The 1st Asia-Pacific Consultation on PrEP Implementation17 January 2017, Bangkok, Thailand

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The 1st Asia-Pacific Consultation on PrEP Implementation17 January 2017, Bangkok, Thailand

OBJECTIVES:

• To advocate for PrEP implementation in the Asia-Pacific countries by sharing experience, lessons learned and opportunities in implementing PrEP

• To document PrEP implementation models in the Asia-Pacific countries to be used for supporting PrEP scale up among key populations

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OPENING REMARKS:

Dr. Patchara SirivongrangsanDepartment of Disease Control,Ministry of Public Health

There has been a fast-changing landscape of HIV prevention techniques in Thailand in last couple years. I have seen increasing number of PrEPprograms in the Asia-Pacific region and that reflects growing empowerment and importance of new HIV preventive methods. Today, we will learn from the experienced implementers such as San Francisco and New South Wales on how they implemented those programs. I hope today we will plan together on how to scale up PrEP implementation in theregion through perspectives of various stakeholders.

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OPENING REMARKS:

Prof. Emeritus Dr. Praphan Phanuphak Thai Red Cross AIDS Research Centre

PrEP efficacy has been proven in many studies. There is an urgent need to alter from providing technical knowledge to advocating PrEP. Thailand has been engaged in PrEP programs for many years and we have seen commitments from the Ministry of Public Health. It is conceivable that in the near future PrEP will be subsidized, but it requires a strong collaborative effort from various stakeholders. As we learn from our friends today, I do hope that we can pack together to move PrEP forward to fight HIV new infections.

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Where are we with PrEP implementation in Asia-Pacific region and globally?

Dr. Michael CassellUnited States Agency for International Development, Regional Development Mission for Asia (USAID/RDMA)*

• The global target for PrEP is to reach 3 million people at risk by 2020. As of June 2016, only 2% of the target are enrolled on PrEP, mostly in the US.

• Although treatment coverage has increased 2.3 fold since 2010 resulting in 25% decrease in AIDS-related deaths, the number of new HIV infections among KP remains.

• In Asia Pacific, 2015, 64% people know their status, 41% of PLHIV access ART, and 34% has viral suppression. In Thailand, it is estimated that 53% of new infections will be among MSM and TGW. However, only 19% of MSM and TGW are diagnosed with HIV.

• Key priorities for PrEP implementation: maximizing adherence, promoting other behavioral prevention and monitoring for seroconversion and clinical condition.

• Until we have near universal coverage for all HIV-infected individuals, PrEP will be critical to accelerate progress and reach the ultimate goal of ending AIDS.

• To answer, we are lagging far behind in terms of PrEP implementation in the Asia-Pacific region.

*currently with FHI 360

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Recent updates from who on PrEP implementation tools

Dr. Mukta Sharma World Health Organization (WHO)

• 2015 WHO Recommendations on PrEP emphasize that oral PrEP should be offered as an additional prevention choice for people with substantial risks of HIV infection, as a part of combination prevention.

• The recommendations cover important topics such as who should be offered PrEP, where PrEP should be delivered, how to monitor safety, and other concerns on PrEP.

• WHO is also developing the PrEP Implementation

Toolkit with 11 modules for various stakeholders such as, political leaders, community advocates, public health officials, clinicians and program evaluators and essential pocket cards for PrEP providers and clients. • WHO also includes clinical recommendations during the first visit and follow up visits and guidance to help minimize PrEP-related stigma.

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San Francisco experience on PrEP implementation, scale up and evidence

Dr. Pierre-Cedric Crouch San Francisco AIDS Foundation

• In San Francisco, there are ~ 16,000 people with HIV, ~ 255 new HIV diagnoses and ~ 200 deaths which have stabilized.

• SF’s getting to zero initiatives is a multi-sector consortium with collective impact on a common agenda. Signature initiatives include RAPID program or rapid ART in decentralized treatment hubs, client-centered linkage and engagement in care, ending HIV stigma and city-wide coordinated PrEP initiatives for providers and clients.

• Magnet is a community-based, nurse-led PrEP program providing HIV testing, STI testing and treatment, vaccination and PrEP. The clinic also runs recreational activities that truly connect with community. The clinic has initiated PrEP to 1,900

individuals. The rate of condom use remains the same. • The clinic provides same day PrEP initiation. During the first enrollment visit, the clients will undergo: a) lab & STI testing, b) PrEP evaluation and sexual health screening, c) benefits navigation to review insurance coverage, dealing with paperwork (if necessary, register to a better insurance plan).

• Magnet is funded by: government grant (43%), private and corporate donation (43%) and 340B Drug Pricing Program (14%). (340B Drug Pricing Program – Government program that requires drug manufacturers to provide drugs at reduced prices)

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Programs Model Target Primary endpoints Key Highlights

EPIC – New South Wales,

Australia

Kirby Institute

a multi-state demonstration project

with over 8,000 PrEP users

Public

& private

settings

3,700 MSM

in NSW

(8,300

nationwide)

HIV incidence in cohort

and HIV diagnoses

in the state

1. Multi-sectoral partnerships

2. Community leadership helps to promote PrEP

3. Professional consensus – national guidelines

and highly informed clinicians

4. Functional primary health care system at low

cost for clients

5. Free PrEP & plan for subsidization

PrEP – Thailand

Empirical research translated into dynamic

PrEP services, with continuous advocacy

and government partnership

Community-

based & facility-

based model;

free PrEP

& fee-based

> 2,000

MSM/TGW

in 10 focused

provinces

Feasibility of PrEP delivery,

uptake, adherence,

retention, HIV/STI incidence,

toxicities

1. Multi-sectoral partnerships

2. Many models: community-based

& facility-based model; free PrEP & fee-based

3. Inform policy changes and national guidelines

PrEP - Vietnam

PATH

a pilot project in response to VT ‘s HIV

Epidemic, using fee-based model

Community

and

fee-based

1,000 MSM/TGW

200 discordant

PWID couples

in Ho Chi Min

City

Feasibility and acceptability

of PrEP, HIV/STI incidence,

adherence, willingness to pay

and cost-recovery for clinics

1. High willingness of MSM/TGW to take and pay for

PrEP with preferred location at community-based

organizations

2. Multi-agency collaboration

PrEPPY – Manila, Philippines

WHO

PrEP clinics in Manila to assess feasibility

and effectiveness of community-based model

Community-

based model

200 MSM

in Manila

(2 clinics)

