The Potential Utility of PREP for Gay men and other MSM across Sub-Saharan Africa Stefan Baral, FRCPC CCFP Key Populations Program, Department of Epidemiology, Johns Hopkins School of Public Health
Outline Moving Forward Global Epidemiology of HIV among Gay men and other MSM Epidemiology of HIV among MSM in Sub Saharan Africa Ongoing PrEP Demonstration Projects for MSM in South Africa PrEP in other Places? Moving Forward
Global HIV Prevalence among MSM, 2007-2012 Modified From: Beyrer, Baral, van Griensven, Goodreau, Chariyalertsak, Wirtz, Brookmeyer, The Lancet, 2012
HIV Prevalence among MSM in Africa 4.9% (1,778) 4.4% (90) Morocco Tunisia 6.2% (267) 5.7% (259) 5.9% (262) Egypt 21.5% (463) 21.8% (501) 19.0% (n/a) 9.3% (713) 7.3% (406) 0.98% (n/a) 17.2% (1,291) 50.0% (96) 13.4% (1,125) 21.1% (712) Senegal Sudan 9.8% (205) Burkina Faso 17.0% (n/a) 13.3% (215) Nigeria 24.6% (285) 14.3% (449) Cote d’Ivoire Togo CAR 13.2% (306) The Gambia 19.0% (563) Ghana 20.3% (N/A) 37.0% (511) Uganda 25.0% (N/A) Cameroon Kenya 19.8% (253) Legend Tanzania 2005 12.3% (509) 33.0% (641) 2006 Zambia 21.4% (201) 2007 Malawi 3.1% (353) 12.4% (218) 9.1% (583) Nampula 2008 19.7% (117) 2009 Beira Namibia 8.1% (358) Botswana 31.1% (318) 2010 Maputo 8.1% (358) 40.7% (285) Maseru 2011 Swaziland 25.5% (200) 35.4% (211) 2012 28.9% (249) 10.6% (538) Soweto Maputsoe 2013 Cape Town (Township) Cape Town 2014 Modified From : van Griensven, Baral, et al. The Global Epidemic of HIV Infection among Men who have Sex with Men. Curr Opinion on HIV/AIDS, 2009
HIV Incidence among MSM, 1995-2014 High Income Countries Low and Middle Income Countries
HIV Incidence among MSM in Sub-Saharan Africa 16.0% Senegal 14.0% Nigeria 3.6% Uganda 7.2-20% Kenya 7.1% Malawi 5-6% South Africa Modified From : van Griensven, Baral, et al. The Global Epidemic of HIV Infection among Men who have Sex with Men. Curr Opinion on HIV/AIDS, 2009
HIV Incidence among MSM in Kilifi, Kenya Source: Sanders, Mugo, van der Elst, Smith, Graham. High HIV-1 incidence, correlates of HIV-1acquisition, and high viral loads following seroconversion among MSM JAIDS ,2013
Modified: Abdool Karim et al, AVAC Report, 2014 Oral/Topical PrEP Efficacy/Effectiveness Modified: Abdool Karim et al, AVAC Report, 2014
“Forgiveness” TFV Concentration: Rectal>Cervical>Vaginal Days post single-dose Patterson KB et al. Sci Transl Med. 2011.
HIV prevalence and awareness of HIV positivity by age, Cape Town and Port Elizabeth, South Africa
Modeling Utility of PrEP For MSM in South Africa Source: Brookmeyer et al, PLoS ONE 2014
PrEP Continuum for MSM in Cape Town and Port Elizabeth, South Africa, 2014-2016
Person Days on and off PrEP among 80 MSM in Cape Town and Port Elizabeth, South Africa, 2014-2016
SA PrEP Demo Project Assess feasibility of delivering PrEP in standard PHC facilities In line with International and SA Guidelines 300 MSM across 2 sites (Woodstock, CPT & Yeoville, JNB) Minimal additional research components (i.e no active recruitment)
SA PrEP Demo: Retention Outcomes Source: Brown, Rebe, Bekker, McIntyre
SA PrEP Demo: Adherence Outcomes 81% 19% 85% 15% 87% 13% Source: Brown, Rebe, Bekker, McIntyre
Ever Used any PrEP among MSM
Key Themes The world is more similar than it is different Wherever HIV is studied around the world, risk is not evenly distributed Highest incidence appears to be among young gay men and other MSM Similar Risk factors for HIV Infections among MSM Sustained HIV incidence supports the need for addition of PrEP Demonstration data from South Africa suggests feasibility in the context of primary health care facilities
Acknowledgements CPHHR Desmond Tutu HIV Foundation Key Populations Program Carrie Lyons, Sosthenes Ketende, Ben Liestman, Amrita Rao, Sheree Schwartz, Gnilane Turpin Nunez, Karleen Coly, Shauna Stahlman Emory Travis Sanchez, Patrick Sullivan, Rachel Kearns, Ryan Zahn Human Sciences Research Council Refilwe Phaswana-Mafuya, Ebrahim Hossein, Batlile Maseko Desmond Tutu HIV Foundation Linda Gail-Bekker, Karen Dominguez, Ben Brown, Andrew Scheibe CPHHR Chris Beyrer, Emily Clouse, Andrea Wirtz, Kristin Hunt, Michele Decker, Len Rubinstein