Uptake and outcomes of a novel community-based HIV post-exposure prophylaxis (PEP) programme in rural Kenya and Uganda

Effectiveness of onsite and online education in enhancing knowledge and use of human immunodeficiency virus pre- and post-exposure prophylaxis

BACKGROUND

Enhancing awareness and use of pre-exposure prophylaxis (PrEP) and post-exposure prophylaxis (PEP) is vital to curb human immunodeficiency virus (HIV) spread. High-risk behaviors prevalent among sexually transmitted infection clinic outpatients underscore the need for increased PrEP/PEP education in this group.

AIM

To investigate the effects of both onsite and online health education on the knowledge of, and willingness to use, PrEP and PEP among individuals receiving PEP services.

METHODS

Participants were drawn from a cohort study on PEP service intervention at an STD/AIDS outpatient clinic in designated HIV/AIDS hospitals in Beijing, conducted from January 1 to June 30, 2022. Health education was provided both onsite and online during follow-up. Surveys assessing knowledge of, and willingness to use, PrEP/PEP were administered at baseline and again at 24 wk post-intervention.

RESULTS

A total of 112 participants were enrolled in the study; 105 completed the follow-up at week 24. The percentage of participants with adequate knowledge of, and willingness to use, PrEP significantly increased from 65.2% and 69.6% at baseline to 83.8% and 82.9% at the end of the intervention (both P < 0.05). Similarly, those with adequate knowledge of, and willingness to use, PEP increased from 74.1% and 77.7% at baseline to 92.4% and 89.5% at week 24 (P < 0.05). Being between 31 years and 40 years of age, having a postgraduate degree or higher, and reporting a monthly expenditure of RMB 5000 or more were found to be significantly associated with knowledge of PrEP and PEP (both P < 0.05).

CONCLUSION

The findings show that both onsite and online health education significantly improved the knowledge of, and increased willingness to use, PrEP and PEP in individuals utilizing PEP services.

Dynamic choice HIV prevention intervention at outpatient departments in rural Kenya and Uganda

OBJECTIVE

HIV prevention service delivery models that offer product choices, and the option to change preferences over time, may increase prevention coverage. Outpatient departments in sub-Saharan Africa diagnose a high proportion of new HIV infections, but are an understudied entry point to biomedical prevention.

DESIGN

Individually randomized trial of dynamic choice HIV prevention (DCP) intervention vs. standard-of-care (SOC) among individuals with current/anticipated HIV exposure risk at outpatient departments in rural Kenya and Uganda (SEARCH; NCT04810650).

METHODS

Our DCP intervention included 1) product choice (oral preexposure prophylaxis [PrEP] or postexposure prophylaxis [PEP]) with an option to switch over time, 2) HIV provider- or self-testing, 3) service location choice (community vs. clinic-based), and 4) provider training on patient-centered care. Primary outcome was proportion of follow-up covered by PrEP/PEP over 48 weeks assessed via self-report.

RESULTS

We enrolled 403 participants (61% women; median 27 years, IQR 22-37). In the DCP arm, 86% ever chose PrEP, 15% ever chose PEP over 48 weeks; selection of HIV self-testing increased from 26 to 51% and of out-of-facility visits from 8 to 52%. Among 376 of 403 (93%) with outcomes ascertained, time covered by PrEP/PEP was higher in DCP (47.5%) vs. SOC (18.3%); difference = 29.2% (95% confidence interval: 22.7-35.7; P  < 0.001). Effects were similar among women and men (28.2 and 31.0% higher coverage in DCP, respectively) and larger during periods of self-reported HIV risk (DCP 64.9% vs. SOC 26.3%; difference = 38.6%; 95% confidence interval: 31.0-46.2; P  < 0.001).

CONCLUSION

A dynamic choice HIV prevention intervention resulted in two-fold greater time covered by biomedical prevention products compared to SOC in general outpatient departments in eastern Africa.

