Factors associated with retention and adherence on Pre-Exposure Prophylaxis among men who have sex with men in Kigali, Rwanda

Pre-Exposure Prophylaxis (PrEP) is recommended as an HIV prevention measure for men who have sex with men (MSM). We assessed factors associated with PrEP retention and adherence among MSM in Kigali, Rwanda. We undertook a retrospective cross-sectional study and used a questionnaire to obtain PrEP retention and adherence history from MSM enrolled in the key population (KP) program that attended scheduled follow-up clinics from four (4) health facilities between April 2021 to June 2021. Retention was defined as attending scheduled PrEP follow-up appointments and adherence as taking PrEP medication 95% or more of the time. We used multivariable cox proportion hazard regression to determine factors associated with 3-month retention and principal component analysis (PCA) to determine factors associated with self-reported adherence. Data were analyzed using STATA (version 16.0). We interviewed 439 MSM aged 18 years and above that were initiated on PrEP. Majority were employed (57%, n = 251), between ages 25-34 years (49%, n = 217), close to half completed primary level education (47%, n = 206), were involved in sex work (42%, n = 184), and over a half lived in household of 1-2 members (55%, n = 241). Ninety percent of the MSM respondents (n = 393) were retained on PrEP at 3 months and among those retained, 287 (73%) had good adherence. Multivariable cox regression revealed that MSM more likely to be retained on PrEP, were those that are sex workers (adjusted Hazard Ratio (aHR) = 4.139; 95% Confidence Interval (95%CI): 1.569, 10.921), had more than one (1) regular sexual partners (aHR = 3.949; 95%CI: 2.221, 7.022), lived in households of 3-5 members (aHR = 3.755; 95%CI: 1.706, 8.261), completed secondary school education (aHR = 2.154; 95%CI: 1.130, 4.108), and were circumcised (aHR = 2.218, 95%CI: 1.232, 3.993). Employed MSM had a 66% decreased likelihood to be retained on PrEP (aHR = 0.345; 95%CI: 0.168, 0.707). Similarly, MSM that used condoms consistently had an 85% decreased likelihood to be retained on PrEP (aHR = 0.149; 95%CI: 0.035, 0.632). Principal component regression analysis showed that the component with MSM with higher numbers of regular sexual partners had increased odds of adhering to PrEP (Crude Odds Ratio (cOR) = 1.32; 95%CI: 1.144, 1.530). The study highlighted that MSM using PrEP as the main method of HIV prevention were more likely to be retained and adherent to PrEP. There is need to emphasize PrEP use alongside other HIV prevention methods and targeted STI testing and treatment among PrEP users.

A Systematic Review and Meta-analysis of the Impact of the COVID-19 Pandemic on Access to HIV Pre-exposure Prophylaxis: Lessons for Future Public Health Crises

BACKGROUND

The World Health Organization is committed to strengthening access to pre-exposure prophylaxis (PrEP) for HIV prevention and its integration into primary care services. Unfortunately, the COVID-19 pandemic has disrupted the delivery of primary care, including HIV-related services. To determine the extent of this disruption, we conducted a systematic review and meta-analysis of the changes in access to PrEP services during the pandemic and the reasons for these changes.

METHODS

A search was conducted using PubMed, Scopus, Embase, PsycINFO, and Cinahl for studies published between January 2020 and January 2023. Selected articles described self-reported disruptions to PrEP service access associated with the COVID-19 pandemic or its responses. Pooled effect sizes were computed using a random-effects model.

RESULTS

Thirteen studies involving 12,652 PrEP users were included in our analysis. The proportion of participants reporting a disruption in access to PrEP services during the COVID-19 pandemic ranged from 3% to 56%, with a pooled proportion of 21% (95% confidence intervals: 8% to 38%). Social restrictions, financial constraints, and limited health insurance coverage were key factors affecting access to PrEP services during the pandemic.

CONCLUSIONS

To our knowledge, this is the first meta-analysis to quantify the extent of disruptions to accessing PrEP services because of the COVID-19 pandemic. To increase the ability of primary care services to maintain PrEP services during public health crises, a mixture of strategies is worth considering. These include multi-month PrEP prescriptions, telehealth services, deployment of peer support groups to provide a community-based service or home delivery, and provision of financial support interventions.

Perceived patient navigator services and characteristics to address barriers to linkage to hepatitis C care among people released from provincial prison in Quebec, Canada

BACKGROUND

Patient navigation increases linkage to hepatitis C virus (HCV) care following release from prison; however, little is known about the services patient navigators should provide to maximize linkage to care. We aimed to identify perceived barriers and facilitators to linkage to HCV care post-release, and to determine patient navigator services and characteristics best suited to address barriers to linkage to care among people released from prison.

METHODS

Ten semi-structured interviews were conducted with adult (age ≥18 years) men living with chronic HCV, released from the largest Quebec provincial prison, and linked to HCV care by a patient navigator. Interviews were guided by the Socio-Ecological Model (SEM) and aimed to explore the multi-level barriers and facilitators to linkage to HCV care post-release. Interviews were audio-recorded, transcribed, and analyzed using a deductive, thematic approach.

RESULTS

The median age of participants was 54 years. Barriers to linkage to HCV care included competing priorities post-release (e.g., substance use, mental health issues, unstable housing), stigma (related to HCV, injection drug use, and incarceration), and lack of transportation. Facilitators included social support, established relationships with existing healthcare providers, prior cure with direct-acting antivirals, and HCV-related health literacy and knowledge. Perceived essential patient navigator services to enhance linkage included pre-release discharge appointments, housing assistance, and facilitated transportation to HCV appointments. Ensuring a consistent, non-judgemental, and empathetic patient navigator were considered important characteristics; lived experiences of incarceration and/or HCV were not felt to be essential for a patient navigator.

CONCLUSIONS

Interventions that seek to improve linkage to HCV care for people following release from prison should address many levels (individual, interpersonal, and policy) of the SEM. While people experience several competing priorities post-release, having an empathetic and consistent patient navigator, regardless of their lived experiences of HCV and/or incarceration, may improve linkage to HCV care post-release.

Transgender-Specific Differentiated HIV Service Delivery Models in the South African Public Primary Health Care System (Jabula Uzibone): Protocol for an Implementation Study

BACKGROUND

Almost 60% of transgender people in South Africa are living with HIV. Ending the HIV epidemic will require that transgender people successfully access HIV prevention and treatment. However, transgender people often avoid health services due to facility-based stigma and lack of availability of gender-affirming care. Transgender-specific differentiated service delivery (TG-DSD) may improve engagement and facilitate progress toward HIV elimination. Wits RHI, a renowned South African research institute, established 4 TG-DSD demonstration sites in 2019, with funding from the US Agency for International Development. These sites offer unique opportunities to evaluate the implementation of TG-DSD and test their effectiveness.

OBJECTIVE

The Jabula Uzibone study seeks to assess the implementation, effectiveness, and cost of TG-DSD for viral suppression and prevention-effective adherence.

METHODS

The Jabula Uzibone study collects baseline and 12-month observation checklists at 8 sites and 6 (12.5%) key informant interviews per site at 4 TG-DSD and 4 standard sites (n=48). We seek to enroll ≥600 transgender clients, 50% at TG-DSD and 50% at standard sites: 67% clients with HIV and 33% clients without HIV per site type. Participants complete interviewer-administered surveys quarterly, and blood is drawn at baseline and 12 months for HIV RNA levels among participants with HIV and tenofovir levels among participants on pre-exposure prophylaxis. A subset of 30 participants per site type will complete in-depth interviews at baseline and 12 months: 15 participants will be living with HIV and 15 participants will be HIV negative. Qualitative analyses will explore aspects of implementation; regression models will compare viral suppression and prevention-effective adherence by site type. Structural equation modeling will test for mediation by stigma and gender affirmation. Microcosting approaches will estimate the cost per service user served and per service user successfully treated at TG-DSD sites relative to standard sites, as well as the budget needed for a broader implementation of TG-DSD.

RESULTS

Funded by the US National Institutes of Mental Health in April 2022, the study was approved by the Human Research Ethics Committee at University of Witwatersrand in June 2022 and the Duke University Health System Institutional Review Board in June 2023. Enrollment began in January 2024. As of July 31, 2024, a total of 593 transgender participants have been enrolled: 348 are living with HIV and 245 are HIV negative. We anticipate baseline enrollment will be complete by August 31, 2024, and the final study visit will take place no later than August 2025.

CONCLUSIONS

Jabula Uzibone will provide data to inform HIV policies and practices in South Africa and generate the first evidence for implementation of TG-DSD in sub-Saharan Africa. Study findings may inform the use of TG-DSD strategies to increase care engagement and advance global progress toward HIV elimination goals.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

DERR1-10.2196/64373.

Perceived Feasibility and Acceptability of HIV Prevention Research With Daily Oral PrEP Among Young Transgender Women (YTGW) Who Sell or Trade Sex in Bangkok and Pattaya, Thailand

Young transgender women (YTGW) who sell or trade sex have among the highest HIV incidence rates in Thailand. Using qualitative methods, we assessed perceived acceptability, feasibility, and optimal design of a combination HIV prevention intervention including PrEP for YTGW. Key informant interviews were conducted during July 2016-July 2018 with 21 YTGW, aged 18-26 years, who sold sex and resided in Bangkok or Pattaya, Thailand. Grounded theory and content analysis were used for data analysis. Most YTGW interviewed reported high interest in HIV prevention research and believed participation in it supported sexual health. However, participants perceived HIV studies as complicated and time-consuming. Regarding PrEP, participants suggested more PrEP options beyond daily oral PrEP and expressed concerns related to perceived side effects of PrEP, including interaction with gender-affirming hormone therapy. Improving PrEP knowledge, being able to self-assess HIV risk, and reducing HIV/PrEP stigma could increase interest in research and PrEP uptake among YTGW.

Programme science in action: lessons from an observational study of HIV prevention programming for key populations in Lusaka, Zambia

INTRODUCTION

Optimizing uptake of pre-exposure prophylaxis (PrEP) for individuals at risk of HIV acquisition has been challenging despite clear scientific evidence and normative guidelines, particularly for key populations (KPs) such as men who have sex with men (MSM), female sex workers (FSWs), transgender (TG) people and persons who inject drugs (PWID). Applying an iterative Programme Science cycle, building on the effective programme coverage framework, we describe the approach used by the Centre for Infectious Disease Research in Zambia (CIDRZ) to scale up PrEP delivery and address inequities in PrEP access for KP in Lusaka, Zambia.

