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Stoner MCD, Mathebula F, Sedze N, Seyama L, Mohuba R, Fabiano Z, Etima J, Young A, Scheckter R, van der Straten A, Piper J, Noguchi L, Montgomery ET, Balán IC. Depression Among Pregnant and Breastfeeding Persons Participating in Two Randomized Trials of the Dapivirine Vaginal Ring and Oral Pre-Exposure Prophylaxis (PrEP) in Malawi, South Africa, Uganda, and Zimbabwe. AIDS Behav 2024; 28:2264-2275. [PMID: 38526641 DOI: 10.1007/s10461-024-04321-2] [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: 03/11/2024] [Indexed: 03/27/2024]
Abstract
Depression is associated with lower adherence to oral pre-exposure prophylaxis (PrEP) to prevent HIV, but data are not currently available on how depression may affect use of other HIV prevention methods including the dapivirine vaginal ring (DVR). We conducted a mixed methods study using data from the Microbicide Trials Network (MTN) 042/DELIVER (n = 558) and MTN-043/B-PROTECTED (n = 197) studies to describe the prevalence of depressive symptoms and explore how depressive symptoms may have influenced attitudes about use of the monthly DVR and once-daily oral PrEP tablet among pregnant and breastfeeding persons, respectively, in Malawi, South Africa, Uganda, and Zimbabwe. Eleven participants had high Edinburgh Postnatal Depression scores ≥ 10 in MTN-042/DELIVER (2%) and four participants (2%) in MTN-043/B-PROTECTED. In interviews with 9 participants who had high scores (6 DVR, 3 oral PrEP), those with depressive symptoms described overlapping stressors which were magnified by job loss and economic instability during the COVID-19 pandemic, and by experiences of pregnancy/postpartum. These participants experienced a lack of support from partners or family members, and conflict with partners related to trust, and infidelity. While we did not find evidence of a change in product adherence, there was a strong sense of commitment and motivation to use the study products for protection from HIV for participants themselves and their baby. Although lack of social support is usually an obstacle to adherence, in this study, the participants' lives and relationships seemed to have reinforced the need for HIV prevention and motivated women to protect themselves and their babies from HIV.
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Affiliation(s)
| | - Florence Mathebula
- Wits RHI, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Natasha Sedze
- Clinical Trials Research Centre, University of Zimbabwe, Harare, Zimbabwe
| | - Linly Seyama
- Johns Hopkins Project, Kamuzu University of Health Sciences, Blantyre, Malawi
| | - Rebone Mohuba
- Wits RHI, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Zayithwa Fabiano
- Johns Hopkins Project, Kamuzu University of Health Sciences, Blantyre, Malawi
| | - Juliane Etima
- Makerere University - Johns Hopkins University (MU-JHU) Research Collaboration, Kampala, Uganda
| | | | | | | | - Jeanna Piper
- National Institute of Allergy and Infectious Diseases (NIAID), Bethesda, MD, USA
| | - Lisa Noguchi
- Division of Reproductive, Maternal, Newborn, Child and Adolescent Health, Jhpiego/Johns Hopkins University, Washington, DC, USA
| | | | - Iván C Balán
- Florida State University College of Medicine, Tallahassee, FL, USA
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Young AM, Mancuso N, Atujuna M, Tenza S, Chitukuta M, Kemigisha D, Ngure K, van der Straten A, Garcia M, Szydlo D, Soto-Torres L, Roberts ST. Adolescent Girls and Young Women's Experiences with Disclosing Oral PrEP or Dapivirine Vaginal Ring Use: a Multi-Country Qualitative Analysis. AIDS Behav 2023; 27:3941-3951. [PMID: 37392268 PMCID: PMC10598125 DOI: 10.1007/s10461-023-04109-w] [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: 06/02/2023] [Indexed: 07/03/2023]
Abstract
Effective use of oral pre-exposure prophylaxis (PrEP) has been low among adolescent girls and young women (AGYW) in Eastern and Southern Africa, partly due to stigma and opposition from key influencers. Understanding AGYW's experiences of disclosure of different PrEP modalities to key influencers may inform strategies to motivate uptake and adherence. We analyzed qualitative in-depth interviews and focus group discussions data from 119 participants in the MTN-034/REACH (Reversing the Epidemic in Africa with Choices in HIV Prevention) study of oral PrEP and the dapivirine vaginal ring (ring) to explore AGYW's disclosure experiences. We found that AGYW disclosure experiences varied across influencers and product type. The ring was disclosed less often to most influencers, except partners, because it was discreet. Oral PrEP was disclosed more often, because pills were more common and to avoid HIV stigma given that oral PrEP resembled HIV treatment. Ultimately, disclosure typically led most key influencers to support product use through reminders and encouragement. While disclosure yielded positive support from influencers, further community awareness of both PrEP products is essential to reduce potential opposition and perceived stigma.Clinical Trial Number: NCT03593655.
