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      Views of policymakers, healthcare workers and NGOs on HIV pre-exposure prophylaxis (PrEP): a multinational qualitative study

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          Abstract

          Objectives

          To examine policymakers and providers' views on pre-exposure prophylaxis (PrEP) and their willingness to support its introduction, to inform policy and practice in this emerging field.

          Design

          Semistructured qualitative interview study.

          Setting

          Peru, Ukraine, India, Kenya, Uganda, Botswana and South Africa.

          Participants

          35 policymakers, 35 healthcare workers and 21 non-governmental organisation representatives involved in HIV prevention.

          Results

          Six themes emerged from the data: (1) perceived HIV prevention landscape: prevention initiatives needed to be improved and expanded; (2) PrEP awareness: 50 of 91 participants had heard of PrEP; (3) benefits of PrEP: one component of the combination prevention arsenal that could help prioritise HIV prevention, empower key populations and result in economic gains; (4) challenges of PrEP: regimen complexity, cost and cost-effectiveness, risk compensation, efficacy and effectiveness, stigmatisation and criminalisation, information and training and healthcare system capacity; (5) programmatic considerations: user eligibility, communication strategy, cost, distribution, medication and HIV testing compliance and (6) early versus late implementation: participants were divided as to whether they would support an early introduction of PrEP in their country or would prefer to wait until it has been successfully implemented in other countries, with around half of those we spoke to supporting each option. Very few said they would not support PrEP at all.

          Conclusions

          Despite the multiple challenges identified, there was general willingness to support the introduction of PrEP. Yet, strengthening existing HIV prevention efforts was also deemed necessary. Our results suggest that an effective PrEP programme would be delivered in healthcare facilities and involve non-governmental organisations and the community and consider the needs of mobile populations. Comprehensive information packages and training for users and providers would be critical. The cost of PrEP would be affordable and possibly segmented. Extensive counselling and innovative monitoring measures ought to be considered.

          Article summary

          Article focus
          • Understanding the attitudes, perceptions and preferences of key stakeholders towards PrEP to identify important programmatic aspects that may enhance or hinder its effectiveness.

          Key messages
          • Policymakers, healthcare workers and NGOs, particularly from Sub-Saharan Africa, would be willing to support PrEP if proven cost-effective.

          • PrEP was envisaged as part of a combination prevention strategy deeply rooted in and driven by its beneficiaries.

          • To effectively tackle the HIV epidemic, reducing stigmatisation against those at higher risk of infection and strengthening existing prevention programmes is as critical as introducing new ones.

          Strengths and limitations of this study
          • This is the first international study on key stakeholders' preferences and concerns regarding PrEP and how best to address these at a policy and service level.

          • The interview guides and local interviewers' training were standardised, which facilitated data comparability.

          • Relevant PrEP stakeholders were recruited.

          • Limitations include the largely hypothetical nature of the addressed PrEP characteristics, potential social desirability bias and purposive recruitment—mainly in urban areas.

          Related collections

          Most cited references21

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          Towards an improved investment approach for an effective response to HIV/AIDS.

          Substantial changes are needed to achieve a more targeted and strategic approach to investment in the response to the HIV/AIDS epidemic that will yield long-term dividends. Until now, advocacy for resources has been done on the basis of a commodity approach that encouraged scaling up of numerous strategies in parallel, irrespective of their relative effects. We propose a strategic investment framework that is intended to support better management of national and international HIV/AIDS responses than exists with the present system. Our framework incorporates major efficiency gains through community mobilisation, synergies between programme elements, and benefits of the extension of antiretroviral therapy for prevention of HIV transmission. It proposes three categories of investment, consisting of six basic programmatic activities, interventions that create an enabling environment to achieve maximum effectiveness, and programmatic efforts in other health and development sectors related to HIV/AIDS. The yearly cost of achievement of universal access to HIV prevention, treatment, care, and support by 2015 is estimated at no less than US$22 billion. Implementation of the new investment framework would avert 12·2 million new HIV infections and 7·4 million deaths from AIDS between 2011 and 2020 compared with continuation of present approaches, and result in 29·4 million life-years gained. The framework is cost effective at $1060 per life-year gained, and the additional investment proposed would be largely offset from savings in treatment costs alone. Copyright © 2011 Elsevier Ltd. All rights reserved.
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            Coming to terms with complexity: a call to action for HIV prevention.