METHODS

In 2019, CIDRZ partnered with 10 local KP civil society organizations (CSOs) and the Ministry of Health (MOH) to offer HIV services within KP-designated community safe spaces. KP CSO partners led KP mobilization, managed safe spaces and delivered peer support; MOH organized clinicians and clinical commodities; and CIDRZ provided technical oversight. In December 2021, we introduced a community-based intervention focused on PrEP delivery in venues where KP socialize. We collected routine programme data from September 2019 to June 2023 using programme-specific tools and the national electronic health record. We estimated the before-after effects of our intervention on PrEP uptake, continuation and equity for KP using descriptive statistics and interrupted time series regression, and used mixed-effects regression to estimate marginal probabilities of PrEP continuity.

RESULTS

Most (25,658) of the 38,307 (67.0%) Key Population Investment Fund beneficiaries were reached with HIV prevention services at community-based venues. In total, 23,527 (61.4%) received HIV testing services, with 15,508 (65.9%) testing HIV negative and found PrEP eligible, and 15,241 (98.3%) initiating PrEP. Across all programme quarters and KP types, PrEP uptake was >90%. After introducing venue-based PrEP delivery, PrEP uptake (98.7% after vs. 96.5% before, p < 0.001) and the number of initiations (p = 0.014) increased significantly. The proportion of KP with ≥1 PrEP continuation visit within 6 months of initiation was unchanged post-intervention (46.7%, 95% confidence interval [CI]: 45.7%, 47.6%) versus pre-intervention (47.2%, 95% CI: 45.4%, 49.1%).

CONCLUSIONS

Applying Programme Science principles, we demonstrate how decentralizing HIV prevention services to KP venues and safe spaces in partnership with KP CSOs enabled successful community-based PrEP delivery beyond the reach of traditional facility-based services.

Low clinical impact of HIV drug resistance mutations in oral pre-exposure prophylaxis: a systematic review and meta-analysis

INTRODUCTION

Despite the widespread use of pre-exposure prophylaxis (PrEP) in preventing human immunodeficiency virus (HIV) transmission, scant information on HIV drug resistance mutations (DRMs) has been gathered over the past decade. This review aimed to estimate the pooled prevalence of pre-exposure prophylaxis and its two-way impact on DRM.

METHODS

We systematically reviewed studies on DRM in pre-exposure prophylaxis according to the Preferred Reporting Items for Systematic Reviews and Meta-Analysis 2020 guidelines. PubMed, Cochrane, and SAGE databases were searched for English-language primary studies published between January 2001 and December 2023. The initial search was conducted on 9 August 2021 and was updated through 31 December 2023 to ensure the inclusion of the most recent findings. The registration number for this protocol review was CRD42022356061.

RESULTS

A total of 26,367 participants and 562 seroconversion cases across 12 studies were included in this review. The pooled prevalence estimate for all mutations was 6.47% (95% Confidence Interval-CI 3.65-9.93), while Tenofovir Disoproxil Fumarate/Emtricitabine-associated drug resistance mutation prevalence was 1.52% (95% CI 0.23-3.60) in the pre-exposure prophylaxis arm after enrolment. A subgroup analysis, based on the study population, showed the prevalence in the heterosexual and men who have sex with men (MSM) groups was 5.53% (95% CI 2.55-9.40) and 7.47% (95% CI 3.80-12.11), respectively. Notably, there was no significant difference in the incidence of DRM between the pre-exposure prophylaxis and placebo groups (log-OR = 0.99, 95% CI -0.20 to 2.18, I2 = 0%; p = 0.10).

DISCUSSION

Given the constrained prevalence of DRM, the World Health Organization (WHO) advocates the extensive adoption of pre-exposure prophylaxis. Our study demonstrated no increased risk of DRM with pre-exposure prophylaxis (p > 0.05), which is consistent with these settings. These findings align with the previous meta-analysis, which reported a 3.14-fold higher risk in the pre-exposure prophylaxis group than the placebo group, although the observed difference did not reach statistical significance (p = 0.21).

CONCLUSIONS

Despite the low prevalence of DRM, pre-exposure prophylaxis did not significantly increase the risk of DRM compared to placebo. However, long-term observation is required to determine further disadvantages of extensive pre-exposure prophylaxis use. PROSPERO Number: CRD42022356061.

Assessing awareness and utilisation of pre-exposure prophylaxis for HIV prevention among women who inject drugs in Lagos, Nigeria: a cross-sectional study

Introduction

Women who inject drugs (WWID) in Nigeria are more likely to be living with HIV than their male counterparts and could benefit from pre-exposure prophylaxis (PrEP). Our study therefore sought to determine the awareness and use of PrEP among WWID in Lagos, Nigeria.

Methods

The study was descriptive cross-sectional in design and involved 422 participants recruited by using the snowballing technique. Interviewer-administered questionnaires were used to collect data which were analysed using Epi Info software and presented as frequency tables. χ2 test was used to analyse the categorical data and investigate relationships, associations, and independence between categorical variables with the level of significance set at p<0.05.

Results

There were 422 respondents with 60.2% of them between 18 and 30 years of age with the majority (90.1%) identifying as females while 6.9% identified as transgender. Half of the respondents (50.2%) were unemployed, 56.6% were single while 7.8% were aware of PrEP with only 1.9% reporting that they had ever used it. Factors significantly associated with awareness of PrEP were age (p<0.038), period of residence (p<0.001) and the level of education (p<0.001). Increased awareness of PrEP was associated with residence within the local government area for 1 year or more (adjusted OR (AOR) 0.20, 95% CI 0.08 to 0.49) and completion of at least secondary school education (AOR 7.63, 95% CI 2.59 to 22.45).

Conclusions

This study sheds light on the crucial issue of awareness and utilisation of PrEP for HIV prevention among WWID in Lagos, Nigeria. The findings highlight the need for tailored interventions bearing in mind the determinants of PrEP use within this specific demographic group. Addressing these correlates of PrEP use will be pivotal in developing effective strategies to reduce HIV transmission and improve the overall health outcomes in this vulnerable population.

The impact of HIV preexposure prophylaxis on bacterial sexually transmitted infection occurrence in MSM: a systematic review and meta-analysis

OBJECTIVE

To evaluate the effect of preexposure prophylaxis (PrEP) initiation on bacterial sexually transmitted infection (STI) occurrence (overall; chlamydia; gonorrhea; syphilis), in MSM.

DESIGN

Systematic review and meta-analysis.

METHODS

Systematic searches were performed in PubMed, Embase, and Scopus without language restrictions until 1 February 2023. We sought studies reporting data for the estimation of incidence rate ratios (IRR), prevalence ratios or cumulative incidence ratios (the latter in equal time periods before and after PrEP initiation) regarding bacterial STI occurrence. Separate analyses were performed overall for any STI, syphilis, chlamydia and gonorrhea (overall; rectal; urethral; pharyngeal for the two latter conditions); ratios greater than unity denoted increase in STI occurrence after PrEP initiation.

RESULTS

Twenty-three eligible studies with 11 776 participants (age range: 18-71 years) with a median follow-up of 12 months were included. Overall, PrEP initiation was associated with a significant increase in the occurrence of any STI (pooled effect size: 1.15, 95% confidence interval (CI): 1.04-1.26), any gonorrhea (pooled effect size: 1.17, 95% CI: 1.02-1.34), any chlamydia (pooled effect size: 1.31, 95% CI: 1.09-1.58) and rectal chlamydia (pooled effect size: 1.31, 95% CI: 1.05-1.64), whereas a borderline increase was found in urethral chlamydia (pooled effect size: 1.25, 95% CI: 0.99-1.60, P  = 0.064). Changes in pharyngeal chlamydia and site-specific gonorrhea occurrence did not reach statistical significance. Syphilis showed virtually no change after PrEP initiation (pooled effect size: 0.99, 95% CI: 0.72-1.37).

CONCLUSION

These results highlight the need for more comprehensive, accessible STI testing to tackle bacterial STI infections in PrEP users.

Experiences and challenges of pre-exposure prophylaxis initiation and retention among high-risk populations: qualitative insights among service providers in Thailand

Objectives

Pre-exposure prophylaxis (PrEP) has been an essential element of the national combination prevention package and included in the Universal Health Coverage (UHC) of Thailand since 2019. As a part of the national monitoring and evaluation framework, this qualitative study aims to describe experiences and barriers concerning PrEP initiation and retention among service providers from both hospital and Key Population Led Health Service (KPLHS) settings under the country's UHC roll-out.

Methods

Between September and October 2020, ten focus group discussions with PrEP service providers from both hospitals and KPLHS across Thailand were conducted of which there were six hospitals, one health service center, three KPLHS. All interviews were recorded and transcribed verbatim to identify providers' experiences, attitudes, and perceived barriers regarding PrEP service delivery in Thailand.

Results

Among the 35 PrEP service providers, most of them reported positive attitudes toward PrEP and believed that it is an effective tool for HIV prevention. Men who have sex with men were perceived to be the easiest group to reach while PrEP uptake remains a challenge in other key populations. Integration of a PrEP clinic with other HIV services at hospitals made most healthcare providers unable to adopt an active approach in recruiting new clients like at KPLHS settings. Challenges in delivering PrEP services included lack of public awareness, high workload, limited benefit package coverage, structural and human resources.

Conclusion

Additional services to address different health needs should be considered to increase PrEP uptake among harder-to-reach populations. Novel approaches to PrEP service integration and close collaboration between hospitals and KPLHS would be essential in optimizing PrEP uptake and retention. Support regarding raising awareness, expanding service coverage and access, improving facilities and workforce, and providers' capacities are crucial for the success of the national PrEP programme.

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.

PrEPare_Morocco a successful community-based PrEP delivery demonstration program for men who have sex with men and female sex workers in Morocco

Pre-exposure prophylaxis (PrEP) is an effective HIV prevention tool, recommended for persons at substantial risk for HIV, such as female sex workers (FSW) and men who have sex with men (MSM). We present Morocco's and the Middle East/North Africa's first PrEP demonstration project. Our pilot aimed to assess the feasibility and acceptability of a community-based PrEP program for FSW and MSM in Morocco's highest HIV prevalence cities: Agadir, Marrakech, and Casablanca. From May to December 2017, 373 eligible participants engaged in a 5-9 month program with daily oral TDF/FTC and clinic visits. Of these, 320 initiated PrEP, with 119 retained until the study's end. We report an 86% PrEP uptake, 37% overall retention, and 78% retention after 3 months. No seroconversions occurred during follow-up. These results underscore PrEP's need and acceptability among MSM and FSW and demonstrate the effectiveness of a community-based PrEP program in Morocco. These findings informed Morocco's current PrEP program and hold potential for the wider region with similar challenges.

