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Stalter RM, Dong TQ, Hendrix CW, Palanee-Phillips T, van der Straten A, Hillier SL, Kiweewa FM, Mgodi NM, Marzinke MA, Bekker LG, Soto-Torres L, Baeten JM, Brown ER. Assessing Per-Sex-Act HIV-1 Risk Reduction Among Women Using the Dapivirine Vaginal Ring. J Infect Dis 2024; 229:1158-1165. [PMID: 38099506 PMCID: PMC11011174 DOI: 10.1093/infdis/jiad550] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2023] [Revised: 11/10/2023] [Accepted: 12/13/2023] [Indexed: 03/14/2024] Open
Abstract
BACKGROUND Confounding introduced by individuals' sexual risk behavior is potentially a significant source of bias in HIV-1 prevention intervention studies. To more completely account for sexual behaviors when assessing the efficacy of the monthly dapivirine ring, a new longer-acting HIV-1 prevention option for women, we estimated per-sex-act risk reduction associated with product use. METHODS We conducted a secondary analysis of data from MTN-020/ASPIRE, a phase 3, randomized, placebo-controlled efficacy trial of the dapivirine ring that recruited HIV-uninfected, African women aged 18-45 years. With cumulative sex acts as the time scale, we used multivariable Cox regression with inverse probability of censoring weights to estimate HIV-1 risk reduction associated with a rate of dapivirine release indicative of consistent product use. RESULTS Women in the dapivirine ring group (n = 1187) had an estimated incidence rate of 2.3 (95% confidence interval [CI], 1.8-3.1) HIV-1 acquisition events per 10 000 sex acts versus 3.6 (95% CI, 2.9-4.4) per 10 000 acts in the placebo group (n = 1187). Dapivirine release indicative of consistent ring use was associated with a 63% (95% CI, 33%-80%) per-sex-act HIV-1 risk reduction. CONCLUSIONS These results support the efficacy of the dapivirine vaginal ring for HIV-1 prevention and help to inform decision-making for women, providers, and policymakers regarding product use. CLINICAL TRIALS REGISTRATION NCT01617096.
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Affiliation(s)
- Randy M Stalter
- Department of Epidemiology, University of Washington, Seattle, WA, USA
| | - Tracy Q Dong
- Vaccine and Infectious Disease Division, Fred Hutchinson Cancer Research Center, Seattle, WA, USA
| | - Craig W Hendrix
- Department of Medicine, Johns Hopkins University, Baltimore, MD, USA
| | - Thesla Palanee-Phillips
- Department of Epidemiology, University of Washington, Seattle, WA, USA
- Wits Reproductive Health and HIV Research Institute, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Ariane van der Straten
- Center for AIDS Prevention Studies, Department of Medicine, University of California San Francisco, San Francisco, CA, USA
- ASTRA consulting, Kensington, CA, USA
| | - Sharon L Hillier
- Department of Obstetrics, Gynecology, and Reproductive Sciences, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
- Magee-Womens Research Institute, Pittsburgh, PA, USA
| | - Flavia M Kiweewa
- Research Department, Makerere University-Johns Hopkins University Research Collaboration, Kampala, Uganda
| | - Nyaradzo M Mgodi
- Clinical Trials Research Centre, University of Zimbabwe, Harare, Zimbabwe
| | - Mark A Marzinke
- Department of Medicine, Johns Hopkins University, Baltimore, MD, USA
| | - Linda-Gail Bekker
- The Desmond Tutu HIV Centre, University of Cape Town, Cape Town, South Africa
| | - Lydia Soto-Torres
- Division of AIDS, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, MD, USA
| | - Jared M Baeten
- Department of Epidemiology, University of Washington, Seattle, WA, USA
- Departments of Medicine and Global Health, University of Washington, Seattle, WA, USA
| | - Elizabeth R Brown
- Vaccine and Infectious Disease Division, Fred Hutchinson Cancer Research Center, Seattle, WA, USA
- Department of Biostatistics, University of Washington, Seattle, WA, USA
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Chou R, Spencer H, Bougatsos C, Blazina I, Ahmed A, Selph S. Preexposure Prophylaxis for the Prevention of HIV: Updated Evidence Report and Systematic Review for the US Preventive Services Task Force. JAMA 2023; 330:746-763. [PMID: 37606667 DOI: 10.1001/jama.2023.9865] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 08/23/2023]
Abstract
Importance A 2019 review for the US Preventive Services Task Force (USPSTF) found oral preexposure prophylaxis (PrEP) associated with decreased HIV infection risk vs placebo or no PrEP in adults at increased HIV acquisition risk. Newer PrEP regimens are available. Objective To update the 2019 review on PrEP, to inform the USPSTF. Data Sources Ovid MEDLINE, Cochrane Database of Systematic Reviews, Cochrane Central Register of Controlled Trials, and Embase (January 2018 to May 16, 2022); surveillance through March 24, 2023. Study Selection Randomized clinical trials of PrEP vs placebo or no PrEP or newer vs older PrEP regimens and diagnostic accuracy studies of instruments for predicting incident HIV infection. Data Extraction and Synthesis Dual review of titles and abstracts, full-text articles, study quality, and data abstraction. Data were pooled using the DerSimonian and Laird random-effects model. Main Outcomes and Measures HIV acquisition, mortality, and harms; and diagnostic test accuracy. Results Thirty-two studies were included in the review (20 randomized clinical trials [N = 36 543] and 12 studies of diagnostic accuracy [N = 5 544 500]). Eleven trials in the 2019 review found oral PrEP associated with decreased HIV infection risk vs placebo or no PrEP (n = 18 172; relative risk [RR], 0.46 [95% CI, 0.33-0.66]). Higher adherence was associated with greater efficacy. One new trial (n = 5335) found oral tenofovir alafenamide/emtricitabine (TAF/FTC) to be noninferior to tenofovir disoproxil fumarate/emtricitabine (TDF/FTC) in men who have sex with men (RR, 0.47 [95% CI, 0.19-1.14]). Two new trials found long-acting injectable cabotegravir associated with decreased risk of HIV infection vs oral TDF/FTC (RR, 0.33 [95% CI, 0.18-0.62] in cisgender men who have sex with men and transgender women [n = 4490] and RR, 0.11 [95% CI, 0.04-0.31] in cisgender women [n = 3178]). Discrimination of instruments for predicting incident HIV infection was moderate in men who have sex with men (5 studies; n = 25 488) and moderate to high in general populations of persons without HIV (2 studies; n = 5 477 291). Conclusions and Relevance In adults at increased HIV acquisition risk, oral PrEP was associated with decreased risk of acquiring HIV infection compared with placebo or no PrEP. Oral TAF/FTC was noninferior to oral TDF/FTC, and injectable cabotegravir reduced the risk of HIV infection compared with oral TDF/FTC in the populations studied.
