On-Demand Oral Pre-exposure Prophylaxis with Tenofovir/Emtricitabine: What Every Clinician Needs to Know

Barriers and facilitators to pre-exposure prophylaxis (PrEP) uptake and adherence among men who have sex with men (MSM) in Thailand: a qualitative study

Young MSM (YMSM), aged 15-24, account for nearly half of new HIV infections in Thailand. Pre-exposure prophylaxis (PrEP) is an effective prevention medicine for populations at substantial HIV risk, yet YMSM frequently have suboptimal uptake of and adherence to PrEP. We conducted 35 in-depth interviews with YMSM to explore barriers and facilitators of both PrEP initiation and adherence. Interviews also elicited the perceptions and experiences of healthcare providers (HCPs) working with YMSM at three clinics in Bangkok. Primary barriers to PrEP initiation were limited accessibility, insufficient knowledge, and efficacy concerns; HCPs identified no-to-low self-perception of HIV risk, pre-existing health problems, fears of side effects, and living in distant provinces as barriers to PrEP initiation. YMSM primarily reported PrEP information and self-perceptions of elevated HIV risk as facilitators to PrEP initiation. Additionally, forgetfulness and low HIV risk awareness were common barriers to PrEP adherence. Reminders were a prominent facilitator of PrEP adherence alongside disclosure to close relationships, the routinization of regimens, and convenient facilities. HCPs regarded counseling as the leading facilitator of PrEP adherence. By understanding the barriers/facilitators of PrEP use, the current study seeks to help develop evidence-informed PrEP intervention programs among YMSM while considering cultural sensitivity.

Dynamicity of HIV Pre-exposure Prophylaxis Usage Pattern and Association with Executed Adherence in MSM: An Implementation Study in Hong Kong

Pre-exposure prophylaxis (PrEP) use has been shown to be effective for HIV prevention in men who have sex with men (MSM). PrEP use coverage aside, maintenance of high PrEP adherence is crucial in ensuring the achievement of HIV prevention. In this PrEP implementation study in Hong Kong, we examined the patterns of PrEP use in MSM and evaluated their association with prevention-effective adherence for HIV prevention. In January 2020-June 2021 in Hong Kong, 312 recruited MSM (median 30 years old) were followed up for 1 year, with HIV and creatinine testing, consultation, and PrEP refill. No HIV breakthrough infection was observed. As a measure of prevention-effective adherence, executed adherence (EA) was expressed as the proportion of days with HIV risk that were protected by PrEP and/or condom in 6 months. In 65,585 diary entries of 215 MSM, the median proportion of EA achieved was 89% (IQR 84-93%). Three latent classes of PrEP users were identified by latent class analysis. Taking Class 1 "daily dominant PrEP" (n = 113, 53%) as reference, Class 2 "episodic PrEP" (n = 76, 35%) was adopted by MSM with less sexual activity, had less PrEP refill and lower EA level, while Class 3 "mixed PrEP schedule" (n = 26, 12%) MSM were more sexually active but with a similar EA level. The study findings showed varied and dynamic PrEP usage patterns in the real-world setting. Strategies for promoting adherence are needed to ensure the maintenance of high EA level among PrEP-using MSM especially those on episodic PrEP schedule.

Acute facial neuralgia related to initiation of emtricitabine/tenofovir for HIV PrEP: a report of two cases in a PrEP demonstration trial

BACKGROUND

Emtricitabine (FTC) and tenofovir disoproxil fumarate (TDF) fixed-dose combination (FTC/TDF) is generally well-tolerated, although treatment-related adverse events have been reported.

METHODS

We report two cases of persons using FTC/TDF PrEP who had acute neuralgia in a Chinese PrEP demonstration trial.

RESULTS

Neurological symptoms subsided upon treatment discontinuation. Symptoms were reported as similar to one case's previous experiences with dolutegravir (DTG)+FTC+tenofovir alafenamide (TAF) (for PEP), leading to permanent discontinuation of PrEP.

CONCLUSION

Acute facial neuralgia appears to be a rare idiosyncratic adverse event to FTC/TDF.

HIV in youth prevention in the emergency department initiative: A survey of pediatric emergency medicine providers

BACKGROUND

The incidence of HIV among adolescents remains high, and adolescents are known to participate in sexual behaviors that increase their risk for HIV, such as unprotected sex and sex with multiple partners. HIV pre-exposure prophylaxis (PrEP) has been shown to be effective at preventing HIV when taken daily and is approved by the FDA for use in adolescents. Efforts to screen patients in adult emergency departments and connect them with PrEP services have been validated. We surveyed pediatric emergency medicine (PEM) providers to determine their knowledge of PrEP, prescribing practices, willingness to prescribe, and barriers to a screening protocol in the pediatric emergency department (PED).

