, when taking into account burdens of taking PrEP as well as more structural health policy issues.

Read more of the study here.

AFEW’s Intern Researches PrEP in Kazakhstan

Is Kazakhstan prepared for pre-exposure prophylaxis (PrEP)? Master student majoring in International Public Health at VU University in Amsterdam Marieke Bak was finding the answer to this question during her recent internship with AFEW International. For this reason, she spent five months in Almaty, Kazakhstan, doing her research.

“For the past five months, I have had the opportunity to do an internship at AFEW International,” says Marieke. “From the start, I felt very welcome in this inspiring organisation and it was great to experience what it is like to work for an NGO. As part of my internship, I went to Kazakhstan to explore the potential implementation of a new HIV prevention method among men who have sex with men. The interviews were incredibly interesting and I learned a lot from the people I met. Moreover, I had the opportunity to do some travelling, which made me fall in love with the region. I hope to go back there someday and I will keep following the work of AFEW with much interest.”

The global HIV/AIDS epidemic remains a major public health issue. Among the countries with the fastest accelerating incidence rates is Kazakhstan, which is characterised by a concentrated epidemic among key populations. Addressing the epidemic requires effective primary prevention, but current methods are often of limited use. PrEP is a new method of HIV prevention consisting of a daily pill combining two anti-retroviral drugs, which has been found very effective when taken consistently. Generally, men who have sex with men (MSM) are seen as the target group for PrEP. As the most developed country in Central Asia, it seems that Kazakhstan could act as a frontrunner in providing PrEP. However, in order to inform the implementation of PrEP, there is a need to understand the awareness and attitudes of MSM towards this new method.

The aim of Marieke Bak’s study was to explore the possibilities for future PrEP initiatives in Kazakhstan by investigating the potential of this prevention method among men who have sex with men. You can find the report on the study findings here.

PrEP: effective and empowering

Author: Marieke Bak

Pre-exposure prophylaxis (PrEP) is a new HIV prevention method that consists of a daily pill taken by HIV-negative people to reduce their risk of becoming infected with HIV. PrEP is highly effective in preventing HIV transmission, as scientific research shows. A large international study among gay men and transgender women, the so-called iPrEx trial suggested that PrEP can reduce the risk of HIV infection by at least 92% when the pills are taken consistently. PrEP is also effective when used by heterosexual men and women, as well as by people who inject drugs.

Although PrEP is more expensive than other HIV prevention methods, it can be a cost-effective tool, especially when delivered to people at high risk of HIV. By preventing the costs of lifetime HIV treatment, PrEP may even lead to healthcare savings, especially when the drug patents expire and the cost drops.

Moreover, PrEP is the first method of HIV prevention that is directly under the control of the at-risk individual. This is in contrast with treatment as prevention (TasP), which is dependent upon partners’ HIV treatment adherence to ensure suppressed viral load. Besides, because PrEP separates the act of prevention from the sexual encounter, it can be used without sexual partners knowing and provides additional protection when condoms are not used consistently.

The World Health Organization now recommends that PrEP should be offered as a choice to key populations affected by HIV as well as to anyone else at substantial risk of HIV infection.

TRANSFORMING HIV INFECTION

PrEP is a pill consisting of anti-retroviral drugs that needs to be taken every day in order to be effective. Currently, the only drug approved for use as PrEP is sold by Gilead Sciences and is called Truvada, which consists of a combination of tenofovir and emtricitabine (TDF/FTC). Truvada was first approved for prevention in 2012 in the United States of America.

In contrast to PEP, or post-exposure prophylaxis, PrEP is taken before exposure to HIV to prevent any possible transmission. PrEP works by blocking an enzyme called HIV reverse transcriptase, thereby preventing HIV from establishing itself in the body. While PEP can be thought of as a “morning-after pill” for HIV prevention, PrEP can be compared to the contraceptive pill that is taken every day. Similarly, PrEP may transform HIV infection just like the pill transformed family planning.

The most common side effects of Truvada for PrEP are nausea, vomiting, dizziness, headache and fatigue, although these symptoms usually resolve within a few weeks. Some people in trials also experienced small changes in kidney function or a decrease in bone mineral density. An updated version of Truvada was created that contains a new form of tenofovir, which is thought to be safer for bones and kidneys. At the moment, the so-called “Discover study”, is being set up in North America and Europe to investigate the new PrEP medicine called Descovy.