Optimising HIV pre-exposure prophylaxis and testing strategies in men who have sex with men in Australia, Thailand, and China: a modelling study and cost-effectiveness analysis

BACKGROUND

Men who have sex with men (MSM) in the Asia-Pacific region have a disproportionately high burden of HIV infection compared with the general population. Although pre-exposure prophylaxis (PrEP) for HIV is highly effective at preventing new HIV infections, the cost-effectiveness of PrEP for MSM in different countries in the Asia-Pacific region with varying PrEP coverage and HIV testing frequencies remains unstudied. We aimed to analyse the economic and health benefits of long-acting injectable cabotegravir (CAB-LA) compared with oral PrEP in high-income countries and low-income and middle-income countries within the Asia-Pacific region.

METHODS

We developed a decision-analytic Markov model to evaluate the population impact and cost-effectiveness of PrEP scale-up among MSM in Australia, Thailand, and China. We assumed a static cohort of 100 000 MSM aged 18 years or older who were at risk of HIV infection, with a monthly cycle length over a 40-year time period. We evaluated hypothetical scenarios with universal PrEP coverage of 80% among 100 000 suitable MSM in each country. We modelled oral PrEP and CAB-LA for MSM with diverse HIV testing frequency strategies. We adopted the health-care system's perspective with a 3% annual discount rate. We calculated the incremental cost-effectiveness ratio (ICER), measured as additional cost per quality-adjusted life-year (QALY) gained, to compare different strategies with the status quo in each country. All costs were reported in 2021 US$. We also performed one-way, two-way, and probabilistic sensitivity analyses to assess the robustness of our findings.

FINDINGS

Compared with the status quo in each country, expanding oral PrEP to 80% of suitable MSM would avert 8·1% of new HIV infections in Australia, 14·5% in Thailand, and 26·4% in China in a 40-year period. Expanding oral PrEP use with 6-monthly HIV testing for both PrEP and non-PrEP users was cost-saving for Australia. Similarly, expanding oral PrEP use remained the most cost-effective strategy in both Thailand and China, but optimal testing frequency varied, with annual testing in Thailand (ICER $4707 per QALY gained) and 3-monthly testing in China (ICER $16 926 per QALY gained) for both PrEP and non-PrEP users. We also found that replacing oral PrEP with CAB-LA for MSM could avert more new HIV infections (12·8% in Australia, 27·6% in Thailand, and 32·8% in China), but implementing CAB-LA was not cost-effective due to its high cost. The cost of CAB-LA would need to be reduced by 50-90% and be used as a complementary strategy to oral PrEP to be cost-effective in these countries.

INTERPRETATION

Expanding oral PrEP use for MSM, with country-specific testing frequency, is cost-effective in Australia, Thailand, and China. Due to the high cost, CAB-LA is currently not affordable as a single-use strategy but might be offered as an additional option to oral PrEP.

FUNDING

Ministry of Science and Technology of the People's Republic of China, the Australian National Health and Medical Research Council, National Key Research and Development Program of China, and National Natural Science Foundation of China.

Lived experiences with pre-exposure prophylaxis uptake and adherence among transgender women in Thailand: a qualitative study

BACKGROUND

Transgender women (TGW) are disproportionately affected by HIV, and HIV prevalence among TGW in Thailand has been increasing. Although oral daily pre-exposure prophylaxis (PrEP) is effective for HIV prevention, PrEP uptake and persistence among TGW have been low. This study aimed to provide a deeper understanding of TGW's experiences with PrEP uptake and adherence, and to identify major barriers to PrEP use to inform intervention adaptation.

METHODS

We interviewed 20 young TGW (six non-PrEP users, eight adherent, six non-adherent) and 10 health care providers from two HIV clinics in Bangkok, Thailand, in 2022. We focused on understanding challenges to PrEP use in this population using an interview guide based on a theoretical model of behaviour change and thematic content analysis.

RESULTS

Thematic analysis identified major barriers to and facilitators of PrEP uptake and adherence. Barriers to PrEP initiation included low self-perceived HIV risk, concern about potential side-effects, patient burdens such as frequent HIV testing for prescription refills and social stigma against PrEP. Barriers to adherence included side-effects, inconvenient access to health services (especially during COVID-19 lockdowns), forgetfulness resulting from busy schedules and low self-perceived HIV risk. TGW also reported health care providers' stigma against PrEP users deterred them from seeking further PrEP services. TGW identified major facilitators of PrEP initiation, including awareness about the benefits of PrEP, concern about risks of HIV and supportive social networks of PrEP users. As to PrEP regimens, most TGW participants reported a clear preference for long-lasting, injectable PrEP over daily oral PrEP. TGW and health care providers largely agreed on barriers and facilitators of PrEP use, but they differed in perceptions of HIV risk.

CONCLUSIONS

The results highlighted challenges and opportunities to improve the delivery of PrEP, as well as other sexually transmissable infection and mental health services, especially among TGW. Thus, there is an urgent need for developing effective intervention programs that could raise PrEP awareness and knowledge, reduce PrEP stigma, and improve PrEP delivery systems among TGW in Thailand.

Addressing disparities in Pre-exposure Prophylaxis (PrEP) access: implementing a community-centered mobile PrEP program in South Florida

BACKGROUND

Pre-exposure prophylaxis (PrEP) for HIV prevention is highly effective, but disparities in PrEP access remain considerable, particularly among Black and Latino men who have sex with men (MSM). To address this, the University of Miami Mobile PrEP Program was created, offering mobile HIV prevention/PrEP services in areas throughout South Florida where HIV incidence is high and PrEP access is geographically limited. Using a community-centered participatory approach, the program strategized and executed expansion into the Liberty City neighborhood of Miami. This study qualitatively assessed factors affecting Mobile PrEP implementation as perceived by community stakeholders, clients, and program staff.

METHODS

Forty-one in-depth interviews were conducted with 21 Mobile PrEP clients, 10 key informants from local health organizations, and 10 program staff. Interview questions queried perceived organizational and positional barriers and facilitators to mobile clinic implementation. Service satisfaction, setting preferences, social factors, and likelihood of recommending Mobile PrEP were also assessed. A thematic content analysis was performed using the Consolidated Framework for Implementation Research (CFIR) taxonomy as the guiding constructs for the analysis.

RESULTS

Participant statements indicated that providing no-cost services, convenient location, program-covered rideshares, individualized patient navigation, and a community-centric approach to patient care, which included staff members with shared lived experiences to increase positive interactions and renewed trust among poorly served communities, were facilitators of PrEP access and intervention uptake. The importance of program familiarization with the community before implementation, particularly for Black and African American communities, who may experience unique barriers to accessing sexual healthcare was strongly emphasized by participants.

CONCLUSIONS

The Mobile PrEP intervention was found to be an acceptable and accessible mode of HIV/STI preventive care. The importance of pre-implementation community engagement and preparation is emphasized. Future research is needed to refine understanding of the intervention's components and evaluate implementation determinants in other highly impacted neighborhoods.

Demand creation and retention strategies for oral pre-exposure prophylaxis for HIV prevention among men who have sex with men and transgender women: a systematic review and meta-analysis

BACKGROUND

Men who have sex with men (MSM) and transgender women (TGW) have a disproportionately higher risk of human immunodeficiency virus (HIV) infection than other groups. Oral HIV pre-exposure prophylaxis (PrEP) is an effective prevention tool and should be offered to those at higher risk. Identifying demand creation strategies (DCS) and retention strategies (RS) to improve PrEP persistence is essential to control the HIV epidemic.

AIM

We aimed to identify the (DCS and RS with higher proportions among MSM and TGW.

METHODS

A systematic review and meta-analysis of prospective studies were conducted, with studies retrieved from five databases until November, 2022 following the Cochrane and PRISMA guidelines. The study protocol was registered in PROSPERO (CRD42022323220). The outcomes were DCS and RS for PrEP use among MSM and TGW. Strategies used for users enrolled in the PrEP-recruited (DCS) were classified as face-to-face (peer educator recruitment at social venues, nongovernmental organizations, and parties; direct referrals by health services; friends and/or sexual partners); online (chatbot or peer educator recruitment on social media [e.g., , Instagram or Facebook] or dating/hook-up apps [e.g., Grindr, Tinder, Badoo, and Scruff]); and mixed (face-to-face and online). RS was classified as provider counseling (face-to-face by a health professional; prevention of HIV risk counseling, distribution of condoms, lubricants, and testing for HIV or other sexually transmitted infections); online counseling (text messages, chatbots, telephone calls, social media, and peer educators); and mixed (all previous strategies). Subgroup analyses were conducted for each treatment strategy. Meta-analyses were performed using the R software version 4.2.1.

RESULTS

A total of 1, 129 studies were retrieved from the five databases. After eligibility, 46 studies were included. For MSM, most DCS and RS were online at 91% (95% CI: 0.85-0.97; I2=53%), and 83% (95% CI: 0.80-0.85; I2=17%) respectively. For TGW, mixed DCS and RS were the most frequent at85% (95% CI: 0.60-1.00; I2=91%) and online counseling at 84% (95% CI: 0.64-0.95) compared to other strategies.

CONCLUSION

Critical issues play. Pivotal role in increasing PrEP awareness among MSM and TGW, minimizing access gaps, and ensuring retention of PrEP services. Offering oral PrEP using online DCS and RS can reach and retain high numbers of MSM and TGW, and reduce HIV incidence in these populations.

Low awareness but high acceptability of pre-exposure prophylaxis for HIV among men who have sex with men and transgender persons in Delhi, India

Background: HIV pre-exposure prophylaxis (PrEP) is part of India's HIV prevention policy. We aimed to determine awareness of and willingness-to-use PrEP among men-who-have-sex-with-men (MSM) and transgender-persons (TG) in Delhi, India.Methods: A cross-sectional study was conducted at five purposively selected targeted-intervention projects in Delhi. Participants included self-identified MSM/TG aged ≥18 years, with negative/unknown HIV serostatus. A structured interview schedule, developed using formative research, was used. Primary outcomes were awareness of, and willingness-to-use PrEP. Socio-demographic and behaviour variables included age, living situation, education, anal-sex, condom-use and experiences of physical-violence. Determinants of outcome were identified in univariable logistic regression; variables associated at p < .25 were included in multivariable regression models.Results: Of 400 (224 MSM, 176 TG), mean ± SD age 25.7 ± 7.2 years, 14.5% (95% CI 11.0, 18.0) were aware of PrEP, while 63.3% (95% CI: 58.6, 68.1) reported willingness-to-use PrEP. PrEP-awareness was independently associated with formal-education (adjusted odds ratio; AOR = 1.20), professional occupation (AOR = 5.45) and condom-use (AOR = 3.07). Willingness-to-use PrEP was higher if participants had recent anal-sex (AOR = 2.29), had used condoms during anal-sex (AOR = 2.09), or recently experienced physical-violence (AOR = 3.65).Conclusions: PrEP awareness was low, but most were willing to use PrEP, implying that communication is key to PrEP awareness and uptake.

