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Bogart LM, Musoke W, Mukama CS, Allupo S, Klein DJ, Sejjemba A, Mwima S, Kadama H, Mulebeke R, Pandey R, Wagner Z, Mukasa B, Wanyenze RK. Enhanced Oral Pre-exposure Prophylaxis (PrEP) Implementation for Ugandan Fisherfolk: Pilot Intervention Outcomes. AIDS Behav 2024:10.1007/s10461-024-04432-w. [PMID: 39028385 DOI: 10.1007/s10461-024-04432-w] [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] [Accepted: 06/26/2024] [Indexed: 07/20/2024]
Abstract
Mobile populations such as fisherfolk show high HIV incidence and prevalence. We pilot-tested implementation strategies to enhance pre-exposure prophylaxis (PrEP) uptake and adherence in the context of healthcare outreach events in two mainland fisherfolk communities on Lake Victoria, Uganda from September 2021 to February 2022. The implementation strategies included PrEP adherence supporters (selected from PrEP users' social networks), community workshops (to address misconceptions and stigma, and empower PrEP advocacy), and check-in calls (including refill reminders). PrEP medical records data were collected from 6-months pre-intervention to 6-months post-intervention. Qualitative interviews with 20 PrEP users (10 who continued, 10 who discontinued), 9 adherence supporters, and 7 key partners (providers, community leaders) explored acceptability. Percentages of PrEP initiators (of those eligible) were significantly higher during the intervention (96.5%) than 6-months before the intervention (84.5%), p < 0.0001; percentages of PrEP users who persisted (i.e., possessed a refill) 6-months post-initiation (47.9% vs. 6.7%) and had at least 80% PrEP coverage (based on their medication possession ratio) from the initiation date to 6-months later (35.9% vs. 0%) were higher during versus pre-intervention, p < 0.0001. A comparison fisherfolk community with better healthcare access had lower uptake (78.3%; p < 0.0001) and persistence at 6-months (34.0%; p < 0.001), but higher coverage during the intervention period (70.4%; p < 0.0001). Qualitative data suggested the strategies promoted PrEP use through reduced stigma and misconceptions. The intervention bundle cost was $223.95, $172.98, and $94.66 for each additional person for PrEP initiation, persistence, and coverage, respectively. Enhanced community-based PrEP implementation that fosters a supportive community environment can improve PrEP use in mobile populations without easy access to healthcare. (NCT05084716).
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Affiliation(s)
- Laura M Bogart
- RAND Corporation, 1776 Main Street, P.O. Box 2138, Santa Monica, CA, 90407-2138, USA.
- Department of Psychiatry, Charles R. Drew University of Medicine and Science, Los Angeles, CA, USA.
| | | | | | | | - David J Klein
- RAND Corporation, 1776 Main Street, P.O. Box 2138, Santa Monica, CA, 90407-2138, USA
| | | | - Simon Mwima
- School of Social Work, University of Illinois at Urbana Champagne, Urbana, IL, USA
| | | | | | - Rakesh Pandey
- RAND Corporation, 1776 Main Street, P.O. Box 2138, Santa Monica, CA, 90407-2138, USA
| | - Zachary Wagner
- RAND Corporation, 1776 Main Street, P.O. Box 2138, Santa Monica, CA, 90407-2138, USA
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Perez-Urbano I, Dilraj A, Pitsi A, Hlongwane N, Abdelatif N, Dietrich J, Ahmed K. Strategies to Close the PrEP Uptake Gap Among Transgender People and Men Who Have Sex with Men in Tshwane, South Africa: Perspectives from the Community. AIDS Behav 2024; 28:1999-2014. [PMID: 38427124 PMCID: PMC11161427 DOI: 10.1007/s10461-024-04300-7] [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: 02/21/2024] [Indexed: 03/02/2024]
Abstract
HIV Pre-exposure Prophylaxis (PrEP) uptake among transgender (TG) people and gay men and other men who have sex with men (MSM) remains low, despite South Africa being the first African country to approve PrEP. This mixed-methods study used a two-phase explanatory sequential design: (1) quantitative analysis of cross-sectional surveys followed by (2) qualitative in-depth interviews. This study explored facilitators and barriers to PrEP uptake to identify strategies to increase utilization in these key populations. We conducted 202 cross-sectional surveys and 20 in-depth interviews between July 2021 and March 2022 in Soshanguve, Tshwane, Gauteng. Quantitative data were analyzed using univariate logistic regression; thematic analysis was performed for qualitative data. Findings show high willingness to use PrEP but low PrEP uptake. We outline strategies to facilitate PrEP use: (1) demystify daily PrEP by deploying community-engaged PrEP education campaigns; (2) capitalize on existing peer networks; and (3) expand accessible and culturally responsive PrEP service delivery models. We provide feasible recommendations to close the PrEP uptake gap in these key populations in South Africa.
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Affiliation(s)
- India Perez-Urbano
- University of California San Francisco School of Medicine, San Francisco, CA, 94143, USA.
| | | | - Annah Pitsi
- Setshaba Research Centre, Tshwane, Soshanguve, South Africa
| | | | - Nada Abdelatif
- Biostatistics Research Unit, South African Medical Research Council, Cape Town, South Africa
| | - Janan Dietrich
- Perinatal HIV Research Unit, University of Witwatersrand, Johannesburg, South Africa
- African Social Sciences Unit of Research and Evaluation (ASSURE), Wits Health Consortium, Johannesburg, South Africa
- Health Systems Research Unit, South African Medical Research Council, Bellville, South Africa
| | - Khatija Ahmed
- Setshaba Research Centre, Tshwane, Soshanguve, South Africa
- Department of Medical Microbiology, University of Pretoria, Tshwane, South Africa
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Ntabadde K, Kagaayi J, Ssempijja V, Feng X, Kairania R, Lubwama J, Ssekubugu R, Yeh PT, Ssekasanvu J, Tobian AAR, Kennedy CE, Mills LA, Alamo S, Kreniske P, Santelli J, Nelson LJ, Reynolds SJ, Chang LW, Nakigozi G, Grabowski MK. Pre-exposure prophylaxis (PrEP) knowledge, use, and discontinuation among Lake Victoria fisherfolk in Uganda: a cross-sectional population-based study. MEDRXIV : THE PREPRINT SERVER FOR HEALTH SCIENCES 2024:2024.03.29.24305076. [PMID: 38585794 PMCID: PMC10996747 DOI: 10.1101/2024.03.29.24305076] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 04/09/2024]
Abstract
Background There are limited population-level data on the pre-exposure prophylaxis (PrEP) care continuum in eastern Africa. Here, we assessed the PrEP care continuum following PrEP rollout in a Ugandan community with ~40% HIV seroprevalence. Methods We used cross-sectional population-based data collected between September 3 and December 19, 2018 from a Lake Victoria fishing community in southern Uganda to measure levels of self-reported PrEP knowledge, ever use, and discontinuation following 2017 PrEP rollout via a U.S. President's Emergency Plan for AIDS Relief (PEPFAR)-supported phased implementation program. Our analysis included HIV-seronegative persons reporting having ever received an HIV test result. We examined associations between demographic, behavioral, and health utilization factors with each outcome using age-adjusted modified Poisson regression. Results There were 1,401 HIV-seronegative participants, of whom 1,363 (97.3%) reported ever receiving an HIV test result. Median age was 29 years (IQR: 23-36), and 42.3% (n=577) were women. Most (85.5%; n=1,166) participants reported PrEP knowledge, but few (14.5%; n=197) reported ever using PrEP. Among 375 (47.7%) men and 169 (29.3%) women PrEP-eligible at time of survey, 18.9% (n=71) and 27.8% (n=47) reported ever using PrEP, respectively. Over half (52.3%, n=103) of those who had ever used PrEP, self-reported current use. Conclusion In this Lake Victoria fishing community, there were low levels of PrEP use despite high levels of PrEP awareness and eligibility, particularly among men. Efforts that enhance awareness of HIV risk and increase PrEP accessibility may help increase PrEP use among HIV-seronegative persons in African settings with high HIV burden.
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Affiliation(s)
| | - Joseph Kagaayi
- Rakai Health Sciences Program, Kalisizo, Uganda
- Makerere University School of Public Health, Kampala, Uganda
| | - Victor Ssempijja
- Rakai Health Sciences Program, Kalisizo, Uganda
- Clinical Monitoring Research Program Directorate, Frederick National Laboratory for Cancer Research, Frederick, MD, USA
| | - Xinyi Feng
- Department of Pathology, Johns Hopkins School of Medicine, Baltimore, MD, USA
| | | | | | | | - Ping Teresa Yeh
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | | | - Aaron A R Tobian
- Department of Pathology, Johns Hopkins School of Medicine, Baltimore, MD, USA
| | - Caitlin E. Kennedy
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Lisa A. Mills
- United States Centers for Disease Control and Prevention, Uganda, Division of Global HIV & TB, Kampala Uganda
| | - Stella Alamo
- United States Centers for Disease Control and Prevention, Uganda, Division of Global HIV & TB, Kampala Uganda
| | - Philip Kreniske
- Community Health and Social Sciences Department, Graduate School of Public Health and Health Policy, City University of New York (CUNY)
| | - John Santelli
- Department of Population and Family Health and Pediatrics, Columbia University Mailman School of Public Health, New York, New York, USA
| | - Lisa J. Nelson
- United States Centers for Disease Control and Prevention, Uganda, Division of Global HIV & TB, Kampala Uganda
| | - Steven J. Reynolds
- Rakai Health Sciences Program, Kalisizo, Uganda
- Division of Intramural Research, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, Maryland, USA
- Division of Infectious Diseases, School of Medicine, Johns Hopkins University, Baltimore, Maryland, USA
| | - Larry William Chang
- Rakai Health Sciences Program, Kalisizo, Uganda
- Division of Infectious Diseases, School of Medicine, Johns Hopkins University, Baltimore, Maryland, USA
| | | | - M. Kate Grabowski
- Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
- Rakai Health Sciences Program, Kalisizo, Uganda
- Department of Pathology, Johns Hopkins School of Medicine, Baltimore, MD, USA
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Nardell MF, Govathson C, Mngadi-Ncube S, Ngcobo N, Letswalo D, Lurie M, Miot J, Long L, Katz IT, Pascoe S. Migrant men and HIV care engagement in Johannesburg, South Africa. BMC Public Health 2024; 24:435. [PMID: 38347453 PMCID: PMC10860300 DOI: 10.1186/s12889-024-17833-2] [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: 09/28/2023] [Accepted: 01/20/2024] [Indexed: 02/15/2024] Open
Abstract
BACKGROUND South Africa (SA) has one of the highest rates of migration on the continent, largely comprised of men seeking labor opportunities in urban centers. Migrant men are at risk for challenges engaging in HIV care. However, rates of HIV and patterns of healthcare engagement among migrant men in urban Johannesburg are poorly understood. METHODS We analyzed data from 150 adult men (≥ 18 years) recruited in 10/2020-11/2020 at one of five sites in Johannesburg, Gauteng Province, SA where migrants typically gather for work, shelter, transit, or leisure: a factory, building materials store, homeless shelter, taxi rank, and public park. Participants were surveyed to assess migration factors (e.g., birth location, residency status), self-reported HIV status, and use and knowledge of HIV and general health services. Proportions were calculated with descriptive statistics. Associations between migration factors and health outcomes were examined with Fisher exact tests and logistic regression models. Internal migrants, who travel within the country, were defined as South African men born outside Gauteng Province. International migrants were defined as men born outside SA. RESULTS Two fifths (60/150, 40%) of participants were internal migrants and one fifth (33/150, 22%) were international migrants. More internal migrants reported living with HIV than non-migrants (20% vs 6%, p = 0.042), though in a multi-variate analysis controlling for age, being an internal migrant was not a significant predictor of self-reported HIV positive status. Over 90% all participants had undergone an HIV test in their lifetime. Less than 20% of all participants had heard of pre-exposure prophylaxis (PrEP), with only 12% international migrants having familiarity with PrEP. Over twice as many individuals without permanent residency or citizenship reported "never visiting a health facility," as compared to citizens/permanent residents (28.6% vs. 10.6%, p = 0.073). CONCLUSIONS Our study revealed a high proportion of migrants within our community-based sample of men and demonstrated a need for HIV and other healthcare services that effectively reach migrants in Johannesburg. Future research is warranted to further disaggregate this heterogenous population by different dimensions of mobility and to understand how to design HIV programs in ways that will address migrants' challenges.
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Affiliation(s)
- Maria Francesca Nardell
- Division of Global Health Equity, Brigham and Women's Hospital, 75 Francis Street, Boston, MA, 02115, USA.
