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Prakash S, Kumar M. The Hidden Enemy Within: Uncovering the Secrets of HIV Tissues Reservoirs and Current mRNA Vaccine Development. Curr HIV Res 2024; 22:73-81. [PMID: 38639272 DOI: 10.2174/011570162x301593240409072840] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2024] [Revised: 03/23/2024] [Accepted: 03/28/2024] [Indexed: 04/20/2024]
Abstract
Human Immunodeficiency Viruses (HIV) continue to pose a significant global health threat despite the availability of antiretroviral therapy (ART). As a retrovirus, HIV persists as a stable, integrated, and replication-competent provirus within a diverse array of long-lived cells for many years, often termed “latent reservoirs” in individuals. Thus, this review aims to furnish a comprehensive overview of diverse tissue reservoirs where HIV persists, elucidating their pathogenesis and advancement in their strategies for clinical management. Understanding the mechanisms underlying HIV persistence within tissue reservoirs is of significant interest in developing effective ART for suppressing the virus in the blood. In addition, we also discussed the ongoing mRNA HIV vaccine that has shown promising results in clinical trials to elicit broadly neutralizing antibodies and effective T-cell responses against HIV.
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Affiliation(s)
- Satyendra Prakash
- Centre of Biotechnology, Faculty of Science, University of Allahabad, Allahabad, India
| | - Mayank Kumar
- Technical Research Analyst (TRA), Electronics/Biomedical Engineering, Aranca, Maharashtra, Mumbai, 400076, India
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Ortblad KF, Bardon AR, Mogere P, Kiptinness C, Gakuo S, Mbaire S, Thomas KK, Mugo NR, Baeten JM, Ngure K. Effect of 6-Month HIV Preexposure Prophylaxis Dispensing With Interim Self-testing on Preexposure Prophylaxis Continuation at 12 Months: A Randomized Noninferiority Trial. JAMA Netw Open 2023; 6:e2318590. [PMID: 37318803 PMCID: PMC10273023 DOI: 10.1001/jamanetworkopen.2023.18590] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/19/2022] [Accepted: 04/27/2023] [Indexed: 06/16/2023] Open
Abstract
Importance Daily oral HIV preexposure prophylaxis (PrEP) delivery requires quarterly clinic visits for HIV testing and drug refilling that are costly to health systems and clients. Objective To evaluate whether 6-month PrEP dispensing supported with interim HIV self-testing (HIVST) results in noninferior PrEP continuation outcomes at 12 months compared with standard quarterly clinic visits. Design, Setting, and Participants This randomized noninferiority trial was conducted from May 2018 to May 2021 with 12 months of follow-up among PrEP clients aged 18 years or older who were returning for their first refill at a research clinic in Kiambu County, Kenya. Intervention Participants were randomized 2:1 to (1) 6-month PrEP dispensing with semiannual clinic visits and interim HIVST at 3 months or (2) standard-of-care (SOC) PrEP delivery with 3-month dispensing, quarterly clinic visits, and clinic-based HIV testing. Main Outcomes and Measures Prespecified 12-month outcomes included recent HIV testing (any in past 6 months), PrEP refilling, and PrEP adherence (detectable tenofovir-diphosphate concentrations in dried blood spots). Binomial regression models were used to estimate risk differences (RDs), and a 1-sided 95% CI lower bound (LB) of -10% or greater was interpreted as noninferior. Results A total of 495 participants were enrolled, with 329 enrolled in the intervention group and 166 enrolled in the SOC group; 330 (66.7%) were women, 295 (59.6%) were in serodifferent relationships, and the median (IQR) age was 33 (27-40) years. At 12 months, 241 individuals in the intervention group (73.3%) and 120 in the SOC group (72.3%) returned to clinic. In the intervention group, recent HIV testing was noninferior (230 individuals [69.9%]) compared with the SOC group (116 [69.9%]; RD, -0.33%, 95% CI LB, -7.44%). PrEP refilling in the intervention group (196 [59.6%]) was inconclusive compared with the SOC group (104 [62.7%]; RD, -3.25%; 95% CI LB, -10.84%), and PrEP adherence was noninferior in the intervention group (151 [45.9%]) compared with the SOC group (70 [42.2%]; RD, 4.96%; 95% CI LB, -2.46%). No HIV seroconversions were observed over the follow-up period. Conclusions and Relevance In this analysis of secondary trial end points at 1 year, semiannual PrEP dispensing with interim HIVST resulted in noninferior recent HIV testing and PrEP adherence compared with SOC quarterly PrEP dispensing. This novel model has the potential to optimize PrEP delivery. Trial Registration ClinicalTrials.gov Identifier: NCT03593629.
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Affiliation(s)
- Katrina F. Ortblad
- Public Health Sciences Division, Fred Hutchinson Cancer Center, Seattle, Washington
| | - Ashley R. Bardon
- Department of Global Health, University of Washington, Seattle
- Department of Epidemiology, University of Washington, Seattle
| | - Peter Mogere
- Center for Clinical Research, Kenya Medical Research Institute, Nairobi, Kenya
| | | | - Stephen Gakuo
- Center for Clinical Research, Kenya Medical Research Institute, Nairobi, Kenya
| | - Sarah Mbaire
- Center for Clinical Research, Kenya Medical Research Institute, Nairobi, Kenya
| | | | - Nelly R. Mugo
- Department of Global Health, University of Washington, Seattle
- Center for Clinical Research, Kenya Medical Research Institute, Nairobi, Kenya
| | - Jared M. Baeten
- Department of Global Health, University of Washington, Seattle
- Department of Epidemiology, University of Washington, Seattle
- Department of Medicine, University of Washington, Seattle
- now with Gilead Sciences, Foster City, California
| | - Kenneth Ngure
- Department of Global Health, University of Washington, Seattle
- School of Public Health, Jomo Kenyatta University of Agriculture and Technology, Nairobi, Kenya
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Joseph Davey D, Nyemba DC, Castillo‐Mancilla J, Wiesner L, Norman J, Mvududu R, Mashele N, Johnson LF, Bekker L, Gorbach P, Coates TJ, Myer L. Adherence challenges with daily oral pre-exposure prophylaxis during pregnancy and the postpartum period in South African women: a cohort study. J Int AIDS Soc 2022; 25:e26044. [PMID: 36480171 PMCID: PMC9731362 DOI: 10.1002/jia2.26044] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2022] [Accepted: 11/21/2022] [Indexed: 12/13/2022] Open
Abstract
INTRODUCTION Daily oral pre-exposure prophylaxis (PrEP) can reduce HIV acquisition. However, prevention effectiveness requires daily adherence prior to and during periods of sexual activity. Little is known about pharmacologic measures of PrEP adherence during pregnancy and postpartum and the factors related to optimal adherence during periods of sexual activity in this population. METHODS Between August 2019 and October 2021, we enrolled pregnant women without HIV at their first antenatal care visit followed-up through 12 months postpartum. Eligible women ≥16 years old received HIV prevention counselling and were offered oral PrEP (TDF-FTC). We quantified tenofovir-diphosphate (TFV-DP) in dried blood spots in women who reported taking PrEP in the past 30 days (at quarterly follow-up visits). We used regression models with generalized estimating equations to evaluate correlates of TFV-DP (any vs. none, and ≥2 vs. <2 doses/week), adjusting for maternal age and pregnancy status. RESULTS AND DISCUSSION In 382 women who started PrEP in pregnancy, returned for follow-up and reported PrEP use in the past 30 days, the median age was 27 years (interquartile range [IQR] = 23-32), and the median time on PrEP was 168 days (IQR = 84-252 days). Half of the samples had quantifiable TFV-DP at any time point (52%), declining from 67% of pregnant women 3 months post-initiation to 31% of postpartum women by 12 months. Overall, 72% had concentrations corresponding to <2 doses/week; 25% ≥2 doses/week; 3% 7 doses/week. Concentrations were lower in postpartum versus pregnancy (age-adjusted odds ratio [aOR] = 0.44; 95% confidence interval [CI] = 0.35-0.54). The correlation of self-reported adherence and TFV-DP ranged from -0.07 in pregnancy to 0.25 in postpartum women. Variables associated with having quantifiable TFV-DP included partner living with HIV/unknown serostatus (aOR = 1.50; 95% CI = 1.01-2.22), and reported frequency of sexual activity in the past month (aOR sex >5/month vs. no sex or <5 times/month = 2.11; 95% CI = 1.58-2.82) adjusting for age and pregnancy versus postpartum status. TFV-DP concentrations declined over follow-up time (aOR for 6 vs. 3 months = 0.49; 95% CI = 0.36-0.67). CONCLUSIONS Objectively measured adherence to PrEP was low overall and did not correlate with self-reported use. There is an urgent need for objective adherence measures to support clinical decision-making as well as adherence support interventions as part of PrEP services for pregnant and postpartum women at risk of HIV.
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Affiliation(s)
- Dvora Joseph Davey
- Division of Infectious DiseasesGeffen School of MedicineUniversity of California Los AngelesLos AngelesCaliforniaUSA
- Division of Epidemiology and BiostatisticsSchool of Public HealthUniversity of Cape TownCape TownSouth Africa
- The Desmond Tutu Health FoundationUniversity of Cape TownCape TownSouth Africa
| | - Dorothy C. Nyemba
- Division of Epidemiology and BiostatisticsSchool of Public HealthUniversity of Cape TownCape TownSouth Africa
| | - Jose Castillo‐Mancilla
- Division of Infectious DiseasesSchool of MedicineUniversity of Colorado‐Anschutz Medical CampusAuroraColoradoUSA
| | - Lubbe Wiesner
- Division of Clinical PharmacologyDepartment of MedicineUniversity of Cape TownCape TownSouth Africa
| | - Jennifer Norman
- Division of Clinical PharmacologyDepartment of MedicineUniversity of Cape TownCape TownSouth Africa
| | - Rufaro Mvududu
- Division of Epidemiology and BiostatisticsSchool of Public HealthUniversity of Cape TownCape TownSouth Africa
| | - Nyiko Mashele
- Division of Epidemiology and BiostatisticsSchool of Public HealthUniversity of Cape TownCape TownSouth Africa
| | - Leigh F. Johnson
- Centre for Infectious Disease Epidemiology and ResearchUniversity of Cape TownCape TownSouth Africa
| | - Linda‐Gail Bekker
- The Desmond Tutu Health FoundationUniversity of Cape TownCape TownSouth Africa
| | - Pamina Gorbach
- Division of Infectious DiseasesGeffen School of MedicineUniversity of California Los AngelesLos AngelesCaliforniaUSA
| | - Thomas J. Coates
- Division of Infectious DiseasesGeffen School of MedicineUniversity of California Los AngelesLos AngelesCaliforniaUSA
| | - Landon Myer
- Division of Epidemiology and BiostatisticsSchool of Public HealthUniversity of Cape TownCape TownSouth Africa
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Heffron R, Muwonge TR, Thomas KK, Nambi F, Nakabugo L, Kibuuka J, Thomas D, Feutz E, Meisner A, Ware NC, Wyatt MA, Simoni JM, Katz IT, Kadama H, Baeten JM, Mujugira A. PrEP uptake and HIV viral suppression when PrEP is integrated into Ugandan ART clinics for HIV-negative members of HIV-serodifferent couples: A stepped wedge cluster randomized trial. EClinicalMedicine 2022; 52:101611. [PMID: 35990584 PMCID: PMC9386395 DOI: 10.1016/j.eclinm.2022.101611] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/27/2022] [Revised: 07/15/2022] [Accepted: 07/22/2022] [Indexed: 11/11/2022] Open
Abstract
Background Global scale-up of HIV pre-exposure prophylaxis (PrEP) includes services to HIV-negative people in partnerships with people living with HIV (serodifferent couples). Data are needed on HIV outcomes, including uptake and adherence to PrEP and antiretroviral treatment (ART), to describe the impact of integrating PrEP into an existing HIV program. Methods Using a stepped-wedge cluster randomized trial design, we launched PrEP delivery for HIV-negative members of serodifferent couples in Uganda by integrating PrEP into existing ART programs for people living with HIV. The program provided PrEP training for ART providers, ongoing technical assistance, and a provisional supply chain mechanism for PrEP medication. Primary data on PrEP initiation, PrEP refills, ART initiation, and HIV viremia at 6 months (measured at 42-270 days) were collected through data abstraction of medical records from HIV-serodifferent couples sequentially enrolling at the ART clinics. Modified Poisson regression models, controlling for time and cluster, compared viral suppression (<1000 copies/ml) before and after launch of the PrEP program. This trial was registered at ClinicalTrials.gov, NCT03586128. Findings From June 1, 2018-December 15, 2020, 1,381 HIV-serodifferent couples were enrolled across 12 ART clinics in Kampala and Wakiso, Uganda, including 730 enrolled before and 651 after the launch of PrEP delivery. During the baseline period, 99.4% of partners living with HIV initiated ART and 85.0% were virally suppressed at 6 months. Among HIV-negative partners enrolled after PrEP launched, 81.0% (527/651) initiated PrEP within 90 days of enrolling; among these 527, 11.2% sought a refill 6 months later. In our powered intent-to-treat analysis, 82.1% and 76.7% of partners living with HIV were virally suppressed, respectively, which was not a statistically significant difference (RR=0.94, 95% CI: 0.82-1.07) and was stable across sensitivity analyses. Interpretation Integration of PrEP into ART clinics reached a high proportion of people in HIV-serodifferent relationships and did not improve the already high frequency of HIV viral suppression among partners living with HIV. Funding National Institute of Mental Health (R01MH110296).
