Outcomes and Interventions for Sexually Transmitted Infections in sub-Saharan Africa

By Samantha Dulak BS and Heather F. McClintock PhD MSPH MSW

This is the second part of a IH Blog series featured this summer, Sexually Transmitted Infections in sub-Saharan Africa: Determinants, Outcomes, and Interventions.

Part II: Outcomes and Interventions for Sexually Transmitted Infections in sub-Saharan Africa

Sexually transmitted infections (STIs) are a significant public health burden globally and are a leading cause of mortality in lower middle income countries (LMICs). In 2016, there were 988,000 women infected with syphilis worldwide, resulting in 350,000 deaths and delivery complications (Korenromp, Rowley, Alonso, et al., 2019). Human papillomavirus (HPV), an incurable STI, leads to over half a million new cases of cervical cancer every year (Bray, Ferlay, Soerjomataram, et al., 2018). Cervical cancer can be the result of other factors, however, in 90% of all cervical cancer cases that resulted in death, the cancer was caused by HPV (WHO, 2018). Of the 1.8 million newly diagnosed HIV infections each year, 940,000 individuals died globally from AIDS related factors (UNAIDS, 2019a). Unfortunately, a third of those deaths (302,700) are among females aged 15-49 living in sub-Saharan Africa (UNAIDS, 2019b). Higher rates of complications are found in sub-Saharan Africa because of inadequate clinician training, delayed diagnosis, and limited care seeking behaviors (Mayaud & Mabey, 2004). STI surveillance systems are absent or poorly functioning in Africa causing unreliable data on the prevalence of these infections.

STIs are common in low resource settings and their impact can be catastrophic on the lives of individuals. The list of potential complications is extensive. Untreated gonorrhea and chlamydia are associated with the development of arthritis, hepatitis B with liver cancer, and syphilis with central nervous system disorders (Aral, Over, Manhart, & Holmes, 2006). While all individuals are at risk, women and children are disproportionately affected by a greater burden of disability, as assessed by disability adjusted life years. Women suffering without treatment can experience chronic pelvic and abdominal inflammation leading to infertility, spontaneous abortions, and many adverse pregnancy outcomes (Chesson, Mayaud, & Aral, 2017). 

International attention on STI outcomes is imperative to reducing the incidence of STIs not only in sub-Saharan Africa, but globally. Most attention has focused on HIV due to the public health crisis we are experiencing now. The World Health Organization (WHO) and the Joint United Nations Programme on HIV/AIDS (UNAIDS) reported that Africa has the highest burden of STIs compared to all other continents (Lewis, 2011). The UNAIDS 2018 report on the global AIDS epidemic found that there are 37.9 million people living with AIDS in the world and 20.6 million of them live in eastern and southern Africa (UNAIDS, 2019a). 

Prevention strategies in sub-Saharan Africa place a heavy emphasis on sexual health education. A meta analysis of 51 papers reported that while school-based sexual health education significantly increased condom usage, there was no significant effect on the incidence of STIs (Sani, Abraham, Denford, & Ball, 2016). This information is promising, though. School aged children are experiencing positive behavior changes through the use of physical protection methods. Some studies even report a change of attitude towards persons living with HIV/AIDS (Paul-Ebhohimhen, Poobalan, & van Teijlingen, 2008). However, a focus on at-risk groups is missing. Sex workers, men who have sex with men, and intravenous drug users all have high susceptability to contracting an STI and greater attention needs to be directed towards prevention in these populations to reduce the incidence of STIs. 

To address the vast number of cases of cervical cancer caused by HPV, many sub-Saharan countries now qualify for assistance from the Global Alliance for Vaccines and Immunization. As of 2018, eight countries have HPV vaccine programs for school aged children, with pilot programs implemented in nearly 16 additional countries (Black and Richmond, 2018). Data for all 8 countries is not public as of now, but of the five countries with available data, the success rate for at least one dose of the vaccine is 83% (Black and Richmond, 2018). Rwanda was the only country to successfully complete three doses, covering 98.7% of girls (Black and Richmond, 2018).

