HIV Drug Therapy Glasgow 2016, ECDC presentation from Teymur Noori.

1. PrEP implementation strategies across
Europe – an overview
Teymur Noori, ECDC
25 October, 2016
HIV Drug Therapy Glasgow 2016

2. Outline
 Context and ECDC opinion on PrEP
 ECDC meeting on PrEP in April 2016
 Informal use of PrEP in Europe (Hornet/ECDC survey)
 Status of PrEP implementation in Europe

3. Injecting drug use
Heterosexual contact
(women)
Heterosexual contact
(men)
Sex between men
Source: ECDC/WHO (2015). HIV/AIDS Surveillance in Europe, 2014
+44%
-28%
-33%
-19%
HIV diagnoses, by mode of transmission
2005-2014, EU/EEA
Data is adjusted for reporting delay. Cases from Estonia and Poland excluded due to incomplete reporting on transmission mode during the
period; cases from Italy and Spain excluded due to increasing national coverage over the period.
Source: ECDC/WHO (2015). HIV/AIDS Surveillance in Europe, 2014

4. Percentage of HIV diagnoses, by route of
transmission, 2014, EU/EEA
Source: ECDC/WHO (2015). HIV/AIDS Surveillance in Europe, 2014

5. Which
interventions
work?
Hepatitis A
and B
vaccination
Condoms
and
lubricants
HIV and STI
testing
Treatment
for HIV,
viral
hepatitis
and STI
Health
promotion
MSM-
competent
health
services
Targeted
care for
MSM living
with HIV
ECDC guidance on HIV/STI
prevention among MSM (2015)
The evidence indicates
that these 7 services and
interventions, can:
 Effectively prevent and
reduce HIV/STI transmission
among MSM
 Address the needs of MSM
who are living with HIV
 Promote sexual health among
all MSM
 Have most impact when
when provided in
combination

6. Which
interventions
work?
Hepatitis A
and B
vaccination
Condoms
and
lubricants
HIV and STI
testing
Treatment
for HIV,
viral
hepatitis
and STI
Health
promotion
MSM-
competent
health
services
Targeted
care for
MSM living
with HIV
ECDC guidance on HIV/STI
prevention among MSM (2015)
The evidence indicates
that these 7 services and
interventions, can:
 Effectively prevent and
reduce HIV/STI transmission
among MSM
 Address the needs of MSM
who are living with HIV
 Promote sexual health among
all MSM
 Have synergistic effects when
provided in combination
 Evidence review and grading were performed prior to
release of the PROUD and IPERGAY studies
 The scientific panel viewed the lack of European
evidence (at the time) and the EMA not having
approved PrEP as sizeable barriers to strongly
recommending PrEP as part of comprehensive
programmes

7. ECDC opinion on PrEP April 2015
 Countries should give consideration to
integrating PrEP into their existing HIV
prevention package for those most at-
risk, starting with MSM
 Issues related to PrEP implementation
will need to be addressed in the context
of each Member State's health system
 ECDC will provide support to Member
States and the European Commission
with regards to PrEP implementation

8. ECDC meeting on PrEP
27-28 April, 2016
Objectives:
 Discuss key issues related to PrEP in
the EU/EEA setting
 Assess whether ECDC has a role to
play in supporting countries who are
considering PrEP implementation
Participants:
 Public health/policy makers
 Clinicians
 Community representatives
 Agency representatives

9. Key issues discussed
Session 1
Eligibility criteria for
PrEP in Europe
(Elske Hoornenborg)
Session 2
Appropriate models of
service delivery
(Sheena McCormack)
Session 3
Cost and cost-
effectiveness
(Valentina Cambiano & Nigel Field)
Session 4
Clinical and public
health monitoring
(Pep Coll, Robert Grant, Sheena
McCormack)