- Harvard Medical School, Boston, MA, USA.
| | - Caroline Govathson
- Health Economics and Epidemiology Research Office (HE2RO), Johannesburg, South Africa
- Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Sithabile Mngadi-Ncube
- Health Economics and Epidemiology Research Office (HE2RO), Johannesburg, South Africa
- Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Nkosinathi Ngcobo
- Health Economics and Epidemiology Research Office (HE2RO), Johannesburg, South Africa
- Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Daniel Letswalo
- Health Economics and Epidemiology Research Office (HE2RO), Johannesburg, South Africa
- Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Mark Lurie
- Brown University School of Public Health, Brown University, Providence, Rhode Island, USA
| | - Jacqui Miot
- Health Economics and Epidemiology Research Office (HE2RO), Johannesburg, South Africa
- Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Lawrence Long
- Health Economics and Epidemiology Research Office (HE2RO), Johannesburg, South Africa
- Department of Global Health, Boston University School of Public Health, Boston, MA, USA
| | - Ingrid Theresa Katz
- Harvard Medical School, Boston, MA, USA
- Division of Women's Health, Brigham and Women's Hospital, Boston, MA, USA
| | - Sophie Pascoe
- Health Economics and Epidemiology Research Office (HE2RO), Johannesburg, South Africa
- Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
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Bogart LM, Musoke W, Mayatsa J, Marsh T, Naigino R, Banegura A, Mukama CS, Allupo S, Odiit M, Kadama H, Mukasa B, Wanyenze RK. Recommendations for Improving Oral Pre-exposure Prophylaxis Implementation and Social Marketing in Ugandan Fisherfolk Communities: A Qualitative Exploration. COMMUNITY HEALTH EQUITY RESEARCH & POLICY 2024; 44:189-199. [PMID: 36194425 PMCID: PMC10070557 DOI: 10.1177/0272684x221113608] [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: 04/06/2023]
Abstract
Background: HIV is hyperendemic among fisherfolk in Sub-Saharan Africa, especially around Lake Victoria, Uganda. Purpose/Research Design: We conducted cross-sectional semi-structured interviews about oral pre-exposure prophylaxis (PrEP) implementation with 35 Ugandan fisherfolk (15 women, 20 men) and 10 key stakeholders (healthcare providers, policymakers, community leaders). We used a directed content analysis approach based on implementation science and social marketing frameworks. Results: Participants showed high acceptability for PrEP. Anticipated barriers among fisherfolk included stigma (due to similar medications/packaging as HIV treatment); misconceptions; mobility, competing needs, poverty, and partner conflict. Anticipated provider barriers included insufficient staffing and travel support. Recommendations included: change PrEP packaging; integrate PrEP with other services; decrease PrEP refill frequency; give transportation resources to providers; train more healthcare workers to provide PrEP to fisherfolk; and use positively framed messages to promote PrEP. Conclusions: Results can inform policymakers and healthcare organizations on how to overcome barriers to PrEP scale-up in most at-risk populations with poor healthcare access.
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Affiliation(s)
| | | | - Jimmy Mayatsa
- Ministry of Health, Republic of Uganda, Kampala, Uganda
| | - Terry Marsh
- RAND Corporation, Santa Monica, California, United States
| | - Rose Naigino
- Ministry of Health, Republic of Uganda, Kampala, Uganda
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Ramraj T, Chirinda W, Jonas K, Govindasamy D, Jama N, McClinton Appollis T, Zani B, Mukumbang FC, Basera W, Hlongwa M, Turawa EB, Mathews C, Nicol E. Service delivery models that promote linkages to PrEP for adolescent girls and young women and men in sub-Saharan Africa: a scoping review. BMJ Open 2023; 13:e061503. [PMID: 36972966 PMCID: PMC10069497 DOI: 10.1136/bmjopen-2022-061503] [Citation(s) in RCA: 10] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/29/2023] Open
Abstract
BACKGROUND Pre-exposure prophylaxis (PrEP) is an emerging biomedical prevention intervention. Documenting PrEP service delivery models (SDMs) that promote linkage to and continuation of PrEP will inform guidelines and maximise roll-out. OBJECTIVES To synthesise and appraise the effectiveness and feasibility of PrEP SDMs designed to promote linkage to PrEP care among adolescent girls and young women (AGYW) and men in sub-Saharan Africa (SSA). ELIGIBILITY CRITERIA Primary quantitative and qualitative studies published in English and conducted in SSA were included. No restrictions on the date of publication were applied. SOURCES OF EVIDENCE Methodology outlined in the Joanna Briggs Institute reviewers' manual was followed. PubMed, Cochrane library, Scopus, Web of Science and online-conference abstract archives were searched. CHARTING METHODS Data on article, population, intervention characteristics and key outcomes was charted in REDCap. RESULTS AND CONCLUSION Of the 1204 identified records, 37 (met the inclusion criteria. Health facility-based integrated models of PrEP delivery with family planning, maternal and child health or sexual and reproductive services to AGYW resulted in PrEP initiation of 16%-90%. Community-based drop-in centres (66%) was the preferred PrEP outlet for AGYW compared with public clinics (25%) and private clinics (9%). Most men preferred community-based delivery models. Among individuals who initiated PrEP, 50% were men, 62% were <35 years old and 97% were tested at health fairs compared with home testing. Integrated antiretroviral therapy (ART)-PrEP delivery was favoured among serodiscordant couples with 82.9% of couples using PrEP or ART with no HIV seroconversions. PrEP initiation within healthcare facilities was increased by perceived client-friendly services and non-judgemental healthcare workers. Barriers to PrEP initiation included distance to travel to and time spent at health facilities and perceived community stigma. PrEP SDMs for AGYW and men need to be tailored to the needs and preferences for each group. Programme implementers should promote community-based SDMs to increase PrEP initiation among AGYW and men.
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Affiliation(s)
- Trisha Ramraj
- HIV and Other Infectious Diseases Research Unit, South African Medical Research Council, Durban, KwaZulu-Natal, South Africa
| | - Witness Chirinda
- Health Systems Research Unit, South African Medical Research Council, Tygerberg, Western Cape, South Africa
| | - Kim Jonas
- Health Systems Research Unit, South African Medical Research Council, Tygerberg, Western Cape, South Africa
- Adolescent Health Research Unit, University of Cape Town, Rondebosch, Western Cape, South Africa
| | - Darshini Govindasamy
- Health Systems Research Unit, South African Medical Research Council, Tygerberg, Western Cape, South Africa
- Adolescent Health Research Unit, University of Cape Town, Rondebosch, Western Cape, South Africa
| | - Ngcwalisa Jama
- Burden of Disease Research Unit, South African Medical Research Council, Tygerberg, Western Cape, South Africa
| | - Tracy McClinton Appollis
- Health Systems Research Unit, South African Medical Research Council, Tygerberg, Western Cape, South Africa
- Adolescent Health Research Unit, University of Cape Town, Rondebosch, Western Cape, South Africa
| | - Babalwa Zani
- Burden of Disease Research Unit, South African Medical Research Council, Tygerberg, Western Cape, South Africa
| | - Ferdinand C Mukumbang
- Burden of Disease Research Unit, South African Medical Research Council, Tygerberg, Western Cape, South Africa
| | - Wisdom Basera
- Burden of Disease Research Unit, South African Medical Research Council, Tygerberg, Western Cape, South Africa
| | - Mbuzeleni Hlongwa
- Burden of Disease Research Unit, South African Medical Research Council, Tygerberg, Western Cape, South Africa
- College of Health Sciences, School of Nursing and Public Health Medicine, University of KwaZulu-Natal, Durban, South Africa
| | - Eunice B Turawa
- Burden of Disease Research Unit, South African Medical Research Council, Tygerberg, Western Cape, South Africa
- Faculty of Medicine and Health Sciences, Stellenbosch University, Stellenbosch, Western Cape, South Africa
| | - Catherine Mathews
- Health Systems Research Unit, South African Medical Research Council, Tygerberg, Western Cape, South Africa
- Adolescent Health Research Unit, University of Cape Town, Rondebosch, Western Cape, South Africa
| | - Edward Nicol
- Burden of Disease Research Unit, South African Medical Research Council, Tygerberg, Western Cape, South Africa
- Faculty of Medicine and Health Sciences, Stellenbosch University, Stellenbosch, Western Cape, South Africa
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Self-reported and pill count measures of adherence to oral HIV PrEP among female sex workers living in South-Western Uganda. PLoS One 2022; 17:e0277226. [DOI: 10.1371/journal.pone.0277226] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2022] [Accepted: 10/23/2022] [Indexed: 11/12/2022] Open
Abstract
Background
Female sex workers (FSWs) in Uganda are at high risk of HIV infection. Scaling up oral pre-exposure prophylaxis (PrEP) will reduce HIV incidence if high levels of adherence are maintained. This study evaluates PrEP adherence using clinic-based pill counts and self-reported measures, and factors associated with protective levels of adherence.
Methods
Participants were sex workers who had been taking PrEP for at least 5 months and were attending routine follow-up visits for PrEP care in fishing communities and along the Trans-African Highway. Participants who had a pill count showing at least 85% use since their last clinic visit and those who reported taking their PrEP every day in the last 5 months were categorised as having ‘protective adherence’. Spearman’s correlation and weighted kappa assessed the relationship between pill count and self-reported measures. Bivariate and multivariate logistic regression was used to determine factors associated with protective adherence as measured by pill count.
Results
We recruited 524 FSWs, with a median age of 29 years (IQR 23–35). Participants were recruited from fishing communities and Trans-African Highway towns (n = 297, 56.7%, and n = 227, 43.0%). Nearly three quarters (n = 372, 71.0%) of women were estimated to have protective adherence based on pill count (i.e., a pill count of >85%) and 50.4% by self-report in last 3 months. There was a strong positive association between self-reported measures and pill count measures (rest = 0.6453, 95% CI = 0.5924–0.6927) and a moderate agreement between self-reported measures and pill count measures, κ = 0.544 (95%CI = 0.4869–0.6011, p < 0.001).
Factors associated with protective adherence included being aged 35 years or older (aOR = 2.40, 95% CI = 1.17–4.86), living in a fishing community (aOR = 1.45, 95% CI = 0.62–3.38), and having an STI in last 3 months (aOR = 1.64, 95% CI = 1.07–2.49).
Conclusion
Our findings indicate that PrEP-experienced FSWs attending clinical follow-up visits reported high protective levels of oral pre-exposure prophylaxis, as measured by both pill count and self-reported measures, and a moderate agreement between pill count and self-reported measures.
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Camlin CS, Getahun M, Koss CA, Owino L, Akatukwasa C, Itiakorit H, Onyango A, Bakanoma R, Atwine F, Maeri I, Ayieko J, Atukunda M, Owaraganise A, Mwangwa F, Sang N, Kabami J, Kaplan RL, Chamie G, Petersen ML, Cohen CR, Bukusi EA, Kamya MR, Havlir DV, Charlebois ED. Providers' Attitudes and Experiences with Pre-Exposure Prophylaxis Implementation in a Population-Based Study in Kenya and Uganda. AIDS Patient Care STDS 2022; 36:396-404. [PMID: 36201226 PMCID: PMC9595612 DOI: 10.1089/apc.2022.0084] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/29/2023] Open
Abstract
Pre-exposure prophylaxis (PrEP) implementation is underway across sub-Saharan Africa. However, little is known about health care providers' experiences with PrEP provision in generalized epidemic settings, particularly outside of selected risk groups. In this study (NCT01864603), universal access to PrEP was offered to adolescents and adults at elevated risk during population-level HIV testing in rural Kenya and Uganda. Providers received training on PrEP prescribing and support from local senior clinicians. We conducted in-depth interviews with providers (n = 19) in four communities in Kenya and Uganda to explore the attitudes and experiences with implementation. Transcripts were coded and analyzed using interpretivist methods. Providers had heterogenous attitudes toward PrEP in its early implementation: some expressed enthusiasm, while others feared being blamed for "failures" (HIV seroconversions) if participants were nonadherent, or that offering PrEP would increase "immorality." Providers supported PrEP usage among HIV-serodifferent couples, whose mutual support for daily pill-taking facilitated harmony and protection from HIV. Providers reported challenges with counseling on "seasons of risk," and safely stopping and restarting PrEP. They felt uptake was hampered for women by difficulties negotiating with partners, and for youth by parental consent requirements. They believed PrEP continuation was hindered by transportation costs, stigma, pill burden, and side effects, and was facilitated by counseling, proactive management of side effects, and home/community-based provision. Providers are critical "implementation actors" in interventions to promote adoption of new technologies such as PrEP. Dedicated training and ongoing support for providers may facilitate successful scale-up.