From a global perspective, Sustainable Development Goals (SDGs) aim to ensure access to sexual and reproductive care and end the AIDS epidemic by 2030 (UN General Assembly, 2015). Primary prevention strategies have become popular among many countries to promote these goals. In 2018, the WHO reported on global STI surveillance, indicating that 44% of countries have HPV vaccines in their immunization programs (WHO, 2018). To reach those who are not benefiting from immunization initiatives, the 2016 Global STI Strategy, along with strategies for HIV and viral hepatitis, fight to meet the SDG 2030 agenda (WHO, 2018). The Global STI Strategy focuses on creating affordable interventions for at-risk individuals and adolescents in all countries. These plans are financed and delivered by promoting universal health care coverage to keep costs low (WHO, 2018). Additionally, the Gonococcal Antimicrobial Surveillance Programme (GASP) has improved national monitoring of antimicrobial resistance to gonorrhea in order to provide stronger data for new treatment research (Wi et al., 2017).

Samantha Dulak BS

Ms. Dulak was a biology major and global public health minor at Arcadia University. She has a strong interest in nutrition as well as maternal and child health. She now hopes to attend graduate school for public health and pediatrics.

Heather F. McClintock PhD MSPH MSW 

Dr. McClintock is an IH Section Member and Assistant Professor in the Department of Public Health, College of Health Sciences at Arcadia University. She earned her Master of Science in Public Health from the Department of Global Health and Population at the Harvard School of Public Health. Dr. McClintock received her PhD in Epidemiology from the University of Pennsylvania with a focus on health behavior and promotion. Her research broadly focuses on the prevention, treatment, and management of chronic disease and disability globally. Recent research aims to understand and reduce the burden of intimate partner violence in Sub-Saharan Africa. Prior to completing her doctorate she served as a Program Officer at the United States Committee for Refugees and Immigrants and a Senior Project Manager in the Center for Clinical Epidemiology and Biostatistics, University of Pennsylvania. At the University of Pennsylvania she led several research initiatives that involved improving patient compliance and access to quality healthcare services including the Spectrum of Depression in Later Life and Integrating Management for Depression and Type 2 Diabetes Mellitus Studies.

References

Aral, S.O., Over, M., Manhart, L., Holmes, K.K. (2006). Sexually Transmitted Infections. In Jamison, D.T., Breman, J.G., Measham, A.R, Alleyne, G., Claeson, M., Evans, D.B., Jha, P., Mills, A., Musgrove, P. (Eds), Disease Control Priorities in Developing Countries, second edition. 311–30. Washington (DC): World Bank and Oxford University Press.

Black, E., Richmond, R. (2018) Prevention of Cervical Cancer in Sub-Saharan Africa: The Advantages and Challenges of HPV Vaccination. Vaccines, 6(3), 61. doi: https://doi.org/10.3390/vaccines6030061

Bray, F., Ferlay, J., Soerjomataram, I., Siegel, R.L., Torre, L.A., Ahmedin, J. (2018). Global Cancer Statistics 2018: GLOBOCAN Estimates of Incidence and Mortality Worldwide for 36 Cancers in 185 Countries. CA: A Cancer Journal for Clinicians, 68: 394–424.

Chesson, H.W., Mayaud, P., & Aral, S.O. (2017). Sexually Transmitted Infections: Impact and Cost-Effectiveness of Prevention. In Holmes, K.K., Bertozzi, S., Bloom, B.R., & Jha, P. (Eds.), Major Infectious Diseases, third edition. Washington (DC): The International Bank for Reconstruction and Development and The World Bank.

Mayaud, P., Mabey, D. (2004). Approaches to the Control of Sexually Transmitted Infections in Developing Countries: Old Problems and Modern Challenges. Sexually Transmitted Infections, 80(3), 174–182. doi: 10.1136/sti.2002.004101

Korenromp, E.L., Rowley, J., Alonso, M., Mello, M.B., Wijesooriya, N.S., et al. (2019) Global burden of maternal and congenital syphilis and associated adverse birth outcomes—Estimates for 2016 and progress since 2012. PLOS One, 14(2): e0211720.

Lewis, D.A. (2011). HIV/sexually transmitted infection epidemiology, management and control in the IUSTI Africa region: focus on sub-Saharan Africa Sexually Transmitted Infections. BMJ, 87(2), ii10-ii13. doi: 10.1136/sextrans-2011-050178

Paul-Ebhohimhen, V.A., Poobalan, A., van Teijlingen, E.R. (2008). A systematic review of school-based sexual health interventions to prevent STI/HIV in sub-Saharan Africa. BMC Public Health, 8(4). doi: 10.1186/1471-2458-8-4

Sani, A.S., Abraham, C., Denford, S., & Ball, S. (2016). School-based sexual health education interventions to prevent STI/HIV in sub-Saharan Africa: a systematic review and meta-analysis. BMC Public Health, 16, 1069. doi: 10.1186/s12889-016-3715-4

