Abstract
Following recommendations by the World Health Organization in 2015, and key clinical trials, countries in sub-Saharan Africa, the region with the highest burden of human immunodeficiency virus (HIV), developed policies that incorporate pre-exposure prophylaxis (PrEP) into national HIV-prevention strategies. By the end of 2019, more than one third of people receiving PrEP globally were in Africa. Crucial understandings gained from early rollout among at-risk populations, such as HIV-serodiscordant couples, adolescent girls and young women, female sex workers, and men who have sex with men, include the importance of strategies for maintaining persistent adherence to PrEP and novel approaches to making PrEP services accessible, simplified and efficient. This Perspective will discuss the current status of these programs and how to further widen their implementation.
Similar content being viewed by others
References
Joint United Nations Programme on HIV/AIDS. UNAIDS Data 2019 (UNAIDS, Geneva, Switzerland, 2019).
UNAIDS. AIDSinfo. UNAIDS http://aidsinfo.unaids.org/ (2019).
Fonner, V. A. et al. Effectiveness and safety of oral HIV preexposure prophylaxis for all populations. AIDS 30, 1973–1983 (2016).
Baeten, J. M. et al. Antiretroviral prophylaxis for HIV prevention in heterosexual men and women. N. Engl. J. Med. 367, 399–410 (2012).
Grant, R. M. et al. Preexposure chemoprophylaxis for HIV prevention in men who have sex with men. N. Engl. J. Med. 363, 2587–2599 (2010).
Mayer, C. M. et al. Distance to clinic is a barrier to PrEP uptake and visit attendance in a community in rural Uganda. J. Int. AIDS Soc. 22, e25276 (2019).
Centers for Disease Control and Prevention (CDC). Interim guidance: preexposure prophylaxis for the prevention of HIV infection in men who have sex with men. MMWR Morb. Mortal. Wkly. Rep. 60, 65–68 (2011).
Food and Drug Administration. FDA approves first drug for reducing the risk of sexually acquired HIV infection. AIDSinfo https://aidsinfo.nih.gov/news/1254/fda-approves-first-drug-for-reducing-the-risk-of-sexually-acquired-hiv-infection (2012).
World Health Organization. Guidelines on when to start antiretroviral therapy and on pre-exposure prophylaxis for HIV (World Health Organization, Geneva, 2015).
World Health Organization. Consolidated Guidelines on the Use of Antiretroviral Drugs for Treating and Preventing HIV Infection: Recommendations for a Public Health Approach 2nd edn. (World Health Organization, Geneva, 2016).
AVAC. PrEPWatch. AVAC https://www.prepwatch.org/country-updates/ (accessed 20 December 2019).
World Health Organization. Guidance on Oral Pre-Exposure Prophylaxis (PrEP) for Serodiscordant Couples, Men and Transgender Women Who Have Sex with Men at High Risk of HIV. Recommendations for Use in the Context Of Demonstration Projects (World Health Organization, Geneva, 2012).
Dunkle, K. L. et al. New heterosexually transmitted HIV infections in married or cohabiting couples in urban Zambia and Rwanda: an analysis of survey and clinical data. Lancet 371, 2183–2191 (2008).
Grabbe, K. L. & Bunnell, R. Reframing HIV prevention in sub-Saharan Africa using couple-centered approaches. J. Am. Med. Assoc. 304, 346–347 (2010).
Matthias, A. et al. Nigerian pre-exposure prophylaxis (PrEP) study: sociodemographic profile and fertility desire among HIV-1 sero-discordant couples in Nigeria. Gates Open Res. https://gatesopenresearch.org/posters/3-1490 (2017).
Baeten, J. M. et al. Integrated delivery of antiretroviral treatment and pre-exposure prophylaxis to HIV-1-serodiscordant couples: a prospective implementation study in Kenya and Uganda. PLoS Med. 13, e1002099 (2016).
Heffron, R. et al. Pre-exposure prophylaxis for HIV-negative persons with partners living with HIV: uptake, use, and effectiveness in an open-label demonstration project in East Africa. Gates Open Res. https://doi.org/10.12688/gatesopenres.12752.2 (2018).
