1
|
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; 28:3512-3524. [PMID: 39028385 PMCID: PMC11427177 DOI: 10.1007/s10461-024-04432-w] [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: 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).
Collapse
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
| | | | | |
Collapse
|
2
|
Kumar R, Rao D, Sharma A, Phiri J, Zimba M, Phiri M, Zyambo R, Kalo GM, Chilembo L, Kunda PM, Mulubwa C, Ngosa B, Mugwanya KK, Barrington WE, Herce ME, Musheke M. Mixed-methods protocol for the WiSSPr study: Women in Sex work, Stigma and psychosocial barriers to Pre-exposure prophylaxis in Zambia. BMJ Open 2024; 14:e080218. [PMID: 39242170 PMCID: PMC11381648 DOI: 10.1136/bmjopen-2023-080218] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 09/09/2024] Open
Abstract
INTRODUCTION Women engaging in sex work (WESW) have 21 times the risk of HIV acquisition compared with the general population. However, accessing HIV pre-exposure prophylaxis (PrEP) remains challenging, and PrEP initiation and persistence are low due to stigma and related psychosocial factors. The WiSSPr (Women in Sex work, Stigma and PrEP) study aims to (1) estimate the effect of multiple stigmas on PrEP initiation and persistence and (2) qualitatively explore the enablers and barriers to PrEP use for WESW in Lusaka, Zambia. METHODS AND ANALYSIS WiSSPr is a prospective observational cohort study grounded in community-based participatory research principles with a community advisory board (CAB) of key population (KP) civil society organi sations (KP-CSOs) and the Ministry of Health (MoH). We will administer a one-time psychosocial survey vetted by the CAB and follow 300 WESW in the electronic medical record for three months to measure PrEP initiation (#/% ever taking PrEP) and persistence (immediate discontinuation and a medication possession ratio). We will conduct in-depth interviews with a purposive sample of 18 women, including 12 WESW and 6 peer navigators who support routine HIV screening and PrEP delivery, in two community hubs serving KPs since October 2021. We seek to value KP communities as equal contributors to the knowledge production process by actively engaging KP-CSOs throughout the research process. Expected outcomes include quantitative measures of PrEP initiation and persistence among WESW, and qualitative insights into the enablers and barriers to PrEP use informed by participants' lived experiences. ETHICS AND DISSEMINATION WiSSPr was approved by the Institutional Review Boards of the University of Zambia (#3650-2023) and University of North Carolina (#22-3147). Participants must give written informed consent. Findings will be disseminated to the CAB, who will determine how to relay them to the community and stakeholders.
Collapse
Affiliation(s)
- Ramya Kumar
- Centre for Infectious Disease Research in Zambia, Lusaka, Zambia
- Epidemiology, University of Washington School of Public Health, Seattle, Washington, USA
| | - Deepa Rao
- University of Washington School of Public Health, Seattle, Washington, USA
| | - Anjali Sharma
- Centre for Infectious Disease Research in Zambia, Lusaka, Zambia
| | - Jamia Phiri
- Centre for Infectious Disease Research in Zambia, Lusaka, Zambia
| | | | | | | | | | | | | | - Chama Mulubwa
- Centre for Infectious Disease Research in Zambia, Lusaka, Zambia
| | - Benard Ngosa
- Centre for Infectious Disease Research in Zambia, Lusaka, Zambia
| | - Kenneth K Mugwanya
- Epidemiology, Global Health, University of Washington School of Public Health, Seattle, Washington, USA
| | - Wendy E Barrington
- Epidemiology; Child, Family, and Population Health Nursing; Health Systems and Population Health, University of Washington School of Public Health, Seattle, Washington, USA
| | - Michael E Herce
- Centre for Infectious Disease Research in Zambia, Lusaka, Zambia
- Institute for Global Health and Infectious Diseases, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Maurice Musheke
- Centre for Infectious Disease Research in Zambia, Lusaka, Zambia
| |
Collapse
|
3
|
Kiggundu R, Soh QR, Tieosapjaroen W, Fairley CK, Tucker JD, Tang W, Zhang L, Ong JJ. Restarting pre-exposure prophylaxis (PrEP) for HIV: a systematic review and meta-analysis. EClinicalMedicine 2024; 72:102647. [PMID: 38800799 PMCID: PMC11127197 DOI: 10.1016/j.eclinm.2024.102647] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/11/2024] [Revised: 04/29/2024] [Accepted: 04/30/2024] [Indexed: 05/29/2024] Open
Abstract
Background High coverage of pre-exposure prophylaxis (PrEP) will reduce HIV transmission and help end the HIV/AIDS pandemic. However, PrEP users face challenges, including long-term adherence. The study aimed to document the proportions of individuals who restart HIV PrEP after they stop and the reasons for restarting PrEP. Methods This study is a systematic review and meta-analysis. We systematically searched CINAHL, Embase, Emcare, Global Health, Medline, Scopus, and PsychINFO for peer-reviewed with no date restrictions. A grey literature search was conducted through Google search, a search of abstract books of AIDS conferences and the websites of WHO and UNAIDS. The data search was conducted in April 2023 and updated in February 2024. Two authors extracted data on the proportion of people who stopped and then restarted PrEP, reasons for restarting, and strategies to support people restarting PrEP. Two authors appraised the data using the Joanna Briggs Institute Appraisal Tools. We used a random-effects meta-analysis to pool estimates of restarting. We conducted meta-regression to determine potential sources of heterogeneity. This study is registered with PROSPERO, CRD42023416777. However, we deviated from our original plan as we did not identify enough studies for strategies to support restarting PrEP (primary objective). Subsequently, we revised our plan to strengthen our secondary objective to quantify the proportion of people who stopped and restarted PrEP, and explore possible reasons for its heterogeneity. Findings Of 988 studies, 30 unique studieswere included: 27 reported the proportion restarting PrEP, and of these, 7 also reported reasons for restarting PrEP, and 3 studies reported only on the reasons for restarting PrEP. No study evaluated interventions for restarting PrEP. For the meta-analysis, we included 27 studies. Most studies were from high-income countries (17/27, 63%) or the USA (15/27, 56%). Overall, 23.8% (95% CI: 15.9-32.7, I2 = 99.8%, N = 85,683) of people who stopped PrEP restarted PrEP. There was a lower proportion of restarting in studies from middle-income countries compared to high-income countries (adjusted odds ratio (aOR) 0.6, 95% CI: 0.50-0.73, p < 0.001). There was higher restarting in studies from Africa compared to the USA (aOR 1.55, 95% CI: 1.30-1.86), heterosexual populations compared to men who have sex with men or transgender women (aOR 1.50, 95% CI: 1.25-1.81, p < 0.001) and in studies defining restarting as those who had stopped PrEP for >1 month compared to those who stopped <1 month (aOR 1.20, 95% CI: 1.06-1.36, p < 0.001). Reasons for restarting PrEP included perceived higher risk for HIV acquisition and removal of barriers to access PrEP. In terms of quality assessment, overall, both randomised controlled trials had a low risk of bias, while the observational studies used in the meta-analysis had some potential risk of bias related to not explicitly addressing potential confounders (15/25, 60%) or not describing strategies to address incomplete follow-up (24/25, 96%). Interpretation About a quarter of people who stopped PrEP would restart, with substantial variation across countries and populations. It is important to understand the motivations and contextual factors influencing restarting PrEP and the support systems to enable restarting PrEP for those at ongoing risk. Funding Australian National Health and Medical Research Council.
Collapse
Affiliation(s)
- Reuben Kiggundu
- Melbourne Sexual Health Centre, Alfred Health, Melbourne, Australia
- School of Translational Medicine, Faculty of Medicine, Nursing and Health Sciences, Monash University, Melbourne, Australia
| | - Qi Rui Soh
- Melbourne Sexual Health Centre, Alfred Health, Melbourne, Australia
- University of Melbourne, Melbourne, Victoria, Australia
| | - Warittha Tieosapjaroen
- Melbourne Sexual Health Centre, Alfred Health, Melbourne, Australia
- School of Translational Medicine, Faculty of Medicine, Nursing and Health Sciences, Monash University, Melbourne, Australia
| | - Christopher K. Fairley
- Melbourne Sexual Health Centre, Alfred Health, Melbourne, Australia
- School of Translational Medicine, Faculty of Medicine, Nursing and Health Sciences, Monash University, Melbourne, Australia
| | - Joseph D. Tucker
- Faculty of Infectious and Tropical Diseases, London School of Hygiene and Tropical Medicine, London, United Kingdom
- Institute for Global Health and Infectious Diseases, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Weiming Tang
- Institute for Global Health and Infectious Diseases, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Lei Zhang
- Melbourne Sexual Health Centre, Alfred Health, Melbourne, Australia
- School of Translational Medicine, Faculty of Medicine, Nursing and Health Sciences, Monash University, Melbourne, Australia
- Clinical Medical Research Center, Children's Hospital of Nanjing Medical University, Nanjing, Jiangsu Province, China
| | - Jason J. Ong
- Melbourne Sexual Health Centre, Alfred Health, Melbourne, Australia
- School of Translational Medicine, Faculty of Medicine, Nursing and Health Sciences, Monash University, Melbourne, Australia
- University of Melbourne, Melbourne, Victoria, Australia
- Faculty of Infectious and Tropical Diseases, London School of Hygiene and Tropical Medicine, London, United Kingdom
| |
Collapse
|
4
|
Lichtwarck HO, Mbotwa CH, Kazaura MR, Moen K, Mmbaga EJ. Early disengagement from HIV pre-exposure prophylaxis services and associated factors among female sex workers in Dar es Salaam, Tanzania: a socioecological approach. BMJ Glob Health 2023; 8:e013662. [PMID: 38154811 PMCID: PMC10759139 DOI: 10.1136/bmjgh-2023-013662] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2023] [Accepted: 11/25/2023] [Indexed: 12/30/2023] Open
Abstract
INTRODUCTION Pre-exposure prophylaxis (PrEP) is an effective HIV prevention tool when taken as prescribed. However, suboptimal use may challenge its real-life impact. To support female sex workers in their efforts to prevent themselves from HIV, it is essential to identify factors that contribute to early disengagement from PrEP care. In this study, we aimed to estimate the risk of early disengagement from PrEP services among female sex workers in Tanzania and associated factors using a socioecological model as a guiding framework. METHODS The study was conducted as part of a pragmatic mHealth trial for PrEP roll-out in Dar es Salaam in 2021. We estimated the risk of early disengagement, defined as not presenting for the first follow-up visit (within 56 days of enrolment), and its associations with individual, social, behavioural and structural factors (age, self-perceived HIV risk, mental distress, harmful alcohol use, condom use, number of sex work clients, female sex worker stigma and mobility) using multivariable logistic regression models, with marginal standardisation to obtain adjusted relative risks (aRR). RESULTS Of the 470 female sex workers enrolled in the study, 340 (74.6%) did not attend the first follow-up visit (disengaged). Mental distress (aRR=1.14; 95% CI 1.01 to 1.27) was associated with increased risk of disengagement. Participants who reported a higher number of clients per month (10-29 partners: aRR=0.87; 95% CI 0.76 to 0.98 and ≥30 partners: aRR=0.80; 95% CI 0.68 to 0.91) and older participants (≥35 years) (RR=0.75; 95% CI 0.56 to 0.95) had a lower risk of disengagement. CONCLUSIONS AND RECOMMENDATIONS Early disengagement with the PrEP programme was high. Mental distress, younger age and having fewer clients were risk factors for disengagement. We argue that PrEP programmes could benefit from including mental health screening and treatment, as well as directing attention to younger sex workers and those reporting fewer clients.
