Like a breath of fresh air, the news that a combination prevention drug would soon hit the Nigerian market is definitely something to cheer about, given Nigeria’s high prevalence of HIV rate, which is said to be second only to South Africa in the African continent. WINIFRED OGBEBO reports.
It is like Sunday-Sunday malaria drugs. But in this case, you take HIV drug to prevent HIV and HIV negative people, says the Director-General, National Agency for the Control of AIDS (NACA), Prof John Idoko, explaining the new prevention treatment drug, pre- exposure Prophylaxis.
“From what we learnt from malaria for example, he explains further, “if we give the drugs to somebody who doesn’t have HIV, and the person has sexual relationship with an HIV positive partner, it can prevent transmission from the positive person to the person. That is why it’s called a pre- exposure prophylaxis because before exposure, the person has taken the drugs and because he has the drugs in him, the virus cannot infect him or her.”
Also, Idoko says, “ If you take this sero-discordant couples; one is positive and the other is negative, instead of giving the drug to the negative person before the sexual relationship, just put the positive one on drug as soon as you know. It doesn’t matter what his CD-4 count is even if it’s 500, just give him the drugs. It has shown clearly one of the best study results that we have seen, as 96 per cent chance of the person transmitting HIV is blocked. So we call that treatment as prevention. So you can now imagine that if you go to a community, and they are using this method, your chances of blocking transmission are very high. We believe that these are the two things we need to put together as part of our combination prevention method.”
The pre-exposure prophylaxis is the newest HIV prevention tool that has been developed. It involves the use of Truvada, an antiretroviral to prevent HIV infection. A few studies have shown the ability of this drug to prevent HIV infection in sero-discordant couples, MSMs, transgenders and in men and women.
Most recently, on the 10th of this month,2012, the drug was approved by FDA in USA for use for HIV prevention tool also. It had been previously approved for use as an HIV treatment drug.
PrEP may be part of a new comprehensive HIV prevention services that had been proved “safe and effective” in which HIV negative people who are at high risk take antiretroviral medication daily to prevent infection.
The director (Prevention, Care and Treatment) at the Family Health International, Dr Hadiza Khamofu, said that infections in low risk relationships are acquired from high risk sexual encounters.
She cited a recent study carried out by Dr Taiwo Ijawogin of the University of Ibadan on condom use with sex workers and abstinence behavior among men in Nigeria.
According to her, about 62 per cent of new infections occur among persons perceived as practising “low risk sex” including married sexual partners.
She stated that the ante-natal care prevalence rate of 4.1 per cent exists among the 160 million Nigerian populations, adding that pregnancy presents a period of higher risk of acquiring or transmitting HIV infection.
At the moment, there are stakeholders conducting a study in the country to evaluate the use of Truvada as PrEp in combination with other HIV prevention tools (male and female condoms, PMTCT, HTC, PEP, behaviour change communication) in reducing the incidence of HIV in Nigeria.
According to the director of resource mobilization, NACA, Dr Emmauel Alhassan, the roadmap for moving forward the agenda on PrEP access in Nigeria aims at identifying areas of collaboration on policy, regulatory and delivery and implementation.
“We’ve found out in other countries that the prep actually reduces new infections- and very significantly. And so, this particular meeting is trying to look at ways and means of using that in Nigeria to ensure that we bring down the rate of new infection of HIV.”
“It’s been in use now for quite some time, although its relatively new. There’s been some research done in South Africa and in some other countries and the results have started coming in. In the past, I guess two to three years, there’s been a lot of work, and we feel that this is something we should explore in Nigeria.”
“In South Africa, it’s something that has been used and that’s why we have this stakeholders meeting to decide, to see whether we should do feasibility study first. We need to get all the stakeholders involved to look at evidence from other countries, to look at our programmes especially the rate of discordance in couples, because some men could be HIV positive and their wives negative and vice versa. We are looking at this as a potential to helping those who are not positive to, at least, remain negative. So at the end of the meeting, we’ll have some timelines for moving the prep access forward in Nigeria.”
However, a lecturer at the Obafemi Awolowo University who is also involved in the research, Mrs Morenike Ukpong, noted that combination prevention is not a new phenomenon.
According to her, HIV has structural issues that promote it. For example, she says, poverty, gender inequality and stigma are structural problems that must be addressed.
“We also appreciate that there are biomedical interventions: male and female condom, male circumcision, prEp, treatment and prevention. Behaviour also matters if you’re asked to use a condom. If you don’t use it, you won’t use it. So behaviour also has a component. So, people do appreciate that when you’re talking about prevention, all those things must come together for it to have effect in the nation. So that is the concept of combination prevention. So the things that you add on for cumulative effect, and the combination that you put together for young people might not be the same combination you put together for adults.
“The combination you put together for male sex workers might not be the same combination for females. This is why combination prevention becomes specific in strategy.”
She said that right now, there is an interest in looking at prEp as a component of combination treatment for women who are pregnant and are into discordant relationship, knowing that within that structure, the use of condom becomes a challenge.
Evidence suggests that the magnitude of serodiscordance among pregnant couples is high and is a significant window for transmitting new HIV infections.
“It’s a challenge especially when you’re asking couples now who are sero discordant to use condom all the rest of their lives. Within that challenging situation, if you now use prEp, how effective will it be on the population? That is what we are looking at, prEp as a combination prevention,” Ukpong said.
Idoko said that combination prevention, addressing PMTCT, putting people on drugs, and putting more efforts and investment in these places, are the best way to bring down HIV prevalence in Nigeria.
However as good as this new ‘wonder prevention’ drug may seem, many experts have expressed some reservations.
Tope, a midwife and HIV Counsellor based her concerns on the issue of adherence to the drug.
“I read on the internet that Truvada needs to be taken every day, 100% of time for prevention of HIV virus in HIV sero-negative person/partner. My 22 years experience as registered nurse/midwife and 5 years experience as an adherence counsellor tells me that won’t happen. It is difficult to get somebody that is not sick to take drug consistently every day. Adherence is a big issue that must be critically discussed. “
Also, she observed that the use of PrEp drug could give the users a false sense of security and encourage risky behaviour. For example, she says men who had had challenges using condom who now hear about PrEP could abandon condom and there is the risk of contracting other sexually transmitted diseases like gonorrhea and syphilis.
Another expert expressed the fear that if clients on PrEP get infected with HIV either by skipping some doses of the drug or by stopping the use of condom, then the country will be faced with the problem of drug resistance which is more deadly. “Imagine spreading drug resistance virus in Nigeria,” the expert warned.
However, Ukpong says that despite the fears, it is a proof that there is hope in the fight of HIV infection. “So we should not be tired and we should continue the fight. We shall overcome.”