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Horvath KJ, Helm JL, Black A, Chase GE, Ma J, Klaphake J, Garcia-Myers K, Anderson PL, Baker JV. A Pilot Randomized Controlled Trial of an mHealth Intervention to Improve PrEP Adherence Among Young Sexual Minority Men. AIDS Behav 2024; 28:2804-2820. [PMID: 38816592 DOI: 10.1007/s10461-024-04374-3] [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] [Accepted: 05/08/2024] [Indexed: 06/01/2024]
Abstract
This randomized controlled study assessed the feasibility, acceptability, and preliminary impact of the PrEP iT! mHealth intervention designed to improve PrEP adherence among young men who have sex with men (YMSM). A national sample of 80 YMSM in the U.S. (Mage = 25 years; 54% racial/ethnic minority), recruited through social media ads, were randomized to either the PrEP iT! or usual PrEP care conditions. Participants completed online surveys and submitted self-collected dried blood sample (DBS) data as measures of PrEP adherence. Differences in PrEP adherence across treatment arms and between participants with high versus low engagement in PrEP iT! were assessed. Retention was high at the three (94%) and six (93%) month assessment, and participants in PrEP iT! reported satisfactory acceptability of the intervention. There were no significant differences in self-reported or DBS-derived PrEP adherence between randomized groups. However, YMSM in the PrEP iT! group with high PrEP adherence (the equivalent of four or more doses/week through self-report and DBS-derived measures) demonstrated significantly higher engagement in the intervention than those with low PrEP adherence (the equivalent of 3 or fewer doses/week). Overall, the PrEP iT! intervention demonstrated strong feasibility and acceptability. The finding that high PrEP iT! intervention engagement was associated with protective levels of PrEP adherence suggests it is a viable adherence support tool that should be further evaluated in definitive trial among YMSM who need basic support, or as part of a more comprehensive adherence support package for those who need greater assistance.Trial registration Clinical Trials # NCT04509076 (registered August 10, 2020).
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Affiliation(s)
- Keith J Horvath
- Department of Psychology, College of Sciences, San Diego State University, 5500 Campanile Drive, San Diego, CA, 92182, USA.
- San Diego State University, University of California San Diego Joint Doctoral Program in Clinical Psychology, 6363 Alvarado Court, San Diego, CA, 92120, USA.
| | - Jonathan L Helm
- Department of Psychology, College of Sciences, San Diego State University, 5500 Campanile Drive, San Diego, CA, 92182, USA
| | - Ashley Black
- Division of Infectious Diseases, Hennepin Healthcare Research Institute, 701 Park Avenue, Minneapolis, MN, 55415, USA
| | - Gregory E Chase
- Department of Psychology, University of North Carolina at Greensboro, 296 Eberhart Building, P.O. Box 26170, Greensboro, NC, 27402, USA
| | - Junye Ma
- San Diego State University, University of California San Diego Joint Doctoral Program in Clinical Psychology, 6363 Alvarado Court, San Diego, CA, 92120, USA
| | - Jonathan Klaphake
- Division of Infectious Diseases, Hennepin Healthcare Research Institute, 701 Park Avenue, Minneapolis, MN, 55415, USA
| | - Kelly Garcia-Myers
- Division of Infectious Diseases, Hennepin Healthcare Research Institute, 701 Park Avenue, Minneapolis, MN, 55415, USA
| | - Peter L Anderson
- Skaggs School of Pharmacy and Pharmaceutical Sciences, University of Colorado Anschutz Medical Campus, 12850 East Montview Boulevard, Aurora, CO, 80045, USA
| | - Jason V Baker
- Division of Infectious Diseases, Hennepin Healthcare Research Institute, 701 Park Avenue, Minneapolis, MN, 55415, USA
- Department of Medicine, University of Minnesota, 401 East River Parkway VCRC 1st Floor, Suite 131, Minneapolis, MN, 55455, USA
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2
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Garcia C, Rehman N, Matos-Silva J, Deng J, Ghandour S, Huang Z, Mbuagbaw L. Interventions to Improve Adherence to Oral Pre-exposure Prophylaxis: A Systematic Review and Network Meta-analysis. AIDS Behav 2024; 28:2534-2546. [PMID: 38814406 DOI: 10.1007/s10461-024-04365-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/30/2024] [Indexed: 05/31/2024]
Abstract
For people at risk of HIV infection, pre-exposure prophylaxis (PrEP) can reduce the risk of infection in anticipation of exposure to HIV. The effectiveness of PrEP relies upon a user's adherence to their PrEP regimen. We sought to assess the effect of PrEP adherence interventions compared to usual care or another intervention for people at risk of HIV. We searched electronic databases from 2010 onwards for randomized controlled trials (RCTs) involving persons at risk of HIV randomized to an adherence promoting intervention vs usual care or another intervention. We used network meta-analyses to compare PrEP adherence for all participant populations. Certainty of evidence was assessed using Confidence in Network Meta-Analysis (CINeMA). 21 trials (N = 4917) were included in qualitative analysis (19 in network meta-analyses (N = 4101)). HIV self-testing interventions with adherence feedback elements improved adherence compared to usual care (risk ratio (RR): 1.83, 95%CI 1.19, 2.82). In contrast, HIV self-testing alone was inferior to HIV self-testing with adherence feedback (RR: 0.58, 95%CI 0.37-0.92). Reminders alone also were inferior to HIV self-testing with adherence feedback on adherence (RR: 0.53, 95%CI 0.34-0.84) and had similar effects on adherence as usual care (RR: 0.98, 95%CI: 0.86-1.11). Interventions with only one component were inferior for adherence than those with two components (RR: 0.74, 95%CI 0.62-0.88) and those with three components (RR: 0.78, 95%CI 0.65-0.93). The certainty of evidence was moderate for HIV self-testing plus adherence feedback and interventions with two or three components. When designing future PrEP adherence interventions, we recommend strategies with more than one but no more than three components.
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Affiliation(s)
- Cristian Garcia
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON, Canada.
- Temerty Faculty of Medicine, University of Toronto, Toronto, ON, Canada.
| | - Nadia Rehman
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON, Canada
| | - Jéssyca Matos-Silva
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON, Canada
| | - Jiawen Deng
- Temerty Faculty of Medicine, University of Toronto, Toronto, ON, Canada
| | - Sara Ghandour
- Temerty Faculty of Medicine, University of Toronto, Toronto, ON, Canada
| | - Zhongyu Huang
- Temerty Faculty of Medicine, University of Toronto, Toronto, ON, Canada
| | - Lawrence Mbuagbaw
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON, Canada
- Department of Anesthesia, McMaster University, Hamilton, ON, Canada
- Department of Pediatrics, McMaster University, Hamilton, ON, Canada
- Biostatistics Unit, Father Sean O'Sullivan Research Centre, St Joseph's Healthcare, Hamilton, ON, Canada
- Division of Epidemiology and Biostatistics, Department of Global Health, Stellenbosch University, Cape Town, South Africa
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3
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Kamitani E, Peng Y, Hopkins D, Higa DH, Mullins MM. A Community Guide Systematic Review: Digital HIV Pre-Exposure Prophylaxis Interventions. Am J Prev Med 2024; 67:303-310. [PMID: 38367928 PMCID: PMC11260538 DOI: 10.1016/j.amepre.2024.02.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/08/2023] [Revised: 02/09/2024] [Accepted: 02/09/2024] [Indexed: 02/19/2024]
Abstract
INTRODUCTION HIV preexposure prophylaxis (PrEP) is highly effective when taken as prescribed. Digital health adherence interventions have been identified as effective for improving antiretroviral therapy adherence among people with HIV, but limited evidence exists for PrEP adherence interventions among people without HIV. The purpose of this Community Guide systematic review was to present the characteristics and effectiveness of digital PrEP adherence interventions. METHODS The author searched the CDC HIV Prevention Research Synthesis cumulative database for digital health interventions with PrEP adherence outcomes published in peer-reviewed journals from 2000 to 2022. Studies with comparison arms or pre-post data evaluating interventions in high-income countries were included. Two reviewers independently screened citations, extracted data, conducted risk of bias assessment, and resolved discrepancies through discussion. Summary effect estimates were calculated using median and interquartile interval. RESULTS Nine studies were included and all focused on gay, bisexual, and other men who have sex with men. Eight studies were U.S.-based while the other was conducted in the Netherlands. Five were randomized control trials and four were pre-/post studies. All studies showed improved adherence in the intervention arms compared with comparison groups or preintervention data. One study also reported improvement in PrEP care retention. DISCUSSION Digital health adherence interventions with different strategies to improve PrEP and HIV-related outcomes were identified. The small number of studies identified is a limitation. Findings from this review served as the basis for the Community Preventive Services Task Force recommendation to use these interventions to increase PrEP adherence to prevent HIV infection.
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Affiliation(s)
- Emiko Kamitani
- Division of HIV Prevention, National Center for HIV/AIDS, Viral Hepatitis, STD, & TB Prevention, the Centers for Disease Control and Prevention (CDC), Atlanta, GA 30329-4027.
| | - Yinan Peng
- Community Guide Program, Office of Science, CDC, Atlanta, GA 30329-4027
| | - David Hopkins
- Community Guide Program, Office of Science, CDC, Atlanta, GA 30329-4027
| | - Darrel H Higa
- Division of HIV Prevention, National Center for HIV/AIDS, Viral Hepatitis, STD, & TB Prevention, the Centers for Disease Control and Prevention (CDC), Atlanta, GA 30329-4027
| | - Mary M Mullins
- Division of HIV Prevention, National Center for HIV/AIDS, Viral Hepatitis, STD, & TB Prevention, the Centers for Disease Control and Prevention (CDC), Atlanta, GA 30329-4027
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4
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Haines M, Vandyk A, Skidmore B, Orser L, O'Byrne P. A Systematic Review of Oral Pre-exposure Prophylaxis HIV Adherence Interventions. J Assoc Nurses AIDS Care 2024; 35:309-324. [PMID: 38564213 PMCID: PMC11195928 DOI: 10.1097/jnc.0000000000000460] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/04/2024]
Abstract
ABSTRACT Clinical trials of pre-exposure prophylaxis (PrEP) to prevent HIV infection have established its efficacy as upwards of 99%. Despite this, the effectiveness of this medication has been shown to be diminished by individual factors, such as medication adherence. We completed a systematic review to identify and describe interventions to improve oral PrEP adherence. Overall, 16 articles were located. Two of the articles reported on results from the same trial and were collapsed for analysis, bringing the total to 15 studies. Twelve unique PrEP adherence interventions were tested, with the most common intervention being the use of mobile phone technology, which was used in 7 (46%) of the studies. Ten (67%) studies found that medication adherence improved when participants received an intervention to support adherence. Adherence intervention strategies effectively improved PrEP adherence. Further research into PrEP adherence interventions is warranted, particularly among diverse groups.
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Affiliation(s)
- Marlene Haines
- Marlene Haines, RN, BHSc, BScN, is a Research Assistant, School of Nursing, University of Ottawa, Ottawa, Canada ( )
- Amanda Vandyk, RN, PhD, is an Associate Professor, School of Nursing, University of Ottawa, Ottawa, Canada
- Becky Skidmore, MLIS, is an Information Specialist, Ottawa Hospital Research Institute, Ottawa, Canada
- Lauren Orser, RN, is a Research Assistant, School of Nursing, University of Ottawa, Ottawa, Canada
- Patrick O'Byrne, RN-EC, PhD, is a Full Professor, School of Nursing, University of Ottawa, Ottawa, Canada
| | - Amanda Vandyk
- Marlene Haines, RN, BHSc, BScN, is a Research Assistant, School of Nursing, University of Ottawa, Ottawa, Canada ( )
- Amanda Vandyk, RN, PhD, is an Associate Professor, School of Nursing, University of Ottawa, Ottawa, Canada
- Becky Skidmore, MLIS, is an Information Specialist, Ottawa Hospital Research Institute, Ottawa, Canada
- Lauren Orser, RN, is a Research Assistant, School of Nursing, University of Ottawa, Ottawa, Canada
- Patrick O'Byrne, RN-EC, PhD, is a Full Professor, School of Nursing, University of Ottawa, Ottawa, Canada
| | - Becky Skidmore
- Marlene Haines, RN, BHSc, BScN, is a Research Assistant, School of Nursing, University of Ottawa, Ottawa, Canada ( )
- Amanda Vandyk, RN, PhD, is an Associate Professor, School of Nursing, University of Ottawa, Ottawa, Canada
- Becky Skidmore, MLIS, is an Information Specialist, Ottawa Hospital Research Institute, Ottawa, Canada
- Lauren Orser, RN, is a Research Assistant, School of Nursing, University of Ottawa, Ottawa, Canada
- Patrick O'Byrne, RN-EC, PhD, is a Full Professor, School of Nursing, University of Ottawa, Ottawa, Canada
| | - Lauren Orser
- Marlene Haines, RN, BHSc, BScN, is a Research Assistant, School of Nursing, University of Ottawa, Ottawa, Canada ( )
- Amanda Vandyk, RN, PhD, is an Associate Professor, School of Nursing, University of Ottawa, Ottawa, Canada
- Becky Skidmore, MLIS, is an Information Specialist, Ottawa Hospital Research Institute, Ottawa, Canada
- Lauren Orser, RN, is a Research Assistant, School of Nursing, University of Ottawa, Ottawa, Canada
- Patrick O'Byrne, RN-EC, PhD, is a Full Professor, School of Nursing, University of Ottawa, Ottawa, Canada
| | - Patrick O'Byrne
- Marlene Haines, RN, BHSc, BScN, is a Research Assistant, School of Nursing, University of Ottawa, Ottawa, Canada ( )
- Amanda Vandyk, RN, PhD, is an Associate Professor, School of Nursing, University of Ottawa, Ottawa, Canada
- Becky Skidmore, MLIS, is an Information Specialist, Ottawa Hospital Research Institute, Ottawa, Canada
- Lauren Orser, RN, is a Research Assistant, School of Nursing, University of Ottawa, Ottawa, Canada
- Patrick O'Byrne, RN-EC, PhD, is a Full Professor, School of Nursing, University of Ottawa, Ottawa, Canada
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5
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Kamitani E, Higa DH, Crepaz N, Wichser M, Mullins MM. Identifying Best Practices for Increasing HIV Pre-exposure Prophylaxis (PrEP) Use and Persistence in the United States: A Systematic Review. AIDS Behav 2024; 28:2340-2349. [PMID: 38743381 PMCID: PMC11199112 DOI: 10.1007/s10461-024-04332-z] [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] [Accepted: 03/26/2024] [Indexed: 05/16/2024]
Abstract
A qualitative systematic review was conducted to evaluate pre-exposure prophylaxis (PrEP) interventions, describe characteristics of best practices for increasing PrEP use and persistence, and explore research gaps based on current PrEP interventions. We searched CDC's Prevention Research Synthesis (PRS) Project's cumulative HIV database (includes CINAHL, EMBASE, Global Health, MEDLINE, PsycInfo, and Sociological Abstracts) to identify PrEP intervention studies conducted in the U.S., published between 2000 and 2022 (last searched January 2023). Eligibility criteria include studies that evaluated PrEP interventions for persons testing negative for HIV infection, or for healthcare providers who prescribed PrEP; included comparisons between groups or pre/post; and reported at least one relevant PrEP outcome. Each eligible intervention was evaluated on the quality of study design, implementation, analysis, and strength of evidence (PROSPERO registration number: CRD42021256460). Of the 26 eligible interventions, the majority were focused on men who have sex with men (n = 18) and reported PrEP adherence outcomes (n = 12). Nine interventions met the criteria for Best Practices (i.e., evidence-based interventions, evidence-informed interventions). Five were digital health interventions while two implemented individual counseling, one offered motivational interviewing, and one provided integrated medical care with a PrEP peer navigator. Longer intervention periods may provide more time for intervention exposure to facilitate behavioral change, and engaging the community when developing, designing and implementing interventions may be key for effectiveness. For digital health interventions, two-way messaging may help participants feel supported. Research gaps included a lack of Best Practices for several populations (e.g., Black persons, Hispanic/Latino persons, persons who inject drugs, and women of color) and evidence for various intervention strategies (e.g., interventions for promoting provider's PrEP prescription behavior, peer support). These findings call for more collaborative work with communities to develop interventions that work and implement and disseminate Best Practices for increasing PrEP use and persistence in communities.
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Affiliation(s)
- Emiko Kamitani
- Division of HIV Prevention, U.S. Centers for Disease Control and Prevention, Atlanta, GA, 30329-4027, USA.
| | - Darrel H Higa
- Division of HIV Prevention, U.S. Centers for Disease Control and Prevention, Atlanta, GA, 30329-4027, USA
| | - Nicole Crepaz
- Division of HIV Prevention, U.S. Centers for Disease Control and Prevention, Atlanta, GA, 30329-4027, USA
| | - Megan Wichser
- Division of HIV Prevention, U.S. Centers for Disease Control and Prevention, Atlanta, GA, 30329-4027, USA
- SeKON Enterprise, Inc., Atlanta, GA, 30329, USA
| | - Mary M Mullins
- Division of HIV Prevention, U.S. Centers for Disease Control and Prevention, Atlanta, GA, 30329-4027, USA
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6
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Browne S, Umlauf A, Moore DJ, Benson CA, Vaida F. User Experience of Persons Using Ingestible Sensor-Enabled Pre-Exposure Prophylaxis to Prevent HIV Infection: Cross-Sectional Survey Study. JMIR Mhealth Uhealth 2024; 12:e53596. [PMID: 38722201 PMCID: PMC11085042 DOI: 10.2196/53596] [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: 10/16/2023] [Revised: 02/26/2024] [Accepted: 04/01/2024] [Indexed: 05/12/2024] Open
Abstract
Background A digital health technology's success or failure depends on how it is received by users. objectives We conducted a user experience (UX) evaluation among persons who used the Food and Drug Administration-approved Digital Health Feedback System incorporating ingestible sensors (ISs) to capture medication adherence, after they were prescribed oral pre-exposure prophylaxis (PrEP) to prevent HIV infection. We performed an association analysis with baseline participant characteristics, to see if "personas" associated with positive or negative UX emerged. Methods UX data were collected upon exit from a prospective intervention study of adults who were HIV negative, prescribed oral PrEP, and used the Digital Health Feedback System with IS-enabled tenofovir disoproxil fumarate plus emtricitabine (IS-Truvada). Baseline demographics; urine toxicology; and self-report questionnaires evaluating sleep (Pittsburgh Sleep Quality Index), self-efficacy, habitual self-control, HIV risk perception (Perceived Risk of HIV Scale 8-item), and depressive symptoms (Patient Health Questionnaire-8) were collected. Participants with ≥28 days in the study completed a Likert-scale UX questionnaire of 27 questions grouped into 4 domain categories: overall experience, ease of use, intention of future use, and perceived utility. Means and IQRs were computed for participant total and domain subscores, and linear regressions modeled baseline participant characteristics associated with UX responses. Demographic characteristics of responders versus nonresponders were compared using the Fisher exact and Wilcoxon rank-sum tests. Results Overall, 71 participants were enrolled (age: mean 37.6, range 18-69 years; n=64, 90% male; n=55, 77% White; n=24, 34% Hispanic; n=68, 96% housed; and n=53, 75% employed). No demographic differences were observed in the 63 participants who used the intervention for ≥28 days. Participants who completed the questionnaire were more likely to be housed (52/53, 98% vs 8/10, 80%; P=.06) and less likely to have a positive urine toxicology (18/51, 35% vs 7/10, 70%; P=.08), particularly methamphetamine (4/51, 8% vs 4/10, 40%; P=.02), than noncompleters. Based on IQR values, ≥75% of participants had a favorable UX based on the total score (median 3.78, IQR 3.17-4.20), overall experience (median 4.00, IQR 3.50-4.50), ease of use (median 3.72, IQR 3.33-4.22), and perceived utility (median 3.72, IQR 3.22-4.25), and ≥50% had favorable intention of future use (median 3.80, IQR 2.80-4.40). Following multipredictor modeling, self-efficacy was significantly associated with the total score (0.822, 95% CI 0.405-1.240; P<.001) and all subscores (all P<.05). Persons with more depressive symptoms reported better perceived utility (P=.01). Poor sleep was associated with a worse overall experience (-0.07, 95% CI -0.133 to -0.006; P=.03). Conclusions The UX among persons using IS-enabled PrEP (IS-Truvada) to prevent HIV infection was positive. Association analysis of baseline participant characteristics linked higher self-efficacy with positive UX, more depressive symptoms with higher perceived utility, and poor sleep with negative UX.
