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Good evening, everyone. Welcome to today's Stash webinar. My name is Tony Masters. I'm one of the ST education reps. And just before we start this evening's event, I just want to make everyone aware of a bash recruitment survey. So Bash are the British Association for Sexual Health and HIV. And they're just starting a big recruitment drive um to push gum as potential future career and they're really keen to get everyone's um sort of thoughts and opinions on how they view gum as a specialty. So I'm gonna pop the link into the chat and it would be great if everyone could get a chance to complete that at some point over the next couple of days, I think it's open for the rest of this week. So I'll put that into the chat now and I'm just gonna hand over to Grace, who's my co-chair for this evening to present herself and the speakers. Hi. Um I'm Grace. I'm the local ambassador for Newcastle University. Um Tonight, our talk is by Doctor Simon Dey who is a GU registrar in the East mid east Midlands. He has a special interest in global sexual health with a background in public health. He is currently working out a program in on a project about prep delivery in rural communities. We're also joined by doctor Miriam Rsha who is a sexual health and HIV register stress trainer in Brighton. She completed medical training in 2019 and spent the following four years doing a deployment in medicine and hygiene and volunteer as a doctor in a clinic in Sierra Leone and working on a variety of register fellows in renal geriatrics, stroke and respiratory. Before starting ST four disorders, she spent six months in managing a project, a increase in HIV, private education and uptake as part of an improving Global Health Fellowship in NHS England. Um and also a reminder to complete the feedback form at the end so you can get your certificate. Good evening everyone. Thank you so much for that wonderful introduction and thank you to the ST committee for inviting us to speak this evening. Er Miriam and I have both been involved in the same prep project that is currently running in the soho. I'm extremely grateful to spread the good word about the fantastic hard work that is being done on project prep, but also across the U. So given that stash is about encouraging careers in gum, I'm gonna hope briefly start with my career path and how I got into gum. Then we'll get right on to the heart of the matter, set the scene of HIV and S TI S in the U. We'll go on to discuss some of the challenges of delivering prep in Southern Africa and also how project prep is trying to overcome these. And hopefully if everybody isn't asleep and if my internet holds are, we can do a bit of AQ and A at the end. So taking right me right back to the start of my medical career, I went to medical school in Nottingham. Absolutely loved it. But unfortunately, didn't get really much exposure to Goman medical school, which is quite common for medical trainees. I did an academic foundation in East Midlands and then after foundation took some time out, uh locum travel, bought a flat but most importantly, assessed my career options and had a real think about what I wanted to do and I've added an estate, a completely superfluous photo of me sat at the edge of the Grand Canyon thinking about my medical career. Then I took a bit of a sideway step and I worked as a public health registrar on the public health training program for a while. And that's what I sort of like put down to explore my options of my career. I loved that public health was really interesting. However, eventually I realized that I missed patients too much and I came back under clinical medicine, uh which when retrained in what was CMT and is now I mt with the thought of probably doing possibly ID during that time, worked through membership, worked through COVID like most of us, but I was really lucky enough to have the time to work on microbiology. Again. Loved it really interesting. But I realized just like public health where my heart l was with patient facing medicine. That's when I found out about gum and I realized gum is fantastic. So for me, gum was the perfect nexus point of like all the specialities that I loved. So it was about public health. It was about the HIV from infectious diseases, a bit of a lot of microbiology, but also as well, all the other specialities that I love, dermatology, gynecology and there's loads more that I could list on. I was really lucky. Got onto the training program first time, got to stay in the East Midlands and uh like then and probably now gone remains undersubscribed. So I'd encourage everybody on the, on the call that's thinking about it. Absolutely. Get in there where it's not competitive. Um I biased and I think is a fantastic speciality. It's got a mixture of detail orientated HIV patients with long term relationships. But then also as well, it's got the contrast of fast paced turnover of the General Gum Clinic where you're seeing lots of patients quite quickly. Well, I've been a common trainee, I've been really lucky cos I've had a supportive training program director that's allowed me to take some time out of program both last year to do my diploma in tropical medicine. But also this year to take to work on project prep and au the project that I keep talking about has been through the NHS Improving Global Health Fellowships um that have just rebranded because NHS England has moved into the NHS and they're now called the Quality Improvement Fellowships. If anybody is interested in this opportunity, the current round of equipment for this August is starting pretty much now. So I would encourage them to check out this website as soon as possible after this talk. So back to the topic at hand, sexual health in the low and middle income setting, and most specifically in the suit room. So to try and set the scene a bit, Lesotho, you probably need to look it up on a map. It's a small landlocked country completely on the side, Southern Africa. So it's an enclave and it's extremely mountainous. So it's a very high altitude. The lowest altitude in the country is 1400 m above sea level. It's the only independent country in the world with its entire altitude above 1000 m above sea level. But why am I banging on about geography? Well, it provides unique challenges for healthcare delivery. As you can imagine, places like this have limited access by road. Patients can travel large distances and long lengths of time just to access healthcare. So it can be quite problematic. The country is relatively new. It was founded in the 19th century. And it remained independent until it became a British protectorate and then gained its own independence from Britain in 1966. The result of this time under British control was that it has got a strong British influence in the way that it organizes its healthcare system. And then it's been a bonus for me. English has spoken quite widely throughout the country alongside the national language of soho. In terms of how the country governs itself, it's got a constitutional monarchy um just like the governmental system similar to the UK. But what I would add is that like several African nations is politically much less stable than the UK. And