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South-to-South Learning (Knowledge Exchange Event) Nassau, The Bahamas May 6-10, 2019

On May 6-10, 2019, the PANCAP-K4Health Partnership hosted a South-to-South Learning Exchange in Nassau, The Bahamas. Nine persons participated from three countries namely Guyana, Jamaica and Trinidad and Tobago. Country teams comprised of NAP managers, HIV Clinicians and representatives from Civil Society Organisations (CSO). The main objective of the Learning Exchange was to share The Bahamas HIV model of care focused on their Pre-Exposure Prophylaxis (PrEP) implementation experiences and understanding their process in transitioning to the use of Dolutegravir as an highly efficacious first line HIV treatment regimen.

The Bahamas HIV response

In 2017, The Bahamas reported an adult (15-49 years) HIV prevalence of 1.9% with an estimated 5,300 persons living with HIV and less than 200 annual new infections. Prevalence is significantly higher for men who have sex with men (MSM) at 25% with an estimated population size of 2,085. Regarding the 90-90-90 targets, at the of 2017, The Bahamas reported 68% of persons living with HIV knowing their status, 56% of those who knew their status were receiving antiretroviral therapy, and 69% of those on treatment have achieved viral suppression. Importantly, in pivoting their HIV response, significant gains were made in testing and treating key populations. In 2017, 91% of MSM in The Bahamas knew their HIV status, however only 63% reported condom use. Prevention among this population was strengthened with The Bahamas leading in the implementation of PrEP in the Caribbean.

Engagement with The Ministry of Health

From second left in front row - Permanent Secretary (ag), Mrs Prenell King-Rolle, Cheif Medical Officer (ag), Dr Pearl McMillan, Director of National HIV/AIDS & Infectious Dieases Programme, Dr Nikkiah Forbes

The learning exchange commenced with a brief meeting at the Ministry of Health (MoH) . Dr. Nikkiah Forbes, Director of HIV/ AIDS and Infectious Diseases Programme led the meeting and introduced the Ministry's team which included Acting Permanent Secretary, Ms. Prenell King Rolle, Chief Medical Officer, Dr. Pearl Mc Millian, HIV Clinical practitioner, Dr. Norad Morgan, and other staff of the national HIV response. Dr. Forbes and the MoH team welcomed participants to The Bahamas and expressed the hope for a successful learning exchange. Dr. Forbes shared the objectives of the South to South Learning Exchange and briefly discussed the activities planned for participants. She noted that this will include a mix of didactic sessions on the epidemiology of the HIV epidemic in The Bahamas and site visits to public and community service delivery points. She also noted that participants will be engaged on real time conversations with representatives of civil society organisations and PrEP clients. Dr. Pearl Mc Millian thanked PANCAP for the partnership with The Bahamas Ministry of Health and welcomed all participants to The Bahamas. Participants expressed their enthusiasm in learning from The Bahamas' experience in implementing PrEP.

Expectations and Visioning Boards

Participants worked as country teams- Guyana, Jamaica and The Republic of Trinidad and Tobago. They shared their expectations of the learning exchange, many of which were focused on achieving a greater understanding of PrEP.

Country teams developed visioning boards to provide a snap shot of the status of PrEP in their country focusing on the current status, highlighting the steps to an optimal PrEP programme, including the challenges and opportunities. Republic of Trinidad and Tobago representative from FPATT stressed the importance of capturing and collecting data on key populations that would be important to guide decision making for PrEP. Guyana's presentation focused on identifying key populations outside of Georgetown. The team shared the challenges in identifying and recruiting key populations into HIV prevention and screening services. In this regard, the team highlighted the role of stigma and discrimination, especially from family members. Guyana has established five key populations friendly sites that are centrally located- Georgetown- however emphasized the importance of decentralising the services for wider reach. In Jamaica, there are several Sexually Transmitted Infection (STI) clinics operating daily and treatment is widely available. The team noted that this could serve as the foundation for PrEP implementation. They also highlighted the importance of data and shared their concern around adherence to PrEP.

