Negotiating the use of female-initiated HIV prevention methods in a context of gender-based violence: the narrative of rape

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

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

Tu'Washindi na PrEP: Working With Young Women and Service Providers to Design an Intervention for PrEP Uptake and Adherence in the Context of Gender-Based Violence

HIV pre-exposure prophylaxis (PrEP) reduces HIV acquisition among adolescent girls and young women (AGYW). Existing evidence suggests that uptake and adherence are low among AGYW and that relationship factors such as gender-based violence (GBV) are important barriers. Through a community-based participatory research (CBPR) process, a youth advisory board (YAB), service providers (SP), and a study team developed the Tu'Washindi na PrEP intervention to support AGYW PrEP use in the context of GBV. The YAB also guided the formative research and interpretation of results. The authors pretested the intervention with SP, AGYW and their partners, and community change agents, and then developed guides for AGYW support clubs, community-based male sensitization sessions, and couples-based events that included formulation of story lines for dramatized PrEP negotiation and information dissemination skills. Stakeholder engagement led to an intervention responsive to AGYW's needs for PrEP support in the context of their relationships, which was evaluated through a 6-month pilot community randomized controlled trial.

Acceptability and feasibility of the CHARISMA counseling intervention to support women's use of pre-exposure prophylaxis: results of a pilot study

Background

Women may need or seek male partner approval to safely and consistently use oral antiretroviral pre-exposure prophylaxis (PrEP) or vaginal microbicides. We developed CHARISMA, a counseling intervention to support women’s relationships and their ability to consistently use HIV prevention products.

Methods

In a pilot study with 95 female participants in Johannesburg, South Africa, lay counselors implemented CHARISMA, assessing participants’ relationship(s) with their male partner(s) and barriers or facilitators to HIV prevention method use, and then providing tailored, interactive counseling. We conducted study participant surveys and clinic staff interviews to evaluate CHARISMA’s feasibility and acceptability.

Results

The CHARISMA pilot study indicates that a two-session relationship counseling intervention with 6-month follow-up to support women’s ability to safely and effectively use vaginal microbicides was generally acceptable and feasible. Most participants thought CHARISMA was relevant, helpful, and about the right length, and that it had a positive impact on their relationships with their partners and their product use. Staff estimated that the intervention took 1.5–2 h to implement at enrollment and 45 min to an hour for the month 1 visit. They thought that overall CHARISMA was generally feasible to implement.

Conclusions

Findings from this study suggest several lessons learned that may be relevant to others developing interventions supporting women’s use of oral PrEP or vaginal microbicides. The use of lay counselors instead of nurses to deliver counseling appeared to be successful, but the counselors experienced significant stress from hearing about participants’ traumatic experiences and required emotional support to avoid burnout. Although staff and participants felt that having multiple intervention sessions over time was valuable, a similar level of intensity may not be feasible in other settings. Further research is needed to determine an intervention delivery mode and follow-up period that optimally balances participant needs and clinic resources. Male engagement was a challenge, as it has been in previous studies of vaginal microbicides. Alternative strategies to reach men that do not require them to come to the clinic or rely on their female partners may be more effective.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12905-021-01262-z.

Intimate Partner Violence and Pre-exposure Prophylaxis (PrEP): A Rapid Review of Current Evidence for Women's HIV Prevention

Pre-exposure prophylaxis (PrEP) is a valued component of HIV prevention and increasing attention is focusing on women's PrEP use. Common HIV prevention options (e.g., condoms) remain underused and fail to consider the context of intimate partner violence (IPV). PrEP presents an opportunity to expand viable options for women. A systematic rapid review using key word searches of PubMed and proceedings from six national and international conferences related to HIV, women's health, or interpersonal violence identified nine studies which met set inclusion criteria. Studies were coded using a structured abstraction form and summarized according to relevant themes. IPV was found to have implications on women's interest and willingness to use PrEP, partner interference or interruptions in PrEP use, and adherence. Findings indicate a dearth of research on women's PrEP use and IPV and highlight the urgency for research, public heath practice, and policy attention around the HIV risk context and needs of women who experience IPV.

Forming and implementing community advisory boards in low- and middle-income countries: a scoping review

BACKGROUND

Community advisory boards (CABs) have expanded beyond high-income countries (HICs) and play an increasing role in low- and middle-income country (LMIC) research. Much research has examined CABs in HICs, but less is known about CABs in LMICs. The purposes of this scoping review are to examine the creation and implementation of CABs in LMICs, including identifying frequently reported challenges, and to discuss implications for research ethics.