Adherence to Oral Pre-Exposure Prophylaxis Intervention by Transgender Women: A Systematic Review

Prevalence of human immunodeficiency virus (HIV) is higher in transgender populations. Pre-exposure prophylaxis (PrEP) intervention is successful in reducing HIV acquisition. We aimed to investigate the adherence to oral PrEP by HIV-negative transgender women (TW). We followed the Cochrane Handbook for Systematic Reviews of Interventions and the PRISMA Statement. We searched in WoS, OVID, Scopus, MEDLINE, and the Cochrane Central Register of Controlled Trials databases. Participation and adherence to the intervention were low for TW compared to cisgender men who have sex with men (cMSM), and it was measured mostly by self-report (72.7%) or tenofovir-diphosphate/emtricitabine triphosphate dried blood spot (45.5%). Awareness should increase and the effect of oral PrEP on gender-affirming hormone therapy should be explained to TW at the beginning of the trials. One limitation is that our sample size was dominated by two Thai studies with TW sex workers. Future studies should evaluate adherence to new PrEP modalities.

A Scoping Review of Oral Pre-exposure Prophylaxis for Cisgender and Transgender Adolescent Girls and Young Women: What Works and Where Do We Go from Here?

Adolescent girls and young women (AGYW) are disproportionately affected by HIV, and oral pre-exposure prophylaxis (PrEP) can reduce HIV acquisition. The purpose of this scoping review was to synthesize results from interventions along the PrEP continuum for AGYW to inform research and programs. We searched electronic databases for studies published between January 2012-July 2021 and conducted secondary reference searching. Studies were included if they assessed interventions to increase PrEP interest, uptake, or continuation among AGYW. Results were synthesized narratively. Of 2168 citations identified, 50 studies were eligible for inclusion, and 20 contained AGYW-specific data. Among cisgender and transgender AGYW, studies overall demonstrated a positive impact on PrEP interest and uptake but generally attained suboptimal continuation rates. Results demonstrate feasibility of deploying PrEP across diverse settings-particularly when interventions are layered, tailored to AGYW, and include differentiated delivery-but also highlight knowledge gaps and the need for more holistic metrics of success.

Adapting Effective mHealth Interventions to Improve Uptake and Adherence to HIV Pre-Exposure Prophylaxis Among Thai Young Men Who Have Sex With Men: Protocol for a Randomized Controlled Trial

BACKGROUND

Young men who have sex with men (YMSM) are the fastest-growing HIV-positive population worldwide. Thailand has the highest adult HIV seroprevalence in Asia; over 25% of men having sex with men in Bangkok are HIV positive. Pre-exposure prophylaxis (PrEP) is an efficacious HIV prevention strategy recommended for all at-risk individuals. PrEP is highly effective when taken as prescribed, but PrEP utilization rate has been low, and adherence is often inadequate.

OBJECTIVE

We propose to develop and pilot a multicomponent, technology-based intervention to promote motivation to begin PrEP ("uptake") and sustained adherence to PrEP among HIV-negative Thai YMSM. We will adapt an existing 2-session technology-delivered, motivational interviewing-based intervention to focus on PrEP use in YMSM in Thailand. The resulting intervention is called the Motivational Enhancement System for PrEP Uptake and Adherence (MES-PrEP). We will also develop motivational text messaging (MTM) to send two-way motivational messages to promote PrEP use.

METHODS

The proposed study includes 3 phases. Phase 1 includes in-depth interviews with HIV-negative Thai YMSM and providers to explore barriers and facilitators of PrEP initiation and adherence, aiming to inform intervention content. Phase 2 consists of adapting and beta-testing MES-PrEP and MTM for functionality and feasibility using a youth advisory board of Thai YMSM. In Phase 3, we will conduct a pilot randomized controlled trial to evaluate the feasibility, acceptability, and preliminary efficacy of MES-PrEP and MTM to increase PrEP uptake and adherence among Thai YMSM. A total of 60 HIV-negative Thai YMSM who have not started PrEP and 60 YMSM who are on PrEP but not adherent to it will be randomized 2:1 to receive MES-PrEP and MTM (n=40) or standard PrEP counseling (n=20). The feasibility and acceptability of the intervention will be assessed through usage patterns and the System Usability Scale. The preliminary impact will be assessed by evaluating the proportion of PrEP initiation and level of adherence to PrEP. Participants will complete the assessments at baseline and at 1-, 3-, and 6-month postintervention. Biomarkers of adherence to PrEP and biomarkers of HIV and sexually transmitted infections will be collected.

RESULTS

Recruitment for this study began in January 2022 for phase 1. Qualitative interviews were completed with 30 YMSM and 5 clinical providers in May 2022. Phase 3, the pilot feasibility and acceptability trial, began in July 2023. Upon project completion, we shall have developed a highly innovative mobile health intervention to support YMSM using PrEP, which will be ready for testing in a larger efficacy trial.

CONCLUSIONS

This study addresses a critical problem (ie, high HIV incidence and low PrEP use) among Thai YMSM. We are developing 2 potentially synergistic technology-based, theory-driven interventions aimed at maximizing PrEP use. The proposed project has the potential to make significant contributions to advancing HIV prevention research and implementation science.

TRIAL REGISTRATION

ClinicalTrials.gov NCT05243030; https://clinicaltrials.gov/ct2/show/NCT05243030.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

DERR1-10.2196/46435.

Unique HIV Risk Factors and Prevention Needs for Transgender Women and Cisgender Men Who Have Sex with Men in Bangkok, Thailand

Background

Transgender women (TGW) and cisgender men who have sex with men (cis-MSM) are often grouped together as key populations. We evaluated behavioral and other characteristics that may distinguish TGW from cis-MSM in Bangkok, Thailand.

Methods

We enrolled into an 18-month cohort cis-MSM and TGW 18-35 years of age without HIV, who reported anal intercourse plus condomless anal intercourse, multiple partners, transactional sex, and/or sexually transmitted infection. Robust multivariable Poisson regression was used to estimate adjusted prevalence ratios (aPRs) and confidence intervals (95% CIs) for associations with being a TGW. Among TGW, logistic regression with generalized estimating equations was used to estimate adjusted odds ratios (aORs) and 95% CIs for associations with taking hormones and having undergone gender affirmation surgery (GAS).

Results

From 2017 to 2019, 660 cis-MSM and 348 TGW were enrolled. Compared to cis-MSM, TGW were more likely to be attracted to mostly/only men (aPR: 3.79, 95% CI: 1.57-9.13), have a higher monthly income (aPR: 1.25, 95% CI: 1.04-1.50), have lived in their current residence for <1 year (aPR: 1.21, 95% CI: 1.01-1.46), have engaged in sex work (aPR: 1.48, 95% CI: 1.23-1.77), and be less likely to have ever undergone HIV testing (aPR: 0.83, 95% CI: 0.70-0.98). Among TGW, 149 (42.8%) were taking hormones and 33 (9.5%) had undergone GAS. GAS was more common among TGW who ever used methamphetamines (aOR: 1.55, 95% CI: 1.00-2.41) and those >23 years (18-20-year olds aOR: 0.17, 95% CI: 0.05-0.55; 21-23-year olds aOR: 0.36, 95% CI: 0.20-0.65).

Conclusions

TGW and cis-MSM are unique populations; tailored, gender-affirming, differentiated models of HIV prevention and care are necessary to address vulnerabilities specific to each key population.

High PrEP uptake, adherence, persistence and effectiveness outcomes among young Thai men and transgender women who sell sex in Bangkok and Pattaya, Thailand: findings from the open-label combination HIV prevention effectiveness (COPE) study

Background

Daily oral pre-exposure prophylaxis (PrEP) is effective in preventing HIV infection, but no study has evaluated combination prevention interventions with PrEP for transgender women (TGW) and men who have sex with men (MSM) who sell sex.

Methods

The Combination Prevention Effectiveness (COPE) study was a community-based, non-randomized implementation study in Bangkok and Pattaya, Thailand. Participants were HIV-negative MSM and TGW aged 18-26 years who reported exchanging sex with men in the prior 12 months and who met 2014 U.S. Public Health Service PrEP eligibility criteria. The intervention included quarterly HIV testing, semiannual testing for sexually transmitted infections, provision of condoms with lubricant, and the opportunity to initiate or end daily oral PrEP use at any time during study participation. Participants taking PrEP received monthly adherence counseling and short message service reminders. The primary outcome was HIV incidence rate ratio (IRR) on PrEP vs. not on PrEP. Secondary outcomes were PrEP initiation, PrEP use at 12 months, and PrEP adherence.

Findings

From October 2017 to August 2019, 846 participants were enrolled: 531 (62.8%) immediately initiated PrEP; 104 (12.3%) subsequently initiated PrEP, and 211 (24.9%) never initiated PrEP. Among those initiating PrEP within 30 days of enrollment; 85.9% were on PrEP at the 12-months. When taking PrEP, participants reported adherent PrEP use at 94.2% of quarterly assessments. Ten HIV seroconversions occurred without PrEP use (incidence rate [IR] = 3.42 per 100 person-years [PY]; 95% CI = 1.64-6.30), while zero cases occurred with PrEP use (IR = 0.0 per 100PY; 95% CI = 0.0-0.62), with IRR = 0.0 (95% CI = 0.0-0.22; p < 0.001).

Interpretation

Young Thai MSM and TGW who exchange sex can have high PrEP uptake, persistence and adherence, and low HIV incidence when offered in supportive community-based settings.

Funding

U.S. National Institute of Allergy and Infectious Diseases; Centers for Disease Control and Prevention.

Systematic review of alternative HIV preexposure prophylaxis care delivery models to improve preexposure prophylaxis services

OBJECTIVES

To identify types, evidence, and study gaps of alternative HIV preexposure prophylaxis (PrEP) care delivery models in the published literature.