Collapse
Affiliation(s)
- Hanne Ochieng Lichtwarck
- Department of Community Medicine and Global Health, University of Oslo, Faculty of Medicine, Oslo, Norway
| | - Christopher Hariri Mbotwa
- Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania
- University of Dar es Salaam, Mbeya College of Health and Allied Sciences, Mbeya, Tanzania
| | | | - Kåre Moen
- Department of Community Medicine and Global Health, University of Oslo, Faculty of Medicine, Oslo, Norway
| | - Elia John Mmbaga
- Department of Community Medicine and Global Health, University of Oslo, Faculty of Medicine, Oslo, Norway
- Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania
| |
Collapse
|
5
|
Phillips AN, Bansi-Matharu L, Shahmanesh M, Hargreaves JR, Smith J, Revill P, Sibanda E, Ehrenkranz P, Sikwese K, Rodger A, Lundgren JD, Gilks CF, Godfrey C, Cowan F, Cambiano V. Potential cost-effectiveness of community availability of tenofovir, lamivudine, and dolutegravir for HIV prevention and treatment in east, central, southern, and west Africa: a modelling analysis. Lancet Glob Health 2023; 11:e1648-e1657. [PMID: 37734807 DOI: 10.1016/s2214-109x(23)00383-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2023] [Revised: 07/23/2023] [Accepted: 08/04/2023] [Indexed: 09/23/2023]
Abstract
BACKGROUND Post-exposure prophylaxis (PEP) offers protection from HIV after condomless sex, but is not widely available in a timely manner in east, central, southern, and west Africa. To inform the potential pilot implementation of such an approach, we modelled the effect and cost-effectiveness of making PEP consisting of tenofovir, lamivudine, and dolutegravir (TLD) freely and locally available in communities without prescription, with the aim of enabling PEP use within 24 h of condomless sex. Free community availability of TLD (referred to as community TLD) might also result in some use of TLD as pre-exposure prophylaxis (PrEP) and as antiretroviral therapy for people living with HIV. METHODS Using an existing individual-based model (HIV Synthesis), we explicitly modelled the potential positive and negative effects of community TLD. Through the sampling of parameter values we created 1000 setting-scenarios, reflecting the uncertainty in assumptions and a range of settings similar to those seen in east, central, southern, and west Africa (with a median HIV prevalence of 14·8% in women and 8·1% in men). For each setting scenario, we considered the effects of community TLD. TLD PEP was assumed to have at least 90% efficacy in preventing HIV infection after condomless sex with a person living with HIV. FINDINGS The modelled effects of community TLD availability based on an assumed high uptake of TLD resulted in a mean reduction in incidence of 31% (90% range over setting scenarios, 6% increase to 57% decrease) over 20 years, with an HIV incidence reduction over 50 years in 91% of the 1000 setting scenarios, deaths averted in 55% of scenarios, reduction in costs in 92% of scenarios, and disability-adjusted life-years averted in 64% of scenarios with community TLD. Community TLD was cost-effective in 90% of setting scenarios and cost-saving (with disability-adjusted life-years averted) in 58% of scenarios. When only examining setting scenarios in which there was lower uptake of community TLD, community TLD is cost-effective in 92% of setting scenarios. INTERPRETATION The introduction of community TLD, enabling greater PEP access, is a promising approach to consider further in pilot implementation projects. FUNDING Bill & Melinda Gates Foundation to the HIV Modelling Consortium.
Collapse
Affiliation(s)
| | | | - Maryam Shahmanesh
- Institute for Global Health, University College London, London, UK; Africa Health Research Institute, KwaZulu-Natal, South Africa
| | | | - Jennifer Smith
- Institute for Global Health, University College London, London, UK
| | - Paul Revill
- Centre for Health Economics, University of York, York, UK
| | - Euphemia Sibanda
- CeSHHAR Zimbabwe, Harare, Zimbabwe; Liverpool School of Tropical Medicine, Liverpool, UK
| | | | | | - Alison Rodger
- Institute for Global Health, University College London, London, UK
| | - Jens D Lundgren
- Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
| | | | - Catherine Godfrey
- Office of the Global AIDS Coordinator, Department of State, Washington, DC, USA
| | - Frances Cowan
- CeSHHAR Zimbabwe, Harare, Zimbabwe; Liverpool School of Tropical Medicine, Liverpool, UK
| | | |
Collapse
|
6
|
Dayton RL, Fonner VA, Plourde KF, Sanyal A, Arney J, Orr T, Nhamo D, Schueller J, Limb AM, Torjesen K. A Scoping Review of Oral Pre-exposure Prophylaxis for Cisgender and Transgender Adolescent Girls and Young Women: What Works and Where Do We Go from Here? AIDS Behav 2023; 27:3223-3238. [PMID: 37119401 PMCID: PMC10148005 DOI: 10.1007/s10461-023-04043-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/14/2023] [Indexed: 05/01/2023]
Abstract
Adolescent girls and young women (AGYW) are disproportionately affected by HIV, and oral pre-exposure prophylaxis (PrEP) can reduce HIV acquisition. The purpose of this scoping review was to synthesize results from interventions along the PrEP continuum for AGYW to inform research and programs. We searched electronic databases for studies published between January 2012-July 2021 and conducted secondary reference searching. Studies were included if they assessed interventions to increase PrEP interest, uptake, or continuation among AGYW. Results were synthesized narratively. Of 2168 citations identified, 50 studies were eligible for inclusion, and 20 contained AGYW-specific data. Among cisgender and transgender AGYW, studies overall demonstrated a positive impact on PrEP interest and uptake but generally attained suboptimal continuation rates. Results demonstrate feasibility of deploying PrEP across diverse settings-particularly when interventions are layered, tailored to AGYW, and include differentiated delivery-but also highlight knowledge gaps and the need for more holistic metrics of success.
Collapse
Affiliation(s)
| | | | | | - Ameya Sanyal
- FHI 360, Global Health and Population, Durham, NC, USA
| | - Jennifer Arney
- FHI 360, Global Health and Population, Washington, DC, USA
| | - Tracy Orr
- FHI 360, Global Health and Population, Atlanta, GA, USA
| | | | - Jane Schueller
- United States Agency for International Development, Bureau of Global Health, Office of Population and Reproductive Health, Washington, DC, USA
| | - Annaliese M Limb
- United States Agency for International Development, Bureau of Global Health, Office of HIV/AIDS, Washington, DC, USA
| | | |
Collapse
|
7
|
Barnabee G, Billah I, Ndeikemona L, Silas L, Ensminger A, MacLachlan E, Korn AK, Mawire S, Fischer-Walker C, Ashipala L, Forster N, O’Malley G, Velloza J. PrEP uptake and early persistence among adolescent girls and young women receiving services via community and hybrid community-clinic models in Namibia. PLoS One 2023; 18:e0289353. [PMID: 37647257 PMCID: PMC10468070 DOI: 10.1371/journal.pone.0289353] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2022] [Accepted: 07/17/2023] [Indexed: 09/01/2023] Open
Abstract
INTRODUCTION Adolescent girls and young women (AGYW) face barriers in accessing clinic-based HIV pre-exposure prophylaxis (PrEP) services and community-based models are a proposed alternative. Evidence from such models, however, is limited. We evaluated PrEP service coverage, uptake, and early persistence among AGYW receiving services through community and hybrid models in Namibia. METHODS We analyzed routine data for AGYW aged 15-24 who initiated PrEP within HIV prevention programming. PrEP was delivered via three models: community-concierge (fully community-based services with individually-tailored refill locations), community-fixed (community-based initiation and refills delivered by community providers on a set schedule at fixed sites), and hybrid community-clinic (community-based initiation and referral to clinics for refills delivered by clinic providers). We examined proportions of AGYW engaged in services along a programmatic PrEP cascade, overall and by model, and assessed factors associated with PrEP uptake and early persistence (refill within 15-44 days after initiation) using multivariable generalized estimating equations. RESULTS Over 10-months, 7593 AGYW participated in HIV prevention programming. Of these, 7516 (99.0%) received PrEP education, 6105 (81.2%) received HIV testing services, 6035 (98.9%) tested HIV-negative, and 2225 (36.9%) initiated PrEP. Of the 2047 AGYW expected for PrEP refill during the study period, 254 (12.4%) persisted with PrEP one-month after initiation. Structural and behavioral HIV risk factors including early school dropout, food insecurity, inconsistent condom use, and transactional sex were associated with PrEP uptake. AGYW who delayed starting PrEP were 2.89 times more likely to persist (95% confidence interval (CI): 1.52-5.46) and those receiving services via the community-concierge model were 8.7 times (95% CI: 5.44-13.9) more likely to persist (compared to the hybrid model). CONCLUSION Community-based models of PrEP service delivery to AGYW can achieve high PrEP education and HIV testing coverage and moderate PrEP uptake. AGYW-centered approaches to delivering PrEP refills can promote higher persistence.
Collapse
Affiliation(s)
- Gena Barnabee
- International Training and Education Center for Health, Department of Global Health, University of Washington, Seattle, WA, United States of America
- International Training and Education Center for Health, Department of Global Health, University of Washington, Windhoek, Namibia
| | - Idel Billah
- International Training and Education Center for Health, Department of Global Health, University of Washington, Seattle, WA, United States of America
- International Training and Education Center for Health, Department of Global Health, University of Washington, Windhoek, Namibia
| | | | - Lukas Silas
- International Training and Education Center for Health, Department of Global Health, University of Washington, Seattle, WA, United States of America
- International Training and Education Center for Health, Department of Global Health, University of Washington, Windhoek, Namibia
| | - Alison Ensminger
- International Training and Education Center for Health, Department of Global Health, University of Washington, Seattle, WA, United States of America
- International Training and Education Center for Health, Department of Global Health, University of Washington, Windhoek, Namibia
| | - Ellen MacLachlan
- International Training and Education Center for Health, Department of Global Health, University of Washington, Seattle, WA, United States of America
- International Training and Education Center for Health, Department of Global Health, University of Washington, Windhoek, Namibia
| | - Abigail K. Korn
- International Training and Education Center for Health, Department of Global Health, University of Washington, Seattle, WA, United States of America
- International Training and Education Center for Health, Department of Global Health, University of Washington, Windhoek, Namibia
| | | | | | - Laimi Ashipala
- Ministry of Health and Social Services, Windhoek, Namibia
| | - Norbert Forster
- International Training and Education Center for Health, Department of Global Health, University of Washington, Seattle, WA, United States of America
- International Training and Education Center for Health, Department of Global Health, University of Washington, Windhoek, Namibia
| | - Gabrielle O’Malley
- International Training and Education Center for Health, Department of Global Health, University of Washington, Seattle, WA, United States of America
- International Training and Education Center for Health, Department of Global Health, University of Washington, Windhoek, Namibia
| | - Jennifer Velloza
- Department of Epidemiology & Biostatistics, University of California San Francisco, San Francisco, CA, United States of America
| |
Collapse
|
8
|
Celum C, Seidman D, Travill D, Dehlendorf C, Gumede S, Zewdie K, Wilson W, Morton JF, Baeten JM, Donnell D, Delany‐Moretlwe S. A decision support tool has similar high PrEP uptake and increases early PrEP persistence in adolescent girls and young women in South Africa: results from a randomized controlled trial. J Int AIDS Soc 2023; 26:e26154. [PMID: 37634942 PMCID: PMC10460672 DOI: 10.1002/jia2.26154] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2022] [Accepted: 08/15/2023] [Indexed: 08/29/2023] Open
Abstract
INTRODUCTION African adolescent girls and young women (AGYW) have high rates of HIV acquisition and are a priority population for HIV pre-exposure prophylaxis (PrEP). PrEP implementation has been limited by AGYW's low perceived HIV risk and provider demands. A decision support tool (DST) with information about PrEP could improve clients' risk perception, knowledge about PrEP, informed decision-making and motivation to use PrEP based on their risk, facilitating PrEP delivery in primary healthcare (PHC) clinics. METHODS We designed MyPrEP, a client-facing DST about PrEP and HIV prevention, with youth-friendly information and images. The impact of the MyPrEP tool was assessed among HIV-negative women aged 18-25 years presenting to a PHC clinic in Johannesburg, South Africa from March 2019 to 2020. AGYW were randomized by day to the DST or a general health website as the control condition. A clinician blinded to DST versus control allocation provided standard of care counselling about PrEP, offered PrEP, administered a questionnaire and conducted sexually transmitted infection testing. The primary outcome was PrEP initiation and the secondary outcome was PrEP persistence at 1 month, determined by pharmacy dispensation records. RESULTS Of 386 AGYW screened, 353 were randomized (DST n = 172, control n = 181) with a median age of 21 years (interquartile range [IQR] 20, 23) and 56% (199/353) attending the clinic for HIV testing, 46% (164/353) using contraception, 15% (53/353) using condoms consistently and 37% (108/353) with a curable sexually transmitted infection. PrEP was initiated by 97% in the DST group and 94% in the control group (OR 1.79; 95% confidence interval, CI = 0.79-1.53), of whom two-thirds planned to continue PrEP until they decided if they liked PrEP. At 1 month, PrEP persistence was 19% in the DST and 10% in the control group (OR 1.97, 95% CI 1.08-3.69). Ninety-nine percent randomized to the DST reported satisfaction with MyPrEP. CONCLUSIONS Among AGYW attending a South African PHC clinic, PrEP uptake was >90% with two-fold higher PrEP persistence at 1 month in those randomized to use the MyPrEP DST. Given the need for strategies to support PrEP implementation and improve low PrEP persistence among African AGYW, a PrEP DST warrants further evaluation.