Some expectations of the participants

Guyana Team working on their visioning board

Jamaica Team putting ideas together for their visioning board

Republic of Trinidad and Tobago representative sharing her visioning board

What is Pre-Exposure Prophylaxis (PrEP)

Pre-exposure prophylaxis, or PrEP, is a way for people who do not have HIV but who are at substantial risk of getting it to prevent HIV infection by taking a pill every day. The pill (brand name Truvada) contains two medicines (tenofovir and emtricitabine) that are used in combination with other medicines to treat HIV. When someone is exposed to HIV through sex or injection drug use, these medicines can work to keep the virus from establishing a permanent infection. When taken consistently, PrEP has been shown to reduce the risk of HIV infection in people who are at high risk by up to 92%. PrEP is much less effective if it is not taken consistently.

PrEP is a powerful HIV prevention tool and can be combined with condoms and other prevention methods to provide even greater protection than when used alone. But people who use PrEP must commit to taking the drug every day and seeing their health care provider for follow-up every 3 months.

Discussions on PrEP

Dr. Nikkiah Forbes provided a background to PrEP in The Bahamas which comprised information on why and how the decision was made to include PrEP in their program, their implementation experiences, lessons learned, challenges faced, and recommendations. Dr. Forbes noted that The Bahamas acknowledged the science on PrEP and recognised the impact of PrEP as a key prevention modality.

Dr. Nikkiah Forbes sharing on background to PrEP in The Bahamas

More on PrEP from the Clinical Team

A clinical PrEP team which comprised of an HIV physician and nurse share the process of initiating and maintaining clients on PrEP. The team noted that at the beginning of PrEP implementation, many clients were registered with the government clinic. This quickly changed as clients were transferred out to private clinics. The PrEP team noted that this was an important lesson learnt since clients are more inclined to access services in the private health sector. In regards to recruitment of clients, the team shared that this is done primarily via direct referrals from CSOs and through contact tracing. Contact tracing is done for each HIV positive patient and negative partners are then evaluated to determine eligibility for PrEP. Participants expressed satisfaction at the high-level of commitment of the PrEP team in recruiting, initiating and maintaining persons on PrEP.

The Client's Perspective on PrEP

Participants had the opportunity to speak with two male PrEP clients – one currently on PrEP and the other, preparing to start PrEP. They shared their journeys to finding out about PrEP, weighing the benefits and risks of starting PrEP and the role of CSOs and health care workers in supporting them to make the decision to start PrEP.

Participants toured the PrEP clinic and were given an overview of the organisation of the clinic and services. The staff emphasized the importance of a high level of privacy and confidentiality of client information.

CSO representatives sharing with the team

Participants interacted with representatives of civil society organisations- Society against stigmatization and hate for HIV and AIDS (SASH Bahamas), DeMarco Foundation, Care to Care, Bahamas National Network for Seropositives (BNN+), United Caribbean TRANS (UCTRANS), Samaritan Ministry and the Broadcasting Commission of The Bahamas. CSO representatives shared highlights of their response and underlined the importance of collaboration with the National AIDS Programme in ensuring HIV health care services can be accessed easily by key populations including PrEP.

Discussions on Dolutegravir

The learning exchange included a session focused on addressing the second 90 – the treatment programme in The Bahamas. Dr. Nikkiah Forbes spoke briefly on Treat All, however focused the discussion on transitioning to Dolutegravir as a highly efficacious first line treatment for HIV. Dr. Forbes provided the evidence behind Dolutegravir, nothing the superiority of Dolutegravir in achieving viral suppression, lower adverse events, greater tolerability. There was significant discussions on the use of Dolutegravir in women of childbearing age and the nuances of family planning in this population. The group also discussed options for second and third line treatment when Dolutegravir is used as first line.

Dr. Nikkiah Forbes speaking on transitioning to Dolutegravir as the first-line treatment regimen

Site Visits

The team paid a site visit to The Bahamas AIDS Foundation, which provides support to approximately 90 children living with and affected by HIV. The organisation implements an after school programme which supplements education activities for school aged children. The organisation also provide psycho-social support and assist with adherence to medication for children who are HIV infected.

