Introducing the Dapivirine Vaginal Ring in Sub-Saharan Africa: What Can We Learn from Oral PrEP?

Abstract Purpose of review Clinical trials have found that the dapivirine vaginal ring (DVR) is safe to use and effective at reducing women’s risk of acquiring HIV infection. As countries prepare for the introduction of this novel long-acting, woman-controlled prevention method, an examination of key learnings from oral pre-exposure prophylaxis (PrEP) delivery will help programs leverage successful innovations and approaches to support DVR scale-up and expand the method mix for HIV prevention. Recent findings Intensive efforts over the past 5 years have yielded lessons on how to facilitate access to oral PrEP; expand service delivery for PrEP; address the knowledge, attitudes, and skills providers need to support PrEP initiation and effective use; develop messaging that builds community and partner support and combats stigma; and understand the cyclical nature of PrEP use. Summary Evidence from oral PrEP introduction and scale-up can help inform and expedite DVR introduction.

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Health system adaptations and considerations to facilitate optimal oral pre-exposure prophylaxis scale-up in sub-Saharan Africa

The Lancet HIV ◽

10.1016/s2352-3018(21)00129-6 ◽

2021 ◽

Author(s):

Daniel K Were ◽

Abednego Musau ◽

Kaitlyn Atkins ◽

Prakriti Shrestha ◽

Jason Reed ◽

...

Keyword(s):

Health System ◽

Scale Up ◽

Sub Saharan Africa ◽

Sub Saharan ◽

Exposure Prophylaxis

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Integrating Oral PrEP Into Family Planning Services for Women in Sub-saharan Africa: Findings From a Multi-Country Landscape Analysis

Frontiers in Reproductive Health ◽

10.3389/frph.2021.667823 ◽

2021 ◽

Vol 3 ◽

Author(s):

Neeraja Bhavaraju ◽

Rose Wilcher ◽

Regeru Njoroge Regeru ◽

Saiqa Mullick ◽

Imelda Mahaka ◽

...

Keyword(s):

Family Planning ◽

Service Delivery ◽

Health Care Providers ◽

Sub Saharan Africa ◽

Management Service ◽

Care Providers ◽

Road Map ◽

Sub Saharan ◽

Exposure Prophylaxis ◽

Oral Prep

Integration of HIV and family planning (FP) services is a renewed focus area for national policymakers, donors, and implementers in sub-Saharan Africa as a result of high HIV incidence among general-population women, especially adolescent girls and young women (AGYW), and the perception that integrating HIV pre-exposure prophylaxis (PrEP) into FP services may be an effective way to provide comprehensive HIV and FP services to this population. We conducted a focused desk review to develop a PrEP-FP integration framework across five key categories: plans and policies, resource management, service delivery, PrEP use, and monitoring and reporting. The framework was refined via interviews with 30 stakeholders across seven countries at varying stages of oral PrEP rollout: Kenya, Lesotho, Malawi, South Africa, Uganda, Zambia, and Zimbabwe. After refining the framework, we developed a PrEP-FP integration matrix and assessed country-specific progress to identify common enablers of and barriers to PrEP-FP integration. None of the countries included in our analysis had made substantial progress toward integrated PrEP-FP service delivery. Although the countries made progress in one or two categories, integration was often impeded by lack of advancement in other areas. Our framework offers policymakers, program implementers, and health care providers a road map for strategically assessing and monitoring progress toward PrEP-FP integration in their contexts.

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Going global: the adoption of the World Health Organization’s enabling recommendation on oral pre-exposure prophylaxis for HIV

Sexual Health ◽

10.1071/sh18125 ◽

2018 ◽

Vol 15 (6) ◽

pp. 489 ◽

Cited By ~ 17

Author(s):

Ioannis Hodges-Mameletzis ◽

Shona Dalal ◽

Busisiwe Msimanga-Radebe ◽

Michelle Rodolph ◽

Rachel Baggaley

Keyword(s):

