While pre-exposure prophylaxis (PrEP) has been shown to be highly efficacious, with up to 99% protection if the drug is taken as directed, delivering a successful PrEP program is challenging. A recent analysis of the Ashodaya PrEP demonstration project, which provided pre-exposure prophylaxis (PrEP) to female sex workers in south India, provides insights to help strengthen PrEP and HIV prevention programs and accelerate implementation beyond demonstration and pilot projects.
HIV prevention efforts among sex workers have traditionally focussed on condom use, and while a range of successful programs have contributed towards the decline in new HIV infections in the Asia-Pacific region, sex workers still experience a disproportionate burden of infection. In 2019, 9% of the estimated 300,000 new infections in the Asia-Pacific region were among sex workers and the relative risk of HIV infection is 21 times higher among sex workers than the general population globally.
PrEP is a recent addition to the range of HV prevention options available and involves an HIV negative individual taking antiretroviral drugs (usually tenofovir and emtricitabine) prior to exposure to HIV. Although recommended by WHO for all people at substantial risk of HIV since 2015, PrEP is inaccessible to the majority of key populations, including sex workers, and their partners in Asia and the Pacific. There is limited evidence on PrEP use among women, and particularly among female sex workers, in Asia and the Pacific.
The Ashodaya PrEP demonstration project was one of two community-led and -owned initiatives to provide PrEP to female sex workers supported by the Gates Foundation (the other was led by Durbar Mahila Samanwaya Committee (DMSC in Kolkata)). Sex workers in India had been intrigued by the fact that, although condom use was high, some sex workers still acquired HIV and ‘why some of their sisters were not able to use condoms [in some circumstances]’. A feasibility assessment began a stepwise and community-led process of close community consultation, community preparedness, discussion of a demonstration project to integrate PrEP delivery with the existing HIV program and the conduct of the project. WHO supported the process of community preparedness and feasibility assessment.
The PrEP demonstration project, which began on April 2016 and ended on January 2018, reported good results. High levels of continuation on PrEP were reported with 99% of the 647 participants completing the 16-months of follow-up. For women, it is critical to take PrEP daily to maintain protection. Although adherence was only 70% at month 3, this increased to 90% at month 6 and was 98% in the final month of the project. Self-reported adherence was verified in the blood of a subset of participants at months 3 and 6.
The project not only helped to dispel some common fears about PrEP, but showed benefits in bridging the prevention gap. Rather than undermining condom use, it remained stable. Condom use was high for occasional clients at approximately 98%, but lower for repeat clients (87-96%) and regular partners (63%). There were also no increases in symptomatic STIs and no HIV sero-conversions during the follow-up period.
A number of factors likely contributed to the success of the Ashodaya PrEP Project, including:
- Fully integrating PrEP into an existing range of health services, outreach and community mobilisation. This approach recognised that PrEP is not just a drug or a standalone service but is part of a prevention and health package including sexual and reproductive health (SRH) services. Independently of whether an individual was able to access PrEP, efforts were made to connect individuals with Ashodaya’s range of services and to provide access to social, health, and financial support programs.
- Community leading the way: planning, implementation, and monitoring. Ashodaya is a well-established community organization with a track record in mobilisation and innovation in sexual health interventions. Ashodaya leaders had a keen interest in innovations that would benefit the community. Although PrEP was new, community participation in deliberations about introducing PrEP, led to the community engagement and trust with the new prevention tool. Community empowerment and mobilisation has been central to HIV prevention and playing an active role in this new HIV prevention method was a source of pride, as well as new knowledge and skills for the community.
- Preparing the community and ensuring ongoing engagement. An intensive process of community preparedness and on-going engagement allowed sex workers to make informed decisions about participation. Community leaders (part of the implementation team) determined every stage of the project (keeping the requirements in mind). Recruitment was deliberately slow to build acceptance and trust, first enrolling senior community leaders, who then shared their experiences with their peers. Peer educators, outreach workers and mobilisers were able to pass on their knowledge to their peers. Community leaders living with HIV were also engaged early and became champions for PrEP. These testimonials became influential in enrolment and retention.
- Addressing excluded groups early. Recognising that many community members would miss out, the community was proactively informed that not all members would be eligible for PrEP under the demonstration project, given the limited places and scope. Ashodaya gained the community’s support through the endorsement of the project by Ashodaya leaders, proposing to use the project to advocate for national availability, and ensuring that the other services provided by Ashodaya were available to the community.
- Prioritising continued engagement over perfect adherence. Drawing on Ashodaya’s existing network of peer outreach workers allowed for individualised adherence support strategies to best meet the needs of PrEP users, both in terms of scaling up support when dips in adherence were observed and through referrals to Ashodaya’s comprehensive package of health and social services beyond PrEP.
“Our project shows that community- led PrEP delivery can be effectively integrated into the existing HIV prevention and care services for sex workers and result in high retention and adherence. Policy makers need to consult with us, listen to us and trust us as we know what works for us and how to make it work. We have an obligation to make PrEP available as an additional prevention tool in a safe and sustainable way and we are advocating for that” – Bhagya, a sex worker and Secretary of Ashodaya Samithi.
From conceptualizing, planning, implementation and monitoring, the Ashodaya PrEP Demonstration Project was a community-led process. PrEP became an important option for the women who participated in the project and now the community is working with policy makers to ensure PrEP is included as part of prevention package for sex workers in India.
