From policy to practice: uptake of pre-exposure prophylaxis among adolescent girls and young women in United States President's Emergency Plan for AIDS Relief-supported countries, 2017-2020

Patient actor training improves preexposure prophylaxis delivery for adolescent girls and young women in Kenya: a cluster randomized trial

OBJECTIVE

To evaluate effectiveness of a standardized patient actor (SP) training intervention to improve quality of preexposure prophylaxis (PrEP) services for adolescent girls and young women (AGYW) in Kenya.

DESIGN

Cluster randomized trial and mystery shopper evaluation.

METHODS

Twelve of 24 maternal child health and family planning facilities were randomized to SP training. Providers at intervention facilities participated in 2-day training in adolescent health, PrEP guidelines, values clarification, and communication skills, followed by role-playing and de-briefing with trained actors. Control facilities received standard national training. The primary outcome was quality of care, assessed by unannounced SPs (USPs) or "mystery shoppers" blinded to intervention arm. Quality was measured in two domains: guideline adherence and communication skills. Intent to treat analysis compared postintervention quality scores by randomization arm, clustering on facility, and adjusting for baseline scores and USP.

RESULTS

Overall, 232 providers consented to USP visits, and 94 providers completed the training. Following training, USPs posed as AGYW seeking PrEP in 142 encounters (5-6 encounters per site). The mean quality score was 73.6% at intervention sites and 58.4% at control sites [adjusted mean difference = 15.3, 95% confidence interval (CI): 9.4-21.1, P  < 0.001]. Mean guideline adherence scores were 57.2% at intervention sites and 36.2% at control sites (adjusted mean difference = 21.0, 95% CI: 12.5-29.4, P  < 0.001). Mean communication scores were 90.0% at intervention sites and 80.5% at control sites (adjusted mean difference = 9.5, 95% CI: 5.5-13.6, P  < 0.001).

CONCLUSIONS

SP training significantly improved quality of PrEP care for AGYW in Kenya. Incorporating SP training and unannounced SP evaluation could improve PrEP uptake among AGYW.

Factors Associated with PrEP Persistence and Loss of Follow-Up: A 5-Year Historic Cohort

OBJECTIVE

HIV Pre-Exposure Prophylaxis (PrEP) has been used in France since 2016. Its effectiveness is no longer to be demonstrated. However, follow-up and adherence remain the main pitfalls. The main objective of this study was to identify factors associated with persistence or loss of PrEP follow-up.

DESIGN

An historic cohort of PrEP users was compiled from the database of consultations in the Indre-et-Loire dedicated sexual health centers (CeGIDD) from June 2016 to June 2021.

METHODS

Kaplan-Meier curves were performed to compare the group of persistent PrEP users to the discontinuation group. Factors associated with PrEP discontinuation were identified using Cox modelling, considering time-dependent variables. Final variables included in the model were selected based on the Akaike Information Criterion (AIC) and clinical relevance.

RESULTS

Over the period, 568 PrEP users were included in the cohort. Median follow-up was 2.3 years. A quarter of users were lost to follow-up within 3 months after PrEP initiation. Sexual risk reduction AIDS community-based support (HR = 0.65[0.42;0.99]), being in a couple (HR = 0.51[0.38;0.68]), and history of syphilis (HR = 0.57[0.40;0.81]) were significantly associated with persistence of follow-up. Remote consultations (HR = 2.74[1.63;4.61]), chemsex practices (HR = 2.01[1.29;3.14]), and side effects (HR=1.72[1.03;2.88]) were significantly associated with a loss of follow-up.

CONCLUSION

These results suggest that more sexual risk reduction AIDS community-based counseling could be a key, necessary for supporting PrEP users in their follow-up pathway. Indeed, AIDS community-based support could be used to build a basis for developing safe pathways. Remote consultations could represent a response to the issue of access to PrEP. To create a significant impact on global HIV incidence, the PrEP offer must be extended, and at-risk PrEP users supported to maintain PrEP use.

