Preferences for HIV pre-exposure prophylaxis (PrEP) information among men-who-have-sex-with-men (MSM) at community outreach settings

Examining oral pre-exposure prophylaxis (PrEP) literacy among participants in an HIV vaccine trial preparedness cohort study

BACKGROUND

PrEP literacy is influenced by many factors including the types of information available and how it is interpreted. The level of PrEP literacy may influence acceptability and uptake.

METHODS

We conducted 25 in-depth interviews in a HIV vaccine trial preparedness cohort study. We explored what participants knew about PrEP, sources of PrEP knowledge and how much they know about PrEP. We used the framework approach to generate themes for analysis guided by the Social Ecological Model and examined levels of PrEP literacy using the individual and interpersonal constructs of the SEM.

RESULTS

We found that PrEP awareness is strongly influenced by external factors such as social media and how much participants know about HIV treatment and prevention in the local community. However, while participants highlighted the importance of the internet/social media as a source of information about PrEP they talked of low PrEP literacy in their communities. Participants indicated that their own knowledge came as a result of joining the HIV vaccine trial preparedness study. However, some expressed doubts about the effectiveness of the drug and worried about side effects. Participants commented that at the community level PrEP was associated with being sexually active, because it was used to prevent the sexual transmission of HIV. As a result, some participants commented that one could feel judged by the health workers for asking for PrEP at health facilities in the community.

CONCLUSION

The information collected in this study provided an understanding of the different layers of influence around individuals that are important to address to improve PrEP acceptability and uptake. Our findings can inform strategies to address the barriers to PrEP uptake, particularly at structural and community levels.

TRIAL REGISTRATION

https://clinicaltrials.gov/ct2/show/NCT04066881.

Awareness and uptake of pre-exposure prophylaxis for HIV among low-income, HIV-negative heterosexuals in San Francisco

We examined pre-exposure prophylaxis (PrEP) awareness and uptake among low-income heterosexual men and women in San Francisco in 2019. Of 294 HIV-negative survey participants, 42.5% were aware of PrEP. Few women (12.5%) and men (8.9%) had discussed PrEP with a healthcare provider; 3.8% of women and 0% of men had used PrEP in the last year. White participants (adjusted odds ratio (aOR) 5.39, 95% CI 1.02, 28.56), women (aOR 2.19, 95% CI 1.30, 3.70), and age 60 years or above (aOR 4.00, 95% CI 1.12, 14.34) had greater odds of being aware of PrEP. Testing for HIV or sexually transmitted infection in the past year was marginally associated with a greater PrEP awareness. Our findings reveal gaps in PrEP implementation associated with social disparities among low-income heterosexuals. Testing services and targeted promotional and educational materials are needed lest high-risk, low-income populations are left behind in San Francisco's aggressive "Getting to Zero" efforts.

Pre-exposure Prophylaxis (PrEP) for HIV Prevention Among Men Who Have Sex with Men (MSM): A Scoping Review on PrEP Service Delivery and Programming

Pre-exposure prophylaxis (PrEP) is an evidence-based new biomedical HIV prevention intervention, which involves the pre-emptive use of daily (or event-based) antiretroviral drugs, to reduce risk of HIV acquisition if exposed. PrEP has recently been positioned as an integral prevention tool to reduce HIV acquisition risk among men who have sex with men (MSM) at country-level and within global prevention strategies. Given this global scale up of PrEP, we conducted a scoping review of extant international literature documenting service related perspectives, models and lessons learnt in PrEP programming for MSM. A systematic search of literature was conducted, and restricted to English language records in the timeframe 2008 to February 2019. Eligibility criteria centered on whether studies broadly described PrEP programming and service delivery for MSM as well as health communication. Following exclusion of ineligible records and removal of duplicates, 84 records were charted and thematically analysed according to scoping review methods. Four themes emerged from the thematic analysis of data; 'PrEP service aspects, settings and staff'; 'PrEP prescriber experiences, therapeutic alliance and care planning'; 'PrEP adherence within formal service structures'; and 'Multi-disciplinary and innovative PrEP care pathways'. The review highlights the complexities in providing optimal PrEP services for MSM by mapping and illustrating the importance of understanding the informal and formal routes to PrEP use among this HIV risk population; the barriers to uptake; the requirement for the presence of a positive therapeutic alliance between patient and prescriber in supporting patient initiation and adherence to PrEP regimes; and the need for availability in different culturally and ethnically sensitive models of PrEP service delivery according to low to high risk groups within the MSM communities.

