Global Implementation of PrEP: The Importance of Addressing Social and Structural Barriers

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Global implementation of pre-exposure prophylaxis (PrEP), a pill taken to prevent HIV infection, has made major strides in the last year. The U.S. Food and Drug Administration first approved Truvada for daily oral PrEP in July 2012, but no other country approved PrEP in the subsequent three years. In November 2015, France became the second country and the first with a centrally organized, national health system to approve PrEP. The French National Agency for Medicines and Health Products Safety authorized both a daily regimen for all people at risk for HIV infection and an intermittent or “on demand” regimen, as used in the IPERGAY study, for men who have sex with men.  This authorization was made possible under a Recommendation for Temporary Use, but recent approval by the European Medicines Agency in July 2016 means that France can now apply PrEP as a permanent part of its health system.

Shortly after France’s approval of PrEP, PrEP was approved in South Africa and Kenya in December 2015. Canada, Israel, Peru, and Australia took the same step in 2016. Just last week, the High Court of Justice ruled that the National Health Service (NHS) in England can legally fund PrEP. Although the High Court ruling does not make funding PrEP automatic and the NHS is set to appeal, the decision further underscores that PrEP is a core component of HIV prevention.

Even as global implementation of PrEP gains momentum, it is not happening quickly enough for millions of men and women at risk for HIV. More countries must approve PrEP and develop effective ways to delivery PrEP to those in need. This includes mobilizing funding, raising medical provider and community awareness, and establishing policies and systems.

To ensure on-the-ground access and impact, it is also critical that all countries remove social and structural barriers to PrEP. Such barriers contribute to HIV disparities among racial, gender, and sexual minorities and could keep these and other vulnerable populations from benefiting from PrEP.

France, for instance, has made a significant investment in PrEP rollout. Up to July 2016, 1077 people, 96.4% of whom identify as gay men, started PrEP through the public health system in France; 90 clinics offer PrEP assessment and prescription and 273 doctors have been accredited as PrEP physicians. But like the United States, France must do a better job ensuring that people of African descent have access to PrEP. Data presented at the 21st International AIDS Conference (AIDS 2016) showed that 87% of PrEP users in France are French, i.e. non-migrants. This suggests a serious need to support greater PrEP uptake among migrants, especially sub-Saharan migrants, who account for nearly one-third of new diagnoses in France. Migrants in France face frequent hardship that increases HIV risk, with one study finding that more than 40% have lived a year or more without a residence permit and more than 20% lack stable housing. PrEP rollout in France will have limited effectiveness if these social problems are not addressed.

Beyond the issue of migration, France faces challenges in thinking of itself as a color-blind society and refusing to measure race in its census and health system. Despite its significant problems of racial segmentation and discrimination, France has limited tools to measure or correct them. As a result, it is difficult to assess the HIV prevention needs of French Blacks and promote PrEP through targeted policy and programmatic activity.

Social and structural barriers need to be addressed for PrEP to have large-scale impact in France and other countries. It is important that we do not ignore or reinforce racial, gender, and sexual inequalities in global HIV prevention.


Posted in Global Health; Tagged: , , , , .


Spike in hepatitis C rates in young women further supports the need for screenings for all pregnant women

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As the rate of Hepatitis C infections among young Americans increases, so does the risk of infections in infants. The CDC reports a 22% increase between 2011 and 2014  in HCV infections in women of childbearing age, between 15-44 years.  There was also a 14% increase in infections in children 2 years and younger seen during this period. Higher rates of HCV infection in childbearing women greatly increases the risk for vertical transmission of the infection from mother to child if these women become pregnant. Vertical transmission occurs in 5.8% of infants born to HCV infected mothers. Although the risk of transmission is low, it still exists, and if more infected women become pregnant still unaware of their diagnosis or without access to treatment, the number of infected babies will continue to rise.

Screening for Hepatitis C is not routine for pregnant women unless they have certain risk factors for the infection, such as an infected partner or intravenous drug use. How can this be? Why are doctors not screening for a communicable infection that affects almost 4 million Americans? This discrepancy can be attributed to several factors. Hepatitis C has been an infection commonly known to affect older Americans, particularly those in the “Baby Boomer” generation. While this is still a demographic at significantly greater risk for the infection, health care practices and policies are not keeping stride with modern shifts in infection rates in other populations. Many doctors may not be aware of the rapid rise in infections in younger women, and thus are not counseling or screening these patients, despite their increased risk. Likewise, some insurers have not expanded coverage of the HCV test to this demographic as part of routine screenings.

From a policy perspective, the CDC states in this latest MMWR report on Hepatitis C that public health authorities should consider making HCV screening routine for all pregnant women. The report also calls for expansion of HCV reporting and surveillance requirements to improve identifying and preventing the spread of the infection.

It is hopeful that as a result of this data the CDC may issue updated recommendations on HCV screenings, to include routine screening of all pregnant women. Pressure from public health officials, providers, politicians and the public will be needed to influence insurers to expand coverage of routine HCV testing to more Americans. The O’Neill Institute’s Hepatitis C Policy Project is already working with representatives from the CDC and other public health agencies to improve HCV data collection and case surveillance, in order to develop long-term strategies to reduce incidence of infection.

