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Adherence to Prep: Experiences from Implementation Projects PSI Zimbabwe

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Adherence to Prep: Experiences from Implementation Projects PSI Zimbabwe Adherence to PrEP: Experiences from Implementation Projects PSI Zimbabwe Dr Emily Gwavava 26 April 2018 Potential Conflicts and Financial Disclosures . I have no actual or potential conflicts to declare in relation to this programme and presentation . Grant/Research support: US National Institutes of Health, Bill and Melinda Gates Foundation, USAID . Consulting: US National Institutes of Health, World Health Organization, Merck PSI PrEP Program Overview . PSI started offering oral PrEP (TDF/FTC) under the DREAMS program in Aug 2016 . Target populations – AGYW aged 18-24 years at substantial risk of HIV – YWSS <18 years old – Female Sex Workers, including Transactional Sex – HIV-negative partner in a serodiscordant relationship – LGBTI . 7 districts – Mutare, Chipinge, Makoni, Gweru, Bulawayo, Harare and Masvingo . Personalised risk assessment – screening tool page 3 New Start Centre – a “one-stop shop” for integrated HIV/SRHR services HIV/SRHR Integrated Services Package .HIV Testing Services, .OI screening and .Family planning services including HIVST treatment including LARCs .OI/ART services .Routine TB screening, .Cervical cancer screening .Laboratory Services GeneXpert testing, TB (VIAC) .Haematology, treatment, and IPT .Cryotherapy and LEEP biochemistry, viral load, .STI screening and .Condom and lubricant serology tests for syphilis, syndromic management promotion and distribution Hepatitis B, and .Pre-Exposure Prophylaxis Cryptococcus, and CD4 .Routine NCD screening (PrEP) count testing .Adherence Counselling .Post-Exposure Prophylaxis .KP friendly services (PEP) page 4 PrEP_NEW Client Age/Sex Disaggregations – Aug 2016 – Feb 2018 1800 1568 • New Start centres – 1600 all services entry point for PrEP 1400 • DREAMS partners 1200 • KP sub partners: Mobilisation CeSHHAR, GALZ, 1000 activities: 1000 SRC • PSI KP mobilisation 800 team – IPC agents, KP officers 600 • Peer Counsellors 405 386 400 142 Number of Clients Enrolled on PrEP on Enrolled Clientsof Number 200 43 45 0 2 31 As at end of • Females 83% of 0 10-14 15-19 20-24 25-49 50+ Feb 2018, a total clients total of Male 0 43 142 386 31 3,622 • AGYW account for Female 2 405 1000 1568 45 clients 39% of the total clients enrolled on Age Disaggregations (Years) enrolled on PrEP PrEP Male Female page 5 PrEP_NEW Client Categories – Aug 2016 – Feb 2018 2000 1841 1800 1600 1400 1200 1000 800 670 627 600 400 242 Number of Clients Enrolled on PrEP on EnrolledClientsof Number 200 161 78 0 FSW TS Discordant YWSS MSM Other Client Categories page 6 PrEP Lessons Learned – What is Working? . High demand among those aware of PrEP . Working with KP CBOs improves reach into these communities – MSM: GALZ, SRC, and Hands of Hope – FSW and YWSS: CeSHHAR . PSI employs IPC agents and KP officers to mobilise KPs for clinical services . PSI has PrEP Champions at all the HIV Care & Treatment clinics . Layering of services with DREAMS partners . Adherence strategies: – Transport reimbursements for clients in need – Phone calls – Home visits – Peer Counsellors/PrEP Champions – Community support at CBOs in between clinic visits page 7 PSI PrEP Program – Challenges . Although uptake has been fairly good, do not understand the PrEP client – EIP other client categories (AGYW/YWSS already done) • Motivators and barriers to adherence unique to each sub-population – Clinic staff main focus on enrolment of clients • More data analysis • More clinical meetings • More involved in data dissemination – Refresher courses . PrEP cascade in view of HIVST . Higher attrition of clients than expected – Retention patterns – data analysis in progress by sub-population page 8 Bambanani NSC AGYW Cohort Analysis – Aug 2016 – Nov 2017 120% 100% 80% 60% 40% 20% 0% Week 0 Week 4 Week 8 Week 12 Week 20 Week 28 Week 36 Week 48 Week 60 Aug-16 Sep-16 Oct-16 Nov-16 Dec-16 Jan-17 Feb-17 Mar-17 Apr-17 May-17 Jun-17 Jul-17 Aug-17 Sep-17 Oct-17 Nov-17 page 9 Bambanani NSC AGYW Cohort Analysis – Aug 2016 – Nov 2017 Week Week Week Week Week Week Week 0 Week 4 Week 8 12 20 28 36 48 60 Week 0 Week 4 Week 8 Week 12 Week 20 Week 28 Week 36 Week 48 Week 60 Aug-16 2 0 0 0 0 0 0 0 0 Aug-16 100% 0% 0% 0% 0% 0% 0% 0% 0% Sep-16 13 5 5 5 5 5 4 3 2 Sep-16 100% 38% 38% 38% 38% 38% 31% 23% 15% Oct-16 24 8 8 6 3 3 3 3 3 Oct-16 100% 33% 33% 25% 13% 13% 13% 13% 13% Nov-16 27 9 8 6 4 4 4 2 1 Nov-16 100% 33% 30% 22% 15% 15% 15% 7% 4% Dec-16 6 6 6 5 3 3 3 0 0 Dec-16 100% 100% 100% 83% 50% 50% 50% 0% 0% Jan-17 16 12 10 9 9 8 8 5 3 Jan-17 100% 75% 63% 56% 56% 50% 50% 31% 19% Feb-17 23 19 16 13 10 6 4 2 Feb-17 100% 83% 70% 57% 43% 26% 17% 9% Mar-17 3 3 3 3 1 1 1 Mar-17 100% 100% 100% 100% 33% 33% 33% Apr-17 5 5 3 3 2 1 1 Apr-17 100% 100% 60% 60% 40% 20% 20% May-17 17 14 13 13 11 8 5 May-17 100% 82% 76% 76% 65% 47% 29% Jun-17 16 7 7 7 6 5 3 Jun-17 100% 44% 44% 44% 38% 31% 19% Jul-17 9 7 4 4 3 3 Jul-17 100% 78% 44% 44% 33% 33% Aug-17 6 