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Affiliation(s)
- Carol S. Camlin
- Department of Obstetrics, Gynecology, & Reproductive Sciences, University of California, San Francisco (UCSF), San Francisco, California, USA
- Department of Medicine, Center for AIDS Prevention Studies, University of California, San Francisco (UCSF), San Francisco, California, USA
| | - Monica Getahun
- Department of Obstetrics, Gynecology, & Reproductive Sciences, University of California, San Francisco (UCSF), San Francisco, California, USA
| | - Catherine A. Koss
- Division of HIV, Infectious Diseases & Global Medicine, Department of Medicine, University of California, San Francisco (UCSF), San Francisco, California, USA
| | - Lawrence Owino
- Kenya Medical Research Institute (KEMRI), Nairobi, Kenya
| | | | | | | | - Robert Bakanoma
- Infectious Diseases Research Collaboration (IDRC), Kampala, Uganda
| | - Fredrick Atwine
- Infectious Diseases Research Collaboration (IDRC), Kampala, Uganda
| | - Irene Maeri
- Kenya Medical Research Institute (KEMRI), Nairobi, Kenya
| | - James Ayieko
- Kenya Medical Research Institute (KEMRI), Nairobi, Kenya
| | | | | | - Florence Mwangwa
- Infectious Diseases Research Collaboration (IDRC), Kampala, Uganda
| | - Norton Sang
- Kenya Medical Research Institute (KEMRI), Nairobi, Kenya
| | - Jane Kabami
- Infectious Diseases Research Collaboration (IDRC), Kampala, Uganda
| | - Rachel L. Kaplan
- Department of Obstetrics, Gynecology, & Reproductive Sciences, University of California, San Francisco (UCSF), San Francisco, California, USA
| | - Gabriel Chamie
- Division of HIV, Infectious Diseases & Global Medicine, Department of Medicine, University of California, San Francisco (UCSF), San Francisco, California, USA
| | - Maya L. Petersen
- Divisions of Biostatistics & Epidemiology, School of Public Health, University of California, Berkeley, Berkeley, California, USA
| | - Craig R. Cohen
- Department of Obstetrics, Gynecology, & Reproductive Sciences, University of California, San Francisco (UCSF), San Francisco, California, USA
| | | | - Moses R. Kamya
- Infectious Diseases Research Collaboration (IDRC), Kampala, Uganda
- Department of Medicine, Makerere University College of Health Sciences, Kampala, Uganda
| | - Diane V. Havlir
- Division of HIV, Infectious Diseases & Global Medicine, Department of Medicine, University of California, San Francisco (UCSF), San Francisco, California, USA
| | - Edwin D. Charlebois
- Department of Medicine, Center for AIDS Prevention Studies, University of California, San Francisco (UCSF), San Francisco, California, USA
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Medina‐Marino A, Bezuidenhout D, Ngwepe P, Bezuidenhout C, Facente SN, Mabandla S, Hosek S, Little F, Celum CL, Bekker L. Acceptability and feasibility of leveraging community-based HIV counselling and testing platforms for same-day oral PrEP initiation among adolescent girls and young women in Eastern Cape, South Africa. J Int AIDS Soc 2022; 25:e25968. [PMID: 35872602 PMCID: PMC9309460 DOI: 10.1002/jia2.25968] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2022] [Accepted: 07/06/2022] [Indexed: 12/22/2022] Open
Abstract
INTRODUCTION Community-based delivery of HIV pre-exposure prophylaxis (PrEP) to South African adolescent girls and young women's (AGYW) could increase access but needs evaluation. We integrated PrEP services via home-based services and pop-up tents into existing community-based HIV testing services (CB-HTS) in Eastern Cape Province, South Africa. METHODS After accessing CB-HTS via a "pop-up" tent or home-based services, HIV-negative AGYW aged 16-25 years were invited to complete a baseline questionnaire and referred for PrEP services at a community-based PrEP site co-located with pop-up HTS tents. A 30-day supply of PrEP was dispensed. PrEP uptake, time-to-initiation, cohort characteristics and first medication refill within 90 days were measured using descriptive statistics. RESULTS Of the 1164 AGYW who tested for HIV, 825 (74.3%) completed a questionnaire and 806 (97.7%) were referred for community-based PrEP. Of those, 624 (77.4%) presented for PrEP (482/483 [99.8%] from pop-up HTS and 142/323 [44.0%] from home-based HTS), of which 603 (96.6%) initiated PrEP. Of those initiating PrEP following home-based HTS, 59.1% initiated within 0-3 days, 25.6% within 4-14 days and 15.3% took ≥15 days to initiate; 100% of AGYW who used pop-up HTS initiated PrEP the same day. Among AGWY initiating PrEP, 37.5% had a detectable sexually transmitted infection (STI). Although AGYW reported a low self-perception of HIV risk, post-hoc application of HIV risk assessment measures to available data classified most study participants as high risk for HIV acquisition. Cumulatively, 329 (54.6%) AGYW presented for a first medication refill within 90 days of accepting their first bottle of PrEP. CONCLUSIONS Leveraging CB-HTS platforms to provide same-day PrEP initiation and refill services was acceptable to AGYW. A higher proportion of AGYW initiated PrEP when co-located with CB-HTS sites compared to those referred following home-based HTS, suggesting that proximity of CB-HTS and PrEP services facilitates PrEP uptake among AGYW. The high prevalence of STIs among those initiating PrEP necessitates the integration of STI and HIV prevention programs for AGYW. Eligibility for PrEP initiation should not be required among AHYW in high HIV burden communities. Community-based service delivery will be crucial to maintaining access to PrEP services during the COVID-19 pandemic and future health and humanitarian emergencies.
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Affiliation(s)
- Andrew Medina‐Marino
- Desmond Tutu HIV CentreUniversity of Cape TownCape TownSouth Africa
- Research UnitFoundation for Professional Development, Buffalo City MetroEastern Cape ProvinceSouth Africa
- Perelman School of MedicineUniversity of PennsylvaniaPhiladelphiaPennsylvaniaUSA
| | - Dana Bezuidenhout
- Research UnitFoundation for Professional Development, Buffalo City MetroEastern Cape ProvinceSouth Africa
- Department of EpidemiologyMailman School of Public HealthColumbia UniversityNew York CityNew YorkUSA
| | - Phuti Ngwepe
- Research UnitFoundation for Professional Development, Buffalo City MetroEastern Cape ProvinceSouth Africa
- Department of Statistical SciencesUniversity of Cape TownCape TownSouth Africa
| | - Charl Bezuidenhout
- Research UnitFoundation for Professional Development, Buffalo City MetroEastern Cape ProvinceSouth Africa
- School of Public HealthBoston UniversityBostonMassachusettsUSA
| | | | - Selly Mabandla
- HIV/AIDSSTIs and TB ProgramBuffalo City Metro Health DistrictEastern Cape Province Department of HealthBhishoSouth Africa
| | - Sybil Hosek
- Departments of Psychiatry and Infectious DiseaseStroger Hospital of Cook CountyChicagoIllinoisUSA
| | - Francesca Little
- Department of Statistical SciencesUniversity of Cape TownCape TownSouth Africa
| | - Connie L. Celum
- Department of Global Health, Medicine and EpidemiologyUniversity of WashingtonSeattleWashingtonUSA
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Mayanja Y, Kamacooko O, Lunkuse JF, Muturi-Kioi V, Buzibye A, Omali D, Chinyenze K, Kuteesa M, Kaleebu P, Price MA. Oral pre-exposure prophylaxis preference, uptake, adherence and continuation among adolescent girls and young women in Kampala, Uganda: a prospective cohort study. J Int AIDS Soc 2022; 25:e25909. [PMID: 35543110 PMCID: PMC9092160 DOI: 10.1002/jia2.25909] [Citation(s) in RCA: 17] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2021] [Accepted: 04/22/2022] [Indexed: 11/08/2022] Open
Abstract
Introduction Oral pre‐exposure prophylaxis (PrEP) has been scaled up; however, data from real‐world settings are limited. We studied oral PrEP preference, uptake, adherence and continuation among adolescent girls and young women (AGYW) vulnerable to HIV in sub‐Saharan Africa. Methods We conducted a prospective cohort study among 14‐ to 24‐year‐old AGYW without HIV who were followed for 12 months in Kampala, Uganda. Within at least 14 days of enrolment, they received two education sessions, including demonstrations on five biomedical interventions that are; available (oral PrEP), will be available soon (long‐acting injectable PrEP and anti‐retroviral vaginal ring) and in development (PrEP implant and HIV vaccine). Information included mode and frequency of delivery, potential side effects and method availability. Volunteers ranked interventions, 1 = most preferred to 5 = least preferred. Oral PrEP was “preferred” if ranked among the top two choices. All were offered oral PrEP, and determinants of uptake assessed using Poisson regression with robust error variance. Adherence was assessed using plasma tenofovir levels and self‐reports. Results Between January and October 2019, 532 volunteers were screened; 285 enrolled of whom 265 received two education sessions. Mean age was 20 years (SD±2.2), 92.8% reported paid sex, 20.4% reported ≥10 sexual partners in the past 3 months, 38.5% used hormonal contraceptives, 26.9% had chlamydia, gonorrhoea and/or active syphilis. Of 265 volunteers, 47.6% preferred oral PrEP. Willingness to take PrEP was 90.2%; however, uptake was 30.6% (n = 81). Following enrolment, 51.9% started PrEP on day 14 (same day PrEP offered), 20.9% within 30 days and 27.2% after 30 days. PrEP uptake was associated with more sexual partners in the past 3 months: 2–9 partners (aRR = 2.36, 95% CI: 1.20–4.63) and ≥10 partners (aRR 4.70, 95% CI 2.41–9.17); oral PrEP preference (aRR 1.53, 95% CI 1.08–2.19) and being separated (aRR 1.55, 95% CI 1.04–2.33). Of 100 samples from 49 volunteers during follow up, 19 had quantifiable tenofovir levels (>10 μg/L) of which only three were protective (>40 μg/L). Conclusions Half of AGYW preferred oral PrEP, uptake and adherence were low, uptake was associated with sexual behavioural risk and oral PrEP preference. Development of alternative biomedical products should be expedited to meet end‐user preferences and, community delivery promoted during restricted movement.
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Affiliation(s)
- Yunia Mayanja
- Medical Research Council/Uganda Virus Research Institute and London School of Hygiene and Tropical Medicine (MRC/UVRI & LSHTM), Uganda Research Unit, Entebbe, Uganda
| | - Onesmus Kamacooko
- Medical Research Council/Uganda Virus Research Institute and London School of Hygiene and Tropical Medicine (MRC/UVRI & LSHTM), Uganda Research Unit, Entebbe, Uganda
| | - Jane Frances Lunkuse
- Medical Research Council/Uganda Virus Research Institute and London School of Hygiene and Tropical Medicine (MRC/UVRI & LSHTM), Uganda Research Unit, Entebbe, Uganda
| | | | - Allan Buzibye
- Infectious Diseases Institute, College of Health Sciences, Makerere University, Kampala, Uganda
| | - Denis Omali
- Infectious Diseases Institute, College of Health Sciences, Makerere University, Kampala, Uganda
| | | | | | - Pontiano Kaleebu
- Medical Research Council/Uganda Virus Research Institute and London School of Hygiene and Tropical Medicine (MRC/UVRI & LSHTM), Uganda Research Unit, Entebbe, Uganda
| | - Matt A Price
- IAVI, New York, New York, USA.,Department of Epidemiology and Biostatistics, University of California San Francisco, San Francisco, California, USA
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11
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Orel E, Esra R, Estill J, Thiabaud A, Marchand-Maillet S, Merzouki A, Keiser O. Prediction of HIV status based on socio-behavioural characteristics in East and Southern Africa. PLoS One 2022; 17:e0264429. [PMID: 35239697 PMCID: PMC8893684 DOI: 10.1371/journal.pone.0264429] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2021] [Accepted: 02/10/2022] [Indexed: 11/30/2022] Open
Abstract
INTRODUCTION High yield HIV testing strategies are critical to reach epidemic control in high prevalence and low-resource settings such as East and Southern Africa. In this study, we aimed to predict the HIV status of individuals living in Angola, Burundi, Ethiopia, Lesotho, Malawi, Mozambique, Namibia, Rwanda, Zambia and Zimbabwe with the highest precision and sensitivity for different policy targets and constraints based on a minimal set of socio-behavioural characteristics. METHODS We analysed the most recent Demographic and Health Survey from these 10 countries to predict individual's HIV status using four different algorithms (a penalized logistic regression, a generalized additive model, a support vector machine, and a gradient boosting trees). The algorithms were trained and validated on 80% of the data, and tested on the remaining 20%. We compared the predictions based on the F1 score, the harmonic mean of sensitivity and positive predictive value (PPV), and we assessed the generalization of our models by testing them against an independent left-out country. The best performing algorithm was trained on a minimal subset of variables which were identified as the most predictive, and used to 1) identify 95% of people living with HIV (PLHIV) while maximising precision and 2) identify groups of individuals by adjusting the probability threshold of being HIV positive (90% in our scenario) for achieving specific testing strategies. RESULTS Overall 55,151 males and 69,626 females were included in the analysis. The gradient boosting trees algorithm performed best in predicting HIV status with a mean F1 score of 76.8% [95% confidence interval (CI) 76.0%-77.6%] for males (vs [CI 67.8%-70.6%] for SVM) and 78.8% [CI 78.2%-79.4%] for females (vs [CI 73.4%-75.8%] for SVM). Among the ten most predictive variables for each sex, nine were identical: longitude, latitude and, altitude of place of residence, current age, age of most recent partner, total lifetime number of sexual partners, years lived in current place of residence, condom use during last intercourse and, wealth index. Only age at first sex for male (ranked 10th) and Rohrer's index for female (ranked 6th) were not similar for both sexes. Our large-scale scenario, which consisted in identifying 95% of all PLHIV, would have required testing 49.4% of males and 48.1% of females while achieving a precision of 15.4% for males and 22.7% for females. For the second scenario, only 4.6% of males and 6.0% of females would have had to be tested to find 55.7% of all males and 50.5% of all females living with HIV. CONCLUSIONS We trained a gradient boosting trees algorithm to find 95% of PLHIV with a precision twice higher than with general population testing by using only a limited number of socio-behavioural characteristics. We also successfully identified people at high risk of infection who may be offered pre-exposure prophylaxis or voluntary medical male circumcision. These findings can inform the implementation of new high-yield HIV tests and help develop very precise strategies based on low-resource settings constraints.
