Speakers discuss PrEP counseling, special situations, and other topics covered in training modules three and four. During this webinar, expert speakers review key highlights from modules three and four, and respond to questions from participants. Part one: https://www.slideshare.net/jsi/prep-elearning-discussion-i

1. PrEP E-learning Discussion II
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 Participating in 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 you lose 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
for Clinical Management

5. Clinically managing special situations
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 hormonal contraception
• HIV PrEP is safe and effective in clients
using hormonal contraceptives (whether
oral, injectable or implantable)

9. Elevated serum creatinine/decreased
creatinine clearance 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
• Stopping HIV 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
• WHO recommends 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 Messages for
Clinicians

14. Counseling Clients about PrEP 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 about PrEP 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 about PrEP 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
• PrEP clients 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
• PrEP in 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 PREP initiated 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 of PREP 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 clients still
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 USAID DISCOVER-Health

25. Analysis of Reasons
for PrEP
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 PrEP Counseling
• 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. Thank you.