3 0 0 0 1 Aug-17 100% 50% 0% 0% 0% 17% Sep-17 16 10 8 7 5 Sep-17 100% 63% 50% 44% 31% Oct-17 19 7 7 5 1 Oct-17 100% 37% 37% 26% 5% Nov-17 7 5 3 1 Nov-17 100% 71% 43% 14% page 10 PrEP Retention - DREAMS Brought Opted Seroconv Transfers Transfers Back into PrEP_CU Registered Initiated Deaths LTFU Out erted out in Care RR Bambanani 297 216 0 32 102 2 0 0 9 89 Gweru 289 289 0 182 2 1 0 0 3 107 Mutare 357 357 0 92 107 0 0 0 2 160 Chipinge 235 235 0 46 4 1 0 0 9 193 Total 1178 1097 0 352 215 4 0 0 23 549 32% 20% page 11 PrEP Lessons Learned – What is Not Working? . Low awareness among the general population, including healthcare workers . Working with KP CBOs improves reach into these communities – GALZ, SRC, CeSHHAR, and Hands of Hope – Capacity building beyond advocacy roles . Difficulties getting reliable contact details, particularly amongst key populations . Low risk perception among AGYW – Stronger demand creation needed to increase uptake . Limited availability of PrEP available through New Start centres – 7 districts . Understanding the prevention needs of clients on PrEP – begin with the end in mind to minimise LTFU – Explore further the reasons for stopping PrEP – EIP other client categories (AGYW/YWSS already done) page 12 EIP Background • Limited demand for PrEP among Adolescent Girls and Young women (AGYW) and Young Women Selling Sex (YWSS) • Empathy, Insight, Prototype (EIP) process implemented in a 5-day workshop to identify key insights, barriers and motivators to develop targeted communications • Workshop done in partnership with the target populations with immersions, through ideation and prototyping • In collaboration with the MOHCC, the team brought in partners who are currently working on PrEP – CHAI and Pangea – as well as DREAMS partners (FACT, fhi360, World Education) and service providers in the New Start clinics IMMERSIONS WITH THE TARGET GROUPS . EMPATHY & INSIGHTS . The groups spent two days immersing in the lives of both of these target populations – walk ing a day in the life in their shoes. They visited their homes and their workplaces and walked through their communities, interacted with their friends and families. These immersions helped them to develop empathy with the target audiences and also to gain deeper insights that built upon learning from literature reviews. Based on key insights from literature reviews, immersions and experiences from services providers participating in the . workshop, the team identified key barriers, motivators, other insights about these BARRIERS, MOTIVATORS target populations and PrEP & OTHER INSIGHTS Barriers Young Women Selling Sex AGYW in transactional sex • Lack of knowledge • PrEP accessibility/ • Perception: PrEP = ART availability • Worry about side effects • Lack of family support • Self-stigma • Health Care • Fear of partner • Limited social support worker attitudes disclosure system • Pill burden • Low risk perception • Community Stigma • Value good status vs good health Motivators Young Women Selling Sex AGYW in transactional sex • Understanding of own high • Support system – risk family • Protection • Good service delivery & from HIV • Peers and health rapport care workers are key • Desire to influencers • PrEP pride - keeping HIV- live long status for self and children healthy life • Fear of getting HIV and dying • Knowledge of how to manage side effects • Social media JOURNEY MAPPING Based on key literature reviews, immersions and service provider experience, the team defined the journey for PrEP for each population Defining the PrEP Journey for Young Women Selling Sex STAGE 5 STAGE 1 STAGE 2 STAGE 3 STAGE 4 PREP CHAMPION AWARENESS CONTEMPLATION INITIATION ADHERENCE ADVOCACY Support system Peers, Family, and Peers on HCW Peers; Stable Communi HC Peer close family and PrEP/ART; friends partner ty W s HCW friends INFLUNCERS peers HIV Being in Acknowledging Maintain Hope Self Desire Empowerme HCW PrEP PrEP not for Good control own risks involved in HIV about empow for nt environme pride life (when at service prevention delivery life having multiple negative life erment protectio nt risk) n from experien sexual partners status Self MOTIVATORS MESSAGES HIV pride PrEP ce pride Service Ministry Healthcare Healthcare Stable partner HCW community Peers providers of Health worker worker INFLUNCERS Lack of Myths Transpo HCW Self Packag Communi Transport Accessibilit Daily Community knowled and rt costs attitude stigma ing ty stigma Pill Drug Side Self Lack of costs y and dosage Stigma ge misconc burden availability effects stigma Accessibi eptions 10 2 18 17 availability frequency lity and 3 availabilit MESSAGES y 1 BARRIERS Makes Realisation decision Clients PrEP Advocacy Adherence & that its to be get on continuation on relevant initiated PrEP Adherence & medication on PrEP continuation on medication MILESTONE INTERVENTION DESIGN : How Might We….? Based on the key barriers prioritized by the group, these How Might We questions were defined by the group to be used to design key interventions Young Women Selling Sex YW in transactional sex .
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