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Zewdie K, Kiweewa FM, Ssebuliba T, Morrison SA, Muwonge TR, Boyer J, Bambia F, Badaru J, Stein G, Mugwanya KK, Wyatt C, Yin MT, Mujugira A, Heffron R. The effect of daily oral PrEP use during pregnancy on bone mineral density among adolescent girls and young women in Uganda. FRONTIERS IN REPRODUCTIVE HEALTH 2024; 5:1240990. [PMID: 38260049 PMCID: PMC10801233 DOI: 10.3389/frph.2023.1240990] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2023] [Accepted: 12/19/2023] [Indexed: 01/24/2024] Open
Abstract
Introduction Oral pre-exposure prophylaxis (PrEP) is recommended during pregnancy for at-risk cisgender women. Pregnancy is known to impede bone growth and tenofovir-based PrEP may also yield detrimental changes to bone health. Thus, we evaluated the effect of PrEP use during pregnancy on bone mineral density (BMD). Methods We used data from a cohort of women who were sexually active, HIV-negative, ages 16-25 years, initiating DMPA or choosing condoms for contraception and enrolled in the Kampala Women's Bone Study. Women were followed quarterly with rapid testing for HIV and pregnancy, PrEP dispensation, and adherence counseling. Those who became pregnant were counseled on PrEP use during pregnancy per national guidelines. BMD of the neck of the hip, total hip, and lumbar spine was measured using dual-energy x-ray absorptiometry at baseline and annually. We compared the mean percent change in BMD from baseline to month 24. Results Among 499 women enrolled in the study, 105 pregnancies occurred in 90 women. At enrollment, the median age was 20 years (IQR: 19-21) and 89% initiated PrEP. During pregnancy, 67% of women continued using PrEP and PrEP was dispensed in 64% of visits. BMD declined significantly in women using PrEP during pregnancy compared to women who were not pregnant nor used PrEP: relative BMD change was -2.26% (95% CI: -4.63 to 0.11, p = 0.06) in the femoral neck, -2.57% (95% CI: -4.48 to -0.66, p = 0.01) in total hip, -3.06% (95% CI: -5.49 to -0.63, p = 0.001) lumbar spine. There was no significant difference in BMD loss when comparing PrEP-exposed pregnant women to pregnant women who never used PrEP. Women who became pregnant were less likely to continue PrEP at subsequent study visits than women who did not become pregnant (adjOR: 0.25, 95% CI: 0.16-0.37, p < 0.001). Based on pill counts, there was a 62% reduction in the odds of high PrEP adherence during pregnancy (adjOR = 0.38, 95% CI: 0.27-0.58, p < 0.001). Conclusion Women who used PrEP during pregnancy experienced a similar reduction in BMD as pregnant women with no PrEP exposure, indicating that BMD loss in PrEP-using pregnant women is largely driven by pregnancy and not PrEP.
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Affiliation(s)
- Kidist Zewdie
- Department of Epidemiology, University of Washington, Seattle, WA, United States
- Department of Global Health, University of Washington, Seattle, WA, United States
| | - Flavia M. Kiweewa
- MakerereUniversity-Johns Hopkins University Research Collaboration, Kampala, Uganda
| | | | - Susan A. Morrison
- Department of Global Health, University of Washington, Seattle, WA, United States
| | | | - Jade Boyer
- Department of Medicine, Division of Infectious Disease, Columbia University, New York, NY, United States
| | - Felix Bambia
- Infectious Diseases Institute, Makerere University, Kampala, Uganda
| | - Josephine Badaru
- Infectious Diseases Institute, Makerere University, Kampala, Uganda
| | - Gabrielle Stein
- Department of Global Health, University of Washington, Seattle, WA, United States
| | - Kenneth K. Mugwanya
- Department of Epidemiology, University of Washington, Seattle, WA, United States
- Department of Global Health, University of Washington, Seattle, WA, United States
| | - Christina Wyatt
- Department of Medicine, Division of Nephrology, Duke University School of Medicine, Durham, NC, United States
| | - Michael T. Yin
- Department of Medicine, Division of Infectious Disease, Columbia University, New York, NY, United States
| | - Andrew Mujugira
- Department of Global Health, University of Washington, Seattle, WA, United States
- Infectious Diseases Institute, Makerere University, Kampala, Uganda
| | - Renee Heffron
- Department of Global Health, University of Washington, Seattle, WA, United States
- Department of Medicine, University of Alabama at Birmingham, Birmingham, AL, United States
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2
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Garcia M, Roberts ST, Mayo AJ, Scheckter R, Mansoor LE, Palanee-Phillips T, Reddy K, Naidoo Y, Akello CA, Gaffoor Z, Siva S, Rushwaya C, Hlahla K, Jambaya J, Makoni R, Kachale E, Ndovie M, Zuma J, Montgomery ET. Integrating Gender-Based Violence Screening and Support into the Research Clinic Setting: Experiences from an HIV Prevention Open-Label Extension Trial in Sub-Saharan Africa. AIDS Behav 2023; 27:1277-1286. [PMID: 36178556 PMCID: PMC10036410 DOI: 10.1007/s10461-022-03864-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/11/2022] [Indexed: 11/24/2022]
Abstract
HIV and gender-based violence (GBV) are syndemic in sub-Saharan Africa and provision of support for participants who disclose GBV constitutes part of comprehensive care. Consequently, a process was undertaken to develop, implement, and evaluate standard operating procedures (SOPs) in MTN-025/HOPE, a study of the dapivirine vaginal ring for HIV prevention. The SOP was developed using needs assessment surveys in addition to World Health Organization (WHO) guidelines and other literature. Sites tailored and implemented the SOP through HOPE implementation. At study end, staff reported increased training 32/35 (91.43%); improved confidence (18/26; 69.23%); and improved vicarious trauma prevention onsite (17/28; 60.71%). Leadership reported increased staff competence in GBV response. Obstacles included limited referral organizations and time for follow-up, continued training needs, and cultural norms. Development and implementation of an SOP is a feasible strategy to build a GBV response to improve health systems and support sustained effective use of HIV prevention products.
