Challenges for Reaching Younger and More Vulnerable MSM

Challenges for Reaching Younger and More Vulnerable MSM and Transgender People Carlos F. Cáceres, MD, MPH, Ph. D

Background • While Pr. EP implementation is moving forward, the pace is still slow – As a preventive intervention, Pr. EP roll-out is not so simple • Making Pr. EP accesible to all those who need it represents a challenge • Who needs Pr. EP? – WHO: All those at substantial risk: Individual prescription vs. public health program – Concentrated epidemic: Groups with HIV incidence > (2 -)3%/yr • Are all members of those group in need? • Implementation in the public sector is an important step – Im. Pr. EP intends to demonstrate its larger-scale feasibility in Latin America • Does implementation in the public sector and a focus on high incidence groups per se guarantee access? • What are the best measures of access?

Our Purpose Here • Quick, Preliminary Review of Enrollement Profiles at Im. Pr. EP – Age, race/ethnicity, educational attainment, gender, sex work, condomless sex with HIV+ partner, use of alcohol and drugs, STIs, reason to visit the site, Early Continuation • Discussion of Differences across Countries • Continuation in Pr. EP: Critical aspect of access • Ideas for further observation/analysis and action

Percentage of Im. Pr. EP Participants who are Transwomen* Percentage of Enrolled participants 16% 14% 12% 10% 8% 14, 4% 6% 4% 6, 3% 2% 4, 5% 1, 8% 0% BRAZIL *The difference is MSM MEXICO PERU TOTAL

Age Distribution among Im. Pr. EP Participants 18 -24 25+ 100% Percentage of Enrolled participants 90% 80% 70% 63, 6% 75, 7% 83, 5% 74, 2% 50% 40% 30% 20% 10% 36, 4% 24, 3% 16, 5% 25, 8% 0% BRAZIL MEXICO PERU TOTAL

Educational Level among Im. Pr. EP Participants less than secondary/secondary more than secondary 100% Percentage of Enrolled participants 90% 80% 70% 63, 5% 79, 1% 76, 7% 85, 8% 50% 40% 30% 20% 10% 36, 5% 20, 9% 26, 3% 14, 2% 0% BRAZIL MEXICO PERU TOTAL

Race/Ethinicity/Skin Color Distribution among Im. Pr. EP Participants White TOTAL PERU non white 35, 5% 64, 5% 10, 0% MEXICO 90, 0% 16, 1% BRAZIL 83, 9% 48, 1% 0% 10% 20% 30% 51, 9% 40% 50% 60% 70% Percentage of Enrolled participants 80% 90% 100%

Age Group, Educational level and Race/Ethinicity/Skin Color among Im. Pr. EP Participants Race/Ethinicity/Skin Educational level Agre Group Color 100% Percentage of Enrolled participants 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% BRAZIL MEXICO PERU TOTAL 18 -24 age 25+ age 24, 3% 16, 5% 36, 4% 25, 8% 75, 7% 83, 5% 63, 6% 74, 2% Less than secondary/secondary 20, 9% 14, 2% 36, 5% 26, 3% More than secondary 79, 1% 85, 8% 63, 5% 76, 7% White Non white 48, 1% 16, 1% 10, 0% 35, 5% 51, 9% 83, 9% 90, 0% 64, 5%

Condomless Anal Sex and History of Sex Work among Im. Pr. EP Participants TOTAL Sex workers Condomless anal sex 13, 78% 91, 1% PERU 25, 50% MEXICO 94, 5% 14, 07% BRAZIL 90, 8% 9, 84% 90, 1% 0% 10% 20% 30% 40% 50% 60% 70% Percentage of Enrolled participants 80% 90% 100%

Condomless Sexual Intercourse with HIV+ Partners among Im. Pr. EP Participants Yes 20, 7% 25, 2% 10, 6% 34, 1% 32, 9% 21, 5% 0% 10% 51, 1% 24, 2% 40, 7% 22, 5% 20% 30% 5, 7% BRAZIL 49, 1% 2, 2% MEXICO NA 4, 2% PERU Don´t know 4, 6% TOTAL No 50, 3% 40% 50% 60% 70% 80% 90% 100%

Binge Drinking, Stimulant Use, Report of Prior STIs and Syphilis at Enrollment among Im. Pr. EP Participants BRAZIL 80% Percentage of Enrolled participants 70% MEXICO PERU TOTAL 74, 6% 65, 2% 62, 0% 66, 7% 60% 54, 3% 50% 40% 30% 21, 1% 26, 0%25, 6% 23, 4% 22, 0% 23, 3% 20% 11, 0% 10, 4% 10, 2% 10, 0% 3, 8% 0% Binge drinking Stimulants* *Stimulant drug use as use of cocaine, amphetamines, or club drugs �vdrl title >=1: 8 Prior report STI Syphilis at enrollment �

Early Continuation in Im. Pr. EP Early continuation Medication Possession Person years (PY) of Ratio (MPR) >= 0. 53 observation Brazil 85. 4% 98. 7% 1438. 6 Mexico 84. 0% 98. 0% 344. 0 Peru 52. 7% 91. 0% 286. 4 Overall 79. 6% 97. 2% 2069. 0

Ideal Recruitment • Reach socially excluded groups – Young people, transwomen, less educated, non-White • Reach those at highest risk – Sex workers, non-condom users, history of STI, alcohol/drugs • Achieve high continuation rates

Recruitment Outcome to Date • Considerable differences across countries • Compared to Brazil and Mexico, Peru seems to have reached: – More individuals from socially excluded groups – More individuals at highest risk • However, continuation rates much lower in Peru • Does this mean that socially excluded individuals at highest risk will always perform in this way if recruited?

Reason to Visit the Sites among those Enrolled in Im. Pr. EP TOTAL Looking for Pr. EP Others PERU 86, 3% 13, 7% MEXICO 49, 7% 96, 2% 3, 8% BRAZIL 50, 7% 96, 0% 4, 0% 0% 10% 20% 30% 40% 50% 60% 70% Percentage of Enrolled participants 80% 90% 100%

Intention to Use Pr. EP Prior to Enrollment • Our analysis is still preliminary/as enrollment profile is ongoing and changing over time – statistical analysis will follow • However, it seems that: Ø Lack of prior intention to use Pr. EP may be a critical predictor of discontinuation in Pr. EP, and yet Ø Factors such as younger age, lesser education, transgender identity and other conditions of social exclusion may also predict discontinuation Both typs of factors converged in the early simple in Peru • More than the outcome of a specific enrollment strategy, the early enrollment profile in Peru seems an artifact of the history of the HIV program (i. e. STI clinics linked to VD control of SW) • Individuals may consent to enrollment out of social

Preliminary Lessons • Pr. EP is effectively implemented if people enroll and continue using it during their eligibility. • To effectively reach those most vulnerable: – Increasing access to health care is critical (times, cost, friendliness, flexibility)… – …but individual/community preparedness (information, demand creation, support) is also paramount. – It is not enough to have them enrolled – they may need more support to remain in the program. • Community education at all levels on Combined HIV Prevention and Pr. EP, as well as support of those enrolled, should be a priority in Pr. EP Roll-Out

Thank you! Gracias! Obrigado! Carlos. caceres@upch. pe Im. Pr. EP Sponsors Support