For nearly 40 years, the only means to avoid contracting HIV was a condom. Now, six shots a year can do the job. South Africa is figuring out ways to deliver the jab—and finally talk about real choice.
South Africa is exploring ways to offer a new HIV prevention injection at mobile clinics. Photo: Project PrEP, an initiative funded by Unitaid and implemented by Wits RHI
It is a summer’s night in 2017 in Cape Town, South Africa, and in the city’s Green Point neighbourhood, Phumlani Kango’s taxi has just turned onto Jarvis Street. In this older part of town, the streets are narrow. Victorian-era row houses rub shoulders with modern homes before giving way to a staple of this LGBTQ-friendly neighbourhood: The Hothouse Sauna.
The car stops in front of the two-storey building and Kango alights from the taxi. In the club’s locker room, he swaps his clothes for a fresh, white towel before heading to the jewel-toned bar. Adverts for the club show the bar surrounded by a sea of cafe tables. Fit young men lounge nearby, enjoying the cozy fireplace, one casually seated on a raised stage beside a stripper pole. Private rooms sit further back.
Almost eight million people in South Africa (14%) are living with HIV, making it the world’s largest HIV epidemic, according to the country’s latest HIV household survey in 2017. HIV prevalence among gay, bisexual and other men who have sex with men (gbMSM) may be as high as 40%, according to several recent studies. In the 15-24 age group, women make up one in four new infections.
Tonight, Kango is meeting a man at the Hothouse. He has been firm about the rules: “I consented only to sex with protection.” Soon, however, the pair meet another two men and they decide on having some “group fun”. But the fun soon sours. Kango suddenly notices that one of the men has removed his condom without permission—popularly known as stealthing.
Kango panics, realising he is now at risk of contracting a sexually transmitted infection (STI), including HIV.
From pill to jab for HIV prevention
Little does Kango know that condoms are no longer the only protection against HIV. A once-a-day HIV prevention pill called pre-exposure prophylaxis (PrEP) had debuted five years ago. Better known by its brand name Truvada, it combines two antiretroviral drugs, emtricitabine and tenofovir disoproxil fumarate. When taken correctly, the blue pill can reduce HIV risk by almost 99%.
Today, a decade since the pill was launched, only 930,000 people are estimated to be on PrEP globally, according to 2020 data compiled by HIV advocacy organisation AVAC. The US, Kenya and South Africa account for about 40% of global users.
Now, clinical trials have made a landmark discovery: an injection of the antiretroviral cabotegravir every other month lowered the risk of HIV by 80%, compared with the HIV prevention pill.
Clinical trials have made a landmark discovery: an injection of the antiretroviral cabotegravir every other month lowered the risk of HIV by 80%, compared with the HIV prevention pill.
The bimonthly shot likely outperformed Truvada, the World Health Organization (WHO) explains in new guidelines released in July 2022, largely because it was easier for people to take than daily pills.
If the injection were rapidly rolled out in sub-Saharan Africa, it could slash new HIV cases by nearly 30% in the next five decades, according to an unpublished modelling presented at the International AIDS Conference in 2022. The study, which has been submitted to The Lancet, showed that greater access to the HIV prevention shot could save about 75,000 lives annually by 2070.
Injectable cabotegravir could finally offer a real choice in protecting against HIV infection, alongside the pill and—for women and transgender men—a monthly antiretroviral-containing vaginal ring.
Whether countries hard-hit by HIV can afford the HIV prevention shot remains to be seen. Still, nations like South Africa are exploring ways to avoid the pitfalls of past PrEP rollouts and chart a brighter future for HIV prevention.
Crunching numbers for change
At US$22,000 a year in the US, the injection does not come cheap. Drugmaker ViiV Healthcare has entered into an agreement with the Medicines Patent Pool (MPP) to eventually enable affordable, generic production for low- and lower-middle income countries, as well as all sub-Saharan African countries, regardless of income level.
ViiV Healthcare and MPP estimate this would take three to five years. Until then the drugmaker has committed to supply at an affordable price to countries covered by the MPP deal. HIV news service aidsmap reports that this price is likely to be about US$240 per patient per year.