UN General Assembly. (2015). Transforming our world : the 2030 Agenda for Sustainable Development. Retrieved 16 July 20219 from https://www.un.org/sustainabledevelopment/health/

UNAIDS. (2019a). Global HIV & AIDS statistics — 2019 fact sheet. Retrieved 16 July 2019 from https://www.unaids.org/en/resources/fact-sheet

UNAIDS. (2019b). In sub-Saharan Africa, three in five new HIV infections among 15–19-year-olds are among girls. Retrieved 15 July 2019 from https://www.unaids.org/en/resources/infographics/women_girls_hiv_sub_saharan_africa

Wi, T., Lahra, M. M., Ndowa, F., Bala, M., Dillon, J. R., Ramon-Pardo, P., . . . Unemo, M. (2017). Antimicrobial resistance in Neisseria gonorrhoeae: Global surveillance and a call for international collaborative action. PLoS Medicine, 14(7). doi:10.1371/journal.pmed.1002344

The World Health Organization [WHO]. (2018). Report on global sexually transmitted infection surveillance. Retrieved 15 July 2019 from https://apps.who.int/iris/bitstream/handle/10665/277258/9789241565691-eng.pdf?ua=1.

Sexually Transmitted Infections in Sub-Saharan Africa

By: Samantha Dulak BS and Heather McClintock PhD MSPH MSW

This is the first part of a IH Blog series featured this summer, Sexually Transmitted Infections in Sub-Saharan Africa: Determinants, Outcomes, and Interventions.

Part I: Sexually Transmitted Infections in Sub-Saharan Africa

Sexually transmitted infections (STIs) are common acute conditions that while exacting a tremendous toll on health and well-being currently receive minimal media coverage and attention. This is likely due to resources being allocated to other new and emerging conditions, the stigma associated with people who are perceived to be able to contract STIs, and a lack of education about STI symptoms and treatment. STIs range from curable (syphilis, gonorrhea, chlamydia, and trichinosis) to incurable (HPV and HIV/AIDS) infections. The nearly 30 STIs are most commonly transmitted through sexual encounters, but contact with blood and mother to child transmission during pregnancy are other ways STIs can be spread (Newman et al., 2015). Comparing the four curable STIs globally, sub-Saharan Africa had the highest incidence and prevalence of syphilis and gonorrhea (Chesson, Mayaud, & Aral, 2017). Unfortunately, STIs can raise HIV transmission up to four times which is why controlling STIs is at the top of the public health professional’s radar (Stillwaggon & Sawers, 2015). The highest prevalence of HIV is found in sub-Saharan Africa with 53% of the world’s HIV population living there and 56% of those individuals being women (UNAIDS, 2018). Although incidence rates are falling globally, 1.8 million people were newly diagnosed in sub-Saharan Africa in 2017; there is much more work to be done to reach the 2020 goal of less than 500,000 new cases in this region (UNAIDS, 2018). The current estimates state that 66% of all new global HIV infections occur in sub-Saharan Africa (UNAIDS, 2018).

STIs affect people of all socioeconomic classes in every country. Without proper precautions, no one is immune from these infections. STIs in sub-Saharan Africa are particularly important because the largest estimates are reported in this region and public health advances can provide insight and hope to other countries that are affected. Combating the negative stigma around STIs will increase the amount of people who will know their status, subsequently increasing treatment for those infections that are treatable. Furthermore, globalization perpetuates the spread of STIs across geographic boundaries highlighting the importance of acknowledging and addressing STIs on a broad scale.

STIs cause major pregnancy complications such as ectopic pregnancies, infertility, and spontaneous abortions (Chesson, Mayaud, & Aral, 2017). In both men and women, liver cancer, central nervous system diseases, and arthritis are all common comorbidities (Aral, Over, Manhart, & Holmes, 2006). Due to insufficient diagnosis and treatment in many lower and middle income countries, the rates of complications are much higher. This inadequacy can be attributed to the asymptomatic nature of some STIs, lack of education on the topic, or poor care-seeking behaviors (Mayaud & Mabey, 2004).

