Of course Africa is ready for PrEP!
Stella Nyanzi
Whether or not Africa is ready for PrEP interests me because of several underlying assumptions in some of the answers about how we define Africa.
Africa’s MSM, Africa’s people who engage in anal sex and Africa’s public health prevention campaigns have been desperately in need of new HIV prevention options for a very long time. Issues of affordability can be strategically handled through diverse modalities. However, there is no doubt in my mind that access and availability remains burning questions at the heart of providing interventions to those who need it. Because there are many people in Africa who need HIV prevention, I say “Africa is ready for PrEP!”
It is important to recognise that there are many faces to Africa. There is the Africa which is poor, under-resourced, without cash reserves and unable to meet the costs of its survival. That’s the Africa in need of greatly subsidised if not entirely free interventions – be it lubes, gels, condoms or even PrEP.
But there are also many African MSM who can afford PrEP. There are many MSM communities that can innovatively strategise through their local and international networks to find the resources to meet the costs of the drugs used for PrEP. There are many ways in which activism and negotiation with the powerful public organisations and actors can win unanticipated victories for providing access to PrEP to MSM who need it.
I have witnessed how innovative local LGBTI support groups and networks can be to access essential sexual health commodities in Kampala. I have observed “wealthier” MSM dispatching materials such as condoms, lubes and education pamphlets to those who cannot afford them or don’t have access to HIV prevention information. I have attended lobbying campaigns where small but significant successes were made to put MSM health onto the health and human rights agendas, particularly through arguing that it contribute to the fight against HIV/AIDS.
At the risk of sounding like a neoliberal capitalist who is blind to the needs of the less financially empowered in Africa, I think that current market trends in Kampala indicate that putting a product on the market, where there is both demand and need, results into the product being bought and used. And again, there is a need for PrEP in Africa.
The bigger question for me is, “Are the manufacturers of the ARVs used for PrEP (whether they are generics or the patented version) ready to meet the terms of the African clientele?” What are the possibility and the margins for negotiating the price of PrEP drugs? We could always argue that there is a sizeable market for PrEP in Africa because of relatively higher prevalence and incidence rates of HIV among those who engage in anal sex (whether MSM, MSW, WSM …). Therefore there is economic sense in reducing the price of drugs in order to capture the African market. If the current price of drugs cannot be negotiated, is it possible to find innovative ways to ensure that Africa can meet the cost of providing PrEP to those who need it? Philanthropists, funding organisations, multi-lateral organisations, and the giants like the Global Fund for AIDS, Malaria and Tuberculosis can be engaged to consider making PrEP available to those who need it but cannot afford it.
Many of our public health systems in Africa are inadequately providing the essential services needed by the Poor in our communities and there are gaps in public health provisioning of mosquito nets, condoms, ARVs and many other essential health saving drugs and interventions. However this is no ground or rationale for claiming that Africa is not ready for another critically essential HIV prevention product.
It is important that we conduct meaningful acceptability trials of rectal microbicides and oral PrEP that have already shown sign of success in previous clinical trials, so that a wide range of people in Africa who practice anal sex can try and test them out. The feedback from these acceptability trials should be the basis upon which decisions about what form(s) of PrEP Africa is ready for are made.
At the micro level of individuals, people, lovers, sex partners, bodies who desire and consummate our passions anally, Africa is ready for PrEP. The macro issues of cost and affordability, acceptability, supply chains, rolling out and scaling up of PrEP interventions, can all be negotiated and strategically resolved.
Africa was ready for PrEP the day that Africa got HIV and AIDS. No question about it.
| Editor’s Note:
The World Trade Organisation’s patent rules, known as Trade-Related Aspect of Intellectual Property Rights (TRIPS), recognise the right of countries to protect public health. They were introduced “in an attempt to narrow the gaps in the way [intellectual property] rights are protected around the world, and to bring them under common international rules”. The 2001 Doha declaration allowed flexibility in the application of TRIPS to ensure that medicines are available and affordable and that generic drugs can be produced and drugs imported at a lower cost than brand versions. Thailand and Brazil have both shown the way on how to use TRIPS to save life. Recently, the World Health Organization, the UN Development Programme, and UNAIDS agencies have encouraged the use of TRIPS to lower the cost of medicines |
6 Comments
"current market trends in Kampala indicate that putting a product on the market, where there is both demand and need, results into the product being bought and used." Right, so there is neither demand nor need for clean water or decent living conditions (water is a product in many African countries, thanks for the World Bank)? There is neither demand nor need for a reduction in water-borne diseases, which affect and kill more than any other group of diseases? There is neither demand nor need for a reduction in acute respiratory infections, which cause around 20% of infant and under five deaths? There is neither demand nor need for TB or malaria treatment or any other diseases that still kill hundreds of thousands of people? The list goes on. Your entire argument may involve wishful thinking but has no bearing on the debate about PrEP. PrEP is a vehicle for selling more antiretroviral drugs. And by the way, in many African countries, it is against the law to be gay or to have anal sex and many would rather risk HIV or anything else than be executed by mob justice.
I don't think that this is what Stella said. There certainly is a demand for all what you say but there has not been a (appropriate) response yet to these demands and needs.