Prevalence and factors associated with uptake of pre-exposure prophylaxis amongst women vulnerable to HIV who received HIV antibodies in Antibody Mediated Prevention HVTN703/HPTN081 trial in Harare, Zimbabwe: a cross-sectional study

Introduction

There is limited evidence on pre-exposure prophylaxis (PrEP) uptake post-trial participation for women vulnerable to HIV. This study investigates the prevalence and factors associated with PrEP uptake post-participation in an HIV prevention trial.

Methods

Former Antibody Mediated Prevention (AMP) study participants were invited to the three AMP clinical research sites in Zimbabwe after at least a year of exiting the study. The AMP study evaluated the safety and efficacy of Vaccine Research Center 01 broadly neutralising monoclonal antibody in reducing acquisition of HIV-1 infection in women in sub-Saharan Africa. Participants vulnerable to HIV were enrolled and risk reduction counselling was done throughout study participation. In a cross-sectional study, semi-structured interview administered questionnaires were completed. The primary outcome was uptake of PrEP after the study exit.

Results

From February 2022 to August 2022, out of 434 participants enrolled in the AMP study, a total of 298 were invited and 225 participated in the study; 28% made an attempt to access PrEP after study participation, 20% used PrEP at some point after study participation and 15% were on PrEP at the time of questionnaire administration. PrEP uptake was associated with new sexual partners after study participation and higher average number of sexual encounters in the previous month. Challenges faced in accessing PrEP included those related to the health facility, transport problems and stigma.

Conclusion

The majority (85%) of former AMP participants were not on PrEP at the time of questionnaire administration. We observed poor uptake of PrEP post-study exit among participants who had received risk reduction counselling through study duration. Measures to improve PrEP uptake should be considered on participants vulnerable to HIV when exiting HIV prevention trials.

Phase 1 randomized trials to assess safety, pharmacokinetics, and vaginal bleeding associated with use of extended duration dapivirine and levonorgestrel vaginal rings

BACKGROUND

Vaginal rings formulated to deliver two drugs simultaneously have potential as user-controlled, long-acting methods for dual prevention of HIV and pregnancy.

METHODS

Two phase 1 randomized trials (MTN-030/IPM 041 and MTN-044/IPM 053/CCN019) respectively enrolled 24 and 25 healthy, HIV-negative participants to evaluate safety, pharmacokinetics, and vaginal bleeding associated with use of a vaginal ring containing 200mg dapivirine (DPV) and 320mg levonorgestrel (LNG) designed for 90-day use. MTN-030/IPM 041 compared the DPV/LNG ring to a DPV-only ring (200mg) over 14 days of use. MTN-044/IPM 053/CCN019 compared continuous or cyclic use of the DPV/LNG ring over 90 days of use. Safety was assessed by recording adverse events (AEs). DPV and LNG concentrations were quantified in plasma, cervicovaginal fluid, and cervical tissue. Vaginal bleeding was self-reported.

RESULTS

There were no differences in the proportion of participants with grade ≥2 genitourinary AEs or grade ≥3 AEs with DPV/LNG ring vs. DPV ring use (p = .22), or with DPV/LNG ring continuous vs. cyclic use (p = .67). Higher plasma DPV concentrations were observed in users of DPV/LNG compared to DPV-only rings (Cmax p = 0.049; AUC p = 0.091). Plasma DPV and LNG concentrations were comparable with continuous and cyclic use (Cmax p = 0.74; AUC p = 0.25). With cyclic use, median nadir plasma DPV concentration was approximately 300 pg/mL two days after removal and median t1/2 for cervicovaginal fluid DPV concentration was 5.76 hours (n = 3). Overall bleeding experiences did not differ between continuous and cyclic users (p = 0.12).

CONCLUSIONS

The extended duration DPV/ LNG rings were well tolerated and the observed DPV concentrations in plasma and cervicovaginal fluid when used continuously exceeded concentrations observed in previous DPV ring efficacy studies. LNG concentrations in plasma were comparable with other efficacious LNG-based contraceptives. Genital DPV concentrations had a short half-life and were thus not well sustained following ring removal.