DESIGN

Systematic review and narrative synthesis.

METHODS

We searched in the US Centers for Disease Control and Prevention (CDC) Prevention Research Synthesis (PRS) database through December 2022 (PROSPERO CRD42022311747). We included studies published in English that reported implementation of alternative PrEP care delivery models. Two reviewers independently reviewed the full text and extracted data by using standard forms. Risk of bias was assessed using the adapted Newcastle-Ottawa Quality Assessment Scale. Those that met our study criteria were evaluated for efficacy against CDC Evidence-Based Intervention (EBI) or Evidence-Informed Intervention (EI) criteria or Health Resources and Services Administration Emergency Strategy (ES) criteria, or for applicability by using an assessment based on the Reach, Effectiveness, Adoption, Implementation, and Maintenance framework.

RESULTS

This review identified 16 studies published between 2018 and 2022 that implemented alternative prescriber ( n  = 8), alternative setting for care ( n  = 4), alternative setting for laboratory screening ( n  = 1), or a combination of the above ( n  = 3) . The majority of studies were US-based ( n  = 12) with low risk of bias ( n  = 11). None of the identified studies met EBI, EI, or ES criteria. Promising applicability was found for pharmacists prescribers, telePrEP, and mail-in testing.

CONCLUSIONS

Delivery of PrEP services outside of the traditional care system by expanding providers of PrEP care (e.g. pharmacist prescribers), as well as the settings of PrEP care (i.e. telePrEP) and laboratory screening (i.e. mail-in testing) may increase PrEP access and care delivery.

Mapping Community-Engaged Implementation Strategies with Transgender Scientists, Stakeholders, and Trans-Led Community Organizations

PURPOSE OF REVIEW

Pre-exposure prophylaxis (PrEP) represents one of the most effective methods of prevention for HIV, but remains inequitable, leaving many transgender and nonbinary (trans) individuals unable to benefit from this resource. Deploying community-engaged PrEP implementation strategies for trans populations will be crucial for ending the HIV epidemic.

RECENT FINDINGS

While most PrEP studies have progressed in addressing pertinent research questions about gender-affirming care and PrEP at the biomedical and clinical levels, research on how to best implement gender-affirming PrEP systems at the social, community, and structural levels remains outstanding. The science of community-engaged implementation to build gender-affirming PrEP systems must be more fully developed. Most published PrEP studies with trans people report on outcomes rather than processes, leaving out important lessons learned about how to design, integrate, and implement PrEP in tandem with gender-affirming care. The expertise of trans scientists, stakeholders, and trans-led community organizations is essential to building gender-affirming PrEP systems.

Addressing Disparities in Pre-Exposure Prophylaxis (PrEP) Access: Implementing a Community-Centered Mobile PrEP Program in South Florida

Background

Pre-exposure prophylaxis (PrEP) for HIV prevention is highly effective, but disparities in PrEP access remain considerable, particularly among Black and Latino men who have sex with men (MSM). To address this, the University of Miami Mobile PrEP Program was created, offering mobile HIV prevention/PrEP services in areas throughout South Florida where HIV incidence is high and PrEP access is geographically limited. Using a community-centered participatory approach, the program strategized and executed expansion into the Liberty City neighborhood of Miami. This study qualitatively assessed factors affecting Mobile PrEP implementation as perceived by community stakeholders, clients, and program staff.

Methods

Forty-one in-depth interviews were conducted with 21 Mobile PrEP clients, 10 key informants from local health organizations, and 10 program staff. Interview questions queried perceived organizational and positional barriers and facilitators to mobile clinic implementation. Service satisfaction, setting preferences, social factors, and likelihood of recommending Mobile PrEP were also assessed. A thematic content analysis was performed using the Consolidated Framework for Implementation Research (CFIR) taxonomy as the guiding constructs for the analysis.

Results

Participant statements indicated that providing no-cost services, convenient location, program-covered rideshares, individualized patient navigation, and a community-centric approach to patient care, which included staff members with shared lived experiences to increase positive interactions and renewed trust among poorly served communities, were facilitators of PrEP access and intervention uptake. The importance of program familiarization with the community before implementation, particularly for Black and African American communities, who may experience unique barriers to accessing sexual healthcare was strongly emphasized by participants.

Conclusions

The Mobile PrEP intervention was found to be an acceptable and accessible mode of HIV/STI preventive care. The importance of pre-implementation community engagement and preparation is emphasized. Future research is needed to refine understanding of the intervention's components and evaluate implementation determinants in other highly impacted neighborhoods.

Insights into barriers and facilitators in PrEP uptake and use among migrant men and transwomen who have sex with men in Belgium

BACKGROUND

PrEP uptake is low among non-Belgian men and transwomen who have sex with men, although the HIV epidemic among men who have sex with men in Belgium is diversifying in terms of nationalities and ethnicity. We lack an in-depth understanding of this gap.

METHODS

We conducted a qualitative study using a grounded theory approach. The data consists of key informants interviews and in-depth interviews with migrant men or transwomen who have sex with men.

RESULTS

We identified four underlying determinants which shape our participants' experiences and contextualize the barriers to PrEP use. These include (1) the intersectional identities of being migrant and men and transwomen who have sex with men, (2) migration related stressors, (3) mental health and (4) socio-economic vulnerability. Identified barriers include: the accessibility of services; availability of information, social resources and providers' attitudes. These barriers influence PrEP acceptance and mediated by individual agency this influences their PrEP uptake.

CONCLUSION

An interplay of several underlying determinants and barriers impacts on PrEP uptake among migrant men and transwomen who have sex with men, illustrating a social gradient in access to PrEP. We need equitable access to the full spectrum of HIV prevention and care for all priority populations, including undocumented migrants. We recommend social and structural conditions that foster exercising these rights, including adapting PrEP service delivery, mental health and social support.

Providing HIV pre-exposure prophylaxis to men who have sex with men and transgender women in hospitals and community-led clinics in Thailand: acceptance, patterns of use, trends in risk behaviors, and HIV incidence

From May 2015 to June 2018, we conducted a PrEP demonstration project at two hospitals and four community-led clinics in Bangkok and Pattaya. HIV-negative, MSM and TGW aged ≥18 years old, reporting sex without a condom, were offered daily PrEP. Participants received HIV testing and completed a computer-based questionnaire at enrollment, 6 and 12 months. We collected self-reported PrEP adherence at months 1, 3, 6, 9, and 12. We used logistic regression to determine factors associated with the decision to take PrEP and calculated HIV incidence among baseline HIV-negative participants. Of 803 participants enrolled, 349 (43.5%) started PrEP. Participants were more likely to start PrEP if they were sex workers, had moderate or high self-perceived risk of HIV, or a high PrEP-knowledge score. Participants used PrEP for a median of 6.1 months. Reported condom use increased and the number of sex partners decreased during follow-up regardless of PrEP use. Six participants not-taking PrEP acquired HIV (HIV incidence 2.2 per 100 person-years), and five taking PrEP acquired HIV (HIV incidence 2.1 per 100 person-years). All five reported taking <4 pills the weeks before study visits.

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.

Acceptability and retention of the key population-led HIV treatment service for men who have sex with men and transgender women living with HIV in Thailand

INTRODUCTION

In Thailand, where the HIV epidemic is concentrated among key populations (KPs), particularly men who have sex with men (MSM) and transgender women (TGW), an HIV service delivery model tailored to KPs was piloted. This study evaluated the acceptability and retention of clients who accepted and declined the KP-led HIV treatment service.

METHODS

A retrospective cohort study was conducted using secondary data from three community-based organizations (CBOs) and three hospitals in Thailand. KP lay providers were trained to lead HIV treatment service in which MSM and TGW living with HIV received counselling and a 3-month antiretroviral therapy (ART) supply at CBOs. Thai MSM and TGW who were at least 18 years, on ART for at least 6-12 months, without co-morbidities/co-infections, and virally suppressed were eligible and offered the service. Those who declined received ART via other service models offered by the hospitals and served as a comparison group.

RESULTS

Of 220 clients screened between February 2019 and February 2020, 72% (159/220) were eligible of which 146 were MSM and 13 were TGW. Overall, 45% (72/159) accepted the KP-led service. Of those who declined, 98% (85/87) preferred to see the physician at the hospital. After 12 months of follow-up, among those accepted, 57% were in care at the CBO, 32% were referred back to and in care in other service models offered by the hospital, 10% were successfully transferred out to other hospital and 1% were lost to follow-up (LTFU); among those declined, 92% were in care in any service models offered by the hospital, 5% were successfully transferred out to other hospital, 2% were LTFU and 1% died (p-value<0.001).

CONCLUSIONS

Despite moderate acceptability and retention in care at the CBO among the clients accepting the KP-led service, almost all clients were engaged in care overall. Multiple service models that meet the preferences and needs of KPs living with HIV should be available to optimize engagement in care.

Assessment of U=U understanding, PrEP awareness, HIV risk behaviours and factors associated with low HIV knowledge among users of Hornet, an online dating application for LGBTQ, in Thailand

BACKGROUND

Over 50% of HIV infections in Thailand annually occur among men who have sex with men (MSM) and transgender women who use online applications to meet their sexual partners. We conducted a cross-sectional study assessing undetectable=untransmittable (U=U) understanding, pre-exposure prophylaxis (PrEP) awareness, sexual behaviours and factors associated with HIV knowledge among users of Hornet in Thailand.

METHODS

From November 2019 to January 2020, a survey was conducted using convenience sampling on Hornet in Thailand. HIV literacy was assessed via 22 questions, and multivariable linear regression was performed.

RESULTS

960 responses were assessed; median age was 34 years, the majority were MSM (80.4%), Thai (83.8%), had at least bachelor's degree (74.9%). Regarding the risk profiles, 39.1% reported inconsistent condom use, 15.0% used amphetamine-type stimulants, 56.9% had not taken PrEP in the last six months and 20.5% never had an HIV test. Only 22.8% thought that U=U was completely accurate. Lower HIV knowledge was associated with being from Africa (β -8.13, 95% CI -14.39 to -1.87), age of 25 years or younger (β -2.6, 95% CI -4.37 to -0.82), education less than bachelor's degree (β -2.58, 95% CI -3.98 to -1.19), having more than one sexual partners (β -2.41, 95% CI -4.13 to -0.69), paying three or more people to have intercourse (β -2.5, 95% CI -4.26 to -0.74), not knowing one's HIV status (β -3.56, 95% CI -5.45 to -1.68) and not answering about previous PrEP use (β -4.11, 95% CI -7.86 to -0.36). Higher HIV knowledge was associated with being from Europe (β 2.54, 95% CI 0.46 to 4.61), the Americas (β 3.37, 95% CI 0.44 to 6.30) and previous PrEP use (β 2.37, 95% CI 0.94 to 3.81).