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Affiliation(s)
- Morgan Garcia
- Global Health Population and Nutrition, FHI 360, Durham, NC, USA.
- Global Health Population and Nutrition, FHI 360, 359 Blackwell St, Ste 200, Durham, NC, 27701, USA.
| | - Sarah T Roberts
- Women's Global Health Imperative (WGHI) RTI International, Berkeley, CA, USA
| | - Ashley J Mayo
- Global Health Population and Nutrition, FHI 360, Durham, NC, USA
| | - Rachel Scheckter
- Global Health Population and Nutrition, FHI 360, Durham, NC, USA
| | - Leila E Mansoor
- Centre for the AIDS Programme of Research in South Africa (CAPRISA), University of KwaZulu-Natal, Durban, South Africa
| | - Thesla Palanee-Phillips
- Faculty of Health Sciences, Wits Reproductive Health and HIV Institute (Wits RHI), University of the Witwatersrand, Johannesburg, South Africa
- University of Washington School of Public Health, Seattle, WA, USA
| | - Krishnaveni Reddy
- Faculty of Health Sciences, Wits Reproductive Health and HIV Institute (Wits RHI), University of the Witwatersrand, Johannesburg, South Africa
| | - Yuthika Naidoo
- Faculty of Health Sciences, Wits Reproductive Health and HIV Institute (Wits RHI), University of the Witwatersrand, Johannesburg, South Africa
| | - Carolyne Agwau Akello
- Makerere University-Johns Hopkins University (MU-JHU) Research Collaboration, Kampala, Uganda
| | - Zakir Gaffoor
- HIV Prevention Research Unit (HPRU), South African Medical Research Council (SAMRC), Durban, South Africa
| | - Samantha Siva
- HIV Prevention Research Unit (HPRU), South African Medical Research Council (SAMRC), Durban, South Africa
| | - Chenai Rushwaya
- University of Zimbabwe Clinical Trials Research Centre, Harare, Zimbabwe
| | - Kudzai Hlahla
- University of Zimbabwe Clinical Trials Research Centre, Harare, Zimbabwe
| | - Jane Jambaya
- University of Zimbabwe Clinical Trials Research Centre, Harare, Zimbabwe
| | - Rujeko Makoni
- University of Zimbabwe Clinical Trials Research Centre, Harare, Zimbabwe
| | - Evans Kachale
- College of Medicine - Johns Hopkins Bloomberg School of Public Health, Blantyre, Malawi
| | | | - Jabulisile Zuma
- Desmond Tutu HIV Foundation (DTHF) - Emavundleni Clinical Research Site, Cape Town, South Africa
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3
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Mirembe BG, Cabrera MV, van der Straten A, Nakalega R, Cobbing M, Mgodi NM, Palanee-Phillips T, Mayo AJ, Dadabhai S, Mansoor LE, Siva S, Nair G, Chinula L, Akello CA, Nakabiito C, Soto-Torres LE, Baeten JM, Brown ER. Correlates of Dapivirine Vaginal Ring Acceptance among Women Participating in an Open Label Extension Trial. AIDS Behav 2023; 27:1030-1043. [PMID: 36066762 PMCID: PMC10102709 DOI: 10.1007/s10461-022-03841-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/27/2022] [Indexed: 11/01/2022]
Abstract
MTN-025/HOPE was an open-label trial of the dapivirine vaginal ring conducted in four African countries between 2016 and 2018. Women were first offered one ring monthly (at baseline, months 1 and 2), thereafter, transitioned to a more applicable real-world dispensation schedule, - 3 rings quarterly (at months 3, 6 and 9). Logistic regression analysis was used to assess correlates of ring acceptance at baseline and through follow-up. A total of 1456 women (median age 31 years) enrolled, 1342 (92.2%) accepted the ring at baseline and 1163 (79.9%) accepted the ring(s) at all visits. Changing ring dispensation from a monthly to a quarterly schedule had no negative effect on acceptance. Having a primary partner and him knowing about the ring being offered in HOPE, use of long-acting contraception (implants, injections, IUDs) or sterilization were associated with ring acceptance, along with prior strong intention to use the ring in the future. Efforts should consider these factors when rolling out the ring for HIV prevention.
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Affiliation(s)
- Brenda Gati Mirembe
- Makerere University-Johns Hopkins University Research Collaboration, Kampala, Uganda.
- Vaccine and Infectious Disease and Public Health Sciences Divisions, Fred Hutchinson Cancer Research Center, Seattle, WA, USA.