METHODS

We searched five databases (PubMed, Embase, Global Health, Scopus, and Google Scholar) for publications describing or evaluating CABs in LMICs. Two researchers independently reviewed articles for inclusion. Data related to the following aspects of CABs were extracted from included publications: time, country, financial support, research focus, responsibilities, and challenges. Thematic analyses were used to summarize textual data describing challenges.

RESULTS

Our search yielded 2005 citations, 83 of which were deemed eligible for inclusion. Most studies (65) were published between 2010 and 2017. Upper-middle-income countries were more likely to have studies describing CABs, with South Africa (17), China (8), and Thailand (7) having the greatest numbers. The United States National Institutes of Health was the main source of financial support for CABs. Many CABs (53/88, 60%) focused on HIV research. Thirty-four studies reported how CABs influenced the informed consent process for clinical trials or other aspects of research ethics. CAB responsibilities were related to clinical trials, including reviewing study protocols, educating local communities about research activities, and promoting the ethical conduct of research. Challenges faced by CABs included the following: incomplete ethical regulations and guidance; limited knowledge of science among members of communities and CABs; unstable and unbalanced power relationships between researchers and local communities; poor CAB management, including lack of formal participation structures and absence of CAB leadership; competing demands for time that limited participation in CAB activities; and language barriers between research staff and community members. Several challenges reflected shortcomings within the research team.

CONCLUSIONS

Our findings examine the formation and implementation of CABs in LMICs and identify several ethical challenges. These findings suggest the need for further ethics training among CAB members and researchers in LMICs.

PrEParing Women to Prevent HIV: An Integrated Theoretical Framework to PrEP Black Women in the United States

Preexposure prophylaxis (PrEP) with optimal adherence has demonstrated efficacy in reducing HIV incidence in women. Black women are disproportionately burdened by the HIV epidemic, accounting for more than half of all new HIV cases in women, thereby making PrEP an ideal prevention strategy for this group. However, to date, PrEP uptake by women in the United States has been slow. Further domestic research is needed to understand the multilevel factors related to PrEP awareness, uptake, and implementation in Black women. Our purpose was to review the current status of HIV prevention in Black women. We summarize clinical trials germane to federal approval of PrEP; discuss important PrEP studies focused on women, including non-oral options; and review multilevel barriers to PrEP uptake. Lastly, we discuss the use of an integrated theoretical framework to organize multilevel factors related to PrEP uptake by Black women in order to guide intervention development.

The relationship between vaginal ring use and intimate partner violence and social harms: formative research outcomes from the CHARISMA study in Johannesburg, South Africa

Despite being designed for autonomous use, research suggests partner approval is often in women's microbicide use. Microbicide study participants have described many ways product use affects relationships, from improving sexual pleasure to increasing harm, including exacerbating intimate partner violence (IPV). As the dapivirine ring proceeds closer to licensure, supporting women's agency to use microbicides safely is a priority. We conducted 42 in-depth interviews with former participants of the Microbicide Trials Network (MTN)-020 trial of the dapivirine vaginal ring and their male partners in Johannesburg, South Africa, to explore how ring use and partnership dynamics interacted. We sampled women who reported harms or partner non-support and women with supportive partners. Male and female narratives revealed high background levels of IPV. Women described how study participation/ring use exacerbated violence, and for a few couples served as a rationale for additional abuse. In response, women described feeling powerless and fearful of conflict, resulting in product nonuse. For one participant violence was reduced, and for several others, empowerment was sparked. These findings suggest future providers have the opportunity to shift more women from a place of fear/violence to one of safety/empowerment through the integration of IPV screening and relationship counselling.

Acceptability of a Tenofovir Disoproxil Fumarate Vaginal Ring for HIV Prevention Among Women in New York City

Vaginal rings for pre-exposure prophylaxis are a female-initiated HIV prevention method that does not require daily or coitally-dependent dosing. As part of a randomized placebo-controlled trial of a tenofovir disoproxil fumarate intravaginal ring, we assessed product acceptability through in-depth interviews with 18 women during and after 14 days of continuous use. Women reported that the ring was comfortable with few side effects, regardless of experimental arm. However, interest in future use by this cohort was modest for several reasons including: low self-perceived HIV risk; concern that use implied promiscuity; potential for interference with relationship formation and trust; concern for interference with menstruation and cleanliness; and worries about partners' acceptability and sexual pleasure. Potential issues were raised with duration of use prior to ring exchange. Future studies should continue to identify and address individual and relationship factors that influence acceptability, early in the product development process.