African activists call for ensuring women and girls have a choice and a voice in HIV prevention choices and applaud UNAIDS for joining the fight…

African feminists and HIV prevention advocates are united in their advocacy for ensuring African women and girls in their diversity have a range of HIV prevention options to choose from, including the dapivirine vagina ring (ring). While several African countries have approved the licensure of the ring and the WHO has included the ring on the list of essential medicines, some donors are backing away from their support of the ring for rollout beyond the planned Introductory studies as well as support for future research in longer acting rings. Advocates have called for accelerated access to the ring and not to lose sight of the importance of championing choice and of the investment African women and communities have made in bringing the ring to this point.

We applaud UNAIDS for promptly responding to a call from advocates to engage on this with their convening of a meeting on 27 & 28 June in Johannesburg to discuss advocacy for ensuring women and girls have a choice and a voice. At the meeting, UNAIDS executive director Winnie Byanyima accepted the challenge to join women activists to call for accelerated global support and access to long acting HIV prevention tools for women, including the ring.

We hold UNAIDS leadership to their commitments:

• To address inequalities, policy and structural barriers to access the new long acting HIV prevention tools, including the ring, through the Global HIV prevention UNAIDS strategy
• For the UNAIDS executive director, Winnie Byanyima, to champion women-led HIV prevention in the continent and beyond, being a voice for African women,
• To open doors with donors - mainly PEPFAR and USAID - and use their influence to put pressure for a change of policy which will allow access and support to roll out the Dapivirine Ring,
• For the UNAIDS Regional East and Southern Africa office to work with advocates in the region to champion women-led prevention campaign for the ring and other HIV prevention options
• To integrate stronger HIV prevention focus into the UNAIDS regional East and Southern African strategy which is in the process of development.
• To ensure that young women have access to spaces where decisions are made that affect their choices.

UNAIDS committed to a follow-on meeting at AIDS2022 to discuss next steps and to ensure that the call for choice resounds through the conference halls.

At the same time, we applaud WHO in their statement of continued support of their 2021 recommendation for the ring as an additional prevention option for women at substantial risk of HIV; and the Global Fund for their inclusion of the dapivirine ring in their procurement catalog. And we applaud the African governments who have approved the ring thus far and see the importance of listening to the communities who have said that choice matters in HIV prevention. We call on other African governments to approve the ring and ensure that young women in particular have options to choose from that can work in their lives. Expanded HIV prevention options are critical for women in east and southern Africa where HIV is a persistent public health, reproductive justice, and human rights issue for girls and women. We call on all community, national, regional and global leaders to join us in ensuring young women have a voice and a choice in protecting their lives!

Authors

Yvette Raphael, Advocates for the Prevention of HIV in Africa, South Africa Nomfundo Eland, Emthojeni, South Africa
Lillian Mworeko, ICW East Africa, Uganda
Vuyiseka Dubula, AEDC, South Africa
Chilufya K Hampongo, Treatment Advocacy and Literacy Campaign, Zambia
Maureen Luba, AVAC, Malawi
Rosemary Mburu, WACI Health, Kenya
Definate Nhamo, PZAT, Zimbabwe
Manju Chatani-Gada, AVAC, USA
Georgina Caswell, GNP+, South Africa
Dr. Lilian Benjamin Mwakyosi, DARE, Tanzania.
Joyce Nganga, Africa Free of New HIV Infections (AfNHi)
Gloria Mululu,Africa Free of New HIV Infections (AfNHi)

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Original statement for reference

Call for accelerated global support and access to long acting HIV prevention tools for women: Dapivirine Vaginal Ring

Following the news indicating that PEPFAR and USAID are backing away from their support of the Dapivirine Vaginal Ring for rollout beyond the planned Introductory studies and USAID indicating they will no longer support research and development of the three-month ring, African feminists and HIV prevention advocates are united in voice in objecting to this extreme policy direction as it could reverse many gains made in advocacy for options and choices in HIV prevention for women in sub-Saharan Africa where the need for new women-centered HIV prevention options remains a public health, reproductive justice, and human rights imperative. The Ring could be a significant additional option to increase acceptance and ease of use and to reduce the cost for annual HIV protection by two-thirds. It is the responsibility of the donors who brought the ring this far to ensure it is included in the range of HIV options women can choose from in protecting their health and lives. Adolescent girls and young women in sub-Saharan Africa have a very high risk of acquiring HIV. The latest global AIDS update report suggests that a staggering six out of seven new infections among 15-19-year-olds in sub-Saharan Africa are among girls. The severity of the HIV epidemic among women in our countries demands action and makes it critical that this product becomes available in our countries and region. We are, and we will continue to push that all women globally have access to the Dapivirine ring.

A WHO meeting conducted on 24 May 24, 2022, disseminated findings from consultations with national ministries of health (MOHs), civil society, ex-ring users, donors, implementing partners, and other key stakeholders in sub-Saharan Africa on moving forward with DVR registration and rollout in the country, found that there was resounding support for ensuring the choice of HIV prevention options and the governments were supportive but concerned about the financial backing.