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Affiliation(s)
- Roger Chou
- The Pacific Northwest Evidence-based Practice Center, Department of Medical Informatics and Clinical Epidemiology, Oregon Health & Science University, Portland
- Division of General Internal Medicine, Oregon Health & Science University, Portland
| | - Hunter Spencer
- Division of General Internal Medicine, Oregon Health & Science University, Portland
| | - Christina Bougatsos
- The Pacific Northwest Evidence-based Practice Center, Department of Medical Informatics and Clinical Epidemiology, Oregon Health & Science University, Portland
| | - Ian Blazina
- The Pacific Northwest Evidence-based Practice Center, Department of Medical Informatics and Clinical Epidemiology, Oregon Health & Science University, Portland
| | - Azrah Ahmed
- The Pacific Northwest Evidence-based Practice Center, Department of Medical Informatics and Clinical Epidemiology, Oregon Health & Science University, Portland
| | - Shelley Selph
- The Pacific Northwest Evidence-based Practice Center, Department of Medical Informatics and Clinical Epidemiology, Oregon Health & Science University, Portland
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Velloza J, Roche S, Concepcion T, Ortblad KF. Advancing considerations of context in the evaluation and implementation of evidence-based biomedical HIV prevention interventions: a review of recent research. Curr Opin HIV AIDS 2023; 18:1-11. [PMID: 36503876 PMCID: PMC9757852 DOI: 10.1097/coh.0000000000000768] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
PURPOSE OF REVIEW A paradigm shift is needed in how we think about biomedical HIV prevention product effectiveness. Often, we expect randomized trial findings to be generalizable across populations and settings where products will be delivered, without consideration of key contextual drivers that could impact effectiveness. Moreover, researchers and policy-makers generally discount products with varied effect sizes across contexts, rather than explicating the drivers of these differences and using them to inform equitable product choice and delivery. We conducted a review of the recent HIV prevention research to advance considerations of context in choices of when, why, and how to implement biomedical HIV prevention products, with a particular focus on daily oral preexposure prophylaxis (PrEP) and the dapivirine vaginal ring (DPV). RECENT FINDINGS Findings across recent studies of PrEP and DPV emphasize that products that do not work well in one context might be highly desirable in another. Key contextual drivers of PrEP and DPV effectiveness, use, and implementation include population, health system, cultural, and historical factors. We recommend conceptualization, measurement, and analysis approaches to fully understand the potential impact of context on prevention product delivery. Execution of these approaches has real-world implications for HIV prevention product choice and could prevent the field from dismissing biomedical HIV prevention products based on trial findings alone. SUMMARY Ending the HIV epidemic will require tailored, person-centered, and equitable approaches to design, implement, and evaluate HIV prevention products which necessitates considerations of context in ongoing research and implementation.
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Affiliation(s)
- Jennifer Velloza
- Department of Epidemiology & Biostatistics, University of California San Francisco, San Francisco, California
| | - Stephanie Roche
- Fred Hutchinson Cancer Center, Public Health Sciences Division
| | - Tessa Concepcion
- Department of Global Health, University of Washington, Seattle, Washington
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Zhong Y, Brooks MM, Kennedy EH, Bodnar LM, Naimi AI. Use of Machine Learning to Estimate the Per-Protocol Effect of Low-Dose Aspirin on Pregnancy Outcomes: A Secondary Analysis of a Randomized Clinical Trial. JAMA Netw Open 2022; 5:e2143414. [PMID: 35262718 PMCID: PMC8908068 DOI: 10.1001/jamanetworkopen.2021.43414] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
IMPORTANCE In randomized clinical trials (RCTs), per-protocol effects may be of interest in the presence of nonadherence with the randomized treatment protocol. Using machine learning in per-protocol effect estimation can help avoid model misspecification owing to strong parametric assumptions, as is common with standard methods (eg, logistic regression). OBJECTIVES To demonstrate the use of ensemble machine learning with augmented inverse probability weighting (AIPW) for per-protocol effect estimation in RCTs and to evaluate the per-protocol effect size of aspirin on pregnancy. DESIGN, SETTING, AND PARTICIPANTS This secondary analysis used data from 1227 women in the Effects of Aspirin in Gestation and Reproduction (EAGeR) trial, a multicenter, block-randomized, double-blind, placebo-controlled clinical trial of the effect of daily low-dose aspirin on pregnancy outcomes in women at high risk of pregnancy loss. Participants were recruited at 4 university medical centers in the US from June 15, 2007, to July 15, 2012. Women were followed up for 6 menstrual cycles for attempted pregnancy and 36 weeks of gestation if pregnancy occurred. Follow-up was completed on August 17, 2012. Data analyses were performed on July 9, 2021. EXPOSURES Daily low-dose (81 mg) aspirin taken at least 5 of 7 days per week for at least 80% of follow-up time relative to placebo. MAIN OUTCOMES AND MEASURES Pregnancy detected using human chorionic gonadotropin (hCG) levels. RESULTS Among the 1227 women included in the analysis (mean SD age, 28.74 [4.80] years), 1161 (94.6%) were non-Hispanic White and 858 (69.9%) adhered to the protocol. Five machine learning models were combined into 1 meta-algorithm, which was used to construct an AIPW estimator for the per-protocol effect. Compared with adhering to placebo, adherence to the daily low-dose aspirin protocol for at least 5 of 7 days per week was associated with an increase in the probability of hCG-detected pregnancy of 8.0 (95% CI, 2.5-13.6) more hCG-detected pregnancies per 100 women in the sample, which is substantially larger than the estimated intention-to-treat estimate of 4.3 (95% CI, -1.1 to 9.6) more hCG-detected pregnancies per 100 women in the sample. CONCLUSIONS AND RELEVANCE These findings suggest that a low-dose aspirin protocol is associated with increased hCG-detected pregnancy in women who adhere to treatment for at least 5 days per week. With the presence of nonadherence, per-protocol treatment effect estimates differ from intention-to-treat estimates in the EAGeR trial. The results of this secondary analysis of clinical trial data suggest that machine learning could be used to estimate per-protocol effects by adjusting for confounders related to nonadherence in a more flexible way than traditional regressions. TRIAL REGISTRATION ClinicalTrials.gov Identifier: NCT00467363.
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Affiliation(s)
- Yongqi Zhong
- Department of Epidemiology, The Johns Hopkins University, Baltimore, Maryland
| | - Maria M. Brooks
- Department of Epidemiology, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Edward H. Kennedy
- Department of Data Science and Statistics, Carnegie Mellon University, Pittsburgh, Pennsylvania
| | - Lisa M. Bodnar
- Department of Epidemiology, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Ashley I. Naimi
- Department of Epidemiology, Emory University, Atlanta, Georgia
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Malone J, Reisner SL, Cooney EE, Poteat T, Cannon CM, Schneider JS, Radix A, Mayer KH, Haw JS, Althoff KN, Wawrzyniak AJ, Beyrer C, Wirtz AL. Perceived HIV Acquisition Risk and Low Uptake of PrEP Among a Cohort of Transgender Women With PrEP Indication in the Eastern and Southern United States. J Acquir Immune Defic Syndr 2021. [PMID: 34397742 DOI: 10.1097/qai.0000000000002726]] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/06/2023]
Abstract
INTRODUCTION Preexposure prophylaxis (PrEP) is effective in preventing HIV among adherent users. However, PrEP uptake among transgender women is low, and current prescribing guidelines from the Centers for Disease Control and Prevention (CDC) are not specific to transgender women. Self-perceived risk of HIV among those who are PrEP-indicated is not well understood. METHODS This cross-sectional analysis included 1293 transgender women screened at baseline from March 2018 to May 2020 for a multisite, prospective cohort study. We compared the prevalence of PrEP indication using current CDC prescribing criteria versus transgender women-specific criteria developed by study investigators with community input. We identified factors associated with study-specific PrEP indication and factors associated with self-perceived low to no HIV risk among those who were PrEP-indicated. We also calculated descriptive statistics to depict the PrEP care continuum. RESULTS PrEP indication prevalence using transgender women-specific criteria was 47% (611), 155 more than who were identified using the CDC criteria. Eighty-three percent were aware of PrEP, among whom 38% had ever used PrEP. Among PrEP ever users, 63% were using PrEP at the time of the study. There were 66% of current PrEP users who reported 100% adherence within the previous 7 days. Among those who were PrEP-indicated, 13% were using and adherent to PrEP at the time of the study. More than half (55%) of PrEP-indicated participants had low or no self-perceived HIV risk. CONCLUSIONS These findings suggest that further guidance is needed for health care providers in prescribing PrEP to transgender women. Greater uptake and adherence are also needed for optimal effectiveness.