Posted in Health reform, National Healthcare, Uncategorized;


Vaping flavor: dangerous trends in youth consumption of e-cigarettes

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This post was written by Irene Cuellar Araiza and Fernanda Alonso 


Currently, we are experiencing a new phenomenon with youth consumption of e-cigarettes all around the United States. For the second consecutive year, e-cigarettes were the most popular product among youth. FDA’s newest statistics indicate that more than 3 million middle and high school students were users of e-cigarettes in 2015, representing 540,000 more consumers than in 2014. New flavors appear to be one of the main reasons why teens are getting hooked on this product. In 2013-2014, 81% of the current e-cigarette youth users, pointed to the appealing flavors of e-cigarettes as one of the main reasons of why they started using them, stating that they used e-cigarettes “because they come in flavors I like.” This is even more concerning when we see how quickly this market is growing. In a report released in January 2014, researchers found that every month, an average of 240 new flavors are added to the e-cigarette market.


Although tobacco companies claim that new flavors are simply a response to adult users’ demand for variety, flavored tobacco products primarily serve to attract new users, particularly kids, and to get them addicted. As shown by the Campaign for Tobacco Free Kids, an industry publication stated, “While different cigars target a variety of markets, all flavored tobacco products tend to appeal primarily to younger consumers.” Even the industry leader Lorillard, which sells flavored e-cigarettes such as kool-aid and gummy bears, has admitted that “kids may be particularly vulnerable to trying e-cigarettes due to an abundance of fun flavors such as cherry, vanilla, pina-colada, and berry.”

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Why We Need Anthropologists During Public Health Emergencies

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Image courtesy of NPR.

Image courtesy of NPR

Anthropologists play a key role in responding to public health emergencies, particularly infectious disease outbreaks. However, in the early stages of the recent Ebola outbreak in West Africa, many of the response teams sent by Doctors Without Borders, the World Health Organization (WHO), the U.S. military, etc. failed to include anthropologists. In the face of resistance to treatment and prevention measures (as well as distrust of the people implementing those measures) by the affected communities, anthropologists could have collaborated with public health professionals to ensure that efforts to contain the outbreak were both culturally sensitive and appropriate.

Fortunately, the international community has made a more concerted effort to include anthropologists as part of the teams that are formulating and implementing the response to the current Zika outbreak. Here are 3 examples of how anthropologists are contributing to these important efforts:

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Posted in Global Health, Human Rights, Uncategorized, WHO; Tagged: , , , , , .


Let the Games Begin: Legal and Health Dramas Off-field Risk Overshadowing Rio

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This week has been an interesting week in the world of international sports and health law. The Court of Arbitration for Sport (CAS) announced today that it will uphold the suspension of the Russian track and field team originally imposed by the International Association of Athletics Federations (IAAF) from the upcoming games in Rio in a month’s time. Russia was originally suspended from track and field events by the IAAF in November 2015 after an independent publication by the World Anti-Doping Agency (Wada) alleged systematic and state-supported doping and recommended lifetime doping bans against a number of athletes and coaches. Russia accepted this ban without requesting a hearing and the Russian sports minister apologized at the time for not having identified that doping was taking place without directly admitting state involvement.

The allegations against Russia worsened this week with the publication of another Wada-report called the McLaren Independent Investigations Report into Sochi Allegations that reviewed Russian activities across a range of sports on numerous international sporting events, from roughly 2011 up to and including the 2014 Sochi Olympic Games. The Report suggests that Russian systemic doping of athletes extends well beyond the track and field team, and was directly overseen by the Ministry of Sport and may have involved active participation by members of the Russian secret service who assisted with sample swapping. The International Olympic Committee (IOC) responded to this report in a statement where they called this a “shocking and unprecedented attack on the integrity of sports and on the Olympic Games” and said that they would “not hesitate to take the toughest sanctions available against any individual or organization implicated”. These allegations have led to calls to have the entire Russian Olympic and Paralympic teams banned from the Rio Games, a process that is currently underway through the international sporting tribunal system.

Despite the ban, it may be possible for some Russian athletes to compete if they are nominated by the Russian Olympic Committee and pass numerous drug tests, but their participation would have to do so under the banner of the IOC and not under their home flag of Russia. It remains to be seen what will happen to the secondary challenge against the wider Russian teams and opinions about the correctness of the findings are mixed. Many athletes have come forward praising the decision as being a strong warning for those who would seek to cheat through doping methods, while others have argued that a blanket ban runs contrary to the principles of justice for the clean Russian athletes who have qualified for the Rio Games without having undertaken doping.

With the Olympic torch on day 80 of 95 on its way to Rio, this is just one more dramatic piece to what has already shaped up to be an incredibly dramatic event with political overthrows, violence in the city’s favelas, fears about Rio’s water quality and the ever present threat of the Zika virus, all of which have somewhat overshadowed enthusiasm for the Games themselves and have left some calling to have the Games cancelled. Despite these difficulties, the Games are set to start in just 15 days time and will undoubtedly be exciting however, let us hope that the excitement on the field far exceeds any excitement off the field!

Posted in Uncategorized;


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The views reflected in this blog are those of the individual authors and do not necessarily represent those of the O’Neill Institute for National and Global Health Law or Georgetown University. This blog is solely informational in nature, and not intended as a substitute for competent legal advice from a licensed and retained attorney in your state or country.

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