this political instability can often make it quite difficult to secure long term funding for health improvement projects and issues with corruption in the political system, particularly procurement can hinder capacity building of the healthcare system in a small country. Lesotho is a poor country other than water. It's got a few natural resources. Um And according to data from the World Bank this year, it's estimated that 33.9% of the country is living below the international poverty line. What that means is less than 1 lb 80 per day per person to survive. Think about what you could get in the hospital canteen for 1 lb 80. I don't think it will go very much further than a ketchup packet. Lesotho's economy cannot be sustained independently without the the benefits that it derives from so South Africa to closest neighbor, which it forms a customs union where large numbers of economic migrants move uh back and forward across the border on a daily basis. Because of that, it's quite difficult to maintain long term health care relationships with people. Because these migrants are moving back and forward for work. The migrants themselves often act as facts of infectious disease, driving the high rates of HIV between the two countries. And then also as well. We know that economic migrant labor in South Africa, particularly in the mining sector is driving quite high rates of HIV and S TI S because of high risk sexual behaviors that are that they, they undertake the the majority of the country unsurprisingly lives in a rural setting, 71%. And there's a mixture of western and traditional culture and authority in the in the country with a system of chieftainship that still possessed to the today, it's a predominantly Christian country, majority Catholic with strong influence of Christian values on health care decision making. And these conservative attitudes can often become resistant to sexual reproductive care that is wrongly perceived as promoting promiscuity or uh at odds with Christian values. According to UN eo they estimate that 85% of women and 68% of men over the age of 15 are literate making Lesotho one of the highest rates of literacy in Africa, which is a huge achievement. However, even with these relatively high rates of literacy. Many Lesotho people battle to get access to the basic health care, travel and educational resources that they need. Now, I did say it's a small country. So the, the last census showed that it had about 2 million people and the estimate of the population last year was that it was about 2.19 million people living in Lesotho. And what this all population pyramid is to demonstrate is that it is a young country as well. So data from the UN Population Fund shows that over 50% of the country are under the age of 25. But why is that important? So we know that younger people are at higher risk of S TI S, they're more likely to be sexually active, more fertile and in need of contraceptions, they're more likely to have new or multiple partners and they're more likely to engage in high risk sexual behaviors. Thus, cumulatively, this country of the is in far greater need of high quality sexual and reproductive care because of its demographics. Whenever you look at data that was provided by the global burden of disease network, we can see that there is a huge burden of sexually transmitted infections in the country. Lesotho has one of the highest rates of S TI in the world with an estimated 32,472 cases per 100,000 inhabitants. That is a staggering statistic that is about three times as many as the UK. Can you imagine your local gum clinic already at capacity with a full waiting room with three times as many patients in that waiting room. We simply could not cope. This incredibly high number is driven by many factors. Unsurprisingly, high rates of poverty, lack of access to health care, but also as well. There is a large amount of stigma still associated with getting tested and treated for STIs s in large parts of Lesotho but also across southern Africa. Moreover, on educated populations are more prone to engage in sexual activities without proper protection leading to large numbers of knee infections per year. But why do higher S ti rates matter? Well, I'm sure so anybody working on go can come up with a long list of reasons why. But in Mau, it is literally a matter of life and death. HIV AIDS still ranks the leading cause of death in the country. Whilst the SU has passed the hyper endemic phase of the HIV epidemic and age deaths are decreasing. It still has the second highest prevalence of HIV in the world. Only, only second behind Eswatini, a close neighbor when we look at modifiable causes of disease and disability. So impairment to full health, the unsafe sexual practices actually ranks as the number one cause of this in the U. And this is absolutely staggering because it's absolutely avoidable. Hopefully many of us on the call tonight will know and realize that sexual reproductive health isn't just about addressing infection. But also there's a huge unmet need for family planning in Lesotho. What data on the screen shows unfortunately, is this unmet need is felt completely disproportionately by the lower socioeconomic backgrounds in the country. You can see that 37% of the lower socioeconomic bracket, uh aged between 15 to 49 have an unmet family planning need. And hopefully we'll know that contraception is an extremely cost effective uh healthcare measure for every 1 lb of that we spend on contraception in the UK. It's estimated that it saves our healthcare system 12 lbs. If you can imagine a poor resource country like Lesotho, that effect is only going to be magnified. So there was a report from the Gut Masher Institute back in 2020 that highlighted in low and middle income countries like Lesotho. There is a significant unmet need for modern contraceptions to the extent that 218 million women, especially those aged between 15 and 19 have an unmet need for modern contraceptions. This lack of access to high quality sexual reproductive care puts women at risk. 3, 35 million have abortions on the safe conditions. 299,000 die from causes related to pregnancy and childbirth. And 100 and 33 million do not receive the treatment that they need for curable STIs such as chlamydia, gonorrhea and others. These numbers are absolutely staggering. And I struggle to comprehend the scale of them, but it's not just a healthcare issue. What the these figures reflect is a global gender and equality. It's not just a, a woman's rights issue that we address this healthcare problem, but as a basic human rights issue that we all have an obligation to try and tackle. So hopefully, I've got everybody quite excited and I'm about to pass over now to Miriam who's gonna introduce project prep and talk about the first phase of the project. Hi there, everyone. And thank you Simon for that brilliant um introduction to Lesotho as well. So my name is Miriam. I'm also a gu registrar, although I'm just starting out in my specialty training. So, um I feel like a bit of a fraud. Um I have however, been doing um this six month fellowship in Lesotho er on project prep. Um And what I want to do is just tell you a little bit about what we did in the first six months of the project