CONCLUSION

Among Hornet users in Thailand, the U=U message was unclear, and PrEP use was suboptimal. Large HIV knowledge gaps and high-risk behaviours were concerning. Educational campaigns in online spaces are needed to promote awareness and HIV prevention strategies.

Planning for decentralized, simplified prEP: Learnings from potential end users in Ga-Rankuwa, gauteng, South Africa

Background

In South Africa, youth experience challenges with oral Pre-Exposure Prophylaxis (PrEP) access and uptake. Taking services out of healthcare settings has the potential to increase reach and overcome these challenges. This paper presents young and older people's preferences for decentralized, simplified PrEP service delivery and new long-acting HIV prevention methods, in Ga-Rankuwa, South Africa.

Methods

Between May and August 2021, both PrEP user and non-user adolescent girls and young women (AGYW), pregnant AGYW, female sex workers, adolescent boys and young men (ABYM), and men who have sex with men (MSM) were recruited to participate in focus group discussions (FDGs) in Ga-Rankuwa, Gauteng. Twenty-two FGDs were conducted. Participants were asked about PrEP uptake, potential acceptability of long-acting HIV prevention products, provision of integrated, simplified, and decentralized services, and digital tools to facilitate access to PrEP and other SRH services. A qualitative approach using inductive thematic analysis was carried out to explore emerging themes on decentralized, simplified delivery and the acceptability of long-acting methods.

Results

Of the 109 participants included in the study approximately 45% (n = 50) were female, the median age was 23 years ± 5.3. A third (n = 37) were current or previous PrEP users, of which, 59.5% (n = 22) collected PrEP refills from the clinic. Decentralized, simplified service delivery was appealing; health facilities, pharmacies and institutions of learning were preferred as service points for PrEP and SRH services, and recreational spaces preferred for dissemination of health information and engagement. ABYM were more open to having recreational spaces as service points. Long-acting Cabotegravir was preferred over the Dapivirine Vaginal Ring due to concerns around perceived side-effects, efficacy, and comfort.

Conclusion

Providing long-acting PrEP methods through decentralized, simplified service delivery was appealing to this population. They provided practical locations for decentralized service provision to potentially increase their engagement with and uptake of HIV prevention and SRH services.

Multilevel Factors Impacting PrEP Engagement Among Young Gay Men and Young Transgender Women in Thailand: A Qualitative Analysis

Half of new HIV infections in Thailand are among young people, the majority of whom are young gay and other men who have sex with men (YMSM) and young transgender women (YTGW). Amid low pre-exposure prophylaxis (PrEP) coverage, we explored practice-based factors that impact PrEP engagement among YMSM and YTGW. In 2018, we conducted 4 focus group discussions with 20 YMSM and 5 YTGW, and 22 in-depth interviews (5 in 2022) with healthcare providers (HCPs), community-based organization (CBO)/nongovernmental organization (NGO) staff, and peer educators. The inclusion of PrEP in universal healthcare coverage, including YMSM and YTGW, is a substantial facilitator of PrEP use; however, systemic barriers at microsocial (lack of communication about PrEP from HCPs, teachers, parents), mesosocial (healthcare-service fragmentation, lack of PrEP-competent HCPs), and macrosocial levels (annual quotas on free HIV-testing, HIV- and sexual-stigma) constrain and disincentivize adolescents' engagement with PrEP. National scale-up of youth-friendly and LGBT-affirmative CBO/NGO clinics, HCP training, and tailored programs to support adolescents' adherence may promote PrEP engagement among YMSM and YTGW in Thailand.

Risk Factors Associated with Loss to Follow-up Among Transgender Women Receiving HIV Pre-exposure Prophylaxis in Chiang Mai province, Thailand

Although HIV pre-exposure prophylaxis (PrEP) is free in Thailand, many transgender women discontinue taking it after initiation. We determined the loss to follow-up (LTFU) rate of transgender women who initiated PrEP at the Mplus Foundation, Chiang Mai, Thailand, and identified associated risk factors using Cox proportional hazard models. Of 235 participants who initiated PrEP, 59 (55%) out of 108 remaining participants had reactive syphilis. The LTFU rate at 6 months was 38% (95% confidence interval [CI]: 29-48%). Multivariable analysis indicates that LTFU is independently associated with age ≥ 26 years old (adjusted hazard ratio [aHR] = 2.09; 95% CI: 1.06-4.14) and reactive syphilis (aHR = 1.98; 95% CI:1.01-3.88). Delayed appointment scheduling by the PrEP providers and the syphilis clinic was associated with transgender women having reactive syphilis, and the lockdown policy during the COVID-19 pandemic might have influenced them to discontinue PrEP and their subsequent LTFU.

Improving HIV pre-exposure prophylaxis persistence among adolescent girls and young women: Insights from a mixed-methods evaluation of community, hybrid, and facility service delivery models in Namibia

Introduction

Despite the potential for community-based approaches to increase access to pre-exposure prophylaxis (PrEP) for adolescent girls and young women (AGYW), there is limited evidence of whether and how they improve PrEP persistence. We compared PrEP persistence among AGYW receiving services through community and hybrid models in Namibia to facility-based services. We subsequently identify potential mechanisms to explain how and why community and hybrid models achieved (or not) improved persistence to inform further service delivery innovation.

Methods

Data were collected from PrEP service delivery to AGYW over two-years in Namibia's Khomas Region. We used Kaplan-Meier analysis to estimate survival curves for PrEP persistence beyond three-months after initiation and report the cumulative probability of persistence at one- and three-months. Persistence was defined as any PrEP use within three months after initiation followed by a PrEP refill or previously prescribed supply of at least 30 days at the three-month visit. Interviews were conducted with 28 AGYW and 19 providers and analyzed using a deductive-inductive thematic approach.

Results

From October 2017 through September 2019, 372 (18.7%) AGYW received services through a facility model, 302 (15.1%) through a community model, and 1,320 (66.2%) through a hybrid model. PrEP persistence at one- and three-months was 41.2% and 34.9% in the community model and 6.2% and 4.8% in the hybrid model compared to 36.8% and 26.7% in the facility model. Within the community and hybrid models, we identified three potential mechanisms related to PrEP persistence. Individualized service delivery offered convenience and simplicity which enabled AGYW to overcome barriers to obtaining refills but did not work as well for highly mobile AGYW. Consistent interactions and shared experiences fostered social connectedness with providers and with peers, building social networks and support systems for PrEP use. PrEP and HIV-related stigma, however, was widely experienced outside of these networks. Community-to-facility referral for PrEP refill triggered apprehension towards unfamiliar PrEP services and providers in AGYW, which discouraged persistence.

Conclusion

Service delivery approaches that offer convenience and simplicity and foster social connectedness may reduce access barriers and increase social support enabling AGYW to self-manage their PrEP use and achieve improved PrEP persistence.

PrEP stigma among current and non-current PrEP users in Thailand: A comparison between hospital and key population-led health service settings

Background

Pre-exposure prophylaxis (PrEP) has demonstrated effectiveness in high-risk populations. PrEP service in Thailand became free of charge under the Universal Health Coverage (UHC) in 2021. The National Health Security Office launched a pilot project in 2020 to ensure sustainable service delivery, and the national monitoring and evaluation (M&E) framework was adopted to evaluate early phase implementation. We carried out a cross-sectional survey as part of the M&E process to investigate PrEP stigma among current and non-current PrEP users from both hospital and Key Population Led Health Services (KPLHS) settings in Thailand.

Methods

Between August and October 2020, an online cross-sectional survey was conducted. A link for a self-administered questionnaire was distributed to all active PrEP centers and PrEP clients were then recruited by PrEP providers. Descriptive and univariate analysis using Chi-square were applied in the analyses. Attitudes toward PrEP were ranked from the most negative to the most positive. The negative attitude can be interpreted as PrEP stigma.

Results

This study included 513 PrEP clients (355 from hospitals and 158 from KPLHS). In both settings, respondents' attitudes toward PrEP were generally positive, but some potential stigma was observed. 31.8% of hospital PrEP clients and 9.5% of KPLHS clients agreed that PrEP users should keep their pills hidden from others. Almost half (44.5%) of hospital clients and 18.4% of KPLHS clients agreed that PrEP users are often viewed negatively by society. More than 20% of hospital clients and 12% of KPLHS agreed that PrEP users frequently experience difficulties when their partner/lover/family find out that he or she is on PrEP. Respondents from the hospitals had slightly higher PrEP stigma than those from KPLHS.

Conclusions

According to our findings, at the policy level, the campaign to provide PrEP education to all groups of people should be continued in order to promote a positive view of PrEP and reduce PrEP-related stigma among the general population, which is critical for successful PrEP implementation.

The epidemiological impact and cost-effectiveness of key population-led PrEP delivery to prevent HIV among men who have sex with men in Thailand: A modelling study

Background

Although key populations (KPs), such as men-who-have-sex-with-men (MSM) are disproportionately affected by HIV, many prevention and treatment services are not easily accessible for KP members. To address the needs of KPs, Thailand established pre-exposure prophylaxis (PrEP) service delivery together with and led by KP members. This study determines the epidemiological impact and cost-effectiveness of key population-led (KP-led) PrEP.

Methods

We calibrated a compartmental deterministic HIV transmission model to the HIV epidemic among Thai MSM. Besides KP-led PrEP, we included other Thai service delivery models of PrEP (fee-based PrEP, the government PrEP program).Data on consistent PrEP use (5 years daily use, 95% effectiveness for preventing HIV) came from Thai PrEP delivery models. For the period 2015-2032, we ranged the number of PrEP starters (40,000-120,000), effectiveness of PrEP (45%-95%), and proportion of consistent users (10%-50%). The analysis started in 2015 when PrEP was introduced. A cost-effectiveness ratio of <160,000 Baht per quality-adjusted life year (QALY) over 40 years was cost-effective.

Findings

Without PrEP, 53,800 (interquartile range 48,700-59,700) new HIV infections are expected in 2015-2032. KP-led PrEP was found to have the strongest epidemiological impact of all delivery models averting 58% of infections compared to without PrEP. The epidemiological impact depends on the number of PrEP starters and proportion of consistent use. Although all PrEP service delivery models are cost-effective, KP-led PrEP is most cost-effective with incremental cost-effectiveness ratios of 28,000-37,300 Thai Baht per QALY.