- MU-JHU research Collaboration/MU-JHU CARE LTD, P.o. Box 23491, Kampala, Uganda.
| | | | - Ariane van der Straten
- Center for AIDS Prevention Studies, University of California San Francisco, San Francisco, CA, USA
- ASTRA Consulting, Kensington, CA, USA
| | - Rita Nakalega
- Makerere University-Johns Hopkins University Research Collaboration, Kampala, Uganda
| | - Mandy Cobbing
- HIV Prevention Research Unit, South African Medical Research Council, Durban, South Africa
| | - Nyaradzo M Mgodi
- University of Zimbabwe Clinical Trials Research Centre, Harare, Zimbabwe
| | - Thesla Palanee-Phillips
- Wits Reproductive Health and HIV Institute (Wits RHI), University of the Witwatersrand, 8 FHI 360, Johannesburg, South Africa
| | | | - Sufia Dadabhai
- College of Medicine-Johns Hopkins Research Project, Blantyre, Malawi
| | - Leila E Mansoor
- Centre for AIDS Programme of Research in South Africa, University of KwaZulu-Natal, Durban, South Africa
| | - Samantha Siva
- HIV Prevention Research Unit, South African Medical Research Council, Durban, South Africa
| | - Gonasagrie Nair
- The Desmond Tutu HIV Centre, University of Cape Town, Cape Town, South Africa
| | - Lameck Chinula
- University of North Carolina (UNC) Project Malawi Clinical Research Site, Lilongwe, Malawi
| | - Carolyne A Akello
- Makerere University-Johns Hopkins University Research Collaboration, Kampala, Uganda
| | - Clemensia Nakabiito
- Makerere University-Johns Hopkins University Research Collaboration, Kampala, Uganda
| | - Lydia E Soto-Torres
- Division of AIDS, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, MD, USA
| | - Jared M Baeten
- Departments of Global Health, Medicine, and Epidemiology, University of Washington, Seattle, USA
- Gilead Sciences, Foster City, CA, USA
| | - Elizabeth R Brown
- Department of Biostatistics, University of Washington, Seattle, WA, USA
- Vaccine and Infectious Disease and Public Health Sciences Divisions, Fred Hutchinson Cancer Research Center, Seattle, WA, USA
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4
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Velloza J, Roche S, Concepcion T, Ortblad KF. Advancing considerations of context in the evaluation and implementation of evidence-based biomedical HIV prevention interventions: a review of recent research. Curr Opin HIV AIDS 2023; 18:1-11. [PMID: 36503876 PMCID: PMC9757852 DOI: 10.1097/coh.0000000000000768] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
PURPOSE OF REVIEW A paradigm shift is needed in how we think about biomedical HIV prevention product effectiveness. Often, we expect randomized trial findings to be generalizable across populations and settings where products will be delivered, without consideration of key contextual drivers that could impact effectiveness. Moreover, researchers and policy-makers generally discount products with varied effect sizes across contexts, rather than explicating the drivers of these differences and using them to inform equitable product choice and delivery. We conducted a review of the recent HIV prevention research to advance considerations of context in choices of when, why, and how to implement biomedical HIV prevention products, with a particular focus on daily oral preexposure prophylaxis (PrEP) and the dapivirine vaginal ring (DPV). RECENT FINDINGS Findings across recent studies of PrEP and DPV emphasize that products that do not work well in one context might be highly desirable in another. Key contextual drivers of PrEP and DPV effectiveness, use, and implementation include population, health system, cultural, and historical factors. We recommend conceptualization, measurement, and analysis approaches to fully understand the potential impact of context on prevention product delivery. Execution of these approaches has real-world implications for HIV prevention product choice and could prevent the field from dismissing biomedical HIV prevention products based on trial findings alone. SUMMARY Ending the HIV epidemic will require tailored, person-centered, and equitable approaches to design, implement, and evaluate HIV prevention products which necessitates considerations of context in ongoing research and implementation.
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Affiliation(s)
- Jennifer Velloza
- Department of Epidemiology & Biostatistics, University of California San Francisco, San Francisco, California
| | - Stephanie Roche
- Fred Hutchinson Cancer Center, Public Health Sciences Division
| | - Tessa Concepcion
- Department of Global Health, University of Washington, Seattle, Washington
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Naidoo K, T ME, Katz AW, Morgan G, Krishnaveni R, Lydia ST, Sarita N, Leila ME. Efficacy and Action of the Dapivirine Vaginal Ring as Understood by Women Participating in an Open Label Extension Study. AIDS Behav 2023; 27:75-81. [PMID: 35672549 DOI: 10.1007/s10461-022-03745-y] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/29/2022] [Indexed: 01/24/2023]
Abstract
The concept of efficacy, and how HIV prevention products biologically work can be complex. We report on women's interpretation of efficacy of the dapivirine vaginal ring and how they understood it to work to prevent HIV during the MTN-025/HOPE study through data collected from individual in-depth interviews. Ten women at each of the 6 HOPE research sites in Lilongwe, Malawi; Durban (2 sites) and Johannesburg, South Africa; Kampala, Uganda; and Chitungwiza, Zimbabwe, were enrolled (n = 60). Despite its partial efficacy, women trusted the ring to prevent HIV even when condoms were not used. The action of the ring was understood by most, however, there were misunderstandings around how quickly or slowly protection was offered when the ring was inserted or removed. Counselling sessions adapted to address partial efficacy, a multi-layered HIV prevention plan and how study products work could alleviate inconsistent adherence and diminished protection and further support women in receiving the best protection from their HIV prevention product of choice.
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Affiliation(s)
- Kalendri Naidoo
- Centre for the AIDS Programme of Research in South Africa (CAPRISA), University of KwaZulu- Natal, Durban, South Africa.
