Reaching those most at-risk through a general population approach: PrEP in the context of a generalized HIV epidemic Sindy Matse Eswatini Ministry of Health July 25, 2018 AIDS 2018 | Amsterdam

eswatini’s rationale for Prep in the general population Generalized epidemic Reduced incidence (2.5 in 2011) but not enough ( 1.48 in 2016)) No incidence data available for KPs. High prevalence in sexually active groups(FSW -70.3%, MSM -17%). 2016 incidence Female 1.99 | male 0.99 Estimated nr of annual infections 7000 Discussion can focus on how it wont be enough to focus on KPs. Graph shows that many new infections occur in general population. Source: Global HIV updates, UNAIDS 2017

a national prep framework was developed to guide implementation of demonstration studies Aim: To assess the operationalization of PrEP in Eswatini as an additional HIV combination prevention method among population groups and individuals at high risk of HIV infection Studies are occurring in government-managed facilities using existing human resources and other supportive systems Health services are decentralized and HIV prevention and care is integrated fully at the majority of primary health care facilities “Target” populations for PrEP in Eswatini: Young women 16-25 years Anyone with a self perceived risk or identified at risk by a HCW can start PrEP Pregnant and lactating women Sero-discordant couples Female sex workers Men who have sex with men (MSM) Clients with STIs

What does a general population approach mean in eswatini? Clients sensitized on PrEP in health facility Self-referral HIV risk assessment done by healthcare worker PrEP tablets Targeted community referral Prioritizing 6 target populations based on high risk/incidence The risk assessment is a discussion tool to raise awareness about HIV risk and is intended to be inclusive rather than exclude clients from PrEP services based on risk assessment conclusion  a client who self-identifies at risk can access PrEP regardless of the outcome of the risk assessment tool (eg HCW determines they are not at risk) PrEP eligibility screening for those at risk and interested in PrEP Same day Prep initiation if no contra-indications Peer-peer referral

26% of PrEP clients do not belong to any target population This slide to be presented as evidence of the advantage of not targeting clients because you may miss those who do not identify/are not identified as a member of a target pop Still reaching high risk populations Charts include data for all 3 demo projects from August 2017 to May 2018

Advantages and disadvantages of general population approach Reducing stigma Looks at individual risk vs generalizing risk No need to disclose individual behaviours/ sexual preference Allows broader access to a proven effective HIV prevention method Integration at many service delivery points Opportunity to engage a broad range of individuals to understand their own HIV risk to make informed HIV prevention decisions Target high risk individuals at community level DISADVANTAGES High number of health care workers to be trained for national scale up Potential for clients to be missed for PrEP engagement in the context of high volume clinics and HCWs with competing client priorities Difficulties in reporting uptake of PrEP within specific key populations (if disclosure not required)] ADVANTAGES: Potential to reduce stigma as PrEP is not for specific populations In high prevalence setting will look at individual risk rather then generalizing risk for specific populations No need to disclose individual behaviours/ sexual preference Allows access to a proven effective HIV prevention method to all at risk instead of limiting it to certain at risk populations Allows for integration at many service delivery points Opportunity to engage a broad range of individuals to understand their own HIV risk to make informed HIV prevention decisions Possibility to target high risks individuals at community level DISADVANTAGES: High number of health care workers to be trained for national scale up Potential for clients to be missed for PrEP engagement in the context of high volume clinics and HCWs with competing client priorities Difficulties in reporting uptake of PrEP within specific key populations (if disclosure not required)

PrEP Study Retrospection What would we do differently? Advocate to MOH to expand cadre of HCWs that are eligible to initiate PrEP Conduct community PrEP initiations with follow ups and refills done at clinics What do we wish we had known earlier? Prior to roll out focus a communication strategy on a national understanding of PrEP and prioritize identifying biggest influencers (eg, HCW, Peer to Peer) for PrEP uptake, supporting improved targeting, reducing PrEP associated stigma post roll out. What do we still want to find out? The cost effectiveness of PrEP approaches for those most at risk only vs. general population combined with demand creation for most at risk. What would happen if we requested disclosure of specific sexual behavior/preference? What would we do differently? Advocate to MOH to expand number of HCWs that are eligible to initiate PrEP due to limited number and availability of HCWs, resulting in reducing the barrier of wait time for clients Conduct community PrEP initiations with follow ups and refills done at clinics to increase access and reduce time requirements at clinic What do we wish we had known earlier? Prior to roll out communication strategy a national general understanding of PrEP and a focus during roll out on identifying biggest influencers (eg, HCW, Peer to Peer) for PrEP uptake, supporting improved targeting, reducing PrEP associated stigma. What do we still want to find out? The cost effectiveness of PrEP for those most at risk only vs. general population targeting most at risk approaches. What would happen if we requested disclosure of specific sexual behavior/preference?

General Population Approaches in other countries Policy Lesotho General population approach for PrEP (2016 guidelines) Kenya PrEP is recommend for for HIV negative individuals at substantial ongoing risk of HIV infection (2016 guidelines) Zambia Population at substantial risk, not limited to KPs (2018 consolidated guidelines) Botswana Population at high risk, not limited to KPs (2016 guidelines) Policy wise in order countries recommendations are broad. Many SSA countries are taking a general population approach in their policies. What is their implementation status? What are their challenges and achievements?

lesotho Implementation status: Preparation for nationwide scale up started in Q3 2017 TWG constituted with four subcommittees Draft implementation framework finalized by MOH National TOT completed, District-level step-down trainings ongoing. National M&E indicators and data collection tools in place PEPFAR supporting 5 districts, other 5 district fully supported by MoH No data available Uptake is slow, mainly sero-discordant couples. Partner driven community based PrEP focusing on KPs TWG constituted with four subcommittees: Clinical, Implementation plan, Advocacy and Communication M&E Community PrEP: Implementation by MOH with support from Jhpiego Funded by USAID in three districts so far Services are provided in non-medical settings to the fullest extent possible, mainly resource centers and mobile services in strategic community locations Demand creation activities and/or service delivery carried out at; schools, factories, urban centers, prisons, sex work hot spots and MSM safe spaces Specifically targeted are AGYW, MSM and FSW

General Population Approaches in other countries Policy Lesotho General population approach for PrEP (2016 guidelines) Kenya PrEP is recommend for HIV negative individuals at substantial ongoing risk of HIV infection (2016 guidelines) Zambia Population at substantial risk, not limited to KPs (2018 consolidated guidelines) Botswana Population at high risk, not limited to KPs (2016 guidelines) Policy wise in order countries recommendations are broad. Many SSA countries are taking a general population approach in their policies. What is their implementation status? What are their challenges and achievements?

kenya Implementation status: Challenges with getting sufficient number of HCW trained to serve the general population High uptake but low numbers returning for follow up  community pressure and limited understanding of clients about PrEP  

conclusion There is a disconnect between countries policies and implementation status regarding to offering PrEP to the general population. A significant number of individuals at high risk will fail to access PrEP if limited for specific populations.

acknowledgements Health care workers from participating PrEP sites, Regional partners, community members and stakeholders