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Affiliation(s)
- Jowanna Malone
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD
| | - Sari L Reisner
- Department of Epidemiology, Harvard T.H. Chan School of Public Health, Boston, MA
- Department of Medicine, Harvard Medical School, Boston, MA
- Division of Endocrinology, Diabetes & Hypertension, Brigham and Women's Hospital, Boston, MA
| | - Erin E Cooney
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD
| | - Tonia Poteat
- Department of Social Medicine, University of North Carolina Chapel Hill School of Medicine, Chapel Hill, NC
| | | | | | - Asa Radix
- School of Medicine, New York University, New York, NY
| | - Kenneth H Mayer
- Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA
- Fenway Community Health Center, The Fenway Institute, Boston, MA
| | - J Sonya Haw
- Division of Endocrinology, Metabolism, and Lipids, School of Medicine, Emory University, Atlanta, GA
| | - Keri N Althoff
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD
| | | | - Chris Beyrer
- Department of Epidemiology, Center for Public Health and Human Rights, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD
| | - Andrea L Wirtz
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD
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6
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Malone J, Reisner SL, Cooney E, Poteat T, Cannon CM, Schneider J, Radix A, Mayer KH, Haw JS, Althoff KN, Wawrzyniak AJ, Beyrer C, Wirtz AL. Perceived HIV Acquisition Risk and Low Uptake of PrEP Among a Cohort of Transgender Women With PrEP Indication in the Eastern and Southern United States. J Acquir Immune Defic Syndr 2021; 88:10-18. [PMID: 34397742 PMCID: PMC8371736 DOI: 10.1097/qai.0000000000002726] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2021] [Accepted: 05/03/2021] [Indexed: 11/25/2022]
Abstract
INTRODUCTION Preexposure prophylaxis (PrEP) is effective in preventing HIV among adherent users. However, PrEP uptake among transgender women is low, and current prescribing guidelines from the Centers for Disease Control and Prevention (CDC) are not specific to transgender women. Self-perceived risk of HIV among those who are PrEP-indicated is not well understood. METHODS This cross-sectional analysis included 1293 transgender women screened at baseline from March 2018 to May 2020 for a multisite, prospective cohort study. We compared the prevalence of PrEP indication using current CDC prescribing criteria versus transgender women-specific criteria developed by study investigators with community input. We identified factors associated with study-specific PrEP indication and factors associated with self-perceived low to no HIV risk among those who were PrEP-indicated. We also calculated descriptive statistics to depict the PrEP care continuum. RESULTS PrEP indication prevalence using transgender women-specific criteria was 47% (611), 155 more than who were identified using the CDC criteria. Eighty-three percent were aware of PrEP, among whom 38% had ever used PrEP. Among PrEP ever users, 63% were using PrEP at the time of the study. There were 66% of current PrEP users who reported 100% adherence within the previous 7 days. Among those who were PrEP-indicated, 13% were using and adherent to PrEP at the time of the study. More than half (55%) of PrEP-indicated participants had low or no self-perceived HIV risk. CONCLUSIONS These findings suggest that further guidance is needed for health care providers in prescribing PrEP to transgender women. Greater uptake and adherence are also needed for optimal effectiveness.
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Affiliation(s)
- Jowanna Malone
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD
| | - Sari L. Reisner
- Department of Epidemiology, Harvard T.H. Chan School of Public Health, Boston, MA
- Department of Medicine, Harvard Medical School, Boston, MA
- Division of Endocrinology, Diabetes & Hypertension, Brigham and Women’s Hospital, Boston, MA
| | - Erin Cooney
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD
| | - Tonia Poteat
- Department of Social Medicine, University of North Carolina Chapel Hill School of Medicine, Chapel Hill, NC
| | | | | | - Asa Radix
- New York University School of Medicine, New York, NY
| | - Kenneth H. Mayer
- Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
- The Fenway Institute, Boston, MA, US
| | - J. Sonya Haw
- Division of Endocrinology, Metabolism, and Lipids, Emory University school of Medicine, Atlanta, GA
| | - Keri N. Althoff
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD
| | - Andrew J. Wawrzyniak
- Department of Psychiatry and Behavioral Sciences, University of Miami Miller School of Medicine
| | - Chris Beyrer
- Center for Public Health and Human Rights, Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD
| | - Andrea L. Wirtz
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD
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Peebles K, Mugwanya KK, Irungu E, Odoyo J, Wamoni E, Morton JF, Ngure K, Bukusi EA, Mugo NR, Masyuko S, Mukui I, Baeten JM, Barnabas RV. Low costs and opportunities for efficiency: a cost analysis of the first year of programmatic PrEP delivery in Kenya's public sector. BMC Health Serv Res 2021; 21:823. [PMID: 34399736 PMCID: PMC8365926 DOI: 10.1186/s12913-021-06832-3] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2020] [Accepted: 07/30/2021] [Indexed: 11/10/2022] Open
Abstract
Background In 2017, the Kenyan Ministry of Health integrated provision of pre-exposure prophylaxis (PrEP) into public HIV-1 care clinics as a key component of the national HIV-1 prevention strategy. Estimates of the cost of PrEP provision are needed to inform the affordability and cost-effectiveness of PrEP in Kenya. Methods We conducted activity-based micro-costing from the payer perspective to estimate both the financial and economic costs of all resources and activities required to provide PrEP in Kenya’s public sector. We estimated total and unit costs in 2019 United States dollars from a combination of project expense reports, Ministry of Health training reports, clinic staff interviews, time-and-motion observations, and routinely collected data from PrEP recipient files from 25 high-volume HIV-1 care clinics. Results In the first year of programmatic PrEP delivery in 25 HIV-1 care clinics, 2,567 persons initiated PrEP and accrued 8,847 total months of PrEP coverage, accounting for 2 % of total outpatient clinic visits. The total financial cost to the Ministry of Health was $91,175, translating to an average of $10.31 per person per month. The majority (69 %) of financial costs were attributable to PrEP medication, followed by administrative supplies (17 %) and training (9 %). Economic costs were higher ($188,584 total; $21.32 per person per month) due to the inclusion of the opportunity cost of staff time re-allocated to provide PrEP and a proportional fraction of facility overhead. The vast majority (88 %) of the annual $80,811 economic cost of personnel time was incurred during activities to recruit new clients (e.g., discussion of PrEP within HIV-1 testing and counselling services), while the remaining 12 % was for activities related to both initiation and maintenance of PrEP provision (e.g., client consultations, technical advising, support groups). Conclusions Integration of PrEP provision into existing public health HIV-1 care service delivery platforms resulted in minimal additional staff burden and low incremental costs. Efforts to improve the efficiency of PrEP provision should focus on reductions in the cost of PrEP medication and extra-clinic demand creation and community sensitization to reduce personnel time dedicated to recruitment-related activities. Trial registration ClinicalTrials.gov registration NCT03052010. Retrospectively registered on February 14, 2017. Supplementary Information The online version contains supplementary material available at 10.1186/s12913-021-06832-3.
