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Implementing preexposure prophylaxis among key populations: an opportunity for patient-centered services and management of hepatitis B

Implementing preexposure prophylaxis among key populations: an opportunity for patient-centered services and management of hepatitis B
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  D ownl    o a d  e d f   r   omh  t    t     p s :   /    /     j    o ur  n al    s .l   ww. c  om /    ai    d  s  onl   i   n e b   y B h DMf    5  eP HK  av 1 z E  o um1  t    Qf   N4  a+ k   J  L h E Z   g b  s I   H o4 X Mi    0 h  C   y w C X 1 A WnY  Q  p /   I   l    Qr  HD 3 I    J  r   t   B K  u S  s  QV MH 9  QN2  b P  QP L 1  G S  S  u o Qf   l    oDZ  5 k   6 f    aw U1 w= on 0 4  /   2  6  /   2  0 1  8  Correspondence  AIDS  2018,  32 : 829–833 Implementing preexposure prophylaxis among key populations: an opportunity for patient-centered servicesand management of hepatitis B When taken properly, Tenofovir-based oral preexposureprophylaxis(PrEP)hasbeenproventobeefficienttopreventHIVacquisition [1–5]. Since 2015, PrEP is recommendedbytheWHOfor populationsat‘substantialrisk’ofHIV[6].However,WHOpointsouttheneedforadditionalresearchon PrEP in ‘real life’ on questions such as demand creationfororal PrEP; best delivery models indifferent contexts andfor different populations; social and behavioral impact of PrEP;orintegrationofPrEPserviceswithotherservices[6].Transitioningfromefficacytrialstoimplementationrequiresto adapt interventions. Preliminary research (ANRS 12361PrEP-CI [7]) has been conducted in Coˆte d’Ivoire (CI) incollaboration with community non-governmental orga-nizations to explore relevance and feasibilityof implement-ing a PrEP program among female sex workers, one of themost exposed populations countrywide (estimated HIVprevalence: 29% [8]). The following observations emergedfrom that collective work.AllefficacyPrEPtrialsprovidedarangeofsexualhealthcareservices in addition to PrEP drugs [9–11]. Such servicesappeared essential for any PrEP program. By design, theywere conditionaltoPrEPuse. However,regardless oftheir interest in using PrEP, female sex workers interviewed inCoˆte d’Ivoire, and more broadly key populationsworldwide [12–16], have many unmet sexual andreproductive health needs: sexually transmitted infectionsscreening and care, contraception and birth control,menstrual management, addictions and risky behaviors . . . When transitioning to real life, we should not reproducethe service model of efficacy PrEP trials, that is a PrEPprogram with additional services. Instead, a paradigm shifttoward a patient-centered approach should be preferred,that is offering sexual and reproductive health services inwhich PrEP is an option but not mandatory.In Western and Central Africa, the prevalence of hepatitisB is relatively high [17]. In Cote d’Ivoire, more than 11%of new blood donors were positive for hepatitis B surfaceantigen in 2008–2012 [18]. Tenofovir is also used for hepatitis B treatment. But, currently, treatment is not freefor monoinfected hepatitis B patients, whereas it iscovered by AIDS programs for HIV-hepatitis B coin-fected patients. In such context, it would be ethicallyunacceptable to provide free HIV PrEP without takinginto account patients in needs of hepatitis B treatment.Actually,for thosepatients,offeringTenofovir-basedHIVPrEP constitutes an opportunity to simultaneously treattheir hepatitis B. It requires to integrate WHOrecommendations on hepatitis B [19] within PrEPguidelines [20], possibly to simplify hepatitis B carealgorithms and to allow hepatitis B care in decentralizedsexual health clinics and not only in hospital services.Most efficacy PrEP trials excluded hepatitis B patients.Additional clinical research exploring interactionsbetween HIV PrEP and hepatitis B treatment, inparticular the risk of flare if PrEP is stopped, is required.PrEP programs could be built on the existing communityservices for HIVcare and treatment.Providingservicesfor HIV positives and HIV negatives within the same clinicscould be a way of minimizing the stigma associated withentry and retention into HIV care. In addition, HIVpatients have unmet sexual and reproductive health needsaswell.IntegratingservicestogetherandtransformingHIVclinics into sexual health clinics could lead to many healthoutcomes improvements and also to possible cost sharingand savings.So far, the focus of HIV programs has mainly been onreaching individuals never tested for HIV, identifying newpositives and linking them to HIV care and treatment.Transitioning PrEP from trials to implementation con-stitutes an opportunity for developing people-centeredapproaches integrating all sexual and reproductive healthservicestogether,includinghepatitisB.Itiscrucialtoavoida silo-based perspective in which services are separatedfrom each other. Moving from HIV care clinics to sexualhealthclinicswouldallowtogloballyimprovethehealthof key populations and their partners, beyond HIVoutcomesalone. To ensure the success of new prevention programs,we have to take the next step forward. Beyond biomedicalinnovations, innovations in terms of intervention imple-mentation, delivery models and public health policies areurgentlyrequired[21],inparticularinWesternandCentralAfrica [22]. Scaling-up PrEP is a key moment. We shouldnot miss out on this opportunity. Acknowledgements The PrEP-CI ANRS 12361 was funded by the Bill andMelinda Gates Foundation and the French NationalAgency for AIDS and Viral Hepatitis Research (ANRS).Author contributions: J.L. and V.B. wrote the article. Allauthors contributed to the interpretation, reviewed thearticle and approved the final version of the article. Conflicts of interest There are no conflicts of interest. ISSN 0269-9370 Copyright  Q  2018 The Author(s). Published by Wolters Kluwer Health, Inc. This is an open access article distributed under theCreative Commons Attribution License 4.0 (CCBY), which permits unrestricted use, distribution, and reproduction in any medium, provided thesrcinal work is properly cited.  829   Joseph Larmarange a  , Valentine Becquet  a  , Jean-MarieMasumbuko b  , Marcellin Nouaman b  , M   elanie Plazy  c   ,Christine Danel  b and Serge Eholi   e b  ,  a Centre Popula-tion et D  eveloppement, Institut de Recherche pour leD  eveloppement, Universit   e Paris Descartes, Inserm,Paris, France,  b Programme PAC-CI, Abidjan, Coˆ ted’Ivoire, and   c Bordeaux Population Health ResearchCenter UMR 1219, ISPED, Universit   e de Bordeaux,Inserm, Bordeaux, France.Correspondence to Joseph Larmarange, PhD, CentrePopulation et D  eveloppement, Universit   e Paris Des-cartes, 45 rue des Saints-Pe` res, 75006 Paris, France.E-mail: joseph.larmarange@ceped.org Received: 22 December 2017; accepted: 5 January 2018. References 1. 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