Overview of the WHO guidelines on implementation of PrEP for adolescents as part of SRHR

1. Overview of the WHO guidelines on implementation of PrEP for adolescents as part of SRHR Maeve Brito de Mello, BSc, PhD Regional Advisor for HIV/STI Prevention

2. Outline Overview of WHO guidance on PrEP for adolescents and young adults Identifying who may benefit from PrEP Clinical considerations Improving access to PrEP: Addressing health system, regulatory barriers and integration of services Making PrEP practical, accessible and impactful Implementation challenges Conclusions

3. Pre-Exposure Prophylaxis (PrEP) • Epidemiology of HIV among adolescents and young adults • Factors influencing HIV susceptibility among adolescents and young adults • Identifying adolescents and young adults who may benefit from PrEP • Clinical considerations • Improving access to PrEP among adolescents and young adults: Addressing health system and regulatory barriers • Making PrEP practical, accessible and impactful • Monitoring PrEP utilization among adolescents and young adult Oral PrEP (containing TDF) should be offered as an additional prevention choice for people with substantial risk* of HIV infection as part of combination prevention approaches (strong recommendation, high quality evidence)

4. Which young people should have access to PrEP? Adolescents and young adults What do WHO recommendations mean in practice?

5. Policies & norms; Existence or not of high quality, accessible, acceptable, affordable, effective and stigma-free health services for youth PrEP in the context of vulnerabilities and the rights of adolescents and youth maximum vulnerability Age group, sex, gender identity, sexual orientation, educational level, knowledge, values, beliefs, sexual practices, etc. Vulnerability related to the programs Punitive or protective laws for youth; Gender, racial, ethnical, intergenerational relations; Access to employment, education, housing, justice, etc. High High High Intermediate Intermediate Intermediate Individual vulnerability Low Low Low 1992 Social vulnerability “V0”=minimal vulnerability

6. Clinical Considerations Monitoring adverse outcomes bone mineral density (BMD), kidney function, weight loss, condom use (risk compensation) Diagnosing & treating STIs and other co-morbidities (mental illness, substance use) Uptake, adherence and retention on PrEP “The Food and Drug Administration approved revisions to the Truvada (emtricitabine and tenofovirdisoproxil fumarate) labeling to expand the Pre-Exposure Prophylaxis (PrEP) indication to include adolescents weighing at least 35 kg who are at risk of HIV-1 acquisition.”

7. Cumulative PrEP Enrolment, KenyaFeb 2017 – Mar 2018 PrEP Uptake, Viet Nam May 2017 – September 2018

8. Overall Retention, Thailand (n=1,697)

9. “service providers expressed concerns that the availability of PrEP would lead to sexual disinhibition and a reduction in condom use among adolescents” Poor adherence was associated with decreased efficacy in all PrEP trials: • Individual-level barriers include limited familiarity with ARV-based prevention, stigma, product storage, and social support • Structuralchallenges include healthcare financing for PrEP • Clinicianacceptability and comfort with PrEP delivery • Limitedyouth-friendly health services available Giovenco D et al. “The Time Has Arrived”: Perceptions of Behavioral Adjustments in the Context of Pre-Exposure Prophylaxis Availability Among Adolescents in South Africa. AIDS Education and Prevention (30):6, 463-473, 2018. Canada, 2015 Summarized by Gray ME, Shenoi SV, Dillingham R. Pre-exposure Prophylaxis as HIV Prevention in High Risk Adolescents. J PediatrPediatr Med. 2018;2(1):5–10.

10. Review of Interventions to Improve Uptake, Adherence and Continuation of Oral Contraceptives Among Youth Source: Velloza et al., unpublished

11. Improving access to PrEP:Addressing health system, regulatory barriers and integration of services Decreasing ethical, legal, and policy barriers aligned with the CRC age of consent to access SRHS, HTS, ART, PrEP legal reporting requirements partnership with Justice Eliminating licensing and regulatory constraints Training health providers Providing age-appropriate, culturally competent counseling and services Improving awareness and reducing providers and communities misconceptions

12. Integration of services Health services often used by sexually active adolescents and young adults, for example: HIV testing and partner notification services antenatal and postnatal care family planning services STI clinics ART for people in serodiscordant relationships gender-based violence services voluntary medical male circumcision clinics health services of tertiary education institutions specific services for young people mobile health clinics near educational establishments sites offering health services for KP

13. Making PrEP practical, accessible and impactful • Creating demand for PrEP • Age-appropriate channels • Sex-positive approaches • Address a set of stigma associated with PrEP • Myth-busters • Counseling and adoption of group-engagement interventions to increase risk perception and reduction

14. Conclusions • Individual, programmatic and social vulnerabilities to HIV infection are intertwined and needs to be addressed as such • PrEP should be seeing in the context of SRHS rights • The lack of autonomy of adolescents are applicable to all SRHS, including HTS and PrEP, and the removal of legal and normative barriers needs to be addressed in a broader context beyond MOHs • Given the current low number of PrEP studies and real life implementations with adolescents, operations research to guide more effective strategies to improve uptake, adherence and retention are urgently needed • Integration of PrEP into existing acceptable services for adolescents may leverage its uptake and sustainability • Monitoring and evaluating implementation is key • But most of all, lets no repeat the same error….

16. Acknowlegments:- Shona Dalal (WHO)- Giovanni Ravasi (PAHO)- InêsDourado (UFBA) Thank you!