which ran from February to July of this year and now Simon has taken over. Um So next slide, please, Simon. So, um I was based at a District General Hospital in Lesotho. Um and actually many patients came from far away to this hospital. It didn't just kind of cover its own catchment area and that's because it had a very good reputation nationally. Um So lots of people traveled from all over the country for what they thought, er, was, er, definitely better care than that they could get locally. Um, and within its own district there are 260,000 patients which, um, er, or people living there. Um, and it shares that population with another hospital and pre exposure prophylaxis was the, the project that was given to me. So I was told, could you please increase pre exposure prophylaxis uptake? Um And I'm sure probably quite a lot of you already know. Um But HIV, pre exposure prophylaxis is medication taken to prevent um HIV acquisition um due to majority of the time sexual contact. Um and it's taken before and after a sexual exposure um to prevent that from happening and it's highly effective if taken as prescribed. Um And in the top right corner of this slide, you can see that there is a bottle of prep. Um And this is the, the brand that, well, the type or formulation that they provide in Lesotho. So it's um Tenofovir and Niv. And um that's a bit different from what we give out here in the UK, which is um uh Truvada or Tenofovir and Tritter. But essentially they work in exactly the same way. Uh I think it's just uh cheaper for them to, to provide it, it's free. Um So patients don't pay for, for prep itself in Lesotho. Um But obviously there are costs attached to traveling to the hospital. So there's unseen costs that people have to commit to. Um, if they're taking it longer term in the bottom corner of this picture or this, um uh uh you can see that there is a photo of the HIV and prep counselor's room. So in this hospital, the counselors would be the people that would screen for HIV, do the tests and counseling, pre and post HIV test. Um, and they would also be the people most expected to have conversations about prep and to screen for eligibility and, and initiate patients on that. And then on the bottom left corner, you can see that's the pharmacy and the top left, that's the main outpatient department which looks unusually empty. Next slide please, Simon. So, um as Simon's already mentioned, the, the rates of HIV are incredibly high in Lesotho, the second highest rates in the world. Um and within the district that the hospital is based. Um One in five adults are living with uh HIV and one in more than one in four women are living with HIV. So women are disproportionately affected by HIV. And that's for a number of reasons which I don't think I've got time to go into now. Um And basically the um the project was identified by the hospital because the um it had been i it had been seen through monthly figures that they weren't reaching their target of initiation rates of prep that was set by the Ministry of Health for the facility. And this diagram here just shows the month, average monthly initiation rates of prep in the previous year before the project. Um And in the, I think it's blue, I can't quite see the, yeah, in the green, you've got the target that was set by the um Ministry of Health for the hospital. And in blue you've got what they were achieving. So um they were below that and if I actually explained the target per month was to initiate 13. So 13 patients on prep, which isn't very much considering they were seeing up to 200 patients a day in their outpatient departments. So 13 patients a month isn't too much in terms of uh how many to expect to be initiated? Can you uh move on to the next slide, please? Thank you. So, um obviously, I was given this project but I didn't know what the problems were or how things were working or not working. And I needed to gather a lot of information and do um a lot of clinical engagement. So I held 1 to 1 interviews with more senior staff. I did like group uh interviews with um with the different departments were involved and I just listened and listened and listened and gathered ideas information um to understand what were the contributing factors to why um initiation of prep was poor. And this is the fish bone diagram that I used as part of my project. Um report um where I try and sort of outline and categorize the different contributing factors. Um And in red, I've circled the ones that I think that phase one of the project touched on. So just very briefly at the top, you've got sort of a poor access to reference materials. So guidelines weren't accessible to staff when they needed them. And in fact, the national guidelines weren't reflected in the practice at the hospital. Um that even though training was provided, um it didn't seem adequate in order to make sure that staff had a good baseline knowledge about prep. Um And um and there weren't any clear standardized pathways for how the hospital expected staff to screen patients for prep. Um And therefore, I think on the whole, it wasn't being done, it wasn't really thought of as a priority. There were many times people said problems to do with staff attitudes and the staff raised this themselves so often. Uh in these interviews, they said, well, actually, I think main, the main problem is staff attitudes. They don't, we don't think it's important. Um We um we, it goes against our religious beliefs because it often involves conversations about sex outside marriage or, or, you know, the classic idea that perhaps it's only homosexuals that can get HIV. Um And therefore it's stigmatized and that it was a perceived unimportance around prep as well. And the fact that it wasn't the hospital's job to provide that although if I just say that there wasn't really any community, um, community network doing it instead. So if the hospital wasn't doing it, then who was, um, and then in terms of processes, there weren't, um, there were process problems. So obviously patients would come for another reason to the hospital, they wouldn't be coming to start prep and then we'd be opportunistically screening them for HIV. And then having a conversation to see if they were eligible and therefore they were already going to be there for a few hours. They didn't like the idea of staying longer and there would often be long waits associated with seeing counselors, um, having additional tests done at the lab waiting for prescriptions. So that was a barrier for patients. The idea that it would mean even more waiting and it's not even why they came. Um, and in the bottom half of this fish bone, you've got main things that were more um, general public problems um across kind of socially across the. So, so you had, um, beliefs about prep that weren't helpful. So a lot of mistrust because um, prep is an A RV and some superstitious beliefs around that there were a lot of exaggerated concerns about side effects and, and the likelihood that you would end up with renal failure. Um There were the geographical and financial limitations of actually accessing that prep prescription regularly and doing the testing that was needed. Prep could cause interpersonal relationship problems and that could lead to