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Affiliation(s)
- Erol Orel
- Institute of Global Health, University of Geneva, Geneva, Switzerland
| | - Rachel Esra
- Institute of Global Health, University of Geneva, Geneva, Switzerland
| | - Janne Estill
- Institute of Global Health, University of Geneva, Geneva, Switzerland
- Institute of Mathematical Statistics and Actuarial Science, University of Bern, Bern, Switzerland
| | - Amaury Thiabaud
- Institute of Global Health, University of Geneva, Geneva, Switzerland
| | | | - Aziza Merzouki
- Institute of Global Health, University of Geneva, Geneva, Switzerland
| | - Olivia Keiser
- Institute of Global Health, University of Geneva, Geneva, Switzerland
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12
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Haberer JE, Mugo N, Bukusi EA, Ngure K, Kiptinness C, Oware K, Garrison LE, Musinguzi N, Pyra M, Valenzuela S, Thomas KK, Anderson PL, Thirumurthy H, Baeten JM. Understanding Pre-Exposure Prophylaxis Adherence in Young Women in Kenya. J Acquir Immune Defic Syndr 2022; 89:251-260. [PMID: 35147580 PMCID: PMC8826617 DOI: 10.1097/qai.0000000000002876] [Citation(s) in RCA: 16] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2021] [Accepted: 10/21/2021] [Indexed: 11/26/2022]
Abstract
OBJECTIVE To present detailed analyses of long-term pre-exposure prophylaxis (PrEP) use and associated behaviors and perceptions among young Kenyan women. DESIGN Prospective, observational cohort. METHODS The Monitoring PrEP among Young Adult women Study involved 18 to 24-year-old women at high HIV risk initiating PrEP in Kisumu and Thika, Kenya. Visits for PrEP counseling and dispensing, HIV testing, and socio-behavioral data collection occurred at Month 1 and quarterly for 2 years. PrEP adherence was measured with pharmacy refill and real-time electronic monitoring, plus tenofovir diphosphate levels in 15% of participants. HIV risk behavior and perception were assessed by self-report in weekly short message service surveys from Months 6-24. Predictors of adherence were assessed with multivariable logistic regression analysis. RESULTS Three hundred forty-eight women (median age 21, VOICE risk score 7) were followed for 617 person-years. Pharmacy refills steadily declined from 100% (Month 0-1) to 54% (Months 22-24). Average electronically monitored adherence similarly declined from 65% (Month 0-1) to 15% (Months 22-24). Electronically monitored adherence had moderately high concordance with tenofovir diphosphate levels (67%). High average adherence (5+ doses/week) was seen at 385/1898 (20%) participant-visits and associated with low baseline VOICE risk score, >1 current sexual partner, ≤1-hour travel time to clinic, and the Kisumu site. short message service-reported behavior and risk perception were not associated with adherence. Four women acquired HIV (incidence 0.7/100 person-years). CONCLUSIONS PrEP adherence was modest and declined over time. HIV risk was inconsistently associated with adherence; clinic access and site-level factors were also relevant. Relatively low HIV incidence suggests participants may have achieved protection through multiple strategies.
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Affiliation(s)
- Jessica E Haberer
- Center for Global Health, Massachusetts General Hospital, Boston, MA
- Department of Medicine, Harvard Medical School, Boston, MA
| | - Nelly Mugo
- Center for Clinical Research, Kenya Medical Research Institute, Thika, Kenya
- Department of Global Health, University of Washington, Seattle, WA
| | - Elizabeth Ann Bukusi
- Department of Global Health, University of Washington, Seattle, WA
- Centre for Microbiology Research, Kenya Medical Research Institute, Kisumu, Kenya
| | - 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
| | | | - Kevin Oware
- Centre for Microbiology Research, Kenya Medical Research Institute, Kisumu, Kenya
| | | | | | - Maria Pyra
- Department of Medicine, University of Chicago, Chicago, IL
| | - Susie Valenzuela
- Department of Global Health, University of Washington, Seattle, WA
| | | | - Peter L Anderson
- Department of Pharmaceutical Sciences, University of Colorado, Denver, CO
| | - Harsha Thirumurthy
- Department of Medical Ethics and Health Policy, Perelman School of Medicine and Center for Health Incentives and Behavioral Economics, University of Pennsylvania, Philadelphia, PA
| | - Jared M Baeten
- Center for Global Health, Massachusetts General Hospital, Boston, MA
- HIV Clinical Development, Gilead Sciences, Foster City, CA
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13
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Bonner R, Stewart J, Upadhyay A, Bruce RD, Taylor JL. A Primary Care Intervention to Increase HIV Pre-Exposure Prophylaxis (PrEP) Uptake in Patients with Syphilis. J Int Assoc Provid AIDS Care 2022; 21:23259582211073393. [PMID: 35001723 PMCID: PMC8753072 DOI: 10.1177/23259582211073393] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Identifying candidates for HIV pre-exposure prophylaxis (PrEP) is a barrier to improving PrEP uptake in priority populations. Syphilis infection is an indication for PrEP in all individuals and can be easily assessed by primary care providers (PCP) and health systems. This retrospective study evaluated the impact of a multidisciplinary provider outreach intervention on PrEP uptake in patients with a positive syphilis test result in a safety-net hospital-based primary care practice. The PCPs of PrEP-eligible patients with a positive syphilis result were notified via the electronic medical record (EMR) about potential PrEP eligibility and institutional HIV PrEP resources. Rates of PrEP offers and prescriptions were compared in the pre (8/1/2018-12/31/2018, n = 60) and post (1/1/2019-5/31/2019, n = 86) intervention periods. Secondary analyzes evaluated receipt of appropriate syphilis treatment and contemporaneous screening for HIV, gonorrhea, and chlamydia. No significant differences in the overall proportion of patients offered (15% vs 19%) and prescribed (7% vs 5%) PrEP were observed between the pre- and post-periods. Overall, 7% of positive tests represented infectious syphilis. The rate of appropriate syphilis treatment was equivalent (57% vs 56%) and contemporaneous screening for other sexually transmitted infections was suboptimal across the entire study period. Although any positive syphilis test may be an easily abstracted metric from the EMR, this approach was inclusive of many patients without current HIV risk and did not increase PrEP uptake significantly. Future research into population health approaches to increase HIV prevention should focus on patients with infectious syphilis and other current risk factors for incident HIV infection.
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Affiliation(s)
- Ryan Bonner
- 12259Boston University School of Medicine and Boston Medical Center, Boston, MA, USA
| | | | - Ashish Upadhyay
- 12259Boston University School of Medicine and Boston Medical Center, Boston, MA, USA
| | - R Douglas Bruce
- 12259Boston University School of Medicine and Boston Medical Center, Boston, MA, USA
| | - Jessica L Taylor
- 12259Boston University School of Medicine and Boston Medical Center, Boston, MA, USA
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Kusemererwa S, Kansiime S, Mutonyi G, Namirembe A, Katana S, Kitonsa J, Kakande A, Okello JM, Kaleebu P, Ruzagira E. Predictors of oral pre-exposure prophylaxis (PrEP) uptake among individuals in a HIV vaccine preparedness cohort in Masaka, Uganda. Medicine (Baltimore) 2021; 100:e27719. [PMID: 34871265 PMCID: PMC8568469 DOI: 10.1097/md.0000000000027719] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/13/2021] [Accepted: 10/21/2021] [Indexed: 01/05/2023] Open
Abstract
Oral pre-exposure prophylaxis (PrEP) significantly reduces human immunodeficiency virus (HIV) acquisition risk. However, data on predictors of PrEP uptake in sub-Saharan Africa are limited. We assessed predictors of PrEP uptake among HIV-uninfected high risk individuals enrolled in a HIV vaccine preparedness study in Masaka, Uganda.Between July 2018 and October 2020, we recruited adults (18-40 years) from sex work hotspots along the trans-African highway and Lake Victoria fishing communities. We collected baseline data on socio-demographics and PrEP awareness, and provided HIV counselling and testing, information on PrEP, and PrEP referrals at quarterly visits. Urine pregnancy tests (women) and data collection on sexual risk behaviour and PrEP uptake were performed every 6 months. We analysed PrEP uptake among participants who had completed 6 months of follow-up.Of the 588 cohort participants, 362 (62%) were included in this analysis. Of these, 176 (49%) were female, 181 (50%) were aged ≤24 years, 104 (29%) worked in sex work hotspots, 74 (20%) were fisher folk. Only 75 (21%) participants initiated PrEP. Predictors of PrEP uptake included having ≥6 sex partners (adjusted odds ratio [aOR] = 2.29; 95% confidence interval [CI] 1.26-4.17), engaging in transactional sex (aOR = 2.23; 95% CI 0.95-5.20), and residence in a nonfishing community (aOR = 2.40; 95% CI 1.14-5.08). The commonest reasons for not starting PrEP were pill burden (38%) and needing more time to decide (27%).PrEP uptake was low and associated with HIV risk indicators in this cohort. Interventions are needed to improve access to PrEP especially in fishing communities.
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Affiliation(s)
- Sylvia Kusemererwa
- Department of HIV and Emerging Infections, Medical Research Council/Uganda Virus Research Institute and London School of Hygiene and Tropical Medicine Uganda Research Unit, Entebbe, Uganda
| | - Sheila Kansiime
- Department of Statistics, Medical Research Council/Uganda Virus Research Institute and London School of Hygiene and Tropical Medicine Uganda Research Unit, Entebbe, Uganda
| | - Gertrude Mutonyi
- Department of Statistics, Medical Research Council/Uganda Virus Research Institute and London School of Hygiene and Tropical Medicine Uganda Research Unit, Entebbe, Uganda
| | - Aeron Namirembe
- Department of Statistics, Medical Research Council/Uganda Virus Research Institute and London School of Hygiene and Tropical Medicine Uganda Research Unit, Entebbe, Uganda
| | - Safina Katana
- Department of HIV and Emerging Infections, Medical Research Council/Uganda Virus Research Institute and London School of Hygiene and Tropical Medicine Uganda Research Unit, Entebbe, Uganda
| | - Jonathan Kitonsa
- Department of HIV and Emerging Infections, Medical Research Council/Uganda Virus Research Institute and London School of Hygiene and Tropical Medicine Uganda Research Unit, Entebbe, Uganda
| | - Ayoub Kakande
- Department of Statistics, Medical Research Council/Uganda Virus Research Institute and London School of Hygiene and Tropical Medicine Uganda Research Unit, Entebbe, Uganda
| | - Joseph Mugisha Okello
- Department of HIV and Emerging Infections, Medical Research Council/Uganda Virus Research Institute and London School of Hygiene and Tropical Medicine Uganda Research Unit, Entebbe, Uganda
| | - Pontiano Kaleebu
- Department of HIV and Emerging Infections, Medical Research Council/Uganda Virus Research Institute and London School of Hygiene and Tropical Medicine Uganda Research Unit, Entebbe, Uganda
| | - Eugene Ruzagira
- Department of HIV and Emerging Infections, Medical Research Council/Uganda Virus Research Institute and London School of Hygiene and Tropical Medicine Uganda Research Unit, Entebbe, Uganda
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Ddaaki W, Strömdahl S, Yeh PT, Rosen JG, Jackson J, Nakyanjo N, Kagaayi J, Kigozi G, Nakigozi G, Grabowski MK, Chang LW, Reynolds SJ, Nalugoda F, Ekström AM, Kennedy CE. Qualitative Assessment of Barriers and Facilitators of PrEP Use Before and After Rollout of a PrEP Program for Priority Populations in South-central Uganda. AIDS Behav 2021; 25:3547-3562. [PMID: 34240317 DOI: 10.1007/s10461-021-03360-3] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/19/2021] [Indexed: 12/19/2022]
Abstract
Uganda piloted HIV pre-exposure prophylaxis (PrEP) for priority populations (sex workers, fishermen, truck drivers, discordant couples) in 2017. To assess facilitators and barriers to PrEP uptake and adherence, we explored perceptions of PrEP before and experiences after rollout among community members and providers in south-central Uganda. We conducted 75 in-depth interviews and 12 focus group discussions. We analyzed transcripts using a team-based thematic framework approach. Partners, family, peers, and experienced PrEP users provided adherence support. Occupational factors hindered adherence for sex workers and fishermen, particularly related to mobility. Pre-rollout concerns about unskilled/untrained volunteers distributing PrEP and price-gouging were mitigated. After rollout, awareness of high community HIV risk and trust in PrEP effectiveness facilitated uptake. PrEP stigma and unexpected migration persisted as barriers. Community-initiated, tailored communication with successful PrEP users may optimize future engagement by addressing fears and rumors, while flexible delivery and refill models may facilitate PrEP continuation and adherence.