ViiV Healthcare spokesperson Catherine Hartley reiterates the company’s commitment to affordable pricing while fast-tracking generic production. As part of this, ViiV Healthcare has partnered with a range of organisations, including AVAC, the Bill & Melinda Gates Foundation and Unitaid, to find a way to provide public sector buyers an affordable access to injectable PrEP, including innovative financing mechanisms. The partnership will include civil society representation and help track and streamline rollouts.
Yet, to be cost-effective in South Africa, the injection would need to be priced about US$100 or less per patient per year, shows a modelling by the University of the Witswatersrand Health Economics and Epidemiology Research Office. The research, available as a pre-print, has not yet been peer reviewed.
It’s a price ViiV Healthcare may be unlikely to meet. “Based on ViiV’s experience of making [cabotegravir] for PrEP, this significantly underestimates the cost of manufacture,” Hartley says. “Manufacturing is more expensive and much harder than for generic oral PrEP. There is an evolving and less-defined demand for the product, making volume forecasts challenging.”
On the front foot with proactive protection
It’s the morning after Kango’s night at The Hothouse Sauna in Cape Town. Still worried, he calls his best friend, who straightaway recommends PEP, a month-long course of antiretrovirals. If started within 72 hours of possible exposure to HIV, PEP is highly effective at preventing HIV infection.
Within hours, Kango is back at Green Point, this time at a clinic specialising in gbMSM health services. As a nurse walks him through the basics of PEP, she asks him: have you heard of PrEP?
Five years on, the freelance communications consultant hasn’t stopped talking about PrEP, often tweeting about it under his handle @Phumlani_PrEP.
“I started on PrEP, and haven't looked back,” Kango says of the HIV prevention pill. “You learn a lot when you start taking PrEP. I’ve learned a lot about myself but also about my sexual health… That includes going for screenings.”
The name on his social media account? A nod to a popular children’s cartoon: #PrEPa Pig.
“[When I’m tweeting] I always think about my younger self—15-year-old Phumlani living in the village—because the first time I had anal sex, I didn’t use a lubricant,” he says. “I was putting myself at risk because the condom could have broken. I want to be the bigger gay brother [to others] that I had wanted when I was growing up.”
Swapping fear for empowerment
South Africa introduced PrEP in 2016, piloting the HIV prevention pill first among female sex workers after research by the national health department and the US Centers for Disease Control and Prevention (CDC) showed nearly 80% of sex workers were living with HIV. Similar demonstration projects followed for other high-risk groups, such as gbMSM, young women and people who use drugs.
Only in 2020 did the country’s health department begin offering PrEP to the public at health facilities. A year later, government statistics show the HIV prevention pill was being offered at 2,700 sites nationwide. Today, the HIV prevention pill is offered at 3,034 facilities nationwide and more than 600,000 people have started on PrEP, according to Wits Reproductive Health and HIV Institute (Wits RHI) director of implementation science Saiqa Mullick.
In Johannesburg, Wits RHI was one of the first NGOs to partner the health department to offer oral PrEP among sex workers before expanding to young women at universities and then in communities—and, as word spread, their male partners.
“Confident, strong, intelligent, loving, healthy, powerful” read the words painted in pink and blue around the mural of a tree in bloom. It hangs in one of Wits RHI’s offices, just steps away from one of Johannesburg’s universities.
A mural with empowering messages hangs in the offices of Wits RHI. Photo: Laura López González
In South Africa’s public sector, PrEP is provided free. But to persuade at-risk groups and communities on the benefits of PrEP, healthcare workers have had to move away from messages centered on the perils of HIV infection.
“In the past, the messaging might have been more about instilling fear,” Mullick says. Today, she explains, it’s about positioning Truvada—and other forms of PrEP in the pipeline—as steps people can take to empower themselves.
“Empowering messaging works—the message that, with PrEP, you have the power to take into your own hands your health and wellbeing.”
Charting the path to implementation
Wits RHI is also set to be among the first in the country to help the national health department pilot the HIV prevention injection in 2023 with Unitaid funding. It was authorised in December 2022 by the South African Health Products Regulatory Authority.
Wits RHI will offer the shot alongside the HIV prevention pill and a new PrEP vaginal ring, which slow-releases the antiretroviral dapivirine over 28 days. In large clinical trials, the silicon ring reduced women’s risk of contracting HIV by 27-35%, but this increased to 50% and above in more real-world settings, the WHO explains.
