Since HIV/AIDS has no cure or vaccine, prevention of new HIV infection remains an important strategy towards ending HIV and AIDS. Effective HIV prevention response needs to consider the various underlying biological, behavioral, sociocultural, economic, political, legal, and other contextual factors.
In recognition of this, Zanzibar implements combination prevention interventions, which include biomedical interventions, such as proper and consistent use of male and female condoms, screening and treatment of sexual transmitted infections(STIs),Post-Exposure Prophylaxis(PEP), and safer conception choices for HIV positive mothers or women of the childbearing age group who are in sero-discordant relationships and Pre-Exposure Prophylaxis(PrPEP),a newly introduced biomedical tool for preventing primary HIV infection among individuals with a substantial ongoing risk of HIV, such as key and vulnerable populations.
Pre-Exposure Prophylaxis (PrEP)
Pre-Exposure Prophylaxis (PrEP) is the use of antiretroviral drugs (ARVs) by people who do not have HIV infection in order to prevent the acquisition of HIV.WHO recommends that oral PrEP containing tenofovir disoproxil fumarate (TDF) should be offered as an additional prevention choice for people at substantial risk of HIV infection as part of combination HIV approaches. These populations include Men who have Sex with Men (MSM), Female Sex Workers (FSW), People Who Inject Drugs (PWID), and discordant couples. However, PrEP should not replace or compete with effective and well-established HIV prevention interventions, such as comprehensive condom programming for sex workers and men who have sex with men and harm reduction for people who inject drugs.
PrEP Target Populations
The target population for PrEP in Zanzibar currently include the following
- Key population (i.e., sex workers, men who have sex with men, and people who inject drugs).
- HIV negative partners in sero-discordant relationships (i.e., when an HIV infected partner is not on ART or is on ART for less than six months or has not attained viral suppression less than 50copies/ml). This includes HIV negative pregnant and breastfeeding mothers in a sero-discordant relationship.
PrEP Eligibility Criteria
- HIV seronegative as per the current national testing algorithm
- No suspicion of acute HIV infection
- Age greater than or equal to 15 years
- Willing to use PrEP as prescribed
- Willing to stop PrEP when no longer eligible
- No contraindications PrEP medicines (TDF/FTC), including having creatinine clearance > 60ml/min**
Having a substantial risk of HIV acquisition, defined as engaging in one or more of the following activities within the last six months:
- Vaginal or anal sex without a condom with more than one partner or,
- History of a new sexually transmitted infection or,
- Use of post-exposure prophylaxis for sexual exposure or,
- Has a known HIV positive sexual partner(s) who is not on ART/ on ART less than six months or refuses to report a risk category but still request PrEP
Clients Ineligible for PrEP
- HIV positive status ‘OR’ Unknown HIV status
- Sign/symptoms of acute HIV Infection (AHI), probably recent exposure to HIV
- Known renal impairment or estimated creatinine clearance <60ml/min (if known)
- Significantly mobile persons who will not be able to attend visits as per prescribed. For example:
- Clients who will not be in a region where PrEP can be provided at the next visit
- Clients who do not have contact information
- Unwilling/unable to take daily medication
- Allergy or contraindication to any medication within PrEP regimen
Preferred ARV PrEP regimens
The recommended PrEP regimen is Emtricitabine (FTC) 200mg/Tenofovir Disoproxil Fumarate (TDF) 300mg (Truvada) taken orally once daily.
Indications for PrEP Discontinuation
Individuals taking PrEP require an ongoing risk assessment, and PrEP can be discontinued if individuals acquire HIV infection, are no longer substantial risk for HIV infection or decide to use other effective prevention methods or poor adherence or severe side effects/adverse events.
Note: PrEP should be provided for at least 28 days after the last possible exposure to HIV.
PrEP Service Delivery Modality
PrEP can be provided both at health facilities or MOH-approved community locations/hotspots. PrEP should be provided as part of a comprehensive prevention package of interventions.