At the beginning of her participation in the REACH HIV prevention study, Gemma, a young single mother who was employed part time, supporting her partner financially and emotionally and hoping to pursue further education to realise her dreams, had this to say “I sometimes feel that had I waited a bit longer to have my child my life would be different.
"Don’t get me wrong, I love my child and can’t imagine my life without him. But had I given myself time to enjoy my youth, things would be so different because I feel like I am taking on a whole lot of burden that is not for a person of my age.”
Her motivation for joining REACH was because her mother was HIV positive and she wanted to learn different ways to prevent HIV without using condoms.
Gemma’s story is important because young women in Africa account for 25% of all new HIV infections, although they make up just 10% of the population. They are not only disproportionally affected in comparison to women globally but also to young men in Africa: six out of seven new infections among adolescents (15-19 years) are in girls.
Young women are vulnerable to HIV infection due to biological, social and cultural factors which include early sexual activity, being involved in relationships with older men, and gender inequalities that sometimes result in gender-based violence.
There are ways to empower adolescent girls and young women to make choices regarding HIV prevention. For example, the dapivirine vaginal ring and oral PrEP (pre-exposure prophylaxis), both ARV-based HIV prevention methods, have proven to be effective in preventing HIV infection.
Oral PrEP, which involves taking a daily pill, is widely available and, in some countries, accessible to adolescents as well.
The vaginal ring, a new HIV prevention method that is used for a month at a time, has been endorsed by the World Health Organisation as an additional option for women at substantial risk of HIV infection – especially for those who are unwilling or not able to use oral PrEP. It was recently approved for use in Zimbabwe, the first African country to do so.
While both methods have shown to be able to prevent HIV in women in Africa, this regrettably has not been the case in younger African women in the 18-to-25-year age group.
In clinical trials, younger women found it difficult to adhere to both these methods. There is an urgent need to make available to younger women methods that can and will work for them.
But what about girls younger than age 18? When approved more widely and I am optimistic that it will be, the ring would be the first long-acting method designed specifically for women, but its use would likely be for women older than 18 years.
Additional safety and adherence data is required before it can be considered for use in adolescents.
We have come a long way in terms of HIV prevention. We have oral PrEP and hopefully ring approval in many more countries in the near future. We can look forward to other options such as injectable methods and long-acting pills in the future, as well.
But for now, we need to see that oral PrEP and the ring can work for and be made available to adolescent girls and young women.
That is the aim of the REACH study and interim results already show that young women in Africa can and will use these methods. The study also aims to see what kind of support young women need to use these methods and which method they would opt for when given a choice.
The REACH Study is taking place in South Africa (in Cape Town and Johannesburg) and in Uganda and Zimbabwe. It began in February 2019 and is expected to be completed in October 2021. Of the 247 young women and girls who joined the study, 35% were in the 16-to 17-year-old age group.
As of now, all the participants have used the ring and oral PrEP for six months each. In the final six months of the study they have the option of choosing which of the two methods to use or no method. The young women receive support and counselling focused on empowering them to make their own decisions related to method use.
Said the one participant: “I know I am very confident right now because I am fully aware of my health and I know that in the REACH study the study products that I get are very helpful towards my life and keeping me safe, healthy, wise. And yes, I am happy.”
Adherence to both methods was higher than previously seen, likely due to the amount and type of support provided. Ninety-seven percent (97%) of participants used both methods all or some of the time with only 3% not using any method at all. In other studies, use had not exceeded 25%.
Eighty eight percent (88%) said they liked using the ring and 64% oral PrEP. Final results of this study, including information on preferences, will be available mid-2022.
Not everyone will want to use the ring, and the same applies to oral PrEP. As life circumstances change, so will choice and preference. That’s why it’s so important to make both methods available as well as additional methods in the future. But we do need to give adolescent girls the power to choose methods that they believe will work best for them.
In her last interview, Gemma had this to say: “I think staying HIV negative, I wouldn’t say it’s simple, no, it’s not simple, but it’s doable if I take the necessary precautions.
"Once I finish my participation in the study, they will give me a referral to go and get my PrEP. I am most definitely go to the clinic and continue with it, continue taking the necessary precautions and using a condom all the time and go for testing so yes I am planning on staying negative for the rest of my life.
REACH is indeed an important study to put HIV prevention in the hands of Gemma and other girls and young women in Africa.
*Dr Gonasagrie Nair is a Senior Lecturer in Medical Ethics at the Centre for Medical Ethics and Law in the Faculty of Medicine and Health Sciences at Stellenbosch University.