Simon, yours are indeed valid questions. And they must be asked. However as you noticed, I wrote in response to the question and debate about whether or not Africa is ready for PrEP. And just as I believe that Africa is very ready for PrEP, I also believe that Africa WAS ready for the list of numerous items you touch upon i.e. 'decent living conditions', 'interventions against water-borne diseases', 'interventions against acute respiratory infections', 'TB and malaria treatments' etc. My argment is about whether or not Africa is ready for PrEP. I am of the strong conviction that Africa and Africans (and anyone else for that matter who finds themself in Africa for whatever duration) is ready for all the other interventions that other humans have access to. Many of us in Africa have anal sex - regardless of whom we love; be it MSM, MSW, WSM or the transgender constituency and the intersex individuals. And because we do, we deserve to be protected from rectal transmission of infections particularly HIV. And so Simon, there is nothing wishful about my argument. My argument is built upon living in Africa where it is constitutionally illegal in many countries to practice alternative sexualities (as you rightfully point out). And because many people who engage in anal sex would rather not spread the word about it, I say we should avail the products that protect infection. If Europe, North America and all those other nice (rich??) places are ready for PrEP, I would still argue that so is Africa. Because many of us in Africa love and express our love anally, give us the protection. Because many of us in Africa are HIV-infected and we have partners who are not HIV-infected, and as irrational desiring human beings we consumate our relationships in diverse fashions - give us PrEP in modes that are acceptable to us. If rectal microbicides are ready for use in America, I say that we are more than ready to use them. Africa is indeed ready for PrEP!
Stella, thank you for your reply. Firstly, I commend you for raising the issue of anal sex, it is in bad need of discussion. But please let me be critical again. My second comment, which aimed to clarify, didn't get passed the censor. You say you are responding to a question and debate about whether Africa is ready for PrEP. That debate was about whether Africa could, for example, successfully roll out a PrEP program, similar to an ARV or a condom program. The answer could be yes or no or somewhere in between, there is a genuine debate. The question you actually deal with in your article is whether something like PrEP, or anything that could reduce HIV transmission, would be good for Africa. The answer to that is a very obvious yes, and I don't think anyone is disputing it. You are playing with two different meanings of the word 'ready'. A question that you don't deal with is 'is PrEP ready for Africa (or for any other country)' and the answer to that is much more difficult. Pharmaceutical companies who are not content to get as many people as possible on their overpriced drugs want us to believe that putting HIV negative people on the drugs would also be a good thing. But the result of the PrEP trials so far do not suggest that putting as many people as can afford it on the drugs will have an appreciable effect. The results of the trials were poor and PrEP is still at an early stage of development. It is premature to start demanding that the drugs be made widely available. Perhaps it is this question you don't ask that I would answer no to. PrEP, I would argue, is not ready for rich countries any more than it is for poor countries.
Simon, the guist of my answer is in the nuanced details pertaining to the generally invisible and yet very real practice of anal sex in Africa. If rectal microbicides were provided, who would use them? The majority users, I suspect, would be those who practice anal sex in Africa. Until Africans are ready to embrace the reality of anal sex (and perhaps oral sex too), PrEP may fail to take off. And those in Africa who practice anal sex particularly in cases of sero discordant couples/ partnerships, are ready for PrEP at the micro level of two guys in love, a man and woman in a sexual liaison, two individuals desperately driven to bareback and yet unsure of the other's HIV sero-status., etc. That is where the readiness can most quickly be organised. And we are ready at the micro level. The macro issues can be worked out. If left to the prioritization of many of our African public health systems, they will give more of the same old lame excuses of insufficient health systems including the myriad of obstacles to PrEP that were raised by commentators to illustrate how Africa is unready for PrEP. And I firmly believe that we should not allow the inefficiencies of our health systems to dictate the terms of the readiness of those individuals who need interventions. Simply because my mother does not cook enough to provide me with adequate food nutrients does not mean that I am not ready to get a blanket to keep me from the cold at night. What lame logic could that be? If there are blankets readily available, avail them to those of us in the cold and the macro mechanisms of how we get them, at what cost, etc will be worked out. HIV sero-discordancy, anal sex and the irrationaliy of sex are evidence that regardless of the inefficiencies of our health systems, when America and Europe are ready for PrEP Phase II and Phase III trials, Africa must also participate - just as we did in the vaginal microbicide trials. Big Pharma and the politics of profiteering can be negotiated when there is strong evidence that the drugs for PrEP are good for all humans (whether in Africa, the Americas, Europe or Asia). On another note, I like the way you end by inverting the statement to 'PrEP is not ready for rich countries any more than it is for poor countries'.
Well, it's been good to meet you and I'll be looking out for you in the future. But anal sex is very risky, PrEP doesn't yet offer a huge amount of protection. Nor does it offer protection against many other sexually transmitted infections. I accept that anal sex is a valid form of sexual expression, therefore I think those who engage in it need to be very well informed about PrEP before advocating it. The CAPRISA trials were also given rave coverage and also doesn't offer much protection. Journalists and even many Big Pharma representatives are not scientists. But even scientists need to interpret data, maximize profits, secure their positions, secure their next grant, get promoted, get published, etc.
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