Individual and Social Network Factors Associated with High Self-efficacy of Communicating about Men's Health Issues with Peers among Black MSM in an Urban Setting

Black men who have sex with men (BMSM) bear a disproportionate burden of HIV in the USA. BMSM face stigma, discrimination and barriers to health care access, and utilization. Peers (male or female) may assist BMSM in navigating their health issues by engaging in communication to support in their health care needs. Individuals with high self-efficacy of communicating about men's health issues with peers can be trained as community popular opinion leaders (CPOLs) to change peer behaviors by promoting risk reduction communication. We examined the characteristics associated with high self-efficacy of communicating with peers about men's health issues among 256 BMSM from a behavioral HIV intervention conducted in Baltimore, Maryland. In the multivariate logistic model, gay identity (AOR: 2.10, 95% CI: 1.15,3.83), involvement in the house and ballroom community (AOR: 2.50, 95% CI: 1.14,5.49), larger number of network members who are living with HIV (AOR: 6.34, 95% CI: 1.48,27.11), and larger number of network members who would loan them money (AOR: 1.46, 95% CI: 1.05,2.03) were statistically significantly associated with high self-efficacy of communicating with peers about men's health issues. We also found that having depressive symptoms (AOR: 0.43, 95% CI: 0.24, 0.77) was negatively associated with high self-efficacy of communicating with peers about men's health issues. Findings from the current study can inform future studies to identify better CPOLs who are able to communicate effectively with peers about men's health issues for BMSM.

Factors associated with knowledge of pre-exposure prophylaxis in pregnant women in Cape Town, South Africa

Pregnant and postpartum women in Southern Africa are at increased risk of HIV infection. Pre-exposure prophylaxis in pregnancy and postpartum periods could significantly reduce the risk of HIV acquisition and transmission in pregnancy. Participants at a community health clinic in Cape Town completed a survey about demographic and sexual risk behaviors, and prior knowledge of pre-exposure prophylaxis. We evaluated factors associated with knowledge of pre-exposure prophylaxis using multivariable logistic regression. We enrolled 50 pregnant and 37 postpartum women, of whom 51% were HIV-uninfected. Twenty-nine (33%) knew about pre-exposure prophylaxis, most from their healthcare provider (69%). Older age (adjusted odds ratio [aOR]/year = 1.09, 95% CI = 1.00–1.19), unintended pregnancy (aOR = 3.36, 95% CI = 1.06–12.12), and more than one sex partner in the last year (aOR = 5.31, 95% CI = 1.12–30.07) were associated with pre-exposure prophylaxis knowledge. Our study identified low levels of pre-exposure prophylaxis knowledge in pregnant and breastfeeding women, but increased knowledge in higher risk women. These results provide guidance to develop interventions to increase pre-exposure prophylaxis knowledge and uptake.

An Integrated Examination of County- and Individual-Level Factors in Relation to HIV Pre-exposure Prophylaxis Awareness, Willingness to Use, and Uptake Among Men Who Have Sex with Men in the US

This study explored the extent to which county- and individual-level factors were associated with awareness, willingness to use, and use of pre-exposure prophylaxis (PrEP) among US men who have sex with men (MSM). We conducted multilevel analyses using a sample of 8338 MSM residing in 1257 US counties drawn from the 2014-2015 American Men's Internet Survey to examine these associations, with focuses on variation in PrEP outcomes across counties and proportion variation explained by county-level factors (HIV prevalence, racial composition, median household income, income inequality, health insurance coverage). Results showed that PrEP awareness varied moderately across counties (intraclass correlation coefficients [ICC] = 7.7%), willingness to use did not vary; however, the actual use varied substantially (ICC = 20.7%). Half of the variation in awareness and use was explained by county-level factors. Higher median household income was associated with greater likelihood of awareness and use. Higher income inequality was associated with greater likelihood of PrEP awareness. Findings can inform the development of multilevel interventions to address PrEP uptake among MSM and identify communities where structural intervention is most needed.