10. Options for delivering PrEP
Options Pros Cons
Clinic-based services  Used to discussing sexual health
 See people with STIs and at risk of HIV
 HIV/STI testing is in place
 Dispense TDF/FTC as part of PEP
 Confidential
 May not be walk-in and/or free
 Under-resourced and under-staffed
 Too few clinics
Community-based
services
 See people at risk of HIV – often peers
 May be the only provider seeing migrants
and minority ethnicities
 Confidential
 HIV testing in place
 Walk-in and free
 Referral pathways to prescribers of ARV
 May not be able to screen for STIs
 May need referral pathways for PrEP
 May not have sustainable funding
HIV specialists  Familiar with ARV
 HIV/STI testing available
 May depend on referrals to reach the
target population
 Notes available throughout hospital
 Appointments required
 Co-payments for some or all STI tests
Primary care
physicians
 If seeing the target population, will be
discussing sexual health, screening for
HIV/STIs, and familiar with ARV
 Set up for short appointments
 Co-payments
 Notes available to practice staff
 Very few primary care physicians are
likely to have the necessary experience
and interest
Peers and online  Peer discussion and support
 Signposting to services for HIV/STIs and
renal monitoring
 Convenient
 Can reach a large population quickly
 Co-payment for drug (could also be a
good thing)
 Not confidential (could also be a good
thing)
 Outside surveillance systems
Adapted from Sheena McCormack's presentation at the ECDC meeting on PrEP (27 April 2016)
 Whichever model is chosen, consideration must be
given to how best to integrate PrEP into existing
services
 Each country will need to consider where HIV/STI
testing and treatment are best delivered
 Given differences in country contexts, it is not feasible
or helpful to make Europe-wide recommendations

11. Meeting outputs
https://www.researchgate.net/publication/303438065_Pre-Exposure_Prophylaxis_in_the_EUEEA_Challenges_and_Opportunities

12. Hornet/ECDC survey
on PrEP

13. Hornet/ECDC survey (23-25 April 2016)
8,543 persons responded (48h)
France
United Kingdom (UK)
Russia
Italy
Germany
Belgium
Turkey
Spain
Netherlands
Denmark
Ukraine
Switzerland
Sweden
Portugal
Other
26%
22%
10%
13%
ECDC. Evidence brief: Pre-exposure prophylaxis for HIV prevention in Europe. Stockholm: ECDC; 2016.

14. Are you HIV-positive?
No
Unsure
Yes
79%
10%
11%
n= 4392 persons responding to this question (51%)
ECDC. Evidence brief: Pre-exposure prophylaxis for HIV prevention in Europe. Stockholm: ECDC; 2016.

15. Are you currently taking PrEP?
98%90%
69% of those on PrEP said their sexual health provider was aware that they were taking PrEP
No
Yes
10%
90%
n= 8048 (excludes HIV-positive respondents)
ECDC. Evidence brief: Pre-exposure prophylaxis for HIV prevention in Europe. Stockholm: ECDC; 2016.

16. Where did you obtain PrEP?
0%
10%
20%
30%
40%
50%
60%
70%
Research study Friend Internet PEP acquired and split Physician/doctor
France Other
n= 528 persons on PrEP responding to this question
Percentage
ECDC. Evidence brief: Pre-exposure prophylaxis for HIV prevention in Europe. Stockholm: ECDC; 2016.

17. Intention to use PrEP
(“I am very likely to use PrEP in the next 6 months”)
n= 7159 HIV-negative persons responding
ECDC. Evidence brief: Pre-exposure prophylaxis for HIV prevention in Europe. Stockholm: ECDC; 2016.

18. Status of PrEP
implementation in
Europe
(Published 16 October)
ECDC. Evidence brief: Pre-exposure prophylaxis for HIV prevention in Europe. Stockholm: ECDC; 2016.