There are many at-risk groups for contracting STIs, including men who have sex with men, female sex workers, children born to women with STIs, and intravenous drug users. An interesting connection to be made exists for women who experience intimate partner violence (IPV). IPV can include physical or sexual violence, stalking, and psychological control over one’s spouse or dating partner (Centers for Disease Control, 2019). Women are already disproportionately affected by STIs, and these rates are greatest in women who also have reported cases of IPV. One answer for this is that women who have experienced IPV are more likely to have high-risk partners (Miller, 1999). Abusive partners may express coercive behaviors both within and outside of the relationship (Miller, 1999). Additionally, people experiencing IPV can suffer psychological trauma leading them to have impaired decision-making skills and experience increased risk-taking behavior (Miller, 1999).

As of 2018, the World Health Organization has been utilizing the Joint United Nations Programme on HIV/AIDS (UNAIDS) Global AIDS Monitoring system to quantify cases of STIs at the country level and the Gonococcal Antimicrobial Surveillance Programme (GASP) to follow antimicrobial resistance for the treatable STI, gonorrhea (Wi et al., 2017). For GASP to have continued success, international collaboration must be strengthened to develop advanced screening procedures and novel antibiotic treatments. By continually improving both monitoring systems, there may be hope for new vaccines for STIs we are still not protected from. Since antimicrobial resistance is not evolving at the same time across all countries, sharing data and laboratory methods for new pharmaceutical development is imperative to control the spread of STIs in sub-Saharan Africa (Wi et al., 2017).

References

Aral, S.O., Over, M., Manhart, L., Holmes, K.K. (2006). Sexually Transmitted Infections. In Jamison, D.T., Breman, J.G., Measham, A.R, Alleyne, G., Claeson, M., Evans, D.B., Jha, P., Mills, A., Musgrove, P. (Eds), Disease Control Priorities in Developing Countries, second edition. 311–30. Washington (DC): World Bank and Oxford University Press.

Center for Disease Control [CDC]. (2019). Preventing Intimate Partner Violence. Retrieved May 27, 2019, from https://www.cdc.gov/violenceprevention/intimatepartnerviolence/fastfact.html

Chesson, H.W., Mayaud, P., & Aral, S.O. (2017). Sexually Transmitted Infections: Impact and Cost-Effectiveness of Prevention. In Holmes, K.K., Bertozzi, S., Bloom, B.R., & Jha, P. (Eds.), Major Infectious Diseases, third edition. Washington (DC): The International Bank for Reconstruction and Development and The World Bank.

Mayaud, P., Mabey, D. (2004). Approaches to the Control of Sexually Transmitted Infections in Developing Countries: Old Problems and Modern Challenges. Sexually Transmitted Infections, 80(3), 174–182. doi: 10.1136/sti.2002.004101

Miller, M. (1999). A model to explain the relationship between sexual abuse and HIV risk among women. AIDS Care, 11(1), 3-20. doi:10.1080/09540129948162

Newman, L., Rowley, J., Hoorn, S. V., Wijesooriya, N. S., Unemo, M., Low, N., . . . Temmerman, M. (2015). Global Estimates of the Prevalence and Incidence of Four Curable Sexually Transmitted Infections in 2012 Based on Systematic Review and Global Reporting. PLos One, 10(12). doi:10.1371/journal.pone.0143304

Stillwaggon, E., & Sawers, L. (2015). Rush to judgment: The STI-treatment trials and HIV in sub-Saharan Africa. Journal of the International AIDS Society, 18(1), 19844. doi:10.7448/ias.18.1.19844

UNAIDS. UNAIDS: Data 2018. 2018. https://www.unaids.org/sites/default/files/media_asset/unaids-data-2018_en.pdf (accessed 26 May 2019).

Wi, T., Lahra, M. M., Ndowa, F., Bala, M., Dillon, J. R., Ramon-Pardo, P., . . . Unemo, M. (2017). Antimicrobial resistance in Neisseria gonorrhoeae: Global surveillance and a call for international collaborative action. PLoS Medicine, 14(7). doi:10.1371/journal.pmed.1002344

Samantha Dulak

Samantha Dulak is a recent graduate from Arcadia University. She received her Bachelor of Science in Biology and a Minor in Global Public Health. Her enthusiasm for medicine and disease prevention perfectly intertwine these two fields of study. Her current public health interests are in maternal and child health and nutrition. Since graduation, Samantha has applied to naturopathic medical school with a goal of becoming a pediatric physician. In her free time, she enjoys reading, playing sports, and baking.

