PrEP Presentation a South African perspective.pptx

Pre - exposure prophylaxis of HIV
Indications for PrEP
Criteria for PrEP
PrEP monitoring
PrEP for pregnant women
PrEP for breastfeeding women
Baseline investigations before taking PrEP

1. PrEP

2. Outline Introduction Definition Difference between PrEP , PEP, ART Provision of PrEP PrEP counselling PrEP follow up and monitoring PrEP monitoring and reporting

3. Introduction Human immunodeficiency virus (HIV) is an infection that attacks the body’s immune system by targeting the body’s white blood cells, weakening the immune system. This makes it easier to get sick with diseases like tuberculosis, infections and some cancers. South Africa has the largest HIV epidemic in the world, with 7.64 million people living with HIV in 2019, representing 20% of the global HIV burden. WHO recommends supporting and strengthening primary HI V p revention alongside treatment, as both are needed to meet the 95-95-95 targets . According to the WHO guidance, PrEP should be an additional prevention choice in a comprehensive package of services that also includes HIV testing risk reduction counselling, male and female condoms, lubricants, ARV treatment for partners with HIV infection, and voluntary medical male circumcision.

4. Definition What is PrEP ? Pre-exposure prophylaxis PrEP is defined by WHO as the use of antiretroviral drugs by HIV-negative individuals who are at substantial risk of acquiring HIV before potential exposure to HIV to prevent HIV acquisition. The current preferred regimen in South Africa is oral TDF/FTC ( Tenofovir disoproxil fumarate/ Emtricitabine ) as a fixed-dose combination.

5. D I FERENCES BETWEEN PrEP, PEP and A

6. Provision of PrEP

7. Identification of potential candidates for PrEP This is Identifying people at greater risk of HIV infection who may benefit from PrEP and are willing to take PrEP; or who may, with assistance, be motivated to continue with PrEP is essential for programme efficiency. 

8. Candidates for PrEP Specific populations considered to be at greater risk of contracting and HIV infection include: Adolescent girls, boys, young women and men Men who have sex with men Individuals with more than one sexual partner People who inject drugs People with a recent history of STI(s) I ndividuals who recognise their own risk and request PrEP Serodiscordant couples if the HIV positive partner is not virally suppressed  Sex workers Migrant workers Pregnant and breastfeeding women

9. Considerations for PrEP in Pregnant and Breastfeeding Women HIV negative pregnant and breastfeeding women at high risk of contracting HIV They must be counselled for and offered HIV prevention interventions including PrEP together with acute HIV infection screening, adherence counselling, safety monitoring and three-monthly HIV testing and antenatal care. Any appropriately trained healthcare provider authorised to assess, diagnose, prescribe, and dispense (doctor, NIMART authorized professional nurse, and PIMART authorized pharmacist) can initiate and issue PrEP.  The woman should be informed about the comprehensive HIV prevention package and care options available for her to choose, emphasizing the importance of follow up ANC visits with regular HIV testing.

10. Minimum Package of Services Offered with PrEP The following minimum package of services must be provided to all clients receiving PrEP services in accordance with national guidelines: HIV Testing Services Risk reduction counselling Voluntary male medical circumcision ART initiation for those diagnosed with HIV Syndromic STI diagnosis and treatment Condoms and lubricants Pregnancy screening Contraception Counselling for Mental Health TB Screening Voluntary partner HIV testing and treatment

11. Screening for Prep Any person requesting PrEP, should be considered for PrEP, even if he/she may not be perceived to be at risk by the provider.  To identify individuals who may benefit from PrEP, the healthcare provider should assess the following individual characteristics and/or behaviour as they increase the individual’s risk for contracting HIV: Any individual who confirms having sex:  With out a condom With more than one partner With an HIV positive partner With a partner/s whose HIV is unknown  While under the influence of alcohol and drug Any individual diagnosed with an STI often or recently Young women or men in age disparate relationships (e.g. with a partner older than 5 years). HIV negative individuals who confirm any of the above should prompt a further discussion about the risks and benefits of PrEP.

12. Criteria used to offer PrEP Patient must be HIV negative by routine rapid antibody test. Absence of symptoms of acute HIV infection ( e.g fatigue, fever, sore throat, body aches, rash, swollen lymph nodes). He/she must be willing and able to take PrEP as prescribed. No contraindications to TDF or FTC. Adolescents >35kg in weight; if they are less 15 years old, they should be tanner stage 3 or greater.