Collapse
Affiliation(s)
- Connie Celum
- Departments of Global HealthMedicine and EpidemiologyUniversity of WashingtonSeattleWashingtonUSA
| | - Dominika Seidman
- Department of ObstetricsGynecology & Reproductive SciencesUniversity of California San FranciscoSan FranciscoCaliforniaUSA
| | | | - Christine Dehlendorf
- Department of Family & Community MedicineUniversity of California San FranciscoSan FranciscoCaliforniaUSA
| | - Sanele Gumede
- Wits RHIUniversity of the WitwatersrandJohannesburgSouth Africa
| | - Kidist Zewdie
- Vaccine and Infectious Disease DivisionFred Hutchinson Cancer Research CenterSeattleWashingtonUSA
- Department of EpidemiologyUniversity of WashingtonSeattleWashingtonUSA
| | - Whitney Wilson
- Department of Family & Community MedicineUniversity of California San FranciscoSan FranciscoCaliforniaUSA
| | | | - Jared M. Baeten
- Departments of Global HealthMedicine and EpidemiologyUniversity of WashingtonSeattleWashingtonUSA
- Gilead SciencesInc.Foster CityCaliforniaUSA
| | - Deborah Donnell
- Vaccine and Infectious Disease DivisionFred Hutchinson Cancer Research CenterSeattleWashingtonUSA
- Department of Global HealthUniversity of WashingtonSeattleWashingtonUSA
| | | |
Collapse
|
9
|
Smith J, Bansi-Matharu L, Cambiano V, Dimitrov D, Bershteyn A, van de Vijver D, Kripke K, Revill P, Boily MC, Meyer-Rath G, Taramusi I, Lundgren JD, van Oosterhout JJ, Kuritzkes D, Schaefer R, Siedner MJ, Schapiro J, Delany-Moretlwe S, Landovitz RJ, Flexner C, Jordan M, Venter F, Radebe M, Ripin D, Jenkins S, Resar D, Amole C, Shahmanesh M, Gupta RK, Raizes E, Johnson C, Inzaule S, Shafer R, Warren M, Stansfield S, Paredes R, Phillips AN. Predicted effects of the introduction of long-acting injectable cabotegravir pre-exposure prophylaxis in sub-Saharan Africa: a modelling study. Lancet HIV 2023; 10:e254-e265. [PMID: 36642087 PMCID: PMC10065903 DOI: 10.1016/s2352-3018(22)00365-4] [Citation(s) in RCA: 18] [Impact Index Per Article: 18.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2022] [Revised: 11/16/2022] [Accepted: 11/22/2022] [Indexed: 01/14/2023]
Abstract
BACKGROUND Long-acting injectable cabotegravir pre-exposure prophylaxis (PrEP) is recommended by WHO as an additional option for HIV prevention in sub-Saharan Africa, but there is concern that its introduction could lead to an increase in integrase-inhibitor resistance undermining treatment programmes that rely on dolutegravir. We aimed to project the health benefits and risks of cabotegravir-PrEP introduction in settings in sub-Saharan Africa. METHODS With HIV Synthesis, an individual-based HIV model, we simulated 1000 setting-scenarios reflecting both variability and uncertainty about HIV epidemics in sub-Saharan Africa and compared outcomes for each with and without cabotegravir-PrEP introduction. PrEP use is assumed to be risk-informed and to be used only in 3-month periods (the time step for the model) when having condomless sex. We consider three groups at risk of integrase-inhibitor resistance emergence: people who start cabotegravir-PrEP after (unknowingly) being infected with HIV, those who seroconvert while on PrEP, and those with HIV who have residual cabotegravir drugs concentrations during the early tail period after recently stopping PrEP. We projected the outcomes of policies of cabotegravir-PrEP introduction and of no introduction in 2022 across 50 years. In 50% of setting-scenarios we considered that more sensitive nucleic-acid-based HIV diagnostic testing (NAT), rather than regular antibody-based HIV rapid testing, might be used to reduce resistance risk. For cost-effectiveness analysis we assumed in our base case a cost of cabotegravir-PrEP drug to be similar to oral PrEP, resulting in a total annual cost of USD$144 per year ($114 per year and $264 per year considered in sensitivity analyses), a cost-effectiveness threshold of $500 per disability-adjusted life years averted, and a discount rate of 3% per year. FINDINGS Reflecting our assumptions on the appeal of cabotegravir-PrEP, its introduction is predicted to lead to a substantial increase in PrEP use with approximately 2·6% of the adult population (and 46% of those with a current indication for PrEP) receiving PrEP compared with 1·5% (28%) without cabotegravir-PrEP introduction across 20 years. As a result, HIV incidence is expected to be lower by 29% (90% range across setting-scenarios 6-52%) across the same period compared with no introduction of cabotegravir-PrEP. In people initiating antiretroviral therapy, the proportion with integrase-inhibitor resistance after 20 years is projected to be 1·7% (0-6·4%) without cabotegravir-PrEP introduction but 13·1% (4·1-30·9%) with. Cabotegravir-PrEP introduction is predicted to lower the proportion of all people on antiretroviral therapy with viral loads less than 1000 copies per mL by 0·9% (-2·5% to 0·3%) at 20 years. For an adult population of 10 million an overall decrease in number of AIDS deaths of about 4540 per year (-13 000 to -300) across 50 years is predicted, with little discernible benefit with NAT when compared with standard antibody-based rapid testing. AIDS deaths are predicted to be averted with cabotegravir-PrEP introduction in 99% of setting-scenarios. Across the 50-year time horizon, overall HIV programme costs are predicted to be similar regardless of whether cabotegravir-PrEP is introduced (total mean discounted annual HIV programme costs per year across 50 years is $151·3 million vs $150·7 million), assuming the use of standard antibody testing. With antibody-based rapid HIV testing, the introduction of cabotegravir-PrEP is predicted to be cost-effective under an assumed threshold of $500 per disability-adjusted life year averted in 82% of setting-scenarios at the cost of $144 per year, in 52% at $264, and in 87% at $114. INTERPRETATION Despite leading to increases in integrase-inhibitor drug resistance, cabotegravir-PrEP introduction is likely to reduce AIDS deaths in addition to HIV incidence. Long-acting cabotegravir-PrEP is predicted to be cost-effective if delivered at similar cost to oral PrEP with antibody-based rapid HIV testing. FUNDING Bill & Melinda Gates Foundation, National Institute of Allergy and Infectious Diseases of the National Institutes of Health.
Collapse
Affiliation(s)
- Jennifer Smith
- Institute for Global Health, University College London, London, UK
| | | | | | - Dobromir Dimitrov
- Public Health Sciences Division, Fred Hutchinson Cancer Center, Seattle, WA, USA
| | - Anna Bershteyn
- Department of Population Health, New York University Grossman School of Medicine, New York, NY, USA
| | | | | | - Paul Revill
- Centre for Health Economics, University of York, York, UK
| | - Marie-Claude Boily
- MRC Centre for Global Infectious Disease Analysis, School of Public Health, Imperial College London, London, UK
| | - Gesine Meyer-Rath
- Health Economics and Epidemiology Research Office (HE2RO), Department of Internal Medicine, School of Clinical Medicine, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | | | - Jens D Lundgren
- Department of Clinical Medicine, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
| | - Joep J van Oosterhout
- Partners in Hope, Lilongwe, Malawi; Department of Medicine, David Geffen School of Medicine, University of California, Los Angeles, CA, USA
| | - Daniel Kuritzkes
- Division of Infectious Diseases, Brigham and Women's Hospital, Boston, MA, USA; Department of Medicine, Harvard Medical School, Boston, MA, USA
| | - Robin Schaefer
- Global HIV, Hepatitis, and STIs Programmes, WHO, Geneva, Switzerland
| | - Mark J Siedner
- Department of Medicine, Harvard Medical School, Boston, MA, USA; Division of Infectious Diseases, Massachusetts General Hospital, Boston, MA, USA; Clinical Research Department, Africa Health Research Institute, Mtubatuba, South Africa
| | | | - Sinead Delany-Moretlwe
- Wits RHI, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Raphael J Landovitz
- Department of Medicine, David Geffen School of Medicine, University of California, Los Angeles, CA, USA; Center for Clinical AIDS Research and Education, University of California, Los Angeles, CA, USA
| | - Charles Flexner
- Johns Hopkins University School of Medicine and Bloomberg School of Public Health, Johns Hopkins University, Baltimore, MD, USA
| | - Michael Jordan
- Tufts Medical Center, Tufts University School of Medicine, Boston, MA, USA
| | - Francois Venter
- Ezintsha, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Mopo Radebe
- Regional Office for Africa, WHO, Gauteng, South Africa
| | - David Ripin
- Infectious Diseases Program, Clinton Health Access Initiative, New York, NY, USA
| | - Sarah Jenkins
- Infectious Diseases Program, Clinton Health Access Initiative, New York, NY, USA
| | - Danielle Resar
- Infectious Diseases Program, Clinton Health Access Initiative, New York, NY, USA
| | - Carolyn Amole
- Infectious Diseases Program, Clinton Health Access Initiative, New York, NY, USA
| | - Maryam Shahmanesh
- Institute for Global Health, University College London, London, UK; Clinical Research Department, Africa Health Research Institute, Mtubatuba, South Africa
| | - Ravindra K Gupta
- Clinical Research Department, Africa Health Research Institute, Mtubatuba, South Africa; Department of Medicine, University of Cambridge, Cambridge, UK
| | - Elliot Raizes
- US Department of Health and Human Services, Centers for Disease Control, Atlanta, GA, USA
| | - Cheryl Johnson
- Global HIV, Hepatitis, and STIs Programmes, WHO, Geneva, Switzerland
| | - Seth Inzaule
- Global HIV, Hepatitis, and STIs Programmes, WHO, Geneva, Switzerland
| | - Robert Shafer
- Department of Medicine, Stanford University, Palo Alto, CA, USA
| | | | - Sarah Stansfield
- Vaccine and Infectious Disease Division, Fred Hutchinson Cancer Center, Seattle, WA, USA
| | - Roger Paredes
- Department of Infectious Diseases, Irsi Caixa Institut de Recerca de la SIDA, Barcelona, Spain
| | | |
Collapse
|
10
|
Abstract
Preexposure prophylaxis (PrEP) is increasingly implemented in national HIV prevention programmes through routine care. Monitoring will be vital to understand whether programmes succeed in engaging people into using PrEP appropriately, and in reducing the HIV epidemic. Yet, it is currently unclear which indicators are most suited to monitor PrEP programmes' performance. We therefore aimed to identify and map indicators that are currently used or suggested for monitoring PrEP programmes. We conducted a scoping review based on the framework by Arksey and O'Malley. We combined a systematic search in the peer-reviewed literature with hand-searching grey literature documents describing indicators and strategies that are used or suggested for PrEP monitoring. Only literature published after 2012 was included. No geographical restrictions were set. We charted data on indicator definitions, data sources used, reported experiences with monitoring and any relevant contextual factors. Ultimately, 35 peer-reviewed and 14 grey literature records were included. We identified indicators related to preuptake stages of PrEP, uptake and coverage, and programme impact. The indicators most commonly suggested for national-level monitoring were the number of new and current PrEP users, the number of HIV seroconversions among PrEP users and some variably defined indicators related to continuation and discontinuation of PrEP. Despite its perceived high relevance, studies reported several challenges to routinely monitor the population in need of PrEP and track prevention-effective PrEP use. In conclusion, a variety of indicators is currently used or suggested for monitoring PrEP programmes. Implementing proxy measures that track different aspects of PrEP use over time, and making synergies with research more explicit, could be used as strategies to obtain more granular insights into trends revealed by routine monitoring.
Collapse
|
11
|
Thomas B, Piron P, de La Rochebrochard E, Segouin C, Troude P. Is HIV Pre-Exposure Prophylaxis among Men Who Have Sex with Men Effective in a Real-World Setting? Experience with One-On-One Counseling and Support in a Sexual Health Center in Paris, 2018-2020. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2022; 19:ijerph192114295. [PMID: 36361171 PMCID: PMC9656100 DOI: 10.3390/ijerph192114295] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/22/2022] [Revised: 10/28/2022] [Accepted: 10/31/2022] [Indexed: 06/04/2023]
Abstract
HIV pre-exposure prophylaxis (PrEP) is highly effective but depends on patients' care engagement, which is often mediocre and poorly measured in real-world settings. This study aimed to assess the effectiveness of a PrEP program in a sexual health center that included accompanying measures to improve engagement. A retrospective observational study was conducted. All men who have sex with men (MSM) who initiated PrEP for the first time between 1 August 2018 and 30 June 2019 in the Fernand-Widal sexual health center, Paris, France, were included. Among the 125 MSM who initiated PrEP, the median age was 33 and most had only male partners. At initiation, 58% were considered at very high risk of HIV infection, mainly due to a history of post-exposure prophylaxis. During the first year, patients attended a median of three visits (Q1-Q3, 2-4). At 12 months, 96% (95% CI, 92.6 to 99.4) had a successful PrEP course, assessed by a novel metric. These results highlight the possibility of achieving a high PrEP success ratio among MSM in a real-world setting. The accompanying measures and one-on-one counseling by a trained counselor could explain the effectiveness of this PrEP program.
