VIEWS OF HIV PREVENTION FOR THOSE AT RISK Robinah Nakabugo, ICW EA The future with PrEP in combination HIV prevention WHO & UNAIDS, Geneva, Switzerland Wednesday 25th March 2015

Background to the presentation A young women’s dialogue was conducted among young women (mostly living with HIV) from Wakiso and Kampala districts to hear their views about PrEP

Babirye’s story Babirye is 15 year old girl in Wakiso, Central Uganda, recently forced into marriage to 50 year old man as a result of poverty and hence failure to complete her ordinary level education. This man is currently married but was widowed before as a result of HIV. The dowry consisted of 1 goat, 1 cow, a jerry can of paraffin and 150,000 UgX (50USD). She was told that as the Buganda custom dictates, her bed would be dismantled and used to make a stand for tying the goat, implying that now she is married, Babirye no longer has a place in her father’s house. 9/18/2018

Babirye’s story (cont’d) Three months later, Babirye discovers her husband’s late wife’s cause of death. Reflecting back she realizes that she has often observed her husband secretly taking medicine. He told her the medication was for TB. The age and power differences in this complex relationship mean she cannot question him further, but she observes that the co-wife is also on the medication but won’t tell her anything about it. During antenatal visits, which Babirye attends alone because the husband vehemently refuses to accompany her, she asks the health worker what the drug label meant and she was told they were ARVs 9/18/2018

Babirye’s story (cont’d) Overcome with grief, Babirye returns home and demands to know why the husband is taking the ARVs without telling her. She is beaten thoroughly and the relationship between the two turns sour. By the time of our interaction, Babirye is still HIV negative and hence not in a prevention of vertical transmission programme but reported that she's afraid her status could turn positive any time as her husband does not use condoms. When PrEP was discussed as a possibility, she repeatedly says even absentmindedly that its something she would consider taking, but secretly.

Views: An additional HIV prevention method A woman-controlled method: young women may not have to totally rely on their male partners When there is condom fatigue or during periods of unsuppressed viral load, e.g for those living in sero-discordant relationships

Questions: How would it work? Would PrEP be accessed from the family planning clinic or the ART clinic? How do we ensure good regular and quality counselling and testing and monitoring when the system is already stretched? How do we ensure support for individuals, especially during periods of vulnerability like when they want to get pregnant?

Concerns: Remembering the bigger picture Will a focus on PrEP as a prevention intervention affect the funding for ARV treatment? What are the long-term effects of taking Truvada? A number of interventions in Uganda lag behind because it’s a patriarchal society. Male partner involvement is important. However, where male involvement is not supportive of women, how do we ensure the burden of responsibility does not fall on women to use it, or that women who want to use PrEP are not at risk of intimate partner violence? PrEP is a biomedical intervention. It does not change the structural and social drivers of HIV. How can we use it most effectively in combination with other interventions?

Dreams: Products that could respond to a range of needs During interaction with the sex workers: While they supported oral PrEP, they were even more interested in microbicide gels because those who were involved in the FACTS 001 trial said that the gel cured their STIs, especially herpes Need microbicide gels to relieve them from drug burden Desire for combined therapy that will address HIV, STIs, and family planning

Thank You 9/18/2018