19. Status of PrEP implementation in Europe
ECDC. Evidence brief: Pre-exposure prophylaxis for HIV prevention in Europe. Stockholm: ECDC; 2016. (updated)

20. Timeframe and setting of PrEP implementation
COUNTRY STATUS OF PrEP TIMEFRAME SETTING
FRANCE Implemented/reimbursed 2016 Health care setting
NORWAY Implemented/reimbursed 2016 Health care setting
BELGIUM Ongoing demonstration project (2015-2018) Health care setting
NETHERLANDS Ongoing demonstration project (2015-2018) Health care setting
ITALY Ongoing demonstration project Health care setting
UNITED KINGDOM Completed demonstration project (2012-2016) Health care setting
CROATIA Planned demonstration project (2016-?) Health care setting
DENMARK Planned demonstration project (2017-2018) Community-based setting
GREECE Planned demonstration project (2016-2017) Health care setting
IRELAND Planned demonstration project (2016-2017) Health care & community setting
LUXEMBOURG Planned demonstration project (2016-2017) Health care setting
MALTA Planned demonstration project -- TBD
PORTUGAL Planned demonstration project (2016-2017) Community-based setting
ROMANIA Planned demonstration project -- TBD
SPAIN Planned demonstration project (2016-2017) Community-based setting/STI clinic
SWEDEN Planned demonstration project (2016-2017) Health care setting
AZERBAIJAN Planned demonstration project (TBD) TBD
GEORGIA Planned demonstration project (2017-2018) TBD
ISRAEL Planned demonstration project (2017-2018) Health care setting
UKRAINE Planned demonstration project (2017-2018) Community-based setting
ECDC. Evidence brief: Pre-exposure prophylaxis for HIV prevention in Europe. Stockholm: ECDC; 2016.

21. What issues are limiting or preventing the
implementation of PrEP in your country?
ECDC. Evidence brief: Pre-exposure prophylaxis for HIV prevention in Europe. Stockholm: ECDC; 2016.
0 5 10 15 20 25 30 35
Drug resistance
Eligibility
Lower condom use
Other/Not licensed
Adherence
Increases in STIs
Feasibility
Cost of service delivery
Cost of PrEP
Number of countries (n=36)
High importance Medium importance Low importance

22. European discourse on PrEP: from a policy
maker/public health perspective
Is PrEP
efficacious?
2014-15

23. What about
STIs, drug
resistance,
condom
use?
Is PrEP
efficacious?
2014-15 2015
European discourse on PrEP: from a policy
maker/public health perspective

24. Can we
afford
PrEP?
What about
STIs, drug
resistance,
condom
use?
Is PrEP
efficacious?
20162014-15 2015
European discourse on PrEP: from a policy
maker/public health perspective

25. How do we
implement
PrEP?
Can we
afford
PrEP?
What about
STIs, drug
resistance,
condom
use?
Is PrEP
efficacious?
20162014-15 2016-172015
European discourse on PrEP: from a policy
maker/public health perspective

26. Conclusions
 Current efforts to reduce STI/HIV incidence among MSM in Europe
are failing
 While countries figure out whether or not to implement PrEP,
community implementation is in full swing, demand increasing
 An increasing number of countries in Europe and Central Asia are
considering implementing PrEP demonstration projects
 Although the costs of PrEP MUST come down, we need focus on
supporting countries who are considering PrEP
– Bringing clinicians, public health experts, community reps and policy makers
together
– Lay out the options for where and how to deliver PrEP

27. Thank you!
Gianfranco Spiteri
Anastasia Pharris
Andrew Amato
Sean Howell (CEO Hornet)
Alex Garner (Senior Health Innovation Strategist, Hornet)
Adam Bourne (LSHTM)
Kathy Attawell, Manuel Battegay, Josip Begovac, Torsten Berglund, Anders Blaxhult, Viviane Bremer, Gus
Cairns, Valentina Cambiano, Jordi Casabona, Olivia Castillo Soria, Pep Coll, Susan Cowan, Caroline Daamen,
Silke David, Antonio Diniz, Nigel Field, Robert Grant, Neta Harel, Elske Hoornenborg, Kristina Ingmarsdotter
Persson, Cary James, Marie Laga, Lennie Lindberg, Fiona Lyons, Bruno Maia, Anna Marzec-Bogusławska,
Sheena McCormack, Michael Meulbroek, Jean-Michel Molina, Arild Johan Myrberg, Otilia Mårdh, Brooke
Nichols, Georgios Nikolopoulos, Velina Pendolovska, Ines Perea, Francois Pichon, Ferran Pujol, Daniela Rojas
Castro, Anders Sönnerborg, Judit Takacs, Lara Tavoschi and Marti Vall