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16
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Loevinsohn G, Kigozi G, Kagaayi J, Wawer MJ, Nalugoda F, Chang LW, Quinn TC, Serwadda D, Reynolds SJ, Nelson L, Mills L, Alamo S, Nakigozi G, Kabuye G, Ssekubugu R, Tobian AAR, Gray RH, Grabowski MK. Effectiveness of Voluntary Medical Male Circumcision for Human Immunodeficiency Virus Prevention in Rakai, Uganda. Clin Infect Dis 2021; 73:e1946-e1953. [PMID: 33043978 PMCID: PMC8492113 DOI: 10.1093/cid/ciaa1533] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2020] [Accepted: 10/06/2020] [Indexed: 01/29/2023] Open
Abstract
BACKGROUND The efficacy of voluntary male medical circumcision (VMMC) for human immunodeficiency virus (HIV) prevention in men was demonstrated in 3 randomized trials. This led to the adoption of VMMC as an integral component of the United States President's Emergency Plan for AIDS Relief (PEPFAR) combination HIV prevention program in sub-Saharan Africa. However, evidence on the individual-level effectiveness of VMMC programs in real-world, programmatic settings is limited. METHODS A cohort of initially uncircumcised, non-Muslim, HIV-uninfected men in the Rakai Community Cohort Study in Uganda was followed between 2009 and 2016 during VMMC scale-up. Self-reported VMMC status was collected and HIV tests performed at surveys conducted every 18 months. Multivariable Poisson regression was used to estimate the incidence rate ratio (IRR) of HIV acquisition in newly circumcised vs uncircumcised men. RESULTS A total of 3916 non-Muslim men were followed for 17 088 person-years (PY). There were 1338 newly reported VMMCs (9.8/100 PY). Over the study period, the median age of men adopting VMMC declined from 28 years (interquartile range [IQR], 21-35 years) to 22 years (IQR, 18-29 years) (P for trend < .001). HIV incidence was 0.40/100 PY (20/4992.8 PY) among newly circumcised men and 0.98/100 PY (118/12 095.1 PY) among uncircumcised men with an adjusted IRR of 0.47 (95% confidence interval, .28-.78). The effectiveness of VMMC was sustained with increasing time from surgery and was similar across age groups and calendar time. CONCLUSIONS VMMC programs are highly effective in preventing HIV acquisition in men. The observed effectiveness is consistent with efficacy in clinical trials and supports current recommendations that VMMC is a key component of programs to reduce HIV incidence.
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Affiliation(s)
- Gideon Loevinsohn
- Department of Epidemiology, Johns Hopkins University Bloomberg School of Public Health, Baltimore, Maryland, USA
- Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | | | | | - Maria J Wawer
- Department of Epidemiology, Johns Hopkins University Bloomberg School of Public Health, Baltimore, Maryland, USA
- Rakai Health Sciences Program, Kalisizo, Uganda
- Department of Population, Family and Reproductive Health, Johns Hopkins University Bloomberg School of Public Health, Baltimore, Maryland, USA
| | | | - Larry W Chang
- Department of Epidemiology, Johns Hopkins University Bloomberg School of Public Health, Baltimore, Maryland, USA
- Rakai Health Sciences Program, Kalisizo, Uganda
- Division of Infectious Diseases, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Thomas C Quinn
- Department of Epidemiology, Johns Hopkins University Bloomberg School of Public Health, Baltimore, Maryland, USA
- Division of Infectious Diseases, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
- Laboratory of Immunoregulation, Division of Intramural Research, National Institute for Allergy and Infectious Diseases, National Institutes of Health, Bethesda, Maryland, USA
| | - David Serwadda
- Rakai Health Sciences Program, Kalisizo, Uganda
- School of Public Health, Makerere University, Kampala, Uganda
| | - Steven J Reynolds
- Department of Epidemiology, Johns Hopkins University Bloomberg School of Public Health, Baltimore, Maryland, USA
- Rakai Health Sciences Program, Kalisizo, Uganda
- Division of Infectious Diseases, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
- Laboratory of Immunoregulation, Division of Intramural Research, National Institute for Allergy and Infectious Diseases, National Institutes of Health, Bethesda, Maryland, USA
| | - Lisa Nelson
- US Centers for Disease Control and Prevention Uganda, Kampala, Uganda
| | - Lisa Mills
- US Centers for Disease Control and Prevention Uganda, Kampala, Uganda
| | - Stella Alamo
- US Centers for Disease Control and Prevention Uganda, Kampala, Uganda
| | | | - Geoffrey Kabuye
- US Centers for Disease Control and Prevention Uganda, Kampala, Uganda
| | | | - Aaron A R Tobian
- Department of Epidemiology, Johns Hopkins University Bloomberg School of Public Health, Baltimore, Maryland, USA
- Rakai Health Sciences Program, Kalisizo, Uganda
- Department of Pathology, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Ronald H Gray
- Department of Epidemiology, Johns Hopkins University Bloomberg School of Public Health, Baltimore, Maryland, USA
- Rakai Health Sciences Program, Kalisizo, Uganda
| | - M Kathryn Grabowski
- Department of Epidemiology, Johns Hopkins University Bloomberg School of Public Health, Baltimore, Maryland, USA
- Rakai Health Sciences Program, Kalisizo, Uganda
- Department of Pathology, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
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Ayieko J, Petersen ML, Kabami J, Mwangwa F, Opel F, Nyabuti M, Charlebois ED, Peng J, Koss CA, Balzer LB, Chamie G, Bukusi EA, Kamya MR, Havlir DV. Uptake and outcomes of a novel community-based HIV post-exposure prophylaxis (PEP) programme in rural Kenya and Uganda. J Int AIDS Soc 2021; 24:e25670. [PMID: 34152067 PMCID: PMC8215805 DOI: 10.1002/jia2.25670] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2020] [Revised: 12/23/2020] [Accepted: 01/21/2021] [Indexed: 11/24/2022] Open
Abstract
INTRODUCTION Antiretroviral-based HIV prevention, including pre-exposure prophylaxis (PrEP), is expanding in generalized epidemic settings, but additional prevention options are needed for individuals with periodic, high-risk sexual exposures. Non-occupational post-exposure prophylaxis (PEP) is recommended in global guidelines. However, in Africa, awareness of and access to PEP for sexual exposures are limited. We assessed feasibility, acceptability, uptake and adherence in a pilot study of a patient-centred PEP programme with options for facility- or community-based service delivery. METHODS After population-level HIV testing with universal access to PrEP for persons at elevated HIV risk (SEARCH Trial:NCT01864603), we conducted a pilot PEP study in five rural communities in Kenya and Uganda between December 2018 and May 2019. We assessed barriers to PEP in the population and implemented an intervention to address these barriers, building on existing in-country PEP protocols. We used community leaders for sensitization. Test kits and medications were acquired through the Ministry of Health supply chain and healthcare providers based at the Ministry of Health clinics were trained on PEP delivery. Additional intervention components were (a)PEP availability seven days/week, (b)PEP hotline staffed by providers and (c)option for out-of-facility medication delivery. We assessed implementation using the Proctor framework and measured seroconversions via repeat HIV testing. Successful "PEP completion" was defined as self-reported adherence over four weeks of therapy with post-PEP HIV testing. RESULTS Community leaders were able to sensitize and mobilize for PEP. The Ministry of Health supplied test kits and PEP medications; after training, healthcare providers delivered the 28-day regimen with high completion rates. Among 124 persons who sought PEP, 66% were female, 24% were ≤25 years and 42% were fisherfolk. Of these, 20% reported exposure with a serodifferent partner, 72% with a new or existing relationship and 7% from transactional sex. 12% of all visits were conducted at out-of-facility community-based sites; 35% of participants had ≥1 out-of-facility visit. No serious adverse events were reported. Overall, 85% met the definition of PEP completion. There were no HIV seroconversions. CONCLUSIONS Among individuals with elevated-risk exposures in rural East African communities, patient-centred PEP was feasible, acceptable and provides a promising addition to the current prevention toolkit.
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Affiliation(s)
- James Ayieko
- Center for Microbiology ResearchKenya Medical Research InstituteNairobiKenya
| | - Maya L Petersen
- Department of BiostatisticsUniversity of CaliforniaBerkeleyCAUSA
| | - Jane Kabami
- Infectious Diseases Research CollaborationKampalaUganda
| | | | - Fred Opel
- Center for Microbiology ResearchKenya Medical Research InstituteNairobiKenya
| | - Marilyn Nyabuti
- Center for Microbiology ResearchKenya Medical Research InstituteNairobiKenya
| | | | - James Peng
- Department of MedicineUniversity of CaliforniaSan FranciscoCAUSA
| | - Catherine A Koss
- Department of MedicineUniversity of CaliforniaSan FranciscoCAUSA
| | - Laura B Balzer
- Department of Biostatistics and EpidemiologyUniversity of MassachusettsAmherstMAUSA
| | - Gabriel Chamie
- Department of MedicineUniversity of CaliforniaSan FranciscoCAUSA
| | - Elizabeth A Bukusi
- Center for Microbiology ResearchKenya Medical Research InstituteNairobiKenya
| | - Moses R Kamya
- Department of MedicineMakerere UniversityKampalaUganda
| | - Diane V Havlir
- Department of MedicineUniversity of CaliforniaSan FranciscoCAUSA
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Abstract
Supplemental Digital Content is Available in the Text. HIV-1 risk scoring tools could help target provision of prevention modalities such as pre-exposure prophylaxis. Recent research suggests that risk scores for women aged 18–45 may not predict risk well among young women aged 18–24. We evaluated the predictive performance of age-specific risk scores compared with the existing non–age-specific VOICE risk score, developed for women aged 18–45.
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Koss CA, Havlir DV, Ayieko J, Kwarisiima D, Kabami J, Chamie G, Atukunda M, Mwinike Y, Mwangwa F, Owaraganise A, Peng J, Olilo W, Snyman K, Awuonda B, Clark TD, Black D, Nugent J, Brown LB, Marquez C, Okochi H, Zhang K, Camlin CS, Jain V, Gandhi M, Cohen CR, Bukusi EA, Charlebois ED, Petersen ML, Kamya MR, Balzer LB. HIV incidence after pre-exposure prophylaxis initiation among women and men at elevated HIV risk: A population-based study in rural Kenya and Uganda. PLoS Med 2021; 18:e1003492. [PMID: 33561143 PMCID: PMC7872279 DOI: 10.1371/journal.pmed.1003492] [Citation(s) in RCA: 34] [Impact Index Per Article: 11.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/14/2020] [Accepted: 01/04/2021] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND Oral pre-exposure prophylaxis (PrEP) is highly effective for HIV prevention, but data are limited on HIV incidence among PrEP users in generalized epidemic settings, particularly outside of selected risk groups. We performed a population-based PrEP study in rural Kenya and Uganda and sought to evaluate both changes in HIV incidence and clinical and virologic outcomes following seroconversion on PrEP. METHODS AND FINDINGS During population-level HIV testing of individuals ≥15 years in 16 communities in the Sustainable East Africa Research in Community Health (SEARCH) study (NCT01864603), we offered universal access to PrEP with enhanced counseling for persons at elevated HIV risk (based on serodifferent partnership, machine learning-based risk score, or self-identified HIV risk). We offered rapid or same-day PrEP initiation and flexible service delivery with follow-up visits at facilities or community-based sites at 4, 12, and every 12 weeks up to week 144. Among participants with incident HIV infection after PrEP initiation, we offered same-day antiretroviral therapy (ART) initiation and analyzed HIV RNA, tenofovir hair concentrations, drug resistance, and viral suppression (<1,000 c/ml based on available assays) after ART start. Using Poisson regression with cluster-robust standard errors, we compared HIV incidence among PrEP initiators to incidence among propensity score-matched recent historical controls (from the year before PrEP availability) in 8 of the 16 communities, adjusted for risk group. Among 74,541 individuals who tested negative for HIV, 15,632/74,541 (21%) were assessed to be at elevated HIV risk; 5,447/15,632 (35%) initiated PrEP (49% female; 29% 15-24 years; 19% in serodifferent partnerships), of whom 79% engaged in ≥1 follow-up visit and 61% self-reported PrEP adherence at ≥1 visit. Over 7,150 person-years of follow-up, HIV incidence was 0.35 per 100 person-years (95% confidence interval [CI] 0.22-0.49) among PrEP initiators. Among matched controls, HIV incidence was 0.92 per 100 person-years (95% CI 0.49-1.41), corresponding to 74% lower incidence among PrEP initiators compared to matched controls (adjusted incidence rate ratio [aIRR] 0.26, 95% CI 0.09-0.75; p = 0.013). Among women, HIV incidence was 76% lower among PrEP initiators versus matched controls (aIRR 0.24, 95% CI 0.07-0.79; p = 0.019); among men, HIV incidence was 40% lower, but not significantly so (aIRR 0.60, 95% CI 0.12-3.05; p = 0.54). Of 25 participants with incident HIV infection (68% women), 7/25 (28%) reported taking PrEP ≤30 days before HIV diagnosis, and 24/25 (96%) started ART. Of those with repeat HIV RNA after ART start, 18/19 (95%) had <1,000 c/ml. One participant with viral non-suppression was found to have transmitted viral resistance, as well as emtricitabine resistance possibly related to PrEP use. Limitations include the lack of contemporaneous controls to assess HIV incidence without PrEP and that plasma samples were not archived to assess for baseline acute infection. CONCLUSIONS Population-level offer of PrEP with rapid start and flexible service delivery was associated with 74% lower HIV incidence among PrEP initiators compared to matched recent controls prior to PrEP availability. HIV infections were significantly lower among women who started PrEP. Universal HIV testing with linkage to treatment and prevention, including PrEP, is a promising approach to accelerate reductions in new infections in generalized epidemic settings. TRIAL REGISTRATION ClinicalTrials.gov NCT01864603.