A community-based dynamic choice model for HIV prevention improves PrEP and PEP coverage in rural Uganda and Kenya: a cluster randomized trial

INTRODUCTION

Optimizing HIV prevention may require structured approaches for providing client-centred choices as well as community-based entry points and delivery. We evaluated the effect of a dynamic choice model for HIV prevention, delivered by community health workers (CHWs) with clinician support, on the use of biomedical prevention among persons at risk of HIV in rural East Africa.

METHODS

We conducted a cluster randomized trial among persons (≥15 years) with current or anticipated HIV risk in 16 villages in Uganda and Kenya (SEARCH; NCT04810650). The intervention was a client-centred HIV prevention model, including (1) structured client choice of product (pre-exposure prophylaxis [PrEP] or post-exposure prophylaxis [PEP]), service location (clinic or out-of-clinic) and HIV testing modality (self-test or rapid test), with the ability to switch over time; (2) a structured assessment of patient barriers and development of a personalized support plan; and (3) phone access to a clinician 24/7. The intervention was delivered by CHWs and supported by clinicians who oversaw PrEP and PEP initiation and monitoring. Participants in control villages were referred to local health facilities for HIV prevention services, delivered by Ministry of Health staff. The primary outcome was biomedical prevention coverage: a proportion of 48-week follow-up with self-reported PrEP or PEP use.

RESULTS

From May to July 2021, we enrolled 429 people (212 intervention; 217 control): 57% women and 35% aged 15-24 years. Among intervention participants, 58% chose PrEP and 58% chose PEP at least once over follow-up; self-testing increased from 52% (baseline) to 71% (week 48); ≥98% chose out-of-facility service delivery. Among 413 (96%) participants with the primary outcome ascertained, average biomedical prevention coverage was 28.0% in the intervention versus 0.5% in the control: a difference of 27.5% (95% CI: 23.0-31.9%, p<0.001). Impact was larger during periods of self-reported HIV risk: 36.6% coverage in intervention versus 0.9% in control, a difference of 35.7% (95% CI: 27.5-43.9, p<0.001). Intervention effects were seen across subgroups defined by sex, age group and alcohol use.

CONCLUSIONS

A client-centred dynamic choice HIV prevention intervention, including the option to switch between products and CHW-based delivery in the community, increased biomedical prevention coverage by 27.5%. However, substantial person-time at risk of HIV remained uncovered.

Risk perception and usage of non-occupational post-exposure prophylaxis among fisherfolk in Ggulwe parish on the shores of Lake Victoria in central Uganda

Background

The use of non-occupational post-exposure prophylaxis (nPEP) to prevent HIV acquisition among those exposed as an approach to HIV prevention has expanded in Uganda. Although there are increased efforts to avail nPEP services among most at-risk populations, the usage of nPEP medicines remains low. Therefore, this study examined the risk perception and usage of non-occupational post-exposure prophylaxis (nPEP) among fisherfolk in the Ggulwe fishing parish, Bussi sub-county, Wakiso district.

Methods

A cross-sectional study among adults was carried out from October 2020 to January 2021 in Ggulwe parish, Bussi sub-county, Wakiso district, to examine the usage of nPEP and factors influencing the usage. Data were collected using semi-structured questionnaires, and key informants' interviews were conducted among healthcare providers and the local leadership. The quantitative data were summarized using bivariate and multivariate logistic regression, while the qualitative data were analyzed thematically to enrich the quantitative results.

Results

Overall, 248 fisherfolk encountered an event that required the use of nPEP, and of these, 55/248 (22.2%) were able to use nPEP to prevent them from acquiring HIV. The usage of nPEP among adults in the Bussi sub-county, Wakiso district, was associated with not knowing that HIV can be prevented using nPEP medicines (AOR:0.1, 95% CI 0.03-0.36, p < 0.001), lack of knowledge of the existence of nPEP (AOR: 0.3, 95% CI 0.13-0.76, p = 0.01), the perception that nPEP can effectively prevent HIV infection after exposure (AOR 0.0586, 95% CI: 0.0177-0.1944, p < 0.001), and the community's opinion affecting the willingness to take nPEP (AOR 0.1924, 95% CI: 0.0380-0.9727, p = 0.0462).