Collapse
Affiliation(s)
- Bérenger Thomas
- Department of Public Health, University Hospital Lariboisière-Fernand-Widal, AP-HP, 75010 Paris, France
| | - Prescillia Piron
- Department of Public Health, University Hospital Lariboisière-Fernand-Widal, AP-HP, 75010 Paris, France
- Free Sexual Health Center, University Hospital Lariboisière-Fernand-Widal, AP-HP, 75010 Paris, France
| | - Elise de La Rochebrochard
- Institut National d’Etudes Démographiques (INED), 93300 Aubervilliers, France
- CESP U1018, Inserm, UVSQ, Université Paris-Saclay, 94800 Villejuif, France
| | - Christophe Segouin
- Department of Public Health, University Hospital Lariboisière-Fernand-Widal, AP-HP, 75010 Paris, France
- Free Sexual Health Center, University Hospital Lariboisière-Fernand-Widal, AP-HP, 75010 Paris, France
| | - Pénélope Troude
- Department of Public Health, University Hospital Lariboisière-Fernand-Widal, AP-HP, 75010 Paris, France
- Institut National d’Etudes Démographiques (INED), 93300 Aubervilliers, France
| |
Collapse
|
12
|
Eubanks A, Coulibaly B, Keita BD, Anoma C, Dah TTE, Mensah E, Maradan G, Bourrelly M, Mora M, Riegel L, Rojas Castro D, Yaya I, Spire B, Laurent C, Sagaon-Teyssier L. Loss to Follow-Up from HIV Pre-Exposure Prophylaxis Care in Men Who Have Sex with Men in West Africa. Viruses 2022; 14:v14112380. [PMID: 36366478 PMCID: PMC9695325 DOI: 10.3390/v14112380] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2022] [Revised: 10/17/2022] [Accepted: 10/26/2022] [Indexed: 01/31/2023] Open
Abstract
Loss to follow-up (LTFU) from HIV pre-exposure prophylaxis (PrEP) care compromises the goal of HIV elimination. We investigated the proportion of LTFU and associated risk factors among men who have sex with men (MSM) enrolled in a PrEP demonstration project in Burkina Faso, Côte d'Ivoire, Mali, and Togo. CohMSM-PrEP, a prospective cohort study, was conducted between November 2017 and June 2021 in community-based clinics. MSM aged 18 years or older at substantial risk of HIV infection received a comprehensive prevention package, including PrEP and peer education. LTFU was defined as not returning to the clinic for six months. Associated risk factors were investigated using a time-varying Cox's model. Of 647 participants followed up for a median time of 15 months, 372 were LTFU (57.5%). LTFU was associated with younger age (adjusted hazard ratio [95% Confidence Interval]; 1.50 [1.17-1.94]), unemployment (1.33 [1.03-1.71]), depression (1.63 [1.12-2.38]), and perceiving no HIV risk with stable male partners (1.61 [1.23-2.10]). Contacting peer educators outside of scheduled visits was protective (0.74 [0.56-0.97]). Our findings show that LTFU from PrEP care in West African MSM is a major challenge to achieving HIV elimination, but that the involvement of peer educators in PrEP delivery helps to limit LTFU by providing users with adequate support.
Collapse
Affiliation(s)
- August Eubanks
- Aix Marseille Univ, INSERM, IRD, SESSTIM, Sciences Economiques & Sociales de la Santé & Traitement de l’Information Médicale, ISSPAM, 13005 Marseille, France
- Correspondence: (A.E.); (L.S.-T.)
| | | | | | | | - Ter Tiero Elias Dah
- Association African Solidarité, Ouagadougou 01 BP 2831, Burkina Faso
- UFR Sciences de la Santé, Université de Ouahigouya, Ouahigouya 01 BP 346, Burkina Faso
| | | | - Gwenaëlle Maradan
- Aix Marseille Univ, INSERM, IRD, SESSTIM, Sciences Economiques & Sociales de la Santé & Traitement de l’Information Médicale, ISSPAM, 13005 Marseille, France
- ORS PACA, Observatoire Régional de la Santé Provence-Alpes-Côte d’Azur, 13005 Marseille, France
| | - Michel Bourrelly
- Aix Marseille Univ, INSERM, IRD, SESSTIM, Sciences Economiques & Sociales de la Santé & Traitement de l’Information Médicale, ISSPAM, 13005 Marseille, France
- Coalition Plus, Community-Based Research Laboratory, 93500 Pantin, France
| | - Marion Mora
- Aix Marseille Univ, INSERM, IRD, SESSTIM, Sciences Economiques & Sociales de la Santé & Traitement de l’Information Médicale, ISSPAM, 13005 Marseille, France
| | - Lucas Riegel
- Coalition Plus, Community-Based Research Laboratory, 93500 Pantin, France
| | - Daniela Rojas Castro
- Aix Marseille Univ, INSERM, IRD, SESSTIM, Sciences Economiques & Sociales de la Santé & Traitement de l’Information Médicale, ISSPAM, 13005 Marseille, France
- Coalition Plus, Community-Based Research Laboratory, 93500 Pantin, France
| | - Issifou Yaya
- TransVIHMI, Univ Montpellier, INSERM, IRD, 34394 Montpellier, France
| | - Bruno Spire
- Aix Marseille Univ, INSERM, IRD, SESSTIM, Sciences Economiques & Sociales de la Santé & Traitement de l’Information Médicale, ISSPAM, 13005 Marseille, France
| | - Christian Laurent
- TransVIHMI, Univ Montpellier, INSERM, IRD, 34394 Montpellier, France
| | - Luis Sagaon-Teyssier
- Aix Marseille Univ, INSERM, IRD, SESSTIM, Sciences Economiques & Sociales de la Santé & Traitement de l’Information Médicale, ISSPAM, 13005 Marseille, France
- ARCAD Santé PLUS, Bamako BP E2561, Mali
- Correspondence: (A.E.); (L.S.-T.)
| | | |
Collapse
|
13
|
Garcia M, Nhamo D, Macagna N, Mamvuto T, Katsande N, Morales G, Lanham M, Murungu J, Mahaka I, Kruse-Levy N, Torjesen K. Engaging HIV-prevention ambassadors to promote oral PrEP among adolescent girls and young women: results of a Zimbabwe field test. AFRICAN JOURNAL OF AIDS RESEARCH : AJAR 2022; 21:287-294. [PMID: 36102070 DOI: 10.2989/16085906.2022.2093232] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/30/2021] [Revised: 02/18/2022] [Accepted: 06/18/2022] [Indexed: 06/15/2023]
Abstract
The HIV Prevention Ambassador Training Package for Adolescent Girls and Young Women was created in collaboration with adolescent girls and young women (AGYW) to improve skills, knowledge, and attitudes about oral pre-exposure prophylaxis (PrEP) among peer "ambassadors". It was field tested with 17 ambassadors in Mazowe District, Zimbabwe and changes in ambassadors' knowledge and attitudes about oral PrEP, as well as changes in oral PrEP uptake among AGYW in the district, were assessed. The training package improved oral PrEP knowledge among trained ambassadors and built AGYW's skills to advocate for oral PrEP awareness and rollout. Use of the training package correlated with a 59% increase in oral PrEP uptake among AGYW in Mazowe District in the seven months following the training. The ambassador training package could help support oral PrEP introduction and scale up in countries with high HIV incidence by engaging AGYW in oral PrEP rollout in their communities.
Collapse
|
14
|
Tapsoba JDD, Cover J, Obong’o C, Brady M, Cressey TR, Mori K, Okomo G, Kariithi E, Obanda R, Oluoch-Madiang D, Chen YQ, Drain P, Duerr A. Continued attendance in a PrEP program despite low adherence and non-protective drug levels among adolescent girls and young women in Kenya: Results from a prospective cohort study. PLoS Med 2022; 19:e1004097. [PMID: 36095005 PMCID: PMC9521917 DOI: 10.1371/journal.pmed.1004097] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/10/2022] [Revised: 09/29/2022] [Accepted: 08/19/2022] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND In sub-Saharan Africa (SSA), adolescent girls and young women (AGYW) ages 15 to 24 years represent <10% of the population yet account for 1 in 5 new HIV infections. Although oral pre-exposure prophylaxis (PrEP) with tenofovir disoproxil fumarate/emtricitabine (TDF/FTC) can be highly effective, low persistence in PrEP programs and poor adherence have limited its ability to reduce HIV incidence among women. METHODS AND FINDINGS A total of 336 AGYW participating in the PEPFAR-funded DREAMS PrEP program in western Kenya were enrolled into a study of PrEP use conducted between 6/2019 to 1/2020. AGYW, who used daily oral TDF/FTC, completed interviews and provided dried blood spots (DBS) for measurement of tenofovir-diphosphate (TFV-DP) concentrations at enrollment and 3 months later, and 176/302 (58.3%, 95% confidence interval [95% CI 52.3 to 63.8]) met our definition of PrEP persistence: having expressed intention to use PrEP and attended both the second interview and an interim refill visit. Among AGYW with DBS taken at the second interview, only 9/197 (4.6%, [95% CI 1.6 to 7.5]) had protective TFV-DP levels (≥700 fmol/punch) and 163/197 (82.7%, [95% CI 77.5 to 88]) had levels consistent with no recent PrEP use (<10 fmol/punch). Perception of being at moderate-to-high risk for HIV if not taking PrEP was associated with persistence (adjusted odds ratio, 10.17 [95% CI 5.14 to 20.13], p < 0.001) in a model accounting for county of residence and variables that had p-value <0.1 in unadjusted analysis (age, being in school, initiated PrEP 2 to 3 months before the first interview, still active in DREAMS, having children, having multiple sex partners, partner aware of PrEP use, partner very supportive of PrEP use, partner has other partners, AGYW believes that a partner puts her at risk, male condom use, injectable contraceptive use, and implant contraceptive use). Among AGYW who reported continuing PrEP, >90% indicated they were using PrEP to prevent HIV, although almost all had non-protective TFV-DP levels. Limitations included short study duration and inclusion of only DREAMS participants. CONCLUSIONS Many AGYW persisted in the PrEP program without taking PrEP frequently enough to receive benefit. Notably, AGYW who persisted had a higher self-perceived risk of HIV infection. These AGYW may be optimal candidates for long-acting PrEP.
Collapse
Affiliation(s)
- Jean de Dieu Tapsoba
- Vaccine and Infectious Disease Division, Fred Hutchinson Cancer Research Center, Seattle, Washington, United States of America
| | - Jane Cover
- PATH, Seattle, Washington, United States of America
| | | | - Martha Brady
- PATH, Seattle, Washington, United States of America
| | | | - Kira Mori
- Vaccine and Infectious Disease Division, Fred Hutchinson Cancer Research Center, Seattle, Washington, United States of America
| | | | | | | | | | - Ying Qing Chen
- Vaccine and Infectious Disease Division, Fred Hutchinson Cancer Research Center, Seattle, Washington, United States of America
| | - Paul Drain
- Department of Global Health, University of Washington, Seattle, Washington, United States of America
| | - Ann Duerr
- Vaccine and Infectious Disease Division, Fred Hutchinson Cancer Research Center, Seattle, Washington, United States of America
- * E-mail:
| |
Collapse
|
15
|
Beesham I, Mansoor LE, Joseph Davey DL, Palanee-Phillips T, Smit J, Ahmed K, Selepe P, Louw C, Singata-Madliki M, Kotze P, Heffron R, Parikh UM, Wiesner L, Rees H, Baeten JM, Beksinska M. Brief Report: Quantifiable Plasma Tenofovir Among South African Women Using Daily Oral Pre-exposure Prophylaxis During the ECHO Trial. J Acquir Immune Defic Syndr 2022; 91:26-30. [PMID: 35972853 PMCID: PMC9377486 DOI: 10.1097/qai.0000000000003023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2022] [Accepted: 05/16/2022] [Indexed: 11/27/2022]
Abstract
BACKGROUND HIV endpoint-driven clinical trials provide oral pre-exposure prophylaxis (PrEP) as HIV prevention standard of care. We evaluated quantifiable plasma tenofovir among South African women who used oral PrEP during the Evidence for Contraceptive Options and HIV Outcomes (ECHO) Trial. METHODS ECHO, a randomized trial conducted in 4 African countries between 2015 and 2018, assessed HIV incidence among HIV-uninfected women, aged 16-35 years, randomized to 1 of 3 contraceptives. Oral PrEP was offered onsite as part of the HIV prevention package at the South African trial sites. We measured tenofovir in plasma samples collected at the final trial visit among women reporting ongoing PrEP use. We used bivariate and multivariate logistical regression to assess demographic and sexual risk factors associated with plasma tenofovir quantification. RESULTS Of 260 women included, 52% were ≤24 years and 22% had Chlamydia trachomatis at enrollment. At PrEP initiation, 68% reported inconsistent/nonuse of condoms. The median duration of PrEP use was 90 days (IQR: 83-104). Tenofovir was quantified in 36% (n = 94) of samples. Women >24 years had twice the odds of having tenofovir quantified vs younger women (OR = 2.12; 95% confidence interval = 1.27 to 3.56). Women who reported inconsistent/nonuse of condoms had lower odds of tenofovir quantification (age-adjusted OR = 0.47; 95% confidence interval = 0.26 to 0.83). CONCLUSIONS Over a third of women initiating PrEP and reporting ongoing use at the final trial visit had evidence of recent drug exposure. Clinical trials may serve as an entry point for PrEP initiation among women at substantial risk for HIV infection with referral to local facilities for ongoing access at trial end. CLINICAL TRIAL NUMBER NCT02550067.
