Pre-exposure Prophylaxis (PrEP)

PrEP is the regular or intermittent use of antiretroviral drugs by HIV negative people to prevent HIV acquisition. It should be offered to all MSM, especially key populations at high risk of HIV infection. For some subgroups of MSM in particular, this method has meant that they are for the first time able to protect themselves reliably from HIV infection. France was the first European country to provide PrEP to all who need it, and more and more countries are now implementing PrEP strategies.

Discussions about whether, how and where to provide PrEP, policy development and trials are under way in many other European countries. There are strong arguments why CBVCTs, as community-based services for MSM, are well placed to play a central role in providing access to PrEP. The Barcelona Checkpoint has articulated these reasons:

Why a community centre for the delivery of PrEP?

  • Persons who are HIV negative are not used to going to hospitals
  • Easy to talk to peers about sexuality, (not) using condoms, risk perception and risk reduction
  • 10 years of experience with HIV rapid testing and linkage to care
  • Promoting regular testing for people at highest risk (4 times/year)
  • New technologies and fast results for viral load testing
  • STI screening (Syphilis, gonorrhoea, chlamydia, HCV) already implemented
  • Long-term collaboration with HIV clinics and physicians
  • Experience with patient preparedness for treatment and adherence issues
  • Community outreach, awareness and information on PrEP.

(Source: bcn Checkpoint)

Expanding CBVCT operations to include PrEP does not necessarily depend on PrEP being provided through the health system. Even if MSM still source PrEP medication privately, information, support and health monitoring are important services that CBVCTs can offer. In the following checklist, we have listed the main elements of a comprehensive PrEP service. Depending on local conditions, not all of these can be provided by CBVCTs in every case. You could consider starting with information/counselling and cooperation with external PrEP prescribers and then add more components over time, up to providing a ’One-Stop-Shop’ that offers everything from testing and counselling to PrEP prescription and monitoring. 

Item Does your CBCVT have this in place? Is there a documented standard, guideline, plan, policy, procedure, contract or agreement? Is it adapted to local needs and conditions? Is it working as intended? Action
Client-centred information and collaboration with external PrEP providers
Description

Description

Your counsellors need knowledge to provide PrEP information (e.g. how it works, availability, cost, criteria for access) and skills advise them based on a risk assessment and individual circumstances. A detailed understanding of the way clients can access the medication in the local context is essential. This also includes the ability to recommend next steps based on the needs and preferences of each client. These services don’t need to be provided by doctors. If your CBVCT does not provide PrEP itself, you can collaborate with external PrEP providers, who will also involve a doctor if required to issue a prescription. It is helpful to coordinate your information and referral process with your collaborating partners, as well as monitor and updated it regularly.   

 

Guidance

Guidance

Based on international good practice examples (e.g. https://www.who.int/hiv/pub/prep/prep-implementation-tool/en/,  http://i-base.info/guides/prep), training materials (https://prepster.info/resources/#training-and-development) and any existing national policies and standards, it is recommended to draft clear organisational procedures to ensure that all information given to clients is correct and up-to-date, and including flow charts for making PrEP recommendations to clients.

 

Adaptation

Adaptation

The levels of access to PrEP are very different across Europe, from universal and free access through the health system to self-funded access from online sources. Information and recommendations on PrEP disseminated by CBVCTs must be closely adapted to local conditions, which may be changing rapidly. Particular care must be taken to prepare for unexpected changes in demand on services as PrEP becomes more widely known and accepted.  

 

Quality improvement

Quality improvement

Medical and community experts should review PrEP information and flow charts for recommending PrEP regularly to ensure they are up-to-date. It is important to ensure that factual information is current by checking with relevant authorities and institutions, but also to regularly review the needs of the target group. A range of tools to consult with and involve the target group is available from the Participatory Quality Development toolkit (PQD) at www.qualityaction.eu.

 


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Pre-PrEP assessment, prescription (if applicable) and ongoing health monitoring by physicians
Description

Description

Using PrEP is best embedded within holistic sexual health care. At a minimum, a physician should carry out an assessment (including baseline HIV testing) before a person begins taking PrEP. Depending on whether the health system provides access to PrEP, the medication may be prescribed by a doctor. However, independent of how the client accesses the medication, regular health monitoring (STIs, kidney function) by a physician should be available.

 

Guidance

Guidance

Physicians may be accessed at the CBVCT if available, or through referral and partnership arrangements with private practices or public health services. Guidelines for pre-PrEP assessments and ongoing medical support and monitoring should be based on good practice clinical guidelines (e.g. https://www.who.int/hiv/pub/prep/prep-implementation-tool/en/https://www.bhiva.org/PrEP-guidelines).