Research institute Ezintsha hopes to pilot the same trio of PrEP options via one of South Africa’s largest private pharmacy chains, according to divisional director Dr Francois Venter.
Demonstration projects of injectable PrEP are also planned in the African countries where it was trialled, such as Kenya, Eswatini and Malawi. A project to provide the shot at local pharmacies, for instance, is already planned in Zimbabwe, which became the first country on the continent to approve the drug in November 2022.
Rollouts of oral PrEP may have been slow, but they were also logistically easier. In South Africa, three-month supplies of the tablets could be given out at clinics or couriered to patients' homes. Thailand, for instance, allows trained, accredited lay providers to dispense the pills.
But without self-administered formulations, the HIV prevention shot is not as simple. Demonstration projects across the world will now aim to test-run what future rollouts will look like—and how to take the shot into communities.
Many healthcare providers believe injectable PrEP will have to be offered, like Truvada, by specially trained nurses alongside other sexual and reproductive health services like treatment for STIs and contraception. In Johannesburg, Wits RHI plans to use nurses trained to dispense oral PrEP and other HIV treatments to administer the shot via specially created youth corners in health facilities or via mobile clinics.
Administering the HIV prevention injection within communities is key to its uptake. Photo: Project PrEP, an initiative funded by Unitaid and implemented by Wits RHI
In Cape Town, the Desmond Tutu Health Foundation’s CEO, Dr Linda-Gail Bekker, believes community “shot clinics”—simple trailers where people can get their injections every other month alongside STI treatment and other regular immunisations—are an effective option.
"We know that daily oral PrEP isn't feasible for everyone," Bekker says. "We need to make PrEP as available as fast food... and begin to talk about HIV prevention as something that creates wellness and wellbeing among the people of South Africa.”
Counselling patients on real choice
As the new HIV prevention shot and vaginal ring find their way to facilities and mobile clinics alongside oral PrEP, a new challenge awaits: nurses and other healthcare professionals will need to begin counselling patients on real choice. It’s a significant change compared to just a few years ago when oral PrEP was the only real preventative option for HIV.
“Our providers have never had to counsel around the choice of biomedical prevention options,” Mullick explains. “How do you train providers to not push particular products based on their own biases but, instead, offer the whole prevention package and counsel on what fits your lifestyle? That’s something we will have to tackle head-on.”
Khanyi Kwatsha works with Wits RHI in Johannesburg helping young people navigate PrEP—whether it is starting on the daily tablets, taking a break from them when they no longer feel at risk, or even connecting them to services for survivors of gender-based violence.
Although the HIV prevention shot outperformed tablets in studies, she warns not to pit one against the others.
Nurses and other healthcare professionals will need to begin counselling patients on real choice. It’s a significant change compared to just a few years ago when oral PrEP was the only real preventative option for HIV.
“The important thing is to show people that these PrEP methods are not in competition,” says Kwatsha, who adds that every PrEP site should ideally be able to offer all three PrEP options in the future. “It's a matter of knowing which one works best for you and just having the information, so that you can make an informed choice about them.”
For many people, Mullick adds, effectiveness is not the only thing that drives choice. They also look for options that work for the lives—and relationships—they have.
Social media, Kwatsha says, will be key to helping spread that message. Kango, in Cape Town, hopes to use Twitter to improve knowledge of the evolution of PrEP.
Five years later, Kango still takes PrEP, although he doesn’t take it every day. Instead, he uses it when he needs it because he currently isn’t as sexually active as he used to be. He takes two pills two to 24 hours before sex, one pill 24 hours after the first dose, and then another pill 24 hours after the second dose. Although this method, commonly known as PrEP ‘on demand’, can be effective for gbMSM, it’s not yet known if it works for women.
Kango wanted to be part of clinical trials for the injection in South Africa and says he would definitely take injectable PrEP.
“I really cannot wait for the PrEP injection to come into play,” he tweeted recently. “It will revolutionise HIV prevention and I do foresee more people getting on it.”
In fact, one day he hopes to be able to provide his own online review of the every-other-month shot.
“We are made to feel shame about the sex that we enjoy as queer people, so we don’t go out and look for information or we’re not open about the type of sex we enjoy,” Kango says. “We’re taught the only form of safe sex is with a condom even though we know you can also have safe sex with PrEP if you test regularly for STIs.”