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Affiliation(s)
- Sara Browne
- Division of Infectious Diseases and Global Public Health, University of California San Diego, San Diego, CA, United States
- Specialists in Global Health, Encinitas, CA, United States
| | - Anya Umlauf
- Department of Psychiatry, University of California San Diego, San Diego, CA, United States
| | - David J Moore
- Department of Psychiatry, University of California San Diego, San Diego, CA, United States
| | - Constance A Benson
- Division of Infectious Diseases and Global Public Health, University of California San Diego, San Diego, CA, United States
| | - Florin Vaida
- Department of Family Medicine and Public Health, University of California San Diego, San Diego, CA, United States
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7
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Zinsli KA, Ramchandani MS, Dombrowski JC, Cannon CA, Golden MR, Malinski C, Khosropour CM. Impact of Text-Based Monthly Check-Ins on Pre-Exposure Prophylaxis Retention at a Sexual Health Clinic. Sex Transm Dis 2024; 51:e11-e13. [PMID: 38301640 PMCID: PMC10978268 DOI: 10.1097/olq.0000000000001942] [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] [Indexed: 02/03/2024]
Abstract
ABSTRACT We conducted a retrospective cohort study of preexposure prophylaxis patients at the municipal Sexual Health Clinic in Seattle-King County, Washington from 2019 to 2021 to determine whether monthly check-in text messages impacted 4- and 6-month pre-exposure prophylaxis retention. Monthly check-ins did not appear to improve retention above and beyond open-ended texting and appointment reminders.
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Affiliation(s)
- Kaitlin A Zinsli
- From the Department of Epidemiology, University of Washington, Seattle, WA
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8
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Wray TB, Chan PA, Kahler CW, Ocean EMS, Nittas V. Pilot Randomized Controlled Trial of Game Plan for PrEP: A Brief, Web and Text Message Intervention to Help Sexual Minority Men Adhere to PrEP and Reduce Their Alcohol Use. AIDS Behav 2024; 28:1356-1369. [PMID: 37971613 PMCID: PMC10947926 DOI: 10.1007/s10461-023-04223-9] [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] [Accepted: 11/07/2023] [Indexed: 11/19/2023]
Abstract
Suboptimal adherence to oral PrEP medications, particularly among younger sexual minority men (SMM), continues to be a key barrier to achieving more substantial declines in new HIV infections. Although variety of interventions, including web and text-message-based applications, have successfully addressed PrEP adherence, very few have addressed the potential influence of alcohol. This pilot study explored whether the Game Plan for PrEP, a brief, web-based and text messaging intervention, helped promote PrEP persistence and adherence and reduced condomless sex and alcohol use. Seventy-three heavy-drinking SMM on PrEP were recruited online from states with Ending the HIV Epidemic jurisdictions and randomly assigned 1:1 to receive either the Game Plan for PrEP intervention or an attention-matched control. We collected online surveys assessing primary outcomes at one, three, and six months post-enrollment. As secondary outcomes, we also collected dried blood spot samples at baseline, three, and six months to analyze for biomarkers of PrEP and alcohol use. Our results showed that the odds of stopping PrEP or experiencing a clinically meaningful lapse in PrEP adherence (≥ 4 consecutive missed doses) were not different across the two conditions. We also did not find evidence of any differences in condomless sex or drinking outcomes across conditions, although participants in both conditions reported drinking less often over time. These findings were consistent across both self-reported outcomes and biomarkers. Overall, we did not find evidence that our brief, web and text messaging intervention encouraged more optimal PrEP coverage or moderate their alcohol use.
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Affiliation(s)
- Tyler B Wray
- Center for Alcohol and Addictions Studies, Brown University School of Public Health, 121 South Main Street, Providence, RI, 02912, USA.
| | - Philip A Chan
- Department of Medicine, Brown University, Providence, RI, USA
| | - Christopher W Kahler
- Center for Alcohol and Addictions Studies, Brown University School of Public Health, 121 South Main Street, Providence, RI, 02912, USA
| | - Erik M S Ocean
- Center for Alcohol and Addictions Studies, Brown University School of Public Health, 121 South Main Street, Providence, RI, 02912, USA
| | - Vasileios Nittas
- Center for Alcohol and Addictions Studies, Brown University School of Public Health, 121 South Main Street, Providence, RI, 02912, USA
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9
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Guo Y, Westmoreland DA, D'Angelo A, Mirzayi C, Dearolf M, Carneiro PB, Ray M, Pantalone DW, Carrico AW, Patel VV, Golub SA, Hirshfield S, Hoover D, Nash D, Grov C. PrEP Discontinuation In A US National Cohort Of Sexual And Gender Minority Populations, 2017-22. Health Aff (Millwood) 2024; 43:443-451. [PMID: 38437609 DOI: 10.1377/hlthaff.2023.00867] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/06/2024]
Abstract
In the US, sexual and gender minority populations are disproportionately affected by HIV. Pre-exposure prophylaxis (PrEP) is a key prevention method, but its effectiveness relies on consistent usage. Our four-year national cohort study explored PrEP discontinuation among sexual and gender minority people who initiated PrEP. We found a high annual rate of discontinuation (35-40 percent) after PrEP initiation. Multivariable analysis with 6,410 person-years identified housing instability and prior history of PrEP discontinuation as predictors of discontinuation. Conversely, older age, clinical indication for PrEP, and having health insurance were associated with ongoing PrEP use. To promote sustained PrEP use, strategies should focus on supporting those at high risk for discontinuation, such as younger people, those without stable housing or health insurance, and prior PrEP discontinuers.
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Affiliation(s)
- Yan Guo
- Yan Guo, City University of New York, New York, New York
| | | | | | | | | | | | - Meredith Ray
- Meredith Ray, University of Memphis, Memphis, Tennessee
| | - David W Pantalone
- David W. Pantalone, University of Massachusetts Boston, Boston, Massachusetts
| | - Adam W Carrico
- Adam W. Carrico, Florida International University, Miami, Florida
| | - Viraj V Patel
- Viraj V. Patel, Albert Einstein College of Medicine, New York, New York
| | | | - Sabina Hirshfield
- Sabina Hirshfield, SUNY Downstate Health Sciences University, New York, New York
| | - Donald Hoover
- Donald Hoover, Rutgers University, New Brunswick, New Jersey
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10
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Biello KB, Chan PA, Ndoye CD, Nelson L, Nelson E, Silva V, Kwak E, Napoleon S, Cormack Orellana C, Richards OG, Davis E, Mimiaga MJ. Study protocol of a randomized controlled trial to assess the efficacy of the "PrEPare for Work" intervention to enhance PrEP uptake and optimize adherence for HIV prevention among male sex workers in the U.S. BMC Public Health 2024; 24:424. [PMID: 38336731 PMCID: PMC10858584 DOI: 10.1186/s12889-024-17710-y] [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: 11/11/2023] [Accepted: 01/09/2024] [Indexed: 02/12/2024] Open
Abstract
BACKGROUND Male sex workers (MSWs), specifically cisgender men who exchange sex for money, goods, drugs, or other items of value with other cisgender men, are at high risk for HIV infection. Compared to men not engaged in sex work, MSWs are more likely to engage in frequent condomless sex with paying and non-paying sexual partners. While MSWs are often included as a subgroup of gay and bisexual men, data show that a large proportion identify as heterosexual; additionally, most MSWs do not identify as "sex workers." This places MSWs in a unique position where they may not engage with traditional HIV prevention programs, and when they do, they may not feel comfortable, leading to poor retention. Thus, HIV prevention interventions that address MSWs' unique life circumstances and provide support in exploring their sexual health options are needed. METHODS In this protocol paper, we describe the design and procedures for a National Institute of Health-funded, randomized controlled trial testing the efficacy of "PrEPare for Work,"- a theory-based, manualized PrEP uptake and adherence intervention for MSW - using a 2-stage randomization design. Stage 1: MSWs are equally randomized to receive either the "PrEPare for Work Stage 1 intervention" (strength-based case management and facilitated PrEP linkage) or Standard of Care (SOC) to evaluate successful PrEP uptake (prescription filled) within two months post-randomization. Stage 2: Those who initiate PrEP are then equally re-randomized to receive either the "PrEPare for Work Stage 2 intervention" (1-on-1 skills training, problem-solving, and motivational interviewing adherence counseling and personalized, daily text message reminders) or SOC to assess adherence (Tenofovir concentrations in hair) over 12 months of follow up. Planned analyses will examine intervention efficacy, specific conceptual mediators, and hypothesized moderators. DISCUSSION Based on our extensive preliminary research, multi-component, theory-informed interventions targeting this subpopulation of MSWs' unique life circumstances are urgently needed. In this study, we are evaluating whether "PrEPare for Work" can improve PrEP uptake and adherence among MSWs. If this intervention is efficacious, it would be readily disseminated to diverse community organizations that serve MSWs and possibly other community or clinic-based settings. TRIAL REGISTRATION ClinicalTrials.gov number NCT05736614, registered February 8, 2023.
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Affiliation(s)
- Katie B Biello
- Department of Behavioral and Social Sciences, Brown University School of Public Health, 121 South Main Street, Providence, RI, 02912, USA.
- Center for Health Promotion and Health Equity Research, Brown University School of Public Health, Providence, USA.
- The Fenway Institute, Fenway Health, Boston, USA.
- Department of Epidemiology, Brown University School of Public Health, 121 South Main Street, Providence, RI, 02912, USA.
| | - Philip A Chan
- Department of Behavioral and Social Sciences, Brown University School of Public Health, 121 South Main Street, Providence, RI, 02912, USA
- Department of Medicine, Brown University, Providence, USA
- Open Door Health, Rhode Island Public Health Institute, Providence, USA
| | - Colleen D Ndoye
- Project Weber/RENEW, 121 South Main Street, Providence, RI, 02912, USA
| | - Lance Nelson
- Center for Health Promotion and Health Equity Research, Brown University School of Public Health, Providence, USA
| | - Elizabeth Nelson
- UCLA Center for LGBTQ+ Advocacy, Research & Health, Los Angeles, CA, USA
| | - Vanessa Silva
- Center for Health Promotion and Health Equity Research, Brown University School of Public Health, Providence, USA
| | - Eun Kwak
- UCLA Center for LGBTQ+ Advocacy, Research & Health, Los Angeles, CA, USA
| | - Siena Napoleon
- Department of Behavioral and Social Sciences, Brown University School of Public Health, 121 South Main Street, Providence, RI, 02912, USA
| | | | - Olly G Richards
- Center for Health Promotion and Health Equity Research, Brown University School of Public Health, Providence, USA
| | - Evan Davis
- Center for Health Promotion and Health Equity Research, Brown University School of Public Health, Providence, USA
| | - Matthew J Mimiaga
- The Fenway Institute, Fenway Health, Boston, USA
- Department of Epidemiology, UCLA Fielding School of Public Health, Los Angeles, CA, USA
- Department of Psychiatry & Biobehavioral Sciences, UCLA David Geffen School of Medicine, Los Angeles, CA, USA
- UCLA Center for LGBTQ+ Advocacy, Research & Health, Los Angeles, CA, USA
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11
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Dumchev K, Kornilova M, Makarenko O, Antoniak S, Liulchuk M, Cottrell ML, Varetska O, Morozova O. Low daily oral PrEP adherence and low validity of self-report in a randomized trial among PWID in Ukraine. THE INTERNATIONAL JOURNAL OF DRUG POLICY 2024; 123:104284. [PMID: 38061223 PMCID: PMC10872244 DOI: 10.1016/j.drugpo.2023.104284] [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: 08/25/2023] [Revised: 11/27/2023] [Accepted: 11/30/2023] [Indexed: 12/20/2023]
Abstract
BACKGROUND The efficacy of daily oral pre-exposure prophylaxis (PrEP) in preventing HIV transmission among people who inject drugs (PWID) was demonstrated over a decade ago. However, only a few studies among PWID have since measured PrEP adherence using laboratory markers. METHODS In this trial, we randomized recently injecting PWID in Kyiv, Ukraine, to receive daily oral TDF/FTC with or without SMS reminders. Enrollment and PrEP initiation took place at an HIV clinic. Subsequent visits at months 1, 3, and 6 were conducted at a community harm reduction center and included a structured interview, adherence counseling, PrEP dispensing, and dried blood spot collection. PrEP adherence was assessed using standard self-reported measures and TDF/FTC biomarkers. RESULTS A total of 199 PWID (99 SMS, 100 No-SMS) were enrolled, of whom 24 % were women, with a median age of 37. At month 6, 79.4 % (158/199) of participants were retained, with 84 % (133/158) reporting opioid injection and 20 % (31/158) reporting stimulant injection in the past 30 days. 77 % (122/158) reported taking >95 % of PrEP doses in the past month, and 87 % reported taking the last dose within 2 days. Tenofovir diphosphate was detected in 17 % (28/158) of participants, and emtricitabine triphosphate was detected in 25 % (40/158). Only 3 % (5/158) had metabolite levels indicative of consistent PrEP uptake at 4+ doses per week. There was no association between the SMS intervention and TDF/FTC metabolite detection. CONCLUSION Adherence to daily oral PrEP among actively injecting PWID, without daily supervision or incentives, was extremely low, despite supportive counseling and SMS reminders. We also observed a high rate of discordance between self-report and classification by a validated biomarker of adherence. Given the scarcity of evidence and emerging data suggesting low oral PrEP adherence among PWID, additional implementation studies with TDF/FTC biomarkers are needed to study whether a sufficient level of adherence to daily PrEP is attainable among PWID, especially as long-acting injectable PrEP offers a promising alternative.
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Affiliation(s)
| | - Marina Kornilova
- International Charitable Foundation "Alliance for Public Health", Kyiv, Ukraine
| | | | - Svitlana Antoniak
- Gromashevsky Institute of Epidemiology and Infectious Diseases, National Academy of Medical Sciences, Kyiv, Ukraine
| | - Mariia Liulchuk
- Gromashevsky Institute of Epidemiology and Infectious Diseases, National Academy of Medical Sciences, Kyiv, Ukraine
| | - Mackenzie L Cottrell
- University of North Carolina Eshelman School of Pharmacy, Chapel Hill, NC, United States of America
| | - Olga Varetska
- International Charitable Foundation "Alliance for Public Health", Kyiv, Ukraine
| | - Olga Morozova
- Department of Public Health Sciences, Biological Sciences Division, University of Chicago, Chicago, Illinois, United States of America
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12
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Storholm ED, Ogunbajo A, Nacht CL, Opalo C, Horvath KJ, Lyman P, Flynn R, Reback CJ, Blumenthal J, Moore DJ, Bolan R, Morris S. Facilitators of PrEP Persistence among Black and Latinx Transgender Women in a PrEP Demonstration Project in Southern California. Behav Med 2024; 50:63-74. [PMID: 35993278 PMCID: PMC9943802 DOI: 10.1080/08964289.2022.2105794] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/13/2021] [Revised: 06/28/2022] [Accepted: 07/19/2022] [Indexed: 11/02/2022]
Abstract
Black and Latinx transgender women in the United States (U.S.) are at disproportionately high risk for HIV. Although HIV pre-exposure prophylaxis (PrEP) reduces the risk of HIV infection, uptake and persistence (i.e., ability to continue taking PrEP over time) can be a challenge for Black and Latinx transgender women due to myriad social and structural forces. In this qualitative study, we present unique data on the facilitators of PrEP persistence from Black and Latinx transgender women who initiated PrEP and exhibited varying levels of persistence during a demonstration project in Southern California. PrEP persistence was assessed by collecting quantitative intracellular tenofovir-diphosphate (TFV-DP) levels on dried blood spot (DBS) samples collected at weeks 12 and 48. Informed by the socioecological framework, we conducted and analyzed interviews using qualitative content analysis to determine themes on the facilitators of PrEP persistence. Individual-level facilitators included the use of reminders, having high individual-level HIV risk perception, feeling empowered to take PrEP, and reporting having improved peace of mind and mental health because of taking PrEP. Interpersonal/Community-level facilitators included feeling motivation to prevent HIV in the community, motivation to prevent HIV in the context of sex work, and having high community-level risk perception. Structural-level facilitators included having positive experiences in affirming healthcare settings and having PrEP visits combined with other gender-related healthcare visits. Interventions aiming to increase PrEP uptake and persistence among Black and Latinx transgender women in the U.S. should harness the multiple levels of support exhibited by those who were able to start and persist on PrEP in the face of the myriad social and structural barriers.
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Affiliation(s)
- Erik D. Storholm
- School of Public Health, San Diego State University
- RAND Corporation
- Center for HIV Identification, Prevention and Treatment Services, Department of Family Medicine, University of California Los Angeles
| | - Adedotun Ogunbajo
- RAND Corporation
- Department of Behavioral and Social Sciences, Brown University School of Public Health
| | | | | | | | | | | | - Cathy J. Reback
- Center for HIV Identification, Prevention and Treatment Services, Department of Family Medicine, University of California Los Angeles
- Friends Research Institute
| | - Jill Blumenthal
- AntiViral Research Center, University of California, San Diego School of Medicine
| | - David J. Moore
- AntiViral Research Center, University of California, San Diego School of Medicine
| | | | - Sheldon Morris
- AntiViral Research Center, University of California, San Diego School of Medicine
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13
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Dayton RL, Fonner VA, Plourde KF, Sanyal A, Arney J, Orr T, Nhamo D, Schueller J, Limb AM, Torjesen K. A Scoping Review of Oral Pre-exposure Prophylaxis for Cisgender and Transgender Adolescent Girls and Young Women: What Works and Where Do We Go from Here? AIDS Behav 2023; 27:3223-3238. [PMID: 37119401 PMCID: PMC10148005 DOI: 10.1007/s10461-023-04043-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/14/2023] [Indexed: 05/01/2023]
Abstract
Adolescent girls and young women (AGYW) are disproportionately affected by HIV, and oral pre-exposure prophylaxis (PrEP) can reduce HIV acquisition. The purpose of this scoping review was to synthesize results from interventions along the PrEP continuum for AGYW to inform research and programs. We searched electronic databases for studies published between January 2012-July 2021 and conducted secondary reference searching. Studies were included if they assessed interventions to increase PrEP interest, uptake, or continuation among AGYW. Results were synthesized narratively. Of 2168 citations identified, 50 studies were eligible for inclusion, and 20 contained AGYW-specific data. Among cisgender and transgender AGYW, studies overall demonstrated a positive impact on PrEP interest and uptake but generally attained suboptimal continuation rates. Results demonstrate feasibility of deploying PrEP across diverse settings-particularly when interventions are layered, tailored to AGYW, and include differentiated delivery-but also highlight knowledge gaps and the need for more holistic metrics of success.