domestic violence due to misunderstandings between um the couple about why somebody had started prep. Um And also there was an issue with women not feeling like they could start a medication without checking with their husband first. Um And of course, a lot of stigma still stigma around HIV, stigma around sexual promiscuity, er, stigma around homosexuality. Um And then there were also concerns about a lack of confidentiality. So um the belief that maybe staff would talk about uh people that come to clinic if they knew, oh I know your daughter, I know your mum through and that therefore that the conversations about their er sexual risk were not actually truly private. There was also very poor baseline knowledge, not only about prep, but also HIV in general. Um So people just didn't know or understand um uh about it. Um So yeah, next slide please, Simon. So we have to focus on a few achievable things in the time and I will just quickly say we created some prep screening tools and pathways. So we made it very clear what was the process um in the two outpatient departments that were involved. Um At what point we expected people to have a conversation about prep and how that would be evidenced so that it made it very clear to people working in those departments, what the expectations were with regards to prep screening. We also created some facility specific prep guidelines in order to standardize the approach to prep um for these patients because as I said, we were kind of deviating from guidelines a lot of the time. Um And we wanted to make those guidelines accessible at all times because that was also a major problem that staff just didn't know where to get the information that, that they needed. Um We provide a staff education and training some patient education. And then, I mean, there was a small amount that may be touched on reducing geographical barriers and looking at other performance indicators, but I won't bore you with those. Um Next slide, please, Simon. So every project has to have outputs outcomes and goals. I've already given you the outputs which are kind of written in a slightly different way here. But essentially that was on the previous slide and those outputs were meant to lead to the following outcomes which were that the staff on the front line who were most expected to have those conversations um were confident and trained in using the new facility, specific guidelines and prep screening pathways. Um And another outcome was to improve client education and meaningful access to prep services at the facility. And the third outcome was to improve staff awareness and attitudes to prep, um which is a more much more generic wooly thing. But we did that with an anonymous survey um to see if we'd really shifted opinions about, about prep within the hospital staff. And finally, those outcomes were meant to lead to the the goal which was to increase prep uptake in patients attending the facility. Um So that was the goal next slide please Simon. So guidelines, as I said, we created hospital specific guidelines and they were more detailed than the national guidelines, but they were based on the national guidelines. And any further detail was taken from wh O guidelines or South African guidelines for prep, which might have had a bit more detail in some areas. Um and also discussed in multiple meetings with the more senior staff at the hospital to agree on what we were happy with, including this was felt like a necessary part of the project because the, the national guidelines on prep were not um were very brief and they were part of a bigger guideline on a RV treatment in general. Um And I don't think a lot of staff knew where it was. Um And they also felt like it didn't actually support them in seeing patients because it was kind of very brief and short. Um And it didn't reflect actual practice at the hospital and we were doing lot things that were quite considerably deviating from the guideline and I felt bad that staff didn't feel supported or confident in doing that. You know, there was nothing to say that they were doing the right thing. We also wanted to make sure that these were available everywhere. So all clinical rooms um in both relevant outpatient departments had copies of these and we also made a website for staff um so that er e copies could be available. Um Most staff had smartphones and wifi as accessible at the hospital, which is why that was an appropriate way. Next slide please, Simon. So I also said that we initiated some prep screening pathways to make it nice and clear what you've got here is to, don't, I mean, you can't see it in detail anyway, but essentially the MC H which was the maternity and child health outpatient department on the left and the Wellness Center, which was the general adults sort of HIV testing and TB and prep sort of service department. On the other side, they have slightly different pathways. But essentially this diagram said that all HIV negative patients should be canceled on prep. Um and a prep screening tool filled out to evidence that this conversation had happened. And that was just to try and make it clear about what we were expecting our staff to do and that we were going to audit it. So to try and um to say we will be monitoring you to make sure that this is happening. Um So could you please move on Simon? Next one. So we did lots of teaching as well. Um Teaching to clinical staff, teaching to nonclinical staff in the kitchen and laundry services. We also did some very focused teaching for the counselors who, as I said, did the bulk of the counseling and initiation of prep and actually even amongst that very specific group, there was poor knowledge and um and a lack of confidence in discussing preexposure prophylaxis. That was a really important part of phase one of the project. We also did guideline focused teaching once those, those had come out just to make it clear. Um and to talk everyone through the new guidelines and there was a bit of community village healthcare worker teaching as well. And if you just go on to the next slide, please, I think this is just a bunch of pictures. Er if you get it up, I think it's just that this slide says that essentially 240 total hours of education were provided um through phase one of the project. And then there are a series of pictures of teaching I think, am I the one who just can't see them or can you see them, Simon? Oh, there we go. Lovely. OK. Yeah. So these are just some pictures of the teaching. So um last couple of slides about phase one, we looked at two main things to see how successful we were. This slide is er and graph shows um what happened after we instigated the new prep screening pathways where we said no, we expect you to actually have these conversations with HIV negative clients that are potentially eligible for prep and to fill in the screening tool to show that you did this and then we audited them. So that was introduced at the end of April. And you can see the two departments one in blue, one in orange. Um And once that, that was instigated, you can see that the percentage of um HIV negative clients who were screened coming through those services increased considerably because of that kind of expectation set out. Um And um and then