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Affiliation(s)
- Renee Heffron
- University of Washington, 325 Ninth Avenue, Box 359927 Seattle, Washington, USA
- University of Alabama Birmingham, Birmingham, Alabama, USA
| | | | - Katherine K. Thomas
- University of Washington, 325 Ninth Avenue, Box 359927 Seattle, Washington, USA
| | - Florence Nambi
- Infectious Diseases Institute, Makerere University, Kampala, Uganda
| | | | - Joseph Kibuuka
- Infectious Diseases Institute, Makerere University, Kampala, Uganda
| | - Dorothy Thomas
- University of Washington, 325 Ninth Avenue, Box 359927 Seattle, Washington, USA
| | - Erika Feutz
- University of Washington, 325 Ninth Avenue, Box 359927 Seattle, Washington, USA
| | - Allison Meisner
- University of Washington, 325 Ninth Avenue, Box 359927 Seattle, Washington, USA
- Fred Hutch, Vaccine and Infectious Disease Division, 1100 Fairview Ave N, Seattle, Washington, USA
| | - Norma C. Ware
- Harvard Medical School, 25 Shattuck St., Boston, Massachusetts, USA
- Brigham and Women's Hospital, Harvard Medical School, 75 Francis St, Boston, Massachusetts, USA
| | - Monique A. Wyatt
- Harvard Medical School, 25 Shattuck St., Boston, Massachusetts, USA
- Harvard Global, Cambridge, Massachusetts, USA
| | - Jane M. Simoni
- University of Washington, 325 Ninth Avenue, Box 359927 Seattle, Washington, USA
| | - Ingrid T. Katz
- Brigham and Women's Hospital, Harvard Medical School, 75 Francis St, Boston, Massachusetts, USA
| | | | - Jared M. Baeten
- University of Washington, 325 Ninth Avenue, Box 359927 Seattle, Washington, USA
- Gilead Sciences LLC, Foster City, California, USA
| | - Andrew Mujugira
- Infectious Diseases Institute, Makerere University, Kampala, Uganda
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Exploring the Role of Provider–Patient Communication in Women’s Sexual Health and Pre-Exposure Prophylaxis Care in the Primary Care Settings in New York State of the United States. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2022; 19:ijerph19138084. [PMID: 35805743 PMCID: PMC9265266 DOI: 10.3390/ijerph19138084] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/29/2022] [Revised: 06/28/2022] [Accepted: 06/29/2022] [Indexed: 11/24/2022]
Abstract
Background: Women shoulder a disproportionate burden of HIV infection in the United States and worldwide. Pre-exposure prophylaxis (PrEP) is an effective tool for HIV prevention, but its use is suboptimal. Primary care providers (PCP) are considered the ideal PrEP caregivers, but they generally underperform in PrEP care implementation. Methods: From 2020 to 2022, we employed semi-structured in-depth interviews to collect information about barriers and facilitators in PrEP care and beliefs and opinions regarding sexual wellness among 18 PCP and 29 PrEP-eligible women. We employed content analysis and thematic analysis to explore the transcribed narrative data. Results: The current study was guided by the “Communication Pathways” Framework. We studied how communication functions affect PrEP care and women’s sexual wellness on the pathways. We identified several specific pathways between communication and PrEP care implementation in primary care settings, including patient knowledge, linkage to care, therapeutic alliance, and decision making on PrEP care. A paradox regarding who should initiate the discussion regarding sexual history and PrEP care was identified. Conclusions: Findings suggested that a navigation and assistance system for PrEP care in patients and providers is urgently needed. Future studies should facilitate PrEP discussion, engagement, and monitoring in primary care settings.
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Thomas D, Mujugira A, Ortblad K, Namanda S, Kibuuka J, Nakitende M, Nambi F, Nakabugo L, Scoville C, Muwonge T, Heffron R. A pragmatic approach to identifying implementation barriers and facilitators for a novel pre-exposure prophylaxis (PrEP) delivery model at public facilities in urban Uganda. Implement Sci Commun 2022; 3:7. [PMID: 35090560 PMCID: PMC8795935 DOI: 10.1186/s43058-022-00254-w] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2021] [Accepted: 01/04/2022] [Indexed: 12/02/2022] Open
Abstract
Background Scalable HIV pre-exposure prophylaxis (PrEP) delivery models for resource-limited settings are critical for improving PrEP coverage and interrupting HIV transmission. This research uses technical assistance (TA) reports to evaluate implementation barriers and facilitators for a novel delivery model integrating PrEP and antiretroviral therapy (ART) delivery for HIV sero-different couples in public health facilities in Kampala, Uganda. Methods We used data from the Partners PrEP Program (PPP)—a stepped-wedge cluster randomized trial that is launching PrEP delivery through an integrated model of oral PrEP and antiretroviral therapy (ART) delivery for HIV sero-different couples at public health facilities in Kampala and Wakiso, Uganda (NCT03586128). Technical assistance teams, comprised of PPP program staff, conducted monthly TA visits to implementing facilities where they identified and addressed implementation challenges in collaboration with health facility staff. Findings were recorded in TA reports, a standardized form structured using the Consolidated Framework for Implementation Research (CFIR). We used a conceptual content analysis approach to evaluate TA reports completed from January to December 2019 and identify implementation barriers and facilitators. Results Among 39 reports from the 8 implementing facilities (~ 5 per facility), we identified 11 CFIR constructs. Key implementation facilitators included sensitizing and educating facility staff about PrEP (knowledge and beliefs about the innovation); establishing formal and informal feedback and accountability mechanisms (reflecting and evaluating); and empowering facility staff to address implementation challenges (self-efficacy). Key implementation barriers were related to ineffective recruitment and referral of sero-different couples to and from nearby facilities (cosmopolitanism) as well as stockouts of laboratory resources and testing supplies (available resources). Conclusions This analysis featured a robust implementation science framework to assess the relationship between early implementation determinants and outcomes of this innovative PrEP delivery model. Further, we have provided important descriptions of early implementation barriers and facilitators that will inform scale-up efforts for PrEP delivery within and beyond Uganda. Future work will refine the analysis of pragmatic program data, qualitatively investigate the identified key themes, and explore strategies for addressing implementation barriers. Supplementary Information The online version contains supplementary material available at 10.1186/s43058-022-00254-w.
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Affiliation(s)
- Dorothy Thomas
- Department of Global Health, University of Washington, Ninth and Jefferson Building, HMC 359927, 325 Ninth Avenue, Seattle, WA, 98104-2499, USA
| | - Andrew Mujugira
- Department of Global Health, University of Washington, Ninth and Jefferson Building, HMC 359927, 325 Ninth Avenue, Seattle, WA, 98104-2499, USA.,Infectious Diseases Institute, Makerere University, Kampala, Uganda
| | - Katrina Ortblad
- Public Health Science Division, Fred Hutchinson Cancer Research Center, 1100 Fairview Ave N, Seattle, WA, 98109, USA
| | - Sylvia Namanda
- Infectious Diseases Institute, Makerere University, Kampala, Uganda
| | - Joseph Kibuuka
- Infectious Diseases Institute, Makerere University, Kampala, Uganda
| | - Mai Nakitende
- Infectious Diseases Institute, Makerere University, Kampala, Uganda
| | - Florence Nambi
- Infectious Diseases Institute, Makerere University, Kampala, Uganda
| | | | - Caitlin Scoville
- Department of Global Health, University of Washington, Ninth and Jefferson Building, HMC 359927, 325 Ninth Avenue, Seattle, WA, 98104-2499, USA
| | - Timothy Muwonge
- Infectious Diseases Institute, Makerere University, Kampala, Uganda
| | - Renee Heffron
- Department of Global Health, University of Washington, Ninth and Jefferson Building, HMC 359927, 325 Ninth Avenue, Seattle, WA, 98104-2499, USA. .,Department of Epidemiology, University of Washington, Ninth and Jefferson Building, HMC 359927, 325 Ninth Avenue, Seattle, WA, 98104-2499, USA.
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Reis RK, Sousa LRM, Melo ES, Fernandes NM, Sorensen W, Gir E. Predictors of HIV Status Disclosure to Sexual Partners Among People Living with HIV in Brazil. AIDS Behav 2021; 25:3538-3546. [PMID: 34173896 DOI: 10.1007/s10461-021-03362-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/21/2021] [Indexed: 11/26/2022]
Abstract
The objective of this study was to identify the factors associated with the non-disclosure of HIV seropositivity among people living with HIV/AIDS undergoing antiretroviral treatment. A cross-sectional study was carried out in five HIV clinics in the interior of the state of São Paulo, Brazil. Logistic regression analysis was used to determine independent predictors of HIV status disclosure. It was found that 68.5% revealed their HIV seropositivity to their most recent sexual partner. The variables "casual partner" [OR 19.08, 95% CI (4.08, 20.23), p = 0.001], "sexual partners with negative HIV or unknown HIV" [OR 4.54, 95% CI (1.58, 1.01), p = 0.005], "multiple sexual partners" [OR = 3.17, 95% CI (1.34, 7.35), p = 0.009], and "lack of communication with the partner on HIV prevention"[OR = 8.3, 95% CI (3.88, 16.61), p = 0.001] were independently associated with non-disclosure of the diagnosis. Future HIV prevention interventions should encourage open communication between sexual partners.