Collapse
Affiliation(s)
- Ivana Beesham
- MatCH Research Unit (MRU), Department of Obstetrics and Gynaecology, Faculty of Health Sciences, University of the Witwatersrand, Durban, South Africa
| | - Leila E. Mansoor
- Centre for AIDS Programme of Research in South Africa (CAPRISA), University of KwaZulu-Natal, Durban, South Africa
| | - Dvora L. Joseph Davey
- Division of Epidemiology and Biostatistics, School of Public Health and Family Medicine, University of Cape Town, Cape Town, South Africa
- Department of Epidemiology, Fielding School of Public Health, University of California Los Angeles, Los Angeles, CA
| | - Thesla Palanee-Phillips
- Wits Reproductive Health and HIV Institute (Wits RHI), Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Jenni Smit
- MatCH Research Unit (MRU), Department of Obstetrics and Gynaecology, Faculty of Health Sciences, University of the Witwatersrand, Durban, South Africa
| | - Khatija Ahmed
- Setshaba Research Centre, Soshanguve, South Africa
- Department of Medical Microbiology, Faculty of Health Sciences, University of Pretoria, Pretoria, South Africa
| | | | - Cheryl Louw
- Madibeng Centre for Research, Brits, South Africa
- Department of Family Medicine, Faculty of Health Sciences, University of Pretoria, Pretoria, South Africa
| | - Mandisa Singata-Madliki
- Effective Care Research Unit, Universities of the Witwatersrand and Fort Hare and Eastern Cape Department of Health, East London, South Africa
| | - Philip Kotze
- Qhakaza Mbokodo Research Clinic, Ladysmith, South Africa;
| | - Renee Heffron
- Department of Global Health and Department of Epidemiology, University of Washington, Seattle, WA
| | - Urvi M. Parikh
- Department of Medicine, Division of Infectious Diseases, University of Pittsburgh School of Medicine, Pittsburgh, PA
| | - Lubbe Wiesner
- Division of Clinical Pharmacology, Department of Medicine, University of Cape Town, Cape Town, South Africa;
| | - Helen Rees
- Wits Reproductive Health and HIV Institute (Wits RHI), Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Jared M. Baeten
- Department of Global Health, Department of Epidemiology, Department of Medicine, University of Washington, Seattle, WA; and
- Gilead Sciences, Foster City, CA
| | - Mags Beksinska
- MatCH Research Unit (MRU), Department of Obstetrics and Gynaecology, Faculty of Health Sciences, University of the Witwatersrand, Durban, South Africa
| |
Collapse
|
16
|
Phillips AN, Sibanda E, Sikwese K, Bansi-Matharu L, Cambiano V, Rodger A, Lundgren J, Shahmanesh M, Gilks C, Godfrey C, Ehrenkranz P, Hargreaves JR, Revill P, Cowan F. Enabling timely HIV postexposure prophylaxis access in sub-Saharan Africa. AIDS 2022; 36:1473-1475. [PMID: 35876709 DOI: 10.1097/qad.0000000000003258] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Affiliation(s)
| | | | - Kenly Sikwese
- African Community Advisory Board (AfroCAB-HIV), Lusaka, Zambia
| | | | | | | | - Jens Lundgren
- Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
| | | | | | - Catherine Godfrey
- Office of the Global AIDS Coordinator, Department of State, Washington, DC, USA
| | | | | | - Paul Revill
- Centre for Health Economics, University of York, UK
| | - Frances Cowan
- Liverpool School of Tropical Medicine, UK, and Harare, Zimbabwe
| |
Collapse
|
17
|
Phillips AN, Bershteyn A, Revill P, Bansi-Matharu L, Kripke K, Boily MC, Martin-Hughes R, Johnson LF, Mukandavire Z, Jamieson L, Meyer-Rath G, Hallett TB, Ten Brink D, Kelly SL, Nichols BE, Bendavid E, Mudimu E, Taramusi I, Smith J, Dalal S, Baggaley R, Crowley S, Terris-Prestholt F, Godfrey-Faussett P, Mukui I, Jahn A, Case KK, Havlir D, Petersen M, Kamya M, Koss CA, Balzer LB, Apollo T, Chidarikire T, Mellors JW, Parikh UM, Godfrey C, Cambiano V. Cost-effectiveness of easy-access, risk-informed oral pre-exposure prophylaxis in HIV epidemics in sub-Saharan Africa: a modelling study. Lancet HIV 2022; 9:e353-e362. [PMID: 35489378 PMCID: PMC9065367 DOI: 10.1016/s2352-3018(22)00029-7] [Citation(s) in RCA: 17] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2021] [Revised: 01/27/2022] [Accepted: 01/28/2022] [Indexed: 02/07/2023]
Abstract
BACKGROUND Approaches that allow easy access to pre-exposure prophylaxis (PrEP), such as over-the-counter provision at pharmacies, could facilitate risk-informed PrEP use and lead to lower HIV incidence, but their cost-effectiveness is unknown. We aimed to evaluate conditions under which risk-informed PrEP use is cost-effective. METHODS We applied a mathematical model of HIV transmission to simulate 3000 setting-scenarios reflecting a range of epidemiological characteristics of communities in sub-Saharan Africa. The prevalence of HIV viral load greater than 1000 copies per mL among all adults (HIV positive and negative) varied from 1·1% to 7·4% (90% range). We hypothesised that if PrEP was made easily available without restriction and with education regarding its use, women and men would use PrEP, with sufficient daily adherence, during so-called seasons of risk (ie, periods in which individuals are at risk of acquiring infection). We refer to this as risk-informed PrEP. For each setting-scenario, we considered the situation in mid-2021 and performed a pairwise comparison of the outcomes of two policies: immediate PrEP scale-up and then continuation for 50 years, and no PrEP. We estimated the relationship between epidemic and programme characteristics and cost-effectiveness of PrEP availability to all during seasons of risk. For our base-case analysis, we assumed a 3-monthly PrEP cost of US$29 (drug $11, HIV test $4, and $14 for additional costs necessary to facilitate education and access), a cost-effectiveness threshold of $500 per disability-adjusted life-year (DALY) averted, an annual discount rate of 3%, and a time horizon of 50 years. In sensitivity analyses, we considered a cost-effectiveness threshold of $100 per DALY averted, a discount rate of 7% per annum, the use of PrEP outside of seasons of risk, and reduced uptake of risk-informed PrEP. FINDINGS In the context of PrEP scale-up such that 66% (90% range across setting-scenarios 46-81) of HIV-negative people with at least one non-primary condomless sex partner take PrEP in any given period, resulting in 2·6% (0·9-6·0) of all HIV negative adults taking PrEP at any given time, risk-informed PrEP was predicted to reduce HIV incidence by 49% (23-78) over 50 years compared with no PrEP. PrEP was cost-effective in 71% of all setting-scenarios, and cost-effective in 76% of setting-scenarios with prevalence of HIV viral load greater than 1000 copies per mL among all adults higher than 2%. In sensitivity analyses with a $100 per DALY averted cost-effectiveness threshold, a 7% per year discount rate, or with PrEP use that was less well risk-informed than in our base case, PrEP was less likely to be cost-effective, but generally remained cost-effective if the prevalence of HIV viral load greater than 1000 copies per mL among all adults was higher than 3%. In sensitivity analyses based on additional setting-scenarios in which risk-informed PrEP was less extensively used, the HIV incidence reduction was smaller, but the cost-effectiveness of risk-informed PrEP was undiminished. INTERPRETATION Under the assumption that making PrEP easily accessible for all adults in sub-Saharan Africa in the context of community education leads to risk-informed use, PrEP is likely to be cost-effective in settings with prevalence of HIV viral load greater than 1000 copies per mL among all adults higher than 2%, suggesting the need for implementation of such approaches, with ongoing evaluation. FUNDING US Agency for International Development, US President's Emergency Plan for AIDS Relief, and Bill & Melinda Gates Foundation.
Collapse
Affiliation(s)
| | - Anna Bershteyn
- Department of Population Health, New York University Grossman School of Medicine, New York, NY, USA
| | - Paul Revill
- Centre for Health Economics, University of York, York, UK
| | | | | | - Marie-Claude Boily
- Department of Infectious Disease Epidemiology, Imperial College London, London, UK; MRC Centre for Global Infectious Disease Analysis, School of Public Health, Imperial College London, London, UK
| | | | - Leigh F Johnson
- Centre for Infectious Disease Epidemiology and Research, University of Cape Town, Cape Town, South Africa
| | - Zindoga Mukandavire
- Centre for Data Science and Artificial Intelligence, Emirates Aviation University, Dubai, United Arab Emirates
| | - Lise Jamieson
- Health Economics and Epidemiology Research Office (HE2RO), Department of Internal Medicine, School of Clinical Medicine, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa; Department of Medical Microbiology, Amsterdam University Medical Centre, Amsterdam, Netherlands
| | - Gesine Meyer-Rath
- Health Economics and Epidemiology Research Office (HE2RO), Department of Internal Medicine, School of Clinical Medicine, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa; Department of Global Health, School of Public Health, Boston University, Boston, MA, USA
| | - Timothy B Hallett
- Department of Infectious Disease Epidemiology, Imperial College London, London, UK; MRC Centre for Global Infectious Disease Analysis, School of Public Health, Imperial College London, London, UK
| | | | | | - Brooke E Nichols
- Health Economics and Epidemiology Research Office (HE2RO), Department of Internal Medicine, School of Clinical Medicine, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa; Department of Medical Microbiology, Amsterdam University Medical Centre, Amsterdam, Netherlands; Department of Global Health, School of Public Health, Boston University, Boston, MA, USA
| | - Eran Bendavid
- Department of Medicine, Stanford University, Stanford, CA, USA
| | - Edinah Mudimu
- Department of Decision Sciences, University of South Africa, Pretoria, South Africa
| | | | - Jennifer Smith
- Institute for Global Health, University College London, London, UK
| | - Shona Dalal
- World Health Organisation, Geneva, Switzerland
| | | | - Siobhan Crowley
- The Global Fund to Fight AIDS, Tuberculosis and Malaria, Geneva, Switzerland
| | | | - Peter Godfrey-Faussett
- Joint UN Programme on HIV/AIDS, Geneva, Switzerland; London School of Hygiene & Tropical Medicine, London, UK
| | - Irene Mukui
- Drugs for Neglected Diseases Initiative, Nairobi, Kenya
| | | | - Kelsey K Case
- Department of Infectious Disease Epidemiology, Imperial College London, London, UK
| | - Diane Havlir
- Department of Medicine, University of California, San Francisco, CA, USA
| | - Maya Petersen
- Divisions of Biostatistics and Epidemiology, School of Public Health, University of California, Berkeley, CA, USA
| | - Moses Kamya
- Department of Medicine, Makerere University, Kampala, Uganda; Infectious Diseases Research Collaboration, Kampala, Uganda
| | - Catherine A Koss
- Department of Medicine, University of California, San Francisco, CA, USA
| | - Laura B Balzer
- Department of Biostatistics and Epidemiology, School of Public Health and Health Sciences, University of Massachusetts, Amherst, MA, USA
| | | | | | - John W Mellors
- Department of Medicine, Division of Infectious Diseases, University of Pittsburgh, Pittsburgh, PA, USA
| | - Urvi M Parikh
- Department of Medicine, Division of Infectious Diseases, University of Pittsburgh, Pittsburgh, PA, USA
| | - Catherine Godfrey
- Office of the Global AIDS Coordinator, Department of State, Washington, DC, USA
| | | |
Collapse
|
18
|
Castor D, Burgess EK, Yende-Zuma N, Heck CJ, Abdool Karim Q. Age-Restriction of a Validated Risk Scoring Tool Better Predicts HIV Acquisition in South African Women: CAPRISA 004. AIDS Behav 2022; 26:3300-3310. [PMID: 35419667 PMCID: PMC9474358 DOI: 10.1007/s10461-022-03664-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/18/2022] [Indexed: 11/27/2022]
Abstract
We examined the predictive ability of the VOICE risk screening tool among adolescent girls and young women at heightened HIV risk in urban and peri-urban Kwa-Zulu-Natal, South Africa. Using participant data from CAPRISA 004’s control arm (N = 444), we applied the initial VOICE risk screening score (IRS), a modified risk score (MRS) based on predictive and non-predictive variables in our data, and age-restricted (AIRS and AMRS, respectively). We estimated incidence rates, 95% confidence bounds, sensitivity, specificity, negative and positive predictive values and area under the curve (AUC). The sample’s HIV incidence rate was 9.1/100 Person-Years [95% CI 6.9–11.7], resulting from 60 seroconversions (60/660.7 Person-Years). The IRS’ ≥ 8 cutpoint produced moderate discrimination [AUC = 0.66 (0.54–0.74), sensitivity = 63%, specificity = 57%]. Restricting to age < 25 years improved the score’s predictive ability (AIRS: AUC = 0.69, AMRS: AUC = 0.70), owing mainly to male partner having other partners and HSV-2. The risk tool predicted HIV acquisition at a higher cutpoint in this sample than in the initial VOICE analysis. After age-stratification, fewer variables were needed for maintaining score’s predictiveness. In this high incidence setting, risk screening may still improve the efficiency or effectiveness of prevention counseling services. However, PrEP should be offered to all prevention-seeking individuals, regardless of risk ascertainment.