if you go on to the last slide, Simon, and then this slide is just to say the overall goal of the project or phase one of the project was to increase prep initiation rates above that set by the Ministry of Health as the target. And as you can see, the project started in February and miraculously, it looked like we were suddenly doing really well. I think in general just having a spotlight shone on the project by the hospital knowing that I was there um encouraging them obviously made all the difference. So I feel like a bit of a fraud but basically Malu in blue there. Well, that's the hospital in blue um well exceeded the target set by the Ministry of Health throughout the whole of phase one of the project. Um But yeah, I feel like it doesn't quite, quite reflect what we actually did nicely because from the outset, it looks like we cracked it. Um Anyway, over to you Simon. Thank you very much for having me speak. Um And yeah, we'll talk about phase two. Thank you so much Miriam, that was really helpful. Um Now I arrived on phase two of the project after all of that groundwork, an amazing achievement by Miriam and the rest of the team. So phase two moved on to more of an assessment of the delivery of prep that was already happening. And following more clinical audit type principles, three work streams quickly emerged. So that was the outpatient department, the O PD, the Maternal Child Health Clinic and then also as well, we wanted to now start to think about outside of the hospital, about outreach. So the first thing that I noticed when I was in the clinic um in the prep clinic was that there was a seemed to be a lack of joined up thinking and care delivery between S ti care between post exposure prophylaxis and between prep. These were often happening in completely different rooms by completely different people. And there wasn't really any joined up thinking but to try and then to focus on the Lesotho national guidelines for prep, it does highlight like many other countries, the importance of prep for people that have had an ST recently and also as well, people who are frequent users of pe post exposure access. So I did a quick audit um to try and establish the proportion of patients who were treated for S TI S that were given prep, um needed to look at uh prep prescriptions both at the time of S TI treatment, but also looked back for the three months prior uh to make sure that they weren't already on prep as well. I also looked at the proportion of post exposure of PP patients that were prescribed prep as a follow on over the five month period that I looked at, there were 341 prep prescriptions at the small rural district General Hospital, which is an incredible achievement. And when I looked at those prescriptions uh and pulled them apart by gender, what we started to see was a huge age discrepancy between uh male and female. So we noticed that our prep patients who were female had an average age of 28 whereas the male patients had an average age of 41 which showed a complete gender disparity in the care that was being delivered. This isn't complete uh completely bad news because like Miriam said women are at a completely disproportionate risk of uh uh HIV about one and four in this country. And then again, that risk is higher for younger adolescent girls and young women. The vast majority, as I said, of patients to the power chart shows that the vast majority were female patients that ever seen you on prep and that's from the MC H. Um And then also as well, the graph on the left shows the duration of the scripts that were issued over the five month period. And the largest bar shows that the vast majority of our prescriptions were for initiations, which in the suit you is just for one month, we do have a problem with continuation and a loss to follow up. So trying to get people to stay on prep through to the three month prescription is a struggle, but that is not unique to Lesotho. It's not unique to the hospital that we're in. It is a global issue trying to get people to stay on prep and keep adherent. And then whenever I drill down to look at more detail at the S TI S it were being treated, uh being treated in the hospital. I used really strict exclusion criteria to make sure that I was just looking at S TI S. So that is really difficult in the low and middle income setting because they don't have access to the same level of diagnostics that we do. So S TI S number one are often treated syndrom ly by the symptoms that present. And then number two, we did not have, we do not have any electronic patient databases. We don't have computers widely available. All the records are majority on uh exercise book. Patient holds called Buchan and then uh massive a three paper register where people write down the diagnosis of the patient. So I excluded anything vague. So there was no uh nonspecific genital diagnosis, no vaginitis without a cause. No genital itch, no scabies discharge herpes uti anything that could have been misconstrued as a non S TA. And then what I found was that none of those patients with definite ST I were given prep on the day of treatment and none of them had received prep in the last three months. So evidence that these high risk S TI patients were being started on prep. So we know that people with a bacterial S TI or uh have got sexual behaviors that put them at risk of HIV because they've got another S TI but also as well. The C the S TI infection puts them at risk of h uh higher risk of HIV as well. Another little point of note was that um from the world cloud, you can see some of the more common diagnosis that came up. What really troubled me was the high rates of reported abuse and assault. More than 20% of the patients that I looked at were actually victims of sexual assault or sexual abuse. And most of that unfortunately is gender based violence directed towards women and highlights the stark inequalities that exist for women in this part of the world. Un fortunately, the results for the PAP order post exposure prophylaxis were disheartening. Uh no prep had being prescribed alongside prep or the follow on on the 30 days after completion. And there is multiple teaching and initiatives um that are going on at the moment to try and change these prescribing practices with the nurses, with the doctors and doing some promotion work as well. Another aspect of the PD that I wanted to change and look at was reducing the barriers to get in prep. So like Miriam tried to describe as the flow of the patient through the department, they seen by a counselor, then they go back to the lab in a different part of the hospital. They have the bloods done, then they come back and they queue up and they pay, they register, then they go and join another queue to see the doctor. So a visit to the hospital with a medical problem can take the whole day. Um if you start to add prep and if you're going to add in any extra hours or extra barriers, the patient is going to give up. So we need to streamline the patient's journey through um the clinic and speed it up as much as possible. One of the things for me was looking at the baseline testing that was taking place because in the PD, the standard operating procedure that the local uh practitioners wanted was that