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Affiliation(s)
- Catherine A. Koss
- Division of HIV, Infectious Diseases, and Global Medicine, University of California, San Francisco, San Francisco, California, United States of America
- * E-mail:
| | - Diane V. Havlir
- Division of HIV, Infectious Diseases, and Global Medicine, University of California, San Francisco, San Francisco, California, United States of America
| | - James Ayieko
- Centre for Microbiology Research, Kenya Medical Research Institute, Nairobi, Kenya
| | | | - Jane Kabami
- Infectious Diseases Research Collaboration, Kampala, Uganda
| | - Gabriel Chamie
- Division of HIV, Infectious Diseases, and Global Medicine, University of California, San Francisco, San Francisco, California, United States of America
| | | | - Yusuf Mwinike
- Infectious Diseases Research Collaboration, Kampala, Uganda
| | | | | | - James Peng
- Division of HIV, Infectious Diseases, and Global Medicine, University of California, San Francisco, San Francisco, California, United States of America
| | - Winter Olilo
- Centre for Microbiology Research, Kenya Medical Research Institute, Nairobi, Kenya
| | - Katherine Snyman
- Division of HIV, Infectious Diseases, and Global Medicine, University of California, San Francisco, San Francisco, California, United States of America
| | - Benard Awuonda
- Centre for Microbiology Research, Kenya Medical Research Institute, Nairobi, Kenya
| | - Tamara D. Clark
- Division of HIV, Infectious Diseases, and Global Medicine, University of California, San Francisco, San Francisco, California, United States of America
| | - Douglas Black
- Division of HIV, Infectious Diseases, and Global Medicine, University of California, San Francisco, San Francisco, California, United States of America
| | - Joshua Nugent
- Department of Biostatistics and Epidemiology, University of Massachusetts, Amherst, Amherst, Massachusetts, United States of America
| | - Lillian B. Brown
- Division of HIV, Infectious Diseases, and Global Medicine, University of California, San Francisco, San Francisco, California, United States of America
| | - Carina Marquez
- Division of HIV, Infectious Diseases, and Global Medicine, University of California, San Francisco, San Francisco, California, United States of America
| | - Hideaki Okochi
- Division of HIV, Infectious Diseases, and Global Medicine, University of California, San Francisco, San Francisco, California, United States of America
| | - Kevin Zhang
- Division of HIV, Infectious Diseases, and Global Medicine, University of California, San Francisco, San Francisco, California, United States of America
| | - Carol S. Camlin
- Department of Obstetrics, Gynecology and Reproductive Sciences, University of California, San Francisco, San Francisco, California, United States of America
| | - Vivek Jain
- Division of HIV, Infectious Diseases, and Global Medicine, University of California, San Francisco, San Francisco, California, United States of America
| | - Monica Gandhi
- Division of HIV, Infectious Diseases, and Global Medicine, University of California, San Francisco, San Francisco, California, United States of America
| | - Craig R. Cohen
- Department of Obstetrics, Gynecology and Reproductive Sciences, University of California, San Francisco, San Francisco, California, United States of America
| | - Elizabeth A. Bukusi
- Centre for Microbiology Research, Kenya Medical Research Institute, Nairobi, Kenya
- Department of Obstetrics, Gynecology and Reproductive Sciences, University of California, San Francisco, San Francisco, California, United States of America
| | - Edwin D. Charlebois
- Division of Prevention Science, Department of Medicine, University of California, San Francisco, San Francisco, California, United States of America
| | - Maya L. Petersen
- Graduate Group in Biostatistics, School of Public Health, University of California, Berkeley, Berkeley, California, United States of America
| | - Moses R. Kamya
- Infectious Diseases Research Collaboration, Kampala, Uganda
- School of Medicine, Makerere University College of Health Sciences, Kampala, Uganda
| | - Laura B. Balzer
- Department of Biostatistics and Epidemiology, University of Massachusetts, Amherst, Amherst, Massachusetts, United States of America
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Krakower DS, Marcus JL. Machine Learning for Human Immunodeficiency Virus Prevention in Rural Africa: The SEARCH for Sustainability. Clin Infect Dis 2020; 71:2334-2335. [PMID: 31697379 PMCID: PMC7713679 DOI: 10.1093/cid/ciz1101] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2019] [Accepted: 11/05/2019] [Indexed: 11/14/2022] Open
Affiliation(s)
- Douglas S Krakower
- Division of Infectious Diseases, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
- Harvard Medical School and Harvard Pilgrim Health Care Institute, Boston, Massachusetts, USA
- The Fenway Institute, Boston, Massachusetts, USA
| | - Julia L Marcus
- Harvard Medical School and Harvard Pilgrim Health Care Institute, Boston, Massachusetts, USA
- The Fenway Institute, Boston, Massachusetts, USA
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21
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Balzer LB, Havlir DV, Kamya MR, Chamie G, Charlebois ED, Clark TD, Koss CA, Kwarisiima D, Ayieko J, Sang N, Kabami J, Atukunda M, Jain V, Camlin CS, Cohen CR, Bukusi EA, Van Der Laan M, Petersen ML. Machine Learning to Identify Persons at High-Risk of Human Immunodeficiency Virus Acquisition in Rural Kenya and Uganda. Clin Infect Dis 2020; 71:2326-2333. [PMID: 31697383 PMCID: PMC7904068 DOI: 10.1093/cid/ciz1096] [Citation(s) in RCA: 34] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2019] [Accepted: 11/05/2019] [Indexed: 12/21/2022] Open
Abstract
BACKGROUND In generalized epidemic settings, strategies are needed to prioritize individuals at higher risk of human immunodeficiency virus (HIV) acquisition for prevention services. We used population-level HIV testing data from rural Kenya and Uganda to construct HIV risk scores and assessed their ability to identify seroconversions. METHODS During 2013-2017, >75% of residents in 16 communities in the SEARCH study were tested annually for HIV. In this population, we evaluated 3 strategies for using demographic factors to predict the 1-year risk of HIV seroconversion: membership in ≥1 known "risk group" (eg, having a spouse living with HIV), a "model-based" risk score constructed with logistic regression, and a "machine learning" risk score constructed with the Super Learner algorithm. We hypothesized machine learning would identify high-risk individuals more efficiently (fewer persons targeted for a fixed sensitivity) and with higher sensitivity (for a fixed number targeted) than either other approach. RESULTS A total of 75 558 persons contributed 166 723 person-years of follow-up; 519 seroconverted. Machine learning improved efficiency. To achieve a fixed sensitivity of 50%, the risk-group strategy targeted 42% of the population, the model-based strategy targeted 27%, and machine learning targeted 18%. Machine learning also improved sensitivity. With an upper limit of 45% targeted, the risk-group strategy correctly classified 58% of seroconversions, the model-based strategy 68%, and machine learning 78%. CONCLUSIONS Machine learning improved classification of individuals at risk of HIV acquisition compared with a model-based approach or reliance on known risk groups and could inform targeting of prevention strategies in generalized epidemic settings. CLINICAL TRIALS REGISTRATION NCT01864603.
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Affiliation(s)
- Laura B Balzer
- Department of Biostatistics and Epidemiology, University of Massachusetts, Amherst, Massachusetts, USA
| | - Diane V Havlir
- Division of HIV, Infectious Diseases, and Global Medicine, Department of Medicine, University of California, San Francisco, California, USA
| | - Moses R Kamya
- Infectious Diseases Research Collaboration, Kampala, Uganda
- School of Medicine, Makerere University College of Health Sciences, Kampala, Uganda
| | - Gabriel Chamie
- Division of HIV, Infectious Diseases, and Global Medicine, Department of Medicine, University of California, San Francisco, California, USA
| | - Edwin D Charlebois
- Division of Prevention Science, Department of Medicine, University of California, San Francisco, California, USA
| | - Tamara D Clark
- Division of HIV, Infectious Diseases, and Global Medicine, Department of Medicine, University of California, San Francisco, California, USA
| | - Catherine A Koss
- Division of HIV, Infectious Diseases, and Global Medicine, Department of Medicine, University of California, San Francisco, California, USA
| | | | - James Ayieko
- Kenya Medical Research Institute, Nairobi, Kenya
| | - Norton Sang
- Kenya Medical Research Institute, Nairobi, Kenya
| | - Jane Kabami
- Infectious Diseases Research Collaboration, Kampala, Uganda
| | | | - Vivek Jain
- Division of HIV, Infectious Diseases, and Global Medicine, Department of Medicine, University of California, San Francisco, California, USA
| | - Carol S Camlin
- Department of Obstetrics, Gynecology, and Reproductive Sciences, University of California, San Francisco, California, USA
| | - Craig R Cohen
- Department of Obstetrics, Gynecology, and Reproductive Sciences, University of California, San Francisco, California, USA
| | - Elizabeth A Bukusi
- Kenya Medical Research Institute, Nairobi, Kenya
- Department of Obstetrics, Gynecology, and Reproductive Sciences, University of California, San Francisco, California, USA
| | - Mark Van Der Laan
- Division of Epidemiology and Biostatistics, University of California, Berkeley, California, USA
| | - Maya L Petersen
- Division of Epidemiology and Biostatistics, University of California, Berkeley, California, USA
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Rowan SE, Patel RR, Schneider JA, Smith DK. Same-day prescribing of daily oral pre-exposure prophylaxis for HIV prevention. Lancet HIV 2020; 8:e114-e120. [PMID: 33128874 DOI: 10.1016/s2352-3018(20)30256-3] [Citation(s) in RCA: 23] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2019] [Revised: 07/08/2020] [Accepted: 07/28/2020] [Indexed: 01/26/2023]
Abstract
Pre-exposure prophylaxis (PrEP) is highly effective in reducing HIV transmission but remains underutilised globally. Same-day PrEP prescribing and medication provision is an emerging implementation approach. The experiences of the three same-day PrEP programmes support the feasibility of the approach. Key elements of safe and effective same-day PrEP programmes include the ability to order laboratory tests at the time of the clinical visit and the ability to contact patients when laboratory results are available. Same-day PrEP has the potential to alleviate the attrition seen in usual care between initial evaluation and receipt of a PrEP prescription. A widespread application of same-day prescribing will be needed to assess its effect on PrEP usage.
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Affiliation(s)
| | - Rupa R Patel
- Division of Infectious Diseases, Washington University in St Louis, St Louis, MO, USA.
| | | | - Dawn K Smith
- Division of HIV/AIDS Prevention, Centers for Disease Control and Prevention, Atlanta, GA, USA
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Kagaayi J, Batte J, Nakawooya H, Kigozi B, Nakigozi G, Strömdahl S, Ekström AM, Chang LW, Gray R, Reynolds SJ, Komaketch P, Alamo S, Serwadda D. Uptake and retention on HIV pre-exposure prophylaxis among key and priority populations in South-Central Uganda. J Int AIDS Soc 2020; 23:e25588. [PMID: 32785976 PMCID: PMC7421540 DOI: 10.1002/jia2.25588] [Citation(s) in RCA: 36] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2019] [Revised: 04/28/2020] [Accepted: 07/01/2020] [Indexed: 11/19/2022] Open
Abstract
INTRODUCTION Pre-exposure prophylaxis (PrEP) programmes have been initiated in sub-Saharan Africa to prevent HIV acquisition in key populations at increased risk. However, data on PrEP uptake and retention in high-risk African communities are limited. We evaluated PrEP uptake and retention in HIV hyperendemic fishing villages and trading centres in south-central Uganda between April 2018 and March 2019. METHODS PrEP eligibility was assessed using a national risk screening tool. Programme data were used to evaluate uptake and retention over 12 months. Multivariable modified Poisson regression estimated adjusted prevalence ratios (aPR) and 95% Confidence intervals (CIs) of uptake associated with covariates. We used Kaplan-Meier analysis to estimate retention and multivariable Cox regression to estimate adjusted relative hazards (aRH) and 95% CIs of discontinuation associated with covariates. RESULTS AND DISCUSSION Of the 2985 HIV-negative individuals screened; 2750 (92.1 %) were eligible; of whom 2,536 (92.2%) accepted PrEP. Male (aPR = 0.91, 95% CI = 0.85 to 0.97) and female (aPR = 0.85, 95% CI = 0.77 to 0.94) fisher folk were less likely to accept compared to HIV-discordant couples. Median retention was 45.4 days for both men and women, whereas retention was higher among women (log rank, p < 0.001) overall. PrEP discontinuation was higher among female sex workers (aRH = 1.42, 95% CI = 1.09 to 1.83) and female fisher folk (aRH = 1.99, 95% CI = 1.46 to 2.72), compared to women in discordant couples. Male fisher folk (aRH = 1.37, 95% CI = 1.07 to 1.76) and male truck drivers (aRH = 1.49, 95% CI = 1.14 to 1.94) were more likely to discontinue compared to men in discordant couples. Women 30 to 34 years tended to have lower discontinuation rates compared to adolescents 15 to 19 years (RH = 0.78 [95% CI = 0.63 to 0.96]). CONCLUSIONS PrEP uptake was high, but retention was very low especially among those at the highest risk of HIV: fisher folk, sex workers and truck drivers and adolescent girls. Research on reasons for PrEP discontinuation could help optimize retention.