Collapse
Affiliation(s)
- Delivette Castor
- Division of Infectious Diseases, Department of Medicine, Columbia University Irving Medical Center, New York, NY, USA
| | | | - Nonhlanhla Yende-Zuma
- Centre for the AIDS Programme of Research in South Africa (CAPRISA), University of KwaZulu-Natal, Private Bag X7, Congella, Durban, 4013, South Africa
| | - Craig J Heck
- Department of Epidemiology, Mailman School of Public Health, Columbia University, New York, NY, USA
| | - Quarraisha Abdool Karim
- Centre for the AIDS Programme of Research in South Africa (CAPRISA), University of KwaZulu-Natal, Private Bag X7, Congella, Durban, 4013, South Africa.
- Department of Epidemiology, Mailman School of Public Health, Columbia University, New York, NY, USA.
| |
Collapse
|
19
|
Velloza J, Poovan N, Ndlovu N, Khoza N, Morton JF, Omony J, Mkwanazi E, Grabow C, Donnell D, Munthali R, Baeten JM, Hosek S, Celum C, Delany-Moretlwe S. Adaptive HIV pre-exposure prophylaxis adherence interventions for young South African women: Study protocol for a sequential multiple assignment randomized trial. PLoS One 2022; 17:e0266665. [PMID: 35417485 PMCID: PMC9007385 DOI: 10.1371/journal.pone.0266665] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2021] [Accepted: 03/11/2022] [Indexed: 12/02/2022] Open
Abstract
INTRODUCTION Pre-exposure prophylaxis (PrEP) is a highly effective HIV prevention strategy and is recommended for populations at risk of HIV, including adolescent girls and young women (AGYW) in HIV endemic settings. However, PrEP continuation and high adherence remain challenges to its impact. Existing PrEP adherence interventions can be time- and cost-intensive. Widescale PrEP delivery will require the identification of layered PrEP support strategies for AGYW with diverse prevention needs. We describe the design of a sequential multiple assignment randomized trial (SMART) to evaluate a PrEP adherence support model using scalable, stepped interventions in AGYW in South Africa. METHODS "PrEP SMART" is a randomized trial in Johannesburg, South Africa, enrolling AGYW who are between 18 and 25 years of age, sexually active, newly initiating PrEP, and have regular access to a mobile phone. Participants are randomized 1:1 to standard-of-care PrEP counseling with either two-way SMS or WhatsApp group adherence support. Adherence is assessed at three months using tenofovir diphosphate (TFV-DP) levels from dried blood spots collected at month 2 to categorize participants as "responders" (TFV-DP ≥500 fmol/punch) or "non-responders" (TFV-DP <500 fmol/punch). AGYW defined as 'non-responders' undergo a secondary 1:1 randomization to either quarterly drug-level feedback counseling or monthly issue-focused counseling, in addition to their first-level intervention. The primary outcome is PrEP adherence at nine months (TFV-DP ≥700 fmol/punch). We will assess the effect of our two initial interventions on TFV-DP levels among responders, assess the effect of our intensified interventions on TFV-DP levels among non-responders, and identify the optimal sequence of adherence interventions through nine months. TRIAL REGISTRATION ClinicalTrials.gov, NCT04038060. Registered on 30 July 2019.
Collapse
Affiliation(s)
- Jennifer Velloza
- Department of Global Health, University of Washington, Seattle, WA, United States of America
| | - Nicole Poovan
- Wits Reproductive Health & HIV Institute (Wits RHI), Faculty of Health Sciences, University of The Witwatersrand, Johannesburg, South Africa
| | - Nontokozo Ndlovu
- Wits Reproductive Health & HIV Institute (Wits RHI), Faculty of Health Sciences, University of The Witwatersrand, Johannesburg, South Africa
| | - Nomhle Khoza
- Wits Reproductive Health & HIV Institute (Wits RHI), Faculty of Health Sciences, University of The Witwatersrand, Johannesburg, South Africa
| | - Jennifer F. Morton
- Department of Global Health, University of Washington, Seattle, WA, United States of America
| | - Jeanne Omony
- Wits Reproductive Health & HIV Institute (Wits RHI), Faculty of Health Sciences, University of The Witwatersrand, Johannesburg, South Africa
| | - Edwin Mkwanazi
- Wits Reproductive Health & HIV Institute (Wits RHI), Faculty of Health Sciences, University of The Witwatersrand, Johannesburg, South Africa
| | - Cole Grabow
- Department of Global Health, University of Washington, Seattle, WA, United States of America
| | - Deborah Donnell
- Department of Global Health, University of Washington, Seattle, WA, United States of America
- Vaccine and Infectious Disease Division, Fred Hutchinson Cancer Research Center, Seattle, WA, United States of America
| | - Richard Munthali
- Wits Reproductive Health & HIV Institute (Wits RHI), Faculty of Health Sciences, University of The Witwatersrand, Johannesburg, South Africa
| | - Jared M. Baeten
- Department of Global Health, University of Washington, Seattle, WA, United States of America
- Department of Epidemiology, University of Washington, Seattle, WA, United States of America
- Department of Medicine, University of Washington, Seattle, WA, United States of America
| | - Sybil Hosek
- Department of Psychiatry, Stroger Hospital of Cook County, Chicago, IL, United States of America
| | - Connie Celum
- Department of Global Health, University of Washington, Seattle, WA, United States of America
- Department of Epidemiology, University of Washington, Seattle, WA, United States of America
- Department of Medicine, University of Washington, Seattle, WA, United States of America
| | - Sinead Delany-Moretlwe
- Wits Reproductive Health & HIV Institute (Wits RHI), Faculty of Health Sciences, University of The Witwatersrand, Johannesburg, South Africa
| |
Collapse
|
20
|
Zhang J, Li C, Xu J, Hu Z, Rutstein SE, Tucker JD, Ong JJ, Jiang Y, Geng W, Wright ST, Cohen MS, Shang H, Tang W. Discontinuation, suboptimal adherence, and reinitiation of oral HIV pre-exposure prophylaxis: a global systematic review and meta-analysis. Lancet HIV 2022; 9:e254-e268. [PMID: 35364026 PMCID: PMC9124596 DOI: 10.1016/s2352-3018(22)00030-3] [Citation(s) in RCA: 76] [Impact Index Per Article: 38.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2021] [Revised: 01/19/2022] [Accepted: 01/26/2022] [Indexed: 12/26/2022]
Abstract
BACKGROUND Poor adherence to oral HIV pre-exposure prophylaxis (PrEP) diminishes its clinical and public health benefits. This study synthesises evidence regarding discontinuation, adherence, and reinitiation of PrEP among geographically diverse PrEP users. METHODS We did a systematic review and meta-analysis evaluating studies published in MEDLINE, Embase, and Cochrane Central Register of Controlled Trials from inception to Dec 18, 2020. We included longitudinal studies that presented data for PrEP discontinuation, defined as investigator-reported loss to follow-up or participant self-reported PrEP stoppage. Data were extracted from published reports and assessed for risk of bias. We used a random-effects meta-analysis to pool estimates of discontinuation and I2 and τ2 to evaluate heterogeneity. This study is registered with PROSPERO, CRD42020155675. FINDINGS We identified 4129 records, of which 59 articles were included (n=43 917 participants). 41·0% (95% CI 18·8-63·5) of participants discontinued PrEP within 6 months, with the highest rates in observational studies. The discontinuation rate in sub-Saharan Africa (47·5%, 95% CI: 29·4-66·4%) was higher than in other regions (p<0·001). Discontinuation rates were lower in studies with adherence interventions than in those without (24·7% vs 36·7%, p=0·015). Gay or bisexual men who have sex with men and transgender women offered daily or non-daily dosing options had lower discontinuation rates than those offered daily dosing alone (21·6% vs 31·5%; p<0·001). The pooled suboptimal adherence within 6 months was 37·7% (95% CI 8·4-66·9). Among people who discontinued PrEP, 47·3% (95% CI 31·5-63·2) reinitiated PrEP within 1 year of PrEP initiation. The included studies had poor quality in terms of study design, with a moderate risk of bias. INTERPRETATION Strategies to encourage reinitiating PrEP for new or persistent risk should be a focus of future PrEP implementation strategies. FUNDING National Institutes of Health and Nature Science Foundation of China.
Collapse
Affiliation(s)
- Jing Zhang
- The NHC Key Laboratory of AIDS Immunology and National Clinical Research Center for Laboratory Medicine of the First Affiliated Hospital of China Medical University
- Key Laboratory of AIDS Immunology, Chinese Academy of Medical Sciences
- Key Laboratory of AIDS Immunology of Liaoning Province
- Collaborative Innovation Center for Diagnosis and Treatment of Infectious Diseases
| | - Chunyan Li
- Department of Health Behavior of University of North Carolina
| | - Junjie Xu
- The NHC Key Laboratory of AIDS Immunology and National Clinical Research Center for Laboratory Medicine of the First Affiliated Hospital of China Medical University
- Key Laboratory of AIDS Immunology, Chinese Academy of Medical Sciences
- Key Laboratory of AIDS Immunology of Liaoning Province
- Collaborative Innovation Center for Diagnosis and Treatment of Infectious Diseases
| | - Zhili Hu
- The NHC Key Laboratory of AIDS Immunology and National Clinical Research Center for Laboratory Medicine of the First Affiliated Hospital of China Medical University
- Key Laboratory of AIDS Immunology, Chinese Academy of Medical Sciences
- Key Laboratory of AIDS Immunology of Liaoning Province
- Collaborative Innovation Center for Diagnosis and Treatment of Infectious Diseases
| | | | - Joseph D. Tucker
- Department of Medicine of University of North Carolina
- University of North Carolina Project-China
- Faculty of Infectious and Tropical Diseases of London School of Hygiene and Tropical Medicine
| | - Jason J Ong
- Faculty of Infectious and Tropical Diseases of London School of Hygiene and Tropical Medicine
- Monash University
| | - Yongjun Jiang
- The NHC Key Laboratory of AIDS Immunology and National Clinical Research Center for Laboratory Medicine of the First Affiliated Hospital of China Medical University
- Key Laboratory of AIDS Immunology, Chinese Academy of Medical Sciences
- Key Laboratory of AIDS Immunology of Liaoning Province
- Collaborative Innovation Center for Diagnosis and Treatment of Infectious Diseases
| | - Wenqing Geng
- The NHC Key Laboratory of AIDS Immunology and National Clinical Research Center for Laboratory Medicine of the First Affiliated Hospital of China Medical University
- Key Laboratory of AIDS Immunology, Chinese Academy of Medical Sciences
- Key Laboratory of AIDS Immunology of Liaoning Province
- Collaborative Innovation Center for Diagnosis and Treatment of Infectious Diseases
| | | | | | - Hong Shang
- The NHC Key Laboratory of AIDS Immunology and National Clinical Research Center for Laboratory Medicine of the First Affiliated Hospital of China Medical University
- Key Laboratory of AIDS Immunology, Chinese Academy of Medical Sciences
- Key Laboratory of AIDS Immunology of Liaoning Province
- Collaborative Innovation Center for Diagnosis and Treatment of Infectious Diseases
| | - Weiming Tang
- Department of Medicine of University of North Carolina
- University of North Carolina Project-China
- Dermatology Hospital of Southern Medical University
| |
Collapse
|
21
|
Vanbaelen T, Rotsaert A, Jacobs BK, Florence E, Kenyon C, Vuylsteke B, Laga M, Thijs R. Why Do HIV Pre-Exposure Prophylaxis Users Discontinue Pre-Exposure Prophylaxis Care? A Mixed Methods Survey in a Pre-Exposure Prophylaxis Clinic in Belgium. AIDS Patient Care STDS 2022; 36:159-167. [PMID: 35438524 PMCID: PMC9057878 DOI: 10.1089/apc.2021.0197] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/02/2022] Open
Abstract
It remains unclear why patients discontinue HIV pre-exposure prophylaxis (PrEP) care and to what extent they remain at risk for HIV when they do. We reviewed routinely collected medical records and patient questionnaires and performed an e-mail/telephone survey to assess reasons for discontinuing PrEP care, ongoing risks for HIV infection, and associated factors. Patients with more than two registered PrEP visits from a PrEP clinic in Antwerp, Belgium between June 2017 and February 2020 were included in this study. Patients who did not return for a visit after October 30, 2019 and who were not transferred out were considered as having discontinued PrEP care. A total of 143/1073 patients were considered as having discontinued PrEP care. Patients who discontinued PrEP care were more likely to be younger than those who remained in care (35 vs. 38 years old, p < 0.01). The most common reasons for discontinuation were having stopped using PrEP (62/101, 61.4%) and "COVID-19" (n = 35, 34.7%). The most common reasons for stopping PrEP use was a decreased sexual activity due to coronavirus disease 2019 (COVID-19; 21/62, 33.9%) or not COVID-19 related (10/62, 16.1%), a monogamous relationship (20/62, 32.3%) and consistent condom use (7/62, 11.3%). Among respondents who reported about current HIV risk the majority reported being at low risk either by still taking PrEP (32/91, 35.2%), consistently using condoms, or limiting number of sex acts or partners (58/91, 52.7%). No HIV seroconversion was reported.