By the way, PrEP does not protect from sexually transmitted diseases (STDs). Fears that PrEP might be used as a “party drug” exist. However, in the iPrEx study as well as in a meta-analysis by the World Health Organisation, it was shown that PrEP does not lead to an increase in the number of STDs and has no effect on condom use. Rather, PrEP reduces the fear and anxiety that often comes with sexual activity for those at high risk of HIV.

However, because PrEP is not 100% effective and because it does not protect from STDs, it should not be used as a standalone prevention method. According to WHO guidance, PrEP should be offered as part of so-called “combination prevention” which includes the use of condoms as well as regular follow-ups and HIV testing.

PREP IN EASTERN EUROPE AND CENTRAL ASIA

Despite the recommendation to offer PrEP to people at high risk of HIV infection, the global availability of PrEP remains limited. The PrEP target set by UNAIDS in their strategy on ending the HIV pandemic is to get three million people on PrEP by 2020. However, only 2% of this target had been reached in June 2016.

At the moment, Truvada for PrEP has been approved in the United States, Canada, Australia, Peru, South Africa, Kenya, Zimbabwe, Israel, and the European Union. Approval is pending in Brazil and Thailand. In the European Union, PrEP has been approved by the European Medicines Agency (EMA) although the implementation of PrEP programmes is the responsibility of each member state separately. To date, only France and Norway have made PrEP available as part of their healthcare system. Scotland recently announced that it will do the same.

In Eastern Europe and Central Asia (EECA), PrEP is not available yet. However, demonstration projects are currently being set up in Georgia, Ukraine and Azerbaijan. These pilot studies consist of several phases. In Georgia, the first stage of PrEP implementation included a training session for those involved in the pilot, as well as the conducting of a needs assessment among Georgian men who have sex with men (MSM) and capacity building for local NGOs, before the actual start of the pilot in 2017. In Central Asian countries, there seems to be less interest in PrEP, although the Ministry of Health of Kyrgyzstan is planning to start an evaluation on the possibilities of introducing PrEP in the country.

Challenges of introducing PrEP in EECA may include the cost of PrEP, but also the high levels of stigma and discrimination in some countries. However, with HIV incidence in EECA rising by 57% between 2010 and 2015, treatment alone will not stop the epidemic. Given its proven effectiveness, providing PrEP to key populations can be a significant step in controlling the explosive growth of the HIV epidemic in this region.

Commentary: the Value of PrEP for People who Inject Drugs

Authors: Rosalind L Coleman and Susie McLean

Corresponding author: Rosalind L Coleman, 20 Avenue Appia, CH-1211 Geneva 27, Switzerland.

INTRODUCTION

HIV prevention is currently insufficient for many populations who inject drugs and who continue to bear a disproportionate burden of HIV. Across all regions, the prevalence of HIV for people who inject drugs is up to 50 times the rate of the rest of the adult population and people who inject drugs account for 30% of all new HIV infections outside sub-Saharan Africa. This inadequacy of HIV prevention is most prominently illustrated in Eastern Europe and Central Asia, where new HIV infections are up 57% compared with 2010 and more than half of these new infections are among people who inject drugs.

Pre-exposure prophylaxis (PrEP) can effectively prevent HIV when introduced in an enabling combination HIV prevention programme and chosen by people at high risk of infection. The integration of PrEP into public health programmes has been presented as an opportunity to strengthen HIV prevention for key populations when implemented in a context of linked action for human rights, supportive laws and violence prevention. PrEP is recommended as a choice for people who inject drugs by the American Centres for Disease control and in the recent WHO recommendation, but some critiques of the value and or effectiveness of PrEP for people who inject drugs are emerging, including from consultations with people who inject drugs. These consultations, co-ordinated by the International Network of People who Use Drugs (INPUD), brought together 75 representatives of people who inject drugs from 33 countries, predominantly from Eastern Europe and Central and Eastern Asia to discuss policy and programme considerations of PrEP in their situations. The implementation challenge is to design PrEP strategies that are context specific and differentiated for key populations in all their diversity, including for people who inject drugs.

The risk of HIV transmission for people who inject drugs exists in a context of other adverse health events and the high HIV rates reflect their broader health problems that include hepatitis C (HCV) and other blood-borne diseases, overdose, vein damage and tuberculosis. Much of the health risk associated with injecting drug use is exacerbated by poverty, inequality, criminalization, violence and discrimination.