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Affiliation(s)
- Kathryn Peebles
- Department of Epidemiology, University of Washington, Seattle, WA, USA. .,International Clinical Research Center, HMC # 359927 325 Ave, WA, 98104, Seattle, USA.
| | - Kenneth K Mugwanya
- Division of Disease Control, School of Public Health, Makerere University, Kampala, Uganda.,Department of Global Health, University of Washington, Seattle, WA, USA
| | - Elizabeth Irungu
- Department of Global Health, University of Washington, Seattle, WA, USA.,Partners in Health and Research Development, Nairobi, Kenya
| | - Josephine Odoyo
- Centre for Microbiology Research, Kenya Medical Research Institute, Nairobi, Kenya
| | | | - Jennifer F Morton
- Department of Global Health, University of Washington, Seattle, WA, USA
| | - Kenneth Ngure
- Department of Public and Community Health, Jomo Kenyatta University of Agriculture and Technology, Nairobi, Kenya
| | - Elizabeth A Bukusi
- Centre for Microbiology Research, Kenya Medical Research Institute, Nairobi, Kenya
| | - Nelly R Mugo
- Department of Global Health, University of Washington, Seattle, WA, USA.,Department of Obstetrics and Gynecology, University of Washington, Seattle, WA, USA
| | - Sarah Masyuko
- National AIDS & Sexually Transmitted Infection Control Programme, Ministry of Health, Nairobi, Kenya
| | - Irene Mukui
- National AIDS & Sexually Transmitted Infection Control Programme, Ministry of Health, Nairobi, Kenya
| | - Jared M Baeten
- Department of Epidemiology, University of Washington, Seattle, WA, USA.,Department of Global Health, University of Washington, Seattle, WA, USA.,Department of Medicine, University of Washington, Seattle, WA, USA
| | - Ruanne V Barnabas
- Department of Epidemiology, University of Washington, Seattle, WA, USA.,Department of Global Health, University of Washington, Seattle, WA, USA
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McGowan IM, Tzakis N, Kosak B, Korczak B, Engstrom J, Tomaszewska-Kiecana M, Hartley O. Evaluation of the Safety, Acceptability, and Pharmacokinetic Profile of a Gel Formulation of OB-002 in Healthy Volunteers. AIDS Res Hum Retroviruses 2021; 37:453-460. [PMID: 33749321 DOI: 10.1089/aid.2021.0010] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Abstract
OB-002 is an extremely potent CCR5 antagonist that has previously been shown to completely block transmission in a nonhuman primate model of HIV infection. The purpose of this study was to characterize the safety, acceptability, and pharmacokinetic profile of a gel formulation of OB-002 (OB-002H). The trial had two phases, an open label single dose exposure (vaginal and rectal) and a randomized placebo controlled multiple dose phase during which study participants received five vaginal daily doses of OB-002H gel or matched placebo in a 2:1 ratio. Serum OB-002 levels were quantified at multiple time points up to 24 h after the first dose. A total of thirty female and male participants were enrolled in the study (12 in the single dose phase and 18 in the multiple dose phase). All adverse events were Grade 1 or 2, and the majority was unrelated to study product. Only two product-related transient Grade 2 events (both vulval dryness) occurred in the study, both in the OB-002H gel randomized multiple dose arm. All colposcopic and anoscopic assessments following product exposure were normal. There was no evidence of systemic absorption of OB-002. Overall, the product had a positive acceptability profile, and most study participants would consider using the product for protection against HIV or pregnancy. Future studies are needed to assess the extended safety and acceptability of OB-002H gel in sexually active participants. Clinical Trial Registration Number: NCT04791007.
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Affiliation(s)
- Ian Michael McGowan
- Orion Biotechnology Polska, Krakow, Poland
- Department of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | | | | | | | | | | | - Oliver Hartley
- Orion Biotechnology, Ottawa, Canada
- Department of Pathology and Immunology, Faculty of Medicine, University of Geneva, Geneva, Switzerland
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Abstract
Supplemental Digital Content is Available in the Text. HIV-1 risk scoring tools could help target provision of prevention modalities such as pre-exposure prophylaxis. Recent research suggests that risk scores for women aged 18–45 may not predict risk well among young women aged 18–24. We evaluated the predictive performance of age-specific risk scores compared with the existing non–age-specific VOICE risk score, developed for women aged 18–45.
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Cooper RL, Juarez PD, Morris MC, Ramesh A, Edgerton R, Brown LL, Mena L, MacMaster SA, Collins S, Juarez PM, Tabatabai M, Brown KY, Paul MJ, Im W, Arcury TA, Shinn M. Recommendations for Increasing Physician Provision of Pre-Exposure Prophylaxis: Implications for Medical Student Training. INQUIRY : A JOURNAL OF MEDICAL CARE ORGANIZATION, PROVISION AND FINANCING 2021; 58:469580211017666. [PMID: 34027712 PMCID: PMC8142521 DOI: 10.1177/00469580211017666] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/25/2021] [Revised: 04/05/2021] [Accepted: 04/26/2021] [Indexed: 12/27/2022]
Abstract
There is growing evidence that pre-exposure prophylaxis (PrEP) prevents HIV acquisition. However, in the United States, approximately only 4% of people who could benefit from PrEP are currently receiving it, and it is estimated only 1 in 5 physicians has ever prescribed PrEP. We conducted a scoping review to gain an understanding of physician-identified barriers to PrEP provision. Four overarching barriers presented in the literature: Purview Paradox, Patient Financial Constraints, Risk Compensation, and Concern for ART Resistance. Considering the physician-identified barriers, we make recommendations for how physicians and students may work to increase PrEP knowledge and competence along each stage of the PrEP cascade. We recommend adopting HIV risk assessment as a standard of care, improving physician ability to identify PrEP candidates, improving physician interest and ability in encouraging PrEP uptake, and increasing utilization of continuous care management to ensure retention and adherence to PrEP.
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Affiliation(s)
| | | | | | | | | | - Lauren L. Brown
- Behavioral Health & Research at Nashville Cares, Nashville, TN, USA
| | - Leandro Mena
- University of Mississippi Medical Center, Jackson, MS, USA
| | | | | | | | | | | | | | - Wansoo Im
- Meharry Medical College, Nashville, TN, USA
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11
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Amrein K, Lasky-Su JA, Dobnig H, Christopher KB. Metabolomic basis for response to high dose vitamin D in critical illness. Clin Nutr 2020; 40:2053-2060. [PMID: 33087250 DOI: 10.1016/j.clnu.2020.09.028] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2020] [Revised: 08/04/2020] [Accepted: 09/21/2020] [Indexed: 12/12/2022]
Abstract
BACKGROUND & AIMS It is unclear if intervention can mitigate the dramatic alterations of metabolic homeostasis present in critical illness. Our objective was to determine the associations between increased 25-hydroxyvitamin D levels following high dose vitamin D3 and more favorable metabolomic profiles in critical illness. METHODS We performed a post-hoc metabolomics study of the VITdAL-ICU randomized double-blind, placebo-controlled trial. Trial patients from Medical and Surgical Intensive Care Units at a tertiary university hospital with 25-hydroxyvitamin D level ≤20 ng/mL received either high dose oral vitamin D3 (540,000 IU) or placebo. We performed an analysis of 578 metabolites from 1215 plasma samples from 428 subjects at randomization (day 0), day 3 and 7. Using mixed-effects modeling, we studied changes in metabolite profiles in subjects receiving intervention or placebo relative to absolute increases in 25-hydroxyvitamin D levels from day 0 to day 3. RESULTS 55.2% of subjects randomized to high dose vitamin D3 demonstrated an absolute increase in 25-hydroxyvitamin D ≥ 15 ng/ml from day 0 to day 3. With an absolute increase in 25-hydroxyvitamin D ≥ 15 ng/ml, multiple members of the sphingomyelin, plasmalogen, lysoplasmalogen and lysophospholipid metabolite classes had significantly positive Bonferroni corrected associations over time. Further, multiple representatives of the acylcarnitine and phosphatidylethanolamine metabolite classes had significantly negative Bonferroni corrected associations over time with an absolute increase in 25-hydroxyvitamin D ≥ 15 ng/ml. Changes in these highlighted metabolite classes were associated with decreased 28-day mortality. CONCLUSIONS Increases in 25-hydroxyvitamin D following vitamin D3 intervention are associated with favorable changes in metabolites involved in endothelial protection, enhanced innate immunity and improved mitochondrial function.