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Affiliation(s)
- Joseph Kagaayi
- Rakai Health Sciences Program, Kalisizo, Uganda
- Makerere University School of Public Health, Kampala, Uganda
| | - James Batte
- Rakai Health Sciences Program, Kalisizo, Uganda
| | | | | | | | - Susanne Strömdahl
- Department of Global Public Health and Karolinska University Hospital, Department of Infectious Diseases, Karolinska Institutet, Stockholm, Sweden
- Department of Medical Sciences, Section of Infectious Diseases, Uppsala University, Stockholm, Sweden
| | - Anna Mia Ekström
- Department of Global Public Health and Karolinska University Hospital, Department of Infectious Diseases, Karolinska Institutet, Stockholm, Sweden
| | - Larry W Chang
- Rakai Health Sciences Program, Kalisizo, Uganda
- Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
- Johns Hopkins School of Medicine, Baltimore, MD, USA
| | - Ron Gray
- Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Steven J Reynolds
- Rakai Health Sciences Program, Kalisizo, Uganda
- Johns Hopkins School of Medicine, Baltimore, MD, USA
- Division of Intramural Research, NIAID/NIH, Bethesda, MD, USA
| | | | - Stella Alamo
- Centers for Disease Control and Prevention, Kampala, Uganda
| | - David Serwadda
- Rakai Health Sciences Program, Kalisizo, Uganda
- Makerere University School of Public Health, Kampala, Uganda
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24
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Camlin CS, Koss CA, Getahun M, Owino L, Itiakorit H, Akatukwasa C, Maeri I, Bakanoma R, Onyango A, Atwine F, Ayieko J, Kabami J, Mwangwa F, Atukunda M, Owaraganise A, Kwarisiima D, Sang N, Bukusi EA, Kamya MR, Petersen ML, Cohen CR, Charlebois ED, Havlir DV. Understanding Demand for PrEP and Early Experiences of PrEP Use Among Young Adults in Rural Kenya and Uganda: A Qualitative Study. AIDS Behav 2020; 24:2149-2162. [PMID: 31955361 PMCID: PMC7909847 DOI: 10.1007/s10461-020-02780-x] [Citation(s) in RCA: 65] [Impact Index Per Article: 16.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
Few studies have sought to understand factors influencing uptake and continuation of pre-exposure prophylaxis (PrEP) among young adults in sub-Saharan Africa in the context of population-based delivery of open-label PrEP. To address this gap, this qualitative study was implemented within the SEARCH study (NCT#01864603) in Kenya and Uganda, which achieved near-universal HIV testing, and offered PrEP in 16 intervention communities beginning in 2016-2017. Focus group discussions (8 groups, n = 88 participants) and in-depth interviews (n = 23) with young adults who initiated or declined PrEP were conducted in five communities, to explore PrEP-related beliefs and attitudes, HIV risk perceptions, motivations for uptake and continuation, and experiences. Grounded theoretical methods were used to analyze data. Young people felt personally vulnerable to HIV, but perceived the severity of HIV to be low, due to the success of antiretroviral therapy (ART): daily pill-taking was more threatening than the disease itself. Motivations for PrEP were highly gendered: young men viewed PrEP as a vehicle for safely pursuing multiple partners, while young women saw PrEP as a means to control risks in the context of engagement in transactional sex and limited agency to negotiate condom use and partner testing. Rumors, HIV/ART-related stigma, and desire for "proof" of efficacy militated against uptake, and many women required partners' permission to take PrEP. Uptake was motivated by high perceived HIV risk, and beliefs that PrEP use supported life goals. PrEP was often discontinued due to dissolution of partnerships/changing risk, unsupportive partners/peers, or early side effects/pill burden. Despite high perceived risks and interest, PrEP was received with moral ambivalence because of its associations with HIV/ART and stigmatized behaviors. Delivery models that promote youth access, frame messaging on wellness and goals, and foster partner and peer support, may facilitate uptake among young people.
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Affiliation(s)
- Carol S Camlin
- Department of Obstetrics, Gynecology & Reproductive Sciences, ANSIRH Program, University of California San Francisco, 1330 Broadway, Suite 1100, Oakland, CA, 94612, USA.
- Department of Medicine, Center for AIDS Prevention Studies, University of California San Francisco, San Francisco, USA.
| | - Catherine A Koss
- Department of Medicine, Division of HIV, Infectious Diseases, and Global Medicine, University of California San Francisco, San Francisco, USA
| | - Monica Getahun
- Department of Obstetrics, Gynecology & Reproductive Sciences, ANSIRH Program, University of California San Francisco, 1330 Broadway, Suite 1100, Oakland, CA, 94612, USA
| | | | | | | | - Irene Maeri
- Kenya Medical Research Institute, Nairobi, Kenya
| | | | | | | | - James Ayieko
- Kenya Medical Research Institute, Nairobi, Kenya
| | - Jane Kabami
- Infectious Diseases Research Collaboration, Kampala, Uganda
| | | | | | | | | | - Norton Sang
- Kenya Medical Research Institute, Nairobi, Kenya
| | | | - Moses R Kamya
- Infectious Diseases Research Collaboration, Kampala, Uganda
- School of Medicine, Makerere University College of Health Sciences, Kampala, Uganda
| | - Maya L Petersen
- Graduate Group in Biostatistics, School of Public Health, University of California Berkeley, Berkeley, USA
| | - Craig R Cohen
- Department of Obstetrics, Gynecology & Reproductive Sciences, ANSIRH Program, University of California San Francisco, 1330 Broadway, Suite 1100, Oakland, CA, 94612, USA
| | - Edwin D Charlebois
- Department of Medicine, Center for AIDS Prevention Studies, University of California San Francisco, San Francisco, USA
| | - Diane V Havlir
- Department of Medicine, Division of HIV, Infectious Diseases, and Global Medicine, University of California San Francisco, San Francisco, USA
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Bershteyn A, Sharma M, Akullian AN, Peebles K, Sarkar S, Braithwaite RS, Mudimu E. Impact along the HIV pre-exposure prophylaxis "cascade of prevention" in western Kenya: a mathematical modelling study. J Int AIDS Soc 2020; 23 Suppl 3:e25527. [PMID: 32602669 PMCID: PMC7325506 DOI: 10.1002/jia2.25527] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2019] [Revised: 04/09/2020] [Accepted: 04/27/2020] [Indexed: 12/15/2022] Open
Abstract
INTRODUCTION Over one hundred implementation studies of HIV pre-exposure prophylaxis (PrEP) are completed, underway or planned. We synthesized evidence from these studies to inform mathematical modelling of the prevention cascade for oral and long-acting PrEP in the setting of western Kenya, one of the world's most heavily HIV-affected regions. METHODS We incorporated steps of the PrEP prevention cascade - uptake, adherence, retention and re-engagement after discontinuation - into EMOD-HIV, an open-source transmission model calibrated to the demography and HIV epidemic patterns of western Kenya. Early PrEP implementation research from East Africa was used to parameterize prevention cascades for oral PrEP as currently implemented, delivery innovations for oral PrEP, and future long-acting PrEP. We compared infections averted by PrEP at the population level for different cascade assumptions and sub-populations on PrEP. Analyses were conducted over the 2020 to 2040 time horizon, with additional sensitivity analyses for the time horizon of analysis and the time when long-acting PrEP becomes available. RESULTS The maximum impact of oral PrEP diminished by over 98% across all prevention cascades, with the exception of long-acting PrEP under optimistic assumptions about uptake and re-engagement after discontinuation. Long-acting PrEP had the highest population-level impact, even after accounting for possible delays in product availability, primarily because its effectiveness does not depend on drug adherence. Retention was the most significant cascade step reducing the potential impact of long-acting PrEP. These results were robust to assumptions about the sub-populations receiving PrEP, but were highly influenced by assumptions about re-initiation of PrEP after discontinuation, about which evidence was sparse. CONCLUSIONS Implementation challenges along the prevention cascade compound to diminish the population-level impact of oral PrEP. Long-acting PrEP is expected to be less impacted by user uptake and adherence, but it is instead dependent on product availability in the short term and retention in the long term. To maximize the impact of long-acting PrEP, ensuring timely product approval and rollout is critical. Research is needed on strategies to improve retention and patterns of PrEP re-initiation.
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Affiliation(s)
- Anna Bershteyn
- Department of Population HealthNYU Grossman School of MedicineNew YorkNYUSA
- Institute for Disease ModelingBellevueWAUSA
| | - Monisha Sharma
- Institute for Disease ModelingBellevueWAUSA
- Department of Global HealthUniversity of WashingtonSeattleWAUSA
| | - Adam N Akullian
- Institute for Disease ModelingBellevueWAUSA
- Department of Global HealthUniversity of WashingtonSeattleWAUSA
| | - Kathryn Peebles
- Department of EpidemiologyUniversity of WashingtonSeattleWAUSA
| | | | | | - Edinah Mudimu
- Department of Decision SciencesUniversity of South AfricaPretoriaSouth Africa
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Marcus JL, Sewell WC, Balzer LB, Krakower DS. Artificial Intelligence and Machine Learning for HIV Prevention: Emerging Approaches to Ending the Epidemic. Curr HIV/AIDS Rep 2020; 17:171-179. [PMID: 32347446 PMCID: PMC7260108 DOI: 10.1007/s11904-020-00490-6] [Citation(s) in RCA: 44] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
PURPOSE OF REVIEW We review applications of artificial intelligence (AI), including machine learning (ML), in the field of HIV prevention. RECENT FINDINGS ML approaches have been used to identify potential candidates for preexposure prophylaxis (PrEP) in healthcare settings in the USA and Denmark and in a population-based research setting in Eastern Africa. Although still in the proof-of-concept stage, other applications include ML with smartphone-collected and social media data to promote real-time HIV risk reduction, virtual reality tools to facilitate HIV serodisclosure, and chatbots for HIV education. ML has also been used for causal inference in HIV prevention studies. ML has strong potential to improve delivery of PrEP, with this approach moving from development to implementation. Development and evaluation of AI and ML strategies for HIV prevention may benefit from an implementation science approach, including qualitative assessments with end users, and should be developed and evaluated with attention to equity.
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Affiliation(s)
- Julia L Marcus
- Harvard Medical School and Harvard Pilgrim Health Care Institute, 401 Park Dr, Ste 401, Boston, MA, 02215, USA.
| | - Whitney C Sewell
- Harvard Medical School and Harvard Pilgrim Health Care Institute, 401 Park Dr, Ste 401, Boston, MA, 02215, USA
| | - Laura B Balzer
- University of Massachusetts Amherst, 715 North Pleasant St, Amherst, MA, 01003, USA
| | - Douglas S Krakower
- Beth Israel Deaconess Medical Center, Division of Infectious Diseases, 110 Francis St., W/LMOB Suite GB, Boston, MA, 02215, USA
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Mobility and its Effects on HIV Acquisition and Treatment Engagement: Recent Theoretical and Empirical Advances. Curr HIV/AIDS Rep 2020; 16:314-323. [PMID: 31256348 DOI: 10.1007/s11904-019-00457-2] [Citation(s) in RCA: 45] [Impact Index Per Article: 11.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Abstract
PURPOSE OF REVIEW We reviewed literature across multiple disciplines to describe issues with the measurement of population mobility in HIV research and to summarize evidence of causal pathways linking mobility to HIV acquisition risks and treatment engagement, with a focus on sub-Saharan Africa. RECENT FINDINGS While the literature on mobility and HIV remains hampered by problems and inconsistency in measures of mobility, the recent research reveals a turn towards a greater attentiveness to measurement and gender. Theoretical and heuristic models for the study of mobility and HIV acquisition and treatment outcomes have been published, but few studies have used longitudinal designs with clear ascertainment of exposures and outcomes for measurement of causal pathways. Notwithstanding these limitations, evidence continues to accumulate that mobility is linked to higher HIV incidence, and that it challenges optimal treatment engagement. Gender continues to be important: while men are more mobile than women, women's mobility particularly heightens their HIV acquisition risks. Recent large-scale efforts to find, test, and treat the individuals in communities who are most at risk of sustaining local HIV transmission have been severely challenged by mobility. Novel interventions, policies, and health systems improvements are urgently needed to fully engage mobile individuals in HIV care and prevention. Interventions targeting the HIV prevention and care needs of mobile populations remain few in number and urgently needed.
