Pre-Exposure Prophylaxis for adolescents: a perspective from India

Dr Sunil Mehra of the MAMTA Health Institute for Mother and Child, based in New Delhi, on the challenges and opportunities of PrEP for under 18s.

Nowhere is the crisis facing HIV prevention seen more clearly than among adolescents and young adults. According to UNICEF, the number of adolescents living with HIV rose by 30% between 2005 and 2016, with young key populations and young women disproportionately affected.

Pre-exposure prophylaxis (PrEP), a course of antiretroviral drugs taken by HIV-negative people to prevent infection, has the potential to help reduce transmission rates but limited research means the effectiveness of PrEP for adolescents remains largely unknown. Even among the handful of countries where PrEP has been licensed for adults, only the USA has approved its use for under-18s at high risk of HIV.

In the latest Journal of Adolescent Health (JAH), leading experts in the field provide a clear set of recommendations for the promotion and use of PrEP for adolescents and young adults.

The report’s co-author Dr Sunil Mehra, executive director at the MAMTA Health Institute for Mother and Child in India (MAMTA), an Alliance Linking Organisation, tells us more.

What’s the situation on PrEP in India?

PrEP is not currently approved for use, regardless of age. In India, PrEP trials have been conducted among men who have sex with men [MSM] and female sex workers [in Mysore and Kolkata and Bangalore], although there have not been many. The Indian Council of Medical Research and the National AIDS Control Organisation are currently seeking more evidence about its effectiveness.

I also get the sense that the repeal of Section 377, which has decriminalised MSM, will definitely help to bring PrEP on board because, in India, PrEP will be used for young MSM and female sex workers more than anybody else.

The JAH article makes clear recommendations, what impact do you hope this will have?

Our paper emphasises the recent World Health Organization guidelines, which recommend for PrEP to be integrated into routine care for at-risk young adults. But it also asks questions beyond this; what is happening to people who are less than 18 is not understood, and that is where the real challenge is.

The availability of drugs is not the only issue, it is about understanding the total programme that needs to be built in a country like India for PrEP to effectively reach adolescents and young adults.

What do you see as the main challenges?

Can I get counselling and testing services if I am 16 without my parent or guardian being there? No, I’m not allowed. You have to be 18-years-old to access services [the age of consent in India is 18] but most high-risk behaviours begin much earlier than that, at around 14, 15 or 16. Many [at risk adolescents] are not in families but they still need to be accompanied by a guardian or some form of caretaker to get services.

Can you envisage Indian health systems providing PrEP for adolescents?

PrEP comes much later. First, do adolescents get sexual and reproductive health services, say for abortion or contraception or for sexually transmitted infections? Legally, yes, but it is extremely difficult for them to access the services because of many socio-cultural obstacles, and a lack of knowledge and skills among providers. Although India has one of the largest networks of adolescent-friendly clinics at more than 8,500, footfall is low. Most adolescents only come for generalised illnesses.

The first challenge is to make service providers comfortable with the sexuality of adolescents. Issues of sexual orientation, premarital sex, and different sexual practices are still a big taboo.

How difficult is it to gather evidence on the effectiveness of PrEP for adolescents?

In any research you do with adolescents and young adults, the ethical clearance you need to get is always a challenge [a parent or guardian must give consent if the participant is under 18]. This is particularly the case in relation to research on sexual orientation, sexual practices and health-seeking behaviours. Even more importantly, it’s about working with adolescents and young adults so they understand why they are participating in this type of study and how it will affect them.

What is the role of sex education in all this?

Many countries where PrEP for adolescents and young adults is needed don’t have well-entrenched sexuality education programmes and young adults are entering into sexual behaviours without basic knowledge on safe sexual practices. India, for example, offers more of a reproductive health education programme than a comprehensive sexuality education programme.

What would be interesting would be to look at countries where sexuality education is well done and the way they have introduced PrEP for adolescents. This could be compared with countries that are struggling to implement sexuality education and introduce PrEP.

What are the next steps in making PrEP available for adolescents in India?

One is to get the mindset of the National AIDS Control Organisation to think positively about PrEP – not to rush into it but to see it as one of the ways we can reverse HIV incidence among high risk adolescents and young adults. I also get the sense that, to introduce PrEP we will have to work with a very dedicated workforce and not with the generalised health system.

But it’s not just about [providing] PrEP, it’s about comprehensive sexuality education, integrated with PrEP. We must ensure that PrEP is not brought in as a vertical [stand-alone] programme but as part of a comprehensive sexuality education programme, that’s how you’re likely to get better results. MAMTA is one of five Alliance Linking Organisations working to address HIV in India. It provides community-based care and support for women, children and adolescents living with and affected by HIV.