Irungu, E. M. et al. Use of a risk scoring tool to identify higher-risk HIV-1 serodiscordant couples for an antiretroviral-based HIV-1 prevention intervention. BMC Infect. Dis. 16, 571 (2016).
Pyra, M. et al. Patterns of oral PrEP adherence and HIV risk among eastern African women in HIV serodiscordant partnerships. AIDS Behav. 22, 3718–3725 (2018).
Pyra, M. et al. Brief Report: PrEP use during periods of HIV risk among East African women in serodiscordant relationships. J. Acquir. Immune Defic. Syndr. 77, 41–45 (2018).
Ware, N. C. et al. What’s love got to do with it? Explaining adherence to oral antiretroviral pre-exposure prophylaxis for HIV-serodiscordant couples. J. Acquir. Immune Defic. Syndr. 59, 463–468 (2012).
Nakku-Joloba, E. et al. Beyond HIV prevention: everyday life priorities and demand for PrEP among Ugandan HIV serodiscordant couples. J. Int. AIDS Soc. 22, e25225 (2019).
Mack, N. et al. The importance of choice in the rollout of ARV-based prevention to user groups in Kenya and South Africa: a qualitative study. J. Int. AIDS Soc. 17, 19157 (2014).
Ngure, K. et al. I knew I would be safer. Experiences of Kenyan HIV serodiscordant couples soon after pre-exposure prophylaxis (PrEP) initiation. AIDS Patient Care STDS 30, 78–83 (2016).
Acom, C.P. Mobile health approaches with facility-based care to improve access and adherence to pre-exposure prophylaxis (PrEP) in Lango region, Uganda. 20th ICASA International Conference on AIDS and STI’s in Africa; 2–7 December (2019).
Masyuko, S. et al. Pre-exposure prophylaxis rollout in a national public sector program: the Kenyan case study. Sex. Health 15, 578–586 (2018).
OPTIONS. PrEP Learning Network Regional Workshop. PrEPWatch https://www.prepwatch.org/wp-content/uploads/2019/11/WelcomeEnablingPolicyEnvironment_malawi_nov2019.pdf (2019).
Mugwanya, K. K. et al. Scale up of PrEP integrated in public health HIV care clinics: a protocol for a stepped-wedge cluster-randomized rollout in Kenya. Implement. Sci. 13, 118 (2018).
Irungu, E. et al. High PrEP use in African men and women continuing PrEP in public health HIV clinics. Conference on Retroviruses and Opportunistic Infections (CROI) (2019).
Evidence for Contraceptive Options and HIV Outcomes (ECHO) Trial Consortium. HIV incidence among women using intramuscular depot medroxyprogesterone acetate, a copper intrauterine device, or a levonorgestrel implant for contraception: a randomised, multicentre, open-label trial. Lancet 394, 303–313 (2019).
Celum, C. L. et al. Rethinking HIV prevention to prepare for oral PrEP implementation for young African women. J. Int. AIDS Soc. 18, 20227 (2015). Suppl 3.
Wekesah, F., Nyakangi, V., Onguss, M., Njagi, J. & Bangha, M. Comprehensive Sexuality Education in Sub-Saharan Africa. APHRC https://aphrc.org/publication/comprehensive-sexuality-education-in-sub-saharan-africa-2/ (2019).
Van Damme, L. et al. Preexposure prophylaxis for HIV infection among African women. N. Engl. J. Med. 367, 411–422 (2012).
Marrazzo, J. M. et al. Tenofovir-based preexposure prophylaxis for HIV infection among African women. N. Engl. J. Med. 372, 509–518 (2015).
Stankevitz, K. et al. Reaching at-risk women for PrEP delivery: What can we learn from clinical trials in sub-Saharan Africa? PLoS One 14, e0218556 (2019).
Henderson, F. et al. Characteristics and oral PrEP adherence in the TDF2 open-label extension in Botswana. International AIDS Conference, 18–22 July (2015).
Bekker, L. G. et al. Daily and non-daily pre-exposure prophylaxis in African women (HPTN 067/ADAPT Cape Town Trial): a randomised, open-label, phase 2 trial. Lancet HIV 5, e68–e78 (2018).
