Increasing PrEP uptake and adherence among MSM and TW sex workers in Lima, Perú: what and whom do different patients trust?

Exploring Attitudes Toward Pre-Exposure Prophylaxis for HIV Prevention Prior to Implementation Among Female Sex Workers in Malaysia: Results from a Qualitative Study

Introduction

Pre-exposure prophylaxis (PrEP) is an effective method for prevention of HIV transmission. Female sex workers (FSW) in Malaysia are at substantially increased risk of acquiring HIV compared to the general female population, yet little is known about this population's current HIV prevention practices or acceptance of PrEP. This study aims to inform the culturally relevant implementation of PrEP through the qualitative exploration of (1) the potential need for PrEP in this population and (2) the factors that determine FSW willingness to use oral PrEP.

Methods

In-depth, semi-structured interviews (n = 30) were conducted with FSW in English, Malay, or Tamil. Transcribed and translated interviews were analyzed using a grounded theory approach.

Results

FSW express positive interest in PrEP but prefer it as a supplement to condoms, not a replacement. Perceived challenges to PrEP use include cost, adherence, and side effects.

Conclusion

The findings suggest that in combination with condom use, PrEP may be an acceptable method of HIV prevention. Effective PrEP rollout may also include condom promotion using a peer-driven model, cost subsidies, and sex work harm reduction and empowerment components.

A Cross-Sectional Analysis of Self-Reported Needs and Health Service Utilization Among Transgender Women in Lima, Perú

Purpose: Globally, transgender women (TGW) experience wide-ranging barriers to health and care, with disproportionately high risks of infectious and chronic diseases. Yet, research on transgender populations' access to care in low- and middle-income countries remains limited, focused on human immunodeficiency virus (HIV) infection, and assesses TGW as a homogenous group. We analyzed morbidity and health service uptake patterns among TGW in Lima, Perú, to understand health outreach and service needs to inform targeting and design of community-level interventions. Methods: This cross-sectional study surveyed a convenience sample of 301 TGW in metropolitan Lima during September-October 2020. We report descriptive statistics and bivariable and multivariable regression model results as adjusted prevalence ratios (aPRs). Results: Health coverage and access to care were suboptimal. Less education and older age were positively associated with illness and negatively associated with HIV and tuberculosis (TB) testing. In the first study to quantitatively examine health utilization by gender identity subgroup (i.e., woman, trans or transgender, transsexual, "transformista," "travesti," and other) in Perú, TGW who identified as women were more likely to ever test for HIV (aPR = 1.49, 95% confidence interval [CI]: 1.16-1.91) and use pre-exposure prophylaxis (PrEP) (aPR = 2.36, 95% CI: 1.15-4.80). Both awareness and interest regarding PrEP were low, as was usage among those who were interested in taking PrEP. Conclusion: Public health efforts should be tailored to meet TGW's diverse needs, expand TB testing, bridge the gap between PrEP interest and use, and increase insurance coverage and access to trans-friendly services for improved health.

A Scoping Review of Biobehavioural Interventions to Improve PrEP Continuum of Care in Latin America

According to the literature, biobehavioural interventions or combined strategies would reduce the risk of HIV infection by more than 7,000 new cases each day, which would contribute to the battle facing Latin America, where despite the high incidence and prevalence of HIV in the region, access to PrEP (pre-exposure prophylaxis) is very limited. The objective of this research was, consistent with the PRISMA guidelines (Preferred Reporting Items for Systematic Reviews and Meta-Analyses), to conduct a scoping review to assess the evidence of available outcome data on biobehavioural interventions and programs to address gaps in the PrEP continuum of care in Latin America. The search was conducted in the databases EBSCOhost, WoS, Scopus, and ProQuest, and include all studies published from 2010 to 2021. One hundred eighty-six studies were identified and evaluated according to the eligibility criteria in six stages starting with the elimination of duplicates until the selection of studies that met the previously mentioned criteria; at the end five studies were chosen which were submitted to the methodological quality assessment including compliance with ethical guidelines. Results show that biobehavioural interventions promoting PrEP in Latin America are effective in increasing condom use, decreasing HIV risk, and increasing PrEP awareness, uptake, adherence, and retention. The limited number of interventions in the PrEP continuum of care indicates a need for the uptake of dissemination and implementation science (D&I) frameworks. D&I could help facilitate the translation of evidence-based practices, interventions, and policies to address the HIV crisis in Latin America.

