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

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

doi:10.7448/ias.19.7.21107

Abstract

IntroductionAdolescents 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.DiscussionOngoing 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.ConclusionsAdolescent 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.

Highlights

Adolescents and young adults aged B25 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
A compelling case has been made for considering adolescent girls in subSaharan Africa, a key population that urgently requires attention and intervention; girls aged 15 to 19 in this region are four to five times more likely to be infected than their male counterparts [13] and HIV incidence rates are 5 to 6% among young women B21 years in recent HIV prevention trials [14,15]
There are only two oral pre-exposure prophylaxis (PrEP) studies currently in the field that exclusively focus on adolescents, which we describe below, as well as several other adolescent-inclusive demonstration projects that began in 2016

Summary

Introduction

Overview of adolescent HIV epidemic According to the World Health Organization (WHO) [1], AIDS is the leading cause of death among adolescents in sub-Saharan Africa and second leading cause for adolescents worldwide. A compelling case has been made for considering adolescent girls in subSaharan Africa, a key population that urgently requires attention and intervention; girls aged 15 to 19 in this region are four to five times more likely to be infected than their male counterparts [13] and HIV incidence rates are 5 to 6% among young women B21 years in recent HIV prevention trials [14,15] Definition of adolescence Both the WHO [16] and the United Nations identify adolescence as the period in human growth and development that occurs after childhood and before adulthood, from ages 10 to 19. There are developmental similarities between those under the age of majority and those just over the age of majority, there are distinct implementation challenges for under age youth that we focus on in this article

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Conclusions