Celum, C. et al. PrEP adherence and effect of drug level feedback among young African women in HPTN 082. International AIDS Society (2019).
Lahuerta, M. et al. Feasibility, acceptability, and adherence with short-term HIV preexposure prophylaxis in female sexual partners of migrant miners in Mozambique. J. Acquir. Immune Defic. Syndr. 76, 343–347 (2017).
Pintye, J. et al. HIV-uninfected Kenyan adolescent and young women share perspectives on using preexposure prophylaxis during pregnancy. AIDS Patient Care STDS https://doi.org/10.1089/apc.2018.0058 (2018).
Govender, E., Mansoor, L., MacQueen, K. & Abdool Karim, Q. Secrecy, empowerment and protection: positioning PrEP in KwaZulu-Natal, South Africa. Cult. Health Sex. 19, 1268–1285 (2017).
Matthews, L. T. et al. High medication adherence during periconception periods among HIV-1-uninfected women participating in a clinical trial of antiretroviral pre-exposure prophylaxis. J. Acquir. Immune Defic. Syndr. 67, 91–97 (2014).
Kinuthia, J. et al. Pre-exposure prophylaxis uptake and early continuation among pregnant and post-partum women within maternal and child health clinics in Kenya: results from an implementation programme. Lancet HIV 7, e38–e48 (2020).
Heffron, R. et al. Fertility intentions, pregnancy, and use of PrEP and ART for safer conception among East African HIV serodiscordant couples. AIDS Behav. 22, 1758–1765 (2018).
World Health Organization. Technical Brief: Preventing HIV during pregnancy and breastfeeding in the context of PrEP (World Health Organization, Geneva, 2017).
Claassen, C.W. et al. First year of implementation of PrEP in Zambia: Service delivery roll-out and scale-up. International AIDS Society http://programme.ias2019.org/Abstract/Abstract/1948 (2019).
Mugwanya, K. K. et al. Integrating preexposure prophylaxis delivery in routine family planning clinics: a feasibility programmatic evaluation in Kenya. PLoS Med. 16, e1002885 (2019).
Mutegi, J. et al. Characteristics of oral pre-exposure prophylaxis (PrEP) clients with periodic use in the Jilinde program, Kenya. International AIDS Society http://programme.ias2019.org/Abstract/Abstract/4681 (2019).
Pyra, M. N. et al. Global implementation of PrEP for HIV prevention: setting expectations for impact. J. Int. AIDS Soc. 22, e25370 (2019).
Joint United Nations Programme on HIV/AIDS (UNAIDS). The Gap Report: Sex workers (UNAIDS, Geneva, Switzerland, 2014).
Mutagoma, M. et al. High HIV prevalence and associated risk factors among female sex workers in Rwanda. Int. J. STD AIDS 28, 1082–1089 (2017).
Teclessou, J. N. et al. HIV prevalence and behavioral studies among female sex workers in Togo in 2015. Bull. Soc. Pathol. Exot. 110, 270–275 (2017).
Hladik, W. et al. Burden and characteristics of HIV infection among female sex workers in Kampala, Uganda - a respondent-driven sampling survey. BMC Public Health 17, 565 (2017).
Eakle, R., Bourne, A., Mbogua, J., Mutanha, N. & Rees, H. Exploring acceptability of oral PrEP prior to implementation among female sex workers in South Africa. J. Int. AIDS Soc. 21, (2018).
Cowan, F. M. et al. Targeted combination prevention to support female sex workers in Zimbabwe accessing and adhering to antiretrovirals for treatment and prevention of HIV (SAPPH-IRe): a cluster-randomised trial. Lancet HIV 5, e417–e426 (2018).
Mboup, A. et al. Early antiretroviral therapy and daily pre-exposure prophylaxis for HIV prevention among female sex workers in Cotonou, Benin: a prospective observational demonstration study. J. Int. AIDS Soc. 21, e25208 (2018).
Kyongo, J. et al. How long will they take it? Oral pre-exposure prophylaxis (PrEP) retention for female sex workers, men who have sex with men and young women in a demonstration project in Kenya. 22nd International AIDS Conference http://programme.aids2018.org/Abstract/Abstract/8788 (2018).