Sub Saharan Africa ◽

Essential Medicines ◽

World Health ◽

Middle Income ◽

Income Status ◽

The World ◽

Sub Saharan ◽

Health Organization ◽

Exposure Prophylaxis ◽

Oral Prep

In September 2015, the World Health Organization (WHO) launched evidence-based guidelines by recommending that any person at substantial HIV risk should be offered oral pre-exposure prophylaxis (PrEP) containing tenofovir disoproxil fumarate (TDF) as an additional prevention choice. Since 2017, PrEP medicines have also been listed in the WHO’s Essential Medicines List, including TDF/emtricitabine (FTC) and TDF in combination with lamivudine (3TC). A descriptive policy review and analysis of countries adopting WHO’s 2015 recommendation on oral PrEP was conducted. As of June 2018, we identified 35 countries that had some type of policy on oral PrEP, and an additional five countries where a specific policy on PrEP is currently pending. A total of 19 high-income countries (HICs) and 21 low- and middle-income countries (LMICs) have adopted or have a pending policy. Most countries that have adopted or pending PrEP are in the European (42.9%) or African (30.0%) region. TDF/FTC is the most commonly recommended PrEP drug in the guidelines reviewed, although seven countries, namely in sub-Saharan Africa (6/7), are also recommending the use of TDF/3TC for PrEP. In sum, by the end of 2018, at least 40 countries (20.6%) are anticipated to have adopted WHO’s oral PrEP recommendation. Nonetheless, policy uptake does not reflect broader programmatic coverage of PrEP services, which remain limited across all settings, irrespective of income status. Enhancing global partnerships is needed to support and track ongoing policy adoption and to ensure that policy is translated into meaningful implementation of PrEP services.

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Lessons from a decade of voluntary medical male circumcision implementation and their application to HIV pre-exposure prophylaxis scale up

International Journal of STD & AIDS ◽

10.1177/0956462418787896 ◽

2018 ◽

Vol 29 (14) ◽

pp. 1432-1443 ◽

Cited By ~ 6

Author(s):

Jason B Reed ◽

Rupa R Patel ◽

Rachel Baggaley

Keyword(s):

Male Circumcision ◽

Scale Up ◽

Health Impact ◽

Lessons Learned ◽

Sub Saharan Africa ◽

Voluntary Medical Male Circumcision ◽

Medical Male Circumcision ◽

Prep Implementation ◽

Sub Saharan ◽

Exposure Prophylaxis

Oral pre-exposure prophylaxis (PrEP) has the ability to curb HIV incidence worldwide and bring us closer to ending the HIV epidemic. Scale up of PrEP service delivery has many similar challenges to those faced by voluntary medical male circumcision (VMMC) services roll-out. This article outlines ten important lessons learned during the scale up of VMMC services in sub-Saharan Africa and their application to current oral PrEP implementation efforts to promote faster expansion for public health impact.

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Understanding and measuring uptake and coverage of oral pre-exposure prophylaxis delivery among adolescent girls and young women in sub-Saharan Africa

Sexual Health ◽

10.1071/sh18061 ◽

2018 ◽

Vol 15 (6) ◽

pp. 513 ◽

Cited By ~ 14

Author(s):

Megan S. Dunbar ◽

Katharine Kripke ◽

Jessica Haberer ◽

Delivette Castor ◽

Shona Dalal ◽

...

Keyword(s):

Hiv Infection ◽

Adolescent Girls ◽

Young Women ◽

Sub Saharan Africa ◽

World Health ◽

Substantial Risk ◽

Sub Saharan ◽

Health Organization ◽

Exposure Prophylaxis ◽

Oral Prep

In response to World Health Organization (WHO) guidance recommending oral pre-exposure prophylaxis (PrEP) for all individuals at substantial risk for HIV infection, significant investments are being made to expand access to oral PrEP globally, particularly in sub-Saharan Africa. Some have interpreted early monitoring reports from new programs delivering oral PrEP to adolescent girls and young women (AGYW) as suggestive of low uptake. However, a lack of common definitions complicates interpretation of oral PrEP uptake and coverage measures, because various indicators with different meanings and uses are used interchangeably. Furthermore, operationalising these measures in real-world settings is challenged by the difficulties in defining the denominator for measuring uptake and coverage among AGYW, due to the lack of data and experience required to identify the subset of AGYW at substantial risk of HIV infection. This paper proposes an intervention-centric cascade as a framework for developing a common lexicon of metrics for uptake and coverage of oral PrEP among AGYW. In codifying these indicators, approaches to clearly define metrics for uptake and coverage are outlined, and the discussion on ‘low’ uptake is reframed to focus on achieving the highest possible proportion of AGYW using oral PrEP when they need and want it Recommendations are also provided for making increased investments in implementation research to better quantify the sub-group of AGYW in potential need of oral PrEP.and for improving monitoring systems to more efficiently address bottlenecks in the service delivery of oral PrEP to AGYW so that implementation can be taken to scale.