Collapse
Affiliation(s)
- Thibaut Vanbaelen
- Department of Clinical Sciences and Institute of Tropical Medicine, Antwerp, Belgium
- Department of Public Health, Institute of Tropical Medicine, Antwerp, Belgium
| | - Anke Rotsaert
- Department of Public Health, Institute of Tropical Medicine, Antwerp, Belgium
| | - Bart K.M. Jacobs
- Department of Clinical Sciences and Institute of Tropical Medicine, Antwerp, Belgium
| | - Eric Florence
- Department of Clinical Sciences and Institute of Tropical Medicine, Antwerp, Belgium
| | - Chris Kenyon
- Department of Clinical Sciences and Institute of Tropical Medicine, Antwerp, Belgium
- Division of Infectious Diseases and HIV Medicine, University of Cape Town, Cape Town, South Africa
| | - Bea Vuylsteke
- Department of Public Health, Institute of Tropical Medicine, Antwerp, Belgium
| | - Marie Laga
- Department of Public Health, Institute of Tropical Medicine, Antwerp, Belgium
| | - Reyniers Thijs
- Department of Public Health, Institute of Tropical Medicine, Antwerp, Belgium
| |
Collapse
|
22
|
Schaefer R, Amparo da Costa Leite PH, Silva R, Abdool Karim Q, Akolo C, Cáceres CF, Dourado I, Green K, Hettema A, Hoornenborg E, Jana S, Kerschberger B, Mahler H, Matse S, McManus H, Molina JM, Reza-Paul S, Azwa I, Shahmanesh M, Taylor D, Vega-Ramirez H, Veloso VG, Baggaley R, Dalal S. Kidney function in tenofovir disoproxil fumarate-based oral pre-exposure prophylaxis users: a systematic review and meta-analysis of published literature and a multi-country meta-analysis of individual participant data. Lancet HIV 2022; 9:e242-e253. [PMID: 35271825 PMCID: PMC8964504 DOI: 10.1016/s2352-3018(22)00004-2] [Citation(s) in RCA: 14] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2021] [Revised: 01/03/2022] [Accepted: 01/05/2022] [Indexed: 12/14/2022]
Abstract
BACKGROUND Previous WHO guidance on tenofovir disoproxil fumarate-based oral pre-exposure prophylaxis (PrEP) suggests measuring creatinine levels at PrEP initiation and regularly afterwards, which might represent barriers to PrEP implementation and uptake. We aimed to systematically review published literature on kidney toxicity among tenofovir disoproxil fumarate-based oral PrEP users and conducted an individual participant data meta-analysis (IPDMA) on kidney function among PrEP users in a global implementation project dataset. METHODS In this systematic review and meta-analysis we searched PubMed up to June 30, 2021, for randomised controlled trials (RCTs) or cohort studies that reported on graded kidney-related adverse events among oral PrEP users (tenofovir disoproxil fumarate-based PrEP alone or in combination with emtricitabine or lamivudine). We extracted summary data and conducted meta-analyses with random-effects models to estimate relative risks of grade 1 and higher and grade 2 and higher kidney-related adverse events, measured by elevated serum creatinine or decline in estimated creatinine clearance or estimated glomerular filtration rate. The IPDMA included (largely unpublished) individual participant data from 17 PrEP implementation projects and two RCTs. Estimated baseline creatinine clearance and creatinine clearance change after initiation were described by age, gender, and comorbidities. We used random-effects regressions to estimate the risk in decline of creatinine clearance to less than 60 mL/min. FINDINGS We identified 62 unique records and included 17 articles reporting on 11 RCTs with 13 523 participants in meta-analyses. PrEP use was associated with increased risk of grade 1 and higher kidney adverse events (pooled odds ratio [OR] 1·49, 95% CI 1·22-1·81; I2=25%) and grade 2 and higher events (OR 1·75, 0·68-4·49; I2=0%), although the grade 2 and higher association was not statistically significant and events were rare (13 out of 6764 in the intervention group vs six out of 6782 in the control group). The IPDMA included 18 676 individuals from 15 countries (1453 [7·8%] from RCTs) and 79 (0·42%) had a baseline estimated creatinine clearance of less than 60 mL/min (increasing proportions with increasing age). Longitudinal analyses included 14 368 PrEP users and 349 (2·43%) individuals had a decline to less than 60 mL/min creatinine clearance, with higher risks associated with increasing age and baseline creatinine clearance of 60·00-89·99 mL/min (adjusted hazard ratio [aHR] 8·49, 95% CI 6·44-11·20) and less than 60 mL/min (aHR 20·83, 12·83-33·82). INTERPRETATION RCTs suggest that risks of kidney-related adverse events among tenofovir disoproxil fumarate-based oral PrEP users are increased but generally mild and small. Our global PrEP user analysis found varying risks by age and baseline creatinine clearance. Kidney function screening and monitoring might focus on older individuals, those with baseline creatinine clearance of less than 90 mL/min, and those with kidney-related comorbidities. Less frequent or optional screening among younger individuals without kidney-related comorbidities may reduce barriers to PrEP implementation and use. FUNDING Unitaid, Bill & Melinda Gates Foundation, WHO.
Collapse
Affiliation(s)
- Robin Schaefer
- Global HIV, Hepatitis and STIs Programmes, World Health Organization, Geneva, Switzerland.
| | | | - Ronaldo Silva
- Department of Infectious-Tropical Diseases and Microbiology, IRCCS Sacro Cuore Don Calabria Hospital, Negrar, Italy
| | - Quarraisha Abdool Karim
- CAPRISA, Nelson R Mandela School of Medicine; University of KwaZulu-Natal, Durban, South Africa
| | | | - Carlos F Cáceres
- Centro de Investigación Interdisciplinaria en Sexualidad, SIDA y Sociedad, Universidad Cayetano Heredia, Lima, Peru
| | - Inês Dourado
- Collective Health Institute, Federal University of Bahia, Brazil
| | | | | | - Elske Hoornenborg
- Center for Sexual Health, Department of Infectious Diseases, Public Health Service Amsterdam, Amsterdam, Netherlands
| | | | | | | | | | - Hamish McManus
- The Kirby Institute, University of New South Wales Sydney, Sydney, NSW, Australia
| | - Jean-Michel Molina
- Department of Infectious Diseases, St-Louis and Lariboisière Hospitals, University of Paris, INSERM U944, Paris, France
| | - Sushena Reza-Paul
- Department of Community Health Sciences, University of Manitoba, Winnipeg, MB, Canada; Ashodaya Samithi, Mysuru, India
| | - Iskandar Azwa
- Infectious Diseases Unit, Faculty of Medicine, University of Malaya, Kuala Lumpur, Malaysia
| | - Maryam Shahmanesh
- Africa Health Research Institute, KwaZulu-Natal, South Africa; Institute for Global Health, University College London, London, UK
| | | | - Hamid Vega-Ramirez
- National Institute of Psychiatry Ramon de la Fuente Muñiz, Mexico City, Mexico
| | - Valdiléa G Veloso
- Evandro Chagas National Institute of Infectious Diseases, Oswaldo Cruz Foundation, Rio de Janeiro, Brazil
| | - Rachel Baggaley
- Global HIV, Hepatitis and STIs Programmes, World Health Organization, Geneva, Switzerland
| | - Shona Dalal
- Global HIV, Hepatitis and STIs Programmes, World Health Organization, Geneva, Switzerland
| |
Collapse
|
23
|
Daily Oral Pre-exposure Prophylaxis (PrEP) Continuation Among Women from Durban, South Africa, Who Initiated PrEP as Standard of Care for HIV Prevention in a Clinical Trial. AIDS Behav 2022; 26:2623-2631. [PMID: 35122575 PMCID: PMC9252967 DOI: 10.1007/s10461-022-03592-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/15/2022] [Indexed: 11/29/2022]
Abstract
HIV incidence among women in Eastern and Southern Africa remains unacceptably high, highlighting the need for effective HIV prevention options, including pre-exposure prophylaxis (PrEP). The Evidence for Contraceptive Options and HIV Outcomes trial offered daily oral PrEP to participants during the latter part of the clinical trial as an additional HIV prevention choice. We explored daily oral PrEP continuation at trial exit among women enrolled from Durban, South Africa who initiated oral PrEP at the trial site. Of the 132 women initiating oral PrEP, 87% reported continuation of oral PrEP at month 1, 80% at month 3, and 75% continued using oral PrEP at their final trial visit and were referred to off-site facilities for ongoing oral PrEP access. The median duration of oral PrEP use in trial participants who used oral PrEP was 91 days (IQR 87 to 142 days). Women who disclosed their oral PrEP use to someone had increased odds of continuing oral PrEP at trial exit. Women who reported > 1 sex partner and those who felt they would probably or definitely get infected with HIV had reduced odds of continuing oral PrEP at trial exit. Of those discontinuing oral PrEP (n = 32), > 50% discontinued within the first month, and the most common reason for discontinuation was reporting side effects. The high rates of oral PrEP continuation in our study are encouraging and our findings can be utilized by other clinical trials providing oral PrEP as standard of care for HIV prevention and by oral PrEP implementation programmes.
Collapse
|
24
|
Pyra M, Brewer R, Rusie L, Kline J, Willis I, Schneider J. Long-term HIV Pre-exposure Prophylaxis Trajectories Among Racial & Ethnic Minority Patients: Short, Declining, & Sustained Adherence. J Acquir Immune Defic Syndr 2022; 89:166-171. [PMID: 34636809 PMCID: PMC8752481 DOI: 10.1097/qai.0000000000002833] [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: 05/27/2021] [Accepted: 07/13/2021] [Indexed: 02/03/2023]
Abstract
BACKGROUND HIV pre-exposure prophylaxis (PrEP) requires continued use at an effective dosage to reduce HIV incidence. Data suggest early PrEP drop-off among many populations. We sought to describe PrEP use over the first year among racial and ethnic minority patients in the US. SETTING Racial and ethnic minority patients initiating PrEP at a federally qualified health center in Chicago, IL. METHODS Using electronic health records, we determined the adherence (≥6 weekly doses) trajectories over the first year of PrEP use and compared baseline and time-varying patient characteristics. RESULTS From 2159 patients, we identified 3 PrEP use trajectories. Sustained use was the most common (40%) trajectory, followed by short use (30%) and declining use (29%). In adjusted models, younger age, Black race, as well as gender, sexual orientation, insurance status at baseline, and neighborhood were associated with trajectory assignment; within some trajectories, insurance status during follow-up was associated with odds of monthly adherence (≥6 weekly doses). CONCLUSION Among racial and ethnic minorities, a plurality achieved sustained PrEP persistence. Access to clinics, insurance, and intersectional stigmas may be modifiable barriers to effective PrEP persistence; in addition, focus on younger users and beyond gay, cismale populations are needed.
Collapse
Affiliation(s)
- Maria Pyra
- Howard Brown Health, Chicago IL
- Department of Medicine, University of Chicago, Chicago IL
| | - Russell Brewer
- Department of Medicine, University of Chicago, Chicago IL
| | | | | | | | - John Schneider
- Howard Brown Health, Chicago IL
- Department of Medicine, University of Chicago, Chicago IL
| |
Collapse
|
25
|
Alt M, Rotert P, Conover K, Dashwood S, Schramm AT. Qualitative investigation of factors impacting pre-exposure prophylaxis initiation and adherence in sexual minority men. Health Expect 2021; 25:313-321. [PMID: 34904322 PMCID: PMC8849378 DOI: 10.1111/hex.13382] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2021] [Revised: 10/19/2021] [Accepted: 10/22/2021] [Indexed: 12/05/2022] Open
Abstract
Introduction Men who have sex with men continue to account for the majority of new HIV infections in the United States. Many of those with new infections are unaware that they have HIV. Preventative measures continue to be essential in reducing new infections, with pre‐exposure prophylaxis (PrEP) being widely recommended. Objectives The overall aim of this qualitative study is to explore the impact of stigma, patient–provider dynamics and patient perception of PrEP on men's engagement with PrEP in a primary care setting. Methods The Consensual Qualitative Research Methodology (Hill, 2012) was used to explore the experiences of 14 men receiving care for PrEP at a Family Medicine clinic in the Midwest. Semistructured interviews were conducted to allow for depth of understanding of individuals' experience. Results Four major domains were identified: motivation to pursue PrEP, barriers and adherence to care, beliefs about how PrEP is perceived by others and experiences discussing sexual health and PrEP with providers. Conclusion It is important to better understand factors contributing to the pursuit of and adherence to HIV prevention measures and HIV care. Further, health systems and providers are encouraged to consider opportunities in terms of how their practice can destigmatize PrEP use and offer a welcoming environment for those pursuing HIV prevention. Patient or Public Contribution Patients were involved in the study through their participation in semistructured interviews, which provided the data analysed for this study. There was no additional participation beyond the one‐time interview or follow‐up poststudy. Their interviews helped contribute to our better understanding of the needs and experiences of those receiving PrEP‐related care.