- Centre for the AIDS Programme of Research in South Africa (CAPRISA), Doris Duke Medical Research Institute (2nd Floor), 719 Umbilo Road, Private Bag X7, 4013, Congella, Durban, South Africa.
| | - Montgomery Elizabeth T
- Women's Global Health Imperative, RTI International, Berkeley, California, United States of America
| | - Ariana Wk Katz
- Women's Global Health Imperative, RTI International, Berkeley, California, United States of America
| | - Garcia Morgan
- Global Health Population and Nutrition, FHI 360, Durham, NC, United States of America
| | - Reddy Krishnaveni
- Wits Reproductive Health and HIV Institute (Wits RHI), Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Soto-Torres Lydia
- Division of AIDS, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Rockville, Maryland, United States of America
| | - Naidoo Sarita
- HIV and Other Infectious Diseases Research Unit (HIDRU), South African Medical Research Council, Durban, South Africa
- The Aurum Institute, Johannesburg, South Africa
| | - Mansoor E Leila
- Centre for the AIDS Programme of Research in South Africa (CAPRISA), University of KwaZulu- Natal, Durban, South Africa
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6
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Qualitative Analysis Using Social Maps to Explore Young Women's Experiences With Social Support of their Oral PrEP Use in Kenya and South Africa. J Assoc Nurses AIDS Care 2023; 34:45-57. [PMID: 36170124 DOI: 10.1097/jnc.0000000000000363] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/24/2023]
Abstract
ABSTRACT Daily oral pre-exposure prophylaxis (PrEP) adherence is challenging. We explored African adolescent girls and young women's (AGYW) perceptions of the social influencers of their PrEP use and the social influencers' PrEP knowledge and support (six focus group discussions; 33 South African and Kenyan AGYW) in the Prevention Options for Women Evaluation Research demonstration project. Participants completed a social mapping exercise indicating strength and direction of influence of members in their social networks. Mothers and counselors were identified as positive influencers and most influential by >50% of participants, sex partners were labeled negative influencers or both positive and negative, and best friends were mostly positive influencers. HIV- and PrEP-related stigma were the major reasons influencers were identified as negative. Participants wanted their social networks to be better educated about PrEP by someone other than the AGYW themselves (e.g., clinic staff) and to support their PrEP use. To improve PrEP adherence, community- and peer-based PrEP sensitization and delivery interventions should be evaluated.
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7
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Katz AWK, Balán IC, Reddy K, Etima J, Weber K, Tauya T, Atujuna M, Scheckter R, Ngure K, Soto-Torres L, Mgodi N, Palanee-Phillips T, Baeten JM, van der Straten A. Women's experience receiving drug feedback and adherence counseling in MTN-025/HOPE - an HIV Prevention open-label trial of the Dapivirine Vaginal Ring. AIDS Behav 2022; 26:3607-3619. [PMID: 35536519 PMCID: PMC9561023 DOI: 10.1007/s10461-022-03663-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/18/2022] [Indexed: 11/01/2022]
Abstract
In the Phase IIIB MTN-025/HOPE open label extension trial, participants were offered the dapivirine vaginal ring as HIV prophylaxis, and those who accepted the ring received semi real-time individual adherence feedback, based on residual drug level (RDL) from returned rings, during Motivational Interviewing-based counseling. Counseling messages, based on the best knowledge at the time, framed RDL results in terms of ring use and HIV protection, from no use /no protection (0 RDL) to high use /high protection (3 RDL). At six HOPE sites, in-depth-Interviews (IDIs) about RDL were conducted with 64 participants who had received at least one RDL result. We found mixed interpretations of what the RDL meant and strong emotional reactions with a focus on the external validation of the level itself. Counseling was critical to help participants process their reactions to the RDL and make decisions accordingly (i.e., persistence, adherence improvement, and/or switching to another HIV prevention method). Providing drug adherence feedback was complex to implement yet proved useful as a component of a multi-pronged adherence support strategy.
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Affiliation(s)
| | - Iván C Balán
- HIV Center for Clinical and Behavioral Studies, Columbia University, New York, New York, United States
- Present affiliation Florida State University College of Medicine, Tallahassee, FL, USA
| | - Krishnaveni Reddy
- Wits Reproductive Health and HIV Institute (Wits RHI), Johannesburg, South Africa
| | - Juliane Etima
- Makerere University, Johns Hopkins University Research Collaboration, Kampala, Uganda
| | | | - Thelma Tauya
- College of Health Sciences Clinical Trials Unit, University of Zimbabwe, Harare, Zimbabwe
| | - Millicent Atujuna
- Desmond Tutu AIDS Foundation, University of Cape Town, Cape Town, South Africa
| | | | - Kenneth Ngure
- Department of Community Health, Jomo Kenyatta University of Agriculture and Technology, Juja, Kenya
| | | | - Nyaradzo Mgodi
- College of Health Sciences Clinical Trials Unit, University of Zimbabwe, Harare, Zimbabwe
| | | | - Jared M Baeten
- University of Washington, Seattle, WA, USA
- Present affiliation Gilead Sciences, Foster City, CA, USA
| | - Ariane van der Straten
- Center for AIDS Prevention Studies (CAPS), University of California San Francisco, San Francisco, CA, USA
- Present affiliation ASTRA Consulting, Kensington, CA, USA
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Montgomery ET, Roberts ST, Reddy K, Tolley E, Hartmann M, Wilson E, Mathebula F, Wagner LD, Zissette S, Lanham M, Wilcher R, Baeten JM, Palanee-Phillips T. Integration of a Relationship-focused Counseling Intervention with Delivery of the Dapivirine Ring for HIV Prevention to Women in Johannesburg: Results of the CHARISMA Pilot Study. AIDS Behav 2022; 26:752-763. [PMID: 34546473 PMCID: PMC8840958 DOI: 10.1007/s10461-021-03434-2] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/10/2021] [Indexed: 12/21/2022]