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Affiliation(s)
- Alinda M Young
- Women's Global Health Imperative, RTI International, 2150 Shattuck Avenue, Suite 800, Berkeley, CA, 94704, USA.
- University of North Carolina at Chapel Hill, Chapel Hill, NC, USA.
| | - Noah Mancuso
- Women's Global Health Imperative, RTI International, 2150 Shattuck Avenue, Suite 800, Berkeley, CA, 94704, USA
| | | | - Siyanda Tenza
- Wits Reproductive Health and HIV Institute (Wits RHI), University of the Witwatersrand, Johannesburg, South Africa
| | - Miria Chitukuta
- University of Zimbabwe Clinical Trials Research Centre (UZ-CTRC), Harare, Zimbabwe
| | - Doreen Kemigisha
- Makerere University - Johns Hopkins University Research Collaboration, Kampala, Uganda
| | - Kenneth Ngure
- School of Public Health, Jomo Kenyatta University of Agriculture and Technology, Nairobi, Kenya
| | - Ariane van der Straten
- ASTRA Consulting, Kensington, CA and CAPS, Department of Medicine, University of California, San Francisco, San Francisco, USA
| | | | - Danny Szydlo
- Statistical Center for HIV/AIDS Research and Prevention, Fred Hutchinson Cancer Research Center, Seattle, WA, USA
| | - Lydia Soto-Torres
- National Institute of Allergy and Infectious Diseases, National Institutes of Health, Maryland, MD, USA
| | - Sarah T Roberts
- Women's Global Health Imperative, RTI International, 2150 Shattuck Avenue, Suite 800, Berkeley, CA, 94704, USA
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Roberts ST, Mancuso N, Williams K, Nabunya HK, Mposula H, Mugocha C, Mvinjelwa P, Garcia M, Szydlo DW, Soto‐Torres L, Ngure K, Hosek S. How a menu of adherence support strategies facilitated high adherence to HIV prevention products among adolescent girls and young women in sub-Saharan Africa: a mixed methods analysis. J Int AIDS Soc 2023; 26:e26189. [PMID: 37936551 PMCID: PMC10630658 DOI: 10.1002/jia2.26189] [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] [Received: 02/13/2023] [Accepted: 10/18/2023] [Indexed: 11/09/2023] Open
Abstract
INTRODUCTION Effective use of pre-exposure prophylaxis (PrEP) has been low among adolescent girls and young women (AGYW) in sub-Saharan Africa. The MTN-034/REACH trial offered AGYW a menu of adherence support strategies and achieved high adherence to both daily oral PrEP and the monthly dapivirine vaginal ring. Understanding how these strategies promoted product use could inform the design of adherence support systems in programmatic settings. METHODS REACH was a randomized crossover trial evaluating the safety of and adherence to the ring and oral PrEP among 247 HIV-negative AGYW (ages 16-21) in South Africa, Uganda and Zimbabwe from January 2019 to September 2021 (NCT03593655). Adherence support included monthly counselling sessions with drug-level feedback (DLF) plus optional daily short message service (SMS) reminders, weekly phone or SMS check-ins, peer support clubs, "peer buddies" and additional counselling. Counsellors documented adherence support choices and counselling content on standardized forms. Through focus groups, serial in-depth interviews (IDIs) and single IDIs (n = 119 total), we explored participants' experiences with adherence support and how it encouraged product use. RESULTS Participants received counselling at nearly all visits. DLF was provided at 54.3% of sessions and, across sites, 49%-68% received results showing high adherence for oral PrEP, and 73%-89% for the ring. The most popular support strategies were in-person clubs and weekly calls, followed by online clubs, additional counselling and SMS. Preferences differed across sites but were similar for both products. Qualitative results demonstrated that the REACH strategies supported adherence by providing information about HIV and PrEP, continually motivating participants, and supporting the development of behavioural skills and self-efficacy, aligning with the Information, Motivation, and Behavioural Skills (IMB) model. Effectiveness was supported by three foundational pillars: strong interpersonal relationships with counsellors; ongoing, easily accessible support and resources; and establishing trust in the counsellors and study products through counsellor relationships, peer-to-peer exchange and DLF. CONCLUSIONS Implementation programmes could support effective PrEP use by offering a small menu of counsellor- and peer-based support options that are youth-friendly and developmentally appropriate. The same menu options can support both ring and oral PrEP users, though content should be tailored to the individual products.