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Affiliation(s)
| | | | | | - Ameya Sanyal
- FHI 360, Global Health and Population, Durham, NC, USA
| | - Jennifer Arney
- FHI 360, Global Health and Population, Washington, DC, USA
| | - Tracy Orr
- FHI 360, Global Health and Population, Atlanta, GA, USA
| | | | - Jane Schueller
- United States Agency for International Development, Bureau of Global Health, Office of Population and Reproductive Health, Washington, DC, USA
| | - Annaliese M Limb
- United States Agency for International Development, Bureau of Global Health, Office of HIV/AIDS, Washington, DC, USA
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14
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Yeager S, Serrano VB, Paltin D, Fisher A, Karris M, Aarons GA, Rangel A, Flynn R, Bolan R, Moore DJ, Montoya JL. Qualitative Examination of the Impact of the COVID-19 Pandemic on Access and Adherence to Pre-exposure Prophylaxis (PrEP) Among Sexual and Gender Minorities. AIDS EDUCATION AND PREVENTION : OFFICIAL PUBLICATION OF THE INTERNATIONAL SOCIETY FOR AIDS EDUCATION 2023; 35:255-267. [PMID: 37535324 PMCID: PMC10849009 DOI: 10.1521/aeap.2023.35.4.255] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 08/04/2023]
Abstract
During the COVID-19 pandemic, pre-exposure prophylaxis (PrEP) access and adherence decreased nationwide. This study examined pandemic-related disruptions to PrEP access and adherence among clients of a health center (Center) in Los Angeles, California. Clients (n = 25) and Center personnel (n = 11) completed qualitative interviews from March to July 2021. Although the Center provided options for remote PrEP care (i.e., telehealth, STI self-testing kits, and prescription delivery), clients experienced difficulty navigating services or lacked equipment for telehealth. More than half (n = 13) of clients discontinued PrEP during COVID-19 due to decreased sexual partners, relocation, or insurance status changes. Among those who continued PrEP, the majority reported no change in adherence, while a minority reported worsening adherence due to distractions/forgetting, prescription refill issues, lack of insurance coverage, and fear of completing in-person visits. Findings highlight the challenges of navigating PrEP services during COVID-19 and suggest PrEP services enhancement to adapt to crisis events.
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Affiliation(s)
- Samantha Yeager
- Department of Medicine, University of California San Diego (UCSD), San Diego, California
| | - Vanessa B Serrano
- San Diego State University/UC San Diego Joint Doctoral Program in Clinical Psychology, San Diego, California
- Department of Psychiatry, UCSD
| | - Dafna Paltin
- San Diego State University/UC San Diego Joint Doctoral Program in Clinical Psychology, San Diego, California
- Department of Psychiatry, UCSD
| | - Arin Fisher
- Department of Psychiatry, UCSD
- Pacific Institute for Research and Evaluation-Southwest Center, Albuquerque, New Mexico
| | - Maile Karris
- Department of Medicine, University of California San Diego (UCSD), San Diego, California
- San Diego Center for AIDS Research, San Diego, California, and the Altman Clinical and Translational Research Institute Dissemination and Implementation Sciences Center, UCSD
| | - Gregory A Aarons
- Department of Psychiatry, UCSD
- San Diego Center for AIDS Research, San Diego, California, and the Altman Clinical and Translational Research Institute Dissemination and Implementation Sciences Center, UCSD
- Child and Adolescent Services Research Center, UCSD
| | - Alvy Rangel
- Los Angeles LGBT Center, Los Angeles, California
| | - Risa Flynn
- Los Angeles LGBT Center, Los Angeles, California
| | - Robert Bolan
- Los Angeles LGBT Center, Los Angeles, California
| | - David J Moore
- Department of Psychiatry, UCSD
- San Diego Center for AIDS Research, San Diego, California, and the Altman Clinical and Translational Research Institute Dissemination and Implementation Sciences Center, UCSD
| | - Jessica L Montoya
- Department of Psychiatry, UCSD
- San Diego Center for AIDS Research, San Diego, California, and the Altman Clinical and Translational Research Institute Dissemination and Implementation Sciences Center, UCSD
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15
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Weir BW, Wirtz AL, Chemnasiri T, Baral SD, Decker M, Dun C, Hnin Mon SH, Ungsedhapand C, Dunne EF, Woodring J, Pattanasin S, Sukwicha W, Thigpen MC, Varangrat A, Warapornmongkholkul A, O'Connor S, Ngo JP, Qaragholi N, Sisel HI, Truong JM, Janyam S, Linjongrat D, Sriplienchan S, Sirivongrangson P, Rooney JF, Sullivan P, Chua-Intra B, Hickey AC, Beyrer C. High PrEP uptake, adherence, persistence and effectiveness outcomes among young Thai men and transgender women who sell sex in Bangkok and Pattaya, Thailand: findings from the open-label combination HIV prevention effectiveness (COPE) study. THE LANCET REGIONAL HEALTH. SOUTHEAST ASIA 2023; 15:100217. [PMID: 37614346 PMCID: PMC10442968 DOI: 10.1016/j.lansea.2023.100217] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 01/15/2023] [Revised: 04/06/2023] [Accepted: 05/02/2023] [Indexed: 08/25/2023]
Abstract
Background Daily oral pre-exposure prophylaxis (PrEP) is effective in preventing HIV infection, but no study has evaluated combination prevention interventions with PrEP for transgender women (TGW) and men who have sex with men (MSM) who sell sex. Methods The Combination Prevention Effectiveness (COPE) study was a community-based, non-randomized implementation study in Bangkok and Pattaya, Thailand. Participants were HIV-negative MSM and TGW aged 18-26 years who reported exchanging sex with men in the prior 12 months and who met 2014 U.S. Public Health Service PrEP eligibility criteria. The intervention included quarterly HIV testing, semiannual testing for sexually transmitted infections, provision of condoms with lubricant, and the opportunity to initiate or end daily oral PrEP use at any time during study participation. Participants taking PrEP received monthly adherence counseling and short message service reminders. The primary outcome was HIV incidence rate ratio (IRR) on PrEP vs. not on PrEP. Secondary outcomes were PrEP initiation, PrEP use at 12 months, and PrEP adherence. Findings From October 2017 to August 2019, 846 participants were enrolled: 531 (62.8%) immediately initiated PrEP; 104 (12.3%) subsequently initiated PrEP, and 211 (24.9%) never initiated PrEP. Among those initiating PrEP within 30 days of enrollment; 85.9% were on PrEP at the 12-months. When taking PrEP, participants reported adherent PrEP use at 94.2% of quarterly assessments. Ten HIV seroconversions occurred without PrEP use (incidence rate [IR] = 3.42 per 100 person-years [PY]; 95% CI = 1.64-6.30), while zero cases occurred with PrEP use (IR = 0.0 per 100PY; 95% CI = 0.0-0.62), with IRR = 0.0 (95% CI = 0.0-0.22; p < 0.001). Interpretation Young Thai MSM and TGW who exchange sex can have high PrEP uptake, persistence and adherence, and low HIV incidence when offered in supportive community-based settings. Funding U.S. National Institute of Allergy and Infectious Diseases; Centers for Disease Control and Prevention.
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Affiliation(s)
- Brian W. Weir
- Center for Public Health and Human Rights, Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
- Department of Health, Behavior & Society, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Andrea L. Wirtz
- Center for Public Health and Human Rights, Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Tareerat Chemnasiri
- Division of HIV Prevention, U.S. Centers for Disease Control and Prevention, Atlanta, GA, USA
- Division of HIV Prevention, Thailand Ministry of Public Health-U.S. Centers for Disease Control and Prevention Collaboration, Nonthaburi, Thailand
| | - Stefan D. Baral
- Center for Public Health and Human Rights, Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Michele Decker
- Center for Public Health and Human Rights, Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
- Department of Population, Family & Reproductive Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Chen Dun
- Center for Public Health and Human Rights, Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
- Department of Health, Behavior & Society, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Sandra Hsu Hnin Mon
- Center for Public Health and Human Rights, Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Chaiwat Ungsedhapand
- Division of HIV Prevention, U.S. Centers for Disease Control and Prevention, Atlanta, GA, USA
- Division of HIV Prevention, Thailand Ministry of Public Health-U.S. Centers for Disease Control and Prevention Collaboration, Nonthaburi, Thailand
| | - Eileen F. Dunne
- Division of HIV Prevention, U.S. Centers for Disease Control and Prevention, Atlanta, GA, USA
- Division of HIV Prevention, Thailand Ministry of Public Health-U.S. Centers for Disease Control and Prevention Collaboration, Nonthaburi, Thailand
| | - Joseph Woodring
- Division of HIV Prevention, U.S. Centers for Disease Control and Prevention, Atlanta, GA, USA
- Division of HIV Prevention, Thailand Ministry of Public Health-U.S. Centers for Disease Control and Prevention Collaboration, Nonthaburi, Thailand
| | - Sarika Pattanasin
- Division of HIV Prevention, U.S. Centers for Disease Control and Prevention, Atlanta, GA, USA
- Division of HIV Prevention, Thailand Ministry of Public Health-U.S. Centers for Disease Control and Prevention Collaboration, Nonthaburi, Thailand
| | - Wichuda Sukwicha
- Division of HIV Prevention, U.S. Centers for Disease Control and Prevention, Atlanta, GA, USA
- Division of HIV Prevention, Thailand Ministry of Public Health-U.S. Centers for Disease Control and Prevention Collaboration, Nonthaburi, Thailand
| | - Michael C. Thigpen
- Division of HIV Prevention, U.S. Centers for Disease Control and Prevention, Atlanta, GA, USA
- Division of HIV Prevention, Thailand Ministry of Public Health-U.S. Centers for Disease Control and Prevention Collaboration, Nonthaburi, Thailand
| | - Anchalee Varangrat
- Division of HIV Prevention, U.S. Centers for Disease Control and Prevention, Atlanta, GA, USA
- Division of HIV Prevention, Thailand Ministry of Public Health-U.S. Centers for Disease Control and Prevention Collaboration, Nonthaburi, Thailand
| | - Anchalee Warapornmongkholkul
- Division of HIV Prevention, U.S. Centers for Disease Control and Prevention, Atlanta, GA, USA
- Division of HIV Prevention, Thailand Ministry of Public Health-U.S. Centers for Disease Control and Prevention Collaboration, Nonthaburi, Thailand
| | - Siobhan O'Connor
- Division of HIV Prevention, U.S. Centers for Disease Control and Prevention, Atlanta, GA, USA
| | - Julie P. Ngo
- Center for Public Health and Human Rights, Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Noor Qaragholi
- Center for Public Health and Human Rights, Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Haley I. Sisel
- Center for Public Health and Human Rights, Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Jasmine M. Truong
- Center for Public Health and Human Rights, Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Surang Janyam
- Service Workers in Group Foundation (SWING), Bangkok and Pattaya, Thailand
| | | | | | - Pachara Sirivongrangson
- Division of HIV Prevention, Thailand Ministry of Public Health-U.S. Centers for Disease Control and Prevention Collaboration, Nonthaburi, Thailand
| | | | - Patrick Sullivan
- Department of Epidemiology, Emory University Rollins School of Public Health, Atlanta, GA, USA
| | - Boosbun Chua-Intra
- Division of HIV Prevention, Thailand Ministry of Public Health-U.S. Centers for Disease Control and Prevention Collaboration, Nonthaburi, Thailand
| | - Andrew C. Hickey
- Division of HIV Prevention, U.S. Centers for Disease Control and Prevention, Atlanta, GA, USA
- Division of HIV Prevention, Thailand Ministry of Public Health-U.S. Centers for Disease Control and Prevention Collaboration, Nonthaburi, Thailand
| | - Chris Beyrer
- Center for Public Health and Human Rights, Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
- Duke Global Health Institute, Duke University, Durham, NC, USA
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Khosropour CM, Riley T, Healy E, Backus KV, Gomillia CE, Mena L, Lockwood KR, Gordon FM, Means AR, Ward LM. Persistence in a pharmacist-led, same-day PrEP program in Mississippi: a mixed-methods study. BMC Public Health 2023; 23:1130. [PMID: 37312077 PMCID: PMC10262591 DOI: 10.1186/s12889-023-16072-1] [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: 10/07/2022] [Accepted: 06/07/2023] [Indexed: 06/15/2023] Open
Abstract
INTRODUCTION Mississippi has one of the highest rates of HIV in the United States but low PrEP uptake. Understanding patterns of PrEP use can improve PrEP initiation and persistence. METHODS This is a mixed-method evaluation of a PrEP program in Jackson, Mississippi. Between November 2018-December 2019, clients at high risk for HIV attending a non-clinical testing site were referred to a pharmacist for same-day PrEP initiation. The pharmacist provided a 90-day PrEP prescription and scheduled a follow-up clinical appointment within three months. We linked client records from this visit to electronic health records from the two largest PrEP clinics in Jackson to determine linkage into ongoing clinical care. We identified four distinct PrEP use patterns, which we used for qualitative interview sampling: 1) filled a prescription and linked into care within three months; 2) filled a prescription and linked into care after three months; 3) filled a prescription and never linked into care; and 4) never filled a prescription. In 2021, we purposively sampled patients in these four groups for individual interviews to ascertain barriers and facilitators to PrEP initiation and persistence, using guides informed by the Theory of Planned Behavior. RESULTS There were 121 clients evaluated for PrEP; all were given a prescription. One-third were less than 25 years old, 77% were Black, and 59% were cisgender men who have sex with men. One-quarter (26%) never filled their PrEP prescription, 44% picked up the prescription but never linked into clinical care, 12% linked into care at some point after three months (resulting in a gap in PrEP coverage), and 18% linked into care within 3 months. We interviewed 26 of 121 clients. Qualitative data revealed that cost, stigmas related to sexuality and HIV, misinformation about PrEP, and perceived side effects were barriers to uptake and persistence. Individuals' desire to stay healthy and the support of PrEP clinic staff were facilitators. CONCLUSIONS The majority of individuals given a same-day PrEP prescription either never started PrEP or stopped PrEP within the first three months. Addressing noted barriers of stigma and misinformation and reducing structural barriers may increase PrEP initiation and persistence.
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Affiliation(s)
- Christine M Khosropour
- Department of Epidemiology, Hans Rosling Center for Population Health, University of Washington, 3980 15th Ave NE, Seattle, WA, 98195, USA.
| | - Taylor Riley
- Department of Epidemiology, Hans Rosling Center for Population Health, University of Washington, 3980 15th Ave NE, Seattle, WA, 98195, USA
| | - Elise Healy
- Department of Medicine, Health Sciences Building, University of Washington, 1959 NE Pacific Street, Seattle, WA, 98195, USA
| | - Kandis V Backus
- Department of Population Health Science, University of Mississippi Medical Center, 2500 N State Street, Jackson, MS39216, USA
| | - Courtney E Gomillia
- Department of Population Health Science, University of Mississippi Medical Center, 2500 N State Street, Jackson, MS39216, USA
| | - Leandro Mena
- Department of Population Health Science, University of Mississippi Medical Center, 2500 N State Street, Jackson, MS39216, USA
| | - Khadijra R Lockwood
- Department of Population Health Science, University of Mississippi Medical Center, 2500 N State Street, Jackson, MS39216, USA
| | - Felicia M Gordon
- Department of Population Health Science, University of Mississippi Medical Center, 2500 N State Street, Jackson, MS39216, USA
| | - Arianna R Means
- Department of Global Health, Hans Rosling Center for Population Health, University of Washington, 3980 15th Ave NE, Seattle, WA, 98195, USA
| | - Lori M Ward
- Department of Population Health Science, University of Mississippi Medical Center, 2500 N State Street, Jackson, MS39216, USA
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17
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Haberer JE, Mujugira A, Mayer KH. The future of HIV pre-exposure prophylaxis adherence: reducing barriers and increasing opportunities. Lancet HIV 2023:S2352-3018(23)00079-6. [PMID: 37178710 DOI: 10.1016/s2352-3018(23)00079-6] [Citation(s) in RCA: 10] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2022] [Revised: 03/19/2023] [Accepted: 03/27/2023] [Indexed: 05/15/2023]
Abstract
The effectiveness of HIV pre-exposure prophylaxis (PrEP) hinges on adherence, which has been restricted by multifaceted barriers. Uptake of PrEP has been impeded by poor access resulting from high costs, provider uncertainty, discrimination, stigma, and poor understanding within the health-care community and the public of who can benefit from PrEP. Other important barriers to adherence and persistence over time relate to individuals (eg, depression) and their community, partners, and family (eg, poor support), and their effects vary substantially with each person, population, and setting. Despite these challenges, key opportunities for improving PrEP adherence exist, including novel delivery systems, tailored individual interventions, mobile health and digital health interventions, and long-acting formulations. Objective monitoring strategies will help to improve adherence interventions and alignment of PrEP use with the need for HIV prevention (ie, prevention-effective adherence). The future of PrEP adherence lies in person-centred approaches to service delivery that meet the needs of individuals while creating supportive environments and facilitating health-care access and delivery.
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Affiliation(s)
- Jessica E Haberer
- Center for Global Health, Massachusetts General Hospital, Boston, MA, USA; Department of Medicine, Harvard Medical School, Boston, MA, USA.
| | - Andrew Mujugira
- Infectious Diseases Institute, Makerere University, Kampala, Uganda; Department of Global Health, University of Washington, Seattle, WA, USA
| | - Kenneth H Mayer
- Department of Medicine, Harvard Medical School, Boston, MA, USA; The Fenway Institute, Boston, MA, USA; Department of Medicine, Beth Israel Deaconess Medical Center, Boston, MA, USA
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18
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Dauria E, Rodriguez C, Bauerle Bass S, Tolou-Shams M, Christopoulos K. Implementation strategies to screen, refer and link women involved in the carceral system to PrEP for HIV prevention. Int J Prison Health 2023; 19:10.1108/IJPH-06-2022-0037. [PMID: 37113046 PMCID: PMC11058187 DOI: 10.1108/ijph-06-2022-0037] [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] [Indexed: 04/29/2023]
Abstract
PURPOSE Women involved in the carceral system (CS) experience several conditions that increase their risk for HIV (e.g. high rates of substance use, psychiatric disorders, histories of victimization). The purpose of this study is to explore perspectives on potential strategies to connect women in the CS to pre-exposure prophylaxis (PrEP) services. DESIGN/METHODOLOGY/APPROACH This study conducted in-depth interviews with 27 women involved in the CS eligible for PrEP. Using vignettes, interviews explored attitudes, barriers and facilitators toward PrEP screening, referral and linkage facilitated via a CS stakeholder, an mHealth application or providing PrEP service referrals during detention via a navigator. FINDINGS Most women were, on average, 41.3 years, from racial and ethnic minority groups (56% black/African American; 19% Latinx). Inductive thematic analysis revealed CS involved women expressed mostly positive attitudes toward CS-based PrEP implementation. Younger women were more accepting of and interested in mHealth interventions. Implementation facilitators included leveraging relationships with trusted allies (e.g. "peers") and existing systems collaborations. Recommended implementation strategies included providing HIV and PrEP-specific education and training for system stakeholders and addressing issues related to privacy, system mistrust and stigma. ORIGINALITY/VALUE Results provide a critical foundation for the implementation of interventions to improve PrEP access for women involved in the CS and have important implications for implementation strategies for all adults involved in the CS. Improving access to PrEP among this population may also support progress toward addressing national disparities in PrEP uptake, where women, black and Latinx populations have substantial unmet need.
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Affiliation(s)
- Emily Dauria
- Department of Behavioral and Community Health Sciences, Graduate School of Public Health, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Christopher Rodriguez
- Department of Psychiatry and Behavioral Sciences, University of California San Francisco, San Francisco, California, USA
| | - Sarah Bauerle Bass
- Department of Social and Behavioral Sciences, College of Public Health, Temple University, Philadelphia, Pennsylvania, USA
| | - Marina Tolou-Shams
- Department of Psychiatry and Behavioral Sciences, University of California, San Francisco, San Francisco, California, USA
| | - Katerina Christopoulos
- Department of Medicine, University of California San Francisco, San Francisco, California, USA
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19
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Chase E, Mena L, Johnson KL, Prather M, Khosropour CM. Patterns of Pre-exposure Prophylaxis (PrEP) Use in a Population Accessing PrEP in Jackson, Mississippi. AIDS Behav 2023; 27:1082-1090. [PMID: 36094635 PMCID: PMC9465129 DOI: 10.1007/s10461-022-03845-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/27/2022] [Indexed: 11/30/2022]
Abstract
Pre-exposure prophylaxis (PrEP) persistence is suboptimal in the United States. In the Deep South, a region with high rates of new HIV diagnosis, patterns of PrEP discontinuation remain unexplored. We evaluated data from a clinic-based PrEP program in Jackson, Mississippi and included patients initiating PrEP between August 2018 and April 2021. We considered patients to have a gap in PrEP coverage if they had at least 30 days without an active PrEP prescription; those who restarted PrEP after 30 days were classified as 'stopped and restarted' and those who never obtained a new PrEP prescription were classified as 'stopped and did not restart'. Patients without a gap in coverage were considered 'continuously on PrEP'. We estimated median time to first PrEP discontinuation and examined factors associated with time to first PrEP discontinuation. Of 171 patients who received an initial 90-day PrEP prescription; 75% were assigned male at birth and 74% identified as Black. The median time to first discontinuation was 90 days (95% CI 90-114). Twenty-two percent were continuously on PrEP, 28% stopped and restarted (median time off PrEP = 102 days), and 50% stopped and did not restart. Associations with early PrEP stoppage were notable for patients assigned sex female vs male (adjusted hazard ratio [aHR] = 1.6, 95% CI 1.0-2.5) and those living over 25 miles from clinic vs. 0-10 miles (aHR 1.89, 95% CI 1.2-3.0). Most patients never refilled an initial PrEP prescription though many patients re-started PrEP. Interventions to improve persistence and facilitate re-starts are needed.
