PrEPare for Work: A Pilot Randomized Controlled Trial of an Intervention to Optimize HIV PrEP Outcomes Among Male Sex Workers

Interventions to Improve Adherence to Oral Pre-exposure Prophylaxis: A Systematic Review and Network Meta-analysis

For people at risk of HIV infection, pre-exposure prophylaxis (PrEP) can reduce the risk of infection in anticipation of exposure to HIV. The effectiveness of PrEP relies upon a user's adherence to their PrEP regimen. We sought to assess the effect of PrEP adherence interventions compared to usual care or another intervention for people at risk of HIV. We searched electronic databases from 2010 onwards for randomized controlled trials (RCTs) involving persons at risk of HIV randomized to an adherence promoting intervention vs usual care or another intervention. We used network meta-analyses to compare PrEP adherence for all participant populations. Certainty of evidence was assessed using Confidence in Network Meta-Analysis (CINeMA). 21 trials (N = 4917) were included in qualitative analysis (19 in network meta-analyses (N = 4101)). HIV self-testing interventions with adherence feedback elements improved adherence compared to usual care (risk ratio (RR): 1.83, 95%CI 1.19, 2.82). In contrast, HIV self-testing alone was inferior to HIV self-testing with adherence feedback (RR: 0.58, 95%CI 0.37-0.92). Reminders alone also were inferior to HIV self-testing with adherence feedback on adherence (RR: 0.53, 95%CI 0.34-0.84) and had similar effects on adherence as usual care (RR: 0.98, 95%CI: 0.86-1.11). Interventions with only one component were inferior for adherence than those with two components (RR: 0.74, 95%CI 0.62-0.88) and those with three components (RR: 0.78, 95%CI 0.65-0.93). The certainty of evidence was moderate for HIV self-testing plus adherence feedback and interventions with two or three components. When designing future PrEP adherence interventions, we recommend strategies with more than one but no more than three components.

Study protocol of a randomized controlled trial to assess the efficacy of the "PrEPare for Work" intervention to enhance PrEP uptake and optimize adherence for HIV prevention among male sex workers in the U.S

BACKGROUND

Male sex workers (MSWs), specifically cisgender men who exchange sex for money, goods, drugs, or other items of value with other cisgender men, are at high risk for HIV infection. Compared to men not engaged in sex work, MSWs are more likely to engage in frequent condomless sex with paying and non-paying sexual partners. While MSWs are often included as a subgroup of gay and bisexual men, data show that a large proportion identify as heterosexual; additionally, most MSWs do not identify as "sex workers." This places MSWs in a unique position where they may not engage with traditional HIV prevention programs, and when they do, they may not feel comfortable, leading to poor retention. Thus, HIV prevention interventions that address MSWs' unique life circumstances and provide support in exploring their sexual health options are needed.

METHODS

In this protocol paper, we describe the design and procedures for a National Institute of Health-funded, randomized controlled trial testing the efficacy of "PrEPare for Work,"- a theory-based, manualized PrEP uptake and adherence intervention for MSW - using a 2-stage randomization design. Stage 1: MSWs are equally randomized to receive either the "PrEPare for Work Stage 1 intervention" (strength-based case management and facilitated PrEP linkage) or Standard of Care (SOC) to evaluate successful PrEP uptake (prescription filled) within two months post-randomization. Stage 2: Those who initiate PrEP are then equally re-randomized to receive either the "PrEPare for Work Stage 2 intervention" (1-on-1 skills training, problem-solving, and motivational interviewing adherence counseling and personalized, daily text message reminders) or SOC to assess adherence (Tenofovir concentrations in hair) over 12 months of follow up. Planned analyses will examine intervention efficacy, specific conceptual mediators, and hypothesized moderators.

DISCUSSION

Based on our extensive preliminary research, multi-component, theory-informed interventions targeting this subpopulation of MSWs' unique life circumstances are urgently needed. In this study, we are evaluating whether "PrEPare for Work" can improve PrEP uptake and adherence among MSWs. If this intervention is efficacious, it would be readily disseminated to diverse community organizations that serve MSWs and possibly other community or clinic-based settings.

TRIAL REGISTRATION

ClinicalTrials.gov number NCT05736614, registered February 8, 2023.

Exploring the willingness toward HIV immediate test and treat among MSM in Nairobi and its environs: a cross-sectional study

Background

In the test and treat initiative, high-risk populations are screened for human immunodeficiency virus (HIV) infection and start early treatment if diagnosed positive. This study explores factors associated with willingness to initiate testing and immediate treatment among men who have sex with men (MSM) in Nairobi and its environs. The study was informed by a conceptual framework combining the AIDS Risk Reduction Model (ARRM) and the Modified Social Ecological Model.

Methods

This cross-sectional exploratory study targeted MSM (aged 18-60 years) reporting active engagement in anal or oral sex with men in Nairobi and its surrounding areas. Purposive sampling was used to identify data collection sites, and then snowballing was employed to reach the respondents. Data analysis was performed using SPSS version 23, and binary logistics regression was used for inferential analysis.

Results

Between July 2018 and June 2019, 391 MSM were recruited to fill out a self-administered questionnaire, out of which 345 complete questionnaires were analyzed. Never been tested for HIV, private/NGO as the facility of the last HIV test, and had unprotected anal sex were listed as the reasons for taking the most recent test, and the results of the most recent HIV test and seeking a post self-test confirmation were associated with a higher likelihood of accepting the immediate HIV test and treat initiative. Additionally, a preference for a health provider as the first source of support, belief in the efficacy of ARVs, and disclosure about being on ART were the other reasons. Additionally, being aged 25+ years, having more than 60 USD monthly income, and having inconsistent condom use during sex were associated with a higher likelihood of accepting the immediate HIV test and treat initiative. Barriers to the immediate test and treat strategy included stigma from healthcare providers and concerns about disruptions in lifestyle through antiretroviral therapy (ART) use.

Conclusion

Interventions aimed at increasing the HIV test and treat initiative in Kenya may need to take into account the demographic and social characteristics of MSM, including age, lack of habitual HIV testing, and lifestyle changes before and upon enrollment in ART. Projects should also consider working closely with healthcare facilities to strengthen treatment preparation, especially for asymptomatic MSM and those who may not be immediately willing to choose the test and treat strategy.