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Affiliation(s)
- Karin Amrein
- Division of Endocrinology and Diabetology, Medical University of Graz, Graz, Austria
| | - Jessica A Lasky-Su
- Channing Division of Network Medicine, Brigham and Women's Hospital, USA
| | - Harald Dobnig
- Thyroid Endocrinology Osteoporosis Institute Dobnig, Graz, Austria
| | - Kenneth B Christopher
- Division of Renal Medicine, Channing Division of Network Medicine, Brigham and Women's Hospital, USA.
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12
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Janes H, Brown MD, Glidden DV, Mayer KH, Buchbinder SP, McMahan VM, Schechter M, Guanira J, Casapia M. Evaluating the impact of policies recommending PrEP to subpopulations of men and transgender women who have sex with men based on demographic and behavioral risk factors. PLoS One 2019; 14:e0222183. [PMID: 31536518 PMCID: PMC6752862 DOI: 10.1371/journal.pone.0222183] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2018] [Accepted: 08/23/2019] [Indexed: 11/26/2022] Open
Abstract
INTRODUCTION Developing guidelines to inform the use of antiretroviral pre-exposure prophylaxis (PrEP) for HIV prevention in resource-limited settings must necessarily be informed by considering the resources and infrastructure needed for PrEP delivery. We describe an approach that identifies subpopulations of cisgender men who have sex with men (MSM) and transgender women (TGW) to prioritize for the rollout of PrEP in resource-limited settings. METHODS We use data from the iPrEx study, a multi-national phase III study of PrEP for HIV prevention in MSM/TGW, to build statistical models that identify subpopulations at high risk of HIV acquisition without PrEP, and with high expected PrEP benefit. We then evaluate empirically the population impact of policies recommending PrEP to these subpopulations, and contrast these with existing policies. RESULTS A policy recommending PrEP to a high risk subpopulation of MSM/TGW reporting condomless receptive anal intercourse over the last 3 months (estimated 3.3% 1-year HIV incidence) yields an estimated 1.95% absolute reduction in 1-year HIV incidence at the population level, and 3.83% reduction over 2 years. Importantly, such a policy requires rolling PrEP out to just 59.7% of MSM/TGW in the iPrEx population. We find that this policy is identical to that which prioritizes MSM/TGW with high expected PrEP benefit. It is estimated to achieve nearly the same reduction in HIV incidence as the PrEP guideline put forth by the US Centers for Disease Control, which relies on the measurement of more behavioral risk factors and which would recommend PrEP to a larger subset of the MSM/TGW population (86% vs. 60%). CONCLUSIONS These findings may be used to focus future mathematical modelling studies of PrEP in resource-limited settings on prioritizing PrEP for high-risk subpopulations of MSM/TGW. The statistical approach we took could be employed to develop PrEP policies for other at-risk populations and resource-limited settings.
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Affiliation(s)
- Holly Janes
- Vaccine and Infectious Disease Division, Fred Hutchinson Cancer Research Center, Seattle, Washington, United States of America
| | - Marshall D. Brown
- Vaccine and Infectious Disease Division, Fred Hutchinson Cancer Research Center, Seattle, Washington, United States of America
| | - David V. Glidden
- Department of Epidemiology and Biostatistics, University of California School of Medicine, San Francisco, California, United States of America
| | - Kenneth H. Mayer
- Division of Infectious Diseases, Beth Israel Deaconess Medical Center, and The Fenway Institute, Fenway Health, Boston, Massachusetts, United States of America
| | - Susan P. Buchbinder
- Bridge HIV, San Francisco Department of Public Health, San Francisco, California, United States of America
| | - Vanessa M. McMahan
- Department of Medicine, University of Washington, Seattle, Washington, United States of America
| | - Mauro Schechter
- Projeto Praça Onze, Universidade Federal do Rio de Janeiro, Rio de Janeiro, Brazil
| | - Juan Guanira
- Asociación Civil Impacta Salud y Educación, Lima, Peru
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13
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Chou R, Evans C, Hoverman A, Sun C, Dana T, Bougatsos C, Grusing S, Korthuis PT. Preexposure Prophylaxis for the Prevention of HIV Infection: Evidence Report and Systematic Review for the US Preventive Services Task Force. JAMA 2019; 321:2214-2230. [PMID: 31184746 DOI: 10.1001/jama.2019.2591] [Citation(s) in RCA: 160] [Impact Index Per Article: 32.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
IMPORTANCE Effective prevention strategies for HIV infection are an important public health priority. Preexposure prophylaxis (PrEP) involves use of antiretroviral therapy (ART) daily or before and after sex to decrease risk of acquiring HIV infection. OBJECTIVE To synthesize the evidence on the benefits and harms of PrEP, instruments for predicting incident HIV infection, and PrEP adherence to inform the US Preventive Services Task Force. DATA SOURCES Ovid MEDLINE, the Cochrane Central Register of Controlled Trials, the Cochrane Database of Systematic Reviews, and EMBASE through June 2018, with surveillance through January 2019. STUDY SELECTION English-language placebo-controlled randomized clinical trials of oral PrEP with tenofovir disoproxil fumarate/emtricitabine or tenofovir disoproxil fumarate monotherapy; studies on the diagnostic accuracy of instruments for predicting incident HIV infection; and studies on PrEP adherence. DATA EXTRACTION AND SYNTHESIS Dual review of titles and abstracts, full-text articles, study quality, and data abstraction. Data were pooled using the Dersimonian and Laird random-effects model for effects of PrEP on HIV infection, mortality, and harms. MAIN OUTCOMES AND MEASURES HIV acquisition, mortality, and harms; adherence to PrEP; and diagnostic test accuracy and discrimination. RESULTS Fourteen RCTs (N = 18 837), 8 observational studies (N = 3884), and 7 studies of diagnostic accuracy (N = 32 279) were included. PrEP was associated with decreased risk of HIV infection vs placebo or no PrEP after 4 months to 4 years (11 trials; relative risk [RR], 0.46 [95% CI, 0.33-0.66]; I2 = 67%; absolute risk reduction [ARD], -2.0% [95% CI, -2.8% to -1.2%]). Greater adherence was associated with greater efficacy (RR with adherence ≥70%, 0.27 [95% CI, 0.19-0.39]; I2 = 0%) in 6 trials. PrEP was associated with an increased risk of renal adverse events (12 trials; RR, 1.43 [95% CI, 1.18-1.75]; I2 = 0%; ARD, 0.56% [95% CI, 0.09%-1.04%]) and gastrointestinal adverse events (12 trials; RR, 1.63 [95% CI, 1.26-2.11]; I2 = 43%; ARD, 1.95% [95% CI, 0.48%-3.43%]); most adverse events were mild and reversible. Instruments for predicting incident HIV infection had moderate discrimination (area under the receiver operating characteristic curve, 0.49-0.72) and require further validation. Adherence to PrEP in the United States in men who have sex with men varied widely (22%-90%). CONCLUSIONS AND RELEVANCE In adults at increased risk of HIV infection, PrEP with oral tenofovir disoproxil fumarate monotherapy or tenofovir disoproxil fumarate/emtricitabine was associated with decreased risk of acquiring HIV infection compared with placebo or no PrEP, although effectiveness decreased with suboptimal adherence.