Staff from The Bahamas AIDS Foundation interacting with participants

Community Outreach

Participants had an opportunity to witness the operation at an evening community outreach for HIV testing. The response by persons in the community was overwhelming. In approximately one and a half hours, a total of 50 persons were registered and counselled, did their HIV test and received their results with post test counselling. The outreach team also distributed packages containing condoms, lubricants and leaflets with information on HIV/AIDS.

Dr Singh interacting with a health care staff

Demonstration on using a condom

Participant displaying one of the packets that was distributed at the community outreach

Visit to Infectious Diseases (ID) Clinic

Participants visited the infectious diseases clinic at the Princess Margaret Hospital in Nassau. Participants had first hand experience on how the clinic functions and used the opportunity to interact with health care providers from the different areas within the clinic. Participants expressed appreciation for the way in which the clinic was integrated into other out-patient departments of the hospital and noted that this augurs well for anonymity.

Visit to the infectious diseases clinic at Princess Margaret Hospital

Participants visited the National Reference Laboratory and took note on how it was structured as they engaged with the lab staff on HIV testing, access to viral load testing in support of the third 90 and discussed access to genotyping.

Laboratory staff interacting with participants

Sharing of Best Practices

Each County team was given an opportunity to share a best practice from their HIV response.

Guyana focused on extended hours clinic in order to reach key populations- Presented by Dr. Abiola Jacobs, Government Medical Officer, National Care & Treatment Centre

Jamaica focused on a community facilitator’s initiative in support of the third 90 - Presented by Dr Alisha Robb-Allen, Medical Health Officer, Kingston & St. Andrew Health Department

Trinidad and Tobago focused on how they are prioritizing and integrating HIV services through the Family Planning Association of Trinidad and Tobago (FPATT) - Presented by Ms. Angelie Chotalal, Clinic Coordinator

Participants Feedback

Participants were very pleased with the learning exchange and expressed a great appreciation for the site visits and discussions in enriching their learning experience. The following are direct quotes for the way in which some participants voiced their gratitude:

Salima Bacchus, Guyana

“I'm excited to play my role in initiating what was learnt over the 5 days in Bahamas. I think the visit has proven to be invaluable, not only for the information and science provided, but the connections that were developed”

Dr. Rhonda Moore, Guyana

“As I reflect on the last four days here in the Bahamas, one thing resonates with me, more than the model of care, which by the way is almost identical to that of Guyana, is the dynamic, highly dedicated team. This team does whatever it takes to get the patients the care they need".

Dr. Alicia Webster, Jamaica

“ As a pioneer for Pre-exposure Prophylaxis (PrEP) for HIV in the Caribbean the Bahamas has paved the way for developing a strategy that could be emulated by other Caribbean countries.”

Beyond the South-to-South Learning Exchannge

Work plans for each country will be finalised and shared . PANCAP will conduct periodic three-month follow up after the event to check on the progress with implementation. Webinars will be hosted and shared to update the partnership on PrEP in the Bahamas, and participants will also have an opportunity to share their experiences, lessons learned and implementation plans for their country programme.

Thank You

Thank you to all of the learning exchange participants for their engagement! A special thanks to Director of National HIV/AIDS & Infectious Dieases Programme, Dr Nikkiah Forbes for facilitating a successful learning event where country teams benefited from the valuable information on The Bahamas' journey on the implementation of PrEP which could assist them in rolling out new activities like PrEP and Dolutegravirin in their individual country program.

Participants capturing a photo op with Dr Nikkiah Forbes
www.pancap.org

www.K4Health.org

This publication is made possible by the support of the American People through the President’s Emergency Plan for AIDS Relief (PEPFAR) and the U.S. Agency for International Development (USAID) under the Knowledge for Health (K4Health) Project (AID-OAA-A-13-00068). The contents of this publication do not necessarily reflect the views of the U.S. Government, PEPFAR, USAID, or K4Health.

Photography & preparation of report: N. DeNobrega

Credits:

Created with an image by Allen Dewberry Jr - "untitled image"

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