Demedicalized delivery of PrEP possible, improves access

A peer-led demedicalized delivery of same-day HIV pre-exposure prophylaxis (PrEP) in various community centres is feasible, suggests a Philippines study presented at the recent IAS 2023.

“This mechanism promotes task-shifting, showing that peers can provide PrEP at scale to high-priority populations,” said the researchers, led by Jan Dio Miguel Dela Cruz from LoveYourself, Mandaluyong City, Philippines. “This evidence also empowers nonmedical providers through a guided approach.”

LoveYourself is a network of community clinics that provides HIV screening and PrEP through a peer-led approach. Challenges observed in their clinics were delay in PrEP initiation due to long queues for medical consultation, long turnaround time of test results for serum creatinine, hepatitis B screening, and hesitancy of clients who use gender-affirming hormone therapy or body-building supplements.

To address these challenges, the researchers explored the program shifting PrEP delivery to trained peer counsellors known as PrEPPY Peers. An algorithm was developed to guide PrEPPY Peers in providing same-day PrEP and when to refer clients to a physician.

In addition, counsellors underwent training on assessment of HIV nonreactive clients with no symptoms of acute retroviral syndrome within 30 days, age 18‒50 years, body weight of 35‒90 kg, kidney-related comorbidity, and supplementation. They also trained to compute creatinine clearance and to teach about follow-up care.

An on-call physician was present for any urgent referral and to check the quality of all charts submitted by the PrEPPY Peers. All PrEP-naïve clients were advised to take PrEP daily for at least 3 months before considering an event-driven use to monitor recent exposure and possible seroconversion.

As a result, demedicalizing PrEP increased client enrolments from an average of 568 in Q3 2021 to 1,256 in Q2 2022. In total, the clinic had 7,134 enrolled individuals by the end of December 2022. [IAS 2023, abstract 3166]

Online PrEP service

These findings supported those of another study that activated an all-virtual, community-led and demedicalized PrEP service for men who have sex with men (MSM) in the Philippines.

A total of 230 individuals were initiated on PrEP between August and April 2023, translating to 10.44 percent of 2,203 clients who reported HIV-negative via the all-virtual HIV self-testing process. Of these, 100 (43.48 percent) completed the first monthly visit, with 92 clients taking PrEP daily. [IAS 2023, abstract 5947]

“This program provides evidence that an all-virtual, community-led and demedicalized PrEP approach integrated with unassisted HIV self-testing is possible,” the investigators said. “Further demand-generation and other offline-based key-population-friendly activities will be done to increase awareness and enable access to more clients.”

This study, led by John Danvic Rosadiño from LoveYourself, offered PrEP to interested MSM clients who reported HIV-negative in an online unassisted HIV self-testing program. A blood-based self-test kit was delivered to their address, with instructions-for-use and result reporting.

If the results turned out nonreactive, a self-assessment tool was then sent to determine their sexual behaviour, as well as the presence of any of the following: acute retroviral syndrome, kidney-related morbidity, and supplementation. Trained community peers would validate these data and provide PrEP information and counselling via telemedicine.

Upon assessment and confirmation of eligibility, clients would receive one PrEP bottle, another self-test kit, and a QR code for their refill instructions.

“Since its introduction in 2017, the uptake of PrEP in the Philippines has reached more than 10,000 individuals,” the investigators said. “Barriers in PrEP uptake include challenges to service access, further highlighted by limited mobility caused by COVID-19.”