Dr. Heather F. McClintock PhD MSPH MSW

Dr. McClintock is an IH Section Member and Assistant Professor in the Department of Public Health, College of Health Sciences at Arcadia University. She earned her Master of Science in Public Health from the Department of Global Health and Population at the Harvard School of Public Health. Dr. McClintock received her PhD in Epidemiology from the University of Pennsylvania with a focus on health behavior and promotion. Her research broadly focuses on the prevention, treatment, and management of chronic disease and disability globally. Recent research aims to understand and reduce the burden of intimate partner violence in Sub-Saharan Africa. Prior to completing her doctorate she served as a Program Officer at the United States Committee for Refugees and Immigrants and a Senior Project Manager in the Center for Clinical Epidemiology and Biostatistics, University of Pennsylvania. At the University of Pennsylvania she led several research initiatives that involved improving patient compliance and access to quality healthcare services including the Spectrum of Depression in Later Life and Integrating Management for Depression and Type 2 Diabetes Mellitus Studies.

The Future of HIV: Novel Treatment Options & A Possible Cure

As the medical community and those it serves welcomed in a new year, it brought with it the hope of scientific advancements that will alter the course of certain disease states. These advancements include the use of stem cells to treat to treat macular degeneration, novel microscopic techniques to capture images of the brain, the continued observed effectiveness of the experimental Ebola vaccine, and countless other interventions aimed at creating a healthier global society. Included in these optimisms for 2019 is the possibility for novel treatment options and a possible cure for one of the world’s leading causes of death, HIV. The stories of Timothy Brown – the only individual ever to be cured of HIV, the Mississippi baby and Clark Hawley – both having an extended period of time with undetectable HIV viral load with an interruption of Antiretroviral Therapy (ART), and the Boston patients/Mayo Clinic patient – all three having undetectable HIV viral loads for an extended period of time after a stem cell transplant, have brought much sanguinity to health care professionals and patients alike. However, these exciting results have been unable to be replicated in the majority of the population suffering from HIV and remain unique in their respective occurrences. Although ART has been vital to the HIV community in terms of longevity and quality life, there are still certain populations that are seeking other mechanisms to treat this infectious disease – and, of course, always coveting the idea of a cure. The following is a brief glimpse at the vast pipeline that awaits 2019 and the anticipations of the global healthcare community.  

Combination Approaches

  1. The AIDS Clinical Trial Group (ACTG) is currently exploring the option of combining vorinostat, a HDAC inhibitor along with tamoxifen, which is an FDA approved medication the treatment of breast cancer for postmenopausal women. Utilizing this approach is thought to prevent the reactivation of HIV in CD4+ cells that are latent in addition to increasing the latency-reversal effect of vorinostat through tamoxifen.
  2. Researchers from the USA, France, Germany, Italy, Spain, Switzerland, and the UK are collaborating for a trial testing the combination of two HIV vaccine candidates alongside a monoclonal antibody called vedolizumab. This method of treatment is thought to target a certain protein in the body, α4β7 integrin, that plays a role in transmission of HIV into CD4+ cells. In a macaque model, this combination has shown the control of SIV (HIV but in simians) after discontinuing ART.
  3. At the University of Minnesota, researchers are testing infusions of natural killer (NK) cells with the administration of cytokine interleukin-2 (IL-2). The researchers are hoping to add to the evidence of NK cells being able to exhaust HIV reservoirs and to control virus replication.
  4. In a version of the “kick & kill” method of curing HIV, researchers in Oxford and Barcelona are using a medication to active the latent HIV reservoir while boosting the immune response 1000 times stronger than the usual to rid the body of the virus. Preliminary results showed that 5/15 patients had undetectable viral loads for seven months without ART.

Immunotherapy Approaches

  1. Immunocore, a company founded in Oxford with heavy investment by Bill Gates, has designed T cell receptors that seek out and bind with the HIV virus. These receptors then instruct immune T cells to eliminate any HIV-infected cells, even when the levels happen to be extremely low. Since levels can be rather low in the reservoir of HIV virus that exists in an infected individual, this is a promising lead to completely remove this retrovirus from the body. This immunotherapy has shown to be effective in human tissue samples, but no results being tested in humans have been released.
  2. In France, a company known as InnaVirVax has established a vaccine, VAC-3S, that allows the body to stimulate a production of antibodies against the HIV protein 3S. This, in turn, causes T cells to attack the virus. This is considered a novel approach because it encourages the immune system to recover while equipping it with the tools to continue fighting off the virus. VAC-3S has completed Phase 2a trials, and is partnered with a DNA-based vaccine from FIT Biotech, a Finnish company, that both parties believe can lead to a functional cure.  
  3. In a recently initiated trial, IMPAACT 2008, held in the USA, Botswana, Brazil, and Zimbabwe, a broadly neutralizing antibody termed VRC01 is being investigated for its effectiveness in infants with HIV who are also started on ART within 12 weeks of birth. Although the study aims at establishing the safety profile for VRC01, it is also observing the difference in the HIV reservoir compared with only ART.

