1. 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

2. 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

3. 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?

4. 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

5. 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

6. 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 Nov 15;61(10):

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).

8. 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?

9. 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.

10. 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