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Affiliation(s)
- Roger Chou
- Pacific Northwest Evidence-based Practice Center, Department of Medical Informatics and Clinical Epidemiology, Oregon Health & Science University, Portland
- Division of General Internal Medicine and Geriatrics, Oregon Health & Science University, Portland
| | - Christopher Evans
- Division of General Internal Medicine and Geriatrics, Oregon Health & Science University, Portland
| | - Adam Hoverman
- Oregon Health & Science University-Portland State University School of Public Health, Portland
| | - Christina Sun
- Oregon Health & Science University-Portland State University School of Public Health, Portland
| | - Tracy Dana
- Pacific Northwest Evidence-based Practice Center, Department of Medical Informatics and Clinical Epidemiology, Oregon Health & Science University, Portland
| | - Christina Bougatsos
- Pacific Northwest Evidence-based Practice Center, Department of Medical Informatics and Clinical Epidemiology, Oregon Health & Science University, Portland
| | - Sara Grusing
- Pacific Northwest Evidence-based Practice Center, Department of Medical Informatics and Clinical Epidemiology, Oregon Health & Science University, Portland
| | - P Todd Korthuis
- Division of General Internal Medicine and Geriatrics, Oregon Health & Science University, Portland
- Oregon Health & Science University-Portland State University School of Public Health, Portland
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14
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Levy E, Gidron Y, Deschepper R, Olley BO, Ponnet K. Effects of a computerized psychological inoculation intervention on condom use tendencies in sub Saharan and Caucasian students: two feasibility trials. Health Psychol Behav Med 2019; 7:160-178. [PMID: 34040845 PMCID: PMC8114391 DOI: 10.1080/21642850.2019.1614928] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2019] [Accepted: 04/29/2019] [Indexed: 01/05/2023] Open
Abstract
Objective: An effective method for preventing the Human Immunodeficiency Virus (HIV) is condom use. Yet, research shows limited effects of education on increasing condom use. This research examined the effects of psychological inoculation (PI) versus education on condom use -barriers and -tendencies, using a fully automatized online system. Design: Two randomized controlled trials. In Study 1, 59 Sub-Saharan students were included while Study 2 20 European students were included. In both studies, participants were randomly assigned to PI or control conditions. In Study 2, we additionally matched pairs on gender and condom barriers. In the PI, participants received challenging sentences they had to refute. Main outcome measures: An indirect condom use test (I-CUTE) and a condom use barriers questionnaire, assessed at baseline and a month later. Results: In Study 1, a significant increase in I-CUTE scores and no change in barriers was found in the PI condition. Controls did not change on either outcome. In Study 2, two sub-scales of condom barriers (concerning partner and satisfaction) were significantly decreased in the PI group, while in controls, barriers significantly increased over time. In both groups, I-CUTE scores tended to increase. Conclusions: These results replicate previous studies and extend them to a fully automatized system without counselors.
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Affiliation(s)
- Einav Levy
- Faculty of Medicine and Pharmacy, Free University of Brussels, Brussels, Belgium
- The Israeli School of Humanitarian Action, Tel Aviv, Israel
| | - Yori Gidron
- The Israeli School of Humanitarian Action, Tel Aviv, Israel
- SCALab, Lille3 University, Lille, France
| | - Reginald Deschepper
- Faculty of Medicine and Pharmacy, Free University of Brussels, Brussels, Belgium
| | | | - Koen Ponnet
- Department of Communication Sciences, imec-mict-Ghent University, Ghent, Belgium
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15
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Taking stock of the present and looking ahead: envisioning challenges in the design of future HIV prevention efficacy trials. Lancet HIV 2019; 6:e475-e482. [PMID: 31078451 DOI: 10.1016/s2352-3018(19)30133-x] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2018] [Revised: 02/28/2019] [Accepted: 03/25/2019] [Indexed: 12/12/2022]
Abstract
Despite the recent success of antiretrovirals for HIV prevention, additional, more effective, or more acceptable biomedical interventions will ultimately be needed to end the HIV epidemic. Designing clinical trials to evaluate the efficacy of new products that reduce HIV infection risk is challenging because of the existence of highly effective interventions to prevent HIV. However, the implementation of these interventions is uneven, and the fact that multiple HIV prevention efficacy trials are currently evaluating new products means the field confronts uncertainty in the emerging standard of prevention. In this Viewpoint, we take stock of the current state of HIV prevention, and subsequently discuss the key challenges in designing future trials to evaluate the next generation of HIV prevention products. We also highlight gaps in the knowledge base that need to be addressed to advance the design of research. Future trials are tenable, even in the context of existing and effective interventions, and should involve careful statistical approaches and multidisciplinary collaborative design.
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Oldenburg CE, Seage GR, Tanser F, De Gruttola V, Mayer KH, Mimiaga MJ, Bor J, Bärnighausen T. Antiretroviral Therapy and Mortality in Rural South Africa: A Comparison of Causal Modeling Approaches. Am J Epidemiol 2018; 187:1772-1779. [PMID: 29584868 PMCID: PMC6070080 DOI: 10.1093/aje/kwy065] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2017] [Accepted: 03/15/2018] [Indexed: 11/22/2022] Open
Abstract
Estimation of causal effects from observational data is a primary goal of epidemiology. The use of multiple methods with different assumptions relating to exchangeability improves causal inference by demonstrating robustness across assumptions. We estimated the effect of antiretroviral therapy (ART) on mortality in rural KwaZulu-Natal, South Africa, from 2007 to 2011, using 2 methods with substantially different assumptions: the regression discontinuity design (RDD) and inverse-probability–weighted (IPW) marginal structural models (MSMs). The RDD analysis took advantage of a CD4-cell-count–based threshold for ART initiation (200 cells/μL). The 2 methods yielded consistent but nonidentical results for the effect of immediate initiation of ART (RDD intention-to-treat hazard ratio (HR) = 0.66, 95% confidence interval (CI): 0.35, 1.26; RDD complier average causal effect HR = 0.56, 95% CI: 0.41, 0.77; IPW MSM HR = 0.49, 95% CI: 0.42, 0.58). Although RDD and IPW MSM estimates have distinct identifying assumptions, strengths, and limitations in terms of internal and external validity, results in this application were similar. The differences in modeling approaches and the external validity of each method may explain the minor differences in effect estimates. The overall consistency of the results lends support for causal inference about the effect of ART on mortality from these data.
