After 40 years of HIV, why are we still not optimally reaching the most vulnerable groups?

What exactly is PrEP?

Thijs: PrEP stands for 'Pre-Exposure Prophylaxis'. It is a preventive strategy. People at high risk of HIV infection take oral medication to prevent contracting the virus. PrEP blocks the spread of HIV in the body when a person is exposed to the virus.

You have been working on HIV prevention via PrEP for some years. Could you tell us more about that?

Thijs: My involvement in HIV prevention began with the Be-PrEP-ared study. That was a study from 2015 to 2018 on the feasibility of oral PrEP for gay men. This study provided valuable insights into how PrEP can work as a preventive tool. After this study, I have been involved in various projects, including expanding the implementation of PrEP in Belgium and research on vulnerable groups such as men who have sex with men in West African countries.

What do you see as the biggest challenges in HIV prevention, especially regarding the acceptance of PrEP?

Thijs: It is crucial to address the persistent gap in knowledge and access to PrEP. We need to continue investigating why some people do not have access to PrEP or choose not to use it, and then develop effective strategies to overcome these barriers. Additionally, we must keep working on reducing the stigma around HIV and PrEP, as that also prevents people from seeking preventive care.

How are you tackling these complex challenges?

Thijs: One example of how we aim to increase access to PrEP is a pilot project in Zambia. There, we offer PrEP through vending machines. As a user, you receive a code to obtain your PrEP medication from the machines. This anonymity lowers the threshold and reduces the sense of shame.

Additionally, we are exploring possibilities for self-sampling and self-testing. This not only lowers the threshold but also offers other advantages. Currently, there are approximately 8,000 PrEP users in Belgium, but this number could be much higher. There was previously an overwhelming demand for PrEP, leading to long waiting times for appointments at health centres. Although these waiting times are being addressed, there remains a need for more capacity to treat everyone effectively and to thoroughly investigate the broader context of HIV prevention. Self-testing can help by reducing the pressure on existing health services.

Besides researching improved access, we are also studying the acceptance of PrEP to understand and increase it, particularly among vulnerable populations. We are looking into why people choose not to use PrEP and what methods of HIV prevention work for them.

A concrete example is our project in Burkina Faso, which delves into the barriers sex workers face in HIV prevention. Oral PrEP has been available to them since July 2021. However, very few of them start using PrEP, and those who do often stop quickly. Why is that? Together with local partners and sex workers, we are seeking possible answers, and we will also develop interventions for the initiation and follow-up of PrEP.

Which research areas do you believe deserve further exploration in the field of HIV prevention, and what added value can the Institute of Tropical Medicine provide?

Thijs: In addition to the potential impact of new preventive products, reach remains a major issue. How do these products effectively reach the groups that need them most, and how can we reach communities that are difficult to access? This requires not only more research in the field of public health but also research into the application of prevention strategies in different circumstances.

Although the situation around HIV in some parts of the world appears stable or even declining, the number of affected individuals remains high globally, especially in continents where access to preventive care is limited. ITM can play a crucial role in this regard. Not only because of the extensive experience built around the implementation of PrEP, but primarily because of our strong focus on community-based approaches and our local partnerships. By promoting collaboration and knowledge sharing, institutions like ITM can help shape the future of HIV prevention. They can ensure that no one is left behind in the fight against HIV/AIDS, in a sustainable manner alongside the most affected communities.