title: PrEP implementation research in Africa: what is new?
abstract: Of the two million new HIV infections in adults in 2014, 70% occurred in sub-Saharan Africa. Several African countries have already approved guidelines for pre-exposure prophylaxis (PrEP) for individuals at substantial risk of HIV as part of combination HIV prevention but key questions remain about how to identify and deliver PrEP to those at greatest need. Throughout the continent, individuals in sero-discordant relationships, and members of key populations (sex workers, men who have sex with men (MSM), transgender women and injection drug users) are likely to benefit from the availability of PrEP. In addition, adolescent girls and young women (AGYW) are at substantial risk in some parts of the continent. It has been estimated that at least three million individuals in Africa are likely to be eligible for PrEP according to WHO's criteria. Tens of demonstration projects are planned or underway across the continent among a range of countries, populations and delivery settings.
  
  
  
  In each of the target populations, there are overarching issues related to (i) creating demand for PrEP, (ii) addressing supply-side issues and (iii) providing appropriate and tailored adherence support. Critical for creating demand for PrEP is the normalization of HIV prevention. Community-level interventions which engage opinion leaders as well as empowerment interventions for those at highest risk will be key. Critical to supply of PrEP is that services are accessible for all, including for stigmatized populations. Establishing accessible integrated services provides the opportunity to address other public health priorities including the unmet need for HIV testing, contraception and sexually transmitted infections treatment. National policies need to include minimum standards for training and quality assurance for PrEP implementation and to address supply chain issues. Adherence support needs to recognize that social and structural factors are likely to have an important influence. Combining interventions that build self-efficacy, empowerment and social cohesion, with evidence-based individualized adherence support for PrEP, are most likely to be effective.
  
  
  
  Efficacy of tenfovir-based PrEP is proven but many issues related to implementation remain unclear. Here, we have summarized some of the important implementation questions that need to be assessed as PrEP is rolled out across Africa.
authors.affiliation: Department of International Public Health, Liverpool School of Tropical Medicine, Liverpool, UK.|Centre for Sexual Health and HIV AIDS Research (CeSHHAR), Harare, Zimbabwe; frances.cowan@lstmed.ac.uk.
authors.forename: Frances M
authors.initials: FM
authors.lastname: Cowan
authors.affiliation: Wits Reproductive Health and HIV Institute, University of Witwatersrand, Johannesburg, South Africa.
authors.forename: Sinead
authors.initials: S
authors.lastname: Delany-Moretlwe
authors.affiliation: Kenya Medical Research Institute, Nairobi, Kenya.|Nuffield Department of Medicine, University of Oxford, Oxford, UK.
authors.forename: Eduard J
authors.initials: EJ
authors.lastname: Sanders
authors.affiliation: Center for Clinical Research, Kenya Medical Research Institute, Nairobi, Kenya.|Department of Global Health, University of Washington, Seattle, WA, USA.|Partners in Health Research and Development, Thika, Kenya.
authors.forename: Nelly R
authors.initials: NR
authors.lastname: Mugo
authors.affiliation: Dispensaire IST, Cotonou, Bénin.
authors.forename: Fernand A
authors.initials: FA
authors.lastname: Guedou
authors.affiliation: Centre de Recherche du CHU de Québec, Université Laval, Québec, Canada.
authors.forename: Michel
authors.initials: M
authors.lastname: Alary
authors.affiliation: Dispensaire IST, Cotonou, Bénin.
authors.forename: Luc
authors.initials: L
authors.lastname: Behanzin
authors.affiliation: Ministry of Health and Child Care, Harare, Zimbabwe.
authors.forename: Owen
authors.initials: O
authors.lastname: Mugurungi
authors.affiliation: The Desmond Tutu HIV Centre, University of Cape Town, Cape Town, South Africa.
authors.forename: Linda-Gail
authors.initials: LG
authors.lastname: Bekker
mesh_terms: D000293:Adolescent; D000328:Adult; D000349:Africa; D019380:Anti-HIV Agents / Q000627:therapeutic use*; D005260:Female; D015658:HIV Infections / Q000517:prevention & control*; D006301:Health Services Needs and Demand; D006801:Humans; D008297:Male; D008403:Mass Screening; D065129:Pre-Exposure Prophylaxis; D060386:Sex Workers; D055815:Young Adult
chemical_list: D019380:Anti-HIV Agents
keywords: Africa; HIV/AIDS; adherence; empowerment; implementation; key populations; pre-exposure prophylaxis; prevention