PrEP Scale Up in Kenya: Bridge to Scale Project IAS Satellite Session 25th July 2017 Dr. Daniel Were Jhpiego, Kenya Dr. Elizabeth Irungu Partners Scale up Project, Kenya

Background on HIV in Kenya National HIV Prevalence – 5.6% 29% FSW 18.2% MSM 18.2% IDU 51% new infections among adolescents 44% of new infections Sero discordant couples

PrEP Journey in Kenya 2008-2012 – Partners PrEP study 2013-2017 Demonstration projects July 2016 – Revised ART guidelines October 2016 - TWG formed December 2016 – TDF generics variation by Pharmacy and Poisons Board May 2017 – National PrEP scale up launch

Composition of TWG NASCOP NACC MOH WHO UNAIDS Donor agencies – PEPFAR (USAID, CDC) Implementing partners

TWG Sub-committees Service delivery Advocacy, communication and community engagement Research and impact evaluation Monitoring and evaluation Commodities and Supply chain Costing and resource mobilization

TWG Milestones November 2016 – PrEP implementers forum November 2016 – Implementation Planning and Document Review Workshop January 2017 – Document Finalization Workshop Monthly TWG meetings and recurrent consultations November 2016 – March 2017 - TWG sub-committees working group meetings

TWG sub committee outputs PrEP implementation framework Service providers tool kit Training manual for health workers Communication plan M&E and LMIS tools Research plan Financing and resource mobilization plan

Bridge to Scale (JILINDE) Project Goal To demonstrate and document an effective model for how oral Pre-exposure Prophylaxis (PrEP) can be scaled up as an HIV-prevention intervention in low-resource settings

Target Populations Female sex workers (FSWs) Men who have sex with men (MSMs) Including male sex workers Adolescent girls and young women (AGYW)

Geographic Locations and Targets

JILINDE PrEP Delivery Approaches Drop in centers Public health facilities Private health facilities

Partners Scale up project Objectives Geographical locations Target population Targets Delivery Approaches

Training Approaches: Case Based Training Curriculum Unit 1: CLINICAL CASE MANAGEMENT OF PrEP Case 1: Risk Assessment and indications for PrEP Case 2: Initiating PrEP in a Discordant Couple Case 3: PrEP in special circumstances e.g. pregnancy Case 4: A male with multiple male sexual partners Unit 2: DRUG RESISTANCE TESTING FOR PrEP SERO-CONVERTERS

Unit 3: COMMODITY MANAGEMENT FOR ORAL PrEP Case Study 1: Dispensing oral PrEP Case Study 2: Completing ART LMIS Tools Unit 4: MONITORING AND EVALUATION OF PrEP SERVICES Case Scenario 1: PrEP Clinical Encounter Form and Register Case Scenario 2: PrEP Monthly Summary Tool

Partners Scale Up Complementary Training Content and Approaches Sero discordant couples Training on Treatment as prevention Inclusion of SDC at the training Facility PrEP delivery champions Facility based CMEs

JILINDE Complementary Training Content and Approaches Whole site orientations CMEs Mentorship Satisfied PrEP users Key Populations Sensitivity orientation

Training achievements Trained over 984 providers between both projects Cadres include; Medical officers Clinical officers Nurses HIV testing counselors Pharmacists Laboratory technologists

Training Plans Service providers at PrEP delivery clinics – Critical mass HTS providers Peer Educators and community Health volunteers

Challenges Solutions Few trained providers (Attrition, redeployment) Train additional providers – critical mass Off site training models On site training models (Modular CMEs) Senior cadres not trained on PrEP Sensitization of senior cadres through professional bodies Lack of a quick reference document for providers PrEP Pocket book for providers Perceived huge workload and provider attitudes Mentorship, experience sharing by champion providers, Key Populations sensitivity orientation Few providers trained on Couples HIV testing and counselling CHTC Sensitization

Challenges Solutions PrEP counselling skills gaps Training of HTS providers Develop Counselling module for PrEP Information gaps on PrEP efficacy Experiences by PrEP users Lack of confidence to prescribe PrEP Develop a pool of clinical mentors, practical PrEP initiation session during training Functional database of trained providers Industrial action

Acknowledgments Partners scale up team Bridge to scale team Bill and Melinda gates foundation Nascop PrEP technical working group