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Vaginal Ring Adherence in Sub-Saharan Africa: Expulsion, Removal, and Perfect Use

10.31234/osf.io/cm8vg ◽

2020 ◽

Author(s):

Lungwani Muungo

Keyword(s):

Hiv Prevention ◽

Hormone Replacement ◽

Vaginal Ring ◽

Sub Saharan Africa ◽

African Women ◽

Prevention Trials ◽

Sub Saharan ◽

Prevention Method ◽

Prevention Methods ◽

Hiv Negative

In sub-Saharan Africa, HIV incidence andprevalence remain disproportionately high among women.Vaginal rings (VRs) have been formulated for the deliveryof antiretroviral-based microbicides, and their favorablesafety and tolerability profiles reported in clinical studies.Although the concept of drug release through a VR hasexisted since 1970, and VRs have been marketed since1992 for contraceptive or hormone replacement purposes,VR use as a microbicide delivery system is a novelapplication. This is the first study to evaluate VR adherenceamong African women in the context of its potential use asan HIV prevention method, to examine predictors ofadherence, and to describe clinical or contextual reasonsfor VR removals or nonadherence. This was a randomizedtrial of the safety and acceptability of a placebo VR wornfor 12 weeks in 170 HIV-negative, African women aged18–35 in four clinic sites in South Africa and Tanzania.The findings suggest that adherence to VR use in thecontext of HIV prevention trials in these communitiesshould be high, thereby enabling more accurate assessmentof an active microbicide safety and efficacy.Keywords Vaginal ring ? Adherence ? Sub-SaharanAfrica ? Female-controlled HIV prevention methods ?Microbicide delivery

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Maintaining paediatric cardiac services during the COVID-19 pandemic in a developing country in sub-Saharan Africa: guidelines for a “scale up” in the face of a global “scale down”

Cardiology in the Young ◽

10.1017/s1047951120003650 ◽

2020 ◽

Vol 30 (11) ◽

pp. 1588-1594

Author(s):

Ogochukwu J. Sokunbi ◽

Ogadinma Mgbajah ◽

Augustine Olugbemi ◽

Bassey O. Udom ◽

Ariyo Idowu ◽

...

Keyword(s):

Scale Up ◽

Global Scale ◽

International Travel ◽

Sub Saharan Africa ◽

African Continent ◽

Tertiary Centre ◽

The Face ◽

Scale Down ◽

Sub Saharan ◽

International Experts

AbstractThe COVID-19 pandemic is currently ravaging the globe and the African continent is not left out. While the direct effects of the pandemic in regard to morbidity and mortality appear to be more significant in the developed world, the indirect harmful effects on already insufficient healthcare infrastructure on the African continent would in the long term be more detrimental to the populace. Women and children form a significant vulnerable population in underserved areas such as the sub-Saharan region, and expectedly will experience the disadvantages of limited healthcare coverage which is a major fall out of the pandemic. Paediatric cardiac services that are already sparse in various sub-Saharan countries are not left out of this downsizing. Restrictions on international travel for patients out of the continent to seek medical care and for international experts into the continent for regular mission programmes leave few options for children with cardiac defects to get the much-needed care.There is a need for a region-adapted guideline to scale-up services to cater for more children with congenital heart disease (CHD) while providing a safe environment for healthcare workers, patients, and their caregivers. This article outlines measures adapted to maintain paediatric cardiac care in a sub-Saharan tertiary centre in Nigeria during the COVID-19 pandemic and will serve as a guide for other institutions in the region who will inadvertently need to provide these services as the demand increases.

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Promoting Scale-Up Across a Global Project Platform: Lessons from the Evidence to Action Project

Global Implementation Research and Applications ◽

10.1007/s43477-021-00013-4 ◽

2021 ◽

Author(s):

Laura Ghiron ◽

Eric Ramirez-Ferrero ◽

Rita Badiani ◽

Regina Benevides ◽

Alexis Ntabona ◽

...

Keyword(s):

Family Planning ◽

Scale Up ◽

Scaling Up ◽

Sub Saharan Africa ◽

Health System Strengthening ◽

Country Level ◽

Look Ahead ◽

Republic Of The Congo ◽

Sub Saharan ◽

Multi Stakeholder

AbstractThe USAID-funded flagship family planning service delivery project named Evidence to Action (E2A) worked from 2011 to 2021 to improve family planning and reproductive health for women and girls across seventeen nations in sub-Saharan Africa using a “scaling-up mindset.” The paper discusses three key lessons emerging from the project’s experience with applying ExpandNet’s systematic approach to scale up. The methodology uses ExpandNet/WHO’s scaling-up framework and guidance tools to design and implement pilot or demonstration projects in ways that look ahead to their future scale-up; develop a scaling-up strategy with local stakeholders; and then strategically manage the scaling-up process. The paper describes how a scaling-up mindset was engendered, first within the project’s technical team in Washington and then how they subsequently sought to build capacity at the country level to support scale-up work throughout E2A’s portfolio of activities. The project worked with local multi-stakeholder resource teams, often led by government officials, to equip them to lead the scale-up of family planning and health system strengthening interventions. Examples from project experience in the Democratic Republic of the Congo, Kenya, Nigeria, and Uganda illustrating key concepts are discussed. E2A also established a community of practice on systematic approaches to scale up as a platform for sharing learning across a variety of technical agencies engaged in scale-up work and to create learning opportunities for interacting with thought leaders around critical scale-up issues.

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