The promises and challenges of pre-exposure prophylaxis as part of the emerging paradigm of combination HIV prevention.

INTRODUCTION: Towards the end of the twentieth century, significant success was achieved in reducing incidence in several global HIV epidemics through ongoing prevention strategies. However, further progress in risk reduction was uncertain. For one thing, it was clear that social vulnerability had to be addressed, through research on interventions addressing health systems and other structural barriers. As soon as antiretroviral treatment became available, researchers started to conceive that antiretrovirals might play a role in decreasing either susceptibility in uninfected people or infectiousness among people living with HIV. In this paper we focus on the origin, present status, and potential contribution of pre-exposure prophylaxis (PrEP) within the combination HIV prevention framework. DISCUSSION: After a phase of controversy, PrEP efficacy trials took off. By 2015, daily oral PrEP, using tenofovir alone or in combination with emtricitabine, has been proven efficacious, though efficacy seems heavily contingent upon adherence to pill uptake. Initial demonstration projects after release of efficacy results have shown that PrEP can be implemented in real settings and adherence can be high, leading to high effectiveness. Despite its substantial potential, beliefs persist about unfeasibility in real-life settings due to stigma, cost, adherence, and potential risk compensation barriers. CONCLUSIONS: The strategic synergy of behavioural change communication, biomedical strategies (including PrEP), and structural programmes is providing the basis for the combination HIV prevention framework. If PrEP is to ever become a key component of that framework, several negative beliefs must be confronted based on emerging evidence; moreover, research gaps regarding PrEP implementation must be filled, and appropriate prioritization strategies must be set up. Those challenges are significant, proportional to the impact that PrEP implementation may have in the global response to HIV.

Maternal and congenital syphilis programmes: case studies in Bolivia, Kenya and South Africa.

Preventing congenital syphilis is not technically difficult, however operational difficulties limit the effectiveness of programmes in many settings. This paper reports on programmes in Bolivia, Kenya, and South Africa. All three countries have established antenatal syphilis control programmes. Early antenatal syphilis screening and management of positive cases were difficult to implement since most women presented for their first antenatal clinic visit after 6 months of pregnancy. Most women had rapid plasma reagin (RPR) testing; results were available on the same day in some clinics but took up to 4 weeks in others. No clinic had a system for tracking RPR-reactive women who did not return for their results. There were no guidelines for providers in Kenya and Bolivia. In all countries, supplies, drugs, notification cards, and other consumables were often unavailable. Health-care providers were unmotivated in Kenya and reported an excessive client load. In South Africa and Kenya some clients reported at their exit interview that they had never heard of syphilis nor had they been informed why blood was collected. Several prevention strategies could be implemented at the clinic level. These include encouraging women to attend for antenatal care before the fourth month of pregnancy, providing point-of-care testing so that results are available immediately and women who test positive can be treated, implementing presumptive treatment of sexual partners of women who test positive, adding a second test later in pregnancy so that incident cases can be managed, and improving the quality of syphilis care during pregnancy, delivery, and the neonatal period.