The recent results from the REACH study, which studied informed choice including both ring ,and oral PrEP made this point unmistakable. Almost all of the 247 adolescent girls and young women in this study chose to use either the ring or oral PrEP when given a choice, with two-thirds of them choosing the ring. The REACH study shows the potential impact of simply allowing young women and girls the ability to choose.

While we acknowledge the decision taken by the International Partnership for Microbicides, which developed the Dapivirine ring, to withdraw its application for the ring approval from the US Food and Drug Administration in December 2021 after feedback from the FDA that they are unlikely to support US approval at this time because of the perceived lack of relevance to the US epidemic, the FDA decision primarily affects black and brown women in the US as one of the communities who already have limited access to oral PrEP compared to other vulnerable groups. Women need more products than only limiting their choices to daily oral PrEP. Hence, we are concerned about the exclusion of the Dapivirine ring as an additional option for women in the US. However, this decision is now being seemingly applied to decisions to support African countries, several of which have already approved the use of the ring as an additional HIV option (namely South Africa, Kenya, Uganda, Zambia and Zimbabwe) with many others on the cusp of approving the ring. The decision to withdraw the Ring for review by the FDA, cannot and should not affect plans to support its ring introduction and rollout in Africa by African Ministries of Health and funders.

For too long, we have seen very high rates of HIV incidence among women, this is driven by many factors, including high rates of gender-based violence, intergenerational and transactional sex driven by poverty, inequality and inadequate access to quality, and comprehensive sexuality education. We need to give women more control over their health and bodies and access to a range of safe and effective options, including the Dapivirine Ring.

Progressive milestones for the Ring by different stakeholders ;

• European Medicines Agency (EMA) approval of the Dapivirine Vaginal Ring for HIV prevention for women in high HIV burden settings
• World Health Organization (WHO) in 2021, has included the Ring in their list of prequalified medicines under the EMA Article 58 label using the alternative listing procedure
• World Health Organization (WHO) for drafting the 2021 recommendation for the Ring as an additional prevention option for women at substantial risk of HIV and further supporting this position by their recent statement
• The Global Fund for the inclusion of the Dapivirine Ring in their procurement catalogue
• African governments who have approved the ring thus far and seen the importance of listening to the communities who have said that choice matters in HIV prevention. We continue to call on the other African governments to approve the ring and ensure that young women in particular have options to choose from that can work in their lives
• Two-day consultative UNAIDS meeting with African women and HIV prevention advocates from Eastern and Southern Africa on the Ethical Dimensions of Access to Long-Acting HIV Prevention and Treatment Technologies conducted on 28th – 29th June 2022 in Johannesburg.

We applaud the UNAIDS Executive Director and senior officials from Eastern and Southern Africa for promptly meeting with African women feminists and HIV prevention advocates to steer leadership on Ethical Dimensions of Access to Long-Acting HIV Prevention and Treatment Technologies for women in Africa. The meeting challenged UNAIDS to join women activists in the streets to call for accelerated global support and access to long acting HIV prevention tools for women.

We celebrate and welcome the UNAIDS Executive Director, Winnie Byanyima, for accepting our call to champion HIV prevention for Adolescent Girls and Young Women in Africa (AGYW).

As HIV prevention advocates we pledge to work with Winnie Byanyima, to ensure that (i)Women are given HIV prevention options that are convenient and easy to use to meet their unmet needs.(ii) Confront inequalities that places women and girls in sub-Saharan Africa at a higher risk of HIV infection, with gender inequality and gender-based violence that robs women and girls of their fundamental human rights, including the right to education, health and economic opportunities. (iii)To reduce new HIV infections among adolescent girls and young women who account for 25% of all new HIV infections despite representing just 10% of the population.

Other commitments made by UNAIDS were, (i) To address inequalities, policy and structural barriers to access the new long acting HIV prevention tools through the Global HIV prevention UNAIDS strategy, (ii)The UNAIDS executive director, Winnie Byanyima, to champion women-led HIV prevention in the continent and beyond, being a voice for African women,(iii)The UNAIDS Regional East and Southern Africa office committed to work with advocates in the region to champion women-led prevention campaign and the DVR,(iv)Open doors with donors mainly PEPFAR and USAID and use their influence to put pressure for a change of policy which will allow access and support to roll out the Dapivirine Ring,(v)UNAIDS committed to support a women-led campaign for women-controlled HIV prevention, (vi)UNAIDS South Africa office committed to working closely with South Africa-based advocates for ring advocacy.

Authors

Yvette Raphael, Advocates for the Prevention of HIV in Africa, South Africa Nomfundo Eland, Emthojeni, South Africa
Lillian Mworeko, ICW East Africa, Uganda
Vuyiseka Dubula, AEDC, South Africa
Chilufya K Hampongo, Treatment Advocacy and Literacy Campaign, Zambia
Maureen Luba, AVAC, Malawi
Rosemary Mburu, WACI Health, Kenya
Definate Nhamo, PZAT, Zimbabwe
Manju Chatani-Gada, AVAC, USA
Georgina Caswell, GNP+, South Africa
Dr. Lilian Benjamin Mwakyosi, DARE, Tanzania.
Joyce Nganga, Africa Free of New HIV Infections (AfNHi)
Gloria Mululu,Africa Free of New HIV Infections (AfNHi)