METHODS

We administered a survey to a multidisciplinary group of PEM providers to measure knowledge, use, willingness, and implementation barriers to PrEP as well as elements needed for a successful referral system.

RESULTS

A total of 87 responses were included for analysis. While 79.1% of all providers had heard of PrEP, only 14.8% of prescribing providers had ever discussed PrEP with a patient, and none had ever prescribed PrEP. Overall, 76.3% of all providers were knowledgeable about PrEP based on answers to true/false questions, with prescribing providers significantly more likely to be knowledgeable compared to nurses (p = 0.005). Knowledgeable providers had higher willingness scores to refer for PrEP compared to providers who were not knowledgeable. Ninety-two percent of providers felt a PrEP referral process from the PED would be feasible. Creation of an eligibility algorithm and educational materials were the most common efforts providers preferred to make them more likely to refer for PrEP. The most notable barriers perceived by providers included patient noncompliance with therapy (20.9%), acceptance of PrEP discussion among patients and parents (19.8%), and cost of therapy (15.1%).

CONCLUSION

PEM providers are knowledgeable about PrEP but have little experience with discussing or prescribing PrEP. Their willingness to refer for PrEP and anticipated feasibility of a PrEP referral system is encouraging. These results support the need for future educational efforts among PEM providers and creation of referral systems for PrEP services from the PED.

Pre-exposure prophylaxis service among men who have sex with men in Malaysia: findings from a discrete choice experiment

Men who have sex with men (MSM) in Malaysia are disproportionately affected by HIV. As pre-exposure prophylaxis (PrEP) is being introduced, we assessed population-based PrEP delivery preferences among MSM in Malaysia. We conducted a discrete choice experiment through an online survey among 718 MSM. The survey included 14 choice tasks presenting experimentally varied combinations of five attributes related to PrEP delivery (i.e., cost, dosing strategy, clinician interaction strategy, dispensing venue, and burden of visits to start PrEP). We used latent class analysis and Hierarchical Bayesian modeling to generate the relative importance of each attribute and preference across six possible PrEP delivery programs. PrEP dosing, followed by cost, was the most important attribute. The participants were clustered into five preference groups. Two groups (n = 290) most commonly preferred on-demand, while the other three preferred injectable PrEP. One group (n = 188) almost exclusively considered cost in their decision-making, and the smallest group (n = 86) was substantially less interested in PrEP for reasons unrelated to access. In simulated scenarios, PrEP initiation rates varied by the type of program available to 55·0% of MSM. Successful PrEP uptake among Malaysian MSM requires expanding beyond daily oral PrEP to on-demand and long-acting injectable PrEP, especially at affordable cost.

Barriers to uptake of PrEP across the continuum among transgender women: A global scoping review

BACKGROUND

Although preexposure prophylaxis (PrEP) has demonstrated high efficacy for HIV prevention, rates of PrEP uptake remain low among the transgender population, especially in transgender women (TGW). We conducted this scoping review to assess and characterize barriers to PrEP use along the PrEP care continuum among TGW.

METHODS

We conducted this scoping review by searching studies in Embase, PubMed, Scopus, and Web of Science. Eligibility criteria included: reporting a PrEP related quantitative result among TGW; peer-reviewed and published in English between 2010-2021.

RESULTS

Globally, high willingness (80%) to use PrEP was found, yet uptake and adherence (35.4%) were low. TGW experiencing hardship, including poverty, incarceration, and substance use, were associated with higher odds of PrEP awareness but lower odds of PrEP use. Structural and social barriers such as stigma, medical mistrust, and perceived racism can be important barriers for PrEP continuation. High social cohesion and hormone replacement therapy were associated with greater odds of awareness. In addition, our study confirmed prior research showing that PrEP does not lower feminizing hormone levels in TGW.

CONCLUSIONS

Significant demographic factors among TGW that are associated with PrEP engagement. It is imperative to focus on TGW as a population with independent needs, requiring specific PrEP care guidelines and tailored resource allocation, that fully considers individual-, provider-, and community/structural-level barriers and facilitators. The present review also indicates that combining PrEP care with GAHT or broader gender-affirmation care may facilitate PrEP use.

Projected Impact of Expanded Long-Acting Injectable PrEP Use Among Men Who Have Sex With Men on Local HIV Epidemics

BACKGROUND

Pre-exposure prophylaxis (PrEP) is a key component in helping to reduce HIV incidence in the United States. Long-acting injectable (LAI) PrEP is a new alternative to oral PrEP; its potential to affect local HIV epidemics remains unclear.