The Ashodaya PrEP demonstration project was conducted by the Community of Ashodaya and the University of Manitoba with support from the National AIDS Control Organization (NACO), India and Karnataka State AIDS Prevention Society, The Bill and Melinda Gates Foundation, the WHO Geneva, WHO SEARO, UNAIDS India, Gilead Sciences, Mylan, the National AIDS Research Institute (Pune, India), Bio-Analytical Technologies (India), Ashakirana Hospital and K.R. Hospital.
References and further information :
Reza-Paul S, Lazarus L, Maiya R, Haldar P, Rewari BB, Venugopal MS, et al. The Ashodaya PrEP project: Lessons and implications for scaling up PrEP from a community-led demonstration project among female sex workers in Mysore, India. Global Public Health 2020,15:889-904.
Lazarus L, Reza-Paul S, Rahman SHU, Ramaiah M, Venugopal MS, Venukumar KT, et al. Beyond remedicalisation: a community-led PrEP demonstration project among sex workers in India. Culture, Health & Sexuality 2020:1-15.
Reza-Paul S, Lazarus L, Jana S, et al. Community Inclusion in PrEP Demonstration Projects: Lessons for Scaling up. How to cite this article: et al. Gates Open Research 2019:1504
Reza-Paul S, Lazarus L, Lorway R, et al. Prioritizing Risk in Preparation for a Demonstration Project: A Mixed Methods Feasibility Study of Oral Pre-Exposure Prophylaxis (PREP) among Female Sex Workers in South India; PLOS ONE | DOI:10.1371/journal.pone.016688
UNAIDS Update: Sex workers often not accessing HIV prevention services (18 November 2019). Available from: https://www.unaids.org/en/resources/presscentre/featurestories/2019/november/20191118_sex-workers
UNAIDS Data 2020. Available from: https://www.unaids.org/en/resources/documents/2020/unaids-data
In this first episode, we talk with Rosma about her experiences going through over 17 different types of drug treatment and rehabilitation programmes in Indonesia. She bravely opens up about how she started using drugs, struggles with her family, and why she believes it is important to talk about her difficult experiences.
The Interagency Task Team on Young Key Populations (IATT on YKPs) in Asia Pacific, with support from Youth LEAD, UNAIDS, UNICEF East Asia and Pacific Regional Office and UNDP, is delighted to announce the launch of its new website www.ykptaskteam.org
The goal with this new website is to gather and pool together available information and guidance on COVID-19 that cater to young key populations (YKPs) and young people living with HIV (PLHIV) from Asia and the Pacific. This platform will serve as an online resource to document and communicate on the challenges YKPs face in the pandemic as well as their approaches in identifying gaps, solutions and innovations in their responses to COVID-19. Navigating the different sections of the page, you will also find analysis of the findings from COVID-19 and YKP surveys, resources available for YKPs, stories and lived experiences from young people across the region. Read More
“I thought when my parents took me to rehabilitation, it was like when something is wrong with your car, and you take it to the service center. When your car comes out of the service center, the car will be good.” Rosma Karlina
When we think about people who use drugs, there is a tendency to refer to drug rehabilitation centers as the solution, and without thinking about the importance of what the person actually needs or wants. Moreover, for women who use drugs, their experiences too often involve stigmatization, marginalization, and violence. Little is known about what happens in the many drug rehabilitation and treatment centers around Asia and whether they are helping or hurting. Conditions in drug rehabilitation centers can be overcrowded and poor, and fail to treat people with the standard of health and human rights that each of us deserve. Read More
Beijing, 17 August 2020 – UNAIDS lauds China’s decision to approve Truvada, an HIV medicine, for Pre-Exposure Prophylaxis (PrEP), as an additional prevention choice for people at risk of HIV infection, but more work needs to be done to make it accessible and affordable for all those who need it.
“UNAIDS commends the National Medical Products Administration (NMPA) of China for approving Truvada for PrEP use,” says Eamonn Murphy, UNAIDS Regional Director for Asia and the Pacific. “This is an important step in addressing what has been a critical gap in HIV prevention.” Read More
The COVID-19 pandemic is affecting the lives and livelihoods of people everywhere, but the impact is especially severe among people who are socioeconomically disadvantaged and marginalized and among people with underlying medical conditions.
Young people are particularly vulnerable to the disruption the pandemic has caused, and many are now at risk of being left behind in education, economic opportunities, and health during a crucial phase of their development. For young key populations (YKPs) – including young people living with HIV, young gay men and other men who have sex with men, transgender youth, young sex workers, young people who use drugs, young migrants and prisoners – already facing challenges and disenfranchisement from the wider community, the hardships they face in employment, household settings, livelihood and social protections have been exacerbated by the COVID-19 pandemic. Read More
In Asia and the Pacific, young key populations (YKPs) experience gender-based violence (GBV) and multiple, intersecting discrimination on the basis of age, race, ethnicity, HIV status, economic status, geographical status, religion, migration status, disability, and sexual orientation and gender identity, expression and sex characteristics (SOGIESC).
Stigma, discrimination and GBV aggravate HIV and other health threats faced by YKPs. They also obstruct YKPs from accessing vital information and the services they need, including health, social protection and legal services. Read More
SOCIAL MEDIA PACKAGE AND KEY MESSAGES
For those most vulnerable to HIV – including people living with HIV, gay men and other men who have sex with men, transgender people, sex workers, people who use drugs, young people, migrants and prisoners – already facing challenges and disenfranchisement from the wider community, the hardships they face in employment, accessing healthcare, household settings, livelihood and social protections have only been exacerbated by the COVID-19 pandemic. At the same time, civil society and key population (KP) networks report alarming instances of human rights violations and growing concerns about the rise in discrimination targeting vulnerable groups and health care professionals. Read More