Novel Antiretroviral Agents

  1. The manufacturer, ABIVAX, believes it has developed a compound that may help the immune system recognize cells infected with HIV by allowing an increased presentation of HIV antigens on the cell’s service. This would lead to an augmented immune response to abolish these infected cells. This compound has been labelled ABX464 and targets the HIV protein Rev, which is responsible for the transcription of HIV RNA. Reductions of measured HIV DNA have been reported from 25% to 50% in eight of the fifteen patients participating in the study; however, no delay in viral load rebound was found when compared with placebo.
  2. Gilead has created a novel mechanism of targeting the HIV virus through the capsid inhibitors class. Capsids are involved in protecting HIV RNA and related proteins, and capsids also breaks down to release the viral contents into CD4 cells which enable reverse transcription to take place. The novel agent by Gilead, GS-CA1, blocks both the assembly and disassembly of capsids that create non-infectious and defective viruses.

Gene Therapy

  1. Chimeric antigen receptor (CAR) T therapy has been re-initiated in the first cure related clinical trial of this approach in people living with HIV who are on ART. CAR T cell therapy involves the modification of an individual’s T cells that can target antigens of interest. The specific cells modified by the initiative in China, called VC-CAR-T cells, have been modified to target HIV gp120. These modified cells were able to induce the destruction of HIV-infected cells, including latently infected cells exposed to latency-reversing agents, in the laboratory setting.  
  2. With the knowledge of knowing that about 1% of the world’s population is immune to HIV due to a genetic mutation on the gene that encodes for CCR5, US-based Sangamo has begun to edit DNA to introduce the aforementioned mutation. The CCR5 protein is attached to the surface of CD4 cells that allows HIV to enter and infect the cell; with the mutation, it would be impossible for HIV to enter cells. This company extracts patient’s CD4 cells in order to use zinc finger nucleases to edit patient’s DNA to make them resistant to HIV.
  3. Although a highly controversial topic amid the recent publication of the use of CRISPER in twin daughters in China, scientists believe that this tool can lead to a cure for HIV as it is believed to be a much easier, faster, and effective approach than other gene-editing methods. However, the majority of the global health community is in agreement that years of laboratory research and ethical standards need to be established before human trials are properly started.

With the HIV virus adapting and mutating to evade treatments almost as rapidly as the world is producing novel approaches to treating this infectious disease, the drive for continued research and testing should be relentless. These aforementioned examples of novel treatments and possible cures display the creative and diverse thought processes the medical community has put forth to tackle one of the most stigmatized diseases on this earth. However, the ethics behind these trials need to be sound and forthcoming for all of humanity. The trials that occur need to ensure an assortment of demographics including individuals from both developed and developing nations – a subtle form of medical colonialism has no place in the global health community. In addition, trials that enroll patients who willingly accept the benefits and risks associated with the experimental therapy have the moral obligation to supply lifetime treatment if it happens to be effective. The researchers and medical professionals who monitor these participants need to take extreme caution in ART interruptions/discontinuations and certify that the patients realize what complications could transpire due to them. Finally, and most importantly, the interventions that show promise of novel ways to approach HIV or even a cure have to be accessible, affordable, and available to all humans who suffer from HIV. The health inequalities that plague this fragile planet have already been clearly highlighted in this ailment throughout history; the global health community is in debt to humanity for a cure for all when discovered.  

With the global health community’s commitment, the future of the HIV virus continues to transition from infectious disease to chronic disease. While the step that will advance the chronic disease to a cure is still thought to be unknown, the excitement behind the aforementioned gene editing therapy is substantial. The ability to safely, effectively and ethically modify human cells to prevent the entry of the virus into the immune system is certainly the most promising option recently and possibly from this disease’s initial appearance; although, health care professionals haven’t quite figured out how to combine these aspects yet. A cure or even functional cure may be years away, but the global health community needs to continue to accompany those inflicted by this chronic infectious disease to meet the hopes and expectations of alleviating the burdens of HIV.

Empowering Women to Take Control of their Sexual Health

Two weeks ago, I attended a powerful and motivating summit hosted by Florida International University (FIU) Robert Stempel College of Public Health and Social Work on empowering women to take control of their sexual health through knowledge of biomedical HIV prevention methods, connecting to community resources, and mobilizing key community stakeholders and providers.

