Eswatini: The end of the HIV epidemic is within reach

Over the last few years, progress has been made in the fight against HIV using some new tools. A vaginal ring and oral pre-exposure prophylaxis (known as PrEP) have given people ways to protect themselves before becoming exposed to the virus. But oral PrEP has its challenges.    

“One of the main barriers to people using oral PrEP currently is the fact that they have to take tablets every day,” says Antonio Flores, MSF senior advisor on HIV and TB at the Southern Africa Medical Unit. This ‘pill burden’ has contributed to HIV prevalence remaining high.  

Understanding the social landscape  

In Eswatini, HIV remains the leading cause of death. An estimated one quarter of people live with HIV. Nearly a third of women aged 15-49 are HIV-positive. Social stigma exacerbates the problem, resulting in low uptake of the oral PrEP: only 11 per cent of eligible people take it.  And only a quarter of those enrolled on PrEP come back for refills.  

“In a qualitative study we did we learned that it’s gender and social norms that influence health seeking behaviour,” says Sinikiwe Dlamini, MSF’s data entry operator at Sitsandziwe Clinic in Eswatini. “Eswatini, being quite a traditional and cultural country, where men are the leaders in society, means everything for a woman, especially having a male partner, will have to be agreed upon with the male partner.”  

Majuba Mambo, MSF nurse at Sitsandziwe says, “The packaging of the oral PrEP that we have in the country is almost the same as the ARV [antiretrovirals for treatment of HIV]; and when going with the tablets, people start discriminating.” Some women feel they have to hide their medication bottles.   

The potential of long-acting injectable HIV prevention  

CAB-LA (Cabotegravir) is one of the new long-acting injectables, which provides pre-exposure protection for two months. (A six-month option is currently awaiting FDA approval and World Health Organization recommendation.)  

The roll-out has started in a number of countries supported by PEPFAR (the US President's Emergency Plan for AIDS Relief). MSF is supporting the roll out of CAB-LA in four countries in southern Africa, including Eswatini. “MSF secured a number of doses of CAB-LA, but the plan is that once the MSF roll-out is ready, it will be handed over to Ministry of Health,” says Flores.  

The dismantling of aid and uncertainty around funding from programs like PEPFAR, that support HIV prevention, testing and treatment, is making it more difficult for people to access medical tools like CAB-LA. “This is a very rapidly evolving situation, and our role is changing as a result,” says Flores.    

Yet the initial response to the injectable PrEP is excellent. “In the first month more than 20 clients started on CAB-LA, which shows people are happy about it,” says Mambo. “They are saying it is private, and they can take it discreetly.”    

The two-month window means that people don't have to worry about daily adherence. Plus, long-acting prophylaxis is 80 per cent more effective than the oral alternative, says Flores.   

We now have the tools to end HIV  

It is hard to overstate the potential impact of the long-acting injectable PrEP.  

“We expect injectable PrEP to be a game-changer, and we don’t use this term lightly,” says Flores.  

“Injectable PrEP has the potential to end the HIV epidemic, but it will only end the HIV epidemic if people are getting it. We know from the study data, and we know from early implementation that we would reduce new infections drastically.  

“We already see the impact of oral prep in places where it has been rolled out en masse, where the uptake was greater. And of course, that's normally high-income countries or even very specific places: London, Amsterdam, Sydney, Sao Paulo.  

“We have seen over the years a decline in HIV incidence among high-risk populations. So we know that there is a potential in PrEP. We have ended other diseases with vaccines, we can end this epidemic with an injectable drug that is given every few months. But people have to have access.”  

Advocating for access    

“We need to focus on the populations at high risk and remember that some of these populations are actually criminalised. You do have a higher burden of HIV in key populations: men who have sex with men, transgender women and men, sex workers. So, these are very vulnerable populations to HIV but are very vulnerable to criminalisation,” says Flores.    

“Paradoxically, although the burden of HIV is much greater in Africa and the region, the epidemic is in a way better controlled than in other regions. Cost (sometimes more than €1,000 per vial) is one of the main barriers that we have now in terms of rolling out to regions where actually HIV incidence is going up, and that is the Americas, Latin America, Eastern Europe, and the Middle East.  

“This is something we have to factor in when planning implementation in places like Honduras, and of course in the situation in southern Africa and Africa as a whole, where we don’t have certainty about PEPFAR anymore.”  

“Our role as MSF is really to support countries where possible to advocate for access. And engage in discussions about how to make access sustainable.  

“If there is wide access to injectable prep, we can definitely end the epidemic because we’re going to control it. Twenty-five years ago, ARVs did change the epidemic, and now we can really stop the epidemic, if people have access to these new tools.  

“Injectable PrEP is a turning point in the history of HIV. But we need to get it to people.”