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Amsterdam, Netherlands — 25 July 2018
At the 22nd International AIDS Conference (AIDS 2018), held in Amsterdam from 23 to 27 July 2018, the scaling up of pre-exposure prophylaxis (PrEP) across Africa emerged as a central theme — framed by both optimism for its potential as a transformative prevention tool and candid acknowledgement of the challenges of real-world implementation. The conference, convened by the International AIDS Society, brought together more than 15,000 researchers, advocates, policymakers, and people living with HIV from over 160 countries.
By mid-2018, several high-burden African countries had moved beyond small-scale pilot projects and begun implementing broader, national-level PrEP programmes. The shift marked a turning point: the clinical efficacy of daily oral PrEP had been established in prior trials, and the focus at AIDS 2018 turned decisively to the question of how to deliver it effectively within existing health systems.
National PrEP Programmes Taking Shape
Data presented at the conference indicated measurable progress in several countries:
| Country | PrEP Initiations (approx. mid-2018) | Key Populations Targeted |
|---|---|---|
| South Africa | 25,000–30,000 | Sex workers, adolescent girls and young women, MSM |
| Kenya | ~25,000 | Serodiscordant couples, sex workers, youth |
| Eswatini | Several thousand | Young women, serodiscordant couples |
| Zimbabwe | Several thousand | Adolescent girls and young women |
Kenya's programme was notable for its integration of PrEP into clinics providing family planning and other reproductive health services — a model that presenters highlighted as a promising approach for reaching adolescent girls and young women (AGYW), who bear a disproportionate burden of new HIV infections in eastern and southern Africa.
Implementation Science Takes Centre Stage
Rather than testing whether PrEP worked, sessions at AIDS 2018 focused on implementation science — evaluating how to effectively deliver PrEP within existing health platforms such as family planning clinics and youth centres. Presentations from the MeSH Consortium and other research groups underscored the need for better routine data to track PrEP demand and continuation, noting that existing monitoring data was often weak.
A recurring theme was the need to integrate PrEP into broader health services to increase uptake and retention. Presentations highlighted programmes in Kenya and Zimbabwe where PrEP was successfully integrated into family planning and reproductive health services for AGYW. Researchers emphasised that the "end game is HIV prevention, not PrEP use" — a framing that positioned PrEP as one tool within a comprehensive prevention package, to be offered alongside condoms, HIV testing, treatment as prevention, and structural interventions.
Barriers to Scale-Up
Despite its potential, experts noted that PrEP roll-out across Africa was progressing slowly. Identified challenges included:
- Structural barriers: Stigma, limited health system capacity, and legal and social challenges — particularly for key populations such as men who have sex with men (MSM) in countries where homosexuality was marginalised or criminalised.
- Service delivery: Difficulties in maintaining the consistent follow-up and adherence required for daily oral PrEP, as well as supply chain issues affecting drug availability.
- User agency: Advocates emphasised that PrEP must be treated as a choice, and that successful implementation depends on respecting user autonomy rather than pressuring uptake.
The West Africa PrEP initiative, discussed at the conference by the Institute of Tropical Medicine (ITM) and partners, illustrated the challenges of adapting PrEP protocols to restrictive social and legal environments. The project focused on PrEP use among gay men and other MSM in Burkina Faso, Côte d'Ivoire, Mali, and Togo — countries where stigma and legal barriers complicate access to prevention services.
The ECHO Trial Looming
While PrEP implementation was a major focus at AIDS 2018, the conference also drew attention to the forthcoming ECHO (Evidence for Contraceptive Options and HIV Outcomes) trial, which was actively enrolling over 7,800 women in Eswatini, Kenya, South Africa, and Zambia. The trial was designed to determine whether three specific contraceptive methods — DMPA-IM, the copper IUD, and the LNG implant — carried different risks of HIV acquisition. Its results, not released until June 2019, would have significant implications for how PrEP and contraceptive services are integrated.
A Diverse Prevention Front
Conference attendees consistently stressed that PrEP was one tool within a broader, diverse prevention landscape. Discussions highlighted that treatment alone would not end the epidemic and that prevention must be prioritised through a mix of biomedical interventions (including PrEP, condoms, and vaccines) and structural, rights-based approaches to reach the most vulnerable populations.
The momentum around long-acting PrEP options was also building. While daily oral tenofovir disoproxil fumarate/emtricitabine (TDF/FTC) remained the only licensed PrEP regimen at the time, conference sessions previewed the development pipeline for long-acting injectable agents such as cabotegravir (CAB-LA), which would later demonstrate high efficacy in the HPTN 083 and 084 trials.
Sources
- International AIDS Society: AIDS 2018 Conference, Amsterdam, 23–27 July 2018.
- Aidsmap: PrEP spreads across Africa — slowly, August 2018.
- Institute of Tropical Medicine: PrEP as part of HIV prevention in Africa.
- Gates Foundation: AIDS 2018 — PrEP and epidemic delivery.
- MeSH Consortium: Repositioning Implementation Science in the HIV Response.
- UNAIDS: AIDS 2018 conference coverage.
FIRAT Editorial Board
Institutional Research Desk · Foresight Institute of Research and Translation
The collective editorial and research translation board of FIRAT, synthesising peer-reviewed evidence, policy briefs, and division milestones across our seven foundational research pillars.