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Affiliation(s)
- Renata Karina Reis
- Department of General and Specialized Nursing, WHO Collaborating Centre for Nursing Research Development, University of São Paulo At Ribeirão Preto College of Nursing, Avenida: Bandeirantes, 3900 Campus Universitário - Bairro Monte Alegre, Ribeirão Preto, São Paulo, Brazil.
| | - Laelson Rochelle Milanês Sousa
- Department of General and Specialized Nursing, WHO Collaborating Centre for Nursing Research Development, University of São Paulo At Ribeirão Preto College of Nursing, Avenida: Bandeirantes, 3900 Campus Universitário - Bairro Monte Alegre, Ribeirão Preto, São Paulo, Brazil
| | - Elizabete Santos Melo
- Department of General and Specialized Nursing, WHO Collaborating Centre for Nursing Research Development, University of São Paulo At Ribeirão Preto College of Nursing, Avenida: Bandeirantes, 3900 Campus Universitário - Bairro Monte Alegre, Ribeirão Preto, São Paulo, Brazil
| | | | - William Sorensen
- Department of Health and Kinesiology, University of Texas, Tyler, TX, USA
| | - Elucir Gir
- Department of General and Specialized Nursing, WHO Collaborating Centre for Nursing Research Development, University of São Paulo At Ribeirão Preto College of Nursing, Avenida: Bandeirantes, 3900 Campus Universitário - Bairro Monte Alegre, Ribeirão Preto, São Paulo, Brazil
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Antonini M, Pontes PS, Melo ES, de Souza Alves R, Gir E, Sorensen W, Reis RK. Serodiscordance predictors among couples in the HIV context: implications for health care. BMC Public Health 2021; 21:1849. [PMID: 34645401 PMCID: PMC8513240 DOI: 10.1186/s12889-021-11835-0] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2020] [Accepted: 09/22/2021] [Indexed: 11/10/2022] Open
Abstract
Background After HIV diagnosis, people maintain, reestablish their sexual lives, or build new relationships, often with HIV seronegative partners. Therefore, understanding the factors concerning couple-vulnerability is essential in order to design effective HIV preventive strategies. We examined HIV serodiscordant couples prevalence and their associated factors from a Brazilian city. Methods This is a cross-sectional analytical study carried out with people living with HIV (PLHIV) who had an active sex life and were engagement in HIV health care follow-up. Data were collected using a semi-structured questionnaire during individual interviews. We analyzed data using bivariate and multiple logistic regression analyses. Results There was 72.0% of HIV serodiscordant partnerships. Those who inconsistently used condoms (aOR: 0.3[0.13–0.7]) and/or had HIV detectable viral load (aOR: 0.29 [0.12–0.7]) were less likely to have an HIV serodiscordant sexual partner. On other hand, the lack of HIV transmission counseling by the health service (aOR: 5.08 [2.02–12.76]), or those who had a casual partner (aOR: 8.12 [1.7–38.8]) or a steady and casual one concomitantly (aOR: 24.82 [1.46–420.83]), were more likely to indicate an HIV serodiscordant partnership. Conclusion The findings showed a high prevalence of serodiscordant partnerships in PLHIV. Greater visibility among couples in the health services is needed as well as a reassessment in order to provide PLHIV and their sexual partners with care strategies, by the health professionals. Supplementary Information The online version contains supplementary material available at 10.1186/s12889-021-11835-0.
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Affiliation(s)
- Marcela Antonini
- Department of General and Specialized Nursing, University of São Paulo, Ribeirão Preto College of Nursing, Bandeirantes Ave, 3900, Vila Monte Alegre SP, CEP, Ribeirão Preto, 14040-902, Brazil.
| | - Priscila Silva Pontes
- Department of General and Specialized Nursing, University of São Paulo, Ribeirão Preto College of Nursing, Bandeirantes Ave, 3900, Vila Monte Alegre SP, CEP, Ribeirão Preto, 14040-902, Brazil
| | - Elizabete Santos Melo
- Paulista University at São José do Rio Preto, São José do Rio Preto, São Paulo, Brazil
| | - Regina de Souza Alves
- Department of General and Specialized Nursing, University of São Paulo, Ribeirão Preto College of Nursing, Bandeirantes Ave, 3900, Vila Monte Alegre SP, CEP, Ribeirão Preto, 14040-902, Brazil
| | - Elucir Gir
- Department of General and Specialized Nursing, University of São Paulo, Ribeirão Preto College of Nursing, Bandeirantes Ave, 3900, Vila Monte Alegre SP, CEP, Ribeirão Preto, 14040-902, Brazil
| | - William Sorensen
- Department of Health and Kinesiology, University of Texas at Tyler, Tyler, TX, USA
| | - Renata Karina Reis
- Department of General and Specialized Nursing, University of São Paulo, Ribeirão Preto College of Nursing, Bandeirantes Ave, 3900, Vila Monte Alegre SP, CEP, Ribeirão Preto, 14040-902, Brazil
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Bärnighausen K, Geldsetzer P, Matse S, Hettema A, Hughey AB, Dlamini P, Mavuso M, Fakudze D, Kahn K, Bärnighausen T, McMahon SA. Qualitative accounts of PrEP discontinuation from the general population in Eswatini. CULTURE, HEALTH & SEXUALITY 2021; 23:1198-1214. [PMID: 32633617 DOI: 10.1080/13691058.2020.1770333] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/12/2019] [Accepted: 05/13/2020] [Indexed: 06/11/2023]
Abstract
People in receipt of pre-exposure prophylaxis (PrEP) for the prevention of HIV in Sub-Saharan Africa often discontinue taking the medication. We conducted 27 semi-structured interviews with men and women who had started PrEP but did not return to the clinic for a refill after a 1, 2 or 3-month period. These 'discontinuation' clients were enrolled in a PrEP demonstration project for the general population in nurse-led, public-sector, primary-care clinics in Eswatini. Reasons for discontinuation included changes to self-perceived HIV risk such as the end of pregnancy and absent partners. Others described PrEP as inaccessible when working away from home and many described difficulties relating to a daily pill regimen and managing side effects. Female clients described being prohibited from using PrEP by their partners and co-wives. From these results, we recommend that client-centred counselling stresses the prevention-effective adherence paradigm, which promotes PrEP use in risk periods that are identifiable and PrEP discontinuation when the risk period has finished. A national scale up of PrEP may mitigate problems accessing PrEP. Extended counselling and support could assist with adherence and the management of side effects. Education and support for partners and families of PrEP clients may also contribute to better PrEP continuation.
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Affiliation(s)
- Kate Bärnighausen
- School of Public Health, University of the Witwatersrand, Johannesburg, South Africa
| | - Pascal Geldsetzer
- Faculty of Medicine, Heidelberg Institute of Global Health, University of Heidelberg, Heidelberg, Germany
- Stanford University School of Medicine, Stanford, CA, USA
| | - Sindy Matse
- Eswatini Ministry of Health, Mbabane, Eswatini
| | - Anita Hettema
- Clinton Health Access Initiative Eswatini, Mbabane, Eswatini
| | | | - Phiwa Dlamini
- Clinton Health Access Initiative Eswatini, Mbabane, Eswatini
| | - Mxolisi Mavuso
- Clinton Health Access Initiative Eswatini, Mbabane, Eswatini
| | - David Fakudze
- Clinton Health Access Initiative Eswatini, Mbabane, Eswatini
| | - Kathleen Kahn
- School of Public Health, University of the Witwatersrand, Johannesburg, South Africa
| | - Till Bärnighausen
- Faculty of Medicine, Heidelberg Institute of Global Health, University of Heidelberg, Heidelberg, Germany
| | - Shannon A McMahon
- Faculty of Medicine, Heidelberg Institute of Global Health, University of Heidelberg, Heidelberg, Germany
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
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10
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Chakraborty D, Ganguly S, Debnath F, Biswas S, Saha MK, Dutta S. Socio- demographic correlates of HIV sero-discordance among couples in West Bengal, India; A cross sectional analysis. Jpn J Infect Dis 2021; 75:169-176. [PMID: 34470966 DOI: 10.7883/yoken.jjid.2021.330] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Serodiscordant couples serves as potential source of Human Immunodeficiency Virus (HIV) transmission. Understanding demographic dynamics of serodiscordant couples plays an important role in tailoring interventions towards eliminating HIV. We conducted this cross sectional analysis in 314 Integrated Counseling and Testing Centres (ICTCs) in West Bengal, India during April 2016 to March 2020. General individuals who were detected as HIV reactive and whose spouses were also tested for HIV comprised the study population (8740 couples). Sociodemographic variables were compared across concordant and discordant arms and also between male positive (M+ F-) and female positive (F+ M-) subgroups of serodiscordant. Among the couples studied, 35.2% (95% CI: 34.2- 36.2 %) were serodiscordant. Among serodiscordant couples, the proportion of M+ F- (86.1%) was significantly higher than F+ M- (13.9%). We observed higher mean ages of couples, higher education, business & service occupations and urban residence as significantly associated with serodiscordance relationship (p < 0.05). Higher mean age of couple and lower proportion of housewives were associated with F+M- subgroup. As around 35% serodiscordant couples carry the risk of transmission to negative spouses particularly in higher age and urban residence, thus reorientation of HIV programme may be required accordingly to avert transmission in future.
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Affiliation(s)
- Debjit Chakraborty
- Division of Epidemiology, ICMR- National Institute of Cholera and Enteric Disease, India
| | - Suman Ganguly
- West Bengal State AIDS Prevention & Control Society, India
| | - Falguni Debnath
- Division of Epidemiology, ICMR- National Institute of Cholera and Enteric Disease, India
| | - Subrata Biswas
- Division of Virology, ICMR- National Institute of Cholera and Enteric Disease, India
| | - Malay Kumar Saha
- Division of Virology, ICMR- National Institute of Cholera and Enteric Disease, India
| | - Shanta Dutta
- ICMR- National Institute of Cholera and Enteric Disease, India
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11
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Sack DE, De Schacht C, Paulo P, Graves E, Emílio AM, Matino A, Fonseca CL, Aboobacar AU, Van Rompaey S, Audet CM. Pre-exposure prophylaxis use among HIV serodiscordant couples: a qualitative study in Mozambique. Glob Health Action 2021; 14:1940764. [PMID: 34229580 PMCID: PMC8266225 DOI: 10.1080/16549716.2021.1940764] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Background Pre-exposure prophylaxis (PrEP) has the potential to reduce HIV transmission and stem the HIV epidemic. Unfortunately, PrEP uptake in rural sub-Saharan Africa has been slow and medication adherence has been suboptimal. Objective To explore the perspectives, attitudes, and experiences of HIV serodiscordant partners taking PrEP and develop a messaging campaign to improve PrEP uptake in rural Mozambique to reduce HIV transmission among serodiscordant partners. Methods In this qualitative study, we interviewed 20 people in serodiscordant relationships using PrEP at a rural health center in Zambézia province, Mozambique and employed inductive and deductive coding to elicit their perspectives, attitudes, and experiences related to learning their partner’s HIV status, barriers to PrEP uptake, obstacles to PrEP adherence, and decisions to disclose their PrEP use with family and friends using thematic analysis. Results Our analysis generated nine themes across various levels of the socioecological model. Participants reported a strong desire to stay in the discordant relationship and highlighted the importance of working together to ensure PrEP and antiretroviral therapy adherence, with the majority skeptical that adherence could be achieved without both partners’ support (individual and interpersonal). Although most participants were reticent about sharing their serodiscordant status with family and friends (individual and interpersonal), those who did found their family and friends supportive (interpersonal). Participants suggested increasing community health agent availability to help people navigate HIV prevention and treatment (organizational). We then created three oral stories, using themes from the interviews, with examples from various levels of the socioecological model that will be used to generate support for PrEP use among community members. Conclusions Our findings informed oral template stories that will be used to emphasize how couples can work together to improve PrEP uptake and reduce incident HIV infections in serodiscordant couples elsewhere in rural Mozambique.