HIV PrEP Coverage Among Black Adults: A Concept Analysis of the Inequities, Disparities, and Implications

Background

Significant racial disparities exist in HIV pre-exposure prophylaxis (PrEP) coverage in the United States (U.S), with Black individuals experiencing seven times higher new HIV infection rates compared to their White counterparts. Despite being the highest priority population at risk for HIV, Black adults have the lowest PrEP coverage, impacting the overall progress toward meeting the ending the HIV epidemic (EHE) goals in the U.S.

Methods

Utilizing the Walker and Avant method, this concept analysis examined existing literature and U.S. Centers for Disease Control and Prevention resources to explore HIV PrEP coverage.

Results

Findings highlighted a lack of clarity in the concept, resulting in four operational definitions. To address this ambiguity, a conceptual definition of HIV PrEP coverage was proposed, focusing on equitable access to PrEP medication among sexually active individuals aged 18-64 years, particularly those traditionally underserved and would benefit from PrEP. This inclusive definition aims to align with the dynamics of sexual behavior in racial minority groups. Key attributes of this conceptual definition include estimates of PrEP use, access, need, cost, side effects, frequency of HIV testing, and self-efficacy. Antecedents entail HIV status, testing behaviors, transmission risks, and communication with health care providers. Consequences involve perceptions of risk, screening routines, provider biases, stigma, and potential HIV transmission reduction.

Conclusion

Analyzing HIV PrEP coverage offers useful insights into social and structural factors exacerbating health inequities in the field of HIV prevention and control. This concept analysis underscores the importance of unified sexual health communication, diverse approaches to PrEP access for racial minorities, and improved sexual health policies for Black adults. Moreover, understanding and advocating for equity in HIV PrEP coverage is crucial for addressing the existing racial disparities and achieving the EHE objectives in the U.S.

Brief Report: HIV Pre-Exposure Prophylaxis Awareness and Use Among Adolescents in Kenya

BACKGROUND

HIV pre-exposure prophylaxis (PrEP) is an effective prevention tool; however, use among adolescents is thought to be low. To determine the unmet need and opportunity to expand use, we assessed awareness, prior use, and willingness to take PrEP among Kenyan adolescents.

METHODS

The Maneno Yetu study recruited a community-based sample of adolescents aged 15-19 years (N = 3061) in Kisumu for a survey using respondent-driven sampling.

RESULTS

Overall, 50% of adolescents had heard of PrEP and 2% had used PrEP. Girls were more likely than boys to have heard of PrEP (53.4% vs. 45.1%; P < 0.001) and used PrEP (3.6% vs. 0.3%; P < 0.001). Among participants, 14% engaged in transactional sex and 21% experienced forced sexual contact. PrEP use was higher among adolescents who engaged in transactional sex (4.8% vs. 0.6%; P < 0.001) and experienced forced sexual contact (2.7% vs. 0.7%; P < 0.001) compared with those who did not. Among adolescents with no prior use, 53% were willing to consider using PrEP, although girls were less willing than boys (49.7% vs. 55.9%; P = 0.001).

CONCLUSIONS

PrEP is an important prevention tool, especially for adolescents whose circumstances potentially expose them to HIV-positive or unknown status sexual partners, yet remains underused, particularly in resource-limited settings. Although many expressed willingness to use PrEP, low awareness and use highlight the need to expand HIV prevention education and services tailored for adolescents. Our finding that boys were more willing to use PrEP suggests campaigns should also be designed to reach male youth to narrow the gender gap and expand uptake in the adolescent population.

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?

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.

