HIV pre-exposure prophylaxis for women

Drug transporter mRNA expression and genital inflammation in South African women on oral pre-exposure prophylaxis (PrEP)

Globally HIV remains a major public health problem. In sub-Saharan Africa most new HIV infections occur in adolescent girls and young women. Previously tested antiretroviral drugs as different pre-exposure prophylaxis (PrEP) formulations have shown inconsistent levels of protection against HIV in African women. Besides adherence, biological factors such as drug transporter proteins are increasingly recognized as key modulators of PrEP levels. Drug transporter mRNA expression levels has been significantly correlated to altered PrEP levels in-vitro in different tissues, with inflammation identified as a further modifier of drug transporters mRNA expression and thus PrEP levels. We therefore, aimed to determine possible concordance between drug transporter mRNA expression in the female genital tract (FGT) and blood of N = 45 South African women taking oral PrEP-Truvada® [TDF/FTC)] over 6 months for HIV prevention. Additionally, we determined associations between drug transporter mRNA expression, genital inflammation, and blood-tenofovir diphosphate (TFV-DP). mRNA-expression of four efflux P-gp; MATE-1; MRP-2; MRP-4 and two influx OAT-1 and OAT-3 drug transporters were determined by qRT-PCR. Multiplexed technology was used to measure 27 cytokines to define genital inflammation. Significant positive correlations of mRNA expression for P-gp, MATE-1, MRP-2, and MRP-4 were observed between the FGT and blood at 3- and 6-months post-PrEP initiation (p < 0.05). For OAT-1 however, significant positive correlations were observed pre- and post-PrEP exposure (p < 0.05). Linear-mixed models showed moderate associations between FGT cytokines and drug transporter mRNA expression, with a  direct relationship observed between MIP-1β concentration and MATE-1 mRNA expression. Similarly, PLS-DA showed that in women with genital inflammation, consistently higher mRNA expression of MATE-1 was observed compared to women without genital inflammation. No significant associations were observed between drug transporter mRNA expression and blood TFV-DP. Our results suggest that drug transporters may be similarly expressed in the FGT and blood. Furthermore, genital inflammation may modify PrEP levels by altering drug transporter mRNA expression. Collectively, our data may be used to better understand biological factors that may affect PrEP efficacy in African women who remain vulnerable to HIV.

Community and familial dynamics influencing risk behavior for HIV acquisition among adolescent girls and young women in Uganda: Qualitative analysis using Protective Motivation Theory

BACKGROUND

In Uganda, adolescent girls', and young women's (AGYW-15-24 years) current HIV prevalence is fourfold compared with their male counterparts due to compounded social, economic, and environmental factors. Using the Protective Motivation Theory (PMT), we explored HIV-acquisition risk sources and perceived protective factors from AGYW and caregivers' perspective.

MATERIALS AND METHODS

During 2018, we conducted a qualitative study guided by PMT to explore factors influencing HIV acquisition among AGYW. We purposively sampled two groups of key informants, AGYW at high-risk for HIV acquisition (uninfected) and AGYW living with HIV, varied by age and place of residence (urban/rural). We conducted 34 focus group discussions with AGYW, nine with AGYW parents, and 25 key informant interviews. Data were analyzed using the framework method based on the PMT and developed from participants' narratives.

RESULTS

AGYW were knowledgeable about HIV, HIV acquisition risk factors, and HIV prevention interventions. Nonetheless, few AGYW knew about pre-exposure prophylaxis (PrEP). Imbalance in power relations between the genders explained inability of AGYW making safe healthy decisions, with social norms giving men power over women. Parents modelling positively influenced HIV risk behavior. Many AGYW viewed staying in school a protective factor both while at school and further for life. AGYW identified alcohol use, desire for material possessions, discounting HIV disease severity, social norms, and poverty as barriers to engaging in self-protective behaviors. Several AGYW believed that access to AGYW-focused programs would facilitate healthy sex-positive, protective behaviors.

DISCUSSION

While PMT focuses on individual factors confirmed by our findings, we found HIV risk behavior to be influenced by complex contextual factors including poverty, gender inequality and cultural norms. Distinct HIV risk factors among AGYW require policy and comprehensive targeted interventions addressing violence, alcohol consumption, increased economic opportunities, educational opportunities, safe-sex practices, and PrEP scale-up which may prevent HIV in AGYW and facilitate HIV epidemic control.

Barriers to PrEP use and adherence among adolescent girls and young women in Eastern, Southern, and Western Africa: a scoping review

BACKGROUND

Adolescent girls and young women (AGYW) are disproportionately affected by HIV. Globally, in 2022, an estimated 4000 AGYW 15-24 were newly infected with HIV weekly, and nearly 78% of these infections occurred in sub-Saharan Africa. Oral Pre-Exposure Prophylaxis (PrEP) is a key HIV prevention option within an overall HIV combination prevention approach with an efficacy of over 90% when taken correctly. However, uptake of and adherence to PrEP remains low, particularly among AGYW. This scoping review aims to map available evidence on factors that limit PrEP use among AGYW in Eastern, Southern, and Western African countries to inform research, policy, and practice on delivery of PrEP. Our review identified factors that affect PrEP journey among AGYW along the HIV prevention cascade.

METHODS

Guided by Arksey and O'Malley framework and using the PRISMA extension for scoping reviews, we searched the Web of Science, Global Health, and PubMed databases. Our review focused on oral PrEP, specifically papers reporting on barriers to PrEP experienced by AGYW, and peer-reviewed English-language articles published between 2012 and 2023.

RESULTS

Of 1063 papers screened, 25 were included. Over half (60%) of the studies were qualitative; 72% were conducted in Kenya and South Africa. The barriers affecting motivation were, fear of side effects and pill burden, percieved low HIV risk, perceived stigma, PrEP use disapproval from parents and partners. PrEP access was limited by healthcare providers' stigma, isolated clinic setup, and lack of resources. Effective PrEP use was limited by a lack of parental or partner support, stigma, and lifestyle changes.

CONCLUSIONS

Adolescent girls and young women face multiple and often intersecting barriers to effective PrEP use with stigma being a factor cross-cutting all steps of the prevention cascade. Similarly, lack of social support, reflected through disapproval and judgmental attitudes and low HIV risk perception, also affected two steps of the prevention cascade. Our review identified gaps in available evidence, with most studies conducted in only two countries and few quantitative studies available. Improving PrEP uptake and adherence requires interventions that address barriers across the cascade, with a particular focus on stigma and social support.

Knowledge and attitude to HIV pre exposure prophylaxis among women in five sub-Saharan African countries: a multilevel model analysis of population-based survey 2021-2022

BACKGROUND

HIV Pre-Exposure Prophylaxis (HIV PrEP) may help reduce the rate of HIV infection among women in sub-Saharan Africa (SSA). This study aimed to assess women's knowledge and attitudes toward PrEP, a crucial component of HIV prevention, using nationwide data. It is the first study of its kind conducted in five SSA countries: Burkina Faso, Ghana, Côte d'Ivoire, Kenya, and Tanzania. The primary objective was to examine women's knowledge and attitudes toward PrEP for the prevention of HIV infection, as well as to explore individual- and community-level factors associated with it.

METHODS

The current study utilized the 2021/22 demographic and health survey datasets from five African nations, namely Burkina Faso, Côte d'Ivoire, Ghana, Kenya, and Tanzania. The analysis was performed using Stata 17. A weighted sample of 77,052 women of reproductive age participated in the survey. Univariate and multivariable multilevel logistic regressions were conducted to assess parameters related to knowledge and attitudes toward PrEP in these countries. In both the univariate regression and the final model, the significance of variables was determined using P values of ≤ 0.2 and < 0.05.

RESULTS

Overall, only about 13.88 (95% CI: 13.64,14.12) of women had knowledge and attitudes toward HIV PrEP. The highest (34.29%) and lowest (5.61%) values were observed for Kenya and Tanzania respectively. Higher rates of knowledge, and attitude toward HIV PrEP among women were independently associated with age 25-34 years old (AOR = 1.52, 95% CI:1.41,1.64), and 35-49 years old (AOR = 1.56, 95% CI:1.43,1.69), primary education level (AOR = 1.79,95% CI:1.65,1.95), and secondary/higher education level (AOR = 2.92, 95% CI: 2.67,3.20), richer (AOR = 1.14, 95% CI:1.02,1.27), and richest (AOR = 1.21, 95% CI:1.06,1.37), employed women (AOR = 1.82, 95% CI:1.65,1.99), had media exposure (AOR = 1.49,95% CI:1.40,1.59),knowledge of modern contraception (AOR = 2.62, 95% CI: 1.94,3.43), had at least one ANC visit (AOR = 1.99, 95% CI:1.47,2.69), gave birth at health institutions (AOR = 1.17, 95% CI: 1.02,1.37), ever had given birth (AOR = 1.53, 95% CI: 1.41,1.66), female household heads (AOR = 1.24, 95% CI:1.17,1.31), rural women (AOR = 0.83, 95% CI: 0.76,0.89). Similarly, women from communities with high ANC coverage (AOR = 1.84, 95% CI: 1.61,2.11), high community mass media exposure (AOR = 1.62, 95% CI: 1.39,1.88), and high community wealth level (AOR = 1.48, 95% CI: 1.30,1.68), and women from the high illiteracy rate community (AOR = 0.71, 95% CI: 0.61,0.82) showed statistically significant associations with the outcome variable in the final model.

