NIGERIA: This year, 2021 will make it 40 years since the first reported case of AIDS in the world; HIV/AIDS is being declared as one of the worst pandemics in human history.
Each year, treatment and prevention methods for HIV improves and each year, the mysteries of how HIV is contracted and spread in the body is being discovered.
After 40 years of the first diagnosed case of HIV, only few HIV vaccines have entered phase 3 of the clinical trials, however, scientists have not lost hope that the vaccine would soon be available to the people.
The unavailability of the HIV vaccine is being augmented with Pre-exposure prophylaxis (PrEP) which is one of several HIV prevention strategies for people who are HIV negative but who have a higher risk of acquiring HIV, including sexually active adults and people who engage in injection drug use.
While the oral PrEP is readily available, its off-take and persistence in use seem to be greeted with hesitancy as findings reveal that despite the PrEP, there are still increased new cases of HIV.
At the 11th IAS Conference on HIV Science in July, it was said that 77.5 million people have become infected with HIV, over 34 million people have died from AIDS-related causes while 37.6 million people are currently living with HIV.
During the Conference, experts expressed worry that women account for more than half of all people living with HIV globally, and face persistently high HIV infection rates as approximately 7000 young women and girls aged 15 to 24 become infected with HIV weekly.
Although access to daily oral PrEP is increasing around the world, a daily pill seems not to be a suitable or desirable prevention method for everyone as not everyone is versed in popping pills daily. Research revealed that women face unique challenges when it comes to adhering to a daily pill due to gender inequity, social norms and other structural barriers.
To address these challenges, the Dapivirine Ring which is a female initiated option to reduce the risk of HIV infection has been introduced.
The Dapivirine Ring
Dapivirine (DPV) Ring is an intravaginal silicone ring, developed by the International Partnership for Microbicides (IPM) for HIV prevention.
The ring delivers an antiretroviral drug called dapivirine. The dapivirine is released slowly for one month directly to the vaginal tissue to help protect against HIV at the site of potential infection.
Efficacy data have shown that the ring reduces HIV risk by 35 per cent, with recent data from open-label extension studies suggesting a greater reduction in HIV risk by about half.
The vaginal ring has shown great promise as the ring has received a nod from the European Medicines Agency (EMA) for its use among women ages 18 and older.
The Ring has also been added to the World Health Organization’s (WHO) list of prequalified medicines, the Global Fund has placed the ring on its preferred drug list, PEPFAR is preparing to put it on priority commodity list in 2022, the FDA has agreed to review the Dapivirine Ring and currently under regulatory review in several countries.
To use, the Dapivirine Ring is placed inside the vagina for 28 days after which it is replaced by a new ring; the ring is made of silicone and is easy to bend and insert. It works by releasing the ARV drug, dapivirine from the ring into the vagina slowly over 28 days.
The Dapivirine Ring was one of the highly discussed prevention topics during the 11th IAS Conference on HIV Science held virtually in July.
During one of the symposiums titled “Intravaginal options: Today and in the future”, the Director, Global HIV, Hepatitis, STI Programmes at WHO, Meg Doherty noted that the Dapivirine Ring is indicated for reducing the risk of HIV 1 infection in sexually active HIV un-infected women in combination with safer sex practices.
According to her, the WHO recognized the potential benefit of additional options of including the Dapivirine Ring for PrEP for women at risk for HIV particularly in high HIV-incidence and prevalence settings and would improve the choice of women in PrEP selection.
A new research whose interim results were reported during the official IAS press conference at the 11th International AIDS Society (IAS) 2021 Conference revealed that adolescent girls and young women in African have a strong desire to protect themselves against HIV and are willing to use HIV prevention products with consistency if it is provided to them.
The research is based on the study of two different methods, the daily use of the antiretroviral (ARV) tablet Truvada as oral pre-exposure prophylaxis (PrEP) and the monthly dapivirine vaginal ring.
Previous studies had shown that young women would find it difficult to take HIV prevention products regularly in a way that would prevent HIV.
The study known as REACH (Reversing the Epidemic in Africa with Choices in HIV Prevention) is being conducted at four clinical research sites in Uganda, South Africa and Zimbabwe by the National Institutes of Health-funded Microbicide Trials Network (MTN).
The study showed that 97 per cent of the participants used the vaginal ring and daily oral PrEP some or all of the time for six months while only three per cent of participants used neither of the products.
“Both approaches received high marks from the study’s participants: during the six months they were asked to use the monthly dapivirine ring, 88 per cent said they liked it, and during the period when they were assigned to use oral PrEP, 64 percent said they liked the daily pill-taking regimen”, the abstract on the research read.
The Research team attributed the study’s findings of high product adherence and acceptability to the support measures, tailored for the population, and the nonjudgmental counselling approach provided as part of the study.
The Reversing the Epidemic in Africa with Choices in HIV prevention (REACH) began in February 2019 and is expected to be completed by October 2021, with final results.
In Africa, the Dapivirine Ring has been submitted for approval in ten Africa countries where the incidence of HIV infection in women is high. The countries include South Africa, Zambia, Rwanda, Uganda, Malawi, Tanzania, Kenya, Botswana, Ethiopia and Nigeria. Zimbabwe is the first Africa country that has approved the Dapivirine Ring after it was included in the WHO list of prequalified medicines for HIV prevention.
Is there hope for the Dapivirine Ring in Nigeria?
A Professor of Paediatric Dentistry of the Obafemi Awolowo University, Ile-Ife, Professor Morenike Oluwatoyin Ukpong said that the Dapivirine Ring would be acceptable in Nigeria if it is well promoted.
“Anything good that you promote negatively is not acceptable. What would make the ring uptake acceptable is the way you promote it and make it accessible to people. I don’t think it would not be acceptable, I think there may be challenges in finding the right way to promote the ring so that its use is not stigmatized.”
Morenike advised that one way of not promoting the ring is by associating it with HIV, “Anything you associate with HIV including HIV test, come with slow uptake because of the stigma around HIV and not because of the product itself.
“The Dapivirine ring is an important addition to the tools for the prevention of HIV especially for females who need it more and it should come with appropriate marketing.”
She said that the Dapivirine Ring would be very accepted in the country because Nigerians are not adherent to swallowing medicine, “The PrEP being used in the country means that you are going to have to be swallowing medicine every day and you might also be seen and asked why you are taking medications. Being sick is stigmatized in many ways and moreover when someone who is not ill takes medication everyday.”
Speaking further about PrEP administration during the COVID-19 pandemic, she said that the HIV response during the COVID-19 pandemic in Nigeria was reported as a huge success as the country was able to adapt promptly to the pandemic and continue to offer HIV treatment, counselling and prevention service delivery.
According to her, the country could promptly adapt its HIV response in the country because of the specialized and siloed HIV services provision.
“The HIV response during the pandemic includes delivering services to the people in the homes or place of comfort rather than waiting for people to come into the facility. Drugs were taken to the people in their home, to places close to them where they can have easy access.”
She further commented on vulnerable populations who were worse affected during the lockdowns noting that, “generally, Nigeria did well and there is a global acknowledgement of the excellent job Nigeria did in the area of HIV prevention, treatment and counselling during the lockdown.
“So the pandemic did not affect the system in any way. However, individuals who were vulnerable before the pandemic were badly affected during the pandemic as they were cut off from services. Going forward these special groups of individuals need to be programmed appropriately.