Conclusion

The usage of nPEP among fisherfolk was low (22.2%). The low usage of nPEP was associated with a lack of knowledge and awareness about nPEP. This effort to improve the usage of nPEP should include community sensitization and HIV infection prevention using nPEP to raise awareness about HIV infection exposures and the risk of HIV infection during non-occupational exposures.

Potential cost-effectiveness of community availability of tenofovir, lamivudine, and dolutegravir for HIV prevention and treatment in east, central, southern, and west Africa: a modelling analysis

BACKGROUND

Post-exposure prophylaxis (PEP) offers protection from HIV after condomless sex, but is not widely available in a timely manner in east, central, southern, and west Africa. To inform the potential pilot implementation of such an approach, we modelled the effect and cost-effectiveness of making PEP consisting of tenofovir, lamivudine, and dolutegravir (TLD) freely and locally available in communities without prescription, with the aim of enabling PEP use within 24 h of condomless sex. Free community availability of TLD (referred to as community TLD) might also result in some use of TLD as pre-exposure prophylaxis (PrEP) and as antiretroviral therapy for people living with HIV.

METHODS

Using an existing individual-based model (HIV Synthesis), we explicitly modelled the potential positive and negative effects of community TLD. Through the sampling of parameter values we created 1000 setting-scenarios, reflecting the uncertainty in assumptions and a range of settings similar to those seen in east, central, southern, and west Africa (with a median HIV prevalence of 14·8% in women and 8·1% in men). For each setting scenario, we considered the effects of community TLD. TLD PEP was assumed to have at least 90% efficacy in preventing HIV infection after condomless sex with a person living with HIV.

FINDINGS

The modelled effects of community TLD availability based on an assumed high uptake of TLD resulted in a mean reduction in incidence of 31% (90% range over setting scenarios, 6% increase to 57% decrease) over 20 years, with an HIV incidence reduction over 50 years in 91% of the 1000 setting scenarios, deaths averted in 55% of scenarios, reduction in costs in 92% of scenarios, and disability-adjusted life-years averted in 64% of scenarios with community TLD. Community TLD was cost-effective in 90% of setting scenarios and cost-saving (with disability-adjusted life-years averted) in 58% of scenarios. When only examining setting scenarios in which there was lower uptake of community TLD, community TLD is cost-effective in 92% of setting scenarios.

INTERPRETATION

The introduction of community TLD, enabling greater PEP access, is a promising approach to consider further in pilot implementation projects.

FUNDING

Bill & Melinda Gates Foundation to the HIV Modelling Consortium.

Provider perspectives on service delivery modifications to maintain access to HIV pre-exposure prophylaxis during the COVID-19 pandemic: qualitative results from a PrEP implementation project in Kenya

INTRODUCTION

HIV pre-exposure prophylaxis (PrEP) is an essential prevention strategy being scaled up for priority populations in Kenya, including for HIV serodiscordant couples. The COVID-19 pandemic posed challenges to PrEP rollout. We conducted a qualitative study of PrEP providers to understand how clinics adjusted PrEP delivery during the COVID-19 pandemic.

METHODS

Since 2017, the Partners Scale-Up Project has integrated PrEP into 25 HIV clinics in Central and Western Kenya. We conducted qualitative interviews with 40 purposively sampled clinic personnel. We interviewed personnel once during the first pandemic wave (May-Aug 2020) and again after some decline in COVID-19 rates (Nov-Jan 2021). We analysed data using inductive memo-writing and summarized data by themes along the PrEP delivery cascade, guided by the Framework for Reporting Adaptation and Modifications (FRAME).

RESULTS

We interviewed 27 clinical officers, five nurses, four health records and information officers, and four counsellors from Central (n = 20) and Western (n = 20) Kenya. About half (n = 19) were female, with a median age of 32 (IQR: 29-34) and 2.3 years of experience delivering PrEP (IQR: 2-3). All participants reported clinic changes in PrEP demand creation and service delivery during the pandemic. Modifications occurred during PrEP implementation and sustainment phases, were partly reactive to the pandemic and also facilitated by interim Ministry of Health guidance on PrEP delivery during COVID, and were made by PrEP delivery teams, clients and clinic managers. Commonly reported modifications included dispensing multiple-month PrEP refills, intensifying phone-based client engagement and collaborating with other HIV clinics to ensure that clients with prolonged stays in other regions could continue to access PrEP. Some clinics also adopted practices to streamline visits, such as within clinical-room PrEP dispensing, pre-packing PrEP and task-shifting. Most providers liked these changes and hoped they would continue after the pandemic subsides.