Abstract
Biomedical, female-initiated HIV prevention methods can help reduce disproportionately high HIV rates among women in sub-Saharan Africa, but male partner resistance and intimate partner violence (IPV) may impact ability to ensure effective use. To support consistent use of the dapivirine vaginal ring (VR), we pilot-tested the impact of the CHARISMA relationship counseling intervention ("CHARISMA") with women enrolled in the multi-site open-label Microbicide Trials Network (MTN) 025/HOPE trial at the Wits Reproductive Health and HIV Research Institute (Wits RHI) site in Johannesburg, South Africa. Lay counselors used a 42-item tool with five subscales to assess relationships and IPV and provide tailored counseling at enrolment, followed by a booster counselling session at Month 1 and follow-up checks at Months 3 and 6. We evaluated potential impact by examining self-reported ring disclosure to partners, partner clinic attendance, self-reported incident social harms (SH) and IPV, and biomarkers of ring adherence at Wits RHI. We subsequently compared these outcomes at three comparator HOPE study sites using multivariable regression models. Comparator study sites were purposively selected as those most similar to Wits RHI for baseline characteristics identified a priori. At Wits RHI, 95 of 96 (99%) HOPE participants enrolled into the CHARISMA pilot study. Mean age was 30, 36.8% lived with a partner, and 85.3% received their partner's financial support. During the six months of pilot study follow-up, participants reported: ring use disclosure to partners at 72.7% visits; 4.3% partners attending the research clinic; one partner-related SH; and 9.5% experienced incident IPV. The mean level of dapivirine released from returned used rings was 3.4 mg (SD 1.56), suggesting moderate adherence. Participants in the CHARISMA pilot had high background prevalence and incidence of IPV but were nevertheless able to adhere to ring use, and some male partners came to the research clinic. In adjusted regression models, compared to Wits RHI, partner clinic attendance was lower at all comparator sites; and significantly so at Site A (aRR 0.12, 95% CI 0.00-0.98). Sites B and C had lower levels of dapivirine released (suggesting lower adherence), but this difference was not significant. Site B women were more likely to report ring disclosure to partners at FU visits (aRR 1.12, 95% CI 1.00-1.25). IPV reported during follow-up was significantly lower at Site B (aRR 0.20, 95% CI 0.04-0.98, p = 0.047). CHARISMA taught women skills to decide on levels of ring-use disclosure to partners or others; therefore it is difficult to interpret differences in ring disclosure to partners with other sites. Similarly, CHARISMA heightened participants' awareness of abuse, possibly increasing IPV reports. Testing CHARISMA under fully-powered controlled conditions will improve understanding of its impact on women's relationships and ability to use female-initiated HIV prevention methods.
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Affiliation(s)
| | - Sarah T Roberts
- Women's Global Health Imperative, RTI International, Berkeley, CA, USA
| | - Krishnaveni Reddy
- Wits Reproductive Health and HIV Institute, University of the Witwatersrand, Johannesburg, South Africa
| | | | - Miriam Hartmann
- Women's Global Health Imperative, RTI International, Berkeley, CA, USA
| | - Ellen Wilson
- Women's Global Health Imperative, RTI International, Berkeley, CA, USA
| | - Florence Mathebula
- Wits Reproductive Health and HIV Institute, University of the Witwatersrand, Johannesburg, South Africa
| | - L Danielle Wagner
- Women's Global Health Imperative, RTI International, Berkeley, CA, USA
| | | | | | | | - Jared M Baeten
- Department of Global Health, University of Washington, Seattle, WA, USA
| | - Thesla Palanee-Phillips
- Wits Reproductive Health and HIV Institute, University of the Witwatersrand, Johannesburg, South Africa
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9
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Balán IC, Lentz C, Giguere R, Dolezal C, Kajura-Manyindo C, Kutner BA, Zalwango A, Makoni R, Madlala B, Makala Y, Khanyile N, Kadyamusuma M, Kachenjera L, Ndhlovu-Forde Z, Tuswa-Haynes N. Inconsistent Counselor Fidelity in Delivering an Evidence-Based Adherence Intervention During a PrEP Trial. AIDS Behav 2022; 26:698-708. [PMID: 34390433 PMCID: PMC8840968 DOI: 10.1007/s10461-021-03429-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/06/2021] [Indexed: 10/20/2022]
Abstract
Evidence-based adherence counseling interventions must be delivered with fidelity to ensure that their effectiveness is retained, but little is known regarding how counselors in biomedical HIV trials deliver these interventions. Forty-two counselors from the MTN-025/HOPE Study, which was conducted in 14 sites in sub-Saharan Africa, participated. They completed a quantitative assessment and consented for their HOPE counseling session ratings to be analyzed. Twenty-two (52%) self-identified as research nurses and 20 (48%) as counselors. Of 928 session ratings, 609 (66%) were classified as Good, 188 (20%) as Fair, and 131 (14%) as Poor, based on pre-established criteria. Overall mean ratings for session tasks and global components (each rated from 1 to 5) were 4.12 (SD = 0.45; range 2.46-4.73) and 4.02 (SD = 0.64; range 1.75-4.79), respectively. Twenty-six (62%) counselors attained Good or Fair ratings on at least 85% of their sessions, but 33% of counselors had more than 25% of their sessions rated as Poor; three counselors (7%) never met criteria for a Good session. Even after extensive training, counselors' fidelity to the intervention varied. Our findings highlight the value of fidelity monitoring using session audio-recordings, the importance of ongoing coaching and support, and the need to plan for counselors with consistently poor fidelity.
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Affiliation(s)
- Iván C Balán
- HIV Center for Clinical and Behavioral Studies at New York State Psychiatric Institute and Columbia University, 1051 Riverside Drive, Unit 15, New York, NY, 10032, USA.
