In April next year, SA, plans to start rolling out an anti-HIV jab, taken only twice a year, that could end Aids in the country within 14 to 18 years — if enough people take it.
The once-every-six-months shot, called lenacapavir (LEN), works 100% of the time to stop young women from getting HIV through sex. Of the about 400 people in SA who still get infected with HIV each day — 122 of them are teen girls and young women.
LEN is a form of PrEP — pre-exposure prophylaxis — which is when medicine normally used to treat people who are infected with HIV, is used to stop HIV-negative people from getting the virus.
But for our LEN roll-out to be successful — so for it to result in ending Aids as a public health threat in SA, the government would need to buy and distribute millions of doses of the jab over the next two decades, modelling studies show.
But is our public health system equipped to keep track of hundreds of thousands of people, let alone millions, who are on the shot — and for how long they stay on it?
Let’s start with the daily HIV prevention pill, also called oral PrEP.
LEN won’t be South Africa’s first HIV prevention meds. Public clinics started to roll out a daily anti-HIV pill in 2016. By April this year, 1.9-million people had used it at least once.
Counting how many people start using the pill is a relatively straightforward process. But the electronic patient tracking system — Tier.net — that the health department uses makes it difficult to keep track of people who stop and restart HIV prevention medication.
“ Keeping track of people stopping and restarting PrEP medication isn’t just difficult in SA, most countries struggle with it,” says Hasina Subedar, a senior HIV prevention technical advisor. That’s because the systems that have, over the years, been used to track HIV-infected people’s use of treatment, are now often also used to monitor HIV-negative people’s use of HIV prevention medication, and the rules for HIV treatment and HIV prevention medication are different.
With LEN’s roll-out on the horizon, the health department will require a system that can track both daily HIV prevention pills and 6-monthly injections properly and that also keeps records accurate when people switch between pills and injections or move on to different clinics.
From studies, we know that many people, especially young women, struggle to take the pill every day. And when someone skips doses, their chances of contracting HIV increase.
But to track how consistently people are taking their pills, is also difficult to do — and, again, not just in SA.
“Prevention has always been a numbers game,” says Mitchell Warren, who heads up the health advocacy organisation Avac, which advocates for HIV prevention options globally. “We hand out a million condoms, a million PrEP pills, and assume protection. But people lie about sex and drugs. They tell you what you want to hear.”
So will LEN use, that only needs to be recorded once every six months, be easier to track than the daily pill?
Well, yes and no.
What makes consistent LEN use easier to track than the daily pill, is the fact that LEN doesn’t require a user to take doses at home; once someone got their shot at a clinic, the dose is done.
“With injectables, once it’s in, it’s in,” explains Linda-Gail Bekker, head of the Desmond Tutu Health Foundation at the University of Cape Town.
“But with pills, people can still fail to take it consistently at home. And when people miss follow-ups, protection can quietly slip away.”
But, even in the case of LEN, tracking patients who stop or restart and, reminding them of 6-monthly follow-up visits, will need a data system that can do this.
To measure effective LEN use during a study (called PURPOSE 1) in which around 2 100 women were offered the injection for over a period of one year, Bekker and her researchers kept tabs on something called “annual persistence”.
For LEN, this was a straightforward measurement: show up, and you’re protected; miss a visit, and there are gaps.
A cohort tracker used in another study — Project PrEP conducted by Wits RHI — recorded when participants started, restarted, or changed to a different PrEP medication.
A cohort tracker looks at information about a patient or a group of people — who all started something at the same time, for instance, PrEP — over time, showing how they’re doing as time goes by.
But the method used in the study is far too labour-intensive for the public system, says Subedar. “We need something that can do the same job, but without adding extra work for health workers or patients.”
“If we get this right, LEN could change the trajectory of the epidemic,” says Bekker. “But it will only happen if we learn quickly from the data, and make the system strong enough to deliver.”
This story was produced by the Bhekisisa Centre for Health Journalism. Sign up for the newsletter.
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