 

Adaptation

Adaptation

Affordable access to medical support for PrEP depends on how such services are covered by public and/or private health insurance arrangements locally. The affordability of regular health monitoring is a major factor for access and uptake of PrEP by those who need it. By adapting their services to the local conditions, CBVCTs can play an important role in ensuring medical support for PrEP is accessible. 

 

Quality improvement

Quality improvement

Keeping up to date with current recommendations for PrEP assessment, prescription and monitoring through the literature and good practice guidelines (e.g. https://www.who.int/hiv/pub/prep/prep-implementation-tool/en/www.bhiva.org/PrEP-guidelines) forms the basis for quality assurance in medical services, whether they are provided by the CBVCT or by partners in the health care system. At the same time, it is important to regularly analyse client feedback and update needs assessments if required, to ensure that services meet the needs of PrEP users as its implementation becomes more widespread.

 


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Promotion/ information campaigns or collaboration with other providers
Description

Description

The basic facts about PrEP are becoming more widely known among MSM populations. It is important that those who would benefit from it most are able to consider on the basis of accurate information. If the CBVCT does not have the capacity to conduct information campaigns itself, collaborations with other community-based MSM services or GLBTIQ* advocacy groups can help to reach subgroups of MSM who are most likely to benefit from PrEP.

 

Guidance

Guidance

The main steps are to articulate clear goals for communication (e.g. increase knowledge among particular MSM subpopulations, increase access to PrEP services etc.), define the audience(s) in detail, develop key messages and then select the most appropriate communication channels. Key guiding questions from the audience’s perspective are:

  • What is PrEP?
  • Is PrEP a good option for me?
  • How and where can I get PrEP?
  • What does it cost?

For a full list of frequently asked questions, see also https://prepster.info/wp-content/uploads/2018/06/PrEP-QA-booklet-e-use.pdf

See also the ‘guidance’ sections in the checklist for the ‘Communications’ topic in this toolkit.

 

Adaptation

Adaptation

Adapting campaigns to local conditions maximises their reach. This is especially relevant when the target group is a subgroup of MSM facing additional barriers, such as language or the ability to understand health information. There may also be locally relevant opportunities, such recruiting opinion leaders in the community (e.g. activists and/or drag performers etc.) to help promote key messages.  

See also the ‘adaptation’ sections in the checklist for the ‘Communications’ topic in this toolkit.

You can find an example of a PrEP campaign at https://www.tht.org.uk/hiv-and-sexual-health/prep-pre-exposure-prophylaxis.

 

Quality improvement

Quality improvement

In the absence of surveys providing insights into the needs and preferences of local MSM regarding PrEP, the participatory needs assessment tools contained in the PQD (Participatory Quality Development) toolkit, available at www.qualityaction.eu, can assist with ensuring that your campaign work responds to local needs.

See also the ‘quality improvement’ sections in the checklist for the ‘Communications’ topic in this toolkit. 

 


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Advocacy for the removal of structural barriers to PrEP
Description

Description

In many places, PrEP is not yet provided by the mainstream health system. Structural barriers may exist at different levels: politicians, prohibitive or lack of supporting legislation, health insurance providers, cost of medication, the medical profession, even MSM community services themselves. CBVCTs are in a good position to facilitate access to PrEP despite structural barriers. They can also act as experts as they can draw on substantial experience in working with MSM. CBVCTs can therefore argue for the benefits of providing PrEP to MSM through targeted advocacy. 

 

Guidance

Guidance

As is the case with any other advocacy topic, success depends not only on the strength of the argument, but also on strategic relationships with activists and advocates, access to decision-makers and the resources to sustain what may be a protracted process. Experience in European countries has shown that community action and advocacy efforts can have a profound effect on PrEP access.

An example of a community-based PrEP advocacy campaign is ‘Prepster’, see https://prepster.info/about/

See also the ‘guidance’ sections in the checklist for the ‘Advocacy’ topic in this toolkit.

 

Adaptation

Adaptation

Timing, support from key stakeholders and the role of public attention and opinion are important local factors for the planning and success of advocacy efforts.

See also the ‘adaptation’ sections in the checklist for the ‘Advocacy’ topic in this toolkit.

 

Quality improvement

Quality improvement

The success of advocacy, including advocacy e.g. for access to PrEP, depends on many external factors that the CBVCT cannot control. Improving the quality of advocacy therefore means reflecting on the processes and strategies used to advocate on a particular issue. Topics for reflection include the involvement and roles of different stakeholders regarding PrEP, and the advocacy strategy or plan used to progress the issue. 

See also the ‘quality improvement’ sections in the checklist for the ‘Advocacy’ topic in this toolkit. 

 


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Pre-exposure Prophylaxis (PrEP)
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