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Affiliation(s)
- Erin Chase
- Department of Epidemiology, Harborview Medical Center, University of Washington, 325 Ninth Avenue, Box 359777, Seattle, WA, 98104, USA
| | - Leandro Mena
- University of Mississippi Medical Center, Jackson, MS, USA
| | | | - Mariah Prather
- University of Mississippi Medical Center, Jackson, MS, USA
| | - Christine M Khosropour
- Department of Epidemiology, Harborview Medical Center, University of Washington, 325 Ninth Avenue, Box 359777, Seattle, WA, 98104, USA.
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20
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Wagner GA, Wu KS, Anderson C, Burgi A, Little SJ. Predictors of Human Immunodeficiency Virus Pre-Exposure Prophylaxis (PrEP) Uptake in a Sexual Health Clinic With Rapid PrEP Initiation. Open Forum Infect Dis 2023; 10:ofad060. [PMID: 36968957 PMCID: PMC10034584 DOI: 10.1093/ofid/ofad060] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2022] [Accepted: 02/07/2023] [Indexed: 02/10/2023] Open
Abstract
Background Improved pre-exposure prophylaxis (PrEP) uptake is essential for human immunodeficiency virus (HIV) prevention initiatives. Offering PrEP at the time of HIV and sexually transmitted infection (STI) testing can improve uptake. We offered rapid PrEP initiation in a sexual health clinic and assessed predictors of PrEP interest, initiation, linkage, and retention. Methods Between November 2018 and February 2020, PrEP-eligible individuals who presented to a sexual health clinic were offered a free 30-day supply of PrEP plus linkage to continued PrEP care. Univariable and multivariable analyses of demographic and HIV risk data were conducted to determine predictors of PrEP uptake. Results Of 1259 adults who were eligible for PrEP (99.7% male, 42.7% White, 36.2% Hispanic), 456 were interested in PrEP, 249 initiated PrEP, 209 were linked, and 67 were retained in care. Predictors of PrEP interest included younger age (P < .01), lower monthly income (P = .01), recreational drug use (P = .02), and a greater number of sexual partners (P < .01). Negative predictors of PrEP initiation included lower monthly income (P = .04), testing positive for chlamydia (P = .04), and exchanging money for sex (P = .01). Negative predictors of linkage included self-identifying as Black (P = .03) and testing positive for an STI (P < .01). Having health insurance positively predicted both linkage (P < .01) and retention (P < .03). Conclusions A minority of PrEP-eligible HIV and STI testers initiated PrEP when offered, suggesting that easy PrEP access in sexual health clinics alone may not improve uptake. Predictors of uptake included established HIV risk factors and markers of higher socioeconomic status, suggesting that those aware of their risk and with the means to utilize health services engaged best with this model.
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Affiliation(s)
- Gabriel A Wagner
- Division of Infectious Diseases & Global Public Health, Department of Medicine, University of California San Diego, San Diego, California, USA
| | - Kuan-Sheng Wu
- Division of Infectious Diseases & Global Public Health, Department of Medicine, University of California San Diego, San Diego, California, USA
- Division of Infectious Diseases, Department of Internal Medicine, Kaohsiung Veterans General Hospital, Kaohsiung City, Taiwan
- Faculty of Medicine, School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan
| | - Christy Anderson
- Division of Infectious Diseases & Global Public Health, Department of Medicine, University of California San Diego, San Diego, California, USA
| | - Alina Burgi
- Division of Infectious Diseases & Global Public Health, Department of Medicine, University of California San Diego, San Diego, California, USA
| | - Susan J Little
- Division of Infectious Diseases & Global Public Health, Department of Medicine, University of California San Diego, San Diego, California, USA
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21
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Storholm ED, Huang W, Ogunbajo A, Horvath KJ, Reback CJ, Blumenthal J, Moore DJ, Flynn RP, Bolan RK, Corado KC, Morris SR. Gender-Based Violence and Post-traumatic Stress Disorder Symptoms Predict HIV PrEP Uptake and Persistence Failure Among Transgender and Non-binary Persons Participating in a PrEP Demonstration Project in Southern California. AIDS Behav 2023; 27:745-759. [PMID: 36053404 PMCID: PMC9908815 DOI: 10.1007/s10461-022-03807-1] [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] [Accepted: 07/27/2022] [Indexed: 11/28/2022]
Abstract
Gender-based violence (GBV) against transgender and nonbinary (TGNB) persons is a pervasive public health issue. GBV has been linked to mental health problems such as depression and posttraumatic stress disorder (PTSD), as well has risk for HIV seroconversion and HIV treatment nonadherence. However, the impact of GBV on HIV pre-exposure prophylaxis (PrEP) use among TGNB persons has yet to be investigated. In the current study we assessed longitudinal PrEP persistence data from dried blood spots (DBS) collected from 172 racially and ethnically diverse TGNB participants during a 48-week PrEP demonstration project in Southern California from June 2017 to September 2020. Participants were categorized into three levels of PrEP uptake and persistence based on their PrEP levels at the start and end of the study: low-low, high-low, and high-high. Individual-, social-, and structural-level variables were then entered into multinomial logistic regression models to predict levels of PrEP uptake and persistence based on hypotheses informed by syndemic and minority stress theories. The models demonstrated that experience of GBV predicted significantly lower odds of PrEP uptake and persistence and greater PTSD symptoms predicted significantly greater odds of early PrEP discontinuation. Higher levels of coping skills, already being on PrEP at baseline, and being in a steady relationship were associated with greater odds of PrEP uptake and persistence. Implications for future GBV research, advocacy, interventions, and much needed structural changes focused on improving the health and safety of TGNB individuals are discussed.
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Affiliation(s)
- Erik D Storholm
- School of Public Health, San Diego State University, San Diego, CA, USA.
- RAND Corporation, Santa Monica, CA, USA.
- Center for HIV Identification, Prevention and Treatment Services, Department of Family Medicine, University of California Los Angeles, Los Angeles, CA, USA.
| | | | - Adedotun Ogunbajo
- RAND Corporation, Santa Monica, CA, USA
- Department of Behavioral and Social Sciences, Brown University School of Public Health, Providence, RI, USA
| | - Keith J Horvath
- Department of Psychology, San Diego State University, San Diego, CA, USA
| | - Cathy J Reback
- Center for HIV Identification, Prevention and Treatment Services, Department of Family Medicine, University of California Los Angeles, Los Angeles, CA, USA
- Friends Research Institute, Los Angeles, CA, USA
| | - Jill Blumenthal
- AntiViral Research Center, University of California, San Diego School of Medicine, San Diego, CA, USA
| | - David J Moore
- AntiViral Research Center, University of California, San Diego School of Medicine, San Diego, CA, USA
| | | | | | | | - Sheldon R Morris
- AntiViral Research Center, University of California, San Diego School of Medicine, San Diego, CA, USA
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22
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Ham L, Montoya JL, Serrano V, Yeager S, Paltin D, Pasipanodya EC, Marquine MJ, Hoenigl M, Ramers CB, Kua J, Moore DJ. High Psychosocial Burden Relates to Poorer Antiretroviral Treatment Adherence Among Black/African American People with HIV. AIDS Patient Care STDS 2023; 37:103-113. [PMID: 36689195 PMCID: PMC9963477 DOI: 10.1089/apc.2022.0180] [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] [Indexed: 01/24/2023] Open
Abstract
Black/African American communities continue to be disproportionately impacted by HIV with Black people with HIV (PWH) exhibiting poorer outcomes along the HIV treatment cascade. Psychosocial burden may, in part, explain these health disparities among PWH. We implemented a culturally adapted intervention [individualized Texting for Adherence Building (iTAB)] to improve ART adherence among 89 Black PWH in San Diego, CA. We aimed to (1) characterize psychosocial risk factors (depression, negative life events, discrimination, medical mistrust) hypothesized to be barriers to HIV outcomes among Black PWH and (2) determine if these factors influence intervention engagement, HIV outcomes, and self-reported physical and mental health. We identified three levels of psychosocial burden (low, moderate, high) through hierarchical cluster analysis. Participants in the high burden cluster (n = 25) experienced the highest levels of depression, negative life events, and discrimination, in addition to the poorest intervention outcomes, HIV outcomes, and physical and mental health compared to low and moderate burden clusters. Participants in the low (n = 29) burden cluster had less medical mistrust than the moderate (n = 34) and high burden clusters, but low and moderate clusters did not differ on any outcomes. Overall, self-reported ART adherence was 83%, which is above estimates of ART adherence in the Western region of the United States. The iTAB intervention shows promise in improving HIV-related outcomes among Black PWH with low to moderate psychosocial burden; however, additional supports may need to be identified for those with high psychosocial burden.
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Affiliation(s)
- Lillian Ham
- HIV Neurobehavioral Research Program, UC San Diego, San Diego, California, USA
- SDSU/UC San Diego Joint Doctoral Program in Clinical Psychology, San Diego, California, USA
| | - Jessica L. Montoya
- HIV Neurobehavioral Research Program, UC San Diego, San Diego, California, USA
- Department of Psychiatry and University of California San Diego, La Jolla, California, USA
| | - Vanessa Serrano
- HIV Neurobehavioral Research Program, UC San Diego, San Diego, California, USA
- SDSU/UC San Diego Joint Doctoral Program in Clinical Psychology, San Diego, California, USA
| | - Samantha Yeager
- HIV Neurobehavioral Research Program, UC San Diego, San Diego, California, USA
- Department of Medicine, University of California San Diego, La Jolla, California, USA
| | - Dafna Paltin
- HIV Neurobehavioral Research Program, UC San Diego, San Diego, California, USA
- SDSU/UC San Diego Joint Doctoral Program in Clinical Psychology, San Diego, California, USA
| | | | - Maria J. Marquine
- Geriatrics Division, Department of Medicine, Duke University School of Medicine, Durham, North Carolina, USA
| | - Martin Hoenigl
- Department of Medicine, University of California San Diego, La Jolla, California, USA
- Department of Medicine, Medical University of Graz, Graz, Austria
| | - Christian B. Ramers
- Laura Rodriguez Research Institute, Family Health Centers, San Diego, California, USA
| | - John Kua
- Laura Rodriguez Research Institute, Family Health Centers, San Diego, California, USA
| | - David J. Moore
- HIV Neurobehavioral Research Program, UC San Diego, San Diego, California, USA
- Department of Psychiatry and University of California San Diego, La Jolla, California, USA
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23
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Mogaka JN, Otieno FA, Akim E, Beima-Sofie K, Dettinger J, Gomez L, Marwa M, Odhiambo B, Ngure K, Ronen K, Sharma M, John-Stewart G, Richardson B, Stern J, Unger J, Udren J, Watoyi S, Pintye J, Kinuthia J. A Text Messaging-Based Support Intervention to Enhance Pre-exposure Prophylaxis for HIV Prevention Adherence During Pregnancy and Breastfeeding: Protocol for a Randomized Controlled Trial. JMIR Res Protoc 2023; 12:e41170. [PMID: 36716092 PMCID: PMC9926344 DOI: 10.2196/41170] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2022] [Revised: 11/22/2022] [Accepted: 12/06/2022] [Indexed: 01/31/2023] Open
Abstract
BACKGROUND Cisgender women in Kenya are at elevated risk of HIV acquisition during pregnancy and post partum. Acute HIV infection during pregnancy and breastfeeding accounts for approximately one-third of all vertical HIV transmissions. The World Health Organization recommends offering oral tenofovir-based pre-exposure prophylaxis (PrEP) to pregnant and postpartum women who are HIV negative but at substantial and ongoing risk for HIV acquisition. PrEP delivery for pregnant and postpartum women is expanding within routine maternal child health clinics in Kenya. However, approximately half of pregnant women discontinue PrEP within 30 days of initiation. Therefore, it is crucial to develop PrEP adherence strategies that enhance support for adherence when peripartum events and health issues pose challenges to sustaining PrEP adherence. OBJECTIVE We are conducting a randomized controlled trial to determine the effect of a bidirectional communication platform named Mobile Solutions for Women's and Children's Health (mWACh), which utilizes two-way SMS text messaging between patients and remote nurses to support PrEP adherence and address maternal health concerns in real time during the peripartum period. METHODS The mWACh-PrEP study is a randomized trial designed to support PrEP adherence during the peripartum period by comparing mWACh-PrEP to the standard of care (ie, in-clinic adherence counseling) among women who are HIV negative and initiating PrEP. Purposive sampling was used to select 5 facilities offering PrEP in antenatal clinics in Kisumu and Siaya Counties, and block randomization will be used to divide participants into groups. Participants in the intervention arm will receive a customized messaging curriculum via SMS text messages targeted toward their particular perinatal stage. The primary outcome, PrEP adherence at 6 months post partum, will be evaluated using a log-binomial regression model, adjusting for imbalanced baseline characteristics. Based on a previous study of directly observed dosing conditions, we will use a hair tenofovir concentration cutoff of 0.038 ng/mg (corresponding to 7 doses/week) as the primary adherence outcome measured at 6 months post partum (binary outcome). Qualitative interviews and cost-effective analyses will be conducted to understand the feasibility, acceptability, and economic impact of the intervention. RESULTS Enrollment began in March 2022 and is projected to continue until July 2023, with follow-up through March 2024. The study results are expected to be reported in 2025. CONCLUSIONS This trial will provide insights into using mobile health to enhance PrEP adherence among pregnant and postpartum mothers. Additionally, the findings will have implications for the use of mobile health technology to improve adherence to other daily medications during the peripartum period. TRIAL REGISTRATION ClinicalTrials.gov NCT04472884; https://clinicaltrials.gov/ct2/show/NCT04472884. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID) DERR1-10.2196/41170.
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Affiliation(s)
| | | | | | - Kristin Beima-Sofie
- Department of Global Health, University of Washington, Seattle, WA, United States
| | - Julia Dettinger
- Department of Global Health, University of Washington, Seattle, WA, United States
| | - Lauren Gomez
- Department of Global Health, University of Washington, Seattle, WA, United States
| | - Mary Marwa
- Kenyatta National Hospital, Nairobi, Kenya
| | | | - Kenneth Ngure
- Department of Global Health, University of Washington, Seattle, WA, United States
- School of Public Health, Jomo Kenyatta University of Agriculture and Technology, Nairobi, Kenya
| | - Keshet Ronen
- Department of Global Health, University of Washington, Seattle, WA, United States
| | - Monisha Sharma
- Department of Global Health, University of Washington, Seattle, WA, United States
| | - Grace John-Stewart
- Department of Global Health, University of Washington, Seattle, WA, United States
| | - Barbra Richardson
- Department of Global Health, University of Washington, Seattle, WA, United States
- Department of Biostatistics, University of Washington, Seattle, WA, United States
| | - Joshua Stern
- Department of Biostatistics, University of Washington, Seattle, WA, United States
| | - Jennifer Unger
- Department of Global Health, University of Washington, Seattle, WA, United States
- Women and Infants Hospital, Providence, RI, United States
| | - Jenna Udren
- Department of Global Health, University of Washington, Seattle, WA, United States
| | | | - Jillian Pintye
- School of Nursing, University of Washington, Seattle, WA, United States
- Department of Global Health, University of Washington, Seattle, WA, United States
| | - John Kinuthia
- Kenyatta National Hospital, Nairobi, Kenya
- Department of Global Health, University of Washington, Seattle, WA, United States
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24
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Serrano VB, Moore DJ, Morris S, Tang B, Liao A, Hoenigl M, Montoya JL. Efficacy of Daily Text Messaging to Support Adherence to HIV Pre-Exposure Prophylaxis (PrEP) among Stimulant-Using Men Who Have Sex with Men. Subst Use Misuse 2023; 58:465-469. [PMID: 36659873 PMCID: PMC10122514 DOI: 10.1080/10826084.2023.2165409] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
Abstract
Background: Men who have sex with men (MSM) who use stimulants are at increased risk for HIV infection. Adherence to pre-exposure prophylaxis (PrEP) reduces the risk of HIV infection. We evaluated the efficacy of the individualized Texting for Adherence Building (iTAB) intervention for PrEP adherence compared to standard of care (SoC) among 119 MSM who use stimulants (cocaine, methamphetamine and/or other amphetamine) from the California Collaborative Treatment Group 595 randomized control trial.Method: Three ordered levels of PrEP adherence (non-adherence, adequate adherence, and near-perfect adherence) were compared between intervention arms across study visits (weeks 12 and 48) using ordinal logistic regressions.Results: The effect of intervention arm was not significant in the final model; however, there was a 38% decrease in odds (OR = 0.62, p=.023) of having near-perfect adherence (versus non-adherence or adequate adherence) at week 48 compared to week 12, indicating a significant effect of time. In a follow-up analysis examining week 48 only, logistic regression examining PrEP adherence showed that receiving iTAB (compared to SoC) trended toward higher odds of near-perfect adherence relative to adequate adherence (OR = 2.48, p=.061). Higher HIV knowledge resulted in higher odds (OR = 1.72, p=.020) of near-perfect adherence (versus non-adherence or adequate adherence).Conclusion: HIV knowledge may influence PrEP adherence, and most notably, the iTAB intervention may support near-perfect adherence relative to adequate adherence.
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Affiliation(s)
- Vanessa B. Serrano
- San Diego State University/University of California, San Diego Joint Doctoral Program in Clinical Psychology, San Diego, CA, USA
| | - David J. Moore
- Department of Psychiatry, University of California, San Diego, La Jolla, CA, USA
| | - Sheldon Morris
- Department of Family Medicine, University of California, San Diego, La Jolla, CA, USA
- Division of Infectious Diseases and Global Public Health, Department of Medicine, University of California, San Diego, La Jolla, CA, USA
| | - Bin Tang
- HIV Neurobehavioral Research Program, San Diego, CA, USA
| | - Antony Liao
- HIV Neurobehavioral Research Program, San Diego, CA, USA
| | - Martin Hoenigl
- Division of Infectious Diseases and Global Public Health, Department of Medicine, University of California, San Diego, La Jolla, CA, USA
- Division of Infectious Diseases, Department of Internal Medicine, Medical University of Graz, Graz, Austria
| | - Jessica L. Montoya
- Department of Psychiatry, University of California, San Diego, La Jolla, CA, USA
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25
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Mbotwa CH, Kazaura MR, Moen K, Lichtwarck HO, Leshabari MT, Metta E, Mmbaga EJ. Effect of an mHealth intervention on retention in HIV pre-exposure prophylaxis services among female sex workers: Preliminary evidence of the use of the Jichunge app in Dar es Salaam, Tanzania. Digit Health 2023; 9:20552076231170507. [PMID: 37113256 PMCID: PMC10126669 DOI: 10.1177/20552076231170507] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2022] [Accepted: 03/31/2023] [Indexed: 04/29/2023] Open
Abstract
Background Mobile health (mHealth) applications have been reported to be effective in promoting access and adherence to health services. However, knowledge about their effect on retention in HIV preventive services among at-risk populations in sub-Saharan Africa is limited. Objective We aimed to evaluate the effect of the Jichunge mHealth application on retention in HIV pre-exposure prophylaxis (PrEP) services among female sex workers in Dar es Salaam, Tanzania. Methods We used respondent-driven sampling to recruit female sex workers eligible for PrEP and who owned a smartphone. All study participants were provided with a smartphone application (Jichunge app) aiming to promote PrEP use through medication reminders, easy access to PrEP information, online consultations with a doctor and/or peer educator, and online discussions between PrEP users. The effect of optimal use of the Jichunge app on retention in PrEP services at 1-month was modelled using log-binomial regression. Results A total of 470 female sex workers with a median age of 26 (interquartile range: 22-30) years were recruited. Overall, 27.7% of female sex workers were retained in PrEP services at 1 month. Retention was twice as high among optimal users of the app than among sub-optimal users (adjusted risk ratios = 2.00, 95% confidence interval (CI): 1.41-2.83, p < 0.001). Conclusion The optimal use of the Jichunge mHealth application was significantly associated with higher retention in PrEP services among female sex workers in Dar es Salaam.