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Affiliation(s)
- Daniel E Sack
- Vanderbilt Institute for Global Health, Vanderbilt University Medical Center, Nashville, TN, USA
| | | | - Paula Paulo
- Friends in Global Health, Quelimane, Mozambique
| | - Erin Graves
- Vanderbilt Institute for Global Health, Vanderbilt University Medical Center, Nashville, TN, USA
| | | | | | | | | | | | - Carolyn M Audet
- Vanderbilt Institute for Global Health, Vanderbilt University Medical Center, Nashville, TN, USA
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12
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Wu H, Yu Q, Ma L, Zhang L, Chen Y, Guo P, Xu P. Health economics modeling of antiretroviral interventions amongst HIV serodiscordant couples. Sci Rep 2021; 11:13967. [PMID: 34234232 PMCID: PMC8263699 DOI: 10.1038/s41598-021-93443-x] [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] [Received: 08/24/2020] [Accepted: 06/21/2021] [Indexed: 02/05/2023] Open
Abstract
Antiretroviral treatment (ART) and pre-exposure prophylaxis (PrEP) for HIV-serodiscordant couples, effectively reduce mortality, transmission events and influence quality of life at the expense of increased costs. We aimed to evaluate health economics of antiretroviral-based strategies for HIV-serodiscordant couples in the China context. A deterministic model of HIV evolution and transmission within a cohort of serodiscordant couples was parameterized using the real-world database of Zhoukou city and published literature. We evaluated the mid-ART (a historical strategy, initiating ART with CD4 < 500 cells/mm3), early-ART (the current strategy, offering ART regardless of CD4 cell counts) and a hypothetical strategy (early-ART combined short-term daily PrEP) versus the late-ART (the baseline strategy, initiating ART with CD4 < 350 cells/mm3) offered by 2008 national guidelines. We estimated the incremental cost-effectiveness ratios (ICER) and incremental cost-utility ratios (ICUR) from a societal perspective, derived by clinical benefits and HIV-caused life quality respectively, and portrayed their changes over a 0-30 year's timeframe. The model projections indicated that the antiretroviral-based interventions were more likely to obtain clinical benefits but difficult to improve quality of life, and cumulative ICER and ICUR were generally decreasing without achieving cost-saving. Scale-up access to ART for the HIV-positive among serodiscordant couples was easily fallen within the range of paying for incremental life-years and quality adjusted life years by the societal willingness. The hypothetical strategy had the potential to prevent most seroconversion events within marriages but required enormous upfront costs, thus it took a long time to reach established thresholds. The current strategy of early-ART is the most cost-effective. Clarifying the obstacles of high cost of PrEP and improving life quality for HIV-serodiscordant couples have emerged as an urgent requisition.
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Affiliation(s)
- Haisheng Wu
- Department of Preventive Medicine, Shantou University Medical College, No. 22 Xinling Road, Shantou, 515041, China
| | - Qiuyan Yu
- Department of Preventive Medicine, School of Public Health and Management, Wenzhou Medical University, University Town, Wenzhou, 325035, China
| | - Liping Ma
- Hengrui Pharmaceutical Co., Ltd., No. 7 Kunlun Mountain Road, Lianyungang Economic and Technological Development Zone, Lianyungang, Jiangsu, China
| | - Lin Zhang
- Zhoukou Center for Disease Control and Prevention, No.10 Taihao Road East Section, Zhoukou, Henan, China
| | - Yuliang Chen
- Department of Preventive Medicine, Shantou University Medical College, No. 22 Xinling Road, Shantou, 515041, China
| | - Pi Guo
- Department of Preventive Medicine, Shantou University Medical College, No. 22 Xinling Road, Shantou, 515041, China.
| | - Peng Xu
- National Center for STD/AIDS Prevention and Control, Chinese Center for Disease Control and Prevention, No. 155 Changbai Road, Beijing, 102206, China.
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13
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Sexual Behaviors After PrEP Discontinuation Among HIV Serodiscordant Couples in Kenya and Uganda. J Acquir Immune Defic Syndr 2021; 85:174-181. [PMID: 32658130 PMCID: PMC7495981 DOI: 10.1097/qai.0000000000002434] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Supplemental Digital Content is Available in the Text. A strategy of pre-exposure prophylaxis (PrEP) transitioning to treatment as prevention is highly efficacious and cost effective for prevention of HIV transmission within HIV serodiscordant couples. We assessed whether couples who adopted this strategy experienced changes in sexual behaviors after HIV-negative partners discontinued PrEP and transitioned to rely primarily on their partner's adherence to antiretroviral therapy (ART) for prevention.
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14
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Jani N, Mathur S, Kahabuka C, Makyao N, Pilgrim N. Relationship dynamics and anticipated stigma: Key considerations for PrEP use among Tanzanian adolescent girls and young women and male partners. PLoS One 2021; 16:e0246717. [PMID: 33596216 PMCID: PMC7888654 DOI: 10.1371/journal.pone.0246717] [Citation(s) in RCA: 24] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2019] [Accepted: 01/25/2021] [Indexed: 01/10/2023] Open
Abstract
OBJECTIVES We examined key gender, interpersonal and community dynamics influencing PrEP acceptability among adolescent girls and young women (AGYW) and their male partners. METHODS We administered 12 in-depth interviews (IDI) to partnered, or married AGYW aged 15-24 years living without HIV, and 16 IDIs to male partners living without HIV aged 18 or older, partnered or married to an AGYW in Tanzania. Card sorting, a participatory qualitative method for facilitating systematic discussion, was used to identify attitudes, values, and desires that would influence PrEP acceptability. RESULTS Relationship distrust, partner communication about HIV risk, and need to control HIV risk were highly influential considerations for PrEP use. AGYW and male partners both wanted to discuss PrEP use amidst relationship distrust, while most male partners encouraged AGYW PrEP use for shared protective benefit. Anticipated stigma of being perceived as a person living with HIV, as a result of PrEP use, was a deterrent for both AGYW and male partners while AGYW also feared additional stigma of being considered sexually promiscuous. CONCLUSIONS Couples counseling for PrEP uptake and adherence might be a well-placed strategy for couples who are living without HIV to educate one another about the relationship benefits of using PrEP, thereby increasing its acceptance and adherence, addressing unequal power dynamics, and reducing associated relationship distrust. Community awareness and education about PrEP can help curb persistent PrEP stigma, including intersectional stigma.
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Affiliation(s)
- Nrupa Jani
- Population Council, Washington, DC, United States of America
- * E-mail:
| | - Sanyukta Mathur
- Population Council, Washington, DC, United States of America
| | | | - Neema Makyao
- National AIDS Control Programme, Dar es Salaam, Tanzania
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15
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Musinguzi N, Kidoguchi L, Mugo NR, Ngure K, Katabira E, Celum CL, Baeten JM, Heffron R, Haberer JE. Adherence to recommendations for ART and targeted PrEP use among HIV serodiscordant couples in East Africa: the "PrEP as a bridge to ART" strategy. BMC Public Health 2020; 20:1621. [PMID: 33115478 PMCID: PMC7594426 DOI: 10.1186/s12889-020-09712-3] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2020] [Accepted: 10/15/2020] [Indexed: 01/29/2023] Open
Abstract
BACKGROUND PrEP use should be aligned with periods of risk for HIV acquisition. For HIV serodiscordant couples, PrEP can be used as a bridge until the partner living with HIV takes antiretroviral therapy (ART) long enough to achieve viral suppression (the "PrEP as a Bridge to ART" strategy). However, adherence to this strategy is unknown. METHODS In a demonstration project in Kenya and Uganda, HIV-uninfected partners of serodiscordant couples were advised to take PrEP until the partner living with HIV took ART for ≥ 6 months. PrEP discontinuation was then recommended unless there were concerns about ART adherence, immediate fertility intentions, or outside partners with unknown HIV/ART status. Electronic adherence monitoring and socio-behavioral questionnaire data were used in logistic regression models to explore completion of this strategy and continuation of PrEP beyond recommendations to stop its use. RESULTS Among 833 serodiscordant couples, 436 (52%) HIV-uninfected partners completed ≥ 6 months of PrEP as a bridge to ART. Strategy completion was associated with older age (aOR per 5 years = 1.1; p = 0.008) and having fewer children (aOR = 0.9; p = 0.019). Of the 230 participants encouraged to stop PrEP according to strategy recommendations, 170 (74%) did so. PrEP continuation among the remaining 60 participants was associated with more education (aOR = 1.1; p = 0.029), a preference for PrEP over ART (aOR = 3.6; p = 0.026), comfort with managing their serodiscordant relationship (aOR = 0.6; p = 0.046), and believing PrEP makes sex safe (aOR = 0.5; p = 0.026). CONCLUSION Half of participants completed the PrEP as a bridge to ART strategy and the majority stopped PrEP as recommended. These findings suggest that targeting PrEP to periods of risk is a promising approach; however, tailoring counseling around aligning PrEP use and HIV risk will be important for optimal strategy implementation.
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Affiliation(s)
- Nicholas Musinguzi
- grid.33440.300000 0001 0232 6272Global Health Collaborative, Mbarara University of Science and Technology, P. O Box 434, Mbarara, Uganda
| | - Lara Kidoguchi
- grid.34477.330000000122986657Department of Medicine, University of Washington, Seattle, USA
| | - Nelly R. Mugo
- grid.33058.3d0000 0001 0155 5938Centres for Clinical Research, Kenya Medical Research Institute, Nairobi, Kenya ,grid.34477.330000000122986657Department of Global Health, University of Washington, Seattle, USA
| | - Kenneth Ngure
- grid.411943.a0000 0000 9146 7108School of Public Health, Jomo Kenyatta University of Agriculture and Technology Nairobi, Nairobi, Kenya
| | - Elly Katabira
- grid.11194.3c0000 0004 0620 0548Infectious Disease Institute, Makerere University, Kampala, Uganda
| | - Connie L. Celum
- grid.34477.330000000122986657Department of Medicine, University of Washington, Seattle, USA ,grid.34477.330000000122986657Department of Global Health, University of Washington, Seattle, USA ,grid.34477.330000000122986657Department of Epidemiology, University of Washington, Seattle, USA
| | - Jared M. Baeten
- grid.34477.330000000122986657Department of Medicine, University of Washington, Seattle, USA ,grid.34477.330000000122986657Department of Global Health, University of Washington, Seattle, USA ,grid.34477.330000000122986657Department of Epidemiology, University of Washington, Seattle, USA
| | - Renee Heffron
- grid.34477.330000000122986657Department of Global Health, University of Washington, Seattle, USA ,grid.34477.330000000122986657Department of Epidemiology, University of Washington, Seattle, USA
| | - Jessica E. Haberer
- grid.32224.350000 0004 0386 9924Massachusetts General Hospital and Harvard Medical School, Boston, USA
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16
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Wanga V, Baeten JM, Bukusi EA, Mugo NR, Asiimwe S, Ngure K, Mujugira A, Muwonge T, Odoyo JB, Haberer JE, Celum C, Heffron R. Sexual Behavior and Perceived HIV Risk Among HIV-Negative Members of Serodiscordant Couples in East Africa. AIDS Behav 2020; 24:2082-2090. [PMID: 31925607 DOI: 10.1007/s10461-019-02773-5] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
HIV risk perception may influence the use of HIV prevention interventions. Using data from HIV-negative adults enrolled in a study of pre-exposure prophylaxis (PrEP) and antiretroviral therapy for HIV-serodiscordant couples in Kenya and Uganda, we examined associations between: (1) condom use and risk perception and (2) risk perception and PrEP adherence. Two-thirds of HIV-negative partners reported condomless sex with their HIV-positive partner or another partner in the month prior to study enrollment. Compared to those who reported no condomless sex, participants who reported condomless sex during the month prior to study visit had fivefold higher odds of reporting "high risk" vs "no risk" perception (36.3 versus 10.9%: aOR 4.9, 95% CI 3.4-6.9). Reporting condomless sex in the most recent sex act was associated with increased odds of perceiving some HIV risk (aOR for high risk = 7.3, 95% CI 4.9-10.8; aOR for moderate risk = 4.8, 95% CI 3.5-6.7; aOR for low risk = 3.5, 95% CI 2.7-4.6). We found no significant association between risk perception and PrEP adherence. Sexual behavior aligned with perceived HIV risk, which can facilitate an HIV-negative individual's decisions about PrEP use.