they had to physically have the U ue results before the prep can be prescribed. So prep with TDF can offer for des proxil um and the majority of patients is associated with a myo reversible rise in creatinine which is usually fine in the young healthy patients. But some uh patients who are older have underlying health problems or renal problems. It could be problematic patient. And then what we need to, what I wanted to do was avoid the patients having to wait for the blood results. So being able to get them the prescription of prep as quick as possible, get out the door on prep and then we can think about the renal testing later. So what I did was I looked at all of the renal function tests for all of the patients that have been treated for prep ever in the in the records. And then thankfully, none of them had a creatinine clearance less than six to cut off for prep here. So that was absolutely fantastic and very reassuring that we can give safely that first one month of prep without a uni test if there was no clinical signs of renal disease, reassuringly as well whenever I looked at the under thirties, was it follows an even smooth or normal distribution with the highest peak and the creatinine clearance about 90 to 100. And this reinforces in aligns with both the national and international guidance here that someone under the age of 30 can safely be started on prep without au ne result. So hopefully, the plan is to unify the SOP protocol across the hospital align it with National and international guidance and hopefully reduce the amount of time that patients will need to spend in the clinic if they want to start on prep um in terms of the maternal child health clinic. So that's a separate part of the hospital. They were doing really, really well with high rates of initiation, you can see that large part of the pie chart was being dominated by female patients at no small part because of the hard work from this part of the hospital. But they do have a problem with loss of follow up. So one of the projects that I'm working on at the moment is develop an electronic database that we can keep on. Excel that will automatically flag when patients are due or as soon due for their follow up and then we can give them electronic reminders. So sending out a whatsapp message or a quick telephone call, whatever the patient's preference is. So the plan is to initially focus on the high risk population. So adolescent young girls and women, but if it's successful, we might consider expanding it and ruling out to boost and reduce the loss to follow up. So that leads me on just the final theme that we're working on now and that's about outreach. So there's lots of uh ideas that we and plans that we're working and developing on. So we want to teach the teachers of secondary schools about prep so they can include it in their lessons. We want to get permission from the government so that we can include prep in the schools based public health talks by run by a public health nurse from the hospital. Then also as well, there's more abstract and long term ideas about uh doing some outreach with the initiation skills that happen in this country. And then also as well, what I am definitely working on right now is about social media advertising and promotion within the community. So we are evidence based practitioners. I am definitely not an advertising uh or uh social media influencer. So I started with some evidence. So there wasn't very much evidence from Lesotho. But looking at our nearest comparator country in neighbor South Africa, I found this qualitative study that helped to identify key themes that were effective in uh prep promotion in this part of the world. And some of the themes that arosa successful for them were prep enhances power and also as well. Prep er allows you to take care of yourself after multiple rounds of different uh community engagement interviews, focus groups. They found that some of the messages uh that resonated more strongly were summarized in the slogans on screen. And the one that I we've chosen to run with is we are the generation to end prep uh end HIV, sorry. Er So the reason that we chose that is cos one of the largest charities in the country also uses that slogan in so u so we don't want to try and compete but we want to complement any uh public health campaigns that are happening at the same time. So I've got some draft versions now of some of the materials that we've used and we're gonna start posting. Um The first thing was that it was really important to have the materials in both languages. So Suzu and English to maximize our reach. But then also as well, you might notice that the prep tablets in the photo that they're blue. So this was my mistake because this was the first draft and I was so used to blue prep tablets back in Europe. But the prep tablets out here, lamiVUDine based ones are white tablets. So that now has been changed. And it's really important for us that we've adapted the public health materials to avoid anything that was Eurocentric. We want the materials to be embedded and the experience and culture of the community that we're trying to uh promote the behavior change with them. So we've used an online program called CVA and that's helped us format uh the posts for the right dimensions, both for Instagram, Facebook and Twitter as well. So we made it the process very easy. The posts that are gonna eventually go out will have details about the local hospital and also some of the other local services nearby where pa patients can't access prep, it's gonna go across social media platforms, but also as well. Whatsapp, which is incredibly common out here uh used more than anything else that I've found. Um just some more examples that we've got. And then the last thing as well was that we're gonna start adapting uh pro promotional materials from other sources as well to make it more accessible to the local community, obviously, with copyright permissions um as well respected. Um The final closing thing that I wanted to mention is that World Aids Day is just around the corner first of December. So out here in the, so we're gonna be running a social media campaign and doing, doing some local events to raise awareness about prep but also as well. One of the things that we're trying to do is change the hearts and minds of people out here. So I've mentioned it and Miriam has mentioned it about some of the conservative Christian values. So one of the things I've done while I've been out here is uh with chaplain of the hospital is co written a HIV prevention, prayer, respectful of their beliefs of the religion that runs the hospital. But we are now gonna get the whole hospital and the community of the hospital to say the prayer on World Age Day to change people's hearts and minds that HIV prevention is part of and acceptable by a Christian ethos as well. So a nice little added note is that my chaplains back at my hospital in the UK are also gonna be joining us out on a in Africa in prayer on that day. So I had planned to talk about working abroad, but I realized I've already gone over time. So if any of these issues come up, hopefully they'll come up in the Q and A now. So I'll skip past this slide and we can start the Q and A. Um That