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Affiliation(s)
- Christopher H Mbotwa
- Department of Epidemiology and
Biostatistics, Muhimbili University of Health and Allied
Sciences, Dar es Salaam, Tanzania
- Mbeya College of Health and Allied
Sciences, University of Dar es Salaam, Mbeya, Tanzania
- Christopher H Mbotwa, Department of
Epidemiology and Biostatistics, Muhimbili University of Health and Allied
Sciences, P.O.Box 65015, Dar es Salaam, Tanzania.
| | - Method R Kazaura
- Department of Epidemiology and
Biostatistics, Muhimbili University of Health and Allied
Sciences, Dar es Salaam, Tanzania
| | - Kåre Moen
- Department of Community Medicine and
Global Health, Institute of Health and Society, Faculty of Medicine, University of Oslo, Oslo, Norway
| | - Hanne O Lichtwarck
- Department of Community Medicine and
Global Health, Institute of Health and Society, Faculty of Medicine, University of Oslo, Oslo, Norway
| | - Melkizedeck T Leshabari
- Department of Behavioural Sciences, Muhimbili University of Health and Allied
Sciences, Dar es Salaam, Tanzania
| | - Emmy Metta
- Department of Behavioural Sciences, Muhimbili University of Health and Allied
Sciences, Dar es Salaam, Tanzania
| | - Elia J Mmbaga
- Department of Epidemiology and
Biostatistics, Muhimbili University of Health and Allied
Sciences, Dar es Salaam, Tanzania
- Department of Community Medicine and
Global Health, Institute of Health and Society, Faculty of Medicine, University of Oslo, Oslo, Norway
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Buchbinder SP, Siegler AJ, Coleman K, Vittinghoff E, Wilde G, Lockard A, Scott H, Anderson PL, Laborde N, van der Straten A, Christie RH, Marlborough M, Liu AY. Randomized Controlled Trial of Automated Directly Observed Therapy for Measurement and Support of PrEP Adherence Among Young Men Who have Sex with Men. AIDS Behav 2023; 27:719-732. [PMID: 35984607 PMCID: PMC9908647 DOI: 10.1007/s10461-022-03805-3] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/24/2022] [Indexed: 11/26/2022]
Abstract
Measurement of adherence to oral pre-exposure prophylaxis (PrEP) in real-time has been challenging. We developed DOT Diary, a smartphone application that combines automated directly observed therapy with a PrEP adherence visualization toolkit, and tested its ability to measure PrEP adherence and to increase adherence among a diverse cohort of young men who have sex with men (MSM). We enrolled 100 MSM in San Francisco and Atlanta and randomly assigned them 2:1 to DOT Diary versus standard of care. Concordance between DOT Diary measurement and drug levels in dried blood spots was substantial, with 91.0% and 85.3% concordance between DOT Diary and emtricitabine-triphosphate and tenofovir-diphosphate, respectively. There was no significant difference in the proportion of participants with detectable PrEP drug levels at 24 weeks between study arms. These results suggest DOT Diary is substantially better than self-reported measures of adherence, but additional interventions are needed to improve PrEP adherence over time.
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Affiliation(s)
- Susan P Buchbinder
- Bridge HIV, San Francisco Department of Public Health, San Francisco, CA, USA.
- Department of Medicine, University of California San Francisco, San Francisco, CA, USA.
- Department of Epidemiology and Biostatistics, University of California, San Francisco, CA, USA.
- Bridge HIV, San Francisco Department of Public Health, 25 Van Ness Avenue, Suite 100, San Francisco, CA, 94102, USA.
| | - Aaron J Siegler
- Department of Epidemiology, Emory University, Atlanta, GA, USA
| | - Kenneth Coleman
- Bridge HIV, San Francisco Department of Public Health, San Francisco, CA, USA
| | - Eric Vittinghoff
- Department of Epidemiology and Biostatistics, University of California, San Francisco, CA, USA
| | - Gretchen Wilde
- Department of Epidemiology, Emory University, Atlanta, GA, USA
| | - Annie Lockard
- Department of Epidemiology, Emory University, Atlanta, GA, USA
| | - Hyman Scott
- Bridge HIV, San Francisco Department of Public Health, San Francisco, CA, USA
- Department of Medicine, University of California San Francisco, San Francisco, CA, USA
| | | | | | - Ariane van der Straten
- Department of Medicine, University of California San Francisco, San Francisco, CA, USA
- ASTRA Consulting, Kensington, CA, USA
| | | | | | - Albert Y Liu
- Bridge HIV, San Francisco Department of Public Health, San Francisco, CA, USA
- Department of Medicine, University of California San Francisco, San Francisco, CA, USA
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27
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Brothers J, Hosek S, Keckler K, Anderson PL, Xiong D, Liu H, Huhn G. The ATEAM study: Advances in technology to enhance PrEP adherence monitoring (ATEAM) among young men who have sex with men. Clin Transl Sci 2022; 15:2947-2957. [PMID: 36106611 PMCID: PMC9747125 DOI: 10.1111/cts.13414] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2022] [Revised: 07/14/2022] [Accepted: 08/17/2022] [Indexed: 01/26/2023] Open
Abstract
Young age has consistently correlated with lower adherence to pre-exposure prophylaxis (PrEP) in young men who have sex with men (YMSM). Digital medicine, a dynamic healthcare platform of wearable physiological sensors and mobile communication technology that can respond to medication nonadherence rapidly, has the potential in promoting PrEP adherence. We evaluated the feasibility and acceptability of Proteus Discover, a digital monitoring adherence system, to measure PrEP adherence and provide real-time feedback among cisgender YMSM and transgender women. One hundred HIV-negative young men and transgender women ages 16-24 years were enrolled in a 24-week randomized controlled crossover study to tenofovir disoproxil fumarate with emtricitabine (TDF/FTC) coencapsulated with Proteus Discover versus TDF/FTC standard-of-care. Participants in the 12-week Proteus Discover arm received weekly SMS text messages to promote pill taking based on Proteus Discover adherence data. Dried blood spots (DBS) were collected at 4-week intervals for tenofovir diphosphate (TFV-DP) in red blood cells as the referent and questionnaires were completed to assess acceptability, usability, and patterns of use. Linear mixed models analyzed the relationship between 30-day adherence measured by DBS and Proteus Discover. PrEP adherence was high overall. Adherence, as measured by DBS, was correlated with adherence as measured by Proteus Discover (p value = 0.03). Most participants reported that Proteus Discover helped them take their PrEP daily and that the system was easy to use. However, a majority (53.5%-60.5%) disagreed with the statement that wearing the patch was not an issue. There was an incremental increase in TFV-DP in DBS with adherence by Proteus Discover. More research is warranted to explore optimizing PrEP adherence for youth through real-time monitoring.
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Affiliation(s)
- Jennifer Brothers
- Hektoen Institute of MedicineChicagoIllinoisUSA,Cook County Department of Public HealthChicagoIllinoisUSA
| | - Sybil Hosek
- Stroger Hospital of Cook CountyChicagoIllinoisUSA
| | | | - Peter L. Anderson
- University of Colorado Skaggs School of Pharmacy and Pharmaceutical SciencesAuroraColoradoUSA
| | - Di Xiong
- Division of Oral and Systemic Health Sciences, School of DentistryUniversity of CaliforniaLos AngelesCaliforniaUSA,Departments of Biostatistics, Fielding School of Public HealthUniversity of CaliforniaLos AngelesCaliforniaUSA
| | - Honghu Liu
- Division of Oral and Systemic Health Sciences, School of DentistryUniversity of CaliforniaLos AngelesCaliforniaUSA,Departments of Biostatistics, Fielding School of Public HealthUniversity of CaliforniaLos AngelesCaliforniaUSA,Department of Health Policy and Management, Fielding School of Public HealthUniversity of CaliforniaLos AngelesCaliforniaUSA
| | - Gregory Huhn
- Stroger Hospital of Cook CountyChicagoIllinoisUSA,Ruth M. Rothstein CORE CenterChicagoIllinoisUSA
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28
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Madhani A, Finlay KA. Using the COM-B model to characterize the barriers and facilitators of pre-exposure prophylaxis (PrEP) uptake in men who have sex with men. Br J Health Psychol 2022; 27:1330-1353. [PMID: 35698439 PMCID: PMC9796940 DOI: 10.1111/bjhp.12605] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2021] [Revised: 04/14/2022] [Accepted: 05/16/2022] [Indexed: 01/07/2023]
Abstract
OBJECTIVES Using the COM-B model, this study aimed to characterize barriers and facilitators to pre-exposure prophylaxis (PrEP) uptake amongst men who have sex with men (MSM). DESIGN AND METHOD Semistructured interviews with 13 MSM who were non-PrEP users were conducted with a specific focus on barriers and facilitators to PrEP uptake. A 15-item interview schedule was created informed by the COM-B model. Transcripts were transcribed verbatim and inductively analysed using thematic analysis. To illustrate pathways for intervention design, inductive themes were then deductively mapped onto COM-B constructs. RESULTS Results demonstrated that barriers to PrEP uptake were closely aligned with five (of six) COM-B components: psychological capability, physical opportunity, social opportunity, reflective motivation and automatic motivation. These COM-B subcomponents reflected seven thematized barriers: (1) limited information about PrEP, (2) restricted access to PrEP, (3) gay identity and sexual stigmatization, (4) social and cultural stigmatization, (5) capabilities in treatment adherence, (6) optimistic bias about sexual behaviours and (7) calculating risk. No facilitators or physical capability concerns were demonstrated. CONCLUSION This study adopted a novel behaviour change-informed approach to understanding barriers and facilitators to PrEP uptake amongst MSM. Unrealistic optimism about self-protective individual behaviours, the physical accessibility of PrEP and (mis)information together interacted closely with perceptions of personal and social stigmatization to dynamically impact PrEP uptake decisions. Barriers to PrEP uptake mapped clearly to the COM-B; therefore, these results provide the foundation for Behaviour Change Wheel intervention development to improve rates of PrEP uptake and its acceptability for MSM.
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Affiliation(s)
- Adam Madhani
- School of PsychologyUniversity of BuckinghamBuckinghamUK
| | - Katherine A. Finlay
- School of Psychology and Clinical Language SciencesUniversity of ReadingReadingUK
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29
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Mitchell JT, Burns CM, Atkinson B, Cottrell M, Frye JK, McKellar MS, Kashuba ADM, McClernon FJ, Okeke NL. Feasibility, Acceptability, and Preliminary Efficacy of a Gamified Mobile Health Contingency Management Intervention for PrEP Adherence Among Black MSM. AIDS Behav 2022; 26:3311-3324. [PMID: 35416595 PMCID: PMC9474612 DOI: 10.1007/s10461-022-03675-9] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/26/2022] [Indexed: 11/01/2022]
Abstract
Oral HIV pre-exposure prophylaxis (PrEP) is effective at preventing HIV. However, low adherence is common and undermines these protective effects. This is particularly relevant for groups with disproportionately higher rates of HIV, including Black men who have sex with men (MSM). The current study tested the feasibility, acceptability, and preliminary efficacy of a gamified mobile health contingency management intervention for PrEP adherence-called mSMART (Mobile App-Based Personalized Solutions for Medication Adherence of Rx Pill Tool). Fifteen Black MSM already prescribed PrEP in the community completed baseline and follow-up assessments separated by 8 weeks of using mSMART. Regarding feasibility, there was no study attrition, no mSMART functional difficulties that significantly interfered with use, and a mean rate of 82% daily mSMART use. Acceptability ratings were in the moderately to extremely satisfied range for factors such as willingness to recommend mSMART to others and user-friendliness, and in the low range for ratings on difficulty learning how to use mSMART. Scores on a system usability measure were in the acceptable range for 73% of the sample. Qualitative analysis of follow-up interviews identified individual components of mSMART that could be modified in future iterations to make it more engaging. PrEP composite adherence scores from biomarkers indicated an improvement from baseline to follow-up with a medium effect size, as well as a decrease in the number of perceived barriers to medication adherence. Findings indicate a future efficacy trial is needed to examine the effects of this gamified mobile health contingency management intervention on PrEP adherence.
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Affiliation(s)
- John T Mitchell
- Department of Psychiatry & Behavioral Sciences, Duke University Medical Center, 2608 Erwin Road, Pavilion East, Suite 300, Durham, NC, 27705, USA.
- Duke Center for Addiction Science and Technology, Durham, NC, USA.
| | - Charles M Burns
- Division of Infectious Diseases, Duke University Medical Center, Durham, NC, USA
| | - Breyah Atkinson
- Division of Infectious Diseases, Duke University Medical Center, Durham, NC, USA
| | - Mackenzie Cottrell
- Division of Pharmacotherapy and Experimental Therapeutics, UNC Eshelman School of Pharmacy, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Justin K Frye
- Division of Infectious Diseases, Duke University Medical Center, Durham, NC, USA
| | - Mehri S McKellar
- Division of Infectious Diseases, Duke University Medical Center, Durham, NC, USA
| | - Angela D M Kashuba
- Division of Pharmacotherapy and Experimental Therapeutics, UNC Eshelman School of Pharmacy, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - F Joseph McClernon
- Department of Psychiatry & Behavioral Sciences, Duke University Medical Center, 2608 Erwin Road, Pavilion East, Suite 300, Durham, NC, 27705, USA
- Duke Center for Addiction Science and Technology, Durham, NC, USA
| | - Nwora Lance Okeke
- Division of Infectious Diseases, Duke University Medical Center, Durham, NC, USA
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30
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Christensen RE, Ranpariya V, Kammrath LK, Masicampo EJ, Roberson KB, Feldman SR. The presence of accountability in digital interventions targeting non-adherence: A review. PATIENT EDUCATION AND COUNSELING 2022; 105:2637-2644. [PMID: 35101306 DOI: 10.1016/j.pec.2022.01.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/11/2021] [Revised: 01/08/2022] [Accepted: 01/21/2022] [Indexed: 06/14/2023]
Abstract
OBJECTIVES Provider-centered accountability, defined as the anticipation of a social interaction between a patient and their provider, increases patients' adherence to prescribed treatment. Digital adherence interventions based on accountability may be especially effective at promoting adherence. The current study aimed to assess whether publications on digital adherence interventions discuss accountability, include intervention components related to accountability, and measure feelings of patient accountability as an outcome. METHODS PubMed was queried between January 2010 and March 2021 to identify randomized controlled trials incorporating digital adherence interventions. Full-text articles were assessed for participant demographics, interventions utilized, outcomes, and intervention effectiveness. RESULTS A total of 131 publications met inclusion criteria. Only four publications discussed accountability as a potential factor influencing patient adherence. Although 11% of publications included an intervention with direct accountability, only one did so by design. None of the included studies assessed feelings of accountability as an outcome. CONCLUSIONS While provider-centered accountability has the potential to boost the efficacy of digital adherence interventions, accountability is rarely incorporated in studies of such interventions. PRACTICE IMPLICATIONS Additional investigation into the influence of accountability on adherence interventions will allow for the development of these interventions as effective tools applicable to the full range of patients.
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Affiliation(s)
- Rachel E Christensen
- Department of Dermatology, Wake Forest School of Medicine, Winston-Salem, North Carolina, USA.
| | - Varun Ranpariya
- Department of Dermatology, Wake Forest School of Medicine, Winston-Salem, North Carolina, USA
| | - Lara K Kammrath
- Department of Psychology, Wake Forest University, Winston-Salem, North Carolina, USA
| | - E J Masicampo
- Department of Psychology, Wake Forest University, Winston-Salem, North Carolina, USA
| | - Kristina B Roberson
- Division of Nursing, School of Health Sciences, Winston-Salem State University, Winston-Salem, North Carolina, USA
| | - Steven R Feldman
- Department of Dermatology, Wake Forest School of Medicine, Winston-Salem, North Carolina, USA; Department of Pathology, Wake Forest School of Medicine, Winston-Salem, North Carolina, USA; Department of Social Sciences & Health Policy, Wake Forest School of Medicine, Winston-Salem, North Carolina, USA; Department of Dermatology, University of Southern Denmark, Odense, Denmark
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31
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Salisbury KR, Ranpariya VK, Feldman SR. Accountability in reminder-based adherence interventions: A review. PATIENT EDUCATION AND COUNSELING 2022; 105:2645-2652. [PMID: 34953618 DOI: 10.1016/j.pec.2021.12.009] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/18/2021] [Revised: 12/09/2021] [Accepted: 12/12/2021] [Indexed: 06/14/2023]
Abstract
OBJECTIVE Interventions to elicit accountability capitalize on social behaviors to improve adherence but are distinct from reminders. However, little is known about the impact of accountability in reminder-based adherence interventions. Through a literature review, we aim to identify the frequency and effectiveness of accountability in reminder-based intervention studies. METHODS PubMed and PsycArticles were searched for reminder-based adherence studies. Articles were categorized as reminder-only or reminder with accountability studies. Studies were characterized by outcome measures, and differences between control and intervention groups were compared for studies that used electronic monitoring devices. RESULTS 165 studies met the inclusion criteria; 154 used reminders without accountability (93%). 79 of the 154 reminder-only studies (51%) improved adherence in intervention groups compared to controls. Eleven of the 165 studies (6.6%) included an accountability aspect. The intervention group had better adherence than controls in 10 out of the 11 reminder with accountability studies (91%). CONCLUSIONS Although distinct from reminders, accountability can be incorporated in reminder-based interventions. However, it is not commonly included in reminder-based interventions. PRACTICE IMPLICATIONS It is important to consider accountability's effects on encouraging patient medication adherence. The addition of accountability interventions may further boost adherence, but few studies currently incorporate these types of interventions.
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Affiliation(s)
- Katherine R Salisbury
- Center for Dermatology Research, Department of Dermatology, Wake Forest School of Medicine, Winston-Salem, USA.
| | - Varun K Ranpariya
- Center for Dermatology Research, Department of Dermatology, Wake Forest School of Medicine, Winston-Salem, USA
| | - Steven R Feldman
- Center for Dermatology Research, Department of Dermatology, Wake Forest School of Medicine, Winston-Salem, USA; Department of Pathology, Wake Forest School of Medicine, Winston-Salem, USA; Department of Social Sciences & Health Policy, Wake Forest School of Medicine, Winston-Salem, USA; Department of Dermatology, University of Southern Denmark, Odense, Denmark
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32
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Mbotwa C, Kazaura M, Moen K, Leshabari M, Metta E, Leyna G, Mmbaga EJ. Predictors of mHealth use in promoting adherence to pre-exposure prophylaxis among female sex workers: an evaluation of the Jichunge intervention in Dar es Salaam, Tanzania. BMC Health Serv Res 2022; 22:859. [PMID: 35787285 PMCID: PMC9254514 DOI: 10.1186/s12913-022-08245-2] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2022] [Accepted: 06/21/2022] [Indexed: 11/10/2022] Open
Abstract
Background There is evidence that pre-exposure prophylaxis (PrEP) is effective in preventing HIV transmission, and PrEP is recommended by the World Health organization (WHO) for use by individuals at high risk of HIV infection. However, low adherence has been reported to hamper its effectiveness. Some evidence indicates that mHealth interventions may be a promising way of promoting PrEP adherence. Nevertheless, evaluations of mHealth interventions in Africa, the region most affected by HIV, are scarce. This study aimed at identifying the extent of and predictors for use of a smartphone based mHealth application among female sex workers in Dar es Salaam, Tanzania. Methods As part of a quasi-experimental study in Tanzania, 470 female sex workers who were eligible for PrEP and who owned a smartphone were recruited using respondent driven sampling. All participants were provided with an mHealth application called Jichunge, a smartphone-based app designed to promote adherence to PrEP by offering users information, advise and support during start-up and use of PrEP. We collected data through structured interviews at baseline and extracted user data from the app for a period of 30 days. Modified Poisson regression model with robust standard errors was used to identify predictors for the optimal use of the Jichunge app. Results Overall, the optimal use of the Jichunge app was 46.4%. Optimal use was significantly higher among women who were older (aPR = 1.3, 95% CI: 1.10-1.65, p = 0.004 for age 25-34 years, and aPR = 1.6, 95% CI: 1.19-2.07, p = 0.001 for age at least 35 years), who had secondary education or higher (aPR = 1.8, 95% CI: 1.08-2.94, p = 0.023), who had suboptimal social support (aPR = 1.2, 95% CI: 1.02-1.48, p = 0.030), who had high awareness of PrEP (aPR = 1.3, 95% CI: 1.08-1.55, p = 0.005), and who had experience using common mainstream social media applications (aPR = 1.4, 95% CI: 1.08-1.71, p = 0.009). Conclusion Optimal use of the Jichunge app was substantially higher among women with higher age, higher education, higher PrEP awareness, less social support, and experience using common social media applications. Individual and interpersonal factors should be considered in planning mHealth interventions. Further studies to determine predictors of longer-term mHealth engagement are needed. Trial registration International Clinical Trials Registry Platform PACTR202003823226570; 04.03.2020.