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17
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Perceived Facilitators and Barriers to Couples' HIV Testing and Counseling in U.S. Clinical Settings: Perspectives From U.S. Health Providers. J Assoc Nurses AIDS Care 2020; 30:279-291. [PMID: 30672780 DOI: 10.1097/jnc.0000000000000055] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
We used a qualitative descriptive design to ascertain perceived facilitators and barriers to couples' HIV testing and counseling (CHTC) by U.S. health care providers. We recruited 22 providers from 4 health care facilities in Miami-Dade County, FL, from November 2015 to March 2016. In-depth, semistructured interviews were conducted. Content analysis categorized and contextualized provider narratives. Perceived facilitators of CHTC were provider experiences with couple-centered HIV-related care, existing patient or client demands for joint HIV screening, and a health care practice environment that fosters an interprofessional approach to addressing client needs. Perceived barriers were partner unwillingness to undergo HIV screening, provider role beliefs and preferences regarding couple-based approaches, and provider time constraints in tandem with funding and billing issues. Overall, providers endorsed CHTC and thought that current challenges and successes with couple-based efforts and HIV screening and care could influence CHTC implementation. Provider recommendations are discussed.
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18
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Koss CA, Charlebois ED, Ayieko J, Kwarisiima D, Kabami J, Balzer LB, Atukunda M, Mwangwa F, Peng J, Mwinike Y, Owaraganise A, Chamie G, Jain V, Sang N, Olilo W, Brown LB, Marquez C, Zhang K, Ruel TD, Camlin CS, Rooney JF, Black D, Clark TD, Gandhi M, Cohen CR, Bukusi EA, Petersen ML, Kamya MR, Havlir DV. Uptake, engagement, and adherence to pre-exposure prophylaxis offered after population HIV testing in rural Kenya and Uganda: 72-week interim analysis of observational data from the SEARCH study. Lancet HIV 2020; 7:e249-e261. [PMID: 32087152 PMCID: PMC7208546 DOI: 10.1016/s2352-3018(19)30433-3] [Citation(s) in RCA: 93] [Impact Index Per Article: 23.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2019] [Revised: 12/14/2019] [Accepted: 12/18/2019] [Indexed: 02/06/2023]
Abstract
BACKGROUND Optimal strategies for pre-exposure prophylaxis (PrEP) engagement in generalised HIV epidemics are unknown. We aimed to assess PrEP uptake and engagement after population-level HIV testing and universal PrEP access to characterise gaps in the PrEP cascade in rural Kenya and Uganda. METHODS We did a 72-week interim analysis of observational data from the ongoing SEARCH (Sustainable East Africa Research in Community Health) study. Following community sensitisation and PrEP education, we did HIV testing and offered PrEP at health fairs and facilities in 16 rural communities in western Kenya, eastern Uganda, and western Uganda. We provided enhanced PrEP counselling to individuals 15 years and older who were assessed as having an elevated HIV risk on the basis of serodifferent partnership or empirical risk score, or who otherwise self-identified as being at high risk but were not in serodifferent partnerships or identified by the risk score. PrEP follow-up visits were done at facilities, homes, or community locations. We assessed PrEP uptake within 90 days of HIV testing, programme engagement (follow-up visit attendance at week 4, week 12, and every 12 weeks thereafter), refills, self-reported adherence up to 72 weeks, and concentrations of tenofovir in hair samples from individuals reporting HIV risk and adherence during follow-up, and analysed factors associated with uptake and adherence. This study is registered with ClinicalTrials.gov, NCT01864603. FINDINGS Between June 6, 2016, and June 23, 2017, 70 379 community residents 15 years or older who had not previously been diagnosed with HIV were tested during population-level HIV testing. Of these individuals, 69 121 tested HIV-negative, 12 935 of whom had elevated HIV risk (1353 [10%] serodifferent partnership, 6938 [54%] risk score, 4644 [36%] otherwise self-identified risk). 3489 (27%) initiated PrEP, 2865 (82%) of whom did so on the same day as HIV testing and 1733 (50%) of whom were men. PrEP uptake was lower among individuals aged 15-24 years (adjusted odds ratio 0·55, 95% CI 0·45-0·68) and mobile individuals (0·61, 0·41-0·91). At week 4, among 3466 individuals who initiated PrEP and did not withdraw or die before the first visit, 2215 (64%) were engaged in the programme, 1701 (49%) received medication refills, and 1388 (40%) self-reported adherence. At week 72, 1832 (56%) of 3274 were engaged, 1070 (33%) received a refill, and 900 (27%) self-reported adherence. Among participants reporting HIV risk at weeks 4-72, refills (89-93%) and self-reported adherence (70-76%) were high. Among sampled participants self-reporting adherence at week 24, the proportion with tenofovir concentrations in the hair reflecting at least four doses taken per week was 66%, and reflecting seven doses per week was 44%. Participants who stopped PrEP accepted HIV testing at 4274 (83%) of 5140 subsequent visits; half of these participants later restarted PrEP. 29 participants of 3489 who initiated PrEP had serious adverse events, including seven deaths. Five adverse events (all grade 3) were assessed as being possibly related to the study drug. INTERPRETATION During population-level HIV testing, inclusive risk assessment (combining serodifferent partnership, an empirical risk score, and self-identification of HIV risk) was feasible and identified individuals who could benefit from PrEP. The biggest gap in the PrEP cascade was PrEP uptake, particularly for young and mobile individuals. Participants who initiated PrEP and had perceived HIV risk during follow-up reported taking PrEP, but one-third had drug concentrations consistent with poor adherence, highlighting the need for novel approaches and long-acting formulations as PrEP roll-out expands. FUNDING National Institutes of Health, President's Emergency Plan for AIDS Relief, Bill & Melinda Gates Foundation, and Gilead Sciences.
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Affiliation(s)
- Catherine A Koss
- Division of HIV, Infectious Diseases and Global Medicine, University of California San Francisco, San Francisco, CA, USA.
| | - Edwin D Charlebois
- Division of Prevention Sciences, Department of Medicine, University of California San Francisco, San Francisco, CA, USA
| | - James Ayieko
- Centre for Microbiology Research, Kenya Medical Research Institute, Nairobi, Kenya
| | | | - Jane Kabami
- Infectious Diseases Research Collaboration, Kampala, Uganda
| | - Laura B Balzer
- Department of Biostatistics and Epidemiology, University of Massachusetts Amherst, Amherst, MA, USA
| | | | | | - James Peng
- Division of HIV, Infectious Diseases and Global Medicine, University of California San Francisco, San Francisco, CA, USA
| | - Yusuf Mwinike
- Infectious Diseases Research Collaboration, Kampala, Uganda
| | | | - Gabriel Chamie
- Division of HIV, Infectious Diseases and Global Medicine, University of California San Francisco, San Francisco, CA, USA
| | - Vivek Jain
- Division of HIV, Infectious Diseases and Global Medicine, University of California San Francisco, San Francisco, CA, USA
| | - Norton Sang
- Centre for Microbiology Research, Kenya Medical Research Institute, Nairobi, Kenya
| | - Winter Olilo
- Centre for Microbiology Research, Kenya Medical Research Institute, Nairobi, Kenya
| | - Lillian B Brown
- Division of HIV, Infectious Diseases and Global Medicine, University of California San Francisco, San Francisco, CA, USA
| | - Carina Marquez
- Division of HIV, Infectious Diseases and Global Medicine, University of California San Francisco, San Francisco, CA, USA
| | - Kevin Zhang
- Division of HIV, Infectious Diseases and Global Medicine, University of California San Francisco, San Francisco, CA, USA
| | - Theodore D Ruel
- Department of Pediatrics, University of California San Francisco, San Francisco, CA, USA
| | - Carol S Camlin
- Department of Obstetrics, Gynecology and Reproductive Sciences, University of California San Francisco, San Francisco, CA, USA
| | | | - Douglas Black
- Division of HIV, Infectious Diseases and Global Medicine, University of California San Francisco, San Francisco, CA, USA
| | - Tamara D Clark
- Division of HIV, Infectious Diseases and Global Medicine, University of California San Francisco, San Francisco, CA, USA
| | - Monica Gandhi
- Division of HIV, Infectious Diseases and Global Medicine, University of California San Francisco, San Francisco, CA, USA
| | - Craig R Cohen
- Department of Obstetrics, Gynecology and Reproductive Sciences, University of California San Francisco, San Francisco, CA, USA
| | - Elizabeth A Bukusi
- Department of Obstetrics, Gynecology and Reproductive Sciences, University of California San Francisco, San Francisco, CA, USA; Centre for Microbiology Research, Kenya Medical Research Institute, Nairobi, Kenya
| | - Maya L Petersen
- Graduate Group in Biostatistics, School of Public Health, University of California Berkeley, Berkeley, CA, USA
| | - Moses R Kamya
- Infectious Diseases Research Collaboration, Kampala, Uganda; School of Medicine, Makerere University College of Health Sciences, Kampala, Uganda
| | - Diane V Havlir
- Division of HIV, Infectious Diseases and Global Medicine, University of California San Francisco, San Francisco, CA, USA
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Zhang C, McMahon J, Fiscella K, Przybyla S, Braksmajer A, LeBlanc N, Liu Y. HIV Pre-Exposure Prophylaxis Implementation Cascade Among Health Care Professionals in the United States: Implications from a Systematic Review and Meta-Analysis. AIDS Patient Care STDS 2019; 33:507-527. [PMID: 31821044 DOI: 10.1089/apc.2019.0119] [Citation(s) in RCA: 62] [Impact Index Per Article: 12.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Abstract
Although pre-exposure prophylaxis (PrEP) has been approved for primary HIV prevention for individuals aged 18 years or older since 2012, PrEP utilization has been suboptimal. To understand trends in PrEP provision from the health care providers' perspective, we systematically assessed each specific stage along the PrEP implementation cascade (i.e., awareness, willingness, consultation, and prescription) among health care professionals (HCPs) in the United States. Between June and December 2018, we conducted a systematic review of published studies on this topic. A total of 36 eligible studies were identified and included in the analyses. Random-effect models were employed to examine the pooled prevalence of each key stage along the cascade. Time trend and subgroup analyses were conducted. A thematic analysis was used to identify barriers and facilitators along the PrEP cascade. In this study, a total of 18,265 HCPs representing diverse demographics were included. The pooled prevalence of PrEP awareness was 68% [95% confidence interval (CI) = 55-80%], willingness to prescribe PrEP was 66% (95% CI = 54-77%), PrEP consultation was 37% (95% CI = 25-51%), and prescription provision was 24% (95% CI = 17-32%). Subgroup analyses revealed that PrEP provision among HCPs was lowest in the south, but has been improving annually nationwide. Infectious disease specialists [odds ratio (OR) = 4.06, 95% CI = 3.12-5.28; compared with primary care providers] and advanced practice registered nurses/physician assistants (OR = 1.51, 95% CI = 1.09-2.09; compared with physicians) had higher odds of prescribing PrEP. Barriers and facilitators regarding optimal PrEP implementation were embedded within individual, dyadic, social, and structural levels. This meta-analysis has comprehensively examined the trend and pattern of PrEP implementation among HCPs. To achieve optimal implementation of the PrEP cascade in the United States, tailored training and programs need to be provided to HCPs.
