Rwanda and other African countries provide Post-Exposure Prophylaxis (PEP) at health facilities for HIV-negative persons with recent exposure to HIV, and are at early stages of implementing Pre-Exposure Prophylaxis (PrEP). PEP programs are an important, unappreciated opportunity to recognize and address HIV risk, both retrospectively relative to a suspected recent HIV exposure, and prospectively via PrEP. Women and girls may disproportionately seek PEP more often than men, often in response to gender-based violence and/or sexual assault. In addition, anecdotal evidence suggests some persons seek PEP repeatedly, and may be discouraged from doing so. We analyzed existing PEP data from a Rwanda national survey to determine whether PEP recipients (who were by definition HIV negative at the time of PEP services) had a higher burden of subsequent HIV, and might benefit from PrEP.
We performed secondary analysis of Rwanda’s AIDS Indicator and HIV Incidence Survey 2013-2015. Logistic regression models were used to assess factors associated with HIV infection. All analyses accounted for the complex survey design and were done in STATA Version 13.
A total of 101/13,893 respondents ages 15-56 reported receiving PEP in the prior 12 months, 40 males and 61 females. Recent PEP recipients had 6.5 times higher odds of being HIV positive (unadjusted Odds Ratio [uOR] 6.5; 95% CI 3.8-11.2). This effect was seen across age and sex disaggregation, and was exaggerated among youth, with persons under 25 years having >9 times higher odds of being HIV positive (uOR 9.1; 95% CI 2.1-39.4). Adolescent girls/young women 15-24 years old with recent PEP exposure had >10 times higher odds of being HIV positive (uOR 10.1; 95% CI 2.26-45.14).
Rwandan PEP recipients are at substantially increased risk of acquiring HIV, suggesting that existing prevention efforts are failing them. PEP programs should be re-emphasized and strengthened, and recipients should be provided effective ongoing prevention services including transition to PrEP for those with ongoing substantial HIV risk. Creation of PEP-to-PrEP transition programs would leverage the existence of PEP clients, who are already seeking HIV prevention services at health facilities because they recognize their own elevated HIV risk. Successful PrEP implementation will also require risk reduction and adherence support, and consideration of PrEP cessation when risk has reduced.