Feasibility, effectiveness,

eligibility, uptake, adherence,

risk behavior, HIV/STI incidence

& prevalence, drug resistance

1. Observational prospective pilot program

2. Customized clinics as safe space for MSM

3. Multi-agency collaboration

PrEP – India

Indian Council of Medical Research

PrEP to maintain low prevalence, reduce

new infection, and generate in-country data

Community-based

vs. clinic-based

model

2,000 MSM/TGW

in Pune, Chennai,

Mumbai, Jalandhar

HIV incidence, PrEP acceptance,

risk behavior, side effects,

adherence and discontinuation

1. Strong government support through a multi-sec

toral consortium

2. Strong willingness to use PrEP among MSM

PrEP Implementation Project: how to launch, stakeholders, and model

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Communityperspectives andparticipationin PrEPimplementation

• PrEP creates sense of privilege and sense of responsibilities for the users. However, the campaign must be designed to normalize HIV, PrEP and sex for MSM/TGW to create positive self-image and promote safe sex practices.

• Online technology should be used to enhance HIV cascade, but security and confidentiality issues must be handled. Health providers and volunteers must be sensible when it comes to selecting suitable platforms of communication based on the degree of data sensitivity. Safety precautions such as various forms of encryption should be used.

• For trans people, HIV testing and PrEP should be promoted in a comprehensive health package. Transgender community needs a whole-life holistic package not just individual services. Transgender community needs an outlet that will help them deal with struggles, learn information and access to comprehensive healthcare.

• Stigmatization among PrEP users will remain, but a big challenge in PrEP implementation is awareness and acceptance among healthcare providers.

• Community representatives should not be viewed as token in any project. Their voices have to be heard and valued. They must get involved since the beginning. • To push PrEP forward, honest conversations about PrEP need to take place as much as bold promotional messages. Community involvement is the key to establishing these conversations.

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• PrEP was approved in 2016, but not yet subsidized on the Pharmaceutical Benefits Scheme.

• Since 2014, Australia held 2 PrEP demonstration trials in three largest states (New South Wales, Victoria and Queensland).

• Over the years, community-based organizations not only showed true leadership on PrEP advocacy, but also are intimately involved in the trials.

• Key success: strong partnership between community, researchers and governments.

• Next steps: advocate to get PrEP subsidized through Pharmaceutical Benefits Scheme.

• Debates on PrEP persists because of low HIV prevalence, declining HIV incidence rate among MSM, existing condom program and costing.

• PrEP is included in the national policy and strategic plan for 2016-2020 and will be implemented as a demonstration project.

• Challenge: awaiting for approval for PrEP funding.

New South Wales, AustraliaEPIC by Benjamin BavintonKirby Institute for Infection and Immunity in Society, University of New South Wales

Lao PDRPrEP by Dr. Bounpheng PhilavongCentre for HIV/AIDS and STI, Ministry of Health

Panel discussion:community, research and policy

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• The National AIDS Committee has endorsed the use of PrEP as an additional HIV prevention method.

• Thai GPO manages to produce lower-priced TDF/FTC. MoPH integrated PrEP into the national guidelines. Unfortunately, PrEP has not yet been included in the universal health care coverage.

• The government has piloted PrEP2Start project in 10 public hospitals. However, challenges include poor adherence, low uptake, low awareness and low acceptability from physicians still remain.

• Challenge: PrEP is not yet registered as a preventive medicine.

• Nurse-led model is the main success factor for Magnet. It has proven itself by the high quality of services and popularity

• Nurse produces higher, but cheaper, health outcome as compared to physicians.

• With proper trainings, nurses and community health workers can help unburden physicians’ workload.

• Therefore, policy on task shifting is a key to move this forward.

ThailandPrEP2Start by Dr. Sumet OngwandeeBureau of AIDS, TB and STIs, Ministry of Public Heath*

San FranciscoNurse-Led Model by Dr. Pierre-Cedric CrouchSan Francisco AIDS Foundation

Panel discussion:community, research and policy

*Currently with Office of Disease Prevention and Control Region 5

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Take homemessages • PrEP is an effective tool to reduce HIV new infection, especially

among KP, to eventually achieve Ending AIDS Agenda. PrEP is still not widely implemented and should go hand in hand with testing and treatment.

• WHO and international agencies has endorsed the use of PrEP as an additional prevention method and launched many toolkits and pocket cards for different stakeholders.

• There are various models and techniques to implement PrEP in different contexts; namely, PrEP in fee-based model, nurse-led model, clinic-based model, community-based model. While waiting for preliminary results, demonstration projects can be used as a platform for preparation, advocacy and capacity building.

• To scale up PrEP projects into the national health system, there is a strong need to consider relevant health system components. This includes task shifting and capacity building of service providers, strong public-private partnerships with community-based services.

• PrEP mobilization requires strong partnerships – domestically, regionally, and globally. The Asia-Pacific Consultation on PrEP will be organized every year to serve as a forum for sharing experiences, lessons learned and opportunities in implementing PrEP.