Both/And: Mixed methods analysis of network composition, communication patterns, and socio-economic support within social networks of transgender women in Lima, Peru

Introduction

Social networks contribute to normative reinforcement of HIV prevention strategies, knowledge sharing, and social capital, but little research has characterized the social networks of transgender women (TW) in Latin America. We conducted a mixed methods analysis of three network clusters of TW in Lima, Peru, to evaluate network composition, types of support exchanged, and patterns of communication.

Methods

We recruited TW residing in or affiliated with three "casas trans" (houses shared among TW) in Lima between April-May 2018. Eligible participants were 18 or older, self-reported HIV-negative, and reported recent intercourse with a cis-male partner. Participants completed demographic questionnaires, social network interviews, and semi-structured interviews to assess egocentric network structures, support exchanged, and communication patterns. Quantitative and qualitative data were analyzed using Stata v14.1 and Atlas.ti, respectively.

Results

Of 20 TW, median age was 26 years and 100% reported involvement in commercial sex work. Respondents identified 161 individuals they interacted with in the past month (alters), of whom 33% were TW and 52% family members. 70% of respondents reported receiving emotional support from family, while 30% received financial support and instrumental support from family. Of the 13 (65%) respondents who nominated someone as a source of HIV prevention support (HPS), the majority (69%) nominated other TW. In a GEE regression analysis adjusted for respondent education and region of birth, being a family member was associated with lower likelihood of providing financial support (aOR 0.21, CI 0.08-0.54), instrumental support (aOR 0.16, CI 0.06-0.39), and HPS (aOR 0.18, CI 0.05-0.64). In qualitative interviews, most respondents identified a cis-female family member as their most trusted and closest network member, but other TW were more often considered sources of day-to-day support, including HPS.

Conclusion

TW have diverse social networks where other TW are key sources of knowledge sharing and support, and family members may also represent important and influential components. Within these complex networks, TW may selectively solicit and provide support from different network alters according to specific contexts and needs. HIV prevention messaging could consider incorporating network-based interventions with TW community input and outreach efforts for supportive family members.

Social Networks Play a Complex Role in HIV Prevention Knowledge, Attitudes, Practices, and the Uptake of PrEP Through Transgender Women Communities Centered Around Three "Casas Trans" in Lima, Peru: A Qualitative Study

Transgender women's (TW) social networks may facilitate HIV prevention information dissemination and normative reinforcement. We conducted a qualitative study of social networks among 20 TW affiliated with 3 "casas trans" (houses shared among TW) in Lima, Peru, using diffusion of innovations theory to investigate community-level HIV prevention norms. Participants completed demographic questionnaires, social network interviews, and semistructured in-depth interviews. Median age was 26 and all participants engaged in sex work. Interviews revealed high HIV prevention knowledge and positive attitudes, but low engagement in HIV prevention. Respondents primarily discussed HIV prevention with other TW. Network members' opinions about pre-exposure prophylaxis (PrEP) frequently influenced respondents' personal beliefs, including mistrust of healthcare personnel, concern that PrEP efficacy was unproven, fear of adverse effects, and frustration regarding difficulty accessing PrEP. Patterns of influence in TW networks may be leveraged to improve uptake of HIV prevention tools, including PrEP.