METHODS

The Johns Hopkins HIV Economic Epidemiological model (JHEEM) is a dynamic model of HIV transmission in 32 US urban areas. We used JHEEM to project the HIV incidence among men who have sex with men (MSM) from 2020 to 2030 under a range of interventions aimed at increasing PrEP use.

RESULTS

In the absence of any intervention (ie, current levels of oral PrEP and HIV care engagement), we projected a 19% reduction (95% credible interval, CrI 1% to 36%) in HIV incidence among MSM from 2020 to 2030 across all 32 cities. Adding 10% LAI PrEP uptake (above a base case of all oral PrEP) reduced the incidence by 36% (95% CrI 23% to 50%) by year 2030. This effect varied between cities, ranging from 22% in Atlanta to 51% in San Francisco. At 25% additional LAI PrEP uptake, this incidence reduction increased to 54% (95% CrI 45% to 64%). Reductions in incidence after introducing LAI PrEP were driven primarily by increased uptake and sustained usage rather than increased efficacy.

CONCLUSIONS

LAI PrEP has the potential to substantially reduce HIV incidence among MSM, particularly if it increases PrEP uptake and continued use beyond existing levels. Because potential effects vary by city, the effectiveness of expanding PrEP use is dependent on local dynamics.

Incorrect Knowledge of Event-Driven PrEP "2-1-1" Dosing Regimen Among PrEP-Experienced Gay and Bisexual Men in Australia

BACKGROUND

Event-driven pre-exposure prophylaxis (ED-PrEP), when taken according to the "2-1-1" dosing method, is highly effective at preventing HIV acquisition for gay, bisexual, and other men who have sex with men (GBM). Any missed doses when using ED-PrEP drastically reduce its effectiveness, so it is vital that people using this method know how to take it correctly. This study investigated Australian GBM's awareness of ED-PrEP and their knowledge of how to take it correctly.

METHOD

We conducted a survey of 1471 PrEP-experienced GBM in Australia, between October 2019 and March 2020. The survey assessed awareness and knowledge of the 3 components of the "2-1-1" ED-PrEP dosing regimen (number of pills for loading dose, timing of loading dose, and number of days after sex to take PrEP pills) among GBM. Characteristics associated with ED-PrEP awareness and correct knowledge of how to take ED-PrEP were assessed with multivariate logistic regression.

RESULTS

Two-thirds (n = 1004, 68.4%) had heard of ED-PrEP, of whom only one-eighth (n = 125, 12.5%) knew the correct details of the "2-1-1" ED-PrEP method; one-third (n = 339, 33.8%) did not know any of the 3 key components. Awareness of ED-PrEP and correct knowledge was associated with greater belief in PrEP efficacy, university education, and intention to take a nondaily PrEP regimen in the next 6 months.

CONCLUSIONS

Although ED-PrEP awareness was considerable, most participants did not know how to use ED-PrEP correctly. Further work is needed to increase awareness and knowledge of ED-PrEP among GBM.

Delayed presentation of HIV among older individuals: a growing problem

Late presentation for care is a major impediment to the prevention and effective treatment of HIV infection. Older individuals are at increased risk of late presentation, represent a growing proportion of people with late presentation, and might require interventions tailored to their age group. We provide a summary of the literature published globally between 2016-21 (reporting data from 1984-2018) and quantify the association of age with delayed presentation. Using the most common definitions of late presentation and older age from these earlier studies, we update this work with data from the International Epidemiology Databases to Evaluate AIDS (IeDEA) consortium, focusing on data from 2000-19, encompassing four continents. Finally, we consider how late presentation among older individuals might be more effectively addressed as electronic medical records become widely adopted.

Changes in Utilization of Birth Control and PrEP During COVID-19 in the USA: A Mixed-Method Analysis

In the USA, the COVID-19 pandemic has created challenges beyond the direct consequences of the infection. Because of shifting resources in response to need, many domains within the healthcare sector unrelated to COVID-19 have had interrupted abilities to provide care. In the current study, we focus on preventative sexual health care during the pandemic. In a sample of 511 (mean age = 27.7) people, we examined quantitative data regarding continuation and discontinuation of birth control and PrEP during the pandemic, along with qualitative data illustrating the underlying reasons for participants' (dis)continuation. Results showed that most (92.5%) of birth control users reported continuation of their birth control, with the predominant reasons reported being use for health reasons, long-acting reversible contraceptive use, access to remote healthcare services, and increased vigilance over pregnancy prevention. Conversely, around half (52.6%) of PrEP-using participants reported already discontinuing or planning to discontinue their PrEP regimen. Temporary abstinence and concerns about accessing in-person health care were the predominant reasons for PrEP discontinuation. These results have implications for both researchers and sexual healthcare providers. Disruptions to preventative sexual health care should be considered in ongoing research about patient needs, and healthcare providers may wish to consider particular challenges faced by PrEP users concerning re-start and continuation.