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Affiliation(s)
- Sarah T. Roberts
- Women's Global Health Imperative, RTI InternationalBerkeleyCaliforniaUSA
| | - Noah Mancuso
- Women's Global Health Imperative, RTI InternationalAtlantaGeorgiaUSA
| | - Kristin Williams
- Applied Public Health Research CenterRTI InternationalResearch Triangle ParkNorth CarolinaUSA
| | | | - Hlengiwe Mposula
- Wits Reproductive Health and HIV InstituteJohannesburgSouth Africa
| | - Caroline Mugocha
- University of Zimbabwe Clinical Trials Research CentreHarareZimbabwe
| | | | | | - Daniel W. Szydlo
- Statistical Center for HIV/AIDS Research and PreventionFred Hutchinson Cancer CenterSeattleWashingtonUSA
| | - Lydia Soto‐Torres
- Division of AIDSNational Institute of Allergy and Infectious Diseases, National Institutes of HealthBethesdaMarylandUSA
| | - Kenneth Ngure
- School of Public HealthJomo Kenyatta University of Agriculture and TechnologyNairobiKenya
- Department of Global HealthUniversity of WashingtonSeattleWashingtonUSA
| | - Sybil Hosek
- Center for Dissemination and Implementation ScienceUniversity of Illinois ChicagoChicagoIllinoisUSA
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Delivering PrEP to Young Women in a Low-Income Setting in South Africa: Lessons for Providing Both Convenience and Support. AIDS Behav 2022; 26:147-159. [PMID: 34259963 PMCID: PMC8786762 DOI: 10.1007/s10461-021-03366-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/28/2021] [Indexed: 11/29/2022]
Abstract
Daily oral pre-exposure prophylaxis (PrEP) is a key tool in addressing high HIV incidence among young women, and breaking the cycle of transmission. From 2017 to 2020, Médecins Sans Frontières (MSF) offered PrEP, in conjunction with contraception and risk-reduction counselling, to women aged 18–25, in a government-run clinic in Khayelitsha, a low income high HIV prevalence area in South Africa. Drawing on clinical, quantitative, and qualitative interview data, we describe participants’ experiences and engagement with the PrEP program, participant adherence (measured by TFV-DP levels in dried blood spots) over time, and the indirect benefits of the PrEP program. Of 224 screened and eligible participants, 164 (73.2%) initiated PrEP, with no large differences between those who initiated and those who did not. Overall, 47 (29%) completed 18 months follow-up, with 15 (9.1%) attending all visits. 76 (46.9%) participants were lost to follow-up, 15 (9.1%) exited when leaving the area, and 28.7% of exits happened in the first month of the study. We identified two different trajectories of PrEP adherence: 67% of participants had, on average, consistently low TFV-DP levels, with the remaining 33% having sustained high adherence. Few baseline characteristics predicted good adherence. The main reported barrier to taking PrEP was forgetting to take or travel with the pills. Encouragement from others declined as a reported facilitator from month 6 to 18 (family: 93.1% vs 77.6%, p = 0.016, friends: 77.6% vs 41.4%, p ≤ 0.001, partners: 62.1% vs 46.6%, p = 0.096, other PrEP users: 89.7% vs 74.1%, p = 0.020). Disclosure to friends and family in some cases opened dialogue around sex, and helped to educate others about PrEP. Self-reported sex with more than one partner, and sex without a condom, decreased significantly after enrolment (p < 0.001, p = 0.063). In the individual interviews, participants credited their PrEP experience with changing their behaviour. Recognising the challenges with, but overall benefits from a package of care that includes the option of PrEP, lessons drawn from this study can help maximise persistence on PrEP within resource constraints. PrEP providers need to address participants’ need for both convenience and social support.
