Thuthukile Mbatha, Spotlight
With around 2 000 new HIV infections every week in young women and girls aged 15 to 24, South Africa is facing an urgent HIV crisis in young women. Given the scale of this crisis, we need to use all the tools at our disposal to help young women stay HIV-free. And yet, uptake of one of the most exciting new tools is happening at a snail’s pace.
Pre-exposure Prophylaxis (PrEP) involves people who are at risk of HIV taking an antiretroviral to avoid becoming HIV-positive. A number of different kinds of PrEP options have been tested, but so far the form of PrEP that has worked best involves taking a daily pill that combines the antiretrovirals tenofovir and emtricitabine. This combination is marketed under various brand names, and when taken as prescribed, it is extremely effective at preventing HIV infection. PrEP in the form of a vaginal ring has also shown some promise, but appears to be less effective than the tenofovir/emtricitabine pill.
So why are we not providing every young woman in South Africa at risk of HIV infection with PrEP? Why, even in 2018, are we talking about providing PrEP to only in the region of ten or twenty thousand young women and girls in the entire country?
One probable reason is that in many of the trials conducted so far, people simply did not take PrEP as regularly and diligently as they should have, i.e. as prescribed. Of course, this difficulty is to be expected – convincing healthy people to take a preventative pill is hard, especially if there might be some minor side effects associated with that pill. Thus there is a worry that pills purchased by the state may go unused, or be used only intermittently.
A second (and related) reason might be that studies and mathematical models suggest that – from a big-picture public health perspective, at least – PrEP is not the game-changer many hoped it would be. Broadly speaking, to roll back the HIV epidemic, prioritising the treatment and retention of treatment of people already living with HIV will have greater impact than a PrEP rollout. From a public health perspective, then, PrEP might have relatively low priority.
A third probable reason is cost. Though a month’s supply of PrEP should cost the state less than R100 per person, there are also the associated costs of counselling, and ongoing care and monitoring.
While the financial and human resource costs of a PrEP rollout would indeed be significant, this should be offset against the economic benefits of preventing HIV infections. Several studies have been done in South Africa to test the cost-effectiveness of rolling out PrEP to young women, and the evidence suggests overwhelmingly that PrEP could be a cost-effective tool to reduce HIV infections among key population groups – especially because it need not be a lifelong drug; it is only taken when one is exposed to a greater risk of contracting HIV.
However, these reasons pay scant regard to individuals and their rights. The statistics clearly tell us that young women are sexually active, and being exposed to the risk of HIV infection – how else would we have 2 000 HIV infections a week?
By dragging its feet with the rollout of PrEP, the state is saying to young women: “This new tool with which you could protect yourselves exists, but we don’t think you should have it. Even if you know you are at high risk of contracting HIV. Even if you have a violent boyfriend who refuses to use a condom. Even then, we will not give you PrEP to help you protect yourself.”
Section 27 of The Bill of Rights in the Constitution of South Africa states that “Everyone has the right to have access to healthcare services, including reproductive health care”. It then goes on to say that the state must take reasonable legislative and other measures, within its available resources, to achieve the progressive realisation of this right.
Every young woman or girl in South Africa at risk of HIV infection has these rights, just like any other individual in the country. Accordingly, the state is obliged to fulfil these rights, as far as is reasonable and within its resources. That PrEP might not be the big game-changer in the HIV epidemic in South Africa does not matter. What matters is that there is a relatively cheap pill that can help young women and girls stay HIV-free, in the midst of a still-raging HIV epidemic.