- Florida State University College of Medicine, Tallahassee, FL, USA.
| | - Cody Lentz
- HIV Center for Clinical and Behavioral Studies at New York State Psychiatric Institute and Columbia University, 1051 Riverside Drive, Unit 15, New York, NY, 10032, USA
| | - Rebecca Giguere
- HIV Center for Clinical and Behavioral Studies at New York State Psychiatric Institute and Columbia University, 1051 Riverside Drive, Unit 15, New York, NY, 10032, USA
| | - Curtis Dolezal
- HIV Center for Clinical and Behavioral Studies at New York State Psychiatric Institute and Columbia University, 1051 Riverside Drive, Unit 15, New York, NY, 10032, USA
| | - Clare Kajura-Manyindo
- HIV Center for Clinical and Behavioral Studies at New York State Psychiatric Institute and Columbia University, 1051 Riverside Drive, Unit 15, New York, NY, 10032, USA
| | - Bryan A Kutner
- HIV Center for Clinical and Behavioral Studies at New York State Psychiatric Institute and Columbia University, 1051 Riverside Drive, Unit 15, New York, NY, 10032, USA
| | - Aisha Zalwango
- Makerere University - Johns Hopkins University Research Collaboration CRS, Kampala, Uganda
| | - Rujeko Makoni
- University of Zimbabwe College of Health Sciences Zengeza Clinical Trials Unit, Harare, Zimbabwe
| | - Bernadette Madlala
- CAPRISA Clinical Trials Unit for AIDS/Tuberculosis Prevention and Treatment, Durban, South Africa
| | - Yvonne Makala
- University of North Carolina Lilongwe Clinical Research Site, Lilongwe, Malawi
| | - Nombuso Khanyile
- South African Medical Research Council Tongaat Clinical Trials Unit, Durban, South Africa
| | - McLoddy Kadyamusuma
- HIV Center for Clinical and Behavioral Studies at New York State Psychiatric Institute and Columbia University, 1051 Riverside Drive, Unit 15, New York, NY, 10032, USA
| | - Lonely Kachenjera
- HIV Center for Clinical and Behavioral Studies at New York State Psychiatric Institute and Columbia University, 1051 Riverside Drive, Unit 15, New York, NY, 10032, USA
| | - Zanele Ndhlovu-Forde
- HIV Center for Clinical and Behavioral Studies at New York State Psychiatric Institute and Columbia University, 1051 Riverside Drive, Unit 15, New York, NY, 10032, USA
| | - NoCamagu Tuswa-Haynes
- HIV Center for Clinical and Behavioral Studies at New York State Psychiatric Institute and Columbia University, 1051 Riverside Drive, Unit 15, New York, NY, 10032, USA
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10
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Joseph Davey DL, Dovel K, Mvududu R, Nyemba D, Mashele N, Bekker LG, Gorbach PM, Coates TJ, Myer L. Pre-exposure Prophylaxis Recent Adherence With Real-Time Adherence Feedback and Partner Human Immunodeficiency Virus Self-Testing: A Pilot Trial Among Postpartum Women. Open Forum Infect Dis 2021; 9:ofab609. [PMID: 35097151 PMCID: PMC8794072 DOI: 10.1093/ofid/ofab609] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2021] [Accepted: 12/01/2021] [Indexed: 12/13/2022] Open
Abstract
Background Pre-exposure prophylaxis (PrEP) is safe and effective in postpartum women. Human immunodeficiency virus self-testing (HIVST) for male partners combined with biofeedback counseling through real-time adherence measures may improve PrEP use among postpartum women. Methods Between August 2020 and April 2021, we randomized postpartum women who initiated PrEP in pregnancy 1:1 to the intervention group (HIVST + biofeedback counseling after urine tenofovir test) or to standard of care ([SOC] facility-based human immunodeficiency virus [HIV] tests and routine counseling without biofeedback). The outcomes of interest were PrEP adherence in the past 48–72 hours via urine tenofovir tests and partner HIV testing, measured 1-month after randomization. Secondary outcomes included the proportion of partners who tested for HIV and the discrepancy between self-reported PrEP adherence and urine tenofovir result. Results We enrolled 106 women (median age = 26 years). At enrollment, 72% of women reported missing <2 doses in the past 7 days; 36% of women had tenofovir present in her urine. One month after enrollment, 62% (n = 33) of women in the intervention arm had tenofovir present in their urine compared to 34% (n = 18) in SOC (risk ratio [RR] = 1.83; 95% confidence interval [CI] = 1.19–2.82; P = .001). Two thirds of women in the intervention arm reported that her partner tested for HIV (66%; n = 35), compared to 17% (n = 9) in SOC (RR = 3.89; 95% CI = 2.08–7.27; P < .001). Self-reported PrEP adherence (took PrEP >5 of last week) with no tenofovir in urine test was lower in the intervention group (17% vs 46%; RR = 0.33; 95% CI = 0.17–0.67; P = .03). No social or clinical adverse events were reported in the intervention arm. Conclusions The HIVST for partners and biofeedback counseling increased levels of recent PrEP adherence, pointing to the importance of these interventions to support PrEP use in this population.