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Abstract
There is growing evidence for the key role of social determinants of health (SDOH) in understanding morbidity and mortality outcomes globally. Factors such as stigma, racism, poverty or access to health and social services represent complex constructs that affect population health via intricate relationships to individual characteristics, behaviors and disease prevention and treatment outcomes. Modeling the role of SDOH is both critically important and inherently complex. Here we describe different modeling approaches and their use in assessing the impact of SDOH on HIV/AIDS. The discussion is thematically divided into mechanistic models and statistical models, while recognizing the overlap between them. To illustrate mechanistic approaches, we use examples of compartmental models and agent-based models; to illustrate statistical approaches, we use regression and statistical causal models. We describe model structure, data sources required, and the scope of possible inferences, highlighting similarities and differences in formulation, implementation, and interpretation of different modeling approaches. We also indicate further needed research on representing and quantifying the effect of SDOH in the context of models for HIV and other health outcomes in recognition of the critical role of SDOH in achieving the goal of ending the HIV epidemic and improving overall population health.
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Rodriguez-Diaz CE, Davis W, Ellis MV, Cameron MS, Donastorg Y, Bowleg L, Greenberg A, Kerrigan D. Disrupting the Systems: Opportunities to Enhance Methodological Approaches to Address Socio-Structural Determinants of HIV and End the Epidemic Through Effective Community Engagement. AIDS Behav 2021; 25:225-231. [PMID: 34618266 PMCID: PMC8494756 DOI: 10.1007/s10461-021-03475-7] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/16/2021] [Indexed: 12/12/2022]
Abstract
A world without HIV is only possible by addressing the socio-structural determinants of health. Our understanding of socio-structural determinants is constantly changing, and parallel changes must occur with the methodologies used to explain the drivers of the HIV epidemic. We argue for the need to engage communities in the planning, implementation, and dissemination of research on the socio-structural determinants of HIV. Community engagement should cross-cut various types of research including rigorous measurement development of socio-structural determinants and novel analytic techniques to model their role in the trajectory of the epidemic and the impact of interventions. Considering the role of place, we recommend collaboration between scientists and communities in the interpretation of results from studies that map HIV-related behaviors and movement. As we collectively delve into historically oppressive systems with colonial antecedents, we must be ready to challenge these systems and replace them with collaborative models. The success of research-driven HIV policy and programming will best be evaluated with methodologies derived from the insights of the very individuals that these policies and programs aim to serve.
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Affiliation(s)
- Carlos E Rodriguez-Diaz
- Department of Prevention and Community Health, Milken Institute School of Public Health, George Washigton University, 950 New Hampshire Ave NW, Suite 300, Washington, DC, 20052, USA.
- DC Center for AIDS Research, Washington, USA.
| | - Wendy Davis
- Department of Prevention and Community Health, Milken Institute School of Public Health, George Washigton University, 950 New Hampshire Ave NW, Suite 300, Washington, DC, 20052, USA
- DC Center for AIDS Research, Washington, USA
| | | | | | - Yeycy Donastorg
- Instituto Dermatológico y Cirugia de Piel, Santo Domingo, Dominican Republic
| | - Lisa Bowleg
- DC Center for AIDS Research, Washington, USA
- Department of Psychology and Brain Sciences, George Washington University, Washington, USA
| | - Alan Greenberg
- DC Center for AIDS Research, Washington, USA
- Department of Epidemiology, George Washington University-Milken Institute School of Public Health, Washington, USA
| | - Deanna Kerrigan
- Department of Prevention and Community Health, Milken Institute School of Public Health, George Washigton University, 950 New Hampshire Ave NW, Suite 300, Washington, DC, 20052, USA
- DC Center for AIDS Research, Washington, USA
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