Making Meaning of the Impact of Pre-Exposure Prophylaxis (PrEP) on Public Health and Sexual Culture: Narratives of Three Generations of Gay and Bisexual Men

Pre-exposure prophylaxis (PrEP) with Truvada has emerged as an increasingly common approach to HIV prevention among gay, bisexual, and other men who have sex with men. This study examined generational differences and similarities in narrative accounts of PrEP among a diverse sample of 89 gay and bisexual men in the U.S. Over 50% of men in the older (52-59 years) and younger (18-25 years) generations endorsed positive views, compared with 32% of men in the middle (34-41 years) generation. Men in the middle cohort expressed the most negative (21%) and ambivalent (47%) views of PrEP. Thematic analysis of men's narratives revealed three central stories about the perceived impact of PrEP: (1) PrEP has a positive impact on public health by preventing HIV transmission (endorsed more frequently by men in the older and younger cohorts); (2) PrEP has a positive effect on gay and bisexual men's sexual culture by decreasing anxiety and making sex more enjoyable (endorsed more frequently by men in the middle and younger cohorts); and (3) PrEP has a negative impact on public health and sexual culture by increasing condomless, multi-partner sex (endorsed more frequently by men in the middle and younger cohorts). Results are discussed in terms of the significance of generation cohort in meanings of sexual health and culture and implications for public health approaches to PrEP promotion among gay and bisexual men.

Medical Mistrust and PrEP Perceptions Among Transgender Women: A Cluster Analysis

Transgender (trans) women experience unique barriers in accessing preventative health services such as HIV preexposure prophylaxis (PrEP). These barriers may be exacerbated by past real or anticipated mistreatment in health care settings, but little is known about the relationship between medical mistrust and poor PrEP uptake and knowledge. Using a multistep approach, this study used a novel survey instrument administered to a pilot sample of 78 trans women. Item responses on a 0-10 scale were subjected to a TwoStep cluster analysis to explore how perceptions of PrEP and experiences with health care vary among trans women. Two distinct clusters (C1,C2) were defined on the basis of race (C1: 82% White, C2: 69% Black) and highest level of education completed (C1: 53% college or above, C2: 42% high school diploma or GED). Analyses suggest that varying levels of medical mistrust exist between clusters. Higher mean scores on medical mistrust items were reported in C1. A similar relationship was found on attitudes toward PrEP. Differences in intention to use PrEP and differences in past PrEP use were not significant; however, C2 members were more likely to have heard of PrEP from a doctor. Results suggest that levels of medical mistrust and PrEP perceptions vary among distinct subpopulations in this community, which may affect willingness to use PrEP. Interventions aimed at addressing unique perceptions in subpopulations could move trans women from intention to PrEP use.

Low-Intensity Outreach to Increase Uptake of HIV Preexposure Prophylaxis Among Patients with Sexually Transmitted Infections

We piloted a low-intensity outreach intervention to increase linkage to PrEP care among HIV-uninfected individuals with rectal sexually transmitted infections or syphilis. We sent a secure email message or letter with information about accessing PrEP. Of those sent an email, 12.4% were linked to PrEP care; linkage differed by race/ethnicity, ranging from 0% of Black individuals to 32% of Hispanic individuals (P = 0.019). No individuals sent letters were linked to PrEP care. A one-time secure email to high-risk patients is feasible to increase linkage to PrEP care. Studies are needed to evaluate scalable interventions to increase PrEP uptake in at-risk populations.

A systematic review of adherence to oral pre-exposure prophylaxis for HIV - how can we improve uptake and adherence?

Introduction

Oral pre-exposure prophylaxis (PrEP) is an effective strategy to reduce the risk of HIV transmission in high risk individuals. However, the effectiveness of oral pre-exposure prophylaxis is highly dependent on user adherence, which some previous trials have struggled to optimise particularly in low and middle income settings. This systematic review aims to ascertain the reasons for non-adherence to pre-exposure prophylaxis to guide future implementation.

