Preventing HIV among adolescents with oral PrEP: observations and challenges in the United States and South Africa

Sybil Hosek; Connie Celum; Craig M Wilson; Bill Kapogiannis; Sinead Delany-Moretlwe; Linda-Gail Bekker

doi:10.7448/IAS.19.7.21107

Preventing HIV among adolescents with oral PrEP: observations and challenges in the United States and South Africa

J Int AIDS Soc. 2016 Oct 18;19(7(Suppl 6)):21107. doi: 10.7448/IAS.19.7.21107. eCollection 2016.

Authors

Sybil Hosek¹, Connie Celum², Craig M Wilson³, Bill Kapogiannis⁴, Sinead Delany-Moretlwe⁵, Linda-Gail Bekker⁶

Affiliations

¹ Department of Psychiatry, Stroger Hospital of Cook County, Chicago, IL, USA; shosek@cookcountyhhs.org.
² Department of Global Health, University of Washington, Seattle, WA, USA.
³ Department of Epidemiology, University of Alabama at Birmingham, Birmingham, AL, USA.
⁴ Maternal and Pediatric Infectious Diseases Branch, Eunice Kennedy Shriver National Institutes of Child Health and Human Development, Washington, DC, USA.
⁵ RHI, University of Witwatersrand, Johannesburg, South Africa.
⁶ The Desmond Tutu HIV Centre, University of Cape Town, Cape Town, South Africa.

Abstract

Introduction: Adolescents and young adults aged <25 are a key population in the HIV epidemic, with very high HIV incidence rates in many geographic settings and a large number who have limited access to prevention services. Thus, any biomedical HIV prevention approach should prepare licensure and implementation strategies for young populations. Oral pre-exposure prophylaxis (PrEP) is the first antiretroviral-based prevention intervention with proven efficacy across many settings and populations, and regulatory and policy approvals at global and national levels are occurring rapidly. We discuss available data from studies in the United States and South Africa on the use of oral PrEP for HIV prevention in adolescent minors, along with some of the implementation challenges.

Discussion: Ongoing studies in the United States and South Africa among youth under the age of 18 should provide the safety data needed by the end of 2016 to contribute to licensure of Truvada as daily PrEP in adolescents. The challenges of completing these studies as well as foreseeable broader challenges highlighted by this work are presented. Adherence to daily PrEP is a greater challenge for younger populations, and poor adherence was associated with decreased efficacy in all PrEP trials. Individual-level barriers include limited familiarity with antiretroviral-based prevention, stigma, product storage, and social support. Structural challenges include healthcare financing for PrEP, clinician acceptability and comfort with PrEP delivery, and the limited youth-friendly health services available. These challenges are discussed in the context of the work done to date in the United States and South Africa, but will likely be magnified in the setting of limited resources in many other countries that are heavily impacted by HIV.

Conclusions: Adolescent populations are particularly vulnerable to HIV, and oral PrEP in these populations is likely to have an impact on population-level HIV incidence. The challenges of disseminating an HIV biomedical prevention tool requiring daily usage in adolescents are formidable, but addressing these issues and starting dialogues will lay the groundwork for the many other HIV prevention tools now being developed and tested.

Keywords: HIV/AIDS; PrEP; adolescents; implementation.

MeSH terms

Adolescent
Adult
Anti-HIV Agents / economics
Anti-HIV Agents / therapeutic use*
Delivery of Health Care
Female
HIV Infections / drug therapy
HIV Infections / prevention & control*
Humans
Male
Pre-Exposure Prophylaxis* / economics
Social Stigma
South Africa
United States
Young Adult

Substances

Anti-HIV Agents