1. Rachel Baggaley and Gottfried Hirnschall WHO HIV Department
Developing implementation guidance and formulating prevention packages and platforms
Rachel Baggaley and Gottfried Hirnschall
WHO HIV Department
Meeting of the Global Prevention Coalition
10-11 October 2017

2. Outline Background UN Prevention Pillars Conclusions OBJECTIVES
Present overview of evidence-based intervention packages recommended by WHO
Highlight country case examples

3. Background

4. Action point 4 Developing guidance, formulating intervention packages , identifying service delivery platforms, and updating operational plans
Normative guidance for various programmes & interventions across the key pillars of prevention
Combination prevention packages for specific key & priority populations
Policy actions to guide activities
Service delivery platforms for various interventions & packages
Standard operating procedures implementation guidance for implementers (facility & community-based programmes)

5. Guiding principles
Country lessons point to key principles for prevention success:
A location-population approach addressing the heterogeneity of the HIV epidemic
A people-centered approach that recognizes that different prevention options exist - individuals may choose various options at different stages of their lives
Partnerships between government and community actors. Renewed prevention activism and a new compact between government and civil society organizations needed

6. Civil society is essential
Can facilitate change and achieving prevention targets:
CBOs can deliver relevant and quality HIV prevention services to young people and key populations in circumstances where governments may struggle
Civil society organizations can also advocate for legal and policy reforms to enable effective programs to be provided at scale.

7. Where we are now
National leadership
Partnerships and engagement
Public sector
Private sector
Community
Evidence based normative guidance→ implementation guidance
Complementary approaches also addressing structural issues
Strategic information for action
Implementation packages and platforms
HOW?
-NSP
Harm reduction: NSP and OST
VMMC
PrEP
PEP
STI management
Condoms and lubricants
HIV testing
Partner/couples testing
Behavioural interventions
Treatment (as prevention)
Mobile technologies
Multiple HIV prevention options
WHAT?
Adolescent girls y
Young women y
Older women >25 y
Serodiscordant couples
Men and adolescent boys
Key populations
(MSM, SW, transgender people PWID and people in prisons)
Other pop groups
Significant heterogeneity, and intersections
WHO?

8. UN Prevention Pillars

9. Adolescent girls, young women & their male partners
Pillar I
Adolescent girls, young women & their male partners

10. Adolescent girls, young women and their male partners: what is needed
Inclusive laws & policies
Remove mandatory parental consent/notification for HIV, SRH services; “mature minors”
Defined packages of services for all adolescents
Diagnosis
Prevention
Comprehensive care, treatment
Adolescent sexual reproductive health service
Comprehensive sexuality education
Address based violence
Adolescent-friendly services
Address structural issues
Keeping girls in school and providing further education and employment opportunities
Improve data – age disaggregation
Not all adolescents are the same – tailored approaches needed

11. Young women & male partners (high HIV incidence setting): priority packages
Standard package (all incidence levels)
Access to SRH/HIV services (HIV testing, ART, condoms, VMMC (14 countries), FP
Access to secondary education inc comprehensive sexuality education, GBV services
Health & community systems, social support, advocacy & leadership
HIV incidence level
(in 100 person years)
Community-based prevention (evidence-informed models addressing social & gender norms, risk perception & demand generation)
School-based prevention (evidence-informed models addressing social & gender norms, risk perception & demand generation)
HIV sensitive cash transfers /social support
(to ↑access to education; complementary to existing social transfer schemes)
Pre-exposure prophylaxis
High ( )
Focused
Focused (SD couples, young key populations)
Very high ( )
Intensive
Extremely high (2.0+)
Expanded
Access & demand generation

12. South Africa: She Conquers
National campaign to empower AGYW, including HIV prevention.
High level political support
53 priority sub-districts identified in 9 provinces
Core package of evidence based interventions tailored for specific target groups
Strategic partnerships, coordinated activities
Technology and innovation: B-wise
Live chat - information on SRH, HIV
Nearest clinic based on location
Package of interventions focus on different contexts (schools, TVETS, colleges, workplaces, communities) and target groups

13. Pillar II Key populations
Men who have sex with men
Transgender people
People who inject drugs
People in prisons or other closed settings
Sex workers

14. Key populations: comprehensive package of service
HIV prevention
Harm reduction interventions for people who use drugs
HIV testing services
HIV treatment and care
Prevention, management of co-infections & comorbidities
Sexual and reproductive health interventions
Supportive legislation, policy and funding
Addressing stigma and discrimination
Health services available, accessible and acceptable
Community empowerment
Addressing violence
Health interventions
WHO positions
structural interventions within a comprehensive public health approach
Structural
interventions
Source: WHO Consolidated guidelines on HIV prevention, diagnosis, treatment and care for key populations