What was most unique about this summit was the rawness of the various conversations. These conversations included voices of state congresswoman Frederica Wilson and Ileana Ros-Lehtinen, community women and activists, a panel of diverse physicians and nurse practitioners, researchers, and LGBT and minority women working across different sectors in the HIV prevention field. When it comes to empowering women surrounding their sexual health, pre-exposure prophylaxis (PrEP) is viewed as the driving vehicle. The problem is that there is a lack of awareness among women particularly LGBT and minority women, and providers about PrEP and post-exposure prophylaxis (PEP). During the engaging providers panel comprised of various physicians working in South Florida, a Haitian physician expressed that before the conference he decided to call several of his provider friends that practice within the local Haitian community and asked them if they have heard of PrEP. How many do you think said, “Of course, I know about PrEP”? The answer is…0. Not one single doctor whom was asked said they have heard of PrEP. We have a lot left to do. The work has not yet been done!

Miami’s HIV Epidemic

So maybe you are wondering…well why host this conference? The county of Miami-Dade continues to lead the nation in new HIV infections. Not too far away is the neighboring county of Broward which continues to compete with Miami when it comes to high prevalence rates as well.

Due to the rising rates of HIV in Miami-Dade County, city officials have responded to the epidemic with the development of a “Getting to Zero” task force comprised of city commissioners and individuals representing various public health agencies throughout Miami-Dade County as well as the state of Florida. The task force devised a multi-pronged action plan with priority goals for the next two years. The plans include to (1) reduce the rates of reported AIDS cases, (2) reduce the percentage of newly diagnosed HIV cases among residents aged 13-19 (3) increase the percentage of newly identified HIV-infected persons who are linked to care within 90 days of diagnosis and are receiving appropriate preventive care and treatment services in Miami-Dade County and (4) reduce the number of newly reported HIV cases in Miami-Dade County (http://www.miamidade.gov/releases/2016-09-29-mayor-getting-to-zero.asp).

Prep around the globe

PrEP has served as a vehicle for prevention and is being used worldwide. Countries such as the United States has large scale PrEP programs while others are still in the stages of development and some have not implemented as of yet. There has been many PrEP initiatives enacted. The US Agency for International Development (USAID) is currently supporting 5 Microbicide Product Introduction Initiative (MPii) projects in Kenya, South Africa, Zimbabwe, Malawi, and Uganda from 2015-2020 focused on gender-based violence, drug resistance, creating demand, introducing new products, and models for delivering services. Another program is the DREAMS (Determined, Resilient, Empowered, AIDS-free, Mentored and Safe) initiative, a collaborative effort between US President’s Emergency Plan for AIDS Relief (PEPFAR), Bill & Melinda Gates Foundation, Girl Effect, Johnson & Johnson, Gilead Sciences and ViiV Healthcare. DREAMS aims to reduce the incidence of HIV by 40% among adolescent girls and young women by 2020 in the highest HIV burden countries including Kenya, Lesotho, Malawi, Mozambique, South Africa, Swaziland, Tanzania, Uganda, Zambia and Zimbabwe. Of the 10 countries, 5 have included PrEP for adolescent girls and young women in their strategic plans to address HIV. Recent data from PEPFAR shows significant declines in new HIV diagnoses among adolescent girls and young women. In the 10 African countries implementing PEPFAR’s DREAMS partnership, the majority of the highest HIV-burden communities or districts achieved greater than a 25 percent–40 percent decline in new HIV diagnoses among young women (https://www.usaid.gov/what-we-do/global-health/hiv-and-aids/technical-areas/dreams). In other areas of the globe such as Latin America and the Caribbean, a combination of biomedical, structural, and behavioral interventions is greatly needed in order to reach target objectives and goals and ultimately increase HIV prevention efforts. I am excited to see the future of PrEP.

Women’s Perspectives

During the women’s perspectives breakout sessions, workshops were broken down into specific focus groups including African American, Latina and Haitian. Amongst the African American women breakout session, some key topics that were addressed included stigma, specifically communication between the medical provider and client such as clear language on how to ask questions during the appointment while also considering time constraints, policy, and the need for funding toward effective behavioral interventions for HIV negative black women in the community.

