1. 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

2. 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

3. Global HIV Prevalence among MSM, 2007-2012
Modified From: Beyrer, Baral, van Griensven, Goodreau, Chariyalertsak, Wirtz, Brookmeyer, The Lancet, 2012

4. 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

5. HIV Incidence among MSM, 1995-2014
High Income Countries
Low and Middle Income Countries

6. 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

7. 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

8. Modified: Abdool Karim et al, AVAC Report, 2014
Oral/Topical PrEP Efficacy/Effectiveness
Modified: Abdool Karim et al, AVAC Report, 2014

9. “Forgiveness” TFV Concentration: Rectal>Cervical>Vaginal
Days post single-dose
Patterson KB et al. Sci Transl Med

10. HIV prevalence and awareness of HIV positivity by age, Cape Town and Port Elizabeth, South Africa

11. Modeling Utility of PrEP For MSM in South Africa
Source: Brookmeyer et al, PLoS ONE 2014

12. PrEP Continuum for MSM in Cape Town and Port Elizabeth, South Africa, 2014-2016

13. Person Days on and off PrEP among 80 MSM in Cape Town and Port Elizabeth, South Africa, 2014-2016

14. 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)

15. SA PrEP Demo: Retention Outcomes
Source: Brown, Rebe, Bekker, McIntyre

16. SA PrEP Demo: Adherence Outcomes
81%
19%
85%
15%
87%
13%
Source: Brown, Rebe, Bekker, McIntyre

17. Ever Used any PrEP among MSM

18. 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

19. 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