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Affiliation(s)
- Christopher Mbotwa
- Department of Epidemiology and Biostatistics, Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania. .,Mbeya College of Health and Allied Sciences, University of Dar es Salaam, Mbeya, Tanzania.
| | - Method Kazaura
- Department of Epidemiology and Biostatistics, Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania
| | - Kåre Moen
- Department of Community Medicine and Global Health, Institute of Health and Society, Faculty of Medicine, University of Oslo, Oslo, Norway
| | - Melkizedeck Leshabari
- Department of Behavioural sciences, Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania
| | - Emmy Metta
- Department of Behavioural sciences, Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania
| | - Germana Leyna
- Department of Epidemiology and Biostatistics, Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania.,Tanzania Food and Nutrition Centre, Dar es Salaam, Tanzania
| | - Elia J Mmbaga
- Department of Epidemiology and Biostatistics, Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania.,Department of Community Medicine and Global Health, Institute of Health and Society, Faculty of Medicine, University of Oslo, Oslo, Norway
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Hassan A, Agustin HGS, Burke L, Kofron R, Corado K, Bolan R, Landovitz RJ, Dubé MP, Morris SR. Low incidence and prevalence of hepatitis C in two cohorts of HIV pre-exposure prophylaxis adherence interventions in men who have sex with men in Southern California. J Viral Hepat 2022; 29:529-535. [PMID: 35357767 PMCID: PMC9908082 DOI: 10.1111/jvh.13678] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/10/2021] [Revised: 03/03/2022] [Accepted: 03/08/2022] [Indexed: 02/02/2023]
Abstract
HIV pre-exposure prophylaxis (PrEP) has been associated with incident hepatitis C virus (HCV) infection in men who have sex with men (MSM) due to decreased condom use. We examined rates of HCV among MSM and transgender women at high-risk of HIV on PrEP in Southern California using data from two trials (NCT01761643 and NCT01781806). Five of 599 participants (0.84%, 95% CI, 0.27-1.93) had HCV antibodies detected at entry. Factors associated with HCV seropositivity included being older (p = .002) and lower education level (p < .001). HCV-positive participants had no reported cases of sexually transmitted infection (rectal, urethral or pharyngeal gonorrhoea and/or chlamydia) at entry while HCV-negative participants had a prevalence of 18% (95% CI, 15%-21%). There were no significant differences in substance use and sexual risk behaviour between HCV-positive and HCV-negative participants 1-3 months prior to entry. Among early PrEP adopters, incident HCV did not occur despite ongoing condomless intercourse. Screening intervals for HCV in MSM on PrEP should be led by a risk behaviour assessment.
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Affiliation(s)
- Adiba Hassan
- Department of Medicine, University of California, San Diego, CA, USA,Department of Epidemiology, University of California Los Angeles Fielding School of Public Health, CA, USA * research was conducted at Department of Medicine, University of California, San Diego, CA, USA
| | | | - Leah Burke
- Department of Medicine, University of California, San Diego, CA, USA
| | - Ryan Kofron
- Department of Medicine, University of California, Los Angeles, CA, USA
| | - Katya Corado
- Division of HIV Medicine, Lundquist Institute for Biomedical Innovation at Harbor-UCLA Medical Center, Torrance, CA, USA
| | | | | | - Michael P Dubé
- Department of Medicine, University of Southern California, Los Angeles, CA, USA
| | - Sheldon R Morris
- Department of Medicine, University of California, San Diego, CA, USA
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Wang Y, Mitchell JW, Zhang C, Liu Y. Evidence and implication of interventions across various socioecological levels to address pre-exposure prophylaxis uptake and adherence among men who have sex with men in the United States: a systematic review. AIDS Res Ther 2022; 19:28. [PMID: 35754038 PMCID: PMC9233830 DOI: 10.1186/s12981-022-00456-1] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2022] [Accepted: 06/16/2022] [Indexed: 02/01/2023] Open
Abstract
BACKGROUND Pre-exposure prophylaxis (PrEP) represents a proven biomedical strategy to prevent HIV transmissions among men who have sex with men (MSM) in the United States (US). Despite the design and implementation of various PrEP-focus interventions in the US, aggregated evidence for enhancing PrEP uptake and adherence is lacking. The objective of this systematic review is to synthesize and evaluate interventions aimed to improve PrEP uptake and adherence among MSM in the US, and identify gaps with opportunities to inform the design and implementation of future PrEP interventions for these priority populations. METHODS We followed the PRISMA guidelines and conducted a systematic review of articles (published by November 28, 2021) with a focus on PrEP-related interventions by searching multiple databases (PubMed, MEDLINE, Web of Science and PsycINFO). Details of PrEP interventions were characterized based on their socioecological level(s), implementation modalities, and stage(s) of PrEP cascade continuum. RESULTS Among the 1363 articles retrieved from multiple databases, 42 interventions identified from 47 publications met the inclusion criteria for this review. Most individual-level interventions were delivered via text messages and/or apps and incorporated personalized elements to tailor the intervention content on participants' demographic characteristics or HIV risk behaviors. Interpersonal-level interventions often employed peer mentors or social network strategies to enhance PrEP adoption among MSM of minority race. However, few interventions were implemented at the community-, healthcare/institution- or multiple levels. CONCLUSIONS Interventions that incorporate multiple socioecological levels hold promise to facilitate PrEP adoption and adherence among MSM in the US given their acceptability, feasibility, efficacy and effectiveness. Future PrEP interventions that simultaneously address PrEP-related barriers/facilitators across multiple socioecological levels should be enhanced with a focus to tackle contextual and structural barriers (e.g., social determinants of health, stigma or medical mistrust) at the community- and healthcare/institution-level to effectively promote PrEP use for MSM of color.
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Affiliation(s)
- Ying Wang
- Department of Public Health Sciences, University of Rochester Medical Center, Rochester, NY, USA
| | - Jason W Mitchell
- Department of Health Promotion and Disease Prevention, Stempel College of Public Health and Social Work, Florida International University, Miami, FL, USA
| | - Chen Zhang
- School of Nursing, University of Rochester Medical Center, Rochester, NY, USA
| | - Yu Liu
- Department of Public Health Sciences, University of Rochester Medical Center, Rochester, NY, USA.
- Division of Epidemiology, Department of Public Health Sciences, University of Rochester Medical Center, 256 Crittenden Blvd, Ste. 3305, Rochester, NY, 14642, USA.
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Evans KN, Hassan R, Townes A, Buchacz K, Smith DK. The Potential of Telecommunication Technology to Address Racial/Ethnic Disparities in HIV PrEP Awareness, Uptake, Adherence, and Persistence in Care: A Review. AIDS Behav 2022; 26:3878-3888. [PMID: 35614366 PMCID: PMC9131988 DOI: 10.1007/s10461-022-03715-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/10/2022] [Indexed: 11/23/2022]
Abstract
Pre-exposure prophylaxis (PrEP) is highly effective in preventing new HIV infection, but uptake remains challenging among Black and Hispanic/Latino persons. The purpose of this review was to understand how studies have used electronic telecommunication technology to increase awareness, uptake, adherence, and persistence in PrEP care among Black and Hispanic/Latino persons and how it can reduce social and structural barriers that contribute to disparities in HIV infection. Of the 1114 articles identified, 10 studies were eligible. Forty percent (40%) of studies focused on Black or Hispanic/Latino persons and 80% addressed social and structural barriers related to PrEP use such as navigation or access to PrEP. Mobile health designs were more commonly used (50%) compared to telehealth (30%) and e-health (20%) designs. There is a need to increase the development of telecommunications interventions that address the needs of Black and Hispanic/Latino persons often challenged with uptake and adherent use of PrEP.
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Li C, Xiong Y, Muessig KE, Tang W, Huang H, Mu T, Tong X, Yu J, Yang Z, Sherer R, Hazra A, Lio J, Matthews DD, Fisher EB, Li L, Tucker JD. Community-engaged mHealth intervention to increase uptake of HIV pre-exposure prophylaxis (PrEP) among gay, bisexual and other men who have sex with men in China: study protocol for a pilot randomised controlled trial. BMJ Open 2022; 12:e055899. [PMID: 35537794 PMCID: PMC9092176 DOI: 10.1136/bmjopen-2021-055899] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/27/2021] [Accepted: 04/12/2022] [Indexed: 12/15/2022] Open
Abstract
INTRODUCTION The large number of key populations in China who would benefit from HIV pre-exposure prophylaxis (PrEP) in the context of limited health system capacity and public awareness will pose challenges for timely PrEP scale-up, suggesting an urgent need for innovative and accessible interventions. This study aims to develop and pilot test a theory-informed, tailored mobile phone intervention that was codeveloped by young gay men, HIV clinicians and public health researchers to increase engagement in PrEP education and initiation among Chinese gay, bisexual and other men who have sex with men (GBMSM), who bear a disproportionate burden of HIV infections and remain underserved in the healthcare system. METHODS AND ANALYSIS This two-phase study includes a formative assessment using in-depth interviews (N=30) and a 12-week experimental pilot study using a two-arm randomised controlled trial design (N=70). The primary intervention is delivered through a WeChat-based mini-app (a program built into a Chinese multipurpose social media application) developed by young GBMSM from a 2019 crowdsourcing hackathon. Using mixed methods, we will further investigate the specific needs and concerns among GBMSM in terms of using PrEP as an HIV prevention strategy, how their concerns and PrEP use behaviours may change with exposure to the mini-app intervention during the study period and how we can further refine this intervention tool to better meet GBMSM's needs for broader implementation. ETHICS AND DISSEMINATION This study and its protocols have been reviewed and approved by the Institutional Review Boards of the University of North Carolina at Chapel Hill, USA (19-3481), the Guangdong Provincial Dermatology Hospital, China (2020031) and the Guangzhou Eighth People's Hospital, China (202022155). Study staff will work with local GBMSM community-based organisations to disseminate the study results to participants and the community via social media, workshops and journal publications. TRIAL REGISTRATION NUMBER The study was prospectively registered on clinicaltrials.gov (NCT04426656) on 11 June 2020.
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Affiliation(s)
- Chunyan Li
- Department of Health Behavior, University of North Carolina at Chapel Hill Gillings School of Global Public Health, Chapel Hill, North Carolina, USA
| | - Yuan Xiong
- University of North Carolina Project-China, Guangzhou, Guangdong, China
| | - Kathryn E Muessig
- Department of Health Behavior, University of North Carolina at Chapel Hill Gillings School of Global Public Health, Chapel Hill, North Carolina, USA
| | - Weiming Tang
- University of North Carolina Project-China, Guangzhou, Guangdong, China
| | - Haojie Huang
- Wuhan Tongxing LGBTQ Center, Wuhan, Hubei, China
| | - Tong Mu
- Qingdao Eighth People's Hospital, Qingdao, Shandong, China
| | - Xiaokai Tong
- Xi'an Polytechnic University, Xi'an, Shaanxi, China
| | | | - Zeyu Yang
- University of North Carolina Project-China, Guangzhou, Guangdong, China
| | - Renslow Sherer
- Department of Medicine, University of Chicago, Chicago, Illinois, USA
| | - Aniruddha Hazra
- Department of Medicine, University of Chicago, Chicago, Illinois, USA
| | - Jonathan Lio
- Department of Medicine, University of Chicago, Chicago, Illinois, USA
| | - Derrick D Matthews
- Department of Health Behavior, University of North Carolina at Chapel Hill Gillings School of Global Public Health, Chapel Hill, North Carolina, USA
| | - Edwin B Fisher
- Department of Health Behavior, University of North Carolina at Chapel Hill Gillings School of Global Public Health, Chapel Hill, North Carolina, USA
| | - Linghua Li
- Infectious Diseases Research Department, Guangzhou Eighth People's Hospital, Guangzhou, Guangdong, China
| | - Joseph D Tucker
- Institute of Global Health and Infectious Diseases, Department of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
- Clinical Research Department, Faculty of Infectious and Tropical Diseases, London School of Hygiene & Tropical Medicine, London, UK
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Zhang J, Li C, Xu J, Hu Z, Rutstein SE, Tucker JD, Ong JJ, Jiang Y, Geng W, Wright ST, Cohen MS, Shang H, Tang W. Discontinuation, suboptimal adherence, and reinitiation of oral HIV pre-exposure prophylaxis: a global systematic review and meta-analysis. Lancet HIV 2022; 9:e254-e268. [PMID: 35364026 PMCID: PMC9124596 DOI: 10.1016/s2352-3018(22)00030-3] [Citation(s) in RCA: 55] [Impact Index Per Article: 27.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2021] [Revised: 01/19/2022] [Accepted: 01/26/2022] [Indexed: 12/26/2022]
Abstract
BACKGROUND Poor adherence to oral HIV pre-exposure prophylaxis (PrEP) diminishes its clinical and public health benefits. This study synthesises evidence regarding discontinuation, adherence, and reinitiation of PrEP among geographically diverse PrEP users. METHODS We did a systematic review and meta-analysis evaluating studies published in MEDLINE, Embase, and Cochrane Central Register of Controlled Trials from inception to Dec 18, 2020. We included longitudinal studies that presented data for PrEP discontinuation, defined as investigator-reported loss to follow-up or participant self-reported PrEP stoppage. Data were extracted from published reports and assessed for risk of bias. We used a random-effects meta-analysis to pool estimates of discontinuation and I2 and τ2 to evaluate heterogeneity. This study is registered with PROSPERO, CRD42020155675. FINDINGS We identified 4129 records, of which 59 articles were included (n=43 917 participants). 41·0% (95% CI 18·8-63·5) of participants discontinued PrEP within 6 months, with the highest rates in observational studies. The discontinuation rate in sub-Saharan Africa (47·5%, 95% CI: 29·4-66·4%) was higher than in other regions (p<0·001). Discontinuation rates were lower in studies with adherence interventions than in those without (24·7% vs 36·7%, p=0·015). Gay or bisexual men who have sex with men and transgender women offered daily or non-daily dosing options had lower discontinuation rates than those offered daily dosing alone (21·6% vs 31·5%; p<0·001). The pooled suboptimal adherence within 6 months was 37·7% (95% CI 8·4-66·9). Among people who discontinued PrEP, 47·3% (95% CI 31·5-63·2) reinitiated PrEP within 1 year of PrEP initiation. The included studies had poor quality in terms of study design, with a moderate risk of bias. INTERPRETATION Strategies to encourage reinitiating PrEP for new or persistent risk should be a focus of future PrEP implementation strategies. FUNDING National Institutes of Health and Nature Science Foundation of China.
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Affiliation(s)
- Jing Zhang
- The NHC Key Laboratory of AIDS Immunology and National Clinical Research Center for Laboratory Medicine of the First Affiliated Hospital of China Medical University
- Key Laboratory of AIDS Immunology, Chinese Academy of Medical Sciences
- Key Laboratory of AIDS Immunology of Liaoning Province
- Collaborative Innovation Center for Diagnosis and Treatment of Infectious Diseases
| | - Chunyan Li
- Department of Health Behavior of University of North Carolina
| | - Junjie Xu
- The NHC Key Laboratory of AIDS Immunology and National Clinical Research Center for Laboratory Medicine of the First Affiliated Hospital of China Medical University
- Key Laboratory of AIDS Immunology, Chinese Academy of Medical Sciences
- Key Laboratory of AIDS Immunology of Liaoning Province
- Collaborative Innovation Center for Diagnosis and Treatment of Infectious Diseases
| | - Zhili Hu
- The NHC Key Laboratory of AIDS Immunology and National Clinical Research Center for Laboratory Medicine of the First Affiliated Hospital of China Medical University
- Key Laboratory of AIDS Immunology, Chinese Academy of Medical Sciences
- Key Laboratory of AIDS Immunology of Liaoning Province
- Collaborative Innovation Center for Diagnosis and Treatment of Infectious Diseases
| | | | - Joseph D. Tucker
- Department of Medicine of University of North Carolina
- University of North Carolina Project-China
- Faculty of Infectious and Tropical Diseases of London School of Hygiene and Tropical Medicine
| | - Jason J Ong
- Faculty of Infectious and Tropical Diseases of London School of Hygiene and Tropical Medicine
- Monash University
| | - Yongjun Jiang
- The NHC Key Laboratory of AIDS Immunology and National Clinical Research Center for Laboratory Medicine of the First Affiliated Hospital of China Medical University
- Key Laboratory of AIDS Immunology, Chinese Academy of Medical Sciences
- Key Laboratory of AIDS Immunology of Liaoning Province
- Collaborative Innovation Center for Diagnosis and Treatment of Infectious Diseases
| | - Wenqing Geng
- The NHC Key Laboratory of AIDS Immunology and National Clinical Research Center for Laboratory Medicine of the First Affiliated Hospital of China Medical University
- Key Laboratory of AIDS Immunology, Chinese Academy of Medical Sciences
- Key Laboratory of AIDS Immunology of Liaoning Province
- Collaborative Innovation Center for Diagnosis and Treatment of Infectious Diseases
| | | | | | - Hong Shang
- The NHC Key Laboratory of AIDS Immunology and National Clinical Research Center for Laboratory Medicine of the First Affiliated Hospital of China Medical University
- Key Laboratory of AIDS Immunology, Chinese Academy of Medical Sciences
- Key Laboratory of AIDS Immunology of Liaoning Province
- Collaborative Innovation Center for Diagnosis and Treatment of Infectious Diseases
| | - Weiming Tang
- Department of Medicine of University of North Carolina
- University of North Carolina Project-China
- Dermatology Hospital of Southern Medical University
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Bristow CC, Hassan A, Moore DJ, Dubé MP, Corado K, Chow K, Ellorin E, Blumenthal J, Morris SR. Sexually transmitted infections among participants in an HIV PrEP adherence trial. Int J STD AIDS 2022; 33:397-403. [PMID: 35239448 DOI: 10.1177/09564624211053428] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND HIV PrEP effectiveness is highly dependent on adherence. High STI incidence has been reported among PrEP users. We assessed the relationship between STI incidence (CT, NG, and syphilis) and PrEP adherence. METHODS We performed a subanalysis of a controlled, open-label, two-arm, randomized clinical demonstration project of a text-message based adherence intervention. Participants had 48 weeks of follow-up and had STI testing every 12 or 24 weeks. PrEP adherence was measured at week 48 using intracellular tenofovir-diphosphate drug concentrations. We calculated incidence rate ratios for STIs among those adherent as compared with those not adherent to PrEP. RESULTS Of the 381 assessed for CT, NG and syphilis at one or more follow-up visits, there were 16 cases of syphilis or 5.0 per 100 person years (95% CI: 2.6, 7.5); 63 cases of NG or 26.3 per 100 person years (95% CI: 19.8, 32.8); and 81 cases of CT or 36.3 per 100 person years (95% CI: 28.4, 44.2). We found no association between adequate PrEP adherence and STI incidence (aIRR: 0.97 95% CI: 0.67, 1.40). CONCLUSIONS We found that the incidence of STIs was not significantly different between those adherent to PrEP and those non-adherent. Further research is needed to assess how PrEP use may impact STIs over time.