Sistas Organizing to Survive (SOS) is a grassroots mobilization of black women in the fight against HIV and AIDS. In Florida, one in 68 non-Hispanic black women are known to be living with HIV/AIDS and has been the leading cause of death among black women aged 25-44 years within the state. (http://www.floridahealth.gov/diseases-and-conditions/aids/administration/minority-initiatives.html)

Call to Action

Miami is the #1 city in the United States with new HIV infections. This is a huge public health issue. We have a call to action to advocate for ourselves and others when it comes to ending the epidemic. We have made significant strides, but the work has not yet been done. Sexual health including HIV prevention should be something that we freely discuss with our family, colleagues, peers, physicians, and anyone that we come in contact with that is willing to listen. It is these conversations that we can decrease stigma surrounding HIV. Women across the counties of Broward, Miami-Dade, and Palm Beach have answered the call to action by organizing and advocating for all women. We have accepted the call to action together that we can get Miami to Zero!

“A future where new HIV infections are rare, and when they do occur, every person, regardless of age, gender, race/ethnicity, sexual orientation, gender identity, or socio-economic circumstance will have unfettered access to high quality, life-extending care, free from stigma and discrimination.”

–Quote from the National HIV/AIDS Strategy Updated to 2020: Strategy Vision

For additional information, please visit http://www.who.int/hiv/topics/prep/en/ http://amp4health.org/ and http://getting2zeromiami.com/

Access to PrEP under NHS England: My trip to London

Pre-exposure prophylaxis (PrEP) is a way to prevent HIV infection for people who do not have HIV but who are at high risk of getting it by taking the pill everyday. When someone is exposed to HIV through sex or injection drug use, PrEP can work to keep the virus from establishing a permanent infection. Individuals who take 7 PrEP pills per week, have an estimated level of protection of 99%. It is a powerful prevention tool combined with condoms.

In the United States, PrEP became available in 2012 by the FDA and can be accessed in most clinics and hospitals and is free under most insurance plans. As of 2017, there are an estimated 136,000 people currently on the drug for HIV prevention. This is not the case in the United Kingdom. As a part of a research project for my MPH degree I traveled to London, England to meet with members from the LGBT community, advocates and public health professionals and to learn more about access to PrEP under the National Healthcare System (NHS) England. Currently, PrEP is not available under NHS England even though HIV continues to be a prevalent problem in England, namely among men who have sex with men (MSM) where approximately 54% of the total of MSM population were diagnosed in 2015. England is however enrolling 10,000 people over 3 years through the PrEP IMPACT trial.

Wales, Scotland, and Northern Ireland are also a component of the NHS. Wales has commenced their PrEPared Wales project, which provided information on where to access PrEP in the country. Scotland is currently the only country in the UK that offers a full PrEP provision through their NHS. Northern Ireland currently has no provision of PrEP.

The NHS is widely regarded as a remarkable system, allowing UK citizens to access certain free healthcare services. England has had some shortcomings however when it comes to preventing HIV and I was interested in learning more. I visited the Terrance Higgins Trust (THT), a British charity that campaigns on and provides services relating to HIV and sexual health. In particular, they aim to end the transmission of HIV in the UK, to support people living with HIV (PLWH), and decrease stigma around HIV. I met Greg Owen, the founder of iWantPrEPNow, a website that explains why it is important for HIV protection, who might consider PrEP, what you need to do before you start, where to buy it online, and how to take it. I also met with Will Nutland, who works alongside Greg and is the founder of Prepster, a guide and movement to safely buying PrEP. Both websites have experienced a lot of traffic since the IMPACT Trial began in October 2017. The trial seems like a step in the right direction when it comes to accessing PrEP, this is not the attitude for many and there continues to be a debate.  While there is significant evidence from other trials that demonstrates PrEP is an effective HIV prevention tool, many people believe that NHS will not endorse PrEP after the trial is complete.

I asked Liam Beattie, also a member of the THT team, why he believes NHS England did not endorse PrEP under its guidelines. He believed that it was because of 1. homophobia among the NHS and 2. the media. Liam was recently interviewed on BBC News. During the interview, PrEP was categorized as a “controversial drug,” which paints a negative light on the topic from the get-go.  While England is well-developed and progressive in so many ways, HIV is still known as the “middle-aged gay male virus.” THT and other organizations continue to develop new marketing tools and programs in order to target women, transgender persons, and people of color to visit a sexual health clinic and get tested. Taking PrEP is an advantage for not only the individuals health but the overall cost of healthcare. Many are hopeful that in the future, the NHS will work with organizations like THT to promote PrEP and other educational resources to prevent HIV.