Methods

We performed structured literature searches of online databases and conference archives between August 8, 2016 and September 16, 2017. In total, 18 prospective randomized control trials and implementation studies investigating oral pre-exposure prophylaxis were reviewed. A structured form was used for data extraction and findings summarized regarding efficacy, effectiveness, adherence and possible reasons for non-adherence.

Results

Adherence varied between differing populations both geographically and socioeconomically. Common reasons for non-adherence reported over multiple studies were; social factors such as stigma, low risk perception, low decision making power, an unacceptable dosing regimen, side effects, and the logistics of daily life. Oral pre-exposure prophylaxis with included antiviral regimens was not associated with a high risk of antiviral resistance development in the reviewed studies.

Conclusion

Our findings indicate that oral pre-exposure prophylaxis should be delivered within a holistic intervention, acknowledging the other needs of the targeted demographic in order to maximise acceptability. Socioeconomic factors and poor governmental policy remain major barriers to widespread implementation of pre-exposure prophylaxis.

Quality of HIV Websites With Information About Pre-Exposure Prophylaxis or Treatment as Prevention for Men Who Have Sex With Men: Systematic Evaluation

Background

Knowledge and uptake of high-efficacy HIV prevention strategies such as pre-exposure prophylaxis (PrEP) and treatment as prevention (TasP) remain low among men who have sex with men (MSM) who are at the highest risk for HIV infection in the United States. Electronic health (eHealth) interventions are promising tools for disseminating information about these critical yet underutilized strategies and addressing key barriers to uptake among target populations. However, existing HIV prevention websites are understudied and unevaluated.

Objective

This study aimed to systematically review and evaluate existing HIV websites that include information about PrEP or TasP for MSM.

Methods

From March 2018 to May 2018, 2 trained research assistants (RAs) entered relevant key words and phrases into 3 commonly used search engines and applied exclusion criteria to all returned results to identify 31 websites included in this review. RAs independently scored each website for authority, usability, interactivity, and PrEP/TasP-related content based on a standardized rating scale and then averaged the results.

Results

No website received a perfect score in any of the 4 categories, and the average website score was 62% (37/60). Less than a quarter of the websites (23%, 7/31) received a score of more than 75% (7.5/10) for content. Approximately two-thirds of the websites (65%, 20/31) received a score of 50% (5/10) or lower for interactivity. The average score in usability was 68% (6.8/10) and in authority was 69% (6.9/10). Other deficiencies observed included difficulty locating relevant content and lack of information targeting audiences with the highest likelihood of HIV infection.

Conclusions

Existing HIV prevention websites with information about PrEP or TasP for MSM fail to provide adequate content as well as present that content to users in an interactive and audience-conscious way. Future eHealth interventions should attempt to rectify these deficiencies to successfully engage and educate MSM at high risk for HIV regarding prevention strategies.

HIV testing and pre-exposure prophylaxis (PrEP) use, familiarity, and attitudes among gay and bisexual men in the United States: A national probability sample of three birth cohorts

This study examined HIV testing and use, familiarity, and attitudes toward pre-exposure prophylaxis (PrEP) among HIV-negative gay and bisexual men in the United States. A national probability sample (N = 470) of three age cohorts (18-25, 34-41, and 52-59 years) completed a survey between March, 2016 and March, 2017. Most men did not meet CDC recommendations for HIV testing, and 25.2% of men in the younger cohort had never tested. Only 4.1% used PrEP across cohorts. Visiting an LGBT clinic and searching for LGBT resources online were associated with PrEP use. Men in the middle cohort were more familiar with PrEP (79%) than men in the younger (52%) and older (57%) cohorts. Bisexual and non-urban men were less familiar with PrEP. Attitudes were positive among most men (68.4%) familiar with PrEP. Findings suggest that most men potentially at risk for HIV do not meet CDC guidelines for testing, and PrEP use continues to be minimal. Efforts to educate gay and bisexual men about HIV risk and prevention need to be reinvigorated and expanded to include non-gay-identified and non-urban men.