CONCLUSIONS

Less than one-seventh of women exhibited knowledge of and positive attitudes toward HIV PrEP. All stakeholders involved in HIV/AIDS prevention and control have recognized the significance of the factors mentioned above. Enhancing maternal health services, such as promoting institutional delivery, contraception, antenatal care (ANC), and women's empowerment, alongside harnessing the power of media and embracing these transformative changes, will contribute to a greater understanding of and more favorable attitudes toward HIV PrEP within the population.

Increasing Urban African American Women's Readiness for Pre-exposure Prophylaxis: A Pilot Study of the Women Prepping for PrEp Plus Program (WP3+)

BACKGROUND

African American women are disproportionately at risk for HIV infection. To increase women's readiness to consider taking pre-exposure prophylaxis (PrEP), we conducted a pilot study of Women Prepping for PrEP Plus (WP3+). Adapted from an evidence-based HIV risk reduction intervention for African American couples who are HIV-serodiscordant, WP3+ is a group-based culturally congruent program designed for African American women without HIV.

METHODS

Women were screened for eligibility; if eligible, they were invited to participate in the four-session WP3+ group. Participants completed surveys at baseline (n = 47) and post-implementation (n = 28); surveys assessed demographics, HIV and PrEP knowledge, depression and posttraumatic stress (PTS) symptoms, substance use, sexual risk behaviors, health care-related discrimination, and social support. In a process evaluation, a subset of women completed qualitative interviews at baseline (n = 35) and post-implementation (n = 18); the interviews were designed to converge with (e.g., on HIV and PrEP knowledge) and expand upon (e.g., unmeasured perceived impacts of WP3+) quantitative measures. To triangulate with the quantitative data, deductive qualitative analysis concentrated on women's knowledge and awareness of PrEP and HIV, their relationship dynamics and challenges, and their considerations (e.g., barriers, facilitators) related to taking PrEP; inductive analysis focused on women's experiences in the intervention.

RESULTS

Participants in the WP3+ intervention reported: improved proportion of condom use in the past 90 days (p < .01) and in a typical week (p < .05); reduced PTS symptoms (p < .05); increased HIV knowledge (p < .0001) and awareness of PrEP (p < .001); and greater consideration of using PrEP (p < .001). In interviews, participants expressed not only increased knowledge but also appreciation for learning how to protect themselves against HIV, communicate with their partners, and take charge of their health, and they expressed greater receptiveness to using PrEP as a result of the knowledge and skills they gained.

CONCLUSIONS

The WP3+ pilot study demonstrated preliminary efficacy and acceptability as an HIV-prevention program for African American women. A controlled trial is needed to confirm its efficacy for increasing PrEP use among African American women.

HIV pre-exposure prophylaxis uptake, retention and adherence among female sex workers in sub-Saharan Africa: a systematic review

OBJECTIVE

To evaluate oral pre-exposure prophylaxis (PrEP) uptake, retention and adherence among female sex workers (FSWs) receiving care through community and facility delivery models in sub-Saharan Africa (SSA).

DESIGN

Systematic review and meta-analysis.

DATA SOURCES

We searched online databases (PubMed, MEDLINE, SCOPUS, EMBASE, Google Scholar, Cochrane Database of Systematic Reviews and Web of Science) between January 2012 and 3 April 2022.

ELIGIBILITY CRITERIA FOR STUDIES

Randomised controlled trials, cohort studies, cross-sectional studies and quasi-experimental studies with PrEP uptake, adherence and retention outcomes among FSWs in SSA.

DATA EXTRACTION AND SYNTHESIS

Seven coders extracted data. The framework of the Cochrane Consumers and Communication Review Group guided data synthesis. The Risk of Bias In Non-Randomized Studies of Interventions tool was used to evaluate the risk of bias. Meta-analysis was conducted using a random-effects model. A narrative synthesis was performed to analyse the primary outcomes of PrEP uptake, adherence and retention.

RESULTS

Of 8538 records evaluated, 23 studies with 40 669 FSWs were included in this analysis. The pooled proportion of FSWs initiating PrEP was 70% (95% CI: 56% to 85%) in studies that reported on facility-based models and 49% (95% CI: 10% to 87%) in community-based models. At 6 months, the pooled proportion of FSWs retained was 66% (95% CI: 15% to 100%) for facility-based models and 83% (95% CI: 75% to 91%) for community-based models. Factors associated with increased PrEP uptake were visiting a sex worker programme (adjusted OR (aOR) 2.92; 95% CI: 1.91 to 4.46), having ≥10 clients per day (aOR 1.71; 95% CI: 1.06 to 2.76) and lack of access to free healthcare in government-run health clinics (relative risk: 1.16; 95% CI: 1.06 to 1.26).

CONCLUSIONS

A hybrid approach incorporating both facility-based strategies for increasing uptake and community-based strategies for improving retention and adherence may effectively improve PrEP coverage among FSWs.

PROSPERO REGISTRATION NUMBER

CRD42020219363.

A Qualitative Exploration of PrEP Interests, Barriers, and Interventions Among Black and Latina Cisgender Women in the U.S

Black and Latina cisgender women (BLCW) are disproportionally affected by HIV, particularly in the southern U.S. In Austin, Texas, Black women contract HIV 18.4 times more and Latinas 2.6 times more compared to White women. Pre-exposure prophylaxis (PrEP) is a medication that prevents contracting HIV; however, PrEP adoption among women is low. The current qualitative study aimed to explore PrEP awareness, interest, preferred PrEP administration methods, barriers to PrEP adoption, and future programs to increase PrEP adoption and adherence among BLCW. A total of 18 BLCW at high risk for HIV were enrolled. Participants completed 3 semi-structured interviews across 3 months. Interviews were transcribed verbatim, coded, and analyzed using thematic content analysis. Results demonstrated that BLCW had low PrEP awareness, high initial PrEP interest, and were interested in a long-acting injectable form of PrEP. Barriers to PrEP adoption included concerns regarding side effects, concerns about adherence to the currently available daily pill, and difficulty with insurance. Participants proposed different ideas for interventions, including support groups, education, community-level programs, and structural interventions. Future studies should focus on increasing PrEP awareness and HIV risk, consider alternative forms of PrEP, educate providers and medical staff on PrEP, and consider tailored interventions to reduce HIV risk among BLCW.

Prevalence and factors associated with pre-exposure prophylaxis awareness among cisgender women of reproductive age in Burkina Faso

BACKGROUND

HIV remains a global public health concern, and women continue to be disproportionately affected. Understanding the factors associated with pre-exposure prophylaxis awareness among women is crucial as an effective HIV prevention strategy.

OBJECTIVES

We investigated the prevalence and associated factors of pre-exposure prophylaxis awareness among women in Burkina Faso.

DESIGN

This was a cross-section study that used population-based data.

METHODS

A total of 17,659 women of reproductive age (15-49 years) from the 2021 Burkina Faso Demographic and Health Survey were analyzed. Percentage and multivariable logistic regression model were used to examine the prevalence and factors associated with pre-exposure prophylaxis awareness.

RESULTS

The prevalence of pre-exposure prophylaxis awareness was 8.2% (95% confidence interval = 7.8%-8.6%). Women's age was positively associated pre-exposure prophylaxis awareness. Women with primary and secondary education had 39% and 48% higher odds of pre-exposure prophylaxis awareness, when compared with women with no formal education. The odds of pre-exposure prophylaxis awareness were 1.40 (95% confidence interval = 1.19-1.66) times higher among Christians when compared with the Muslims. Women who were exposed to mass media including newspaper or magazine, radio, TV, and Internet had higher odds of pre-exposure prophylaxis awareness, when compared with those without exposure to mass media channels. Women who have previously tested for HIV had 37% higher odds of pre-exposure prophylaxis awareness, when compared with those who have not been tested (adjusted odds ratio = 1.37; 95% confidence interval = 1.09-1.72).

CONCLUSION

This study found women's age, geographical region, education, religion, exposure to mass media channels, employment, and HIV testing to be associated with pre-exposure prophylaxis awareness. These findings can inform the development of targeted interventions and public health campaigns to increase awareness and practice to pre-exposure prophylaxis, particularly among key population.

Factors Associated with Planned Future Use of PrEP in the Next 3 Months and Likelihood to Use PrEP Among Black Cisgender HIV-negative Women in Texas

Identifying and then addressing barriers and leveraging facilitators is important to help increase pre-exposure prophylaxis (PrEP) use among Black women vulnerable to HIV acquisition. The present cross-sectional study examined what factors were associated with future plans to use PrEP, and general likelihood to use it among a convenience sample of 152 adult, Black cisgender women from three metropolitan areas in Texas. The final multivariable logistic regression model revealed that relationship status (aOR = 0.20, 95% CI: 0.05-0.73, p < 0.05), PrEP anticipated stigma (aOR = 0.29, 95% CI: 0.10-0.78, p < 0.05), perceived discrimination (aOR = 0.40, 95% CI: 0.21-0.78, p < 0.01) and interest in learning more about PrEP (aOR = 5.32, 95% CI: 2.60-10.9, p < 0.001) were associated with future plans to use PrEP. The final multivariable linear regression model with maximum likelihood estimation identified that perceived discrimination (β=-0.24, SE: -0.38 - -0.10, p < 0.01), perceived HIV risk (β = 0.33, SE: 0.18-0.49, p < 0.001), willingness to use PrEP with condoms (β = 1.26, SE: 0.94-1.60, p < 0.001), and comfort communicating about PrEP with a provider (β = 0.23, SE: 0.06-0.41, p < 0.01) were associated with general likelihood to use PrEP. Findings reveal key factors that warrant further attention and examination toward improving PrEP use within this population.

