1. 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)

2. 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

3. 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,
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)

4. 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

5. Method

6. 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

7. 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

8. Results

9. 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

10. ART Initiation

11. 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

12. 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

13. 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

14. 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”

15. PrEP

16. 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

17. PrEP Statements

18. “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”

19. Limitations
No directory of relevant HCPs
Response rate

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

21. 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

22. Thank You Any Questions?