Using eHealth to Reach Black and Hispanic Men Who Have Sex With Men Regarding Treatment as Prevention and Preexposure Prophylaxis: Protocol for a Small Randomized Controlled Trial

BACKGROUND

Black and Hispanic men who have sex with men in the United States continue to be disproportionately affected by HIV and AIDS. Uptake of and knowledge about biobehavioral HIV prevention approaches, such as treatment as prevention and preexposure prophylaxis, are especially low in these populations. eHealth campaigns and social media messaging about treatment as prevention and preexposure prophylaxis may help to fill this gap in knowledge and lead to increased uptake of such strategies; however, no evidence exists of the effects of these targeted forms of communication on treatment as prevention and preexposure prophylaxis uptake in these populations.

OBJECTIVE

We describe the protocol for a 3-part study aiming to develop and evaluate an eHealth intervention with information about treatment as prevention and preexposure prophylaxis for HIV-positive and HIV-negative black and Hispanic men who have sex with men.

METHODS

Phases 1 and 2 will involve focus groups and cognitive interviews with members of the target populations, which we will use to create a culturally tailored, interactive website and applicable social media messaging for these men. Phase 3 will be a small randomized controlled trial of the eHealth intervention, in which participants will receive guided social media messages plus the newly developed website (active arm) or the website alone (control arm), with assessments at baseline and 6 months.

RESULTS

Participant recruitment began in August 2017 and will end in August 2020.

CONCLUSIONS

Public health interventions are greatly needed to increase knowledge about and uptake of biobehavioral HIV prevention strategies such as treatment as prevention and preexposure prophylaxis among black and Hispanic men who have sex with men. eHealth communication campaigns offer a strategy for engaging these populations in health communication about biobehavioral HIV prevention.

TRIAL REGISTRATION

ClinicalTrials.gov NCT03404531; https://www.clinicaltrials.gov/ct2/show/NCT03404531 (Archived by WebCite at http://www.webcitation.org/70myofp0R).

REGISTERED REPORT IDENTIFIER

RR1-10.2196/11047.

Interest in Long-Acting Injectable PrEP in a Cohort of Men Who have Sex with Men in China

Long-acting injectable (LAI) formulations of antiretrovirals (ARVs) as pre-exposure prophylaxis (PrEP) could be an attractive alternative for men who have sex with men (MSM) who are interested in ARV-based biomedical prevention but will not use a daily pill. This study investigated interest in LAI-PrEP in a cohort of MSM in China and characterized how MSM willing to use only injectable PrEP differed from MSM who would use PrEP regardless of modality or not at all. Demographic, behavioral, and risk perception measures were collected and associations investigated. A licensed LAI-PrEP agent would increase the proportion interested in PrEP by 24.5% over oral PrEP alone. Combining interest in oral and injectable PrEP, 78.5% of the sample could be covered if reported interest in PrEP translated into actual uptake. Partnership factors differentiated those who would be willing to use only LAI-PrEP versus any PrEP modality, while higher self-perception of risk was associated with interest in LAI-PrEP versus no PrEP. The addition of a second PrEP modality could yield increased population coverage of PrEP. Social and behavioral research should be undertaken in parallel with clinical development of injectable PrEP agents to identify characteristics of those who are not interested in oral PrEP but would take advantage of ARV-based prevention with the introduction of an injectable product.

Functional Knowledge of Pre-Exposure Prophylaxis for HIV Prevention Among Participants in a Web-Based Survey of Sexually Active Gay, Bisexual, and Other Men Who Have Sex With Men: Cross-Sectional Study

Background

Awareness of pre-exposure prophylaxis (PrEP) for HIV prevention is increasing, but little is known about the functional knowledge of PrEP and its impact on willingness to use PrEP.

Objective

The objective of this study was to assess the functional knowledge of PrEP among a sample of gay, bisexual, and other men who have sex with men (MSM) participating in a Web-based survey of sexually active MSM.

