Prepping Men who have Sex with Men for better Health Outcomes: A Conversation between Healthcare Providers and their Clients Tuesday 25th July at 11:00. PrEP and condoms: how to promote and implement combination prevention for men who have sex with men Rachel Baggaley, coordinator Key Populations and Innovative Prevention, HIV dept. WHO, Geneva

HIV PREVENTION ??VMMC (Male circumcision) OST for PWIDs STI Treatment WHO rec 2007 ??VMMC (Male circumcision) WHO rec 2000, 09 OST for PWIDs WHO rec 2004 NSP for PWIDs Auvert B, PloS Med 2005 Gray R, Lancet 2007 Bailey R, Lancet 2007 Kaplan, JAIDS, 1994 STI Treatment HIV prevention for MSM Grosskurth H, Lancet 2000 WHO rec 2012,14, 15 Oral PrEP HIV PREVENTION WHO rec 1995 Male Condoms & lubricants Grant R, NEJM 2010 (MSM) Choopanya K, Lancet 2013 (IDU) ?testing WHO rec 2007,14 Post Exposure prophylaxis (PEP) Coates T, Lancet 2000 Sweat M, Lancet 2011 What needs to be done to make PrEP as successful as possible? Behavioral Interventions WHO rec 2012 "Treatment as prevention" U=U Scheckter M, 2002 ?Mobile Technologies WHO rec 2012 Partner/Couples testing WHO rec 2011 MSM Cohen M, NEJM, 2011 Donnell D, Lancet 2010 Tanser, Science 2013 Allen S BMJ, 1992

WHO KP guidelines: The comprehensive package Essential health sector interventions HIV testing comprehensive condom and lubricant programming harm reduction interventions for substance use (incl. NSP &OST) PrEP &PEP behavioural interventions HIV treatment and care (ART) sexual and reproductive health interventions prevention and management of co-morbidities, incl. viral hepatitis, tuberculosis and mental health conditions Essential strategies for an enabling environment supportive legislation, policy and financial commitment, including decriminalisation of behaviours of key populations addressing stigma and discrimination, inc. in the health sector community empowerment addressing violence against people from key populations (inc homophobic violence What needs to be done to make PrEP as successful as possible?

A catalyst for much broader benefits beyond PrEP Re-engage positives Who dropped out of care PrEP services A catalyst for much broader benefits beyond PrEP HIV testing New positives Negatives 'high risk' 'Not interested' Negatives 'low risk' Negative Negatives 'high risk' interested in PrEP New ART initiation PrEP Engagement with services Condoms and lube, STI, HBV, HCV screening, re-testing , partner testing, vaccination tackle HIV stigma, educate about TasP

PrEP not for all; not for ever “Not using PrEP”: other HIV prevention option needed Total population MSM Seeks services 'meets criteria' for offer of PrEP Accept PrEP Eligible for PrEP Starts PrEP Continue on PrEP Re-starts PrEP Seasons of risk “Not using PrEP”: other HIV prevention option needed

Applying a PrEP continuum of care For MSM in Atlanta Georgia Kelley CF, Kahle E, Siegler A, Sanchez T, Del Rio C, Sullivan PS, Rosenberg ES. Clin Infect Dis. 2015 Nov 15;61(10):1590-7.

?? PrEP uptake…. examples San Francisco, USA denominator Cape Town clinic National Department of Health PrEP scale up program for MSM (Kevin Rebe ANOVA Personal communication)) New South Wales, Australia (Andrew Grulich, Kirby Institute Personal communication) San Francisco, USA (Bob Grant, UCSF Very early data ≈25-30% uptake following offer ≈12-30% Eligible for PrEP ≈10-15% on PrEP 80% PrEP users comes asking for PrEP ≈ 100% uptake 20% offered PrEP because of STI ≈60% uptake ?? denominator JR: This issue of the ?denominator? warrants a lot of discussion! it’s a major challenge for implementers who are often asked to estimate coverage and retention (both of which require a denominator).

PrEP plus behavioural and structural interventions needed along the PrEP cascade Awareness Demand creation, inc for YMSM, minorities at higher risk Peer outreach Social media – dating apps Self efficacy Reducing fear, stigma and discrimination Legal and social issues Services Accessibility – cost, geography Heath worker issues – training for inclusive services for KP Specific service delivery approaches, flexible opening hours, decentralisation, integration, community based services Uptake Risk perception Risk screening Choice Adherence Disclosure Peer support Reminders Retention JR: Are the structural interventions in the left margin and the behavioral interventions in the right margin? If so, is the purpose of the orange arrows to show how structural interventions are associated with behavioral interventions? Or are the arrows on the right supposed to also be pointing inward? JR: Are there supposed to be structural and behavioral interventions intended to improve retention?

In summary What needs to be done to make PrEP as successful as possible? PrEP works, when taken (adherence is a critical predictor) Demand is growing, although uptake varies according to setting PrEP brings people at high HIV risk into services with benefits beyond PrEP HIV testing uptake Opportunity to screen for STIs, vaccinate for HepB, HepA Not all MSM want PrEP and not all the time. Other prevention must be available. To support effective and equitable PrEP use, services need to address structural factors and behavioural issues PrEP is not just a biomedical intervention, but also a bio-behavioural one It is important to adopt a public health, human rights and people-centred approach when offering PrEP to those at substantial risk of HIV.

Acknowledgments HIV Dept. WHO, Geneva Ioannis Hodges-Mameletzis, Michelle Rodolph, Florence Koechlin, Shona Dalal, Bob Grant, UCSF, USA Kevin Rebe, Anova, South Africa Andrew Grulich, Kirby Institute, Australia Jason Reed, Jhpiego