Pillay, Y. Challenges of South Africa’s sex worker PrEP programme: Lessons learned, moving towards other key populations. 22nd International AIDS Conference http://programme.aids2018.org/Programme/Session/206 (2018).
Lamontagne, E. et al. A socioecological measurement of homophobia for all countries and its public health impact. Eur. J. Public Health 28, 967–972 (2018).
Beyrer, C. et al. A call to action for comprehensive HIV services for men who have sex with men. Lancet 380, 424–438 (2012).
Hagopian, A., Rao, D., Katz, A., Sanford, S. & Barnhart, S. Anti-homosexual legislation and HIV-related stigma in African nations: what has been the role of PEPFAR? Glob. Health Action 10, 1306391 (2017).
Joint United Nations Programme on HIV/AIDS. Miles to go: closing gaps, breaking barriers, fighting injustices (UNAIDS, 2018).
Mutua, G. et al. Safety and adherence to intermittent pre-exposure prophylaxis (PrEP) for HIV-1 in African men who have sex with men and female sex workers. PLoS One 7, e33103, https://doi.org/10.1371/journal.pone.0033103 (2012).
Van der Elst, E. M. et al. High acceptability of HIV pre-exposure prophylaxis but challenges in adherence and use: qualitative insights from a phase I trial of intermittent and daily PrEP in at-risk populations in Kenya. AIDS Behav. 17, 2162–2172 (2013).
Kimani, M. et al. PrEP interest and HIV-1 incidence among MSM and transgender women in coastal Kenya. J. Int. AIDS Soc. 22, e25323 (2019).
Karuga, R. N. et al. “How I wish this thing was initiated 100 years ago!” Willingness to take daily oral pre-exposure prophylaxis among men who have sex with men in Kenya. PLoS One 11, e0151716 (2016).
Bärnighausen, K. et al. “We know this will be hard at the beginning, but better in the long term”: understanding PrEP uptake in the general population in Eswatini. AIDS Care 32, 267–273 (2020).
Clinicaltrials.gov. PrEP Demonstration Study in Swaziland. https://clinicaltrials.gov/ct2/show/NCT03254550 (accessed 20 December 2019).
Koss, C. et al. PrEP uptake, engagement, and adherence following population-wide HIV testing in rural Kenya and Uganda in the SEARCH study. International AIDS Conference, 21–24 July http://programme.ias2019.org/Abstract/Abstract/1127 (2019).
National AIDS and STI Control Programme. Status on implementation of Oral Pre-exposure Prophylaxis for HIV in Kenya (Ministry of Health, Nairobi, Kenya, 2018).
Jipende JiPrEP. Twitter https://twitter.com/NimejiPrEP (2018).
Were, D., Atkins, K., Musau, A., Plotkin, M. & Curran, K. Manifestations of stigma in the context of a national oral pre-exposure prophylaxis (PrEP) scale-up program in Kenya. International AIDS Society, 21–24 July http://programme.ias2019.org/Abstract/Abstract/4678 (2019).
Ware, N. C. et al. Lay social resources for support of adherence to antiretroviral prophylaxis for HIV prevention among serodiscordant couples in sub-Saharan Africa: a qualitative study. AIDS Behav. 19, 811–820 (2015).
Haberer, J. E. et al. Defining success with HIV pre-exposure prophylaxis: a prevention-effective adherence paradigm. AIDS 29, 1277–1285 (2015).
Coelho, L. E., Torres, T. S., Veloso, V. G., Landovitz, R. J. & Grinsztejn, B. Pre-exposure prophylaxis 2.0: new drugs and technologies in the pipeline. Lancet HIV 6, e788–e799 (2019).
Kambutse, I., Igiraneza, G. & Ogbuagu, O. Perceptions of HIV transmission and pre-exposure prophylaxis among health care workers and community members in Rwanda. PLoS One 13, e0207650 (2018).
Pilgrim, N. et al. Provider perspectives on PrEP for adolescent girls and young women in Tanzania: The role of provider biases and quality of care. PLoS One 13, e0196280 (2018).
Krakower, D. S. & Mayer, K. H. The role of healthcare providers in the roll out of preexposure prophylaxis. Curr. Opin. HIV AIDS 11, 41–48 (2016).