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Affiliation(s)
- Catherine E Oldenburg
- Department of Epidemiology, Harvard T.H. Chan School of Public Health, Boston, Massachusetts
- Francis I. Proctor Foundation, University of California, San Francisco, San Francisco, California
| | - George R Seage
- Department of Epidemiology, Harvard T.H. Chan School of Public Health, Boston, Massachusetts
| | - Frank Tanser
- Africa Health Research Institute, Durban and Somkhele, South Africa
- Department of Epidemiology, Faculty of Health Sciences, University of KwaZulu-Natal, Durban, South Africa
| | - Victor De Gruttola
- Department of Biostatistics, Harvard T.H. Chan School of Public Health, Boston, Massachusetts
| | - Kenneth H Mayer
- The Fenway Institute, Fenway Community Health, Boston, Massachusetts
- Department of Global Health and Population, Harvard T.H. Chan School of Public Health, Boston, Massachusetts
- Department of Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts
| | - Matthew J Mimiaga
- Department of Behavioral and Social Sciences and Department of Epidemiology, Institute for Community Health Promotion, School of Public Health, Brown University, Providence, Rhode Island
| | - Jacob Bor
- Department of Global Health, School of Public Health, Boston University, Boston, Massachusetts
| | - Till Bärnighausen
- Africa Health Research Institute, Durban and Somkhele, South Africa
- Department of Global Health and Population, Harvard T.H. Chan School of Public Health, Boston, Massachusetts
- Research Department of Infection and Population Health, Centre for Sexual Health, University College London, London, United Kingdom
- Heidelberg Institute of Public Health, University of Heidelberg, Heidelberg, Germany
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17
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Janes H, Corey L, Ramjee G, Carpp LN, Lombard C, Cohen MS, Gilbert PB, Gray GE. Weighing the Evidence of Efficacy of Oral PrEP for HIV Prevention in Women in Southern Africa. AIDS Res Hum Retroviruses 2018; 34:645-656. [PMID: 29732896 PMCID: PMC6080090 DOI: 10.1089/aid.2018.0031] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023] Open
Abstract
As oral tenofovir-based regimens for preexposure prophylaxis (PrEP) are adopted as standard of care for HIV prevention, their utilization in clinical trials among women in southern Africa will require an accurate estimate of oral PrEP efficacy in this population. This information is critical for women in choosing this prevention strategy, and in public health policy making. Estimates of the efficacy of oral PrEP regimens containing tenofovir have varied widely across trials that enrolled women, with some studies reporting high efficacy and others reporting no efficacy. Although poor adherence is strongly associated with lack of efficacy, other factors, such as mode of transmission (sexual vs. parenteral), predominant HIV subtype (C vs. non-C), intensity of exposure, and percentage of stable serodiscordant couples, may also contribute to the variation in efficacy estimates. In this article, we evaluate the evidence for PrEP efficacy in women and propose potential explanations for the observed differences in efficacy among studies. Our review emphasizes the need to continue to refine estimates of efficacy and effectiveness of tenofovir-based oral PrEP so as to best develop the next generation of HIV prevention tools, and to inform public policies directed toward HIV prevention.
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Affiliation(s)
- Holly Janes
- Vaccine and Infectious Disease Division, Fred Hutchinson Cancer Research Center, Seattle, Washington
- Department of Biostatistics, University of Washington, Seattle, Washington
| | - Lawrence Corey
- Vaccine and Infectious Disease Division, Fred Hutchinson Cancer Research Center, Seattle, Washington
- Department of Medicine, University of Washington, Seattle, Washington
- Department of Laboratory Medicine, University of Washington, Seattle, Washington
| | - Gita Ramjee
- HIV Prevention Research Unit, South African Medical Research Council, Durban, South Africa
- Department of Epidemiology and Population Health, London School of Hygiene and Tropical Medicine, London, United Kingdom
- Department of Global Health, University of Washington, Seattle, Washington
| | - Lindsay N. Carpp
- Vaccine and Infectious Disease Division, Fred Hutchinson Cancer Research Center, Seattle, Washington
| | - Carl Lombard
- Biostatistics Unit, Medical Research Council of South Africa, Cape Town, South Africa
| | - Myron S. Cohen
- Institute for Global Health and Infectious Diseases, University of North Carolina, Chapel Hill, North Carolina
| | - Peter B. Gilbert
- Vaccine and Infectious Disease Division, Fred Hutchinson Cancer Research Center, Seattle, Washington
- Department of Biostatistics, University of Washington, Seattle, Washington
| | - Glenda E. Gray
- Perinatal HIV Research Unit, University of the Witwatersrand, Chris Hani Baragwanath Academic Hospital, Johannesburg, South Africa
- Office of the President, South African Medical Research Council, Cape Town, South Africa
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18
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Westreich D, Edwards JK, Rogawski ET, Hudgens MG, Stuart EA, Cole SR. Causal Impact: Epidemiological Approaches for a Public Health of Consequence. Am J Public Health 2018; 106:1011-2. [PMID: 27153017 DOI: 10.2105/ajph.2016.303226] [Citation(s) in RCA: 37] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Affiliation(s)
- Daniel Westreich
- Daniel Westreich, Jessie K. Edwards, and Stephen R. Cole are with the Department of Epidemiology, Gillings School of Global Public Health, University of North Carolina-Chapel Hill. Elizabeth T. Rogawski is with the Division of Infectious Diseases and International Health, University of Virginia, Charlottesville. Michael G. Hudgens is with the Department of Biostatistics, Gillings School of Global Public Health, University of North Carolina-Chapel Hill. Elizabeth A. Stuart is with the Departments of Biostatistics, Health Policy and Management, and Mental Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD
| | - Jessie K Edwards
- Daniel Westreich, Jessie K. Edwards, and Stephen R. Cole are with the Department of Epidemiology, Gillings School of Global Public Health, University of North Carolina-Chapel Hill. Elizabeth T. Rogawski is with the Division of Infectious Diseases and International Health, University of Virginia, Charlottesville. Michael G. Hudgens is with the Department of Biostatistics, Gillings School of Global Public Health, University of North Carolina-Chapel Hill. Elizabeth A. Stuart is with the Departments of Biostatistics, Health Policy and Management, and Mental Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD
| | - Elizabeth T Rogawski
- Daniel Westreich, Jessie K. Edwards, and Stephen R. Cole are with the Department of Epidemiology, Gillings School of Global Public Health, University of North Carolina-Chapel Hill. Elizabeth T. Rogawski is with the Division of Infectious Diseases and International Health, University of Virginia, Charlottesville. Michael G. Hudgens is with the Department of Biostatistics, Gillings School of Global Public Health, University of North Carolina-Chapel Hill. Elizabeth A. Stuart is with the Departments of Biostatistics, Health Policy and Management, and Mental Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD
| | - Michael G Hudgens
- Daniel Westreich, Jessie K. Edwards, and Stephen R. Cole are with the Department of Epidemiology, Gillings School of Global Public Health, University of North Carolina-Chapel Hill. Elizabeth T. Rogawski is with the Division of Infectious Diseases and International Health, University of Virginia, Charlottesville. Michael G. Hudgens is with the Department of Biostatistics, Gillings School of Global Public Health, University of North Carolina-Chapel Hill. Elizabeth A. Stuart is with the Departments of Biostatistics, Health Policy and Management, and Mental Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD
| | - Elizabeth A Stuart
- Daniel Westreich, Jessie K. Edwards, and Stephen R. Cole are with the Department of Epidemiology, Gillings School of Global Public Health, University of North Carolina-Chapel Hill. Elizabeth T. Rogawski is with the Division of Infectious Diseases and International Health, University of Virginia, Charlottesville. Michael G. Hudgens is with the Department of Biostatistics, Gillings School of Global Public Health, University of North Carolina-Chapel Hill. Elizabeth A. Stuart is with the Departments of Biostatistics, Health Policy and Management, and Mental Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD
| | - Stephen R Cole
- Daniel Westreich, Jessie K. Edwards, and Stephen R. Cole are with the Department of Epidemiology, Gillings School of Global Public Health, University of North Carolina-Chapel Hill. Elizabeth T. Rogawski is with the Division of Infectious Diseases and International Health, University of Virginia, Charlottesville. Michael G. Hudgens is with the Department of Biostatistics, Gillings School of Global Public Health, University of North Carolina-Chapel Hill. Elizabeth A. Stuart is with the Departments of Biostatistics, Health Policy and Management, and Mental Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD
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Abstract
PURPOSE OF REVIEW Models of implementation of known-effective interventions for HIV prevention indicate that an efficacious vaccine to prevent HIV infection would be critical for controlling the HIV pandemic. Key issues in the design of future HIV vaccine trials are: first, how to develop reliable immunological correlates of vaccine efficacy, second, how to down-select candidate vaccine regimens into efficacy trials, and third, how to learn about vaccine efficacy in the context of the evolving HIV prevention landscape. RECENT FINDINGS Whereas in the past phase-I/-II HIV vaccine trials have addressed the first and second points using a small set of immunological assays and readouts, recently they have used a battery of assays with highly multivariate readouts. In addition, systems vaccinology studies of other pathogens measuring PBMC transcriptomics and other immunological features pre- and postfirst vaccination are demonstrating value, for example, providing discoveries that preimmunization and early postimmunization cell population markers can predict the influenza-specific antibody titer that is a correlate of vaccine protection. The HIV prevention landscape continues to evolve, and the design and analysis of vaccine trials is evolving alongside, to accommodate increasingly dynamic and regional standards of HIV prevention. SUMMARY Development of interpretable and robust functional assays, in addition to the associated bioinformatics and statistical analytic tools, is needed to improve the assessment of correlates of protection in efficacy trials and the down-selection of candidate vaccine regimens into efficacy trials. Moreover, high-priority trials should integrate systems vaccinology, including the analysis of prevaccination and early postvaccination markers.