WHO, UNAIDS and UNODC have defined and endorsed a range of harm reduction interventions to address and prioritize HIV and related health needs of people who inject drugs. Key interventions include needle and syringe programmes (NSP) and opioid substitution therapy (OST) to reduce unsafe injecting and manage drug dependency, as well as the promotion of condom use, facilitated access to testing and treatment for HIV and other sexually transmitted infections, TB, and HCV, and naloxone provision to prevent overdose, supported by appropriate information, education and communication interventions, and “critical enablers,” such as supportive laws, anti-discrimination interventions, interventions to make health services more accessible and acceptable to people who use drugs and anti-violence interventions. This set of interventions represents the formal list of evidence-based “harm reduction” interventions around which significant consensus lies as evidenced by their endorsement by international, regional and national organizations and governments. This harm reduction approach responds to a wide range of adverse health needs, is relatively inexpensive to implement and can have a high impact on HIV and HCV transmission, Despite this, only half of all countries that report injecting drug use provide OST and even fewer offer NSP. Where these interventions are available, they are often provided at an insufficient scale to have a public health impact.

Lack of scale of these evidence-based interventions results from a number of factors: lack of funding and prioritization, the design and delivery of services that are not targeted to reach key populations and structural barriers that prevent people who use drugs from accessing services. These factors shape the wider risk environments of people who inject drugs and constitute a form of structural violence, when associated with repeated incarceration; compulsory registration on official lists as drug users; and high rates of violence, police harassment, homelessness and poverty.

People who inject drugs will need to know about, believe in and value PrEP, alongside other interventions such as clean needles and OST. Without consideration of the sometimes violent and hostile environment in which these harm reduction services are delivered, people who inject drugs may not embrace PrEP and instead view it as a reductionist and potentially destabilizing intervention that could divert attention away from existing harm reduction services.

DISCUSSION

Concerns expressed about PrEP by people who use drugs underline the importance of identifying particular policy environments, geographies and sub-populations of people who inject drugs and their sexual partners for whom PrEP may be of value.

PREP AND HARM REDUCTION SERVICES

The people who inject drugs who were involved in the consultations agreed that, in a context where other key harm reduction services were in place, PrEP would be a desirable option for some people who inject drugs. It was felt, however, that in countries with the highest injection-drug-associated HIV burden, the reality was far from being realized. Respondents expressed opposition to any introduction of PrEP that was not part of an effort to strengthen broader harm reduction and social justice programmes.

Any new intervention, including PrEP, should strengthen broader health promotion and combination HIV prevention approaches, bolster any existent effective interventions and respond to the diverse needs of the population. A comprehensive combination HIV prevention programme includes condom and lubricant provision, immediate initiation of antiretroviral therapy and the offer of PrEP and also supports related interventions such as harm reduction programmes for people who inject drugs and voluntary medical male circumcision (VMMC) for men in eastern and southern Africa.

HIV prevention spending for key populations such as people who inject drugs in low- and middle-income countries is heavily dependent on international financing which is flattening while domestic funding for key populations is low. A change in donor priorities could destabilize existing harm reduction programmes if they compete for limited funding. This threat is intensified by weak policy and financial support by many governments who have permitted harm reduction programmes that are funded by external sources but who show no or limited commitment to funding harm reduction from national budgets when donors retreat. In contexts where harm reduction programmes are politically unpopular, PrEP could present a convenient and “magic bullet” intervention that allows governments to claim that they are addressing HIV prevention, whilst reducing funding and policy support for other evidence-based harm reduction interventions that people who inject drugs need and prioritize. The ethics of providing PrEP when HIV treatment access for people who use drugs is so poor was also questioned at the consultations.

In any situation, PrEP can only be economically and clinically effective when it is funded as part of an accessible and comprehensive HIV prevention and treatment programme.

