FROM UKRAINE. SHE IS THE DIRECTOR OF THE NONGOVERNMENTAL ORGANIZATION LEGALIFE-UKRAINE.
COMMUNITY
VOICES
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on how to respond to illegal detention by the police. I successfully defended my own rights after unlawful detention and abuse of authority by the police in 2008.
Our nongovernmental organization, Legalife-Ukraine, was created in 2012 by former and active sex workers to help their peers. We also became part of a regional network of sex workers: the Sex Workers Advocacy Network (SWAN). My daily work is to lead Legalife-Ukraine and take responsibility for the implementation of projects, but I remain an individual who knows the value of this national, regional and global movement of sex workers, and I guide Ukrainian sex workers to play their part in it.
Now the goals we want to achieve are becoming clearer. We remain focused on our goal of the decriminalization of sex work. The authorities and population at large do not recognize that sex work is work, and they may continue to pursue control by force and by law. Under these circumstances, our work has a specific target audience, which is not society as a whole, but the parliament. Activists train sex workers at the city level, establish partnerships with various organizations and institutions, and plan joint activities. We build momentum and move forward to change policies and laws.
Decreasing donor funding makes it challenging to build capacity and mobilize our community.
But our movement is nonetheless becoming stronger. The meaningful and full participation of sex workers in all processes is essential. Sex workers know that it will not be possible to address the HIV epidemic, no matter how many different HIV programmes and services are implemented, if the affected people themselves are forced to live in the shadows.
PrEP roll-out: learning by doing
Countries are gradually adopting PrEP as an additional HIV prevention option for key populations and young people in high-prevalence settings who are at high risk of HIV infection (33). More than 25 low- and middle-income countries were operating PrEP projects in 2018 to gauge its cost and acceptability and to settle on appropriate service delivery methods. PrEP programmes were being implemented at the national level in fewer than 15 low- and middle-income countries, a number that is expected to rise (Figure 3.15).
More than 300 000 people globally took PrEP at least once in 2018. This does not include the significant but unquantified number of people obtaining PrEP by private means, including online purchasing.
The United States of America remains the single largest provider of PrEP, with more than 130 000 current users in mid-2019. Kenya was one of the first sub-Saharan African countries to roll out PrEP as a national programme in the public sector. More than 30 000 people were accessing PrEP in Kenya in mid-2019, making it Africa’s largest PrEP programme, ahead of South Africa, Uganda and Zimbabwe.
Retention and adherence are challenges for many PrEP efforts. Among gay men and other men who have sex with men participating in a trial in Abuja, Nigeria, interest was high, but only about half (49%) of the 614 participants initiated PrEP, and a little more than half (55%) of those men continued taking PrEP after three months. In Uganda, female sex workers were the most likely among key populations to agree to take PrEP, but retention rates at three and six months were low. One of the apparent hindrances to both uptake and retention was the small number of facilities that provided PrEP, which made it especially difficult for highly mobile women to keep taking PrEP (34).
In some settings, scale-up of PrEP has coincided with a decrease in condom use, which can increase the risk of STI transmission and unplanned pregnancies (35, 36).
These studies underscore the need to ensure that PrEP is offered as part of a comprehensive package of HIV prevention options.
Experience in other regions highlights the importance of close partnerships between health-care providers and community groups for stimulating demand, increasing knowledge and strengthening adherence to PrEP (37). Thailand’s Princess PrEP progamme uses a key population-led model for delivering PrEP. Working in partnership with formal health sector structures, community-based organizations train gay men and
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A COMBINATION APPROACH TO HIV PREVENTION TITLE OF THE ARTICLE
FIGURE 3.15 Adoption of World Health Organization PrEP recommendation and guideline development, 2018
Recommendation adopted, guidelines implemented Recommendation adopted, guidelines pending Recommendation adopted, no guidelines developed Recommendation adoption is pending Recommendation not adopted No data
Source: 2019 National Commitments and Policy Instrument; Hodges-Mameletzis I, Dalal S, Msimanga-Radebe B, Rodolph M, Baggaley R. Going global: the adoption of the World Health Organization’s enabling recommendation on oral pre-exposure prophylaxis for HIV.
Sex Health. 2018;15(6):489-500.
other men who have sex with men and transgender women to serve as community health workers who provide free, rapid HIV testing and PrEP (38).
The VinaPrEP pilot project in Viet Nam has reported high retention: 84% after three months and 70% after nine months (39). Quality peer counselling and support, flexible clinic opening hours and responsiveness to community needs helped strengthen retention (39).
Retention at three months was also strong in the national roll-out: 89% among gay men and other men who have sex with men and 85% among transgender women.
In countries with large proportions of Internet users, adapting existing offline health-care support for online platforms can potentially improve retention and adherence in PrEP programmes and link people to face-to-face services and support (38).
Positioning PrEP programming as part of a positive life choice has proved highly effective in Australia and the United States (40). Potential breakthrough technologies of the future, such as vaginal rings and injectable antiretrovirals, may aid the scale-up of PrEP in challenging environments (41).
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