Collapse
Affiliation(s)
- Marcus Alt
- Department of Psychiatry & Behavioral Sciences, University of Kansas Medical Center, Westwood, Kansas, USA
| | - Paul Rotert
- Department of Family Medicine & Community Health, University of Kansas Medical Center, Westwood, Kansas, USA
| | - Kate Conover
- Department of Family Medicine & Community Health, University of Kansas Medical Center, Westwood, Kansas, USA
| | - Sarah Dashwood
- Department of Family Medicine & Community Health, University of Kansas Medical Center, Westwood, Kansas, USA
| | - Andrew T Schramm
- Department of Surgery, Division of Trauma & Acute Care Surgery, Medical College of Wisconsin, Milwaukee, Wisconsin, USA
| |
Collapse
|
26
|
Ikeda DJ, Kidia K, Agins BD, Haberer JE, Tsai AC. Roll-out of HIV pre-exposure prophylaxis: a gateway to mental health promotion. BMJ Glob Health 2021; 6:e007212. [PMID: 34916275 PMCID: PMC8679108 DOI: 10.1136/bmjgh-2021-007212] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2021] [Accepted: 11/25/2021] [Indexed: 12/11/2022] Open
Abstract
HIV remains a pressing global health problem, with 1.5 million new infections reported globally in 2020. HIV pre-exposure prophylaxis (PrEP) can lower the likelihood of HIV acquisition among populations at elevated risk, yet its global roll-out has been discouragingly slow. Psychosocial factors, such as co-occurring mental illness and substance use, are highly prevalent among populations likely to benefit from PrEP, and have been shown to undermine persistence and adherence. In this analysis, we review the high burden of mental health problems among PrEP candidates and contend that inattention to mental health stands to undermine efforts to implement PrEP on a global scale. We conclude that integration of mental health screening and treatment within PrEP scale-up efforts represents an important strategy for maximising PrEP effectiveness while addressing the high burden of mental illness among at-risk populations. As implementers seek to integrate mental health services within PrEP services, efforts to keep access to PrEP as low-threshold as possible should be maintained. Moreover, programmes should seek to implement mental health interventions that are sensitive to local resource constraints and seek to reduce intersecting stigmas associated with HIV and mental illness.
Collapse
Affiliation(s)
| | - Khameer Kidia
- Division of Global Health Equity, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Bruce D Agins
- Institute for Global Health Sciences, University of California San Francisco, San Francisco, California, USA
| | - Jessica E Haberer
- Center for Global Health and Mongan Institute, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Alexander C Tsai
- Center for Global Health and Mongan Institute, Massachusetts General Hospital, Boston, Massachusetts, USA
| |
Collapse
|
27
|
Bhavaraju N, Shears K, Schwartz K, Mullick S, Jeckonia P, Murungu J, Persaud U, Vij A, Torjesen K. Introducing the Dapivirine Vaginal Ring in Sub-Saharan Africa: What Can We Learn from Oral PrEP? Curr HIV/AIDS Rep 2021; 18:508-517. [PMID: 34910276 PMCID: PMC8671875 DOI: 10.1007/s11904-021-00577-8] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/04/2021] [Indexed: 11/30/2022]
Abstract
PURPOSE OF REVIEW Clinical trials have found that the dapivirine vaginal ring (DVR) is safe to use and effective at reducing women's risk of acquiring HIV infection. As countries prepare for the introduction of this novel long-acting, woman-controlled prevention method, an examination of key learnings from oral pre-exposure prophylaxis (PrEP) delivery will help programs leverage successful innovations and approaches to support DVR scale-up and expand the method mix for HIV prevention. RECENT FINDINGS Intensive efforts over the past 5 years have yielded lessons on how to facilitate access to oral PrEP; expand service delivery for PrEP; address the knowledge, attitudes, and skills providers need to support PrEP initiation and effective use; develop messaging that builds community and partner support and combats stigma; and understand the cyclical nature of PrEP use. Evidence from oral PrEP introduction and scale-up can help inform and expedite DVR introduction.
Collapse
Affiliation(s)
| | - Kathleen Shears
- FHI 360, 1825 Connecticut Avenue NW, Washington, DC 20009 USA
| | | | - Saiqa Mullick
- Wits Reproductive Health and HIV Institute, 8 Blackwood Avenue, Parktown, Johannesburg, South Africa
| | - Patriciah Jeckonia
- LVCT Health, Batian Lane, Off Argwings Kodhek Road, Hurlingam, Nairobi, Kenya
| | - Joseph Murungu
- Pangaea Zimbabwe AIDS Trust, 27 Rowland Square, Milton Park, Harare, Zimbabwe
| | - Udita Persaud
- United States Agency for International Development, 1300 Pennsylvania Avenue NW, Washington, DC 20523 USA
| | - Ashley Vij
- United States Agency for International Development, 1300 Pennsylvania Avenue NW, Washington, DC 20523 USA
| | | |
Collapse
|
28
|
HIV pre-exposure prophylaxis implementation in Africa: some early lessons. Lancet Glob Health 2021; 9:e1634-e1635. [DOI: 10.1016/s2214-109x(21)00460-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2021] [Accepted: 09/30/2021] [Indexed: 11/21/2022]
|
29
|
Vanhamel J, Laga M. Measuring progress in the roll-out of pre-exposure prophylaxis: from counting what we know, to knowing what to count. AIDS 2021; 35:2389-2390. [PMID: 34723853 DOI: 10.1097/qad.0000000000003028] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Affiliation(s)
- Jef Vanhamel
- Department of Public Health, Institute of Tropical Medicine, Nationalestraat, Antwerp, Belgium
| | | |
Collapse
|
30
|
Hensen B, Machingura F, Busza J, Birdthistle I, Chabata S, Chiyaka T, Floyd S, Jamali G, Mushati P, Hargreaves J, Cowan F. How Can We Support the Use of Oral PrEP Among Young Women who Sell Sex? A PrEP Cascade Analysis. J Acquir Immune Defic Syndr 2021; 88:45-56. [PMID: 34050101 PMCID: PMC8357043 DOI: 10.1097/qai.0000000000002733] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2020] [Accepted: 04/19/2021] [Indexed: 11/27/2022]
Abstract
BACKGROUND We constructed self-reported pre-exposure prophylaxis (PrEP) cascades and explored factors associated with and barriers to PrEP use to inform efforts to support PrEP use among young women who sell sex. METHODS Using self-reported data from HIV-negative young women who sell sex enrolled into a cohort study using respondent-driven sampling in Zimbabwe, we constructed PrEP cascades assessing knowledge of, ever offered, ever used, and current PrEP use in 2017 and 2019. We used logistic regression to examine factors associated with PrEP use by 2019. Through qualitative interviews with 43 women enrolled in the cohort, we investigated barriers to PrEP use. RESULTS At enrollment, 50% of women had heard of PrEP, 12% had ever been offered PrEP, and 7% ever used PrEP. Over time, all cascade domains: 96% of women had heard of and 55% reported an active offer of PrEP. Among women retained in the study in 2019 (56%; n = 538), 34% ever took PrEP by 2019. PrEP use was associated with, at enrollment, reporting more clients in the past month (10+: 45% vs 1-3: 27% adjOR = 1.71 95% CI: 1.06 to 2.76), duration of selling sex (24% <2 years vs 38% 2-3 years; adjOR = 0.51 95% CI: 0.32 to 0.83), and having visited a female sex worker program in the past 12 months (55% vs 27%; adjOR = 2.92 95% CI: 1.91 to 4.46). Qualitative interviews revealed fear of disclosing sex work, HIV-related/ART-related stigma, and (opportunity) costs of accessing PrEP as barriers to use. CONCLUSION PrEP use was associated with factors known to increase HIV risk. Fear of stigma, disclosure, and supply-side barriers need to be addressed to increase women's ability to use PrEP.
Collapse
Affiliation(s)
- B. Hensen
- Faculty of Infectious and Tropical Diseases, London School of Hygiene and Tropical Medicine, London, United Kingdom;
| | - F. Machingura
- Centre for Sexual Health and HIV/AIDS Research (CeSHHAR) Zimbabwe, Harare, Zimbabwe;
| | - J. Busza
- Centre for Evaluation, London School of Hygiene and Tropical Medicine, London, United Kingdom;
| | - I. Birdthistle
- Faculty of Epidemiology and Population Health, London School of Hygiene and Tropical Medicine, London, United Kingdom; and
| | - S.T. Chabata
- Centre for Sexual Health and HIV/AIDS Research (CeSHHAR) Zimbabwe, Harare, Zimbabwe;
| | - T. Chiyaka
- Centre for Sexual Health and HIV/AIDS Research (CeSHHAR) Zimbabwe, Harare, Zimbabwe;
| | - S. Floyd
- Faculty of Epidemiology and Population Health, London School of Hygiene and Tropical Medicine, London, United Kingdom; and
| | - G. Jamali
- Centre for Sexual Health and HIV/AIDS Research (CeSHHAR) Zimbabwe, Harare, Zimbabwe;
| | - P. Mushati
- Centre for Sexual Health and HIV/AIDS Research (CeSHHAR) Zimbabwe, Harare, Zimbabwe;
| | - J. Hargreaves
- Centre for Evaluation, London School of Hygiene and Tropical Medicine, London, United Kingdom;
| | - F.M. Cowan
- Centre for Sexual Health and HIV/AIDS Research (CeSHHAR) Zimbabwe, Harare, Zimbabwe;
- Faculty of Clinical Sciences and International Public Health, Liverpool School of Tropical Medicine, Liverpool, United Kingdom.
| |
Collapse
|
31
|
Ongolly FK, Dolla A, Ngure K, Irungu EM, Odoyo J, Wamoni E, Peebles K, Mugwanya K, Mugo NR, Bukusi EA, Morton J, Baeten JM, O’Malley G. "I Just Decided to Stop:" Understanding PrEP Discontinuation Among Individuals Initiating PrEP in HIV Care Centers in Kenya. J Acquir Immune Defic Syndr 2021; 87:e150-e158. [PMID: 33492024 PMCID: PMC8026512 DOI: 10.1097/qai.0000000000002625] [Citation(s) in RCA: 23] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2020] [Accepted: 12/30/2020] [Indexed: 12/19/2022]
Abstract
BACKGROUND Preexposure prophylaxis (PrEP) discontinuation rates in clinical trials and demonstration projects have been well characterized; however, little is known about discontinuation in routine public health settings in sub-Saharan Africa. Understanding discontinuation in nonstudy settings is important for establishing expectations for PrEP continuation in national programs and for facilitating effective PrEP scale-up. METHODS We conducted in-depth interviews with 46 individuals who had initiated PrEP at 25 HIV comprehensive care clinics (CCCs) in central and western Kenya and whose clinic records indicated they had discontinued. RESULTS Many of our study participants discontinued PrEP when their perceived risk decreased (eg, hiatus or end of a sexual relationship or partner known to be living with HIV became virally suppressed). Others reported discontinuation due to side effects, daily pill burden, preference for condoms, or their partner's insistence. Participant narratives frequently described facility level factors such as stigma-related discomforts with accessing PrEP at CCCs, inconvenient clinic location or operating hours, long wait times, and short refill dates as discouraging factors, suggesting actionable areas for improving PrEP access and continuation. CONCLUSION Clients frequently make intentional decisions to discontinue PrEP as they weigh different prevention options within the context of complex lives. Many clients will decide to discontinue PrEP when perceiving themselves to be at reduced risk and PrEP counseling must include provisions for addressing seasons of risk. PrEP will not be the right prevention method for everyone, or forever. Expanding PrEP access points and increasing sex-positive messaging may facilitate PrEP being a better option for many.
Collapse
Affiliation(s)
| | - Annabel Dolla
- Center for Microbiology Research, Kenya Medical Research Institute; Nairobi, Kenya
| | - Kenneth Ngure
- Department of Global Health, Seattle, Washington, USA
- Department of Community Health, Jomo Kenyatta University of Agriculture and Technology, Nairobi, Kenya
| | - Elizabeth M. Irungu
- Center for Clinical Research, Kenya Medical Research Institute; Nairobi, Kenya
| | - Josephine Odoyo
- Center for Microbiology Research, Kenya Medical Research Institute; Nairobi, Kenya
| | - Elizabeth Wamoni
- Center for Clinical Research, Kenya Medical Research Institute; Nairobi, Kenya
| | - Kathryn Peebles
- Department of Epidemiology, Medicine, Seattle, Washington, USA
- University of Washington, Seattle, Washington, USA
| | - Kenneth Mugwanya
- Department of Global Health, Seattle, Washington, USA
- University of Washington, Seattle, Washington, USA
| | - Nelly R. Mugo
- Center for Clinical Research, Kenya Medical Research Institute; Nairobi, Kenya
- Department of Global Health, Seattle, Washington, USA
| | - Elizabeth A. Bukusi
- Department of Global Health, Seattle, Washington, USA
- Department of Obstetrics and Gynecology, Seattle, Washington, USA
- Center for Microbiology Research, Kenya Medical Research Institute; Nairobi, Kenya
| | - Jennifer Morton
- Department of Global Health, Seattle, Washington, USA
- University of Washington, Seattle, Washington, USA
| | - Jared M. Baeten
- Department of Global Health, Seattle, Washington, USA
- Department of Epidemiology, Medicine, Seattle, Washington, USA
- University of Washington, Seattle, Washington, USA
- Center for Microbiology Research, Kenya Medical Research Institute; Nairobi, Kenya
| | - Gabrielle O’Malley
- Department of Global Health, Seattle, Washington, USA
- University of Washington, Seattle, Washington, USA
| |
Collapse
|