Background
The World Health Organisation (WHO) defines oral pre-exposure prophylaxis of HIV infection (PrEP) as the use of antiretroviral (ARV) drugs by people who do not have HIV infection in order to prevent the acquisition of HIV and recommends that people of substantial risk should be offered PrEP. WHO recommends offering PrEP to all population groups at substantial risk of HIV infection. PrEP is considered a key prevention modality and should be an additional prevention choice in a comprehensive package of services that also includes HIV testing, screening and management of sexually transmitted infections, counselling, male and female condoms, lubricants, ARV treatment for partners with HIV infection, voluntary medical male circumcision and harm reduction interventions for people who use drugs.
In the English-speaking Caribbean, only The Bahamas and Barbados have developed and implemented PrEP programmes. In both cases, this was done in close collaboration with civil society organisations and in the case of The Bahamas, with the private health sector. Both countries have at least one year of implementation experience and are ready to share lessons learned that are beneficial and can potentially be applied in other Caribbean countries.
The PANCAP Coordinating Unit (PCU), with funding under the CARICOM-Global Fund Project- Removing Barriers to accessing HIV and Sexual and Reproductive Health Services for Key Populations in the Caribbean - convened a PrEP Share Fair on 16-17 July 2019 in Bridgetown, Barbados. This Share Fair built on the south to south learning exchange to The Bahamas which was focused on understanding lessons learned that can be applied in Guyana, Jamaica and Trinidad and Tobago.
Objectives
The primary objective of the PrEP Share Fair was to increase NAP managers, clinical practitioners, civil society organizations (CSO), and other stakeholders’ understanding of the process for rolling out PrEP programs. Within that, there were specific objectives to:
- Facilitate participants’ understanding of the role of the NAPs and civil society organizations in the design, implementation, and monitoring of PrEP programs.
- Increase participants’ understanding of the collaboration that is required among NAP managers, CSO representatives, and other stakeholders to design, implement, and monitor PrEP programs.
- Enable participants to understand the factors that facilitated Barbados’ design, implementation, and monitoring of its PrEP program, as well as the challenges.
- Identify lessons learned in the design, implementation, and monitoring of Barbados’ PrEP program and how these can be applied to different countries.
- Share country experiences on the status of their planning for, and implementation of PrEP.
- Enable participants to become familiar with the WHO PrEP Toolkit.
- Develop country specific work-plans with time-bound action items to advance PrEP in the respective countries.
Participating countries
Antigua and Barbuda, Barbados, Belize, Dominica, Grenada, Guyana, Saint Lucia, St. Kitts and Nevis, St. Vincent and the Grenadines, Suriname and Trinidad and Tobago
Welcome
Mr. Dereck Springer, PANCAP Director welcomed participants to the Share Fair, noting that this was building on several initiatives such as the most most recent concluded South to South Learning Exchange to The Bahamas. Mr. Springer encouraged participants to maximise the learning and sharing
Fundamentals of PrEP
Dr. Uri Belkin, Clinical Assistant Professor, Department of Pediatrics, NYU School of Medicine, Associate Medical Director, Adolescent Medicine and Clinical Director, Health Outreach to Teens (HOTT), Callen-Lorde Community Health Center in New York presented on the fundamentals of PrEP – first providing the basics of what PrEP is and its utilization as a preventative measure against HIV. He shared the evidence and research of the highly effective drug, when taken as prescribed and touched on daily versus event-drive PrEP, or PrEP on demand. He also provided suggestions on how to counsel clients who may be candidates for PrEP and suggested that the current framing and communication of who PrEP is intended for should be considered, to not continue to contribute to the stigma that is associated with people who take PrEP or are considering taking PrEP. Dr. Belkin also shared the new strategies for PrEP such as Event Driven PrEP or PrEP on Demand noted that WHO will endorse this strategy at the International AIDS Society Scientific Conference in Mexico City on July 21-24.
Ms. Sandra Jones, led a session on WHO’s PrEP Toolkit. She provided an overview of the toolkit’s modules and how they can be used to implement PrEP in the region, for example using Module 4 for Leaders to assist in advocating at the policy level.