Effect of Reminder System on Pre-exposure Prophylaxis Adherence in Men Who Have Sex with Men: A Prospective Cohort Study Based on WeChat Intervention (Preprint)

Background

Objective

Methods

Results

Conclusions

Trial Registration

The wisdom of mistrust: qualitative insights from transgender women who participated in PrEP research in Lima, Peru

INTRODUCTION

Although pre-exposure prophylaxis (PrEP) is a remarkable biomedical advance to prevent HIV, ongoing research on PrEP contributes to and interacts with a legacy of HIV experimentation on marginalized communities in resource-limited settings. This paper explores the complexity of PrEP research mistrust among Peruvian transgender (trans) women who completed a PrEP adherence intervention and those who refused participation (i.e. declined to enrol, voluntarily withdrew, and/or were lost to follow-up).

METHODS

Data were derived from 86 trans women (mean age 29 years) participants in the formative (four focus groups (n = 32), 20 interviews) and the evaluation stages (34 interviews) of a social network-based PrEP intervention for trans women in Lima, Peru. The formative stage took place from May to July 2015, while the evaluative stage took place from April to May 2018. Audio files were transcribed verbatim and analysed via an immersion crystallization approach using Dedoose (v.6.1.18).

RESULTS

Three paradoxes of trans women's participation in PrEP science as a "key" population emerged as amplifying mistrust: (1) increases in PrEP research targeting trans women but limited perceived improvements in HIV outcomes; (2) routine dismissal by research physicians and staff of PrEP-related side effects and the social realities of taking PrEP, resulting in questions about who PrEP research is really for and (3) persistent limitations on PrEP access for trans women despite increasing involvement in clinical trials, fostering feelings of being a "guinea pig" to advance PrEP science.

CONCLUSIONS

Findings highlight the wisdom inherent in PrEP mistrust as a reflection of trans women's experiences that underscore the broken bonds of trust between communities, researchers and the research enterprise. PrEP mistrust is amplified through perceived paradoxes that suggest to trans women that they are key experimental participants but not target PrEP users outside of research settings. Findings highlight the urgent need to reframe mistrust not as a characteristic of trans women to be addressed through education and outreach, but as a systemic institutional- and industry-level problem replicated, manifested and ultimately to be corrected, through global HIV science.

Community Belonging and Attitudes Towards HIV Pre-Exposure Prophylaxis (PrEP) Among Transgender Women

For transgender (trans) women, community belonging may play an important role in shaping perceptions of HIV Pre-exposure Prophylaxis (PrEP). A cluster analysis was performed using data obtained from a survey administered to 128 trans women residing in Philadelphia, PA and the San Francisco Bay area, CA. Six items assessing feelings of community belongingness among trans women produced three distinct clusters. Associations were examined between cluster membership and perceptual items including beliefs about PrEP, experiences with healthcare, patient self-advocacy, and perceived trusted sources for PrEP information. Clusters were demographically comparable apart from age. There were significant differences noted between trust in various communication channels and perceptions of PrEP; the least community-connected cluster had less trust and more negative perceptions of PrEP. Analyses suggest that psychographic differences exist based on perceived community belongingness in this population, and this in turn may be consequential in determining how information about PrEP is communicated and diffused to trans women for whom PrEP may be indicated.

TransPrEP: Results from the Pilot Study of a Social Network-Based Intervention to Support PrEP Adherence Among Transgender Women in Lima, Peru

We conducted a pilot randomized controlled trial of a social network-based intervention to promote PrEP adherence among transgender women (TW) in Lima, Peru. We enrolled 89 TW from six social networks and cluster-randomized them 1:1 to standard of care (n = 44) or the TransPrEP intervention (n = 45). Core workshops discussed strategies to support PrEP adherence and defined group adherence objectives. Maintenance workshops discussed participants' experiences taking PrEP and collective adherence goals. At 3-month follow-up, we evaluated 40 participants and obtained 29 hair samples for tenofovir level measurements. Though no significant differences were observed, 36.4% (4/11) of participants of TransPrEP participants and 10.0% (1/10) of control participants had tenofovir levels > 0.023 ng/mg, consistent with ≥ 4 doses per week. 81.8% (9/11) of intervention and 40.0% (4/10) of control participants had any detectable tenofovir in their hair. Pilot assessment of our network-based intervention suggested a trend towards improved PrEP adherence, measured objectively, for TW in Peru.