13. Contraindications for PrEP HIV infection Estimated glomerular filtration rate (eGFR) of: Less than 50mL/min/1.73 m^2 for adults and adolescents ≥ 16years. Less than 80mL/min/1.73m^2 for children and adolescents ≥ 10 and <16. Serum creatinine greater than 85µmol/L for pregnant women.

14. Baseline investigations Following a negative HIV test and the person confirms that they are interested in taking PrEP,several baseline investigations should be conducted before PrEP can be initiated

15. Prescription of drugs The recommended regimen is TDF/FTC 1 tablet orally (PO) once a day . The drugs can be taken anytime of the day, with or without food. can be stored at room temperature. Prescription intervals: At initiation : give them 1- month PrEP drug supply. At 1 month visit: repeat HIV test and provide 3-month prescription and 3-month PrEP drug supply . Every 3 months: repeat HIV test and if the client remains HIV negative provide 3-month prescription and 3-month PrEP drug suppl y

16. PrEP Counselling Client education is critical to the success of PrEP as part of a comprehensive HIV prevention plan. Providers should educate and counsel PrEP users about PrEP and should provide them with other appropriate prevention options such as male and female condoms. Risk-reduction counselling is a behavioural intervention that attempts to decrease an individual’s likelihood of acquiring HIV and other STIs and should be implemented as part of HIV prevention counselling, with sexual reproductive health and contraceptive counselling at all follow-up visits for PrEP users.

17. PrEP counselling for pregnant women All pregnant women must receive the routine information and counselling provided to all HIV negative at-risk individuals. The choice to start, continue or discontinue PrEP when a woman becomes pregnant should be made by the woman, following discussion of the risks and benefits with her health-care provider. A pregnant and breastfeeding woman should be advised of the safety, benefits, and side effects of taking PrEP during pregnancy and breastfeeding.

18. PrEP follow-up and monitoring Follow-Up procedures for individuals on PrEP , including pregnant women: Confirmation of HIV-negative status(At initiation, at 1 month, then every 3 months) Address side effects (Every visit)
Adherence counselling (Every visit)
Creatinine clearance test (Only if indicated)
STI screening and treatment (Every visit) PrEP medication issuance (1-month supply at initiation, then 3-month supply) Behavioural sexual risk reduction counselling (Every visit)

19. Discontinuation of PrEP PrEP should be stopped if the client: Tests HIV-positive Has persistently low eGFR or high sCr levels (in pregnancy)) Is non-adherent to PrEP No longer needs or wants PrEP If there are safety concerns where the risks of PrEP use outweigh potential benefits NB: For a person stopping PrEP medication should be continued for 7 days after the last potential HIV exposure to ensure protection.

20. PrEP and Hepatitis B TDF and FTC both have hepatitis B antiviral activity. Discontinuation of PrEP may cause serious liver damage resulting from reactivation of HBV. PrEP users with chronic hepatitis B should be carefully monitored when they discontinue PrEP. Some PrEP users may opt to continue using tenofovir to control their hepatitis, even if they no longer require these drugs for the indication of PrEP.

21. PrEP clients who test HIV-positive Taking PrEP after contracting an HIV infection could result in the development of resistance to the drugs used in PrEP – tenofovir and emtricitabine – limiting future antiretroviral treatment options. Clients who test HIV-positive must stop taking PrEP immediately and initiated on ART or referredfor ART as soon as possible, regardless of CD4 count. They must be linked to HIV care, treatment,and support. Where possible, their partners should be encouraged to test for HIV.

22. HIV seroconversion after initiating PrEP can occur and may be due to: - People who take PrEP drugs inconsistently or do not take it as prescribed. - People who stop PrEP for a variety of reasons. PrEP failure: People who take PrEP consistently as prescribed and become infected with HIV while taking PrEP. All persons on PrEP that have seroconverted must be reported on the PrEP seroconversion form

23. PrEP Monitoring and Reporting Routine monitoring of the PrEP programme is essential to assess uptake, effective use, and safety. The data collected will also assist with forecasting demand to ensure sufficient and an uninterrupted supply of all the required commodities. To facilitate standardised and systematic monitoring of the programme, all PrEP service points must use the PrEP Clinical Form to collect client data PrEP providers must ensure that the form is completed in detail and kept in the client file at the healthcare facility

24. The information contained in the clinical form must then be used for entry into TIER.Net after each clinical visit or if there is a change in the clients status as PrEP user

25. PrEP Programme Indicators

26. References 2021 updated guidelines for the provision of oral Pre-exposure Prophylaxis ( PrEP ) to persons at substantial risk of HIV infection.

27. Thank you For listening