title: The preexposure prophylaxis revolution; from clinical trials to programmatic implementation.
abstract: OBJECTIVE
  An investment in preexposure prophylaxis (PrEP) delivery must have public health impact in reducing HIV infections. Sustainable delivery of PrEP requires policy, integration of services, and synergy with other existing HIV prevention programs. This review discusses key policy and programmatic considerations for implementation and scale up of PrEP in Africa.
  
  
  RESULTS
  PrEP delivery has been delayed by concerns about adherence and delivery in 'real world' settings. Demonstration projects and clinical service delivery models are providing evidence of PrEP effectiveness with an impact much higher than that found in randomized clinical trials. Data confirm that PrEP uptake, adherence, and retention has been high, more so by persons who perceive themselves at high risk for HIV infection, and PrEP is well tolerated. PrEP delivery is more than dispensation of a pill and programs should address other risk drivers, which differ by population. In Africa, barriers to PrEP uptake and adherence include stigma among MSM and low HIV risk perception among young women. Additional data have provided insight into optimal points of service delivery, provider training requirements and quality assurance needs. Of the 2 million new HIV infections in 2014, 70% were in Africa. PrEP use is not lifelong, and use limited to periods of risk may be both effective and cost-effective for the continent.
  
  
  CONCLUSIONS
  HIV prevention programs should determine strategies to identify those at substantial risk for HIV infection, formulate and deliver PrEP in combination with interventions that target social drivers of HIV vulnerability specific to each population. Policy guidance for optimal combination of interventions and service delivery avenues, clinical protocols, health infrastructure requirements are required. Cost-effectiveness and efficiency data are essential for policy guidance to navigate ethical questions over use of antiretroviral therapy for HIV-negative individuals when treatment coverage has not been attained in many parts of Africa. Countries need to invest in purposeful advocacy at both local and global forums. Failure to implement PrEP will be a failure to protect future generations.
authors.affiliation: aCenter for Clinical Research, Kenya Medical Research Institute, Nairobi, Kenya bDepartment of Global Health, University of Washington, Seattle, WA, USA cPartners in Health Research and Development, Thika dDepartment of Public Health, Jomo Kenyatta University of Agriculture and Technology, Juja eLVCT-Health fNational AIDS Control Council, Nairobi, Kenya.
authors.forename: Nelly R
authors.initials: NR
authors.lastname: Mugo
authors.forename: Kenneth
authors.initials: K
authors.lastname: Ngure
authors.forename: Michael
authors.initials: M
authors.lastname: Kiragu
authors.forename: Elizabeth
authors.initials: E
authors.lastname: Irungu
authors.forename: Nduku
authors.initials: N
authors.lastname: Kilonzo
mesh_terms: D000349:Africa / Q000453:epidemiology; D019380:Anti-HIV Agents / Q000008:administration & dosage*; D018890:Chemoprevention / Q000379:methods*; D003362:Cost-Benefit Analysis; D003695:Delivery of Health Care / Q000458:organization & administration*; D018562:Disease Transmission, Infectious / Q000517:prevention & control*; D005260:Female; D015658:HIV Infections / Q000453:epidemiology / Q000517:prevention & control* / Q000635:transmission; D006291:Health Policy; D006801:Humans; D008297:Male; D065129:Pre-Exposure Prophylaxis / Q000379:methods* / Q000458:organization & administration*; D016896:Treatment Outcome
chemical_list: D019380:Anti-HIV Agents