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Affiliation(s)
- Claire C Bristow
- Division of Infectious Diseases and Global Public Health, Department of Medicine, 12220University of California San Diego, La Jolla, CA, USA
| | - Adiba Hassan
- Division of Infectious Diseases and Global Public Health, Department of Medicine, 12220University of California San Diego, La Jolla, CA, USA.,Department of Epidemiology, Fielding School of Public Health, 25808University of California Los Angeles, CA, USA
| | - David J Moore
- Department of Psychiatry, 8784University of California San Diego, La Jolla, CA, USA
| | - Michael P Dubé
- Keck School of Medicine, University of Southern California, Los Angeles, CA, USA
| | - Katya Corado
- 117316Los Angeles Biomedical Research Institute at Harbor-UCLA Medical Center, Torrance, CA, USA
| | - Karen Chow
- Division of Infectious Diseases and Global Public Health, Department of Medicine, 12220University of California San Diego, La Jolla, CA, USA
| | - Eric Ellorin
- Division of Infectious Diseases and Global Public Health, Department of Medicine, 12220University of California San Diego, La Jolla, CA, USA
| | - Jill Blumenthal
- Division of Infectious Diseases and Global Public Health, Department of Medicine, 12220University of California San Diego, La Jolla, CA, USA
| | - Sheldon R Morris
- Division of Infectious Diseases and Global Public Health, Department of Medicine, 12220University of California San Diego, La Jolla, CA, USA
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Trang K, Le LX, Brown CA, To MQ, Sullivan PS, Jovanovic T, Worthman CM, Giang LM. Feasibility, Acceptability, and Design of a Mobile Ecological Momentary Assessment for High-Risk Men Who Have Sex With Men in Hanoi, Vietnam: Qualitative Study. JMIR Form Res 2022; 6:e30360. [PMID: 35084340 PMCID: PMC8950985 DOI: 10.2196/30360] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2021] [Revised: 10/28/2021] [Accepted: 11/21/2021] [Indexed: 12/26/2022] Open
Abstract
Background Men who have sex with men (MSM) are at a disproportionate risk for HIV infection and common mental disorders worldwide. In the context of HIV, common mental disorders are important and are frequent drivers of suboptimal prevention and treatment outcomes. Mobile ecological momentary assessments (EMAs), or the repeated sampling of people’s behaviors and psychological states in their daily lives using mobile phones, can clarify the triggers and HIV-related sequelae of depressive-anxious symptoms and contribute toward the design of ecological momentary interventions (EMIs) that cater to the contextually varying needs of individuals to optimize prevention and treatment outcomes. Objective This study aims to characterize the feasibility and acceptability of mobile EMA among high-risk MSM in Hanoi, Vietnam. It aims to evaluate the perceived relevance, usability, and concerns of this group with regard to the content and delivery of mobile EMA and the potential of leveraging such platforms in the future to deliver EMIs. Methods Between January and April 2018, a total of 46 participants were recruited. The participants completed 6 to 8 mobile EMA surveys daily for 7 days. Surveys occurred once upon waking, 4 to 6 times throughout the day, and once before sleeping. All surveys queried participants’ perceived safety, social interactions, psychological state, and mental health symptoms. The morning survey further queried on sleep and medication use within the past 24 hours, whereas the night survey queried on sexual activity and substance use and allowed participants to share an audio recording of a stressful experience they had that day. At the end of the week, participants were interviewed about their experiences with using the app. Results Participants completed an average of 21.7 (SD 12.7) prompts over the 7-day period. Excluding nonresponders, the average compliance rate was 61.8% (SD 26.6%). A thematic analysis of qualitative interviews suggested an overall positive reception of the app and 5 recurring themes, which were centered on the relevance of psychological and behavioral items to daily experiences (eg, mental health symptoms and audio recording), benefits of using the app (eg, increased self-understanding), worries and concerns (eg, privacy), usability (eg, confusion about the interface), and recommendations for future design (eg, integrating more open-ended questions). Conclusions Mobile EMA is feasible and acceptable among young MSM in Vietnam; however, more research is needed to adapt EMA protocols to this context and enhance compliance. Most participants eagerly provided information about their mental health status and daily activities. As several participants looked toward the app for further mental health and psychosocial support, EMIs have the potential to reduce HIV and mental health comorbidity among MSM.
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Affiliation(s)
- Kathy Trang
- Global TIES for Children, New York University, New York City, NY, United States
| | - Lam X Le
- Vietnam National University, Hanoi, Vietnam
| | | | - Margaret Q To
- Department of Psychiatry and Behavioral Sciences, School of Medicine, Emory University, Atlanta, GA, United States
| | - Patrick S Sullivan
- Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, GA, United States
| | - Tanja Jovanovic
- Department of Psychiatry and Behavioral Neuroscience, School of Medicine, Wayne State University, Detroit, MI, United States
| | - Carol M Worthman
- Department of Anthropology, Emory University, Atlanta, GA, United States
| | - Le Minh Giang
- Department of Epidemiology, Hanoi Medical University, Hanoi, Vietnam
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Wong HTH, Prankumar SK, Cui J, Tumwine C, Addo IY, Kan W, Noor MN. Information and communication technology-based health interventions for transgender people: A scoping review. PLOS GLOBAL PUBLIC HEALTH 2022; 2:e0001054. [PMID: 36962672 PMCID: PMC10021903 DOI: 10.1371/journal.pgph.0001054] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/28/2022] [Accepted: 08/19/2022] [Indexed: 11/18/2022]
Abstract
In the recent past, there has been a strong interest in the use of information and communication technology (ICT) to deliver healthcare to 'hard-to-reach' populations. This scoping review aims to explore the types of ICT-based health interventions for transgender people, and the concerns on using these interventions and ways to address these concerns. Guided by the scoping review frameworks offered by Arksey & O'Malley and the PRISMA-ScR checklist, literature search was conducted in May 2021 and January 2022 in three databases (PubMed, CINAHL and Scopus). The two searches yielded a total of 889 non-duplicated articles, with 47 of them meeting the inclusion criteria. The 47 articles described 39 unique health projects/programs, covering 8 types of ICT-based interventions: videoconferencing, smartphone applications, messaging, e-coaching, self-learning platforms, telephone, social media, and e-consultation platforms. Over 80% of the health projects identified were conducted in North America, and 62% focused on HIV/sexual health. The findings of this review suggest that transgender people had often been regarded as a small subsample in ICT-based health projects that target other population groups (such as 'men who have sex with men' or 'sexual minority'). Many projects did not indicate whether transgender people were included in the development or evaluation of the project. Relatively little is known about the implementation of ICT-based trans health interventions outside the context of HIV/sexual health, in resource limiting settings, and among transgender people of Asian, Indigenous or other non-White/Black/Hispanic backgrounds. While the range of interventions identified demonstrate the huge potentials of ICT to improve healthcare access for transgender people, the current body of literature is still far from adequate for making comprehensive recommendations on the best practice of ICT-based interventions for transgender people. Future ICT-based interventions need to be more inclusive and specified, in order to ensure the interventions are safe, accessible and effective for transgender people.
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Affiliation(s)
- Horas T H Wong
- Susan Wakil School of Nursing and Midwifery, The University of Sydney, Sydney, Australia
- The Albion Centre and t150 Transgender Health Service, NSW Health, Surry Hills, Australia
- Centre for Social Research in Health, UNSW Sydney, Kensington, Australia
| | - Sujith Kumar Prankumar
- Centre for Social Research in Health, UNSW Sydney, Kensington, Australia
- ARC Centre of Excellence for Automated Decision-Making and Society, Swinburne University, Melbourne, Australia
| | - Jialiang Cui
- Department of Social Work, Chinese University of Hong Kong, Hong Kong, Hong Kong
| | - Christopher Tumwine
- Department of Mental Health, School of Medicine, Kabale University, Kabale, Uganda
| | | | - Wansang Kan
- Department of Social Work, Chinese University of Hong Kong, Hong Kong, Hong Kong
| | - Muhammad Naveed Noor
- Department of Pathology and Laboratory Medicine, Aga Khan University, Karachi, Pakistan
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Shrestha R, Fisher C, Wickersham JA, Khati A, Kim R, Azwa I, Mistler C, Goldsamt L. Privacy and Confidentiality Concerns Related to the Use of mHealth Apps for HIV Prevention Efforts Among Malaysian Men Who Have Sex With Men: Cross-sectional Survey Study. JMIR Form Res 2021; 5:e28311. [PMID: 34924355 PMCID: PMC8726055 DOI: 10.2196/28311] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2021] [Revised: 07/19/2021] [Accepted: 11/21/2021] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND The use of mobile health (mHealth), including smartphone apps, can improve the HIV prevention cascade for key populations such as men who have sex with men (MSM). In Malaysia, where stigma and discrimination toward MSM are high, the mHealth platform has the potential to open new frontiers for HIV prevention efforts. However, little guidance is available to inform researchers about privacy and confidentiality concerns unique to the development and implementation of app-based HIV prevention programs. OBJECTIVE Given the lack of empirical data in this area, we aim to understand the privacy and confidentiality concerns associated with participation in a hypothetical app-based research study for HIV prevention efforts. METHODS A cross-sectional, web-based survey was conducted between June and July 2020 among 355 Malaysian MSM. The survey included demographic and sexual health questions and a series of short videos describing a hypothetical app-based HIV prevention program, followed by questions related to privacy and confidentiality concerns in each step of the app-based program (ie, recruitment, clinical interaction, risk assessment, and weekly reminder). Multivariable logistic regression models were used to identify the correlates of willingness to use such an app-based program. RESULTS Most of the participants (266/355, 74.9%) indicated their willingness to participate in a hypothetical mHealth app-based HIV prevention program. Participants expressed concerns about privacy, confidentiality, data security, and risks and benefits of participating in all stages of the app-based HIV research process. Multivariate analyses indicated that participants who had a higher degree of perceived participation benefits (adjusted odds ratio [aOR] 1.873; 95% CI 1.274-2.755; P=.001) were more willing to participate. In contrast, participants who had increased concerns about app-based clinical interaction and e-prescription (aOR 0.610; 95% CI 0.445-0.838; P=.002) and those who had a higher degree of perceived risks of participating (aOR 0.731; 95% CI 0.594-0.899; P=.003) were less willing to participate. CONCLUSIONS Overall, our results indicate that mHealth app-based HIV prevention programs are acceptable for future research on Malaysian MSM. The findings further highlighted the role of privacy and confidentiality, as well as the associated risks and benefits associated with participation in such a program. Given the ever-evolving nature of such technological platforms and the complex ethical-legal landscape, such platforms must be safe and secure to ensure widespread public trust and uptake.
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Affiliation(s)
- Roman Shrestha
- Department of Allied Health Sciences, University of Connecticut, Storrs, CT, United States
| | - Celia Fisher
- Center for Ethics Education, Fordham University, New York, NY, United States
| | | | - Antoine Khati
- Department of Allied Health Sciences, University of Connecticut, Storrs, CT, United States
| | - Rayne Kim
- Department of Internal Medicine, Yale University, New Haven, CT, United States
| | - Iskandar Azwa
- Department of Medicine, University of Malaya, Kuala Lumpur, Malaysia
| | - Colleen Mistler
- Department of Allied Health Sciences, University of Connecticut, Storrs, CT, United States
| | - Lloyd Goldsamt
- Rory Meyers School of Nursing, New York University, New York, NY, United States
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van den Elshout MAM, Hoornenborg E, Achterbergh RCA, Coyer L, Anderson PL, Davidovich U, de Vries HJC, Prins M, van der Loeff MFS. Improving adherence to daily preexposure prophylaxis among MSM in Amsterdam by providing feedback via a mobile application. AIDS 2021; 35:1823-1834. [PMID: 34001705 DOI: 10.1097/qad.0000000000002949] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
OBJECTIVE Improving adherence to preexposure prophylaxis (PrEP) by providing automated feedback on self-reported PrEP use via a mobile application (app). DESIGN Randomized clinical trial among MSM participating in the Amsterdam PrEP demonstration project (AMPrEP). METHODS Eligible participants were randomized 1 : 1 to the control or intervention app. Both allowed daily reporting of sexual behaviour and medication intake; the intervention app also provided visual feedback. Dried blood spots collected at 12 and 24 months yielded intracellular tenofovir diphosphate concentrations (TFV-DP). We assessed proportions of participants with poor (TFV-DP <700 fmol/punch; primary outcome), good (TFV-DP ≥700 fmol/punch) and excellent (TFV-DP ≥1250 fmol/punch; secondary outcome) adherence at both time-points, and the association with the control or intervention app. RESULTS We randomized 229 participants, 118 to the intervention and 111 to the control arm. The primary, per-protocol, analysis included 83 participants per arm. In total, 22/166 (13%) of participants adhered poorly, 144/166 (87%) good and 66/166 (40%) excellently. App feedback did not result in a lower proportion of participants with poor adherence [control: 9 of 83 (11%); intervention: 13 of 83 (16%); P = 0.36]. App feedback did result in a larger proportion of participants with excellent adherence [control: 26/83 (31%); intervention: 40/83 (48%); P = 0.026]. CONCLUSION In this highly adherent population, app feedback did not improve the proportion of participants with poor adherence to PrEP.Clinical Trial Number Netherlands Trial Register: NL5413.
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Affiliation(s)
- Mark A M van den Elshout
- Department of Infectious Diseases, Public Health Service of Amsterdam, Amsterdam, the Netherlands
| | - Elske Hoornenborg
- Department of Infectious Diseases, Public Health Service of Amsterdam, Amsterdam, the Netherlands
| | - Roel C A Achterbergh
- Department of Infectious Diseases, Public Health Service of Amsterdam, Amsterdam, the Netherlands
| | - Liza Coyer
- Department of Infectious Diseases, Public Health Service of Amsterdam, Amsterdam, the Netherlands
| | - Peter L Anderson
- Department of Pharmaceutical Sciences, University of Colorado Anschutz Medical Campus, Aurora, Colorado, USA
| | - Udi Davidovich
- Department of Infectious Diseases, Public Health Service of Amsterdam, Amsterdam, the Netherlands
- Department of Social Psychology, University of Amsterdam
| | - Henry J C de Vries
- Department of Infectious Diseases, Public Health Service of Amsterdam, Amsterdam, the Netherlands
- Amsterdam institute for Infection & Immunity (AII), Amsterdam UMC, University of Amsterdam, Amsterdam
- National Institute of Public Health and the Environment, Center for Infectious Disease Control, Bilthoven
| | - Maria Prins
- Department of Infectious Diseases, Public Health Service of Amsterdam, Amsterdam, the Netherlands
- Amsterdam institute for Infection & Immunity (AII), Amsterdam UMC, University of Amsterdam, Amsterdam
- Department of Infectious Diseases, Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlands
| | - Maarten F Schim van der Loeff
- Department of Infectious Diseases, Public Health Service of Amsterdam, Amsterdam, the Netherlands
- Amsterdam institute for Infection & Immunity (AII), Amsterdam UMC, University of Amsterdam, Amsterdam
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Baldwin A, Light B, Allison WE. Pre-Exposure Prophylaxis (PrEP) for HIV Infection in Cisgender and Transgender Women in the U.S.: A Narrative Review of the Literature. ARCHIVES OF SEXUAL BEHAVIOR 2021; 50:1713-1728. [PMID: 34075504 PMCID: PMC8213571 DOI: 10.1007/s10508-020-01903-8] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/01/2019] [Revised: 11/18/2020] [Accepted: 12/09/2020] [Indexed: 05/11/2023]
Abstract
Using a socioecological approach, this review describes the peer-reviewed literature on oral pre-exposure prophylaxis (PrEP) among both cisgender (cis women) and transgender women (trans women) in the U.S. A search of the PubMed database and HIV-related conference abstracts generated over 2,200 articles and abstracts. Of these, 103 fulfilled review inclusion criteria. Most of the existing research presents findings on individual-level factors associated with PrEP use such as willingness and perceived barriers. There was far less investigation of factors related to PrEP at more distal ecological levels. Though trans women are at greater risk of HIV infection than cisgender women, less is known about this population group with respect to PrEP despite their inclusion in many major clinical trials. Further, the literature is characterized by a persistent conflation of sex and gender which makes it difficult to accurately assess the reviewed research on HIV prevention and PrEP apart from risk group. Informed by these findings, we highlight specific opportunities to improve access to PrEP and reduce socioecological barriers to PrEP care engagement for cisgender and transgender women.
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Affiliation(s)
- Aleta Baldwin
- Department of Public Health, California State University, Sacramento, Solano Hall 3014, 6000 J Street, Sacramento, CA, 95819, USA.
| | - Brenda Light
- School of Nursing, University of Texas at Austin, Austin, TX, USA
| | - Waridibo E Allison
- Division of Infectious Disease, Department of Medicine, University of Texas Health Science Center at San Antonio, San Antonio, TX, USA
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Blumenthal J, Jain S, He F, Amico KR, Kofron R, Ellorin E, Stockman JK, Psaros C, Ntim GM, Chow K, Anderson PL, Haubrich R, Corado K, Moore DJ, Morris S, Landovitz RJ. Results from a PrEP Demonstration Project for At-Risk Cisgender Women in the United States. Clin Infect Dis 2021; 73:1149-1156. [PMID: 33864370 DOI: 10.1093/cid/ciab328] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2021] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Daily oral tenofovir disoproxil fumarate/emtricitabine (TDF/FTC) is effective for reducing HIV acquisition among cisgender women. We report results from the first United States observational open-label demonstration project of PrEP among at-risk cisgender women. METHODS Adherence Enhancement Guided by Individualized Texting and Drug Levels (AEGiS) was a 48-week single-arm open-label demonstration study of daily oral TDF/FTC in cisgender women ≥18 years old at-risk for HIV. Adherence was supported using two-way text messaging and titrated adherence counseling based on rapid-turnaround tenofovir diphosphate concentrations from dried blood spots. Study visits occurred at baseline, and at weeks 4, 12, and quarterly through week 48. Outcomes included TDF/FTC adherence, retention and persistence. RESULTS From June 2016 to October 2018, 136 cisgender women enrolled [mean age 40 (SD 11); 38% non-Hispanic (NH) Black and 19% Latina]. At 48 weeks, 84 (62%) participants were retained and 62 (46%) remained on PrEP. Over one-third (12/31) of those on study but off PrEP throughout study discontinued TDF/FTC due to side effects, and one adverse event led to study discontinuation. Of 120 participants with drug concentrations measured, 67 (56%) had at least one concentration consistent with ≥6 doses/week (d/w); 22 (18%) had consistent ≥6 d/w across all study visits attended. There were no incident HIV infections and 4 incident bacterial STIs. CONCLUSION Adequate PrEP adherence for protective drug concentrations was not achieved for most study participants. More work needs to be done to fully explicate the reasons for non-adherence and low retention in cisgender women.