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Affiliation(s)
- Chen Zhang
- School of Nursing, University of Rochester Medical Center, Rochester, New York
| | - James McMahon
- School of Nursing, University of Rochester Medical Center, Rochester, New York
| | - Kevin Fiscella
- Department of Family Medicine, University of Rochester Medical Center, Rochester, New York
| | - Sarahmona Przybyla
- Department of Community Health and Health Behavior, University at Buffalo, Buffalo, New York
| | - Amy Braksmajer
- School of Nursing, University of Rochester Medical Center, Rochester, New York
| | - Natalie LeBlanc
- School of Nursing, University of Rochester Medical Center, Rochester, New York
| | - Yu Liu
- Division of Epidemiology, Department of Public Health Science, School of Medicine and Dentistry, University of Rochester Medical Center, Rochester, New York
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PrEP Discontinuation and Prevention-Effective Adherence: Experiences of PrEP Users in Ugandan HIV Serodiscordant Couples. J Acquir Immune Defic Syndr 2019; 82:265-274. [PMID: 31609925 PMCID: PMC6812551 DOI: 10.1097/qai.0000000000002139] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Abstract
BACKGROUND Optimal adherence to oral pre-exposure prophylaxis (PrEP) for HIV prevention involves aligning consistent PrEP use with periods of risk to achieve prevention-effective adherence. Prevention-effective adherence is predicated on individuals discontinuing PrEP during periods without expected risk. For stable, serodiscordant couples, antiretroviral therapy (ART) adherence by the HIV-positive partner markedly decreases HIV transmission risk, potentially obviating the need for continued PrEP use; yet little is known about actual lived experiences of discontinuing PrEP. METHODS In-depth qualitative interviews were conducted with HIV-uninfected PrEP users in serodiscordant couples taking part in the Partners Demonstration Project at IDI-Kasangati, Kampala, Uganda. Open-ended interviews elicited information on the partnered relationship; understandings of PrEP; prevention strategies; and experiences of PrEP discontinuation. An inductive, thematic, content-analytic approach was used to analyze study data. RESULTS Uninfected partners experienced PrEP as a valued resource for preventing HIV acquisition. Despite ongoing ART use by HIV-positive partners for a period of time consistent with viral suppression, discontinuation of PrEP was experienced as a loss of protection and a corresponding increase in risk of HIV acquisition. Uninfected partners responded with strategies aimed at offsetting this subjective sense of increased risk, specifically: (1) changing sexual practices; (2) prioritizing fidelity in the relationship; (3) increasing reliance on condoms; and (4) seeking evidence of partners' ART adherence. CONCLUSIONS These experiences highlight the challenges PrEP users in serodiscordant couples face in discontinuing PrEP for prevention-effective adherence. Flexible interventions that support individuals during this transition may increase comfort with discontinuing PrEP when alternative prevention strategies provide protection, such as a partner's consistent adherence to ART.
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Heffron R, Ngure K, Velloza J, Kiptinness C, Quame‐Amalgo J, Oluch L, Thuo N, Njoroge J, Momanyi R, Gakuo S, Mbugua S, Morrison S, Haugen H, Chohan B, Celum C, Baeten JM, Mugo N. Implementation of a comprehensive safer conception intervention for HIV-serodiscordant couples in Kenya: uptake, use and effectiveness. J Int AIDS Soc 2019; 22:e25261. [PMID: 30957420 PMCID: PMC6452026 DOI: 10.1002/jia2.25261] [Citation(s) in RCA: 22] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2018] [Accepted: 02/04/2019] [Indexed: 01/20/2023] Open
Abstract
INTRODUCTION Safer conception strategies minimize HIV risk during condomless sex to become pregnant. Gaps remain in understanding the acceptability, feasibility and choices HIV-serodiscordant couples make when multiple safer conception options are available. METHODS We conducted a pilot study of a comprehensive safer conception package for HIV-serodiscordant couples with immediate fertility desires in Kenya from March 2016 to April 2018. The intervention package included antiretroviral therapy (ART) for HIV-positive partners, oral pre-exposure prophylaxis (PrEP) for HIV-negative partners, daily fertility and sexual behaviour tracking via short message service (SMS) surveys, counselling on self-insemination, and referrals for voluntary medical male circumcision and fertility care. Couples attended monthly visits until pregnancy with HIV testing for negative partners at each visit. We estimated the number of expected HIV seroconversions using a counterfactual cohort simulated from gender-matched couples in the placebo arm of a previous PrEP clinical trial. We used bootstrap methods to compare expected and observed seroconversions. RESULTS Of the 74 enrolled couples, 54% were HIV-negative female/HIV-positive male couples. The 6 and 12-month cumulative pregnancy rates were 45.3% and 61.9% respectively. In the month preceding pregnancy, 80.9% of HIV-positive partners were virally suppressed, 81.4% of HIV-negative partners were highly adherent to PrEP, and SMS surveys indicated potential timing of condomless sex to peak fertility (median of sex acts = 10, interquartile range (IQR) 7 to 12; median condomless sex acts = 3.5, IQR 1 to 7). Most (95.7%) pregnancies were protected by ≥2 strategies: 57.4% were protected by high PrEP and ART adherence, male circumcision with or without timed condomless sex; 10 (21.3%) were protected by viral suppression in the HIV-positive partner and male circumcision with or without timed condomless sex; 8 (17.0%) were protected by high PrEP adherence and male circumcision with or without timed condomless sex. We observed 0 HIV seroconversions (95% CI 0.0 to 6.0 per 100 person years), indicating a 100% reduction in HIV risk (p = 0.04). CONCLUSIONS The use of multiple safer conception strategies, primarily PrEP, ART, male circumcision and/or tracking fertility, was acceptable and feasible for African HIV-serodiscordant couples and significantly reduced HIV transmission risk. It is important to increase the availability of and counselling about safer conception services in regions with HIV epidemics involving heterosexual transmission and high fertility.
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Affiliation(s)
- Renee Heffron
- Department of Global HealthUniversity of WashingtonSeattleWAUSA
- Department of EpidemiologyUniversity of WashingtonSeattleWAUSA
| | - Kenneth Ngure
- Department of Global HealthUniversity of WashingtonSeattleWAUSA
- Jomo Kenyatta University of Agriculture and TechnologyNairobiKenya
| | - Jennifer Velloza
- Department of Global HealthUniversity of WashingtonSeattleWAUSA
- Department of EpidemiologyUniversity of WashingtonSeattleWAUSA
| | - Catherine Kiptinness
- Partners in Health and Research DevelopmentCentre for Clinical ResearchKenya Medical Research InstituteNairobiKenya
| | | | - Lynda Oluch
- Partners in Health and Research DevelopmentCentre for Clinical ResearchKenya Medical Research InstituteNairobiKenya
| | - Nicholas Thuo
- Partners in Health and Research DevelopmentCentre for Clinical ResearchKenya Medical Research InstituteNairobiKenya
| | - John Njoroge
- Partners in Health and Research DevelopmentCentre for Clinical ResearchKenya Medical Research InstituteNairobiKenya
| | - Richard Momanyi
- Partners in Health and Research DevelopmentCentre for Clinical ResearchKenya Medical Research InstituteNairobiKenya
| | - Stephen Gakuo
- Partners in Health and Research DevelopmentCentre for Clinical ResearchKenya Medical Research InstituteNairobiKenya
| | - Sarah Mbugua
- Partners in Health and Research DevelopmentCentre for Clinical ResearchKenya Medical Research InstituteNairobiKenya
| | - Susan Morrison
- Department of Global HealthUniversity of WashingtonSeattleWAUSA
| | - Harald Haugen
- Department of Global HealthUniversity of WashingtonSeattleWAUSA
| | - Bhavna Chohan
- Department of Global HealthUniversity of WashingtonSeattleWAUSA
| | - Connie Celum
- Department of Global HealthUniversity of WashingtonSeattleWAUSA
- Department of EpidemiologyUniversity of WashingtonSeattleWAUSA
- Department of MedicineUniversity of WashingtonSeattleWAUSA
| | - Jared M Baeten
- Department of Global HealthUniversity of WashingtonSeattleWAUSA
- Department of EpidemiologyUniversity of WashingtonSeattleWAUSA
- Department of MedicineUniversity of WashingtonSeattleWAUSA
| | - Nelly Mugo
- Department of Global HealthUniversity of WashingtonSeattleWAUSA
- Partners in Health and Research DevelopmentCentre for Clinical ResearchKenya Medical Research InstituteNairobiKenya
- Center for Clinical ResearchKenya Medical Research InstituteNairobiKenya
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Kwena ZA, Njuguna SW, Ssetala A, Seeley J, Nielsen L, De Bont J, Bukusi EA. HIV prevalence, spatial distribution and risk factors for HIV infection in the Kenyan fishing communities of Lake Victoria. PLoS One 2019; 14:e0214360. [PMID: 30908555 PMCID: PMC6433243 DOI: 10.1371/journal.pone.0214360] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2017] [Accepted: 03/12/2019] [Indexed: 11/18/2022] Open
Abstract
INTRODUCTION Global efforts to end HIV by 2030 focus on reducing and eventually eliminating new infections in priority populations. Identifying these populations and characterizing their vulnerability factors helps in guiding investment of scarce HIV prevention resources to achieve maximum impact. We sought to establish HIV prevalence, spatial distribution and risk factors for HIV infection in the Kenyan fishing communities of Lake Victoria. METHODS We conducted a cross-sectional survey of 2637 people from all the 308 fish-landing beaches on the Kenyan shore of Lake Victoria. The number of participants enrolled at each beach were weighted based on the size of the beach, determined by the number of functional registered boats. We used simple random sampling to select those to be approached for study participation. Consenting participants were privately interviewed about their socio-economic and demographic characteristics and sexual behavior, and were invited for HIV test using the Kenya rapid HIV testing protocol. We used descriptive statistics and multivariate logistic and linear regression for analysis. RESULTS We found high HIV prevalence of 32% with significant differences between men (29%) and women (38%). Among men, having an HIV negative sexual partner, being circumcised, increasing number of condom protected sex acts in the preceding month, being younger and being a resident of Homa Bay, Kisumu, Siaya and Busia counties compared to Migori County reduced the risk of HIV infection. For women, being married, having more children with the current spouse, having an HIV negative sexual partner and being a resident of Busia compared to Migori County reduced the risk of HIV infection. We also found that longer distance from the beaches to the nearest public health facilities was associated with increasing cumulative HIV prevalence at the beaches. CONCLUSION Fishing communities have high HIV prevalence and may greatly benefit from interventions such as wider ART coverage, couple HIV risk reduction counseling, PrEP use for HIV negative partner at substantial continuous risk, alongside other HIV prevention services that the Kenyan government is currently rolling out. This will additionally require adequate plans to synchronize the provision of these services with the population's routine schedules for all these options to be reasonably accessible to them.
