Why are discordant couples not being provided with PrEP treatment?

Monday December 1 2014

By Charles Brown

In Uganda, we’ve had a mixed experience in our efforts to address the HV pandemic – from reductions in the 1990s and now a rise in new cases. We need to treat this urgently and provide tools to people – depending on what they need – to help them reduce their risk of HIV.
I am writing today about expanding HIV prevention options for serodiscordant couples (where one partner is HIV positive, the other negative). We know that there are many Ugandans in serodiscordant relationships. Sixty per cent of the reported 124,000 new HIV infections in Uganda each year are among discordant couples. They clearly have special needs for HIV prevention.
I have worked with these couples for many years, first as part of research studies and currently as an HIV advocate. I’m an AVAC Fellow and I have spent the past 12 months trying to lay the ground for the development of guidelines for pre-exposure prophylaxis or PrEP roll out among discordant couples and other key populations in Uganda. While there is a call from many couples for this new option, and interest from stakeholders at every level, there are no concrete strategies. We urgently need a plan!
PrEP is a strategy in which an HIV-negative person takes antiretroviral medication (ARVs) to reduce their risk of HIV infection. ARVs are the drugs traditionally used to treat people living with HIV. In the case of PrEP, ARVs prevent HIV in those who are not infected. Studies conducted in Africa – including right here in Uganda - and elsewhere have proven that PrEP works if used correctly. They show that taking the drugs Truvada or Viread daily can reduce HIV risk by as much as 90 per cent or more when taken as prescribed.
What can couples use now? They can use male and female condoms. But we know there are periods when most people experience condom fatigue or when condom use cannot be negotiated with a partner. We know this is the case or we would not have high rates of HIV transmission among the married.
Discordant couples can also benefit from treatment as prevention (TasP). This is simply when a person with HIV is on antiretroviral treatment and the virus is so diminished that the risk of transmitting HIV to a sexual partner is almost none. However, there are many couples in which the HIV-positive partner has not initiated HIV treatment for reasons ranging from personal preference to lack of accessibility. PrEP can also be used by the HIV-negative partner until their HIV-positive partner is ready to start treatment, or to take control of their own protection.
At a recent community meeting, men and women from Kampala, Luweero, Wakiso, Mpigi and Kayunga districts voiced their desire for PrEP to officials from the Uganda Aids Commission. Unfortunately, they were and continue to be answered with inaction from the government, which has yet to come up with guidelines to implement this new and potentially powerful tool.
The government must move beyond statements, and move from evidence to policy, and from policy to programming.
It’s more than the three years since PrEP was proven to work. The resounding question from couples is still: Why are we not provided PrEP when we know very well that the drugs work? Maybe this World AIDS Day, Uganda’s discordant couples will get an answer from the Ministry of Health.
Mr Brown is an HIV prevention advocate. [email protected]

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