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PrEP E-Learning Discussion 2
The document outlines a webinar discussing the management of Pre-Exposure Prophylaxis (PrEP) in various client scenarios, including young adults, pregnant individuals, and those with specific health conditions. It emphasizes the importance of adherence, counseling, and support for PrEP clients, and provides statistics on PrEP implementation in Zambia, including reasons for client discontinuation. Key recommendations include integrating PrEP with other health services and enhancing client engagement to address barriers to access.
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PrEP E-Learning Discussion 2
- 1. PrEP E-learning DiscussionII May 28, 2020 2:00-3:00 p.m. WAT Expert Panelists: • Jason Reed, Biomedical HIV Prevention Technical Advisor, Jhpiego • Kalasa Mwanda, Deputy Project Director, USAID DISCOVER-Health, JSI Zambia Moderator: • Olawale Durosinmi-Etti, JSI Nigeria
- 2. Tips for Participatingin the Discussion • Type your questions and comments into the Chat box • We will try to get through every question. – We will ask our speaker to provide answers for any questions not covered during this webinar. We will distribute these answers to all participants.
- 3. Troubleshooting • If youlose connectivity or cannot hear – Close the webinar. Re-enter the meeting room by clicking on the webinar link provided. – Run the Audio Setup Wizard • Troubleshoot by asking a question in the Chat box. One of our technical support staff will try to help you. • A recording of the webinar and the slides will be available after the session.
- 4. Special Situations Arising forClinical Management
- 5. Clinically managing specialsituations arising in PrEP clients 1. Adolescent/young adult (< age 25) clients 2. Pregnancy or breastfeeding 3. Clients on hormonal contraception 4. Elevated serum creatinine/decreased creatinine clearance (<60 mL/min) while using PrEP 5. Clients with hepatitis B 6. Seroconversion after starting PrEP 7. Clients injecting or using recreational drugs
- 6. Serving adolescents &young adults • Make efforts to provide additional/flexible/non-judgmental support – Adherence with dosing – Contact need not always be in person – Access to additional services like pregnancy testing, contraception, mental health, substance use and social support.
- 7. Pregnancy or breastfeeding •It is safe to continue taking PrEP • Becoming pregnant (or beginning breastfeeding) further increases women’s risk and the benefits of PrEP
- 8. Clients on hormonalcontraception • HIV PrEP is safe and effective in clients using hormonal contraceptives (whether oral, injectable or implantable)
- 9. Elevated serum creatinine/decreased creatinineclearance while using PrEP • Approx 80% of abnormal creatinine results resolve without stopping PrEP; re-test creatinine by redrawing blood on different day • Consider discontinuing if separate blood specimen test result is still abnormal – A serum creatinine elevation – A decreased creatinine clearance < 60 mL/min • Creatinine elevations usually reverse after stopping PrEP – Once PrEP stopped, recheck creatinine and offer PrEP restart if results normalized – Creatinine abnormalities usually do not reoccur after PrEP restart
- 10. Hepatitis B • StoppingHIV PrEP in a client with hepatitis B can result in a resurgence of hepatitis B virus, called a “flare.” – may occur 1 to 3 months after stopping – often limited to elevations in ALT and AST • Hepatitis flare from discontinuing PrEP treated by restarting tenofovir/TDF
- 11. HIV Seroconversion • WHOrecommends confirming the HIV diagnosis in PrEP clients by testing second blood sample • If an HIV diagnosis is confirmed, offer client fully suppressive HIV antiretroviral therapy—ART—as soon as possible; do not delay – Only ~3% of PrEP recipients HIV seroconverting had resistance to TDF or FTC – Second-line ART regimens for seroconversion after starting PrEP usually not required
- 12. Injecting/Using Recreational Drugs •Main approach to HIV prevention is harm reduction strategies - opioid substitution therapy and needle syringe programmes • Clients using/injecting drugs may also be at risk of sexually acquiring HIV and benefit from oral PrEP – But oral PrEP is not a substitute for OST or syringe programmes
- 13. SAFETY EFFECTIVENESS AVOIDING STIGMA Counseling Messagesfor Clinicians
- 14. Counseling Clients aboutPrEP Safety • PrEP is safe when used by HIV negative people, so we must re-test for HIV every 3 months (and ideally 1 month after starting) • There are no side effects in most people; about 10% may experience side effects (stomach upset, headache), typically mild and resolve without stopping PrEP • Rarely, PrEP may cause problems with kidney function or the hardness of bones o Let me know if you have a related medical condition or history • If you have hepatitis B, daily PrEP use may still be safe o Before stopping PrEP, you should speak with me or another health care provider, since stopping may cause hepatitis B infection to worsen • It is safe to take PrEP throughout pregnancy and breastfeeding
- 15. Counseling Clients aboutPrEP Effectiveness • PrEP highly effective at preventing HIV (~90%) when used as prescribed o Easier to take if a daily habit, when brushing teeth, going to bed; If you forget, take it as soon as you remember • For STARTING and STOPPING PrEP o Needs to be taken for 7 days before you’re protected against HIV o Should be taken for 28 days after last possible HIV exposure/high risk sex for maximum protection