Effect of implementation strategies on pre-exposure prophylaxis persistence among female sex workers in South Africa: an interrupted time series study

BACKGROUND

A disproportionate number of new HIV infections in South Africa are among female sex workers; pre-exposure prophylaxis (PrEP) for HIV prevention is freely available to female sex workers in the country, but unique barriers challenge PrEP persistence. TB HIV Care, a large South African non-profit organisation that provides daily oral PrEP (tenofovir disoproxil fumarate and emtricitabine), has implemented multiple strategies to improve PrEP persistence. We aimed to evaluate the effect of different implementation strategies on PrEP persistence in a large-scale real-world setting.

METHODS

In this interrupted time series study, we estimated level changes in 1-month oral PrEP persistence associated with roll-out of various implementation strategies among female sex workers across nine districts in South Africa. We used routinely collected data from TB HIV Care programme files from June 7, 2016, to April 30, 2021. Poisson regression of 1-month persistence was used to assess the effect of these strategies. In secondary analyses, we tested the association between each of the strategies and 4-month persistence.

FINDINGS

The median 1-month PrEP persistence for female sex workers was 33% (IQR 27-40). SMS support and refill reminders were associated with an 11% relative increase in 1-month persistence (risk ratio [RR] 1·11, 95% CI 1·02-1·26) and clinical mentoring for PrEP providers was associated with a 127% relative increase (RR 2·27, 95% CI 1·94-2·66) among female sex workers. The loyalty rewards programme was negatively associated with 1-month persistence (RR 0·71, 95% CI 0·67-0·83). Although clinical mentoring improved 4-month persistence, SMS support text messages had no significant effect.

INTERPRETATION

Identification and subsequent use of clinical mentoring for PrEP providers and SMS support and refill reminders might improve the usefulness of PrEP overall to prevent new HIV infections among female sex workers. PrEP persistence remains an important issue, and strategies to build on our findings are needed.

FUNDING

National Institute of Mental Health and National Institute of Allergy and Infectious Diseases.

Model-based predictions of protective HIV pre-exposure prophylaxis adherence levels in cisgender women

Most human immunodeficiency virus (HIV) infections occur in cisgender women in resource-limited settings. In women, self-protection with emtricitabine/tenofovir disoproxil fumarate pre-exposure prophylaxis (FTC/TDF-PrEP) constitutes a major pillar of HIV prevention. However, clinical trials in women had inconsistent outcomes, sparking uncertainty about adherence requirements and reluctance in evaluating on-demand regimens. We analyzed data from published FTC/TDF-PrEP trials to establish efficacy ranges in cisgender women. In a 'bottom-up' approach, we modeled hypotheses in the context of risk-group-specific, adherence-efficacy profiles and challenged those hypotheses with clinical data. We found that different clinical outcomes were related to the proportion of women taking the product, allowing coherent interpretation of the data. Our analysis showed that 90% protection was achieved when women took some product. We found that hypotheses of putative male/female differences were either not impactful or statistically inconsistent with clinical data. We propose that differing clinical outcomes could arise from pill-taking behavior rather than biological factors driving specific adherence requirements in cisgender women.

Single-nucleotide polymorphisms in ABC drug transporters alter expression and circulating tenofovir in healthy South African women exposed to pre-exposure prophylaxis

Aim: We investigated if single-nucleotide polymorphisms (SNPs) in ATP-binding cassette (ABC) drug transporters alter gene expression and tenofovir disposition in South African women taking Truvada® for HIV prevention. Materials & methods: In 393 women, real-time PCR was used to determine the associations between six SNPs in ABC transporter genes, mRNA expression and circulating-tenofovir. Results: Univariable and multivariable analyses showed that CT and TT relative to CC genotypes for the ABCC4(3463C/T) SNP had significantly higher tenofovir levels. In contrast, the AA genotype for the ABCC4(4976A/G) SNP showed significantly less tenofovir, while mRNA expression was increased. Conclusion: SNPs in the ABCC4 gene may differentially affect gene expression and circulating tenofovir. Their impact may inform on low pre-exposure prophylaxis efficacy and discern effective drugs in clinical trials of African women enriched for certain genotypes.

Sex Differences in HIV Infection

Biological sex has wide-ranging impacts on HIV infection spanning differences in acquisition risk, the pathogenesis of untreated infection, impact of chronic treated disease and prospects for HIV eradication or functional cure. This chapter summarizes the scope of these differences and discusses several features of the immune response thought to contribute to the clinical outcomes.

Qualitative Analysis Using Social Maps to Explore Young Women's Experiences With Social Support of their Oral PrEP Use in Kenya and South Africa

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.

Pre-exposure Prophylaxis (PrEP) Awareness, Willingness to Use, and Preferred Places for Access Among the Cambodian Female Entertainment Workers: A Cross-Sectional Study

The aim of the study was to determine the awareness, desire to use, and preferred providers of pre-exposure prophylaxis (PrEP) among Female Entertainment Workers (FEWs) aged 18-35 years in Cambodia's Phnom Penh region. Of 1003 FEWs, 31.8% of them had heard of PrEP. When informed about PrEP, 67.4% said they would use PrEP and the most preferred location to access PrEP was a local non-governmental organization (NGO) (63.2%), followed by a government clinic/center (39.8%), ART clinic (26.5%), pharmacy (20.7%), and CBO (14.8%). FEWs who had heard about PrEP (aOR: 2.46; CI: 1.79-3.39) and those with no additional income source other than sex work (aOR: 1.53; CI: 1.16-2.02) were more likely to express their willingness to use PrEP. When the country is in the process of making provisions for PrEP, the study urges policymakers and programmers to take steps towards creating awareness about PrEP among key populations such as FEWs and its availability preferably through local NGOs and government clinics.

Addressing Women’s Needs with Human Immunodeficiency Virus (HIV) and Enhancing the Visibility of Pharmacists in the Public Health Arena

Human Immunodeficiency Virus (HIV) continues to have a staggering effect on women’s lives in the United States (U.S.). Women Living With HIV (WLWH) face many challenges, such as mental health disorders, compared to their male counterparts. These diagnoses make women more disproportionally affected, and meaningful healthcare interventions must address these conditions. This review has three foci: WLWH in the U.S., their access to care and staying in care once antiretroviral treatment has been initiated, coping with mental health, and the role of the U.S. pharmacists in access to the treatment. Pharmacists are the most easily accessible healthcare profession in the U.S. For example, 93% of American customers live within 5 miles of a community pharmacy. Pharmacists are the last healthcare provider with whom the patient interacts before a medication is dispensed; thus, they are in an ideal position to intervene. Engaging pharmacists to provide care for patients with chronic disease states such as HIV has resulted in positive outcomes. Although there are global and U.S. studies that emphasize the role of pharmacists in directing care for persons living with HIV, there is a lack of studies conducted about the role of pharmacists in managing mental health. Future research must address WLWH and mental health conditions to develop targeted interventions from an interdisciplinary team perspective.

Brief Report: Quantifiable Plasma Tenofovir Among South African Women Using Daily Oral Pre-exposure Prophylaxis During the ECHO Trial

BACKGROUND

HIV endpoint-driven clinical trials provide oral pre-exposure prophylaxis (PrEP) as HIV prevention standard of care. We evaluated quantifiable plasma tenofovir among South African women who used oral PrEP during the Evidence for Contraceptive Options and HIV Outcomes (ECHO) Trial.

METHODS

ECHO, a randomized trial conducted in 4 African countries between 2015 and 2018, assessed HIV incidence among HIV-uninfected women, aged 16-35 years, randomized to 1 of 3 contraceptives. Oral PrEP was offered onsite as part of the HIV prevention package at the South African trial sites. We measured tenofovir in plasma samples collected at the final trial visit among women reporting ongoing PrEP use. We used bivariate and multivariate logistical regression to assess demographic and sexual risk factors associated with plasma tenofovir quantification.

RESULTS

Of 260 women included, 52% were ≤24 years and 22% had Chlamydia trachomatis at enrollment. At PrEP initiation, 68% reported inconsistent/nonuse of condoms. The median duration of PrEP use was 90 days (IQR: 83-104). Tenofovir was quantified in 36% (n = 94) of samples. Women >24 years had twice the odds of having tenofovir quantified vs younger women (OR = 2.12; 95% confidence interval = 1.27 to 3.56). Women who reported inconsistent/nonuse of condoms had lower odds of tenofovir quantification (age-adjusted OR = 0.47; 95% confidence interval = 0.26 to 0.83).

CONCLUSIONS

Over a third of women initiating PrEP and reporting ongoing use at the final trial visit had evidence of recent drug exposure. Clinical trials may serve as an entry point for PrEP initiation among women at substantial risk for HIV infection with referral to local facilities for ongoing access at trial end.