PREP, DRUG USE AND SEXUAL TRANSMISSION OF HIV

People who inject drugs account for a disproportionate share of HIV burden whether attributable to injection drug use or in combination with sexual transmission. There is a complex and fluid interaction between the injection or other use of drugs and increased sexual HIV transmission risk. People who inject drugs report low levels of condom use. In Eastern Europe and Central Asia, where half of new infections are among people who inject drugs, 6% of new infections are among sex workers and one-third of new infections are among clients of sex workers and other sexual partners of key populations. Therefore, PrEP has possible value in the social and sexual networks of people who inject drugs where the incidence of HIV is high. These people might include the sexual partners of people who inject drugs, non-opioid drug users who also inject but for whom there is no established substitution treatment and others within the wider drug-using community who are unable to negotiate safe sex, including both women and men who inject drugs and who have sex with men, people who inject drugs and sell sex, transgender people and those who are vulnerable to sexual violence or exploitation. Given what we know of the overlap and double HIV burden of sex work and injection drug use, there is a need for synergy and a broad approach to harm reduction programming. This could include the offer of PrEP to address both sexual and injection-related health risks. The one trial of PrEP that was specific to people who inject drugs was not able to differentiate between the prevention of sexual- and injecting-related HIV transmission.

Consultations with these linked populations could identify additional situations where PrEP might be valuable. Some parallels may be drawn from the views of sex workers who also experience stigma and discrimination that prevents them from engaging with health services. A comprehensive literature search found an “enthusiasm” to use PrEP among sex workers in China, Peru, sub-Saharan Africa and the United States if it were to be distributed through user-friendly services and promoted with non-stigmatizing information and adherence support. This view is tempered with the caution that PrEP introduction should benefit sex workers and their immediate community and not be introduced only for the public health impact in the general population. For some, debate on PrEP promotion provides an opportunity to engage with policy makers on human rights.

This reaction found an echo from a North American INPUD consultation participant and emphasizes the notion that PrEP services should be in step with the varying needs and desires of the priority population for whom it is intended.

It is important to remember that people who inject drugs have the same sexual rights and sexual health needs as those in the general population and that in contexts where HIV transmission is at least partly driven by unsafe injecting in combination with risky sex, HIV prevention impact achieved for people who inject drugs can influence HIV transmission dynamics in the wider population.

PROVISION AND UPTAKE OF PREP

For all criminalized and highly marginalized (key) populations, an enabling environment where their voices can be heard, supported by legislation and zero tolerance for violence, is vital to meet HIV prevention targets and ameliorate many other adverse health events. Where these conditions are still lacking, their absence is a huge constraint to achieving better health and quality of life. Without them, improved services can remain under-utilized and inefficient since key populations will often remain underground for fear of arrest or violence. A person’s request for PrEP can require the disclosure of sometimes illegal and risky practices, along with repeated contact with sometimes hostile health services. In conditions such as these, people who are at substantial risk of HIV exposure and who could benefit from PrEP are unlikely to seek it for fear of discrimination, breaches of privacy, criminal sanctions or other threats.

The history of rights-based health interventions, including for people who inject drugs, has advanced through a series of small victories. The requirement to attend to the context, practices and priorities of key populations applies to all HIV programme implementation, and the emergence of interest in PrEP presents an opportunity to examine these factors more deeply. Current focus and debate on PrEP implementation provides an opportunity for people who inject drugs who are interested to shape the development and design of PrEP services. Health planners and decision-makers will need to engage with people who inject drugs and their sexual partners in order to understand their interest in PrEP, and how any such interest can be integrated with broader prevention services and, for example, the need for drug dependency treatment, overdose treatment, HCV and HIV treatment and the need for protection from human rights violations.

CONCLUSUIONS

PrEP is best understood as an additional potential HIV prevention option for some people who inject drugs and their sexual partners in specific circumstances. The challenge is to ensure that the potential of PrEP is not undermined by narrow and overly biomedical understandings of its value, removed from the real lives of those most at risk of HIV exposure. Harm reduction programmes are intended to address a range of interests and needs, and it is likely that harm reduction programmes could be an effective implementation platform for PrEP for people who inject drugs. (From data and experience of using the medicines in HIV treatment, no interaction is expected between PrEP containing tenofovir/emtricitabine or tenofovir/lamivudine and heroin, methadone or methamphetamine).

PrEP can be an opportunity to harness a specific intervention for longer term public health and human rights outcomes. PrEP will realize its HIV prevention potential if it is introduced in a way that complements and strengthens existing harm reduction and health promotion activities, if it contributes to reducing discrimination and empowers key populations at risk of HIV infection. Creating opportunities to hear from and engage with people who use drugs about their interests, needs, values and preferences regarding HIV prevention, alongside wider health and other needs, is a priority for health programmers and decision-makers. These are some of the factors that will ensure the potential of PrEP for people who inject drugs is realized in a variety of real-world settings.

Full abstract & sources: www.jiasociety.org