Geibel, S. et al. Stigma reduction training improves healthcare provider attitudes toward, and experiences of, young marginalized people in Bangladesh. J. Adolesc. Health 60, s35–s44 (2017).
Risher, K. et al. Sexual stigma and discrimination as barriers to seeking appropriate healthcare among men who have sex with men in Swaziland. J. Int. AIDS Soc. 16, 18715 (2013).
van der Elst, E. M. et al. Men who have sex with men sensitivity training reduces homoprejudice and increases knowledge among Kenyan healthcare providers in coastal Kenya. J. Int. AIDS Soc. 16, 18748 (2013).
van der Elst, E. M. et al. Experiences of Kenyan healthcare workers providing services to men who have sex with men: qualitative findings from a sensitivity training programme. J. Int. AIDS Soc. 16, 18741 (2013).
National AIDS and STI Control Programme (NASCOP). Framework for the Implementation of Pre-exposure Prophylaxis of HIV in Kenya (NASCOP, Nairobi, Kenya, 2017).
Irungu, E. M. et al. Training health care providers to provide PrEP for HIV serodiscordant couples attending public health facilities in Kenya. Glob. Public Health 14, 1524–1534 (2019).
Pillay, Y. South Africa’s experience in bringing PrEP to scale for a range of populations - SUSA0703. 9th IAS Conference on HIV Science http://programme.ias2017.org/Programme/Session/176 (2017).
Koss, C. A. et al. Uptake, engagement, and adherence to pre-exposure prophylaxis offered after population HIV testing in rural Kenya and Uganda: 72-week interim analysis of observational data from the SEARCH study. Lancet HIV 7, e249–e261 (2020).
Gill, K. et al. Pluspills: an open label, safety and feasibility study of oral pre-exposure prophylaxis (PrEP) in 15–19 year old adolescents in two sites in South Africa. International AIDS Conference; July 23–26 http://programme.ias2017.org/Abstract/Abstract/5678 (2017).
Irungu, E. et al. Surmounting PrEP delivery challenges through adaptation of implementation guidelines: Lessons learned from HIV care clinics in Kenya. IAS 2019 http://programme.ias2019.org/Abstract/Abstract/1234 (2019).
Wagner, L. et al. Challenges with oral pre‐exposure prophylaxis (PrEP) disclosure among adolescent girls and young women (AGYW) in Kenya and South Africa. The HIV Research For Prevention Conference (HIVR4P); October 21‐25 https://www.rti.org/publication/challenges-oral-pre-exposure-prophylaxis-prep-disclosure-among-adolescent-girls-and (2018).
Medley, A., Kennedy, C., O’Reilly, K. & Sweat, M. Effectiveness of peer education interventions for HIV prevention in developing countries: a systematic review and meta-analysis. AIDS Educ. Prev. 21, 181–206 (2009).
Hartmann, M. et al. Motivated reasoning and HIV risk? Views on relationships, trust, and risk from young women in Cape Town, South Africa, and implications for oral PrEP. AIDS Behav. 22, 3468–3479 (2018).
Bassett, I. V. et al. Contraception, HIV services, and PrEP in South African hair salons: a qualitative study of owner, stylist, and client perspectives. J. Community Health 44, 1150–1159 (2019).
Rousseau-Jemwa, E., Celum, C., Baeten, J. & Bekker, L.-G. A comparative study of risk among adolescent girls and young women who accept or decline PrEP uptake from a community‐based mobile clinic. International AIDS Conference; July 23–27 http://programme.aids2018.org/Abstract/Abstract/9445 (2018).
Tung, E. L., Thomas, A., Eichner, A. & Shalit, P. Implementation of a community pharmacy-based pre-exposure prophylaxis service: a novel model for pre-exposure prophylaxis care. Sex. Health 15, 556–561 (2018).
O’Malley, G., Barnabee, G. & Mugwanya, K. Scaling-up PrEP delivery in Sub-Saharan Africa: what can we learn from the scale-up of ART? Curr. HIV/AIDS Rep. 16, 141–150 (2019).
Ortblad, K. F. et al. HIV-1 self-testing to improve the efficiency of pre-exposure prophylaxis delivery: a randomized trial in Kenya. Trials 20, 396 (2019).