CLINICAL TRIAL NUMBER

NCT02550067.

Women's views on communication with health care providers about pre-exposure prophylaxis (PrEP) for HIV prevention

Since the beginning of the HIV epidemic in the USA, effective interventions to reduce HIV risk among cisgender women have been lacking. Although oral HIV pre-exposure prophylaxis (PrEP) is effective in pharmacologically preventing HIV infection, there is a gap between the recommended use of PrEP and PrEP uptake among eligible women. This study aimed to identify the role of patient-provider communication in PrEP decision-making among women considering PrEP. Semi-structured in-depth interviews were conducted with 41 PrEP-eligible women in Philadelphia and New York City. A thematic analysis of the responses was conducted, and a conceptual model developed and confirmed as analysis continued. Of the women interviewed, 53.6% were African American and 29.3% were Latina. Women noted that having a trusting relationship with their health care provider, receiving a tailored recommendation for PrEP based upon their specific needs and using their health care provider as support were crucial facilitators of PrEP decision-making. Lack of provider knowledge about PrEP, perceived health care provider stigma about their drug use and sexual activity, and lack of care continuity were all identified as barriers to effective communication. Study findings can inform future interventions to enhance patient-provider communication about PrEP and increase PrEP uptake among women.

Assessment of risk compensation following use of the dapivirine vaginal ring in southwestern Uganda

OBJECTIVES

Participation in HIV prevention trials could trigger risk compensation among participants. We evaluated potential risk compensation following use of a vaginal ring microbicide by women in a phase III trial in southwestern Uganda.

METHODS

We used markers of sexual risk behaviour documented on standardised questionnaires, tested for STIs at baseline and quarterly for 2 years. Risk compensation was defined as a significant increase (trend p<0.05) in the proportion of women reporting risky sexual behaviour or a diagnosed STI between baseline and end of follow-up.

RESULTS

Between September 2013 and December 2016, 197 women (active arm: n=132 and placebo: n=65) were enrolled at the Masaka site. There were decreases in all markers of sexual risk behaviour with statistically significant decreases in only the proportion of women reporting ≥2 sexual partners, p=0.026 and those diagnosed with Trichomonas vaginalis p<0.001 and or Neisseria gonorrhoeae p<0.001 CONCLUSIONS: No evidence of risk compensation was observed in this trial.

TRIAL REGISTRATION NUMBER

NCT01539226.

Considerations for Increasing Racial, Ethnic, Gender, and Sexual Diversity in HIV Cure-Related Research with Analytical Treatment Interruptions: A Qualitative Inquiry

Despite disproportionate incidence and prevalence of HIV among transgender individuals, cisgender women, and racial and ethnic minority groups, all remain underrepresented in HIV cure research. As HIV cure trials are scaled up, there is emerging research on ways to mitigate risks of HIV acquisition for sexual partners of analytical treatment interruption (ATI) trial participants. As such, it is imperative that HIV cure researchers consider the implications of implementing ATIs in populations that are disproportionately affected by HIV, but largely underrepresented in trials to date. In this qualitative study, we sought to derive triangulated perspectives on the social and ethical implications regarding ATIs and partner protection strategies during ATIs among under-represented populations. We conducted 21 in-depth interviews with 5 types of informants: bioethicists, community members [people living with HIV (PLWH) and their advocates], biomedical HIV cure researchers, sociobehavioral scientists, and HIV care providers. We analyzed the data using conventional content analysis and reduced the data to important considerations for implementing ATI trials in diverse communities and settings. Our study revealed the following key themes: (1) attention must be paid to gender and power dynamics in ATI trials; (2) ATI trials should be designed and implemented through the lenses of intersectionality and equity frameworks; (3) ATI trials may have both positive and negative effects on stigma for PLWH and their partners; and (4) partnership dynamics should be considered when designing ATI protocols. Our study generated actionable considerations that could be implemented in ATI trials to promote their acceptability to communities that have been underrepresented in HIV cure research to date. Research teams must invest in robust community and stakeholder engagement to define best practices. Paying attention to representation and equity will also promote better and more equitable implementation of HIV cure strategies once these become ready for rollout.

Overlapping needs for sexual and reproductive health and HIV prevention in women with substance use disorders

OBJECTIVES

Women with substance use disorders have high unmet needs for HIV prevention and drug treatment and face challenges accessing care for other unique health issues, including their sexual and reproductive health.

METHODS

We did a cross-sectional evaluation of sexual and reproductive health behaviors and outcomes among women with substance use disorders, who were enrolled in one of two concurrent clinical trials of pre-exposure prophylaxis for HIV prevention. Descriptive analyses and bivariate logistic regression were used to assess factors driving contraceptive use, and other essential sexual and reproductive health services utilization and outcomes.

RESULTS

Among 226 women, 173 (76.5%) were of reproductive age. Most women had histories of unintended pregnancy (79.2%) or miscarriage (45.1%) and high HIV risk behaviors (53.5%). Most (61%) participants did not use any form of contraception at the time of assessment, although few (15%) reported pregnancy intentions. In bivariate models, ongoing criminal justice involvement was associated with 2.22 higher odds of not using contraception (95% confidence interval = 1.09-4.53; p = 0.03) and hazardous drinking was protective against not using contraception (odds ratio = 0.33, 95% confidence interval = 0.13-0.81; p = 0.02). Contraception use was not significantly associated with any other individual characteristics or need factors.

CONCLUSIONS

This is the first study that identifies the unmet sexual and reproductive health needs of women with substance use disorders who are engaging with pre-exposure prophylaxis. We found that women accessed some health services but not in a way that holistically addresses the full scope of their needs. Integrated sexual and reproductive care should align women's expressed sexual and reproductive health intentions with their behaviors and outcomes, by addressing social determinants of health.

Predictors of Anticipated PrEP Stigma among Women with Self-Reported Problematic Substance Use: Implications for Engaging Women in the PrEP Care Continuum

Pre-exposure prophylaxis (PrEP) is an effective HIV prevention method, but it has been underutilized by women. Anticipated stigma regarding use of PrEP is a contributing factor in the underutilization of this prevention strategy. The current study explored the relationships among PrEP stigma, sex risk (i.e., inconsistent condom use, condomless sex with persons of unknown serostatus, or sex in exchange for money or drugs), substance use, attitudes toward HIV testing, and medical mistrust. Participants were 106 primarily ethnic-minority women who reported recent substance use and agreed to participate in a study exploring HIV prevention attitudes. Within this sample, the majority of participants had one or more CDC-defined PrEP indications. Findings indicate that medical mistrust was associated with perceived PrEP stereotypes and HIV testing attitudes. These results provide some insight into reasons for low PrEP uptake among women at risk for HIV. Implications for HIV prevention with women are discussed.

How Has HIV Pre-Exposure Prophylaxis (PrEP) Changed Sex? A Review of Research in a New Era of Bio-behavioral HIV Prevention

In 2012, the U.S. FDA approved the first drug for use as HIV Pre-Exposure Prophylaxis (PrEP), which is nearly 99% effective when taken as prescribed. Although the manifest function of PrEP is to prevent HIV infection in the event of exposure, the drug has also had a significant impact on various facets of sexuality. In this review, we focus on research that emerged in the near decade since PrEP's approval, with a specific focus on the ways in which different elements of sex and sexuality have been impacted by gay, bisexual, and other men who have sex with men (GBMSM), cisgender women, and transgender individuals. We highlight evidence showing how PrEP has enhanced sexual self-esteem, improved sexual pleasure, reduced sexual anxiety, and has increased sexual agency for those taking it. For many, PrEP also serves as a gateway to improve routine health and increase sexual health-care utilization. Additionally, we review the question of whether PrEP is associated with increased sexual risk taking (i.e. risk compensation), and note that, although some data are mixed, PrEP is not intended as an intervention to reduce condomless anal sex or STIs: it aims to prevent HIV. Finally, our review highlights that, although the volume of research on PrEP among GBMSM is robust, it is underdeveloped for cisgender women and transgender populations and insufficient for inclusion in such a review for cisgender heterosexual men was. PrEP research with these populations is an important direction for future research. Finally, from 2012 to 2019, a single PrEP formulation and delivery method was FDA approved (oral emtricitabine/tenofovir disoproxil fumarate). As additional drug formulations (ie.g., emtricitabine/tenofovir alafenamide) and delivery methods (e.g., microbiocides, vaginal ring, injectable) come to market, it will be important to examine how these, too, impact the spectrum of sexuality.

Barriers and Facilitators to Pre-exposure Prophylaxis Uptake Among Black Women: A Qualitative Analysis Guided by a Socioecological Model

ABSTRACT

Black women experience disparities in HIV incidence. Pre-exposure prophylaxis (PrEP) is a once-daily pill that can prevent HIV transmission. To enhance PrEP uptake among Black women, it is essential to examine their perceptions of PrEP. In 2018, 33 Black women in New York City completed interviews about their attitudes, knowledge, and perceived barriers and facilitators to PrEP use. Emergent themes were organized using a socioecological model. Participants identified barriers at the sociocultural level, including stigma, medical mistrust, and health care avoidance. At the community level, health care access issues and limited community knowledge were reported. Partner-level barriers included trust in partners and meaning attributed to PrEP use within the context of monogamy. Individual-level barriers included low perceived risk and concerns about PrEP's safety and efficacy. Our findings can inform future PrEP research with Black women, as well as PrEP implementation efforts aimed at increasing uptake among this population.