CONCLUSIONS

COVID-19 served as a catalyst for PrEP delivery innovations in Kenya. HIV clinics successfully and rapidly adapted their PrEP demand creation, refill and retention strategies to promote PrEP uptake and effective use. These modified implementation strategies highlight opportunities to streamline the delivery of PrEP, as well as other HIV and chronic care services, and strengthen engagement with populations post-pandemic.

Mixed-methods findings from the Ngutulu Kagwero (agents of change) participatory comic pilot study on post-rape clinical care and sexual violence prevention with refugee youth in a humanitarian setting in Uganda

There is a dearth of evidence-based post-rape clinical care interventions tailored for refugee adolescents and youth in low-income humanitarian settings. Comics, a low-cost, low-literacy and youth-friendly method, integrate visual images with text to spark emotion and share health-promoting information. We evaluated a participatory comic intervention to increase post-exposure prophylaxis (PEP) knowledge and acceptance, and prevent sexual and gender-based violence, in Bidi Bidi refugee settlement, Uganda. Following a formative qualitative phase, we conducted a pre-test post-test pilot study with refugee youth (aged 16-24 years) (n = 120). Surveys were conducted before (t0), after (t1), and two-months following (t2) workshops. Among participants (mean age: 19.7 years, standard deviation: 2.4; n = 60 men, n = 60 women), we found significant increases from t0 to t1, and from t0 to t2 in: (a) PEP knowledge and acceptance, (b) bystander efficacy, and (c) resilient coping. We also found significant decreases from t0 to t1, and from t0 to t2 in sexual violence stigma and depression. Qualitative feedback revealed knowledge and skills acquisition to engage with post-rape care and violence prevention, and increased empathy to support survivors. Survivor-informed participatory comic books are a promising approach to advance HIV prevention through increased PEP acceptance and reduced sexual violence stigma with refugee youth.Trial registration: ClinicalTrials.gov identifier: NCT04656522.

Intersecting Stigma and HIV/AIDS Community Participation Among Young Chinese Men Who Have Sex with Men Living with HIV

Community participation is vital for the recovery and empowerment of men who have sex with men (MSM) living with HIV. Intersectionality also provides an important lens that inequalities operate in an intersectional manner and pose compound challenges to the lives of minority individuals. However, the association between intersecting stigma toward HIV-positive MSM and their community participation is underexplored. The study drew on a sample of young Chinese MSM living with HIV from a community-based online survey that recruited respondents using nonprobability purposive sampling (n = 1004). Structural equation modeling was performed to investigate the associations among perceived stigma against sexual minorities and people living with HIV, HIV-related self-stigma, and HIV/AIDS community participation. The indirect effect of self-stigma and the statistical interaction between perceived homosexual stigma and perceived HIV-related stigma were further examined. Results show that total direct effect was significant [B (SE) = 0.859 (0.233); confidence interval (95% CI) = 0.402-1.316]. Perceived HIV-related stigma was positively correlated with HIV/AIDS community participation, while HIV-related self-stigma was negatively correlated. The mediating role of HIV-related self-stigma was significant in both types of perceived stigma [total indirect effect: B (SE) = -0.935 (0.175); 95% CI = -1.277 to -0.593]. The interaction effect was also significant and negative [B (SE) = -0.117 (0.056), p < 0.001], showing that perceived homosexual stigma could offset the effect of perceived HIV-related stigma on HIV-related self-stigma. The findings illustrate how intersecting stigma is involved in HIV-related self-stigma and community participation and highlight the importance of applying an intersectionality perspective to investigate stigma toward MSM living with HIV and their community participation.