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20
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Karita E, Nsanzimana S, Ndagije F, Wall KM, Mukamuyango J, Mugwaneza P, Remera E, Raghunathan PL, Bayingana R, Kayitenkore K, Bekan-Homawoo B, Tichacek A, Allen S. Implementation and Operational Research: Evolution of Couples' Voluntary Counseling and Testing for HIV in Rwanda: From Research to Public Health Practice. J Acquir Immune Defic Syndr 2016; 73:e51-e58. [PMID: 27741033 PMCID: PMC5367509 DOI: 10.1097/qai.0000000000001138] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2016] [Accepted: 07/14/2016] [Indexed: 01/18/2023]
Abstract
BACKGROUND Couples' voluntary HIV counseling and testing (CVCT) is a WHO-recommended intervention for prevention of heterosexual HIV transmission which very few African couples have received. We report the successful nationwide implementation of CVCT in Rwanda. METHODS From 1988 to 1994 in Rwanda, pregnant and postpartum women were tested for HIV and requested testing for their husbands. Partner testing was associated with more condom use and lower HIV and sexually transmitted infection rates, particularly among HIV-discordant couples. After the 1994 genocide, the research team continued to refine CVCT procedures in Zambia. These were reintroduced to Rwanda in 2001 and continually tested and improved. In 2003, the Government of Rwanda (GoR) established targets for partner testing among pregnant women, with the proportion rising from 16% in 2003 to 84% in 2008 as the prevention of mother-to-child transmission program expanded to >400 clinics. In 2009, the GoR adopted joint posttest counseling procedures, and in 2010 a quarterly follow-up program for discordant couples was established in government clinics with training and technical assistance. An estimated 80%-90% of Rwandan couples have now been jointly counseled and tested resulting in prevention of >70% of new HIV infections. CONCLUSIONS Rwanda is the first African country to have established CVCT as standard of care in antenatal care. More than 20 countries have sent providers to Rwanda for CVCT training. To duplicate Rwanda's success, training and technical assistance must be part of a coordinated effort to set national targets, timelines, indicators, and budgets. Governments, bilateral, and multilateral funding agencies must jointly prioritize CVCT for prevention of new HIV infections.
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Affiliation(s)
- Etienne Karita
- Project San Francisco (PSF), Kigali, Rwanda
- Department of Pathology & Laboratory Medicine, Emory University School of Medicine, Atlanta, GA
| | | | - Felix Ndagije
- US Centers for Disease Control and Prevention (CDC), Kigali, Rwanda
| | - Kristin M. Wall
- Department of Epidemiology, School of Public Health, Emory University, Atlanta, GA
| | - Jeannine Mukamuyango
- Project San Francisco (PSF), Kigali, Rwanda
- Department of Pathology & Laboratory Medicine, Emory University School of Medicine, Atlanta, GA
| | | | - Eric Remera
- Rwanda Biomedical Center (RBC), Kigali, Rwanda
| | - Pratima L. Raghunathan
- US Centers for Disease Control and Prevention, Center for Global Health, Atlanta, GA; and
| | - Roger Bayingana
- Project San Francisco (PSF), Kigali, Rwanda
- Department of Pathology & Laboratory Medicine, Emory University School of Medicine, Atlanta, GA
| | - Kayitesi Kayitenkore
- Project San Francisco (PSF), Kigali, Rwanda
- Department of Pathology & Laboratory Medicine, Emory University School of Medicine, Atlanta, GA
| | - Brigitte Bekan-Homawoo
- Project San Francisco (PSF), Kigali, Rwanda
- Department of Pathology & Laboratory Medicine, Emory University School of Medicine, Atlanta, GA
| | - Amanda Tichacek
- Department of Pathology & Laboratory Medicine, Emory University School of Medicine, Atlanta, GA
| | - Susan Allen
- Department of Pathology & Laboratory Medicine, Emory University School of Medicine, Atlanta, GA
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21
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Murnane PM, Coley RY, Baeten JM. Murnane, Coley, and Baeten respond to "every good randomization deserves observation". Am J Epidemiol 2015; 182:861-2. [PMID: 26487341 DOI: 10.1093/aje/kwv201] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2015] [Accepted: 07/16/2015] [Indexed: 11/14/2022] Open
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Westreich D, Edwards JK. Invited commentary: every good randomization deserves observation. Am J Epidemiol 2015; 182:857-60. [PMID: 26487342 DOI: 10.1093/aje/kwv200] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2015] [Accepted: 06/05/2015] [Indexed: 02/01/2023] Open
Abstract
Preexposure prophylaxis (PrEP) is a promising approach to prevention of human immunodeficiency virus (HIV) transmission, in which an HIV-negative individual takes a single daily dose of an antiretroviral drug so that, if exposed to HIV, an active antiretroviral drug is already present in his or her system. In this issue of the Journal, Murnane et al. (Am J Epidemiol. 2015;182(10):848-856) use data from the Partners PrEP Study (Kenya and Uganda, 2008-2011) to estimate the efficacy of PrEP under perfect adherence. We discuss Murnane et al.'s work and then examine the larger issues of generalizability or transportability of findings from a randomized trial to a new setting when adherence to an intervention determines its effectiveness. We discuss sufficient conditions for generalizability and use causal directed acyclic graphs to show how these assumptions might play out when trials are used to make inferences about the effect of PrEP in current and future real-world target populations.
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