Pre-Exposure Prophylaxis for HIV Infection and the Role of the Women's Health Care Provider in HIV Prevention

HIV infection is a major public health problem for women in the United States. Prevention of new HIV infections is essential to the goal of eliminating HIV in the United States. Pre-exposure prophylaxis (PrEP) is an effective and safe HIV prevention method recommended for women at increased risk for HIV infection, including during pregnancy and lactation. The recommended PrEP regimen is a fixed-dose combination of tenofovir disoproxil fumarate and emtricitabine administered as a single daily dose. The initial evaluation for individuals desiring PrEP for HIV prevention includes obtaining a history, laboratory evaluation, and evaluation of the accessibility and acceptability of PrEP. Individuals using PrEP medications are seen every 3 months for follow-up. These follow-up visits include evaluation for signs and symptoms of seroconversion, management of side effects and adverse reactions, and evaluation of adherence to PrEP. Follow-up visits also include testing for HIV, sexually transmitted infections, and renal function and a review of HIV prevention and risk reduction methods. Despite known safety and efficacy of PrEP among women, PrEP use in women in the United States remains low. Gaps exist in HIV prevention that can in part be addressed by women's health care providers through risk screening and provision of HIV prevention methods. All providers of comprehensive sexual health care can and should assess individuals for risk factors for HIV infection and offer HIV prevention methods, including PrEP, to individuals at risk for HIV.

Linking Women Experiencing Incarceration to Community-Based HIV Pre-Exposure Prophylaxis Care: A Qualitative Study

Women experiencing incarceration (WEI) in the United States are disproportionately impacted by HIV, yet HIV pre-exposure prophylaxis (PrEP) is underutilized by women in the United States. In order to inform an intervention to promote PrEP initiation during incarceration and facilitate linkage to PrEP care following release from incarceration, we conducted individual, semistructured qualitative interviews with WEI (N = 21) and key stakeholders (N = 14). While WEI had little or no previous knowledge about PrEP, they viewed it as something that would benefit women involved in the criminal justice system. Participants stated that HIV-related stigma and underestimation of HIV risk might serve as barriers to PrEP initiation during incarceration. Participants reported that competing priorities, difficulty scheduling an appointment, and lack of motivation could interfere with linkage to PrEP care in the community. Further, cost, substance use, and difficulty remembering to take the medication were cited most commonly as likely barriers to adherence.

Persistence of oral pre-exposure prophylaxis (PrEP) among adolescent girls and young women initiating PrEP for HIV prevention in Kenya

The Determined, Resilient, Empowered, AIDS-free, Mentored, and Safe (DREAMS) Initiative aims to reduce HIV infections among adolescent girls and young women (AGYW) in Africa. Oral pre-exposure prophylaxis (PrEP) is offered through DREAMS in Kenya to eligible AGYW in high burden counties including Kisumu and Homa Bay. This study examines PrEP persistence among AGYW in high burden community-based PrEP delivery settings. We evaluated PrEP persistence among AGYW in the DREAMS PrEP program in Kisumu and Homa Bay using survival analysis and programmatic PrEP refill data collected between March through December 2017. Among 1,259 AGYW who initiated PrEP during the study period, the median persistence time in the program was 56 days (95% CI: 49-58 days) and the proportion who persisted 3 months later was 37% (95% CI: 34-40%). Persistence varied by county (p < 0.001), age at PrEP initiation (p = 0.002), marital status (p = 0.008), transactional sex (p = 0.002), gender-based violence (GBV) experience (p = 0.009) and current school attendance (p = 0.001) at DREAMS enrollment. Persistence did not vary with orphan status, food insecurity, condom use, age at first sexual encounter or engagement in age-disparate sex at DREAMS enrollment. Targeted strategies are needed to improve AGYW retention in the PrEP program.

Applying a Nursing Perspective to Address the Challenges Experienced by Cisgender Women in the HIV Status Neutral Care Continuum: A Review of the Literature

ABSTRACT

The field of HIV research has grown over the past 40 years, but there remains an urgent need to address challenges that cisgender women living in the United States experience in the HIV neutral status care continuum, particularly among women such as Black women, who continue to be disproportionately burdened by HIV due to multiple levels of systemic oppression. We used a social ecological framework to provide a detailed review of the risk factors that drive the women's HIV epidemic. By presenting examples of effective approaches, best clinical practices, and identifying existing research gaps in three major categories (behavioral, biomedical, and structural), we provide an overview of the current state of research on HIV prevention among women. To illustrate a nursing viewpoint and take into account the diverse life experiences of women, we provide guidance to strengthen current HIV prevention programs. Future research should examine combined approaches for HIV prevention, and policies should be tailored to ensure that women receive effective services that are evidence-based and which they perceive as important to their lives.

Pre-Exposure Prophylaxis (PrEP) for HIV Infection in Cisgender and Transgender Women in the U.S.: A Narrative Review of the Literature

Using a socioecological approach, this review describes the peer-reviewed literature on oral pre-exposure prophylaxis (PrEP) among both cisgender (cis women) and transgender women (trans women) in the U.S. A search of the PubMed database and HIV-related conference abstracts generated over 2,200 articles and abstracts. Of these, 103 fulfilled review inclusion criteria. Most of the existing research presents findings on individual-level factors associated with PrEP use such as willingness and perceived barriers. There was far less investigation of factors related to PrEP at more distal ecological levels. Though trans women are at greater risk of HIV infection than cisgender women, less is known about this population group with respect to PrEP despite their inclusion in many major clinical trials. Further, the literature is characterized by a persistent conflation of sex and gender which makes it difficult to accurately assess the reviewed research on HIV prevention and PrEP apart from risk group. Informed by these findings, we highlight specific opportunities to improve access to PrEP and reduce socioecological barriers to PrEP care engagement for cisgender and transgender women.

"PrEP just isn't my priority": Adherence challenges among women who inject drugs participating in a pre-exposure prophylaxis (PrEP) demonstration project in Philadelphia, PA USA

Pre-exposure prophylaxis (PrEP) has the ability to curb HIV transmission among women if they are highly adherent (e.g. 6/7 weekly doses). In a recent PrEP demonstration project with 95 women who inject drugs (WWID) in Philadelphia, PA, USA, PrEP uptake was high but adherence was low. This qualitative study draws upon the Behavioral Model for Vulnerable Populations (BMVP) to describe how the context of 23 WWID's lives challenged PrEP adherence using narrative data from in-depth interviews. Content analysis suggests that women's need to organize their day around predisposing survival needs made it difficult to prioritize PrEP. Adherence was further challenged by dis-enabling structural forces such as entry into institutions that do not provide PrEP (e.g., drug treatment and correctional facilities) and medication diversion to illicit marketplaces. Overtime, women's perceived need for PrEP was dynamic: in periods they characterized as risky, women considered PrEP highly beneficial and described enhanced motivation to adhere. In periods of low perceived risk, women were less committed to continuing daily PrEP in the context of their competing survival needs. In sum, WWID faced challenges to PrEP adherence that correspond to all of the BMVP domains. To optimize PrEP for WWID, multi-level programs are needed that address the determinants that both increase HIV susceptibility and undermine adherence.

Models of HIV Pre-Exposure Prophylaxis Care Used in Title X Family Planning Clinics in the Southern U.S

PURPOSE

HIV pre-exposure prophylaxis (PrEP) is underutilized by adolescent and young adult women, especially in the Southern U.S. Family planning (FP) clinics are potentially ideal PrEP delivery sites for adolescent and young adult women, but little is known about their PrEP services. We describe models of PrEP care in Title X FP clinics in the South and explore clinic resources that are needed to facilitate PrEP provision.

METHODS

Providers and administrators from 38 clinics participated in qualitative interviews. We assessed five steps of PrEP care: (1) HIV risk assessment; (2) PrEP education; (3) laboratory testing; (4) PrEP prescription; and (5) PrEP monitoring.

RESULTS

Among 38 clinics, 23 conducted at least one step and were classified into three models. Model 1 (n = 8) and Model 2 (n = 4) clinics provided up to Steps 1 and 2, respectively, but referred to an external PrEP provider. Model 3 clinics (n = 11) conducted all steps. Few barriers were identified for Step 1; using an HIV risk assessment tool was a key facilitator. PrEP educational materials facilitated Step 2; clinics not providing education believed they could easily do so with training and educational resources. Funding- and staff-related resource barriers were noted for Steps 3-5, including costs of laboratory tests and lack of time for longitudinal visits.

CONCLUSIONS

PrEP-providing publicly funded FP clinics in the Southern U.S. use referral services for many steps of PrEP care, which introduce patient burden. Increasing onsite PrEP services will require addressing concerns related to training, educational materials, cost, and staffing.