- 16. Counseling Clients aboutPrEP Effectiveness • PrEP still protects against HIV even if you’re taking it with alcohol or recreational drugs o Though taking alcohol and drugs may make is more difficult to remember to take PrEP • Using condoms and/or contraception is still a healthy choice; your use of PrEP for HIV prevention does NOT: o prevent other sexually transmitted infections o prevent you or your partner from becoming pregnant
- 17. Avoiding Stigma • PrEPclients often stigmatized – PrEP health care providers can help clients and influence communities to view PrEP as a responsible choice to help protect health – Reducing stigma may increase uptake of PrEP, daily adherence, and impact on HIV epidemic – Seek special training, if needed, to ensure clients don’t feel judged for their reasons to seek PrEP, including if they are not comfortable disclosing
- 18. PrEP Training –Nigeria Scale-up May 28th, 2020 Dr. Kalasa Mwanda
- 19. Presentation Outline • PrEPin Zambia/USAID DISCOVER-Health • Evolution of the PrEP program in Zambia • Counselling around PrEP • Persistence on PrEP • Main reasons for discontinuing PrEP • Q & A
- 20. Background • Zambia– Southern African country with an approximate population of 18m people • PrEP became policy in August, 2018 • The JSI’s USAID DISCOVER-Health project was among the first implementers of PrEP in Zambia • As at 31st March, 2020 • 16,539 clients have ever been initiated on PrEP under the Project • 2,832 clients are active on PrEP
- 21. Volume of PREPinitiated clients from inception to March 2020, by quarter 1232 635 926 1596 2005 3170 2979 3792 FY18 Q3 FY18 Q4 FY19 Q1 FY19 Q2 FY19 Q3 FY19 Q4 FY20 Q1 FY20 Q2
- 22. Percentage distribution ofPREP initiated clients from inception to March 2020, by population and quarter 19% 66% 63% 46% 44% 33% 37% 35% 7% 12% 10% 9% 8% 12% 8% 8% 1% 3% 4% 2% 4% 7% 4% 5% 65% 12% 8% 18% 14% 18% 25% 24% 7% 3% 7% 7% 14% 25% 31% 30% 20% 24% FY18 Q3 FY18 Q4 FY19 Q1 FY19 Q2 FY19 Q3 FY19 Q4 FY20 Q1 FY20 Q2 DC FSW MSM AGYW Inmates Others
- 23. Percentage of clientsstill on PREP at different intervals after initiation, by population Persistence on PrEP varied across different sub-populations - @ 6 months and @ 9 months, higher persistence rates seen among MSMs (39%, 32%) and SDC (37%, 22%) and lowest among the AGYW an the Young Males 38% 55% 37% 76% 53% 30% 25% 49% 35% 41% 50% 23% 13% 37% 25% 17% 39% 13% 6% 22% 18% 0% 32% 5%5% 17% 16% 0% 28% 6% AG/YW DC FSW Inmates MSM Young Males 1 month 3 months 6 months 9 months 12 months
- 24. PrEP in USAIDDISCOVER-Health
- 25. Analysis of Reasons forPrEP Discontinuation 22.90% 19.40% 7.89% 7.70% 3.40% 3.00% 1.50% 18.42% 6.20% 2.07% 2.44% 0.00% 5.00% 10.00% 15.00% 20.00% 25.00% Main Reasons for PrEP Discontinuation • Background • November, 2019 • 2,422/5,859 PrEP Discontinued clients were randomly selected out of 9,423 ever-enrolled between October, 2018 and November, 2019 • 696 respondents interviewed – Male vs. Female: • Lessons: • Most of the discontinuations were as a result of the clients no longer needing PrEP • or because the service was not within easy reach due to travel or long distance to the site providing PrEP Conclusions/Way forward: USAID DISCOVER-Health project looks to; increase its efforts around greater engagement; intensified client and public sensitization; client centered counseling and the application of differentiated models for oral PrEP.
- 26. Approaches Around PrEPCounseling • Integration - with other existing programs – FP/RH, VMMC, AGYW (DREAMS), couple counselling (SDC), etc. • Capacity building – The pre-existing pool of ART providers and lay counsellors were trained around PrEP counseling • Appropriate placement of counsellors – Based on Age and sex i.e. male counselors for Men’s Clinics, and younger female counselors for AGYW service corners, including DREAMS • Differentiated Service Delivery – including beyond hours and weekend clinics where appropriate counseling and other support can be provided. Also provided additional support by phone
- 27.
Editor's Notes
- #8 The medications in PrEP regimens have been widely used in HIV treatment in HIV-positive pregnant and breastfeeding women, and they have shown to be safe. In a study that included HIV-negative women in serodiscordant relationships, there were no differences in birth outcomes, infant birth weight, and congenital malformations in women using PrEP versus placebo.
- #10 Stopping TDF-containing PrEP is typically sufficient to restore baseline renal function. Additional causes and management of serum creatinine elevations should be considered, especially if any of the following are present: - Serum creatinine elevations are greater than 1.5 fold the upper limit of normal - Increased serum creatinine/decreased creatinine clearance do not return to normal levels within 3 months of stopping PrEP - Abnormal creatinine results worsen ≥ 1 month after stopping PrEP In such cases, consider known causes of chronic or severe renal insufficiency, which are rare in PrEP using populations (e.g., diabetes mellitus, uncontrolled systemic hypertension, hepatitis C virus (HCV) infection, liver failure, and pre-eclampsia during pregnancy).