Methods

Men at least 18 years old, residing in the United States, and reporting sex with a man in the previous 6 months were recruited through social networking websites. PrEP functional knowledge included the following 4 questions (1) efficacy of consistent PrEP use, (2) inconsistent PrEP use and effectiveness, (3) PrEP and condom use, and (4) effectiveness at reducing sexually transmitted infections (STIs). Ordinal logistic regression was used to identify respondent characteristics associated with PrEP functional knowledge. In a subsample of participants responding to HIV prevention questions, we compared willingness to use PrEP by response to PrEP functional knowledge using logistic regression analysis adjusted for age, race and ethnicity, and education level.

Results

Among 573 respondents, PrEP knowledge was high regarding adherence (488/573, 85.2%), condom use (532/573, 92.8%), and STIs (480/573, 83.8%), but only 252/573 (44.0%) identified the correct efficacy. Lower functional PrEP knowledge was associated with minority race/ethnicity (P=.005), lower education (P=.01), and not having an HIV test in the past year (P=.02). Higher PrEP knowledge was associated with willingness to use PrEP (P=.009). Younger age was not associated with higher PrEP functional knowledge or willingness to use PrEP.

Conclusions

PrEP knowledge was generally high in our study, including condom use and consistent use but may be lacking in higher risk MSM. The majority of respondents did not correctly identify PrEP efficacy with consistent use, which could impact motivation to seek out PrEP for HIV prevention. Targeted messaging to increase PrEP knowledge may increase PrEP use.

PrEP awareness and decision-making for Latino MSM in San Antonio, Texas

Pre-Exposure Prophylaxis (PrEP) has been promoted among high-risk populations as an effective HIV biomedical intervention. However, limited research is available on the significance of culturally informed biomedical interventions for Latino MSM. A total of 159 self-administered Internet surveys were completed by Latino MSM ages 21–30 in San Antonio, Texas. The purpose of this research was to develop an instrument that measured Latino MSM attitudes and beliefs towards PrEP, identify associations between demographic factors and PrEP related factors and to suggest culturally appropriate strategies for the promotion of PrEP among the Latino MSM population. Research findings revealed implications for PrEP at the structural and individual level for Latino MSM. Structural level indicators emphasized the importance for raising PrEP awareness among Latino MSM in regards to PrEP related expenses, ameliorating stigmatization of high-risk populations, enhancing access to PrEP informed medical providers, and address mistrust of the government and medical providers role on addressing health disparities among Latino MSM. Overall, the findings for individual factors emphasize the need for patient-centered interventions for Latino MSM. Latino MSM currently on PrEP require supplemental resources to enhance PrEP adherence. Latino MSM not on PrEP require alternate options for PrEP delivery and/or cognitive behavioral approaches minimizing HIV risk behavior for Latino MSM concerned with PrEP toxicity, which may require non-biomedical interventions. Integration of Latino MSM currently on PrEP as peer educators provides a valuable resource for developing culturally informed PrEP interventions for Latino MSM. Peer educators are able to share their experiential knowledge of PrEP contextualized through cultural norms, beliefs, and values.

Towards an integrated primary and secondary HIV prevention continuum for the United States: a cyclical process model

Introduction

Every new HIV infection is preventable and every HIV-related death is avoidable. As many jurisdictions around the world endeavour to end HIV as an epidemic, missed HIV prevention and treatment opportunities must be regarded as public health emergencies, and efforts to quickly fill gaps in service provision for all people living with and vulnerable to HIV infection must be prioritized.

Discussion

We present a novel, comprehensive, primary and secondary HIV prevention continuum model for the United States as a conceptual framework to identify key steps in reducing HIV incidence and improving health outcomes among those vulnerable to, as well as those living with, HIV infection. We further discuss potential approaches to address gaps in data required for programme planning, implementation and evaluation across the elements of the HIV prevention continuum.

Conclusions

Our model conceptualizes opportunities to monitor and quantify primary HIV prevention efforts and, importantly, illustrates the interplay between an outcomes-oriented primary HIV prevention process and the HIV care continuum to move aggressively forward in reaching ambitious reductions in HIV incidence. To optimize the utility of this outcomes-oriented HIV prevention continuum, a key gap to be addressed includes the creation and increased coordination of data relevant to HIV prevention across sectors.