By Flavia Nassaka
Should Health ministry approve PrEPs for people at high risk of infection?
Irene Nakyeyune is negative for HIV, the virus that causes AIDS. So she did not feel any apprehension when she got pregnant. But that changed in April last year during one of her antenatal visits at Kawaala Health Center III in in Rubaga division, Kampala district. As is often the case these days, Nakyeyune was accompanied to the antenatal by her husband – and they took an HIV test. Nakyeyune’s husband tested positive. The couple could not believe it. But when they did the recommended three intervals tests, the results were confirmed.
Fortunately, they had an HIV-free baby in September last year and the couple has been consistently using condoms to avoid exposing Nakyeyune to the risk of getting infected. But as the baby nears one year, Nakyeyune is mulling over a tough question: How to get more HIV-free children and also remain safe? Nakyeyune’s dilemma is quite common according to experts from the Uganda AIDS commission (UAC). The UAC statistics show that over 30% of HIV positive married people in the country have a HIV negative spouse and, the experts say, many of these couples; technically called `serodiscordant couples’, encounter serious problems with fertility decision making. Some make wrong choices; leading to 60% of new HIV infections occurring among discordant couples. It is a problem that researchers from the Infectious Disease Institute (IDI) are grappling with. Options they think can work involve giving the HIV-negative partner a drug that they can take before having sex with an HIV-positive person; technically referred to as Pre-Exposure Prophylaxis (PrEP). Under PrEP, the recommended drugs are Truvada and Viread.
The researchers are currently conducting a study on the effectiveness of the drugs on 293 couples where one is positive and the other negative but some have unprotected sex. It is the third study of its kind and is being conducted in Kasangati, a suburb north of Kampala city. The study was recommended by the World Health Organisation in 2012 and results might enable PrEP to be effectively used massively.
Truvada and Viread have been approved in other countries such as the U.S. and Kenya. In Uganda, experts are still divided on whether PrEP is developed enough for general use. The worry is that with PrEPs, some people might start having irresponsible sex. The official Ministry of Health position is that PrEP should not be prescribed outside of a clinical trial context.
Even its most influential proponents, like Dr. Christine Ondoa, the Director General of Uganda AIDS Commission (UAC), say it should not be recommended for general use. Rather, Ondoa says, it should be used only for discordant couples, homosexuals, and injection drug users. These account for only 1% in Uganda.According to Dr. Alex Opio, commissioner National Disease Control at the Ministry, the financial cost of massive use of PrEps is also a concern.“A number of factors would need to be taken into account before rolling out a new approach, including competition with treatment in terms of resources especially within a discordant relationship in which the infected partner may be preferred to receive treatment, rather than a healthy partner receiving PrEP,” he told the Independent. Opio says Ministry position is to first ensure that people will not abandon the cheaper widely available HIV/AIDS prevention techniques like male circumcision and condom use. He says the government is currently grappling with a funding gap US$650 million required to keep people on ARVs for the next three years. About 1.4 million people are need of ARVs in Uganda but only 713,774 are getting them.
According to online resources, in the U.S. where Truvada is already in use, around $1500 is spent on a person per month. This translates to more than Shs3 million and out of range for an average Ugandan.
“The priorities are to increase coverage of ARVs and prevention of mother to child transmission. Other issues will come in with more funding; after all Truvada is not a vaccine for HIV,” Opio says.But some experts argue that with the big numbers of couples where one is positive at the other negative, the government should at least approve guidelines to be followed by practitioners in private service while recommending drugs for those who can afford to pay. They say delaying approval leads to continued HIV infection that could have been prevented. New HIV infections remain high in Uganda at about 380 per day.
How the strategy works
ARVs are the drugs traditionally used to treat people living with HIV. In the case of PrEP, similar drugs are used to prevent HIV infection of those who are negative.
The drug is recommended to be used only during periods of vulnerability; especially when the couple – like Nakyeyune and her husband, wants to have a baby.
Dr. Nulu Bulya, the lead researcher in the Uganda study says unlike ARVs for the HIV-positive where one has to depend on them for a life time, Truvada can be used only when necessary and the rest of the time condoms and other safe sex measures could be considered.