was great. Thank you so much. It was really interesting. Um If people want to put their questions in the chat now and we'll try and answer as many as we can. Um, I had a question about the Quality Improvement Fellowships. Um Are they quite competitive to get on? And if so, what should we be doing as medical students or junior doctors to try and improve our chances of working abroad? Um, correct me if I'm wrong, Miriam. But the NHS uh quality Improvement uh program historically hasn't been very competitive but it is becoming more competitive. I think my year was the first year that they had the, they were fully, uh they had all the people that they needed and they had to turn some people away. Um the to try and make yourself more competitive. I would just make sure that you're engaging with quality improvement early on if this is a program that you want to, to go on any other advice, Miriam, I would just say that in the interview if I remember looking back, the, the things were the questions were orientated around like demonstrating what quality improvement work you've been involved in before and also any kind of experiences that you've had where you've had to, uh, work or work alongside people. So, not necessarily in another country but working with people from different backgrounds and cultures. So, just thinking about how, I mean, that could even be working in a kind of a clinic in an area where you see a lot of, I know patients from, um, specific types of cultures. I don't know, you could try and wing it, but basically those are the sorts of focuses of the, the interview. Um And yeah, I guess it does sound like it's getting a bit more competitive, but I don't know if that put you off. I feel like everyone's always saying that about everything and it may well be do but just ignore it. Like uh I think if, if you are enthusiastic and, and you look like you've got a bit of an interest in global health or quality improvement stuff under your belt, then I'm sure that you have every chance. Maybe if you're not picking South Africa, South Africa was very uh everyone wants to go to South Africa. I mean, Lesotho didn't count as part of that but um I think it was quite high up there, wasn't it Simon? Um because I think they could do a mix of holidaying and unfortunate work. So, yeah, thanks both such an really inspiring talk and project. We've had a question come through from ATI. How did you find trying to challenge the stigma associated with HIV. Um That's a really big question. Um, I have found it so shocking and so difficult. Uh being a gum doctor back in England, you think that you know about HIV stigma and that you deal with it on a daily basis. But out here it's just a completely different scale of problem with prep. We're not even talking about treatment of HIV and people are still so scared of it. They don't even want to be seen with an anti retroviral tablet because you don't want to be associated with HIV. So we're trying to get people to divorce prep from HIV treatment mentally to get them to take. It has been a real struggle. And then also as well, there's a lot, particularly with the younger patients that I've seen in clinic. They don't want to be seen taking a tablet because that someone will spot it and go, oh, they're sick. They've got HIV and it completely, people will be ostracized them and be treated differently. So it has been really, I found it really difficult. Um, but what I really have been inspired by is that how a lot of the clinicians out here are able to normalize it. So because it's HIV is so common, they are trying to change the hearts and minds of the patients and the public that we've got Miriam. What do you think your experience is? I was just say it's a it's a bit, feels like an interesting mixed bag because if you as part of the beliefs and attitudes around prep survey that I did, I asked some questions about HIV and one thing had come up in conversations with people and that actually back in the day, maybe 20 years ago, that people would actually um deliberately get infected with HIV. Er, because it meant that they would get financial support from the government for their families. So they would actually go to what somebody worked there called injecting parties where they would deliberately catch HIV, which is a, a bit similar to COVID. Uh if you think some people went to COVID parties, didn't they? Um, and also on the questionnaire I asked about, um HIV. Um, would they rather have HIV or diabetes? Um, and actually more people would rather have HIV than diabetes. But that doesn't mean there isn't loads of stigma because there is, as Simon said, but actually on an individual level, the fact probably that it's free in terms of the medication. Whereas diabetic treatment isn't means that people aren't scared of it in the same way that they used to be as in it's a death sentence but there is still huge public stigma. So you wouldn't want people knowing that you had it. Um Yeah, so interesting. Um Akash wants to know what were the biggest challenges that you both faced and how often did you find the local community way the people coming in from Europe and trying to change the way they were doing it in their local system. Oh, dear. Um, have you got, do you want to go first, Miriam? So, I mean, the biggest challenge, I don't know, getting people to, um, to sit in a meeting with me and give me the time of day initially and even when I created relationships, um, it still didn't seem to affect whether people would make time for, for the project. Um And as an outsider, I mean, I just basically was very, like, very timid, didn't, like, do anything that I thought could be perceived as bossy or telling other people what to do. So that's how I set out just being like, oh asking questions, you know, listening, listening, listening. I did that for quite a while, weeks and weeks and then, you know, began to get a bit of confidence and, you know, in my presentations and talks, I tried to, you know, instill confidence by, you know, looking like I knew what I was talking about. I think it helped that I was a doctor. They didn't really realize that initially. And I think when they realized that then there was a bit more perhaps like, ok, maybe we won't completely ignore this, like, white girl who's just come in here trying to sort everything out. But yeah, definitely, it feels awkward and I, but I was ready for knowing that I was gonna feel like an outsider and I didn't wanna come across as telling them how to run their hospital because to be honest, it took a very long time to even understand how things worked. So how could I possibly make the suggestions that needed to come from them? Um Yeah. Um in terms of biggest challenges, I think I'm gonna piggyback on what Miriam has said and say the culture shock. So in terms of trying to set meetings and get people to reply and get people to turn up on time, punctuality has driving me insane. So people will turn up an hour late for a meeting, two hours late for a meeting that has been the big struggle to try and push things forward quickly, but then also as well a lack of quality improvement culture and like uh culture to want to change. So if the status quo was working, why are you disrupting things when