Implementation of HIV pre-exposure prophylaxis for women of color: Perspectives from healthcare providers and staff from three clinical settings

Women of color (WOC) account for 83% of new HIV infections among women in the United States. While pre-exposure prophylaxis (PrEP) is a safe, effective HIV prevention method for women, WOC are less likely to be prescribed PrEP than other populations. Guided by an implementation science research framework, we investigated the implementation of a PrEP initiative for WOC in a US city with high HIV incidence. Across three clinical sites, only three WOC were prescribed PrEP after one year. Analysis of qualitative interviews with clinic staff and providers identified time constraints, reluctance to prescribe PrEP, and discomfort with counseling as implementation barriers. Implementation facilitators included staff and leadership support for PrEP, alignment of PrEP services with organizational missions, and having a centralized PrEP Coordinator. By addressing these identified implementation barriers and facilitators, clinic staff and providers can ensure that WOC are provided with the full range of HIV prevention options.

"Yes, I'm interested in taking PrEP!": PrEP interest among women respondents to the European community-based survey "Flash! PrEP in Europe"

The World Health Organization recommends pre-exposure prophylaxis (PrEP) for all populations at substantial risk of HIV infection, including women. However, data regarding PrEP interest among women is lacking, particularly in Europe. Factors associated with interest in using PrEP were assessed among women respondents to the Flash! PrEP in Europe (FPIE) survey. This community-based cross-sectional study, conducted in 12 European countries, aimed to assess PrEP knowledge and interest. "High objective risk" (HOR) was assessed using established risk criteria following EACS and CDC guidelines. Factors associated with interest in using PrEP were assessed in univariable and multivariable logistic regression models. Among 678 women, 12.5% (n = 85) were considered at HOR, 46.8% (n = 317) indicated prior PrEP knowledge and 18.0% (n = 122) reported interest in using PrEP. Among women at HOR, 40.0% (n = 34) were interested in PrEP. Factors significantly associated with PrEP interest in the final multivariable model were: younger age (18-29 years) (aOR 1.91[95CI: 1.07; 3.41]), bad self-perceived financial status (1.84[1.09; 3.11]), migrant status (south to north) (2.87[1.05; 7.89]), single or dating relationship status (1.93[1.23; 3.03]), sexual abuse history (1.86[1.17; 2.97]), "rather high"/ "high" self-perceived HIV risk (3.21[1.32; 7.81]), and HOR (2.49[1.42; 4.35]). These results show that women at HOR and those who perceived themselves to be at high risk are interested in using PrEP. There is a critical need for targeted information and improved access to PrEP to increase uptake of this HIV prevention tool to meet PrEP interest among women.

Hidden in plain sight: sex and gender in global pandemics

PURPOSE OF REVIEW

The global pandemic caused by the severe acute respiratory virus coronavirus 2 (SARS-CoV-2) has a male bias in mortality likely driven by both gender and sex-based differences between male and female individuals. This is consistent with sex and gender-based features of HIV infection and overlap between the two diseases will highlight potential mechanistic pathways of disease and guide research questions and policy interventions. In this review, the emerging findings from SARS-CoV-2 infection will be placed in the context of sex and gender research in the more mature HIV epidemic.

RECENT FINDINGS

This review will focus on the new field of literature on prevention, immunopathogenesis and treatment of SARS-CoV-2 referencing relevant articles in HIV for context from a broader time period, consistent with the evolving understanding of sex and gender in HIV infection. Sex-specific features of epidemiology and immunopathogenesis reported in COVID-19 disease will be discussed and potential sex and gender-specific factors of relevance to prevention and treatment will be emphasized.

SUMMARY

Multilayered impacts of sex and gender on HIV infection have illuminated pathways of disease and identified important goals for public health interventions. SARS-CoV-2 has strong evidence for a male bias in disease severity and exploring that difference will yield important insights.

The pre-exposure prophylaxis (PrEP) consciousness of black college women and the perceived hesitancy of public health institutions to curtail HIV in black women

BACKGROUND

Consistent use of Pre-Exposure Prophylaxis (PrEP), a biomedical intervention for HIV seronegative persons, has been shown to significantly decrease HIV acquisition. Black women are a viable population segment to consider for PrEP use as their HIV incidence is overwhelmingly higher than all other women groups.

METHODS

We developed and piloted a cultural- and age- appropriate PrEP education intervention to determine Black college women's: 1) perceptions of and receptivity to PrEP use; and 2) preferences for PrEP information delivery.

RESULTS

We recruited N = 43 Black college women. Most of our sample were sophomore and Juniors of whom identified as heterosexual (83%) and single (67%). Over 50% of young women had never been HIV tested and only 28% had been tested in the last 6 months; however, 100% of the women believed their HIV status was negative. Prior to participating in the study, most Black college women (67%) had not heard about PrEP and were unsure or apprehensive (72%) to initiate PrEP. The Black college women indicated that our educational intervention was extremely helpful (67%) for understanding and learning about PrEP. Post participating in our PrEP education module, regardless of delivery modality, participants reported being likely (62.55-70%) to initiate PrEP in the future.

CONCLUSIONS

Results indicate that Black college women would strongly consider PrEP when provided with basic knowledge, regardless of delivery modality. Participants also showed greater appreciation for in-person delivery and found it to be significantly more helpful and of greater quality for learning about PrEP; comprehension or perceived usefulness of PrEP-related content was relatively the same between groups. PrEP content delivery -- via in-person or online methods - is contingent on learning style and presentation.

TRIAL REGISTRATION

This study has been registered under the ISRCTN Registry as of July 6, 2020. The trial registration number is ISRCTN14792715 . This study was retrospectively registered.

Brief Report: Impact of PrEP Training for Family Planning Providers on HIV Prevention Counseling and Patient Interest in PrEP in Atlanta, Georgia

BACKGROUND

Safety net family planning (FP) clinics provide vital care for women in high HIV-burden areas and may be ideal pre-exposure prophylaxis (PrEP) delivery sites. Yet, many FP providers lack knowledge about PrEP.

SETTING

Four safety net FP clinics in Atlanta, Georgia.

METHODS

We provided a 1.5-hour PrEP informational training for 28 providers working in these sites. To assess the training's impact on PrEP counseling, we enrolled 500 female patients after training (47% ≤ 28 years; 69% black; 12% Hispanic) and determined their PrEP indication based on CDC guidelines. We conducted a postvisit survey to assess provider counseling and patients' interest in PrEP and acceptance of off-site PrEP referral.

RESULTS

From pre-training to post-training, provider PrEP knowledge and confidence to identify women who may benefit from PrEP significantly increased. Only 19% of women knew about PrEP before the visit. Among 376 sexually active women, 29% had risk consistent with PrEP indication. Among PrEP-indicated women, 66% reported the provider discussed PrEP, 29% were interested in taking PrEP, but only 18% accepted off-site PrEP referral. Most (76%) were more willing to take PrEP if provided by the FP clinic.

CONCLUSIONS

After a brief PrEP training, most women with HIV-risk indicators received PrEP counseling during their visits. Once counseled, women expressed interest if it were offered at the FP clinic rather than through off-site referral. Findings highlight the potential impact that PrEP capacity building within safety net FP clinics in high HIV-burden areas may have on PrEP scale-up for women.

Scaling up pre-exposure prophylaxis in sub-Saharan Africa

PURPOSE OF REVIEW

Pre-exposure prophylaxis (PrEP) is highly efficacious for preventing HIV. Demonstrations worldwide show growing acceptability with nonoral formulations in the pipeline. Despite these successes, oral PrEP scale-up in sub-Saharan Africa (SSA), the region hardest hit by HIV, remains sub-optimal. This review details emerging practises and addresses challenges in PrEP scale-up and delivery within SSA.

RECENT FINDINGS

PrEP scale-up varies across SSA. Some countries face implementation challenges, whereas most have not applied for or received regulatory approval. As governments balance treatment and prevention costs, PrEP advocacy is growing. Demand has been slow, because of low-risk perception, HIV treatment conflation or poor information. Challenges in SSA are markedly different than elsewhere, as delivery is targeted to generalized heterosexuals, rather than only key populations. SSA requires public sector engagement and innovative delivery platforms.

SUMMARY

PrEP scale-up in SSA is sub-optimal, hindered by regulatory processes, implementation challenges, poor community engagement and inadequate funding. Approaches that acknowledge overburdened, under-resourced health sectors, and seek opportunities to integrate, task-shift, decentralize and even de-medicalize, with a tailored approach, while campaigning to educate and stimulate demand are most likely to work. Solutions to oral PrEP scale-up will apply to other formulations, opening new avenues for ARV (microbicides and injectables) and non-ARV-based (future vaccine) biomedical prevention provision.

Brief Report: PrEP Eligibility Among At-Risk Women in the Southern United States: Associated Factors, Awareness, and Acceptability

BACKGROUND

Among women in the United States, non-Latina black women in the South have disproportionately high rates of new HIV infections but low use of pre-exposure prophylaxis (PrEP). Effective strategies to identify factors associated with PrEP eligibility could facilitate improved screening, offering, and uptake of PrEP among US women at risk of HIV.

SETTING AND METHODS

We applied 2014 CDC criteria for PrEP use to at-risk HIV-negative women enrolled in the Southern US sites (Atlanta, Chapel Hill, Birmingham/Jackson, Miami) of the Women's Interagency HIV Study from 2014 to 2015 to estimate PrEP eligibility and assess PrEP knowledge and acceptability. Factors associated with PrEP eligibility were assessed using multivariable models.