PrEP implementation experiences
Dr. Anton Best shared Barbados experience with rolling out their PrEP program. He explained the barriers and challenges in implementation and made recommendations for overcoming those. He emphasised the importance of integrating PrEP within the health care system and discouraged the establishment of stand- alone PrEP programmes. He posited that integration will not require significant additional resources and can be leveraged as a strength in advocating for PrEP with policy makers.
Dr. Nastassia Rambarran shared the PrEP implementation experience from the perspective of the civil society partner, Equals. She spoke about the lead-up to implementation and how the process works within Equals and in partnership with the Ministry of Health and Wellness. She emphasised the importance of collaboration from the earliest planning phases and throughout implementation.
Advocacy for PrEP
Dr. Anton Best emphasized an important factor for Barbados’ advocacy – he did not request or require additional resources to start the PrEP program – rather he used innovative service delivery models and relied on existing budget resources. Mr. Dereck Springer recommended identifying and seeking country champions – for example, First Ladies. He encouraged participants to stay current with knowledge and evidence so as to effectively advocate with policy makers. Ms. Sandra Jones shared the different ways that PAHO can support countries in rolling out their PrEP programs – by advocating at the regional level, assisting in advocating at the national level through the local PAHO representative, supporting in-country training, and putting together a generic policy brief and generic guidelines that can be adapted to each country. Mr. Anderson Langdon, Executive Director, Barbados Family Planning Association spoke about advocacy approaches and the importance of knowing and understanding your role in the advocacy space. He encouraged civil society to know the evidence on PrEP as this is important for them to be taken seriously by governments and policy makers and be counted as an equal voice at the table.
Site Visits
On the afternoon of the first day, participants visited the two sites working together in offering PrEP in Barbados – the Ladymeade Reference Unit and Equals. At each stop, they were given an overview of what occurs at each site and how the two sites work together. They were given a tour of the space and had the opportunity to ask questions to the program managers. Participants shared that they were really impressed with how the two sites worked together and provided a harmonized experience for those seeking PrEP. One participant noted, “The site visit demonstrated the importance of institutions working together – a healthy relationship can get a lot of things done.”
Fish bowl
On the second day, five people participated in a fish bowl exercise – two clients on PrEP, Dr. Tiffany Jordan, Physician, LadyMeade Reference Unit, Nurse Charmaine Ray, Nurse, Ladymeade Reference Unit, and Remington Forde, Outreach Worker, Equals. The Knowledge Coordinator, Dr. Shanti Singh- Anthony who explained the Fish Bowl as a KM methodology and facilitated the session. This experience provided a more intimate view into how and why a person decides to get on PrEP and the lessons that have been learned by healthcare providers in navigating clients to PrEP. It allowed participants to make the connection from policy to PrEP delivery at the community and client levels.
Team Collaboration
Participating country teams were given the opportunity to share their PrEP stories. As part of the visioning board exercise, countries developed their road-map to rolling out PrEP, highlighting and sharing opportunities and challenges to implementing PrEP in their individual countries. Participants then used the visioning board to develop and present a workplan of activities that they will use to continue to or start to implement PrEP on returning to their countries. Limited buy in policy makers and lack of capacity to plan, implement and monitor PrEP programmes were issues affecting most programmes. At the level of the National AIDS Programme and civil society, there was great enthusiasm to advance the current PrEP narrative in countries. Country specific work plans were developed. These will be combined to produce one Regional work plan.
Thank you
PANCAP expresses sincerest thanks to Dr. Anton Best , Dr. Dale Babb, Dr. Tiffany Jordan, Nurse Charmaine Ray and other staff at the Ministry of Health and Wellness, Barbados and Mr. Michael Rapley, Dr. Nastassia Rambarran and staff of Equals Barbados for collaborating with PANCAP team to to plan and implement the Share Fair. Thanks to the planning committee- Dr. Anton Best, Dr. Nastassia Rambarran, Dr. Giovanni Ravasi, Dr. Dale Babb, Ms. Sandra Jones and Ms. Elizabeth Tully for providing technical expertise in defining the content and agenda. A special thanks to all participants for their meaningful participation.
This publication is made possible by the Pan Caribbean Partnership Against HIV and AIDS ( PANCAP)
Credits:
Elizabeth Tully