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Affiliation(s)
| | | | - Ali Ssetala
- UVRI-IAVI HIV Vaccine Program, Entebbe, Uganda
| | | | - Leslie Nielsen
- International AIDS Vaccine Initiative, New York, United States of America
| | - Jan De Bont
- International AIDS Vaccine Initiative, New York, United States of America
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Nakku‐Joloba E, Pisarski EE, Wyatt MA, Muwonge TR, Asiimwe S, Celum CL, Baeten JM, Katabira ET, Ware NC. Beyond HIV prevention: everyday life priorities and demand for PrEP among Ugandan HIV serodiscordant couples. J Int AIDS Soc 2019; 22:e25225. [PMID: 30657642 PMCID: PMC6338102 DOI: 10.1002/jia2.25225] [Citation(s) in RCA: 28] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2018] [Accepted: 12/05/2018] [Indexed: 12/16/2022] Open
Abstract
INTRODUCTION Pre-exposure prophylaxis (PrEP) to prevent HIV infection is being rolled out in Africa. The uptake of PrEP to date has varied across populations and locations. We seek to understand the drivers of demand for PrEP through analysis of qualitative data collected in conjunction with a PrEP demonstration project involving East African HIV serodiscordant couples. Our goal was to inform demand creation by understanding what PrEP means - beyond HIV prevention - for the lives of users. METHODS The Partners Demonstration Project evaluated an integrated strategy of PrEP and antiretroviral therapy (ART) delivery in which time-limited PrEP served as a "bridge" to long-term ART. Uninfected partners in HIV serodiscordant couples were offered PrEP at baseline and encouraged to discontinue once infected partners had taken ART for six months. We conducted 274 open-ended interviews with 93 couples at two Ugandan research sites. Interviews took place one month after enrolment and at later points in the follow-up period. Topics included are as follows: (1) discovery of serodiscordance; (2) decisions to accept/decline PrEP and/or ART; (3) PrEP and ART initiation; (4) experiences of using PrEP and ART; (5) PrEP discontinuation; (6) impact of PrEP and ART on the partnered relationship. Interviews were audio-recorded and transcribed. We used an inductive, content analytic approach to characterize meanings of PrEP stemming from its effectiveness for HIV prevention. Relevant content was represented as descriptive categories. RESULTS Discovery of HIV serodiscordance resulted in fear of HIV transmission for couples, which led to loss of sexual intimacy in committed relationships, and to abandonment of plans for children. As a result, partners became alienated from each other. PrEP countered the threat to the relationship by reducing fear and reinstating hopes of having children together. Condom use worked against the re-establishment of intimacy and closeness. By increasing couples' sense of protection against HIV infection and raising the prospect of a return to "live sex" (sex without condoms), PrEP was perceived by couples as solving the problem of serodiscordance and preserving committed relationships. CONCLUSIONS The most effective demand creation strategies for PrEP may be those that address the everyday life priorities of potential users in addition to HIV prevention. CLINICAL TRIAL NUMBER NCT02775929.
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Affiliation(s)
- Edith Nakku‐Joloba
- Department of Epidemiology and BiostatisticsMakerere University College of Health SciencesKampalaUganda
- STD Clinic/Ward 12Mulago HospitalKampalaUganda
| | - Emily E Pisarski
- Department of Global Health and Social MedicineHarvard Medical SchoolBostonMAUSA
| | - Monique A Wyatt
- Department of Global Health and Social MedicineHarvard Medical SchoolBostonMAUSA
- Harvard GlobalCambridgeMAUSA
| | | | | | - Connie L Celum
- Departments of Global Health, Medicine, and EpidemiologySchool of Medicine and School of Public HealthUniversity of WashingtonSeattleWAUSA
| | - Jared M Baeten
- Departments of Global Health, Medicine, and EpidemiologySchool of Medicine and School of Public HealthUniversity of WashingtonSeattleWAUSA
| | | | - Norma C Ware
- Department of Global Health and Social MedicineHarvard Medical SchoolBostonMAUSA
- Department of MedicineBrigham & Women's HospitalBostonMAUSA
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Fertility Intentions, Pregnancy, and Use of PrEP and ART for Safer Conception Among East African HIV Serodiscordant Couples. AIDS Behav 2018; 22:1758-1765. [PMID: 28894986 DOI: 10.1007/s10461-017-1902-7] [Citation(s) in RCA: 26] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
African HIV serodiscordant couples often desire pregnancy, despite sexual HIV transmission risk during pregnancy attempts. Pre-exposure prophylaxis (PrEP) and antiretroviral therapy (ART) reduce HIV risk and can be leveraged for safer conception but how well these strategies are used for safer conception is not known. We conducted an open-label demonstration project of the integrated delivery of PrEP and ART among 1013 HIV serodiscordant couples from Kenya and Uganda followed quarterly for 2 years. We evaluated fertility intentions, pregnancy incidence, the use of PrEP and ART during peri-conception, and peri-conception HIV incidence. At enrollment, 80% of couples indicated a desire for more children. Pregnancy incidence rates were 18.5 and 18.7 per 100 person years among HIV-uninfected and HIV-infected women, and higher among women who recently reported fertility intention (adjusted odds ratio 3.43, 95% CI 2.38-4.93) in multivariable GEE models. During the 6 months preceding pregnancy, 82.9% of couples used PrEP or ART and there were no HIV seroconversions. In this cohort with high pregnancy rates, integrated PrEP and ART was readily used by HIV serodiscordant couples, including during peri-conception periods. Widespread scale-up of safer conception counseling and services is warranted to respond to strong desires for pregnancy among HIV-affected men and women.
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Malone J, Syvertsen JL, Johnson BE, Mimiaga MJ, Mayer KH, Bazzi AR. Negotiating sexual safety in the era of biomedical HIV prevention: relationship dynamics among male couples using pre-exposure prophylaxis. CULTURE, HEALTH & SEXUALITY 2018; 20:658-672. [PMID: 28872441 PMCID: PMC5837897 DOI: 10.1080/13691058.2017.1368711] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/12/2023]
Abstract
Up to two-thirds of new cases of HIV transmission between gay, bisexual and other men who have sex with men in the USA are attributed to primary relationships. Understanding the relationship dynamics and sexual agreements of male-male couples can provide insight into HIV transmission patterns and prevention needs in this population. The daily use of antiretroviral pre-exposure prophylaxis (PrEP) is highly effective in preventing HIV, but its negotiation and use within social and intimate relationship contexts remain understudied. We conducted semi-structured qualitative interviews with 20 male couples (n = 40 men) in which at least one partner was either using or in the process of initiating PrEP. Congruent with a theoretical focus on social theories of relationships and negotiated risk, couples were interviewed about relationship dynamics, trust, communication and sexual health practices, including their perception and use of PrEP. Overall, we found that couples showed heightened trust and communication when establishing open, sexual agreements and demonstrated high awareness of sexual risks and health practices in the context of PrEP use. This study demonstrates how understanding relationship dynamics can better inform HIV prevention and sexual health promotion efforts for male couples at risk of HIV.
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Affiliation(s)
- Jowanna Malone
- a Harvard T.H. Chan School of Public Health , Boston , MA , USA
| | | | - Blake E Johnson
- c University of North Carolina School of Medicine , Chapel Hill , NC , USA
| | - Matthew J Mimiaga
- d Departments of Behavioral & Social Health Sciences and Epidemiology, School of Public Health , Brown University , Providence , RI , USA
- e Department of Psychiatry & Human Behavior, Alpert Medical School , Brown University , Providence , RI , USA
- f Center for Health Equity Research , Brown University , Providence , RI , USA
- g The Fenway Institute, Fenway Health , Boston , MA , USA
| | - Kenneth H Mayer
- g The Fenway Institute, Fenway Health , Boston , MA , USA
- h Infectious Disease Division , Beth Israel Deaconess Medical Center and Harvard Medical School , Boston , MA , USA
| | - Angela R Bazzi
- i Department of Community Health Sciences , Boston University School of Public Health , Boston MA , USA
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Ware NC, Pisarski EE, Nakku‐Joloba E, Wyatt MA, Muwonge TR, Turyameeba B, Asiimwe SB, Heffron RA, Baeten JM, Celum CL, Katabira ET. Integrated delivery of antiretroviral treatment and pre-exposure prophylaxis to HIV-1 serodiscordant couples in East Africa: a qualitative evaluation study in Uganda. J Int AIDS Soc 2018; 21:e25113. [PMID: 29851436 PMCID: PMC5980503 DOI: 10.1002/jia2.25113] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2017] [Accepted: 05/04/2018] [Indexed: 01/02/2023] Open
Abstract
INTRODUCTION Serodiscordant couples are a priority population for delivery of new HIV prevention interventions in Africa. An integrated strategy of delivering time-limited, oral pre-exposure prophylaxis (PrEP) to uninfected partners in serodiscordant couples as a bridge to long-term antiretroviral treatment (ART) for infected partners has been implemented in East Africa, nearly eliminating new infections. We conducted a qualitative evaluation of the integrated strategy in Uganda, to better understand its success. METHODS Data collection consisted of 274 in-depth interviews with 93 participating couples, and 55 observations of clinical encounters between couples and healthcare providers. An inductive content analytic approach aimed at understanding and interpreting couples' experiences of the integrated strategy was used to examine the data. Analysis sought to characterize: (1) key aspects of services provided; (2) what the services meant to recipients; and (3) how couples managed the integrated strategy. Themes were identified in each domain, and represented as descriptive categories. Categories were grouped inductively into more general propositions based on shared content. Propositions were linked and interpreted to explain "why the integrated strategy worked." RESULTS Couples found "couples-focused" services provided through the integrated strategy strengthened partnered relationships threatened by the discovery of serodiscordance. They saw in services hope for "getting help" to stay together, turned joint visits to clinic into opportunities for mutual support, and experienced counselling as bringing them closer together. Couples adopted a "couples orientation" to the integrated strategy, considering the health of partners as they made decisions about initiating ART or accepting PrEP, and devising joint approaches to adherence. A couples orientation to services, grounded in strengthened partnerships, may have translated to greater success in using antiretrovirals to prevent HIV transmission. CONCLUSIONS Various strategies for delivering antiretrovirals for HIV prevention are being evaluated. Understanding how and why these strategies work will improve evaluation processes and strengthen implementation platforms. We highlight the role of service organization in shaping couples' experiences of and responses to ART and PrEP in the context of the integrated strategy. Organizing services to promote positive care experiences will strengthen delivery and contribute to positive outcomes as antiretrovirals for prevention are rolled out.