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Koss CA, Charlebois ED, Ayieko J, Kwarisiima D, Kabami J, Balzer LB, Atukunda M, Mwangwa F, Peng J, Mwinike Y, Owaraganise A, Chamie G, Jain V, Sang N, Olilo W, Brown LB, Marquez C, Zhang K, Ruel TD, Camlin CS, Rooney JF, Black D, Clark TD, Gandhi M, Cohen CR, Bukusi EA, Petersen ML, Kamya MR, Havlir DV. Uptake, engagement, and adherence to pre-exposure prophylaxis offered after population HIV testing in rural Kenya and Uganda: 72-week interim analysis of observational data from the SEARCH study. Lancet HIV 2020; 7:e249-e261. [PMID: 32087152 PMCID: PMC7208546 DOI: 10.1016/s2352-3018(19)30433-3] [Citation(s) in RCA: 93] [Impact Index Per Article: 23.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2019] [Revised: 12/14/2019] [Accepted: 12/18/2019] [Indexed: 02/06/2023]
Abstract
BACKGROUND Optimal strategies for pre-exposure prophylaxis (PrEP) engagement in generalised HIV epidemics are unknown. We aimed to assess PrEP uptake and engagement after population-level HIV testing and universal PrEP access to characterise gaps in the PrEP cascade in rural Kenya and Uganda. METHODS We did a 72-week interim analysis of observational data from the ongoing SEARCH (Sustainable East Africa Research in Community Health) study. Following community sensitisation and PrEP education, we did HIV testing and offered PrEP at health fairs and facilities in 16 rural communities in western Kenya, eastern Uganda, and western Uganda. We provided enhanced PrEP counselling to individuals 15 years and older who were assessed as having an elevated HIV risk on the basis of serodifferent partnership or empirical risk score, or who otherwise self-identified as being at high risk but were not in serodifferent partnerships or identified by the risk score. PrEP follow-up visits were done at facilities, homes, or community locations. We assessed PrEP uptake within 90 days of HIV testing, programme engagement (follow-up visit attendance at week 4, week 12, and every 12 weeks thereafter), refills, self-reported adherence up to 72 weeks, and concentrations of tenofovir in hair samples from individuals reporting HIV risk and adherence during follow-up, and analysed factors associated with uptake and adherence. This study is registered with ClinicalTrials.gov, NCT01864603. FINDINGS Between June 6, 2016, and June 23, 2017, 70 379 community residents 15 years or older who had not previously been diagnosed with HIV were tested during population-level HIV testing. Of these individuals, 69 121 tested HIV-negative, 12 935 of whom had elevated HIV risk (1353 [10%] serodifferent partnership, 6938 [54%] risk score, 4644 [36%] otherwise self-identified risk). 3489 (27%) initiated PrEP, 2865 (82%) of whom did so on the same day as HIV testing and 1733 (50%) of whom were men. PrEP uptake was lower among individuals aged 15-24 years (adjusted odds ratio 0·55, 95% CI 0·45-0·68) and mobile individuals (0·61, 0·41-0·91). At week 4, among 3466 individuals who initiated PrEP and did not withdraw or die before the first visit, 2215 (64%) were engaged in the programme, 1701 (49%) received medication refills, and 1388 (40%) self-reported adherence. At week 72, 1832 (56%) of 3274 were engaged, 1070 (33%) received a refill, and 900 (27%) self-reported adherence. Among participants reporting HIV risk at weeks 4-72, refills (89-93%) and self-reported adherence (70-76%) were high. Among sampled participants self-reporting adherence at week 24, the proportion with tenofovir concentrations in the hair reflecting at least four doses taken per week was 66%, and reflecting seven doses per week was 44%. Participants who stopped PrEP accepted HIV testing at 4274 (83%) of 5140 subsequent visits; half of these participants later restarted PrEP. 29 participants of 3489 who initiated PrEP had serious adverse events, including seven deaths. Five adverse events (all grade 3) were assessed as being possibly related to the study drug. INTERPRETATION During population-level HIV testing, inclusive risk assessment (combining serodifferent partnership, an empirical risk score, and self-identification of HIV risk) was feasible and identified individuals who could benefit from PrEP. The biggest gap in the PrEP cascade was PrEP uptake, particularly for young and mobile individuals. Participants who initiated PrEP and had perceived HIV risk during follow-up reported taking PrEP, but one-third had drug concentrations consistent with poor adherence, highlighting the need for novel approaches and long-acting formulations as PrEP roll-out expands. FUNDING National Institutes of Health, President's Emergency Plan for AIDS Relief, Bill & Melinda Gates Foundation, and Gilead Sciences.
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Affiliation(s)
- Catherine A Koss
- Division of HIV, Infectious Diseases and Global Medicine, University of California San Francisco, San Francisco, CA, USA.
| | - Edwin D Charlebois
- Division of Prevention Sciences, Department of Medicine, University of California San Francisco, San Francisco, CA, USA
| | - James Ayieko
- Centre for Microbiology Research, Kenya Medical Research Institute, Nairobi, Kenya
| | | | - Jane Kabami
- Infectious Diseases Research Collaboration, Kampala, Uganda
| | - Laura B Balzer
- Department of Biostatistics and Epidemiology, University of Massachusetts Amherst, Amherst, MA, USA
| | | | | | - James Peng
- Division of HIV, Infectious Diseases and Global Medicine, University of California San Francisco, San Francisco, CA, USA
| | - Yusuf Mwinike
- Infectious Diseases Research Collaboration, Kampala, Uganda
| | | | - Gabriel Chamie
- Division of HIV, Infectious Diseases and Global Medicine, University of California San Francisco, San Francisco, CA, USA
| | - Vivek Jain
- Division of HIV, Infectious Diseases and Global Medicine, University of California San Francisco, San Francisco, CA, USA
| | - Norton Sang
- Centre for Microbiology Research, Kenya Medical Research Institute, Nairobi, Kenya
| | - Winter Olilo
- Centre for Microbiology Research, Kenya Medical Research Institute, Nairobi, Kenya
| | - Lillian B Brown
- Division of HIV, Infectious Diseases and Global Medicine, University of California San Francisco, San Francisco, CA, USA
| | - Carina Marquez
- Division of HIV, Infectious Diseases and Global Medicine, University of California San Francisco, San Francisco, CA, USA
| | - Kevin Zhang
- Division of HIV, Infectious Diseases and Global Medicine, University of California San Francisco, San Francisco, CA, USA
| | - Theodore D Ruel
- Department of Pediatrics, University of California San Francisco, San Francisco, CA, USA
| | - Carol S Camlin
- Department of Obstetrics, Gynecology and Reproductive Sciences, University of California San Francisco, San Francisco, CA, USA
| | | | - Douglas Black
- Division of HIV, Infectious Diseases and Global Medicine, University of California San Francisco, San Francisco, CA, USA
| | - Tamara D Clark
- Division of HIV, Infectious Diseases and Global Medicine, University of California San Francisco, San Francisco, CA, USA
| | - Monica Gandhi
- Division of HIV, Infectious Diseases and Global Medicine, University of California San Francisco, San Francisco, CA, USA
| | - Craig R Cohen
- Department of Obstetrics, Gynecology and Reproductive Sciences, University of California San Francisco, San Francisco, CA, USA
| | - Elizabeth A Bukusi
- Department of Obstetrics, Gynecology and Reproductive Sciences, University of California San Francisco, San Francisco, CA, USA; Centre for Microbiology Research, Kenya Medical Research Institute, Nairobi, Kenya
| | - Maya L Petersen
- Graduate Group in Biostatistics, School of Public Health, University of California Berkeley, Berkeley, CA, USA
| | - Moses R Kamya
- Infectious Diseases Research Collaboration, Kampala, Uganda; School of Medicine, Makerere University College of Health Sciences, Kampala, Uganda
| | - Diane V Havlir
- Division of HIV, Infectious Diseases and Global Medicine, University of California San Francisco, San Francisco, CA, USA
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Benitez AE, Musinguzi N, Bangsberg DR, Bwana MB, Muzoora C, Hunt PW, Martin JN, Haberer JE, Petersen ML. Super learner analysis of real-time electronically monitored adherence to antiretroviral therapy under constrained optimization and comparison to non-differentiated care approaches for persons living with HIV in rural Uganda. J Int AIDS Soc 2020; 23:e25467. [PMID: 32202067 PMCID: PMC7086301 DOI: 10.1002/jia2.25467] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2019] [Accepted: 01/27/2020] [Indexed: 12/24/2022] Open
Abstract
INTRODUCTION Real-time electronic adherence monitoring (EAM) systems could inform on-going risk assessment for HIV viraemia and be used to personalize viral load testing schedules. We evaluated the potential of real-time EAM (transferred via cellular signal) and standard EAM (downloaded via USB cable) in rural Uganda to inform individually differentiated viral load testing strategies by applying machine learning approaches. METHODS We evaluated an observational cohort of persons living with HIV and treated with antiretroviral therapy (ART) who were monitored longitudinally with standard EAM from 2005 to 2011 and real-time EAM from 2011 to 2015. Super learner, an ensemble machine learning method, was used to develop a tool for targeting viral load testing to detect viraemia (>1000 copies/ml) based on clinical (CD4 count, ART regimen), viral load and demographic data, together with EAM-based adherence. Using sample-splitting (cross-validation), we evaluated area under the receiver operating characteristic curve (cvAUC), potential for EAM data to selectively defer viral load tests while minimizing delays in viraemia detection, and performance compared to WHO-recommended testing schedules. RESULTS In total, 443 persons (1801 person-years) and 485 persons (930 person-years) contributed to standard and real-time EAM analyses respectively. In the 2011 to 2015 dataset, addition of real-time EAM (cvAUC: 0.88; 95% CI: 0.83, 0.93) significantly improved prediction compared to clinical/demographic data alone (cvAUC: 0.78; 95% CI: 0.72, 0.86; p = 0.03). In the 2005 to 2011 dataset, addition of standard EAM (cvAUC: 0.77; 95% CI: 0.72, 0.81) did not significantly improve prediction compared to clinical/demographic data alone (cvAUC: 0.70; 95% CI: 0.64, 0.76; p = 0.08). A hypothetical testing strategy using real-time EAM to guide deferral of viral load tests would have reduced the number of tests by 32% while detecting 87% of viraemia cases without delay. By comparison, the WHO-recommended testing schedule would have reduced the number of tests by 69%, but resulted in delayed detection of viraemia a mean of 74 days for 84% of individuals with viraemia. Similar rules derived from standard EAM also resulted in potential testing frequency reductions. CONCLUSIONS Our machine learning approach demonstrates potential for combining EAM data with other clinical measures to develop a selective testing rule that reduces number of viral load tests ordered, while still identifying those at highest risk for viraemia.
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Affiliation(s)
- Alejandra E Benitez
- Division of BiostatisticsSchool of Public HealthUniversity of California BerkeleyBerkeleyCAUSA
| | - Nicholas Musinguzi
- Global Health CollaborativeMbarara University of Science and TechnologyMbararaUganda
| | - David R Bangsberg
- Oregon Health & Science University‐Portland State University School of Public HealthPortlandORUSA
| | - Mwebesa B Bwana
- Department of Internal MedicineMbarara University of Science & TechnologyMbararaUganda
| | - Conrad Muzoora
- Department of Internal MedicineMbarara University of Science & TechnologyMbararaUganda
| | - Peter W Hunt
- Division of Experimental MedicineUniversity of California San FranciscoSan FranciscoCAUSA
| | - Jeffrey N Martin
- Department of Epidemiology and BiostatisticsUniversity of California San FranciscoSan FranciscoCAUSA
| | - Jessica E Haberer
- Massachusetts General Hospital Center for Global HealthBostonMAUSA
- Harvard Medical SchoolBostonMAUSA
| | - Maya L Petersen
- Division of BiostatisticsSchool of Public HealthUniversity of California BerkeleyBerkeleyCAUSA
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Golub SA, Myers JE. Next-Wave HIV Pre-Exposure Prophylaxis Implementation for Gay and Bisexual Men. AIDS Patient Care STDS 2019; 33:253-261. [PMID: 31094576 DOI: 10.1089/apc.2018.0290] [Citation(s) in RCA: 35] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023] Open
Abstract
Data indicate that diffusion of pre-exposure prophylaxis (PrEP) programs for HIV prevention is increasing in the United States; however, persistent disparities in PrEP access remain. Earlier waves of PrEP implementation focused on development (2012-2015) and diffusion (2016-2018). To reduce disparities, the next wave of PrEP implementation should focus on integration; that is, the assimilation of PrEP service as an integral part of HIV prevention, sexual health, and primary care. This review analyzes PrEP implementation literature in the context of three "next-wave" challenges: increasing patient demand, enhancing provider investment and competency, and improving health systems capacity. Our review revealed five activities we consider critical to successful next-wave PrEP implementation efforts: (1) redefining PrEP eligibility assessment, (2) de-emphasizing risk perception as a strategy to increase demand, (3) rejecting risk compensation arguments, (4) altering guidelines to make PrEP follow-up less onerous, and (5) focusing directly on strategies to reduce the cost of PrEP medication. This article ends with a case study of a research-practice partnership designed to instantiate new approaches to integrative implementation efforts.
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Affiliation(s)
- Sarit A. Golub
- Department of Psychology, Hunter College of the City University of New York, New York, New York
- Basic and Applied Social Psychology (BASP) PhD Program, Department of Psychology, Graduate Center of the City University of New York, New York, New York
| | - Julie E. Myers
- Bureau of HIV/AIDS Prevention and Control, New York City Department of Health and Mental Hygiene, New York, New York
- Division of Infectious Diseases, Department of Medicine, Columbia University Medical Center, New York, New York
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