RESULTS

Among 225 women, 72 (32%) were PrEP-eligible; the most common PrEP indicator was condomless sex. The majority of PrEP-eligible women (88%) reported willingness to consider PrEP. Only 24 (11%) PrEP-eligible women had previously heard of PrEP, and only 1 reported previous use. Education level less than high school [adjusted odds ratio (aOR) 2.56; 95% confidence interval (CI): 1.22 to 5.37], history of sexual violence (aOR 4.52; 95% CI: 1.52 to 17.76), and medium to high self-perception of HIV risk (aOR 6.76; 95% CI: 3.26 to 14.05) were significantly associated with PrEP eligibility in adjusted models.

CONCLUSIONS

Extremely low PrEP awareness and use despite a high proportion of eligibility and acceptability signify a critical need to enhance PrEP education and delivery for women in this region. Supplementing CDC eligibility criteria with questions about history of sexual violence and HIV risk self-assessment may enhance PrEP screening and uptake among US women.

PrEP Implementation and Persistence in a County Health Department Setting in Atlanta, GA

For marginalized populations, county health departments may be important PrEP access points; however, there are little data on successful PrEP programs at these venues outside of incentivized demonstration projects. Therefore, we implemented an open-access, free PrEP clinic at a county health department in Atlanta, GA to promote PrEP uptake among high-risk clients. The Fulton County Board of Health PrEP clinic launched in October 2015, and eligible clients who expressed interest initiated PrEP and attended follow-up visits per CDC guidelines. Clients engaged in quarterly follow-up and seen within the last 6 months were defined as "persistent", whereas clients with a lapse in follow-up of > 6 months were defined as "not persistent." Factors associated with PrEP persistence were assessed with unadjusted odds ratios. Between October 2015 and June 2017, 399 clients were screened for PrEP, almost all were eligible [392/399 (98%)]; however, 158/392 (40%) did not return to start PrEP after screening. Of 234 patients, 216 (92%) received a prescription for PrEP. As of June 2017, only 69/216 (32%) clients remained persistent in PrEP care, and the only evaluated factor significantly associated with PrEP persistence was age ≥ 30 years (OR 1.86, 95% CI 1.02, 3.42). Implementation of PrEP in the county health department setting is feasible; however, we have identified significant challenges with PrEP uptake and persistence in our setting. Further research is needed to fully understand mediators of PrEP persistence and inform interventions to optimize health department-based PrEP services.

Factors Affecting Pre-Exposure Prophylaxis Implementation for Women in the United States: A Systematic Review

Oral HIV pre-exposure prophylaxis (PrEP) is a highly effective pill that HIV-negative individuals can take once daily to prevent HIV infection. Although PrEP is a private, user-controlled method that empowers women to protect themselves without relying on a partner's behavior, women's PrEP use has been extremely low. We systematically reviewed the literature to identify and summarize factors that may be affecting PrEP implementation for women in the United States. We conducted a search of the Centers for Disease Control and Prevention HIV/AIDS Prevention Research Synthesis Project database (MEDLINE, EMBASE, and CINAHL) and PubMed to identify peer-reviewed studies published between January 2000 and April 2018 that reported U.S. women's or health care providers' PrEP knowledge or awareness, willingness to use or prescribe, attitudes, barriers and facilitators to use or prescription, or PrEP adherence and discontinuation influences. Thirty-nine studies (26 women, 13 providers) met the eligibility criteria. In these studies, 0%-33% of women had heard of PrEP. Between 51% and 97% of women were willing to try PrEP, and 60%-92% of providers were willing to prescribe PrEP to women. Implementation barriers included access, cost, stigma, and medical distrust. Three studies addressed adherence or discontinuation. PrEP knowledge is low among women and providers. However, women and providers generally have positive views when aware of PrEP, including a willingness to use or prescribe PrEP to women. Most of the implementation barriers highlighted in studies were social or structural factors (e.g., access). Additional studies are needed to address research gaps, including studies of PrEP adherence and discontinuation.

Pre-Exposure Prophylaxis Integration into Family Planning Services at Title X Clinics in the Southeastern United States: A Geographically-Targeted Mixed Methods Study (Phase 1 ATN 155)

BACKGROUND

Black adolescent and young adult women (AYAW) in the Southern United States are disproportionately affected by HIV. Pre-exposure prophylaxis (PrEP) is an effective, scalable, individual-controlled HIV prevention strategy that is grossly underutilized among women of all ages and requires innovative delivery approaches to optimize its benefit. Anchoring PrEP delivery to health services that AYAW already trust, access routinely, and deem useful for their sexual health may offer an ideal opportunity to reach women at risk for HIV and to enhance their PrEP uptake and adherence. These services include those of family planning (FP) providers in high HIV incidence settings. However, PrEP has not been widely integrated into FP services, including Title X-funded FP clinics that provide safety net sources of care for AYAW. To overcome potential implementation challenges for AYAW, Title X clinics in the Southern United States are uniquely positioned to be focal sites for conceptually informed and thoroughly evaluated PrEP implementation science studies.

OBJECTIVE

The aim of this study is to assess inner and outer context factors (barriers and facilitators) that may influence the adoption of PrEP prescription and treatment services in Title X clinics serving AYAW in the Southern United States.

METHODS

Phase 1 of Planning4PrEP is an explanatory sequential, mixed methods study consisting of a geographically-targeted Web-based survey of Title X clinic administrators and providers in the Southern United States, followed by key informant interviews among a purposively selected subset of responders to more comprehensively assess inner and outer context factors that may influence adoption and implementation of PrEP in Title X FP clinics in the South.

RESULTS

Phase 1 of Planning4PrEP research activities began in October 2017 and are ongoing. To date, survey and key informant interview administration is near completion, with quantitative and qualitative data analysis scheduled to begin soon after data collection completion.

CONCLUSIONS

This study seeks to assess inner and outer contextual factors (barriers and facilitators) that may influence the adoption and integration of PrEP prescription and treatment services in Title X clinics serving AYAW in the Southern United States. Data gained from this study will inform a type 1 hybrid effectiveness implementation study, which will evaluate the multilevel factors associated with successful PrEP implementation while evaluating the degree of PrEP uptake, continuation, and adherence among women seen in Title X clinics.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

DERR1-10.2196/12774.

Acceptability and Feasibility of Self-Collecting Biological Specimens for HIV, Sexually Transmitted Infection, and Adherence Testing Among High-Risk Populations (Project Caboodle!): Protocol for an Exploratory Mixed-Methods Study

BACKGROUND

Men who have sex with men (MSM) in the United States experience a disproportionate burden of HIV and bacterial sexually transmitted infections (STIs), such as gonorrhea and chlamydia. Screening levels among MSM remain inadequate owing to barriers to testing such as stigma, privacy and confidentiality concerns, transportation issues, insufficient clinic time, and limited access to health care. Self-collection of specimens at home and their return by mail for HIV and bacterial STI testing, as well as pre-exposure prophylaxis (PrEP) adherence monitoring, could be a resource-efficient option that might mitigate some of these barriers.

OBJECTIVE

Project Caboodle! is a mixed-methods study that explores the acceptability and feasibility of self-collecting and returning a bundle of 5 different specimens for HIV and bacterial STI testing, as well as PrEP adherence monitoring, among sexually active HIV-negative or unknown status MSM in the United States aged 18 to 34 years.

METHODS

Participants will be recruited using age, race, and ethnicity varied advertising on social networking websites and mobile gay dating apps. In Phase 1, we will send 100 participants a box containing materials for self-collecting and potentially returning a finger-stick blood sample (for HIV testing), pharyngeal swab, rectal swab, and urine specimen (for gonorrhea and chlamydia testing), and hair sample (to assess adequacy for potential PrEP adherence monitoring). Specimen return will not be incentivized, and participants can choose to mail back all, some, or none of the specimens. Test results will be delivered back to participants by trained counselors over the phone. In Phase 2, we will conduct individual in-depth interviews using a video-based teleconferencing software (VSee) with 32 participants from Phase 1 (half who returned all specimens and half who returned some or no specimens) to examine attitudes toward and barriers to completing various study activities.

RESULTS

Project Caboodle! was funded in May 2018, and participant recruitment began in March 2019. The processes of designing a study logo, creating advertisements, programming Web-based surveys, and finalizing step-by-step written instructions accompanied by color images for specimen self-collection have been completed. The boxes containing 5 self-collection kits affixed with unique identification stickers are being assembled, and shipping procedures (for mailing out boxes to participants and for specimen return by participants using prepaid shipping envelopes) and payment procedures for completing the surveys and in-depth interviews are being finalized.

CONCLUSIONS

Self-collection of biological specimens at home and their return by mail for HIV and bacterial STI testing, as well as PrEP adherence monitoring, might offer a practical and convenient solution to improve comprehensive prevention efforts for high-risk MSM. The potentially reduced time, expense, and travel associated with this approach could facilitate a wider implementation of screening algorithms and remote monitoring strategies.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

PRR1-10.2196/13647.