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Affiliation(s)
- Dvora Leah Joseph Davey
- Department of Epidemiology, Fielding School of Public Health, University of California Los Angeles, Los Angeles, California, USA
- Division of Epidemiology and Biostatistics, School of Public Health and Family Medicine, University of Cape Town, Cape Town, South Africa
- The Desmond Tutu HIV Centre, University of Cape Town, Cape Town, South Africa
- Division of Infectious Diseases, David Geffen School of Medicine, University of California Los Angeles, Los Angeles, California, USA
| | - Kathryn Dovel
- Division of Infectious Diseases, David Geffen School of Medicine, University of California Los Angeles, Los Angeles, California, USA
| | - Rufaro Mvududu
- Division of Epidemiology and Biostatistics, School of Public Health and Family Medicine, University of Cape Town, Cape Town, South Africa
| | - Dorothy Nyemba
- Division of Epidemiology and Biostatistics, School of Public Health and Family Medicine, University of Cape Town, Cape Town, South Africa
| | - Nyiko Mashele
- Division of Epidemiology and Biostatistics, School of Public Health and Family Medicine, University of Cape Town, Cape Town, South Africa
| | - Linda-Gail Bekker
- The Desmond Tutu HIV Centre, University of Cape Town, Cape Town, South Africa
| | - Pamina M Gorbach
- Department of Epidemiology, Fielding School of Public Health, University of California Los Angeles, Los Angeles, California, USA
| | - Thomas J Coates
- Division of Infectious Diseases, David Geffen School of Medicine, University of California Los Angeles, Los Angeles, California, USA
| | - Landon Myer
- Division of Epidemiology and Biostatistics, School of Public Health and Family Medicine, University of Cape Town, Cape Town, South Africa
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11
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Sekhon M, van der Straten A. Pregnant and breastfeeding women's prospective acceptability of two biomedical HIV prevention approaches in Sub Saharan Africa: A multisite qualitative analysis using the Theoretical Framework of Acceptability. PLoS One 2021; 16:e0259779. [PMID: 34784355 PMCID: PMC8594804 DOI: 10.1371/journal.pone.0259779] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2021] [Accepted: 10/26/2021] [Indexed: 11/19/2022] Open
Abstract
HIV infection during pregnancy and breastfeeding has implications for maternal health. Between May- November 2018, we explored prospective acceptability of two novel HIV Pre-exposure Prophylaxis (PrEP) products, oral pills and vaginal rings, through focus group discussions with 65 pregnant and breastfeeding women in Malawi, South Africa, Uganda, Zimbabwe. Qualitative analysis was completed, guided by the Theoretical Framework of Acceptability (TFA). First, a deductive thematic analysis was applied to relevant coded data, into the seven TFA constructs (Affective Attitude; Burden; Ethicality, Intervention Coherence; Opportunity Costs; Perceived Effectiveness; Self-efficacy). Next, an iterative analysis was completed to generate themes within each of the TFA constructs. Women’s positive attitudes towards daily oral PrEP highlighted the familiarity of taking pills, understanding the purpose of taking pills, and the perception that it is an effective method to protect mothers and babies from HIV during pregnancy and breastfeeding. Women emphasized the ease of using the ring given its monthly duration that lowers burden on the user, its discreetness and invisibility once in place. The TFA analysis highlighted how acceptability of both methods could be enhanced by focusing on perceptions of the end users (i.e. the women) and not just the products themselves. This approach provided insights into how to refine the intervention materials and plans for implementation.
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Affiliation(s)
- Mandeep Sekhon
- Department of Population Health Sciences, School of Population Health and Environmental Sciences, Faculty of Life Sciences & Medicine, King’s College London, London, United Kingdom
- * E-mail:
| | - Ariane van der Straten
- Center for AIDS prevention studies, University of California San Francisco, CA, United States of America
- Women’s Global Health imperative, RTI International, Berkeley, CA, United States of America
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12
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Celum CL, Gill K, Morton JF, Stein G, Myers L, Thomas KK, McConnell M, van der Straten A, Baeten JM, Duyver M, Mendel E, Naidoo K, Dallimore J, Wiesner L, Bekker LG. Incentives conditioned on tenofovir levels to support PrEP adherence among young South African women: a randomized trial. J Int AIDS Soc 2021; 23:e25636. [PMID: 33247553 PMCID: PMC7695999 DOI: 10.1002/jia2.25636] [Citation(s) in RCA: 39] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2020] [Revised: 10/12/2020] [Accepted: 10/16/2020] [Indexed: 12/13/2022] Open
Abstract
Introduction HIV incidence remains high among African adolescent girls and young women (AGYW), who would benefit from pre‐exposure prophylaxis (PrEP). Strategies to increase PrEP adherence and persistence need to be evaluated in African AGY, including incentives conditional on high adherence. Methods The 3Ps for Prevention Study was a 12‐month prospective cohort of 200 women ages 16 to 25 initiating PrEP in South Africa from 2017 to 2018. Participants received retrospective feedback about drug levels at Months 1, 2 and 3; half was randomized to receive a 200 Rand shopping voucher ($13 US) at Months 2, 3 and 4, conditioned on high intracellular tenofovir diphosphate (TFV‐DP) levels in dried blood spots (≥500 fmol/punch at Month 1, ≥700 fmol/punch at Months 2 and 3). The primary analysis was intention‐to‐treat, comparing the proportion with high PrEP adherence (≥700 fmol/punch) at Month 3 by randomized group, based on 100% efficacy among men who have sex with men. Results Median age of the 200 women was 19 years (interquartile range [IQR] 17, 21); 86% had a primary sexual partner. At Month 3, the mean TFV‐DP level was 822 fmol/punch (SD 522) in the incentive group and 689 fmol/punch (SD 546) in the control group (p = 0.11). Forty‐five (56%) of 85 women in the incentive group and 35 (41%) of 85 women in the control group had TFV‐DP levels ≥700 fmol/punch (RR 1.35; 95% CI 0.98, 1.86; p = 0.067), which declined to 8% and 5% in the incentive and control groups at Month 12 (no significant difference by arm). 44% refilled PrEP without gaps, 14% had a gap of ≥3 weeks in coverage subsequently restarted PrEP and 54% accepted at the final dispensing visit at Month 9. No new HIV infections were observed after PrEP initiation. Conclusions Among South African AGYW initiating PrEP, drug levels indicated high PrEP adherence in almost half of women at Month 3, with a non‐statistically significant higher proportion with high adherence among those in the incentive group. Over half persisted with the 12‐month PrEP programme although high adherence declined after Month 3. Strategies to support PrEP adherence and persistence and longer‐acting PrEP formulations are needed.
