Antiretroviral Therapy (ART) for HIV Prevention: Attitudes and practice amongst healthcare providers in HIV and STI care in Ireland Garvey P, Kiernan J, O’Leary A, Hurley C, Lyons F SSSTDI Autumn Meeting 26th November 2016 Authors: Garvey P1, Kiernan J2, O’Leary A3, Hurley C4, Lyons F4 1HSE Health Protection Surveillance Centre (HPSC) and European Programme for Intervention Epidemiology Training, ECDC, Stockholm, Sweden. 2St. James’s Hospital, Dublin 3National Centre for Pharmacoeconomics, 4HSE Sexual Health and Crisis Pregnancy Programme (SHCPP)

ART for HIV Prevention Pre-Exposure Prophylaxis (PrEP) Treatment as Prevention (TasP) Post-Exposure Prophylaxis (PEP) PrEP: Administration of ART to those at risk of infection TasP: Treating those with established infection PEP: Administration of ART after potential exposure to HIV

National Sexual Health Strategy 2015-2020 Priority Action: “Prioritise, develop and implement guidance to support the appropriate use of antiretroviral therapy (ART) in HIV prevention.” Currently in Ireland PEP Guidelines in place since 2012 (EMI Toolkit) Updated August 2016, www.emitoolkit.ie No national guidelines for TasP or PrEP TasP: Robust clinical trial (Cohen) and cohort data (Rodger et al) Incorporated into international guidelines for HIV management (BHIVA, EACS, DHSS, WHO) Grade I recommendation PrEP Robust clinical trial data (PROUD, Ipergay) Incorporated into international guidelines for HIV prevention (EACS, WHO, DHSS)

Aims Determine attitudes and practice amongst healthcare providers in Ireland in relation to Timing of ART initiation (TasP) PrEP for HIV prevention Inform the work of the HSE Sexual Health & Crisis Pregnancy Programme

Method

Study Design Ethical approval obtained from RCPI REC List generated from HIV and STI Services Targeting those involved in one to one consultations Cross sectional survey of HCPs involved in HIV and STI care Questions about timing of ART initiation for HIV HCPs Questions about PrEP for all respondents RCPI Research Ethics Committee Healthcare providers: doctors, clinical nurse specialists and pharmacists

Data Collection and Analysis Self administered anonymous online questionnaire Demographix Survey Tool Proportions calculated categorical variables using non-missing values as denominators Medians calculated numerical variables

Results

Respondent Characteristics 67/118(57%) responded 36 (54%) medical 26 (39%) nursing 5 (7%) pharmacists Care provided 21 (31%) HIV & STIs 20 (30%) HIV 26 (39%) STIs Experience (median) HIV 13 years STI 12 years

ART Initiation

HIV Case Load Characteristic Median Range Percentage of HIV patients by HIV risk group (N=41) Women 25 0.5-50 Heterosexual men 20 3-70 Vertically-infected adolescents (<18 years old) 1 0-10 People who inject drugs 1-95 Men who sex with men/ transgender/transsexual 45 5-95 Percentage of HIV patients by country of origin Ireland 10-90 Sub-Saharan Africa 30 2-70 South America 15 0-60 EU other than Ireland 10 2-50 Asia 5 Other 0-19

Initiation of ART - Practice % Guidelines used for timing of ART initiation (N=40) BHIVA 32 80 EACS 25 63 DHHS 9 23 None of the above 2 5 Guidelines used for choice of ART (N=40) 29 73 8 20 Factors prompting respondent to recommend ART (N=38) HIV infected patient having unprotected sex with partner(s) of unknown HIV status 37 97 HIV infected patient in a HIV discordant sexual partnership (patient’s partner is HIV negative) 36 95 HIV infected patient with high viral load (>100,000 copies/mm3) and CD4≥500 35 92 HIV infected patient newly diagnosed with an STI 84 HIV infected patient actively injecting drugs 31 82 British HIV Association 2015 European AIDS Clinical Society 2015 US Department of Health & Human Services 2016

Initiation of ART - Practice “In general, I recommend ART for HIV-infected patients irrespective of CD4 count” 33/36 (92%) indicated they agreed (19%) or strongly agreed (72%) with the statement Characteristic Median Range HIV clinical case load (N=23) Percentage on ART 90 70-100 Number HIV reviewed in last typical month of service 80 3-200 Percentage in whom you initiated ART in the last typical month of service 5 0-30

Initiation of ART - Attitudes Early initiation of ART can slow the spread of HIV in the community 40/40 (100%) agreed or strongly agreed Ireland should adopt policy of offering ART to all HIV infected individuals 39/41 (95%) said “yes”

PrEP

PrEP Awareness & Attitudes “Have you heard of PrEP?” 66/66 (100%), said “yes” “PrEP should be available in Ireland to individuals at high risk for HIV” 55/66 (83%), agreed or strongly agreed “Likelihood of recommending PrEP to high-risk individuals 31/34 (91%) likely or very likely

PrEP Statements

“Costs may decline when medications in generic form become available” PrEP Comments “Who is going to look after this cohort, the services are already bursting at the seams” “Costs may decline when medications in generic form become available” “I do not consider it to be an appropriate use of taxpayers money. Condoms are a cheaper alternative” “The non availability of PrEP is hugely concerning and is impacting on new HIV infection rates. The gay sex landscape has changed... Unsafe sex is now routinely part of the sexual repertoire and the use of recreational drugs have impacted on MSM sexual practises” “Costly prophylaxis that potentially promotes and endorses risky sexual behaviours ... Potential for acquiring resistant strains of HIV and possible increase in STIs” “Politically supplying PrEP free of charge would cause difficulty in the context of rationing of healthcare”

Limitations No directory of relevant HCPs Response rate

Conclusions ART Initiation PrEP In favour of TasP Current practice In favour of PrEP Overall HIV prevention Implications

What Now? ART initiation PrEP HSE position statement on ART for all people with HIV PrEP Helped inform how we should proceed with PrEP in Ireland

Thank You Any Questions?