things are already difficult with the lack of resources? So trying to disrupt and improve things. And then the last third, big challenge has been about trying to get people to focus on holistic care. So when patients come into the outpatient clinic, they've got one clinical problem to sort that day. Why do you want me to do more work? Why do you want me to sort out the contraception and the prep and deal with this chest infection? They've got. So it's trying to change their mindset that dealing with the contraception and the prep now is really important because it's preventing the HIV infection and the unwanted pregnancy and the illegal abortion tomorrow. And I, the only thing I'd add to that is that you've made me think about the hierarchy. So it was much more like a sort of like, I think now it's quite encouraged in the NHS, that people can say everyone has an opinion and every opinion about how things are working or isn't working is valuable. Whereas their people weren't used to talking about what they really thought and the people kind of working on the shop floor. If you like their opinions, they didn't feel like their opinions were valued, they didn't really want to voice them. And therefore, you know, that kind of, that whole, it is very difficult to improve anything if you've got this idea that, oh, it doesn't work like this. You know, we don't get to say, what do you think? Why are you listening to my opinion on this? You know, we need our boss to tell us what to do and then we'll do it? Great. Thank you. Um, we were due to finish questions, but we've got a few more in the chat. Um, so we will push on through them and we'll just run past eight o'clock and that's ok. Um But Eleanor asks, what is the percentage retention for prep and have you had any local government involvement involvement to help this? For example, improving easy access for repeat scripts, et cetera. So I think like the latest statistic about retention on prep is about 5 to 10% of patients remain on prep at, at our hospital. Um That isn't really probably an accurate description of people that are remaining on prep because they can get their prep from somewhere else. So from another healthcare provider, um because things aren't joint up and linked here, there's no way for me to tell if uh my patient is started on prep here when they came in for the chest infection and then decided to continue at their community health care provider. So it may be that the local retention figures are higher than what we're seeing, but it is very low in our hospital. Um The second question of the question was about local government involvement and that's not really exist. It doesn't really exist out here. You don't have the, the city councils or the county councils in the same way that you do back at home involved with public health and promotion of prep and sexual health, safe sex practices. Um What you do have though is a large number of NGO S and independent sector. Um charities that are trying to work with boosting prep and boosting prep continuation. So we've got fantastic chip and we've got egg which are two massive charities in which are working really hard to get people on prep and to get people remaining on prep. Um Florence wants to know why are female patients that are high risk of contracting ST is go on silent. You answer this really good question. So it's completely multifactorial. So there are some biological factors at play that mean that um female patients are at higher risk of HIV, but also as well. It's just the way the society is set up here as well. So there's a completely um an unequal society for females. So they may not be able to negotiate condom use with their partner. They may be victims of sexual violence quite frequently. And then also as well, there may be, um I mentioned earlier about the migrant population, the, the there, there are um moving from South Africa into the without treatment, spreading Ts and women are gonna be victims of those vectors of transmission also as well because we are in a low middle income country. Women are more economically motivated to go into sex work as well. Um Because of the circumstances that they're in but, and I could keep going, I could keep going on all day about it. It is a complex issue. That's really interesting. Thank you. And then we'll just ask the final question from Ella, who asks, what would you say is the main thing you've learned from hospital staff in Lesotho and how has it changed how you practice back in the UK? I feel like I have to write a whole uh I can't remember a single thing I said, oh dear, you've got me, Simon. Anything. I think it's fresh for you. That's why. Maybe. No. I think that what I've learned most about is just the sheer tenacity and resourcefulness that they've got trying to do, make do and do the best they can with what little they have. So they're responding to a medical emergency and they don't have a BP cuff. They don't have a blood sugar machine, but they're gonna give it a go anyway. That resilience and 10 Aetate to me is just like inspiring. And that, that's what I'm gonna take home for sure. And me, I mean, I feel like II learned so much actually. Um, but it's really hard for me to reflect on it now having been back for four months or so. Um but it was an incredible experience and um some of the relationships I built and actually that it was a leadership fellowship. It was about, er, developing your leadership skills and how you, and, and that means how you motivate people, how you get people on board, how you get that buy in from people that you're working with. And it was interesting as a doctor to be in a management position, which is really uncomfortable if you're normally providing clinical care, you're not normally the one going. Oh, why aren't you doing this? And why aren't you doing that? And so to be in that position was quite awkward. Um And then to have to try and galvanize um like everybody around you to actually believe in the idea that the whole process of that was really interesting. And I would just say anyone who don't be put off for applying, I would, I would really consider applying because you will learn a lot, a lot about other cultures, a lot about yourself. Um Yeah, a lot about project management. Um It, it's a great all round experience, so many take homes. Well, thank you so much, both of you, Miriam and Simon for giving up your time and teaching us all about such a worthwhile and inspiring project. And I think we all feel very humbled to have heard from you this evening and hopefully it's given everyone lots of food for thought for their future careers. So just before we leave, just a reminder to everyone to fill in the Bash gum recruitment survey, the link of which is at the top of the chat and also to fill in your feedback forms. It's really important both for our speakers um and to help us plan future webinars and also so that you get your certificates of attendance as well. The link for the feedback is in the chat, but you'll also get an email straight after this talk as well. Um Thank you to grace for co sharing. Thank you again for our wonderful speakers and I will let you all go and enjoy the rest of your evening. Thank you very much, everyone. Thank you. Thank you.