HIV

New HIV prevention strategies, including Pre-Exposure Prophylaxis (PrEP), are crucial for achieving a significant reduction in HIV infections. PrEP involves using antiretroviral drugs to prevent infection. In 2022, the WHO recommended long-acting injectable cabotegravir (CAB-LA) as a new PrEP option. Cabotegravir, an antiviral medication from the drug class of integrase strand-transfer inhibitors (INSTI), and analogue of dolutegravir, offers an alternative to daily oral PrEP with two-monthly injections, particularly benefiting population groups who face challenges to control their access and use of HIV combination prevention such as people who engage in sex work. 

In 2024, Malawi's Ministry of Health (MoH) updated its national PrEP guidelines to include oral and injectable PrEP options. Starting in March 2024, CAB-LA PrEP has been available through the MoH in 36 prescription sites, including drop-in-centers (implementation project), and mainly in Lilongwe and Blantyre (two major cities). Following these guidelines, MSF started to roll out in January 2025 injectable CAB-LA as an alternative PrEP option to sex workers through existing MSF, MoH and sex workers’ associations-supported sexual and reproductive health outreach clinics in sex work hotspots in Dedza and Neno districts, which includes provision in rural, remote areas in with cross-border influx of sex workers and customers. There is a lack of real-world evidence on the acceptability, uptake, and sustained use of PrEP, particularly among vulnerabilized populations like sex workers, as well as on the feasibility of delivering CAB-LA through community-based service models. 

This mixed-method operational research aims to evaluate how injectable CAB-LA, as an alternative HIV PrEP option, influences acceptability, uptake, preferences, and continued use of PrEP (both oral and injectable). Additionally, it seeks to generate practical insights into the feasibility of offering PrEP choices through community-based outreach clinics in sex work hotspots. 

Primary objectives 

• P1. To assess uptake, choices, patterns, and persistence (adherence) of PrEP use (oral PrEP or injectable CAB-LA). 
• P2. To explore and describe barriers and enablers of PrEP uptake, preferences, persistence or discontinuation (oral PrEP or injectable CAB-LA). 
• P3. To describe the PrEP service delivery model. 
• P4. To assess the feasibility and acceptability of providing PrEP (oral or injectable CAB-LA) to clients accessing MSF/MOH/CBO-supported outreach SRH+R clinics in sex work hotspots. 

Country

Malawi 

Status

Ongoing 

Tentative end date

End of 2026  

Our role

Coordination 

Partners

MSF, MoH 

Context

CAR is one of the countries in Central and West Africa with the highest HIV prevalence. In CAR, it is particularly difficult to benefit from good coverage of early antiretroviral treatment and lifelong HIV care. The chronic lack of reliable and conclusive information prevents the implementation of appropriate strategies to improve the care of people living with HIV. In addition, the reasons for engagement - disengagement in care have never been explored in the sites supported by MSF in CAR, where interventions to improve care can only be implemented if the specificities of the context are understood.

Main objectives 

Retrospective component

• To retrospectively describe the main follow-up indicators and the immune-virological outcome of patients included in the MSF-supported Carnot HIV cohort since 2011.

Cross-sectional component

• Estimate the prevalence of virological failures (CV ≥1,000 copies/ml) at 1st and 2nd line among a sample of patients (children and adults) on treatment for at least six months in Carnot district hospital.

Qualitative component (C)

• Describe the factors associated with engagement and disengagement with MSF-supported HIV services in Carnot from the perspective of PLHIV and the health workers responsible for their care.

Country

CAR

Status

Completed, currently being disseminated 

Tentative end date

December 2023

Our role

Coordination

Partners

MSF, MoH, Institut Pasteur de Bangui, KEMRI

Treatment failure is more frequent in adolescents living with HIV than in adults cohorts. In addition, while mortality has declined significantly among children and adults over the past 15 years, it has continued to rise among adolescents until 2015 and has been slowly declining since then.

The reasons for this specificity are multiple: disclosure poorly made or made too late, a long therapeutic history that led to the selection of resistance mutations, the lack of specific management of adolescents by poorly trained teams, etc.

In recent years, MSF France has developed programs in three East African countries with a focus on improving the quality of care for adolescents (10-19 years) living with HIV and on ART. Three different approaches have been developed: in Uganda, MSF supports Arua regional reference hospital’s AERT clinic; in Kenya and Malawi, interventions have been developed in rural districts, mainly at the health center level, but with a different approach. In Chiradzulu, MSF teams directly take care of the patients, while in Kenya's Ndiwa district, teams work in mentoring the Ministry of Health teams.

After about three years of adolescent-centered interventions, quantitative results show an improvement in indicators. It therefore makes it interesting to capitalize on these interventions in order to analyze the strengths and weaknesses of each approach, in order to guide other programs concerned with the problem of HIV-infected adolescents in other contexts.

The purpose of the analysis is to

1. Provide a description of the differentiated service delivery models (DSD) model implemented in the 3 HIV programs supported by MSF (Malawi-Chiradzulu, Kenya-Ndhiwa and Uganda-Arua) and the achieved coverage of the different services offered under the DSD model and

2. Determine the effectiveness of the models-of-care in improving treatment outcomes of adolescents aged 10 to 19 years living with HIV and enrolled in the 3 programs.

Country

Kenya, Malawi, Ouganda

Our Role

Quantitative Analysis of the achieved service coverage and the effectiveness of the model-of-care.

Who's Involved

OCP, Rider