Interpretation

Our model projects KP-led PrEP having the greatest epidemiological impact and being the most cost-effective service delivery model of PrEP in Thailand.

Funding

This study was supported by the US Agency for International Development and U.S. President's Emergency Plan for AIDS Relief through the Linkages Across the Continuum of HIV Services for Key Populations cooperative agreement (AID-OAA-A-14- 0045) managed by FHI 360.

Is HIV Pre-Exposure Prophylaxis among Men Who Have Sex with Men Effective in a Real-World Setting? Experience with One-On-One Counseling and Support in a Sexual Health Center in Paris, 2018-2020

HIV pre-exposure prophylaxis (PrEP) is highly effective but depends on patients' care engagement, which is often mediocre and poorly measured in real-world settings. This study aimed to assess the effectiveness of a PrEP program in a sexual health center that included accompanying measures to improve engagement. A retrospective observational study was conducted. All men who have sex with men (MSM) who initiated PrEP for the first time between 1 August 2018 and 30 June 2019 in the Fernand-Widal sexual health center, Paris, France, were included. Among the 125 MSM who initiated PrEP, the median age was 33 and most had only male partners. At initiation, 58% were considered at very high risk of HIV infection, mainly due to a history of post-exposure prophylaxis. During the first year, patients attended a median of three visits (Q1-Q3, 2-4). At 12 months, 96% (95% CI, 92.6 to 99.4) had a successful PrEP course, assessed by a novel metric. These results highlight the possibility of achieving a high PrEP success ratio among MSM in a real-world setting. The accompanying measures and one-on-one counseling by a trained counselor could explain the effectiveness of this PrEP program.

Loss to Follow-Up from HIV Pre-Exposure Prophylaxis Care in Men Who Have Sex with Men in West Africa

Loss to follow-up (LTFU) from HIV pre-exposure prophylaxis (PrEP) care compromises the goal of HIV elimination. We investigated the proportion of LTFU and associated risk factors among men who have sex with men (MSM) enrolled in a PrEP demonstration project in Burkina Faso, Côte d'Ivoire, Mali, and Togo. CohMSM-PrEP, a prospective cohort study, was conducted between November 2017 and June 2021 in community-based clinics. MSM aged 18 years or older at substantial risk of HIV infection received a comprehensive prevention package, including PrEP and peer education. LTFU was defined as not returning to the clinic for six months. Associated risk factors were investigated using a time-varying Cox's model. Of 647 participants followed up for a median time of 15 months, 372 were LTFU (57.5%). LTFU was associated with younger age (adjusted hazard ratio [95% Confidence Interval]; 1.50 [1.17-1.94]), unemployment (1.33 [1.03-1.71]), depression (1.63 [1.12-2.38]), and perceiving no HIV risk with stable male partners (1.61 [1.23-2.10]). Contacting peer educators outside of scheduled visits was protective (0.74 [0.56-0.97]). Our findings show that LTFU from PrEP care in West African MSM is a major challenge to achieving HIV elimination, but that the involvement of peer educators in PrEP delivery helps to limit LTFU by providing users with adequate support.

Caring for the whole person: transgender-competent HIV pre-exposure prophylaxis as part of integrated primary healthcare services in Vietnam

Introduction

Although HIV prevalence among transgender women who have sex with men in Vietnam is high (16–18%), uptake of pre‐exposure prophylaxis (PrEP) is low compared to other populations. When PrEP was initiated in 2017, gender‐affirming healthcare was largely unavailable. Lack of access to competent, stigma‐free healthcare is a well‐documented barrier to transgender women's uptake of PrEP and primary healthcare (PHC). We aimed to demonstrate the utility of a PrEP quality improvement intervention in pinpointing and addressing barriers to PrEP use among transgender women in Vietnam.

Methods

We applied a real‐world participatory continuous quality improvement (CQI) and Plan‐Do‐Study‐Act (PDSA) methodology to ascertain barriers to PrEP uptake among transgender women and determine priority actions for quality improvement. A CQI team representing transgender women leaders, key population (KP)‐clinic staff, public‐sector HIV managers and project staff applied PDSA to test solutions to identified barriers that addressed the primary quality improvement outcome of the monthly change in PrEP uptake among transgender women and secondary outcomes, including month‐3 PrEP continuation, the impact of offering PHC on PrEP uptake and unmet PrEP need. We utilized routine programmatic data and a descriptive cross‐sectional study enrolling 124 transgender women to measure these outcomes from October 2018 to September 2021.

Results

Five key barriers to PrEP uptake among transgender women were identified and corresponding solutions were put in place: (1) offering gender‐affirming care training to KP‐clinics and community‐based organizations; (2) integrating gender‐affirming services into 10 KP‐clinics; (3) offering PHC through five one‐stop shop (OSS) clinics; (4) implementing a campaign addressing concerns related to hormone use and PrEP interactions; and (5) developing national HIV and transgender healthcare guidelines. New PrEP enrolment and month‐3 PrEP continuation increased significantly among transgender women. Of 235 transgender women who initially sought healthcare other than PrEP at OSS clinics, 26.4% subsequently enrolled in PrEP. About one‐third of transgender women reported unmet PrEP need, while two‐thirds indicated an interest in long‐acting cabotegravir.

Conclusions

Offering gender‐competent, integrated PHC can increase PrEP enrolment and continuation, and can be an entry‐point for PrEP among those seeking care within PHC clinics. More work is needed to expand access to transgender women‐led and ‐competent healthcare in Vietnam.

HIV and syphilis prevalence among transgender women and men who have sex with men, Silom Community Clinic, Bangkok, Thailand, 2017-2019

We assessed HIV and syphilis infection among MSM and TGW attending Silom Community Clinic from 2017 to 2019. Walk-in and referral clients completed a registration application including a question on gender identity. We compared the prevalence of HIV, syphilis, and HIV and syphilis coinfection among TGW and MSM. In a total of 1050 clients, 276 (26.3%) were TGW and 774 (74.7%) were MSM. Among TGW clients, HIV prevalence was 29.8%, syphilis prevalence was 38.4%, and coinfection prevalence was 18.5%. Comparing prevalence among TGW to MSM, the adjusted prevalence ratio (aPR) for HIV was 1.8 (95% CI:1.4-2.3), for syphilis was 1.2 (95% CI:1.0-1.4), and for HIV and syphilis coinfection was 2.1 (95% CI:1.4-2.9). The prevalence of syphilis was higher than HIV among TGW, with a PR of 1.3 (95% CI:1.1-1.6), and among MSM, with a PR of 1.4 (95% CI:1.2-1.7). TGW age 15-21 years had an HIV prevalence of 16.9% and syphilis prevalence of 30.8%. After adjusting for age, referral, and sexual behaviors, TGW remain significantly associated with HIV and syphilis prevalence. There is a substantial burden of HIV and HIV/syphilis co-infection among TGW. HIV/STI prevention are needed for TGW, including linkage to HIV care.

Preferences for pre-exposure prophylaxis for HIV: A systematic review of discrete choice experiments

Background

We aimed to systematically review the health preference literature using discrete choice experiments (DCEs), an attribute-based stated preference method, to investigate patient preferences for HIV pre-exposure prophylaxis (PrEP).

Methods

A search in PubMed, Scopus, CINAHL, and Embase was conducted on July 1, 2021, and updated on November 3, 2021. We used two concepts to create our search strategy: (1) discrete choice experiments/conjoint analysis/best-worst scaling, and (2) HIV PrEP.The study is registered in PROSPERO (CRD42021267026).

Findings

In total, 1060 studies were identified, and 18 were included in the analysis. Various attributes were examined, including dosing regimen, type of PrEP products, side effects, other side benefits, cost, effectiveness, dispensing venue, and additional support services. Dosing frequency, cost, the effectiveness of PrEP, dispensing venue, and side effects were the most common attributes examined in DCEs. Despite significant heterogeneity in preferences across subpopulations, overall, the most important attributes were cost (28%, 5/18), effectiveness (28%, 5/18) followed by dosing frequency (17%, 3/18).

Interpretation

Notably, in studies where all of these three attributes were examined, some individuals would trade effectiveness for cost or vice versa. Ensuring PrEP is low cost or free, widely disseminating information of its effectiveness and advancements in reducing dosing frequency could accelerate the uptake of PrEP for those who would benefit from PrEP the most.

Funding

None.

How could HIV-1 drug resistance impact preexposure prophylaxis for HIV prevention?

PURPOSE OF REVIEW

To review current laboratory and clinical data on the frequency and relative risk of drug resistance and range of mutations selected from approved and investigational antiretroviral agents used for preexposure prophylaxis (PrEP) of HIV-1 infection, including tenofovir disproxil fumarate (TDF)-based oral PrEP, dapivirine ring, injectable cabotegravir (CAB), islatravir, lenacapavir and broadly neutralizing antibodies (bNAbs).

RECENT FINDINGS

The greatest risk of HIV-1 resistance from PrEP with oral TDF/emtricitabine (FTC) or injectable CAB is from starting or continuing PrEP after undiagnosed acute HIV infection. By contrast, the dapivirine intravaginal ring does not appear to select nonnucleoside reverse transcriptase inhibitor resistance in clinical trial settings. Investigational inhibitors including islatravir, lenacapavir, and bNAbs are promising for use as PrEP due to their potential for sustained delivery and low risk of cross-resistance to currently used antiretrovirals, but surveillance for emergence of resistance mutations in more HIV-1 gene regions (gag, env) will be important as the same drugs are being developed for HIV therapy.

SUMMARY

PrEP is highly effective in preventing HIV infection. Although HIV drug resistance from PrEP use could impact future options in individuals who seroconvert on PrEP, the current risk is low and continued monitoring for the emergence of resistance and cross-resistance during product development, clinical studies, and product roll-out is advised to preserve antiretroviral efficacy for both treatment and prevention.

Cost-Effectiveness of Pre-exposure Prophylaxis Among Men Who Have Sex With Men in China: A Systematic Review

Objective

Men who have sex with men in China meet the definition of the population at “substantial risk” of contracting human immunodeficiency virus (HIV) according to the World Health Organization; therefore, initiating pre-exposure prophylaxis (PrEP) is recommended for this population. Lack of convincing evidence on cost-effectiveness has resulted in the lack of large-scale PrEP implementation at a national level. The objective of this review is to assess the cost-effectiveness of pre-exposure prophylaxis implementation among men who have sex with men in China.

