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HIV pre-exposure pill a lifeline for sex workers

One pill a day will soon help keep thousands of sex workers HIV-free after the Department of Health is expected to announce on Friday (March 11) that it will provide antiretrovirals to thousands HIV-negative sex workers in a bid to keep them HIV free. The announcement is expected to make South Africa one of the first countries in the world to bring the latest HIV prevention science to those who need it most.

On Friday the department and the South African National AIDS Council (SANAC) are expected to announce that at least 3 000 HIV-negative sex workers will be eligible to begin taking the combination antiretroviral (ARV) Truvada in order to prevent contracting HIV. Truvada combines the ARVs emtricitabine and tenofovir.

An activist from a non-governmental organisation lights candles during an Aids awareness campaign on the eve of the World Aids Day in Agartala, India. Picture: Reuters/ Jayanta Dey. Credit: REUTERS

Large-scale clinical trials have shown that if taken daily, Truvada can reduce the risk of HIV infection by 90 percent in people at high risk for contracting HIV like sex workers or men who have sex with men.

SANAC and the department are also expected to announce that all HIV-positive sex workers will be eligible to start HIV treatment as soon as they test positive for the virus and regardless of CD4 counts in a model dubbed “test and treat.”

Currently, most people living with HIV must wait until their CD4 counts – a measure of the immune system’s strength – fall to 500 before they can start treatment.

Abdullah likened the concept of HIV treatment as prevention to measures many people take to stave off malaria while travelling.

“Before you go into a malaria area, you take a malaria drug with anti-malaria medication and it reduces the risk of malaria,” he said. “In this case, we are offering sex workers an ARV taken once a day to reduce their risk of contracting HIV by 90 percent.”

Just like anti-malarial drug use, the use of ARVs for prevention – or pre-exposure prophylaxis (PrEP) - might not be forever for some people, added Wits HIV and Reproductive Health Institute Director of Implementation Science Dr Saiqa Mullick.

“PrEP provides an additional prevention option for those who are at risk for HIV,” said Mullick. “It works if people taking PrEP adhere to it and take it every day but they don’t need to take PrEP for the rest of their lives only during the period of their lives when they are at a significant risk.”

In September, the World Health Organisation endorsed PrEP as well as test and treat. Within weeks of the endorsement, the National Department of Health was holding meetings about how the two might be rolled out here, according to Mullick.

The kind of high-level interest shown by Minister of Health Dr Aaron Motsoaledi and Deputy President and SANAC Chair Cyril Ramaphosa in curbing HIV among sex workers may be a rarity, as globally politicians tend to distance themselves from the stigmatised group.

.”It’s rare for a country to have such high-level leadership dealing with HIV among sex workers,” Abdulla said. “It’s a sign that government is taking this very seriously and working with non-governmental organisations and the community to make sure that the right thing is done and done properly.

In South Africa, the roll out of both to sex workers is part or a new three-year national plan to be unveiled today to address HIV prevalence rates that may be as high as 70 percent among sex workers, according to a new study to be released today.

Promise Ngobeni lost her parents to AIDS-related illnesses as a child. The virus that robbed Ngobeni or her parents has stalked her since she began working as a sex worker in a Nelspruit club as a teen.

“I joined a group of teens and started going to night clubs looking for easy money,” she said. “If clients refuse to put on a condom on – even though some are HIV positive and some have sexually transmitted infections (STIs) – you cannot force them (to) because that client can report you to the boss.”

“You may lose your job or your boss can beat you to death,” she added. “Some of us joined the prostitution industry HIV negative but now we are HIV positive.”

Conducted in Cape Town, Johannesburg and Durban, the study also found low levels of HIV treatment and adherence among sex workers. Abdullah is hoping quick access to treatment after testing will help change that.

“If you manage to get a sex worker into a clinic, the last thing you want to do is postpone treatment,” said Abdullah, noting that the plan also provides for extensive outreach conducted by sex workers for sex workers covering everything from HIV to tuberculosis. Cape Town-based sex worker rights organisation Sweat was one of several bodies representing sex workers that helped draft the new plan. The organisation has welcomed the plan’s adoption of international best practices, said Sweat Human Rights and Lobbying Officer Nosipho Vidima.

The ARVs used to in Truvada also form part of standard HIV treatment when combined with a third ARV. People who use PrEP will have to regularly test for HIV to ensure that they are switched on the three-drug regimens needed to avoid drug resistance should they contract HIV.

Anova Health’s Dr Kevin Rebe currently runs a small Cape Town project providing PrEP to high-risk men who have sex with men. He adds that following the Medicines Control Council’s December registration of Truvada for HIV prevention, there is nothing stopping people in the private sector who believe they are at high risk for HIV from discussing PrEP as an option with their doctors.

Rebe added that as the cost of Truvada continues to fall, more medical aids might be willing to pay for its use as PrEP. According to Rebe, Truvada costs about R200 to R550 per month.

The science inside

Taking the pill Truvada as pre-Exposure Prophylaxis for HIV (PrEP) is a scientifically proven way for people at a high risk of contracting HIV to reduce that risk. It does not protect against other sexually transmitted infections like herpes, gonorrhoea or syphilis.

When taken daily, PrEP has been shown to reduce the risk of HIV infection by about 90 percent. This reduction in HIV risk is even greater when people combined daily Truvada with other ways to prevent HIV like using condoms.

PrEP is much less effective if it is not taken consistently and people’s ability to adhere to the daily treatment has been a concern among some of the large clinical trials conducted to evaluate PrEP.

Five large-scale clinical trials conducted among about 400 to 5,000 people each found that Truvada was safe and effective. The World Health Organisation (WHO) recommended PrEP to prevent HIV infection in high-risk people internationally in September 2015.

At the same time, the WHO recommended that all people who test positive for HIV be started on treatment immediately in a model dubbed “test and treat.” Studies have shown that earlier treatment is better for people living with HIV - it may also help reduce new infections.

HIV-positive people who adhere to treatment long enough and well enough to bring levels of the virus down to very low levels in their blood are also less likely to transmit the virus.

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