Linking women experiencing incarceration to community-based HIV pre-exposure prophylaxis care: protocol of a pilot trial

BACKGROUND

Women experiencing incarceration (WEI) engage in high rates of sex- and drug-related behavior that places them at risk for HIV. Pre-exposure prophylaxis (PrEP) is an efficacious means of reducing HIV acquisition. There is a general lack of knowledge regarding PrEP among women at elevated risk, and only a small percentage of at-risk women are currently engaged in PrEP care. The period of incarceration represents an opportunity to identify at-risk women, initiate PrEP during incarceration, and establish linkage to community-based PrEP care upon release from incarceration. Further, post-release is a time period that is particularly risky, and there are numerous barriers, including substance use, that may impede linkage to community-based care in the absence of intervention. The current protocol describes plans for the development and pilot randomized controlled trial (RCT) of an intervention to promote PrEP uptake during incarceration and facilitate linkage to community-based PrEP care post-release.

METHODS/DESIGN

The motivational interviewing-navigation (MI-NAV) study intervention is being developed, refined, and tested over three phases within the framework of the social ecological model. All phases of the study are being conducted at a women's correctional facility and community-based PrEP provider located in the Northeastern region of the United States. Phase 1 consists of individual qualitative interviews to be conducted with key stakeholders (n = 6-10) from the community-based PrEP care site and (n = 6-10) from the women's correctional facility, as well as with (n = 18-30) WEI. Recruitment for Phase 1 was initiated in November 2017. In Phase 2, MI-NAV will be piloted with a small cohort (n = 8-12) of WEI and will be refined based upon participant feedback. During Phase 3, a pilot RCT of MI-NAV and a standard of care condition will be conducted with 80 WEI. RCT participants will complete baseline and follow-up assessments 1, 3, and 6 months post-release. The primary study outcome is linkage to community-based PrEP care, verified via medical records.

DISCUSSION

This study will develop and evaluate a psychosocial intervention (MI-NAV) to promote PrEP uptake and facilitate linkage to community-based PrEP care among women at-risk for HIV. It is expected that, as a result of this project, the feasibility, acceptability, and preliminary efficacy of MI-NAV will be determined. If found to be efficacious, this intervention has the potential to reduce HIV acquisition in a high-need, underserved community. Clinical trial registration NCT03281343.

Patient recommendations for PrEP information dissemination at family planning clinics in Atlanta, Georgia

OBJECTIVE

Family planning (FP) clinics are an ideal setting to disseminate information about pre-exposure prophylaxis (PrEP), but little is known about women's preferences for learning about PrEP in this setting.

STUDY DESIGN

We surveyed 500 women seeking care at 4 FP clinics in Atlanta. Before their provider visit, participants completed an HIV-risk screener. After, we asked participants about the HIV prevention counseling they received and how clinics could share information about PrEP. We performed descriptive analyses on demographics, HIV risk, and PrEP awareness/interest, and conducted thematic analysis on open-ended responses.

RESULTS

Only 18% knew about PrEP before the study; 28% of 376 sexually-active women had≥1 risk indicator consistent with PrEP eligibility. Three hundred forty seven women (69%) shared suggestions about how clinics should share PrEP information. We categorized suggestions into 4 themes - Advertising, Conversations, Awareness and Access. Participants (n=150) suggested clinics should advertise PrEP via brochures, posters, texts, or emails; 134 wanted providers to talk to patients about PrEP. Several (n=71) suggested sharing PrEP information broadly in the community and with other clinics/providers; others (n=11) wanted improved access to PrEP services.

CONCLUSIONS

Our results demonstrate overwhelming patient interest in learning more about PrEP through educational materials and directly from FP providers. Women were vocal about increasing PrEP awareness in the community, particularly among populations especially at risk for HIV (e.g., teens). These suggestions can be translated into actionable steps FP clinics can take to increase PrEP awareness and expand their reach to benefit women at risk for HIV.

IMPLICATIONS

High HIV rates among women in the South make it imperative to increase awareness of PrEP among women. Atlanta women seeking care in FP clinics valued learning about PrEP and recommended feasible strategies for disseminating information about PrEP in community settings, the clinic or during patient-provider discussion.

Preferred Product Attributes of Potential Multipurpose Prevention Technologies for Unintended Pregnancy and Sexually Transmitted Infections or HIV Among U.S. Women

Background: Multipurpose prevention technologies (MPTs) are being developed to simultaneously protect women from unintended pregnancy and sexually transmitted infections (STIs) or human immunodeficiency virus. This study aims to determine MPT characteristics desired by young women in the United States (U.S.). Materials and Methods: This is a cross-sectional national survey administered online by MTurk. Eligibility criteria included female sex, age 18-29 years, U.S. residence, and sexual activity with a male partner in the past 3 months. MPT characteristics were rated for importance. Odds ratios were generated to explore associations between demographics, sexual behaviors, and prior contraceptive use and likelihood of using various MPT formulations. Results: Of 835 women, the largest proportion reported being likely to use MPTs in the form of injectables (45.6%), followed by vaginal gels (33.7%), vaginal rings (26.3%) and diaphragms (17.3%). Women with prior experience using a specific method of contraception appeared more likely to try an MPT of the same form. Women concerned about STIs and unwanted pregnancy, or with a history of such undesirable outcomes, expressed higher likelihood of use for a broad range of products. Women indicated that safety and efficacy at preventing pregnancy were the most important product characteristics when choosing an MPT. Conclusions: MPTs in the form of injectables are most highly desired, but many women would use vaginal methods, highlighting the importance of developing different delivery methods. Women desire safety and emphasize contraceptive efficacy over infection prevention. MPT preferences must be considered during product development to promote future acceptance among young women in the U.S.

Safety and pharmacokinetics of single, dual, and triple antiretroviral drug formulations delivered by pod-intravaginal rings designed for HIV-1 prevention: A Phase I trial

BACKGROUND

Intravaginal rings (IVRs) for HIV pre-exposure prophylaxis (PrEP) theoretically overcome some adherence concerns associated with frequent dosing that can occur with oral or vaginal film/gel regimens. An innovative pod-IVR, composed of an elastomer scaffold that can hold up to 10 polymer-coated drug cores (or "pods"), is distinct from other IVR designs as drug release from each pod can be controlled independently. A pod-IVR has been developed for the delivery of tenofovir (TFV) disoproxil fumarate (TDF) in combination with emtricitabine (FTC), as daily oral TDF-FTC is the only Food and Drug Administration (FDA)-approved regimen for HIV PrEP. A triple combination IVR building on this platform and delivering TDF-FTC along with the antiretroviral (ARV) agent maraviroc (MVC) also is under development.

METHODOLOGY AND FINDINGS

This pilot Phase I trial conducted between June 23, 2015, and July 15, 2016, evaluated the safety, pharmacokinetics (PKs), and acceptability of pod-IVRs delivering 3 different ARV regimens: 1) TDF only, 2) TDF-FTC, and 3) TDF-FTC-MVC over 7 d. The crossover, open-label portion of the trial (N = 6) consisted of 7 d of continuous TDF pod-IVR use, a wash-out phase, and 7 d of continuous TDF-FTC pod-IVR use. After a 3-mo pause to evaluate safety and PK of the TDF and TDF-FTC pod-IVRs, TDF-FTC-MVC pod-IVRs (N = 6) were evaluated over 7 d of continuous use. Safety was assessed by adverse events (AEs), colposcopy, and culture-independent analysis of the vaginal microbiome (VMB). Drug and drug metabolite concentrations in plasma, cervicovaginal fluids (CVFs), cervicovaginal lavages (CVLs), and vaginal tissue (VT) biopsies were determined via liquid chromatographic-tandem mass spectrometry (LC-MS/MS). Perceptibility and acceptability were assessed by surveys and interviews. Median participant age was as follows: TDF/TDF-FTC group, 26 y (range 24-35 y), 2 White, 2 Hispanic, and 2 African American; TDF-FTC-MVC group, 24.5 y (range 21-41 y), 3 White, 1 Hispanic, and 2 African American. Reported acceptability was high for all 3 products, and pod-IVR use was confirmed by residual drug levels in used IVRs. There were no serious adverse events (SAEs) during the study. There were 26 AEs reported during TDF/TDF-FTC IVR use (itching, discharge, discomfort), with no differences between TDF alone or in combination with FTC observed. In the TDF-FTC-MVC IVR group, there were 12 AEs (itching, discharge, discomfort) during IVR use regardless of attribution to study product. No epithelial disruption/thinning was seen by colposcopy, and no systematic VMB shifts were observed. Median (IQR) tenofovir diphosphate (TFV-DP) tissue concentrations of 303 (277-938) fmol/10(6) cells (TDF), 289 (110-603) fmol/10(6) cells (TDF-FTC), and 302 (177.1-823.8) fmol/10(6) cells (TDF-FTC-MVC) were sustained for 7 d, exceeding theoretical target concentrations for vaginal HIV prevention. The study's main limitations include the small sample size, short duration (7 d versus 28 d), and the lack of FTC triphosphate measurements in VT biopsies.

CONCLUSIONS

An innovative pod-IVR delivery device with 3 different formulations delivering different regimens of ARV drugs vaginally appeared to be safe and acceptable and provided drug concentrations in CVFs and tissues exceeding concentrations achieved by highly protective oral dosing, suggesting that efficacy for vaginal HIV PrEP is achievable. These results show that an alternate, more adherence-independent, longer-acting prevention device based on the only FDA-approved PrEP combination regimen can be advanced to safety and efficacy testing.

TRIAL REGISTRATION

ClinicalTrials.gov NCT02431273.