15. Zimbabwe: Sex worker led programmes
“We used to be rounded up in the streets even if we were just standing there, but now they can’t do that ..So cops are finding it hard to arrest us. I’m sure it will also make them think and realize that we are also human beings.”
Court order protecting sex workers
Criminalisation of sex work - direct association with increased HIV risk
A recent court order in Zimbabwe protects sex workers
Fewer arrests
No new reports to human rights lawyers
Comprehensive package
HIV testing
STI FP
Condoms
ART
PrEP
GBV
Social support
A recent court order, however, appears to have resulted in significant change in relations between sex workers and the police. In 2014, nine women from Harare were arrested for solicitation and subsequently convicted. The law stipulates, however, that both the conduct of solicitation must be specified (i.e. evidence of proactive attempt to procure a client rather than based on the person’s location and/or clothing) and the person who was being solicited must be present in court. Based on the absence of these requirements, Zimbabwe Lawyers for Human Rights (ZLHR) took the case to the Constitutional Court, successfully arguing that the women’s conviction was in violation of the newly ratified 2013 Constitution’s Sections 49(1)(b) and 56(1), respectively:
Right to Personal Liberty … which includes the right …not to be deprived of their liberty arbitrarily or without just cause
All persons are equal before the law and have the right to equal opportunities in political, economic, cultural and social spheres
Since the court order, the number of FSW arrests reported to ZLHR has dropped to the extent that they have not yet been able to find a new case with which to test the order.

16. Voluntary medical male circumcision
Pillar III
Voluntary medical male circumcision

17. VMMC: more than just circumcision
>14.5 million performed in 14 countries in ESA 2008–2016 = 70% of 2016 target
Impact estimated: HIV infections averted through 2030
Reached with a package of services:
Minimum: safer sex education, STI management and condoms, HIV testing and entry to other services, ‘essential’ surgical intervention with infection prevention and control, links to ART
Additional: hygiene education, vaccination against tetanus, sexuality, relationships, gender and masculinities
Capacity of health workforce enhanced, inc nurses performing minor surgery
Traditional circumcisers and formal health sector working together

18. Zambia: impressive scale-up (1.48 million circumcisions)
Strong coordination by MOH, partners and stakeholders
Age and geographic targeting and robust demand generation
Operational plans and programme reviews
Engaged community and traditional leaders
Consistent, and diversified, funding

19. Condoms and lubricants
Pillar IV
Condoms and lubricants

20. Comprehensive Condom Programming: components for impact
Leadership & coordination
Coordination of partnerships
Advocacy
Policies and regulations
Resource mobilization
Supply & commodity security
Forecasting and targets setting
Procurement
Quality assurance
Warehousing and storage
Distribution
LMIS
Demand, access and utilization
Market research
Total market approach
Targeted distribution
Behaviour change communication
Social mobilization
Support
Social, behavioural, and operations
Capacity and institutional strengthening
Integration
Monitoring and evaluation
Documentation and dissemination

21. Pre-exposure prophylaxis
Pillar V
Pre-exposure prophylaxis

22. PrEP: Part of combination prevention
What are some key considerations?
Not for EVERYONE
Uptake and continuation is variable
Not for ALWAYS
Seasons of HIV risk
Adherence is critical for PrEP effectiveness
Other services beneficial, valued and necessary
Many benefits beyond PrEP itself
How do we implement strategically?
Start with highest incidence groups
KPs (e.g. MSM)
SDC
Other populations (e.g. AGYW)
Safer conception
Part of enhanced eMTCT
Integration and linkages to existing services
Source: WHO PreP implementation tool
Took out the word PrEP implementation, really want to mention COMBINATION
Unbold Pillar 5: and bolded PrEP
I don’t like the word ‘some AE’s in there.
No such thing as ePMTCT
Added MSM next to KPs, as that’s in many ways the no-brainer KP and should be highlighted.

23. Australia: real-life, public health impact of PrEP
Newly diagnosed HIV cases in New South Wales (including Sydney)
Committed and engaged leadership
Educated community and built demand for PrEP among MSM
PrEP demonstration project at scale
25% reduction in the average number of new cases compared to the previous five years.
PrEP starts March 2016
Source:

24. Conclusions

25. Normative guidance, technical briefs, and tools to support countries

26. We have the tools
Furthermore, the UN family together with key stakeholders including the various population groups themselves have issued comprehensive implementation guidance in recent years, for HIV prevention on AGYW, key populations, VMMC etc

27. Together we can end HIV as a public health threat by 2030
We know what needs to be done
WHO has
assessed the evidence
developed recommendations
translated these into implementation guidance and defined packages
WHO focusing on implementation guidance to support scale up and facilitate introduction of innovation, building on experience to date
It needs to be done to scale
Accelerate to achieve higher coverage
We can only achieve this with leadership, partnerships and synergy
Together we can end HIV as a public health threat by 2030

28. Acknowledgments WHO HIV Department
Annette Verster, Julia Samuelson, Michelle Rodolph, Shona Dalal, Cheryl Johnson, Carmen Figueroa, Ioannis Mameletzis, Virginia Macdonald
WHO Regional and Country Offices
Scientific experts
WHO Guideline Development Groups
Other partners
UNAIDS
UNFPA
UNICEF
Global Fund
GNP+, ICW, KP networks, APCOM
Donors
BMGF
Unitaid
U.S. CDC
USAID