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Affiliation(s)
- Connie L Celum
- Department of Global Health, University of Washington, Seattle, WA, USA.,Department of Medicine, University of Washington, Seattle, WA, USA.,Department of Epidemiology, University of Washington, Seattle, WA, USA
| | - Katherine Gill
- The Desmond Tutu HIV Centre, University of Cape Town, Cape Town, South Africa
| | - Jennifer F Morton
- Department of Global Health, University of Washington, Seattle, WA, USA
| | - Gabrielle Stein
- Department of Global Health, University of Washington, Seattle, WA, USA
| | - Laura Myers
- The Desmond Tutu HIV Centre, University of Cape Town, Cape Town, South Africa
| | | | | | - Ariane van der Straten
- Women's Global Health Imperative, RTI International, Berkeley, CA, USA.,Center for AIDS Prevention Studies, Department of Medicine, University of California, San Francisco, CA, USA
| | - Jared M Baeten
- Department of Global Health, University of Washington, Seattle, WA, USA.,Department of Medicine, University of Washington, Seattle, WA, USA.,Department of Epidemiology, University of Washington, Seattle, WA, USA
| | - Menna Duyver
- The Desmond Tutu HIV Centre, University of Cape Town, Cape Town, South Africa
| | - Eve Mendel
- The Desmond Tutu HIV Centre, University of Cape Town, Cape Town, South Africa
| | - Keshani Naidoo
- The Desmond Tutu HIV Centre, University of Cape Town, Cape Town, South Africa
| | - Jacqui Dallimore
- The Desmond Tutu HIV Centre, University of Cape Town, Cape Town, South Africa
| | - Lubbe Wiesner
- Department of Pharmacology, University of Cape Town, Cape Town, South Africa
| | - Linda-Gail Bekker
- The Desmond Tutu HIV Centre, University of Cape Town, Cape Town, South Africa
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13
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Lentz C, Giguere R, Kutner BA, Dolezal C, Kajura-Manyindo C, Yambira M, Asiimwe F, Mugocha C, Mwenda W, Ndlovu T, Naidu N, Madlala B, Balán IC. Culturally-Based Challenges to and Recommendations for Delivering Adherence Counseling in a Multicultural Biomedical HIV Prevention Trial in Four African Countries. AIDS EDUCATION AND PREVENTION : OFFICIAL PUBLICATION OF THE INTERNATIONAL SOCIETY FOR AIDS EDUCATION 2020; 32:512-527. [PMID: 33779210 PMCID: PMC8059360 DOI: 10.1521/aeap.2020.32.6.512] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/16/2023]
Abstract
Research is needed to identify how to effectively tailor evidence-based interventions across cultures with limited resources, particularly for behavioral components in large HIV prevention trials. Through surveys and interviews with counselors of sub-Saharan African women during an open-label microbicide trial (MTN-025), we examined language, education, and cultural barriers in delivering a motivational interviewing-based adherence counseling intervention (i.e., Options Counseling). Counselors encountered an array of barriers, most prominently that participants struggled to comprehend culturally incongruent pictorial guides, such as traffic light images, and to uphold product use when primary partners disapproved. Overwhelmingly, counselors cited the intervention's inherent flexibility as an asset; it encouraged them to tailor language and examples to be more culturally relevant to participants. Future resource-conscious researchers may preemptively offset similar barriers by consulting with communities during intervention development. Similarly, affording counselors flexibility while delivering the chosen intervention may enable them to troubleshoot barriers that arise on the ground.
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Affiliation(s)
- Cody Lentz
- HIV Center for Clinical and Behavioral Studies at New York State Psychiatric Institute and Columbia University, New York, New York, United States of America
| | - Rebecca Giguere
- HIV Center for Clinical and Behavioral Studies at New York State Psychiatric Institute and Columbia University, New York, New York, United States of America
| | - Bryan A. Kutner
- HIV Center for Clinical and Behavioral Studies at New York State Psychiatric Institute and Columbia University, New York, New York, United States of America
| | - Curtis Dolezal
- HIV Center for Clinical and Behavioral Studies at New York State Psychiatric Institute and Columbia University, New York, New York, United States of America
| | - Clare Kajura-Manyindo
- HIV Center for Clinical and Behavioral Studies at New York State Psychiatric Institute and Columbia University, New York, New York, United States of America
| | - Makanaka Yambira
- University of Zimbabwe College of Health Sciences Clinical Trials Research Center, Harare, Zimbabwe
| | - Florence Asiimwe
- Makerere University – Johns Hopkins University Research Collaboration Clinical Research Site, Kampala, Uganda
| | - Caroline Mugocha
- University of Zimbabwe College of Health Sciences Clinical Trials Research Center, Harare, Zimbabwe
| | - Wezi Mwenda
- Queen Elizabeth Central Hospital, College of Medicine Clinical Research Site, Blantyre, Malawi
| | - Thakasile Ndlovu
- South African Medical Research Council Clinical Trials Unit, Durban, South Africa
| | - Nalini Naidu
- South African Medical Research Council Clinical Trials Unit, Durban, South Africa
| | | | - Iván C. Balán
- HIV Center for Clinical and Behavioral Studies at New York State Psychiatric Institute and Columbia University, New York, New York, United States of America
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