Fostering Access to PrEP Among Adolescent Girls and Young Women Aged 16 to 24 Years at High Risk of HIV Through the DREAMS Initiative in Four Districts in Zambia

Adolescent girls and young women (AGYW) in sub-Saharan Africa remain at high risk for HIV, yet limited data exist on implementation of HIV pre-exposure prophylaxis (PrEP) for this group. We examined PrEP uptake among AGYW using a retrospective cohort enrolled in the Determined Resilient Empowered AIDS-free Mentored Safe (DREAMS) initiative in Zambia between October 2020 and March 2022. Consent was obtained from eligible AGYW at substantial risk for HIV, and they voluntarily participated in PrEP. Multivariable logistic regression was used to examine factors associated with PrEP refills following initiation. Of 4,162 HIV-negative AGYW, 3,233 (77%) were at substantial risk and initiated on PrEP. Overall, 68% of AGYW had at least one refill, but this differed significantly by age group and district. DREAMS was successful at reaching AGYW with PrEP services. More evidence is needed to assess reasons for discontinuation and to improve persistence for those with sustained HIV risk.

Episodic Use of Pre-Exposure Prophylaxis Among Young Cisgender Women in Siaya County, Kenya

The concept "seasons of risk" promotes use of pre-exposure prophylaxis (PrEP) only during periods of HIV risk. PrEP guidelines are aligned on daily use in women having vaginal sex during a risk period, and daily use for 28 days after the last potential exposure is recommended. However, when starting a "season of risk," guidelines vary on "time to protection," and unknowns remain in pharmacological research on PrEP protection in this population. During our iterative research on PrEP persistence using photovoice and in-depth interviews, we identified an ineffective pattern of PrEP use based on current guidelines-that is, routine, episodic use-among young cisgender women (YCW) in Siaya County, Kenya. Through same-group (n = 33 participants) and mixed-group (n = 31 participants) photovoice activities with YCW taking PrEP and female peers, participants explained that YCW associate their HIV risk with the sexual behaviors of their male partners who frequently travel from home. PrEP is considered unnecessary when partners are away because of no perceived risk. YCW re-start PrEP on or around the day of their partners' return because of heightened risk perceptions. Among the YCW interviewed (n = 18), nearly all of their partners traveled for about 1 week to 1 month at a time; about one-third of these women reported stopping PrEP during their partners' absence and re-starting it soon before or immediately upon their partners' arrival home. Additional research is critically needed to better inform PrEP guidelines and the decisions adolescent girls and young women make on how to use PrEP based on their risk context. In the interim, counseling on current dosing guidance when stopping and re-starting PrEP within a "season of risk" is needed.

Modeling DREAMS impact: trends in new HIV diagnoses among women attending antenatal care clinics in DREAMS countries

OBJECTIVES

To understand the impact of United States President's Emergency Plan for AIDS Relief (PEPFAR's) DREAMS (Determined, Resilient, Empowered, AIDS-Free, Mentored, and Safe) Partnership on new HIV diagnoses among women in antenatal care (ANC) settings in 10 African countries from 2015 to 2020.

DESIGN

We modeled spatiotemporal changes in new HIV diagnoses among women in ANC settings using PEPFAR data. Statistical tests were performed in R to compare differences in new diagnoses rates between DREAMS and non-DREAMS subnational units (SNUs) and to explore predictors of new diagnoses declines within DREAMS SNUs.

METHODS

We used a predictive geospatial model to forecast the rate of new diagnoses for each time period in a 5 km grid cell (n = 861 SNUs). Linear model analyses were conducted using predictor variables: urbanicity, DREAMS geographic footprint, 'layering' proxy, and community-level male viral load suppression.

RESULTS

New HIV diagnoses in ANC from 2015 to 2020 declined in nearly all SNUs. 'Always' DREAMS SNUs reported declines of 45% while 'Never' DREAMS SNUs reported a decline of only 37% (F = 8.1, 1 and 829 DF, P < 0.01). Within Always DREAMS SNUs, greater declines were seen in areas with a higher number of minimum services in their DREAMS primary package (t = 2.77, P < 0.01).

CONCLUSION

New HIV diagnoses among women are declining in both DREAMS and non-DREAMS SNUs; mirroring HIV incidence decreases and reflecting increasing community viral load suppression and voluntary male medical circumcision rates. DREAMS programming may have contributed to accelerated declines of new HIV diagnoses in DREAMS SNUs compared with non-DREAMS SNUs. Increased progress is needed to further reduce the disparities between adolescent girls and young women (AGYW) and young men to achieve epidemic control.