Amankwaa, I., Boateng, D., Quansah, D. Y., Akuoko, C. P. & Evans, C. Effectiveness of short message services and voice call interventions for antiretroviral therapy adherence and other outcomes: A systematic review and meta-analysis. PLoS One 13, e0204091 (2018).
Downing, J. & Kawuma, E. The impact of a modular HIV/AIDS palliative care education programme in rural Uganda. Int. J. Palliat. Nurs. 14, 560–568 (2008).
Todd, C. S., Mills, S. J. & Innes, A. L. Electronic health, telemedicine, and new paradigms for training and care. Curr. Opin. HIV AIDS 12, 475–487 (2017).
Wood, B. R. et al. Project ECHO: telementoring to educate and support prescribing of HIV pre-exposure prophylaxis by community medical providers. Sex. Health 15, 601–605 (2018).
Baeten, J. M. et al. Single-agent tenofovir versus combination emtricitabine plus tenofovir for pre-exposure prophylaxis for HIV-1 acquisition: an update of data from a randomised, double-blind, phase 3 trial. Lancet Infect. Dis. 14, 1055–1064 (2014).
Murnane, P. M. et al. Pre-exposure prophylaxis for HIV-1 prevention does not diminish the pregnancy prevention effectiveness of hormonal contraception. AIDS 28, 1825–1830 (2014).
Mugwanya, K. K. et al. Brief Report: frequency of monitoring kidney function in HIV-uninfected persons using daily oral tenofovir disoproxil fumarate pre-exposure prophylaxis. J. Acquir. Immune Defic. Syndr. 77, 206–211 (2018).
Heffron, R. et al. Pregnancy outcomes and infant growth among babies with in-utero exposure to tenofovir-based preexposure prophylaxis for HIV prevention. AIDS 32, 1707–1713 (2018).
van der Straten, A. et al. Women’s experiences with oral and vaginal pre-exposure prophylaxis: the VOICE-C qualitative study in Johannesburg, South Africa. PLoS One 9, e89118 (2014).
Ongwen, P. et al. Adolescent girls on PrEP: Findings from Kenya’s oral PrEP scale-up supported by Jilinde. International AIDS Society http://programme.ias2019.org/Abstract/Abstract/4680 (2019).
Acknowledgements
Supported by US National Institutes of Health under grants R01 MH095507 and P30 AI027757, and the Bill & Melinda Gates Foundation under grant OPP1056051.
Author information
Authors and Affiliations
Corresponding author
Ethics declarations
Competing interests
E.M.I. and J.M.B. have been part of studies with study drug donated by Gilead Sciences. J.M.B. has served as an advisor for Gilead Sciences, Merck and Janssen.
Additional information
Peer review information Hannah Stower was the primary editor on this article, and managed its editorial process and peer review in collaboration with the rest of the editorial team.
Publisher’s note Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.
Rights and permissions
About this article
Cite this article
Irungu, E.M., Baeten, J.M. PrEP rollout in Africa: status and opportunity. Nat Med 26, 655–664 (2020). https://doi.org/10.1038/s41591-020-0872-x
Received:
Accepted:
Published:
Issue Date:
DOI: https://doi.org/10.1038/s41591-020-0872-x
- Springer Nature America, Inc.
This article is cited by
-
Changes in relationships, HIV risk, and feelings towards PrEP: findings from a qualitative explanatory study among participants in the CHARISMA intervention trial
BMC Women's Health (2023)
-
Early implementation learnings on acceptability and feasibility of “V”: a multi-level PrEP intervention designed with and for adolescent girls and young women in Zimbabwe
Health Research Policy and Systems (2023)
-
Binge drinking and condom negotiation behaviours among adolescent girls and young women living in Cape Town, South Africa: sexual control and perceived personal power
BMC Public Health (2023)
-
Uptake of retroviral pre-exposure prophylaxis and its associated factors among female sex workers, Northwest Ethiopia
AIDS Research and Therapy (2023)
-
“These Girls Have a Chance to be the Future Generation of HIV Negative”: Experiences of Implementing a PrEP Programme for Adolescent Girls and Young Women in South Africa
AIDS and Behavior (2023)