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Affiliation(s)
- Jill Blumenthal
- Department of Medicine, University of California San Diego, San Diego, CA, USA
| | - Sonia Jain
- Department of Family Medicine and Public Health, University of California San Diego, San Diego, CA, USA
| | - Feng He
- Department of Family Medicine and Public Health, University of California San Diego, San Diego, CA, USA
| | - K Rivet Amico
- Department of Health Behavior and Health Education, School of Public Health, University of Michigan, Ann Arbor, MI, USA
| | - Ryan Kofron
- Department of Medicine, Ronald Reagan UCLA Medical Center, University of California Los Angeles, Los Angeles, CA, USA
| | - Eric Ellorin
- Department of Medicine, University of California San Diego, San Diego, CA, USA
| | - Jamila K Stockman
- Department of Medicine, University of California San Diego, San Diego, CA, USA
| | - Christina Psaros
- Department of Psychiatry, Massachusetts General Hospital, Boston, MA, USA
| | - Gifty M Ntim
- Department of Medicine, Ronald Reagan UCLA Medical Center, University of California Los Angeles, Los Angeles, CA, USA
| | - Karen Chow
- Department of Medicine, University of California San Diego, San Diego, CA, USA
| | - Peter L Anderson
- Department of Pharmaceutical Sciences, University of Colorado, Denver, CO, USA
| | | | - Katya Corado
- Department of Medicine, Harbor-UCLA Medical Center, Torrance, CA, USA
| | - David J Moore
- Department of Psychiatry, University of California San Diego, San Diego, CA, USA
| | - Sheldon Morris
- Department of Medicine, University of California San Diego, San Diego, CA, USA
| | - Raphael J Landovitz
- Department of Medicine, Ronald Reagan UCLA Medical Center, University of California Los Angeles, Los Angeles, CA, USA
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45
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Haberer JE, Bukusi EA, Mugo NR, Pyra M, Kiptinness C, Oware K, Garrison LE, Thomas KK, Musinguzi N, Morrison S, Anderson PL, Ngure K, Baeten JM. Effect of SMS reminders on PrEP adherence in young Kenyan women (MPYA study): a randomised controlled trial. Lancet HIV 2021; 8:e130-e137. [PMID: 33662265 PMCID: PMC8289198 DOI: 10.1016/s2352-3018(20)30307-6] [Citation(s) in RCA: 43] [Impact Index Per Article: 14.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2020] [Revised: 10/24/2020] [Accepted: 11/05/2020] [Indexed: 04/18/2023]
Abstract
BACKGROUND Pre-exposure prophylaxis (PrEP) is highly effective for preventing HIV acquisition. However, adherence among young women (aged 18-24 years) has been challenging. SMS reminders have been shown to improve adherence to antiretroviral therapy in some contexts, including in combination with real-time adherence monitoring. We aimed to determine the effect of SMS reminders on PrEP adherence among young women in Kenya over a 2-year period. METHODS The monitoring PrEP among young adult women (MPYA) study was an open label randomised controlled trial involving young adult women at high risk of HIV in Thika and Kisumu, Kenya. Participants were recruited from colleges, vocational institutions, informal settlements, and community-based organisations supporting young women. Women had to be aged 18-24 years and at high risk of HIV acquisition (defined as a VOICE risk score of 5 or higher, or being in a serodiscordant relationship). Study staff randomly assigned participants (1:1) to receive either SMS reminders (SMS reminder group) or no reminders (no SMS reminder group). Study group assignment was known to trial staff but masked to investigators. Reminders were initially sent daily and participants could switch to as-needed reminders (ie, sent only if they missed opening the monitor as expected) after 1 month. Study visits occurred at 1 month, 3 months, and then quarterly (ie, every 3 months). The primary outcome was PrEP adherence over 24 months measured with a real-time electronic monitor and assessed by negative binomial models adjusted for the study site and quarter among participants who collected PrEP. This trial is registered with ClinicalTrials.gov, NCT02915367. FINDINGS Of 642 women initially approached, 348 eligible women were enrolled between Dec 21, 2016, and Feb 5, 2018. Participants were randomly assigned to either the SMS reminder group (n=173) or the no SMS reminder group (n=175). The median age was 21 years (IQR 19-22) and 228 (66%) of the 348 participants reported condomless sex in the month before baseline. 24 (14%) of the 173 participants assigned to receive daily SMS reminders later opted for as-needed reminders. 69 291 (97%) of 71 791 SMS reminders were sent as planned. Among participants collecting PrEP (thus potentially suggesting a desire for HIV protection), electronically monitored adherence averaged 26·8% over 24 months and was similar by study group (27·0% with SMS, 26·6% without SMS, adjusted incidence rate ratio 1·16 [95% CI 0·93-1·45], p=0·19). There were no serious adverse events related to trial participation; five social harms occurred in each study group, primarily related to PrEP use. INTERPRETATION SMS reminders were ineffective in promoting PrEP adherence among young Kenyan women. Given the overall low adherence in the trial, additional interventions are needed to support PrEP use in this population. FUNDING US National Institute of Mental Health.
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Affiliation(s)
- Jessica E Haberer
- Center for Global Health, Massachusetts General Hospital, Boston, MA, USA; Department of Medicine, Harvard Medical School, Boston, MA, USA.
| | - Elizabeth A Bukusi
- Centre for Microbiology Research, Kenya Medical Research Institute, Kisumu, Kenya; Department of Global Health, University of Washington, Seattle, WA, USA
| | - Nelly R Mugo
- Department of Global Health, University of Washington, Seattle, WA, USA; Center for Clinical Research, Kenya Medical Research Institute, Thika, Kenya
| | - Maria Pyra
- Department of Medicine, University of Chicago, Chicago, IL, USA
| | | | - Kevin Oware
- Centre for Microbiology Research, Kenya Medical Research Institute, Kisumu, Kenya
| | - Lindsey E Garrison
- Center for Global Health, Massachusetts General Hospital, Boston, MA, USA
| | | | | | - Susan Morrison
- Department of Global Health, University of Washington, Seattle, WA, USA
| | - Peter L Anderson
- Department of Pharmaceutical Sciences, University of Colorado, Denver, CO, USA
| | - Kenneth Ngure
- Center for Clinical Research, Kenya Medical Research Institute, Thika, Kenya; Department of Community Heath, Jomo Kenyatta University of Agriculture and Technology, Nairobi, Kenya
| | - Jared M Baeten
- Department of Global Health, University of Washington, Seattle, WA, USA; Department of Medicine and Department of Epidemiology, University of Washington, Seattle, WA, USA; Gilead Sciences, Redwood City, CA, USA
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46
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Shrestha R, Lim SH, Altice FL, Copenhaver M, Wickersham JA, Saifi R, Ab Halim MA, Naning H, Kamarulzaman A. Use of Smartphone to Seek Sexual Health Information Online Among Malaysian Men Who Have Sex with Men (MSM): Implications for mHealth Intervention to Increase HIV Testing and Reduce HIV Risks. J Community Health 2020; 45:10-19. [PMID: 31375976 DOI: 10.1007/s10900-019-00713-x] [Citation(s) in RCA: 22] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
In settings where stigma and discrimination toward men who have sex with men (MSM) are high or illegal, like in Malaysia, innovative methods to anonymously reach them are urgently needed. The near ubiquitous availability of mobile technology, including smartphones, has the potential to open new frontiers (such as mHealth) to prevent HIV and other sexually transmitted infections (STIs). The extent to which MSM use mHealth tools for HIV and STI prevention in the Malaysia context, however, is unknown. A cross-sectional online survey in 622 Malaysian MSM was conducted between July and November 2017. Participants were recruited via advertisements on mobile apps frequently used by MSM. In addition to demographic, smartphone access and utilization, and other information were assessed using logistic regression to determine factors associated with the use of a smartphone to search for online sexual health information. Nearly all (99.2%) participants owned a smartphone, with 63% reported having used one to seek sexual health information, including HIV/STIs. Overall, 96% used smartphones to find sexual partners, with high levels of HIV risk behavior reported. Independent correlates of smartphone use to seek online sexual health information included older age (aOR 0.943, p = 0.005), higher education (aOR 2.14, p = 027), recent (past year) HIV testing (aOR 3.91, p = 0.026), and seeking sexual partners using geosocial networking apps (aOR 5.58, p = 0.006). These findings suggest high smartphone use by high-risk MSM to seek sexual health information and suggests that mHealth strategies may be an effective strategy to engage MSM in HIV prevention activities.
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Affiliation(s)
- Roman Shrestha
- Section of Infectious Diseases, Department of Internal Medicine, Yale School of Medicine, New Haven, CT, USA. .,Section of Infectious Diseases, Department of Internal Medicine, Yale School of Medicine, 135 College Street, Suite 323, New Haven, CT, 06510, USA.
| | - Sin How Lim
- Centre of Excellence for Research in AIDS (CERiA), Faculty of Medicine, University of Malaya, Kuala Lumpur, Malaysia
| | - Frederick L Altice
- Section of Infectious Diseases, Department of Internal Medicine, Yale School of Medicine, New Haven, CT, USA.,Centre of Excellence for Research in AIDS (CERiA), Faculty of Medicine, University of Malaya, Kuala Lumpur, Malaysia
| | - Michael Copenhaver
- Department of Allied Health Sciences, University of Connecticut, Storrs, CT, USA
| | - Jeffrey A Wickersham
- Section of Infectious Diseases, Department of Internal Medicine, Yale School of Medicine, New Haven, CT, USA.,Centre of Excellence for Research in AIDS (CERiA), Faculty of Medicine, University of Malaya, Kuala Lumpur, Malaysia
| | - Rumana Saifi
- Centre of Excellence for Research in AIDS (CERiA), Faculty of Medicine, University of Malaya, Kuala Lumpur, Malaysia
| | - Mohd Akbar Ab Halim
- Centre of Excellence for Research in AIDS (CERiA), Faculty of Medicine, University of Malaya, Kuala Lumpur, Malaysia
| | - Herlianna Naning
- Centre of Excellence for Research in AIDS (CERiA), Faculty of Medicine, University of Malaya, Kuala Lumpur, Malaysia
| | - Adeeba Kamarulzaman
- Centre of Excellence for Research in AIDS (CERiA), Faculty of Medicine, University of Malaya, Kuala Lumpur, Malaysia.,Department of Epidemiology of Microbial Diseases, Yale School of Public Health, New Haven, CT, USA
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47
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Abstract
PURPOSE OF REVIEW Standard care for HIV pre-exposure prophylaxis (PrEP) in the USA creates substantial burdens for patients, clinicians, and the healthcare system; to optimize uptake, there is a need for innovative strategies to streamline its provision. RECENT FINDINGS Our review, structured by the expanded chronic care model, identified eleven promising strategies to streamline PrEP care. Approaches ranged widely in mechanism of action. Using text messages to support care was the only strategy with clinical trial evidence supporting its use. Other modalities such as patient navigation, telemedicine PrEP models, alternate dosing availability, same-day prescription, and provider training have promising pilot or associational data and seem likely to lower barriers to entering into or remaining in care. Many of the strategies have established success in related domains such as HIV care, meriting consideration in evaluating their use for PrEP. Making PrEP care less burdensome will be an important part of bringing it to scale. Text message interventions have proven efficacy and merit broad adoption. Encouraging preliminary evidence for other strategies indicates the importance of building a stronger evidence base to clarify the effect of each strategy. Ongoing development of an evidence base should not delay the use of these promising strategies; instead, it calls for careful consideration for how each program may best match its environment to facilitate PrEP prescribing and use.
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Affiliation(s)
- Aaron J Siegler
- Department of Behavioral Sciences and Health Education, Emory University, Rollins School of Public Health, Atlanta, GA, USA.
| | - Kevin Steehler
- Department of Behavioral Sciences and Health Education, Emory University, Rollins School of Public Health, Atlanta, GA, USA
- Emory University, School of Medicine, Atlanta, GA, 30322, USA
| | - Jessica M Sales
- Department of Behavioral Sciences and Health Education, Emory University, Rollins School of Public Health, Atlanta, GA, USA
| | - Douglas S Krakower
- Division of Infectious Diseases, Beth Israel Deaconess Medical Center, The Fenway Institute, Fenway Health, Department of Population Medicine, Harvard Medical School, Boston, MA, USA
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48
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Colson PW, Franks J, Wu Y, Winterhalter FS, Knox J, Ortega H, El-Sadr WM, Hirsch-Moverman Y. Adherence to Pre-exposure Prophylaxis in Black Men Who Have Sex with Men and Transgender Women in a Community Setting in Harlem, NY. AIDS Behav 2020; 24:3436-3455. [PMID: 32385678 DOI: 10.1007/s10461-020-02901-6] [Citation(s) in RCA: 30] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
While oral pre-exposure prophylaxis (PrEP) has proven efficacious for HIV prevention, consistent use is necessary to achieve its intended impact. We compared effectiveness of enhanced PrEP (enPrEP) adherence support to standard of care (sPrEP) among Black MSM and TGW attending a community clinic in Harlem, NY. EnPrEP included peer navigation, in-person/online support groups, and SMS messages. Self-reported adherence over previous 30 days, collected in quarterly interviews, was defined as ≥ 57%. Crude and adjusted analyses examined factors associated with adherence. A total of 204 participants were enrolled and randomized; 35% were lost to follow-up. PrEP adherence was 30% at 12-months; no intervention effect was observed (p = 0.69). Multivariable regression analysis found that lower adherence was associated with low education and depressive symptoms. We found that an enhanced adherence intervention did not improve PrEP adherence. Findings point to the need for innovative methods to improve PrEP adherence among Black MSM and TGW.Clinical Trial Registration NCT02167386, June 19, 2014.
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49
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Pasipanodya EC, Li MJ, Jain S, Sun X, Tobin J, Ellorin E, Dube M, Daar ES, Corado K, Milam J, Blumenthal J, Morris SH, Moore DJ. Greater Levels of Self-Reported Adherence to Pre-Exposure Prophylaxis (PrEP) are Associated with Increased Condomless Sex Among Men Who Have Sex with Men. AIDS Behav 2020; 24:3192-3204. [PMID: 32350774 PMCID: PMC7508761 DOI: 10.1007/s10461-020-02881-7] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Abstract
The effectiveness of pre-exposure prophylaxis (PrEP) against HIV acquisition depends on treatment adherence; however, within-person associations between levels of PrEP adherence and engagement in condomless sex have not been well studied. In the context of a demonstration project, 372 men who have sex with men received once-daily PrEP and completed six study visits over 48 weeks. Two-part growth mixture modeling was used to examine the longitudinal trajectory of condomless anal intercourse (CAI) and self-reports of PrEP adherence, controlling for relevant covariates. Over time, greater PrEP adherence was contemporaneously associated with both a higher likelihood of engaging in any CAI and with a greater number of CAI acts. Substance use was also associated with a higher likelihood of engaging in CAI. Contemporaneous associations between self-reported PrEP adherence and CAI suggest that adherence behaviors may be motivated by the desire to mitigate risk of HIV infection; however, exact directionality is unknown.
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Affiliation(s)
| | - Michael J Li
- UCLA Center for HIV Identification, Prevention and Treatment Services (CHIPTS), Los Angeles, CA, 90024, USA
| | - Sonia Jain
- Department of Family Medicine and Public Health, University of California San Diego, San Diego, CA, 92093, USA
| | - Xiaoying Sun
- Department of Family Medicine and Public Health, University of California San Diego, San Diego, CA, 92093, USA
| | - Jessica Tobin
- Keck School of Medicine, University of Southern California, Los Angeles, CA, 90033, USA
| | - Eric Ellorin
- Department of Family Medicine and Public Health, University of California San Diego, San Diego, CA, 92093, USA
| | - Michael Dube
- Keck School of Medicine, University of Southern California, Los Angeles, CA, 90033, USA
| | - Eric S Daar
- Los Angeles Biomedical Research Institute At Harbor-UCLA Medical Center, Torrance, CA, 90502, USA
| | - Katya Corado
- The Lundquist Institute, Torrance, CA, 90502, USA
| | - Joel Milam
- Keck School of Medicine, University of Southern California, Los Angeles, CA, 90033, USA
| | - Jill Blumenthal
- Department of Family Medicine and Public Health, University of California San Diego, San Diego, CA, 92093, USA
| | - Sheldon H Morris
- Department of Family Medicine and Public Health, University of California San Diego, San Diego, CA, 92093, USA
| | - David J Moore
- Department of Psychiatry, HIV Neurobehavioral Research Program, University of California San Diego, 220 Dickinson Street, Suite B, MC8231, San Diego, CA, 92103, USA.
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50
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Liu AY, Vittinghoff E, von Felten P, Rivet Amico K, Anderson PL, Lester R, Andrew E, Estes I, Serrano P, Brothers J, Buchbinder S, Hosek S, Fuchs JD. Randomized Controlled Trial of a Mobile Health Intervention to Promote Retention and Adherence to Preexposure Prophylaxis Among Young People at Risk for Human Immunodeficiency Virus: The EPIC Study. Clin Infect Dis 2020; 68:2010-2017. [PMID: 30239620 PMCID: PMC6541706 DOI: 10.1093/cid/ciy810] [Citation(s) in RCA: 96] [Impact Index Per Article: 24.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2018] [Accepted: 09/13/2018] [Indexed: 12/20/2022] Open
Abstract
BACKGROUND Young men who have sex with men are among the most vulnerable to human immunodeficiency virus (HIV) infection. Although preexposure prophylaxis (PrEP) has demonstrated effectiveness, adherence and retention have been low among youth. METHODS We conducted a randomized controlled trial to evaluate the impact of a youth-tailored, bidirectional text-messaging intervention (PrEPmate) on study retention and PrEP adherence. Young individuals at risk for HIV initiating PrEP within Chicago's safety-net system were randomized 2:1 to receive PrEPmate or standard of care (SoC) for 36 weeks. The primary retention outcome was study-visit completion, and the primary adherence outcome was tenofovir diphosphate (TFV-DP) concentrations ≥700 fmol/punch (consistent with ≥4 doses/week) assessed at 4, 12, 24, and 36 weeks. The impact of PrEPmate on retention and adherence was evaluated using generalized estimating equation logistic models with robust standard errors. RESULTS From April 2015 to March 2016, 121 participants enrolled (mean age 24; 27% black, 36% Latino). Participants who received PrEPmate were more likely to attend study visits (86% PrEPmate vs. 71% SoC, odds ratio [OR] = 2.62, 95% confidence interval [CI] 1.24-5.54) and have TFV-DP levels consistent with ≥4 doses/week (72% PrEPmate vs. 57% SoC, OR = 2.05, 95% CI 1.06-3.94). PrEPmate efficacy did not differ significantly by age, race/ethnicity, education, or insurance. Overall, 88% reported PrEPmate to be very/somewhat helpful, and 92% would recommend PrEPmate to others. CONCLUSIONS An interactive text-messaging intervention had high acceptability and significantly increased study-visit retention and PrEP adherence among young individuals at risk for HIV acquisition. CLINICAL TRIALS REGISTRATION NCT02371525.
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Affiliation(s)
- Albert Y Liu
- Bridge HIV, San Francisco Department of Public Health, University of California, San Francisco.,Department of Medicine, University of California, San Francisco
| | - Eric Vittinghoff
- Department of Epidemiology and Biostatistics, University of California, San Francisco
| | - Patricia von Felten
- Bridge HIV, San Francisco Department of Public Health, University of California, San Francisco
| | - K Rivet Amico
- Department of Health Behavior and Health Education, School of Public Health, University of Michigan, Ann Arbor
| | - Peter L Anderson
- Skaggs School of Pharmacy and Pharmaceutical Sciences, University of Colorado Anschutz Medical Campus, Aurora
| | - Richard Lester
- Division of Infectious Diseases, Department of Medicine, University of British Columbia, Vancouver, Canada
| | - Erin Andrew
- Bridge HIV, San Francisco Department of Public Health, University of California, San Francisco
| | - Ixchell Estes
- Ruth M. Rothstein CORE Center.,Stroger Hospital of Cook County, Department of Psychiatry, Chicago, Illinois
| | - Pedro Serrano
- Ruth M. Rothstein CORE Center.,Stroger Hospital of Cook County, Department of Psychiatry, Chicago, Illinois
| | - Jennifer Brothers
- Ruth M. Rothstein CORE Center.,Stroger Hospital of Cook County, Department of Psychiatry, Chicago, Illinois
| | - Susan Buchbinder
- Bridge HIV, San Francisco Department of Public Health, University of California, San Francisco.,Department of Medicine, University of California, San Francisco.,Department of Epidemiology and Biostatistics, University of California, San Francisco
| | - Sybil Hosek
- Ruth M. Rothstein CORE Center.,Stroger Hospital of Cook County, Department of Psychiatry, Chicago, Illinois
| | - Jonathan D Fuchs
- Department of Medicine, University of California, San Francisco.,Center for Learning and Innovation, San Francisco Department of Public Health, California
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