            A quarter of a century of AIDS responses has created a huge body of knowledge about HIV transmission and how to prevent it, yet every day, around the world, nearly 7000 people become infected with the virus. Although HIV prevention is complex, it ought not to be mystifying. Local and national achievements in curbing the epidemic have been myriad, and have created a body of evidence about what works, but these successful approaches have not yet been fully applied. Essential programmes and services have not had sufficient coverage; they have often lacked the funding to be applied with sufficient quality and intensity. Action and funding have not necessarily been directed to where the epidemic is or to what drives it. Few programmes address vulnerability to HIV and structural determinants of the epidemic. A prevention constituency has not been adequately mobilised to stimulate the demand for HIV prevention. Confident and unified leadership has not emerged to assert what is needed in HIV prevention and how to overcome the political, sociocultural, and logistic barriers in getting there. We discuss the combination of solutions which are needed to intensify HIV prevention, using the existing body of evidence and the lessons from our successes and failures in HIV prevention.
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              The history and challenge of HIV prevention.

              The HIV/AIDS pandemic has become part of the contemporary global landscape. Few predicted its effect on mortality and morbidity or its devastating social and economic consequences, particularly in sub-Saharan Africa. Successful responses have addressed sensitive social factors surrounding HIV prevention, such as sexual behaviour, drug use, and gender equalities, countered stigma and discrimination, and mobilised affected communities; but such responses have been few and far between. Only in recent years has the international response to HIV prevention gathered momentum, mainly due to the availability of treatment with antiretroviral drugs, the recognition that the pandemic has both development and security implications, and a substantial increase in financial resources brought about by new funders and funding mechanisms. We now require an urgent and revitalised global movement for HIV prevention that supports a combination of behavioural, structural, and biomedical approaches and is based on scientifically derived evidence and the wisdom and ownership of communities.
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                Author and article information

                Journal
                BMJ Open
                BMJ Open
                bmjopen
                bmjopen
                BMJ Open
                BMJ Group (BMA House, Tavistock Square, London, WC1H 9JR )
                2044-6055
                2012
                2 July 2012
                2 July 2012
                : 2
                : 4
                : e001234
                Affiliations
                [1 ]Centre for Patient Safety and Service Quality, Imperial College London, London, UK
                [2 ]Imperial College Business School, London, UK
                [3 ]Amsterdam Institute for Global Health and Development, Amsterdam, Netherlands
                [4 ]Ipsos MORI Social Research Institute, London, UK
                [5 ]Georgetown O'Neill Institute for National and Global Health Law, Washington, DC, USA
                [6 ]George W. Bush Institute, Dallas, Texas, USA
                [7 ]London School of Hygiene and Tropical Medicine, London, UK
                Author notes
                Correspondence toAna Wheelock; a.wheelock@ 123456imperial.ac.uk
                Article
                bmjopen-2012-001234
                10.1136/bmjopen-2012-001234
                3391366
                22761288
                a0353396-2f80-4f93-a856-71d4456691ad
                © 2012, Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://group.bmj.com/group/rights-licensing/permissions.

                This is an open-access article distributed under the terms of the Creative Commons Attribution Non-commercial License, which permits use, distribution, and reproduction in any medium, provided the original work is properly cited, the use is non commercial and is otherwise in compliance with the license. See: http://creativecommons.org/licenses/by-nc/2.0/ and http://creativecommons.org/licenses/by-nc/2.0/legalcode.

                History
                : 2 April 2012
                : 21 May 2012
                Categories
                Infectious Diseases
                Research
                1506
                1706
                1725
                1724

                Medicine
                Medicine

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