PrEP Willingness and Adherence Self-Efficacy Among Men Who have Sex with Men with Recent Condomless Anal Sex in Urban China

This study investigates PrEP willingness, adherence self-efficacy and potential impact of PrEP among HIV-negative, Chinese men who have sex with men (MSM; n = 622) with recent condomless anal sex. Facilitative factors of PrEP willingness included migrant status, sexual risk, and prior PrEP use, whereas barriers included concerns over being treated as an HIV/AIDS patient, recent HIV testing, identity concealment, and HIV prevention service usage. Adherence self-efficacy was associated with PrEP knowledge and confidence in PrEP efficacy of HIV prevention. A total of 39.3% anticipated increase in sex partners, 25.6% anticipated decrease in condom use, and 38.0% anticipated increased HIV testing following PrEP uptake. Results suggest a two-step approach to (1) promote PrEP acceptance among Chinese MSM and (2) enhance adherence and risk monitoring among PrEP-willing MSM. Efforts to reduce stigma, incorporate PrEP in the HIV prevention continuum, and increase PrEP knowledge will be crucial to optimize PrEP implementation.

Temporal Variation in One-Time Partnership Rates Among Young Men Who Have Sex With Men and Transgender Women

BACKGROUND

Volatility in sexual contact rates has been recognized as an important factor influencing HIV transmission dynamics. One-time partnerships may be particularly important given the potential to quickly accumulate large number of contacts. Yet, empirical data documenting individual variation in contact rates remain rare. This study provides much needed data on temporal variation in one-time partners to better understand behavioral dynamics and improve the accuracy of transmission models.

METHODS

Data for this study were obtained from a longitudinal cohort study of young men who have sex with men and transgender women in Chicago. Participants provided sexual network data every 6 months for 2 years. A series of random effects models examined variation in one-time partnership rates and disaggregated within and between associations of exposure variables. Exposure variables included prior number of one-time partners, number of casual partners, and having a main partner.

RESULTS

Results indicated substantial between-person and within-person variation in one-time partners. Casual partnerships were positively associated and main partnerships negatively associated with one-time partnership rates. There remained a small positive association between prior one-time partnerships and the current number of one-time partnerships.

CONCLUSIONS

Despite the preponderance of a low number of one-time partners, substantial variation in one-time partnership rates exists among young men who have sex with men and transgender women. Accordingly, focusing on high contact rate individuals alone may be insufficient to identify periods of highest risk. Future studies should use these estimates to more accurately model how volatility impacts HIV transmission and better understand how this variation influences intervention effectiveness.

Facilitators and barriers of 2-1-1 HIV pre-exposure prophylaxis

An alternative strategy for men who have sex with men (MSM) experiencing challenges with daily HIV pre-exposure prophylaxis (PrEP) includes 2-1-1 dosing. Understanding 2-1-1 PrEP facilitators and barriers, especially during the SARS-CoV-2 pandemic, may guide researchers and healthcare providers in future studies and clinical preparedness. We conducted a national cross-sectional study of MSM in the US who had taken 2-1-1 PrEP to examine facilitators and barriers of this on-demand PrEP dosing option. With the shelter-in-place orders in March 2020, this study was adapted to include questions on how the SARS-CoV-2 pandemic affected participants' PrEP use. A total of 140 individuals participated in the survey, 106 of which completed questions pertaining to the SARS-CoV-2 pandemic. The most common reasons for switching from once-daily to 2-1-1 PrEP included having sex less frequently (63.6%) and wanting to take fewer pills (46.4%). Participants reported high medication adherence based on each component of 2-1-1 PrEP dosing (>84%). The most common barriers with 2-1-1 PrEP dosing included unplanned sexual encounters resulting in missing the double-dose pre-sex (43.6%) and trouble remembering doses post-sex (29.3%). Facilitators of the 2-1-1 PrEP dosing strategy included reductions in sexual encounters (63.6%), preference to take fewer pills (46.4%), need to reduce cost (22.1%), and desire to reduce side effects (19.3%). Challenges to receiving PrEP services during the pandemic included obtaining laboratory testing (25.5%) and PrEP refills (either receipt of a refill authorization from a healthcare provider or processing of a refill from the pharmacy) (18.9%). 2-1-1 PrEP is an effective HIV prevention method; therefore, understanding facilitators and barriers of this dosing strategy can result in continuous provision of HIV prevention efforts, particularly during a pandemic.