Methods

The following databases were used to search studies of pre-exposure prophylaxis in China in both English and Chinese: PubMed, Embase, the China National Knowledge Infrastructure (CNKI), and the Wanfang Database. Inclusion criteria included pre-exposure intervention, year for publication (2007–2021), setting (China), and cost-effectiveness estimation.

Results

Seven studies were identified. We found that pre-exposure prophylaxis is only cost-effective among men who have sex with men without prioritization with at least a 5.5% reduction in the market price in the models. Pre-exposure prophylaxis is potentially cost-effective when using the latest market price, combined with other preventive programs or delivered to the population with a high risk of HIV exposure.

Conclusion

Our study identifies key considerations in cost-effectiveness evaluation: cost assumptions, implementation coverage, and targeted population. The scarce evidence available is not comparable to some extent. However, combined with the latest market and policy reform, the cost-effectiveness of PrEP could be achieved as estimated by the underlying model of the included studies. Consequently, it calls for more standard and transparent modeling studies that include the latest drug types and market prices.

Cost-effectiveness and impact of pre-exposure prophylaxis to prevent HIV among men who have sex with men in Asia: A modelling study

INTRODUCTION

More than 70% of new HIV infections in Asia occurred in eight countries in 2020: Cambodia, China, India, Indonesia, Myanmar, Nepal, Thailand, and Vietnam-with a rising incidence among men who have sex with men (MSM). The World Health Organization (WHO) recommends pre-exposure prophylaxis (PrEP) for those at risk of acquiring HIV, yet wide-scale implementation of PrEP, on a daily or event-driven basis, has been limited in Asia.

METHODS

The Optima HIV model was applied to examine the impact of scaling-up PrEP over five-years to cover an additional 15% of MSM compared with baseline coverage, a target deemed feasible by regional experts. Based on behavioral survey data, we assume that covering 15% of higher-risk MSM will cover 30% of all sexual acts in this group. Scenarios to compare the impact of generic-brand daily dosing of PrEP with generic event-driven dosing (15 days a month) were modelled from the start of 2022 to the end of 2026. Cost-effectiveness of generic versus branded PrEP was also assessed for China, the only country with an active patent for branded, higher cost PrEP. The impact on new HIV infections among the entire population and cost per HIV-related disability-adjusted life year (DALY) averted were estimated from the beginning of 2022 to the end of 2031 and from 2022 to 2051.

RESULTS

If PrEP were scaled-up to cover an additional 15% of MSM engaging in higher-risk behavior from the beginning of 2022 to the end of 2026 in the eight Asian countries considered, an additional 100,000 (66,000-130,000) HIV infections (17%) and 300,000 (198,000-390,000) HIV-related DALYs (3%) could be averted over the 2022 to 2031 period. The estimated cost per HIV-related DALY averted from 2022 to 2031 ranged from US$600 for event-driven generic PrEP in Indonesia to US$34,400 for daily branded PrEP in Thailand. Over a longer timeframe from 2022 to 2051, the cost per HIV-related DALY averted could be reduced to US$100-US$12,700.

CONCLUSION

PrEP is a critical tool to further reduce HIV incidence in highly concentrated epidemics. Implementing PrEP in Asia may be cost-effective in settings with increasing HIV prevalence among MSM and if PrEP drug costs can be reduced, PrEP could be more cost-effective over longer timeframes.

A comparison of attitudes and knowledge of pre-exposure prophylaxis (PrEP) between hospital and Key Population Led Health Service providers: Lessons for Thailand's Universal Health Coverage implementation

BACKGROUND

HIV Pre-exposure prophylaxis (PrEP) has demonstrated efficacy and effectiveness among high-risk populations. In Thailand, PrEP has been included in the National Guidelines on HIV/AIDS Treatment and Prevention since 2014. As a part of the national monitoring and evaluation framework for Thailand's universal coverage inclusion, this cross-sectional survey was conducted to assess knowledge of, attitudes to and practice (KAP) of PrEP service providers in Thailand.

METHODS

We conducted a cross-sectional survey to explore knowledge of, and attitudes towards PrEP among providers from hospital and Key Population Led Health Services (KPLHS) settings. The questionnaire was distributed online in July 2020. Descriptive and univariate analysis using an independent-sample t-test were applied in the analyses. Attitudes were ranked from the most negative (score of 1) to the most positive (score of 5).

RESULTS

Overall, there were 196 respondents (158 from hospitals and 38 from KPLHS) in which most hospital providers are female nurse practitioners while half of those from KPLHS report current gender as gay. Most respondents report a high level of PrEP knowledge and support provision in all high-risk groups with residual concern regarding anti-retroviral drugs resistance. Over two-fifths of providers from both settings perceive that PrEP would result in risk compensation and half of KPLHS providers are concerned regarding risk of sexual transmitted infections. Limited PrEP counselling time is a challenge for hospital providers.

CONCLUSIONS

Service integration between both settings, more involvement and distribution of KPLHS in reaching key populations would be essential in optimizing PrEP uptake and retention. Continuing support particularly in raising awareness about PrEP among healthcare providers and key populations, facilities and manpower, unlimited quota of patient recruitment and PrEP training to strengthen providers' confidence and knowledge would be essential for successful PrEP implementation.

Long-acting preexposure prophylaxis in low- and middle-income countries: key considerations for implementation

PURPOSE OF REVIEW

HIV preexposure prophylaxis (PrEP) is a key tool in ending the HIV epidemic. Long-acting cabotegravir (LA- CAB) phase II/III studies revealed promising efficacy in preventing HIV acquisition. Here, we discuss key considerations for implementing LA-CAB in low- and middle-income countries (LMIC).

RECENT FINDINGS

PrEP roll out in LMIC is still far from ideal, and contextual factors within LMIC vary widely. Implementation science studies are urgently needed to optimize the implementation of LA-CAB in different settings, consider effective service delivery models, and ensure program sustainability. Preferences and concerns regarding LA-CAB among potential users are unknown but likely specific to local context. Demedicalized and simplified PrEP service delivery increases uptake, and ways to safely and effectively do the same for LA- CAB need to be explored. Although ideally LA-CAB should be an additional choice of HIV prevention method, its cost will be the major determinant in deciding its position as a first line choice or restricted second-line option.

SUMMARY

LA-CAB has the potential to enhance PrEP uptake. However, several implementation challenges need to be explored and addressed to ensure it can be accessed and utilized in different settings by those who need it the most.

Scaling up access to HIV pre-exposure prophylaxis (PrEP): should nurses do the job?

Task sharing has been one of the most important enabling policies supporting the global expansion of access to HIV testing and treatment. The WHO public health approach, which relies on delivery of antiretroviral therapy (ART) by nurses, has enabled a trebling of the number of people receiving ART during the past decade. WHO recognises that HIV pre-exposure prophylaxis (PrEP) can also be provided by nurses; however, many countries still do not have policies in place that support nurse provision of PrEP. In sub-Saharan Africa, most countries allow nurses to prescribe ART, but only a few countries have policies in place that allow nurses to prescribe PrEP. Nurse-led PrEP delivery is particularly low in the Asia-Pacific region, which has some of the world's fastest growing epidemics. Even in many high-income countries, PrEP scale-up has been limited because policies often require medical doctors or specialists to prescribe. Service providers in many countries are coming to realise that scaling up access to PrEP cannot be achieved by medical doctors alone, and nurse-led PrEP delivery can help to lay the groundwork for supporting uptake of other HIV prevention approaches that will become available in the future. Countries with policies that authorise nurses to prescribe ART could be early adopters and help to pave the way for wider adoption of nurse-led PrEP delivery.

A Mobile Phone App to Support Adherence to Daily HIV Pre-exposure Prophylaxis Engagement Among Young Men Who Have Sex With Men and Transgender Women Aged 15 to 19 Years in Thailand: Pilot Randomized Controlled Trial

Background

Widespread smartphone use provides opportunities for mobile health HIV prevention strategies among at-risk populations.

Objective

This study aims to investigate engagement in a theory-based (information–motivation–behavioral skills model) mobile phone app developed to support HIV pre-exposure prophylaxis (PrEP) adherence among Thai young men who have sex with men (YMSM) and young transgender women (YTGW) in Bangkok, Thailand.

Methods

A randomized controlled trial was conducted among HIV-negative YMSM and YTGW aged 15-19 years initiating daily oral PrEP. Participants were randomized to receive either youth-friendly PrEP services (YFS) for 6 months, including monthly contact with site staff (clinic visits or telephone follow-up) and staff consultation access, or YFS plus use of a PrEP adherence support app (YFS+APP). The target population focus group discussion findings and the information–motivation–behavioral skills model informed app development. App features were based on the 3Rs—risk assessment of self-HIV acquisition risk, reminders to take PrEP, and rewards as redeemable points. Dried blood spots quantifying of tenofovir diphosphate were collected at months 3 and 6 to assess PrEP adherence. Tenofovir diphosphate ≥350-699 fmol/punch was classified as fair adherence and ≥700 fmol/punch as good adherence. Data analysis on app use paradata and exit interviews were conducted on the YFS+APP arm after 6 months of follow-up.

Results

Between March 2018 and June 2019, 200 participants with a median age of 18 (IQR 17-19) years were enrolled. Overall, 74% (148/200) were YMSM; 87% (87/100) of participants who received YFS+APP logged in to the app and performed weekly HIV acquisition risk assessments (log-in and risk assessment [LRA]). The median duration between the first and last log-in was 3.5 (IQR 1.6-5.6) months, with a median frequency of 6 LRAs (IQR 2-10). Moreover, 22% (22/100) of the participants in the YFS+APP arm were frequent users (LRA≥10) during the 6-month follow-up period. YMSM were 9.3 (95% CI 1.2-74.3) times more likely to be frequent app users than YTGW (P=.04). Frequent app users had higher proportions (12%-16%) of PrEP adherence at both months 3 and 6 compared with infrequent users (LRA<10) and the YFS arm, although this did not reach statistical significance. Of the 100 participants in the YFS+APP arm, 23 (23%) were interviewed. The risk assessment function is perceived as the most useful app feature. Further aesthetic adaptations and a more comprehensive rewards system were suggested by the interviewees.

Conclusions

Higher rates of PrEP adherence among frequent app users were observed; however, this was not statistically significant. A short app use duration of 3 months suggests that they may be useful in establishing habits in taking daily PrEP, but not long-term adherence. Further studies on the specific mechanisms of mobile phone apps that influence health behaviors are needed.

Trial Registration

ClinicalTrials.gov NCT03778892; https://clinicaltrials.gov/ct2/show/NCT03778892