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Affiliation(s)
- Norma C Ware
- Department of MedicineBrigham and Women's HospitalBostonMAUSA
- Department of Global Health and Social MedicineHarvard Medical SchoolBostonMAUSA
| | - Emily E Pisarski
- Department of Global Health and Social MedicineHarvard Medical SchoolBostonMAUSA
| | - Edith Nakku‐Joloba
- Department of Epidemiology and BiostatisticsMakerere University College of Health SciencesKampalaUganda
- STD Clinic/Ward 12Mulago HospitalKampalaUganda
| | - Monique A Wyatt
- Department of Global Health and Social MedicineHarvard Medical SchoolBostonMAUSA
- Harvard GlobalCambridgeMAUSA
| | | | | | | | - Renee A Heffron
- Department of Global HealthUniversity of WashingtonSeattleWAUSA
| | - Jared M Baeten
- Department of Global HealthUniversity of WashingtonSeattleWAUSA
| | - Connie L Celum
- Department of Global HealthUniversity of WashingtonSeattleWAUSA
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Kim HY, Hanrahan CF, Dowdy DW, Martinson N, Golub J, Bridges JFP. The effect of partner HIV status on motivation to take antiretroviral and isoniazid preventive therapies: a conjoint analysis. AIDS Care 2018; 30:1298-1305. [PMID: 29595060 DOI: 10.1080/09540121.2018.1455958] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
Abstract
Antiretroviral therapy (ART) and isoniazid preventive therapy (IPT) are important to reduce morbidity and mortality among people newly diagnosed of HIV. The successful uptake of ART and IPT requires a comprehensive understanding of patients' motivation to take such therapies. Partners also play an important role in the decision to be initiated and retained in care. We quantified patients' motivation to take preventive therapies (ART and IPT) and compared by partner HIV status among people newly diagnosed of HIV. We enrolled and surveyed adults (≥18 years) with a recent HIV diagnosis (<6 months) from 14 public primary care clinics in Matlosana, South Africa. Participants received eight forced-choice tasks comparing two mutually exclusive sub-sets of seven possible benefits related to preventive therapies. A linear probability model was fitted to estimate the probability of prioritizing each benefit. Tests of concordance were conducted across partner HIV status (no partner, HIV- or unknown, or HIV+). A total of 424 people completed surveys. At the time of interview, 272 (64%) were on ART and 334 (79%) had a partner or spouse. Keeping themselves healthy for their family was the most important motivator to take preventive therapies (p < 0.001). Preventing HIV transmission to partners was also highly prioritized among participants with current partners independent of partner's HIV status (p < 0.001), but it was least prioritized among those without current partners (p = 0.72). Keeping themselves healthy was less prioritized. We demonstrate that social responsibility such as supporting family and preventing HIV transmission to partners may pose greater motivation for ART and IPT initiation and adherence compared to individual health benefits. These messages should be emphasized to provide effective patient-centered care and counseling.
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Affiliation(s)
- Hae-Young Kim
- a Department of Epidemiology , Johns Hopkins Bloomberg School of Public Health , Baltimore , MD , USA
| | - Colleen F Hanrahan
- a Department of Epidemiology , Johns Hopkins Bloomberg School of Public Health , Baltimore , MD , USA
| | - David W Dowdy
- a Department of Epidemiology , Johns Hopkins Bloomberg School of Public Health , Baltimore , MD , USA.,b Department of International Health , Johns Hopkins Bloomberg School of Public Health , Baltimore , MD , USA
| | - Neil Martinson
- c Perinatal HIV Research Unit , University of Witwatersrand , Johannesburg , South Africa.,d Center for Tuberculosis Research , Johns Hopkins University , Baltimore , MD , USA
| | - Jonathan Golub
- a Department of Epidemiology , Johns Hopkins Bloomberg School of Public Health , Baltimore , MD , USA.,b Department of International Health , Johns Hopkins Bloomberg School of Public Health , Baltimore , MD , USA.,d Center for Tuberculosis Research , Johns Hopkins University , Baltimore , MD , USA
| | - John F P Bridges
- b Department of International Health , Johns Hopkins Bloomberg School of Public Health , Baltimore , MD , USA.,e Department of Health Policy and Management , Johns Hopkins Bloomberg School of Public Health , Baltimore , MD , USA.,f Department of Health Behavior and Society , Johns Hopkins Bloomberg School of Public Health , Baltimore , MD , USA
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Mujugira A, Baeten J, Kidoguchi L, Haberer J, Celum C, Donnell D, Ngure K, Bukusi E, Mugo N, Asiimwe S, Odoyo J, Tindimwebwa E, Bulya N, Katabira E, Heffron R. High levels of viral suppression among East African HIV-infected women and men in serodiscordant partnerships initiating antiretroviral therapy with high CD4 counts and during pregnancy. AIDS Res Hum Retroviruses 2018; 34:140-147. [PMID: 28899162 PMCID: PMC5806074] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/16/2024] Open
Abstract
BACKGROUND People who are asymptomatic and feel healthy, including pregnant women, may be less motivated to initiate ART or achieve high adherence. We assessed whether ART initiation, and viral suppression 6, 12 and 24-months after ART initiation, were lower in HIV-infected members of serodiscordant couples who initiated during pregnancy or with higher CD4 counts. METHODS We used data from the Partners Demonstration Project, an open-label study of the delivery of integrated PrEP and ART (at any CD4 count) for HIV prevention among high-risk HIV serodiscordant couples in Kenya and Uganda. Differences in viral suppression (HIV RNA <400 copies/ml) among people initiating ART at different CD4 count levels (≤350, 351-500, and >500 cells/mm3) and during pregnancy were estimated using Poisson regression. RESULTS Of 865 HIV-infected participants retained after becoming eligible for ART during study follow-up, 95% initiated ART. Viral suppression 24-months after ART initiation was high overall (97%), and comparable among those initiating ART at CD4 counts >500, 351-500 and ≤350 cells/mm3 (96% vs 97% vs 97%; relative risk [RR] 0.98; 95% CI: 0.93-1.03 for CD4 >500 vs <350 and RR 0.99; 95% CI: (0.93-1.06) for CD4 351-500 vs ≤350). Viral suppression was as likely among women initiating ART primarily to prevent perinatal transmission as ART initiation for other reasons (p=0.9 at 6 months and p=0.5 at 12 months). CONCLUSIONS Nearly all HIV-infected partners initiating ART were virally suppressed by 24 months, irrespective of CD4 count or pregnancy status. These findings suggest that people initiating ART at high CD4 counts or due to pregnancy can adhere to ART as well as those starting treatment with symptomatic HIV disease or low CD4 counts.
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Affiliation(s)
- Andrew Mujugira
- University of Washington, Department of Global Health , 901 Boren Ave , Suite 1300 , Seattle, Washington, United States , 98104 ;
| | | | | | | | | | - Deborah Donnell
- Fred Hutchinson Cancer Research Center, SCHARP/VIDI/PHS , 1100 Fairview Ave N , Seattle, Washington, United States , 98109 ;
| | | | | | - Nelly Mugo
- Kenya Medical Research Institute, Nairobi, Kenya ;
| | | | | | | | | | - Elly Katabira
- Makerere University, Infectious Disease Institute, Kampala, Uganda ;
| | - Renee Heffron
- University of Washington, Department of Epidemiology, Seattle, United States ;
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Heffron R, Ngure K, Odoyo J, Bulya N, Tindimwebwa E, Hong T, Kidoguchi L, Donnell D, Mugo NR, Bukusi EA, Katabira E, Asiimwe S, Morton J, Morrison S, Haugen H, Mujugira A, Haberer JE, Ware NC, Wyatt MA, Marzinke MA, Frenkel LM, Celum C, Baeten JM. Pre-exposure prophylaxis for HIV-negative persons with partners living with HIV: uptake, use, and effectiveness in an open-label demonstration project in East Africa. Gates Open Res 2018; 1:3. [PMID: 29355231 DOI: 10.12688/gatesopenres.12752.1] [Citation(s) in RCA: 51] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/23/2017] [Indexed: 01/23/2023] Open
Abstract
Background: Pre-exposure prophylaxis (PrEP) can provide high protection against HIV infection and is a recommended intervention for HIV-negative persons with substantial HIV risk. Demonstration projects conducted in diverse settings worldwide illustrate practical examples of how PrEP can be delivered. This manuscript presents estimates of effectiveness and patterns of PrEP use within a two-year demonstration project of PrEP for HIV-negative members of heterosexual HIV serodiscordant couples in East Africa. Methods: The PrEP delivery model integrated PrEP into HIV treatment services, prioritizing PrEP use for HIV-negative partners within serodiscordant couples before and during the first 6 months after the partner living with HIV initiated antiretroviral therapy (ART). We measured PrEP uptake through pharmacy records and adherence to PrEP through medication event monitoring system (MEMS) bottle caps and quantification of tenofovir in plasma among a random sample of participants. We estimated HIV infections prevented using a counterfactual cohort simulated from the placebo arm of a previous PrEP clinical trial. Results: We enrolled 1,010 HIV serodiscordant couples that were naïve to ART and PrEP. Ninety-seven percent of HIV-negative partners initiated PrEP. Objective measures suggest high adherence: 71% of HIV-negative participants took ≥80% of expected doses, as recorded via MEMS, and 81% of plasma samples had tenofovir detected. Four incident HIV infections were observed (incidence rate=0.24 per 100 person-years), a 95% reduction (95% CI 86-98%, p<0.0001) in HIV incidence, relative to estimated HIV incidence for the population in the absence of PrEP integrated into HIV treatment services. Conclusions: PrEP uptake and adherence were high and incident HIV was rare in this PrEP demonstration project for African HIV-negative individuals whose partners were known to be living with HIV. Delivery of PrEP to HIV-negative partners within HIV serodiscordant couples was feasible and should be prioritized for wide-scale implementation.
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Affiliation(s)
- Renee Heffron
- Department of Epidemiology, University of Washington, Seattle, USA.,Department of Global Health, University of Washington, Seattle, USA
| | - Kenneth Ngure
- College of Health Sciences, Jomo Kenyatta University of Agriculture and Technology, Nairobi, Kenya
| | - Josephine Odoyo
- Centres for Microbiology Research , Kenya Medical Research Institute, Nairobi, Kenya
| | - Nulu Bulya
- Infectious Diseases Institute, Makerere University, Kampala, Uganda
| | | | - Ting Hong
- Department of Global Health, University of Washington, Seattle, USA
| | - Lara Kidoguchi
- Department of Global Health, University of Washington, Seattle, USA
| | - Deborah Donnell
- Department of Global Health, University of Washington, Seattle, USA.,Vaccine and Infectious Disease Division, Fred Hutchinson Cancer Research Center, Seattle, USA
| | - Nelly R Mugo
- Department of Global Health, University of Washington, Seattle, USA.,Centres for Clinical Research, Kenya Medical Research Institute, Nairobi, Kenya
| | - Elizabeth A Bukusi
- Department of Global Health, University of Washington, Seattle, USA.,Centres for Microbiology Research , Kenya Medical Research Institute, Nairobi, Kenya.,Department of Obstetrics and Gynecology, University of Washington, Seattle, USA
| | - Elly Katabira
- Infectious Diseases Institute, Makerere University, Kampala, Uganda
| | | | - Jennifer Morton
- Department of Global Health, University of Washington, Seattle, USA
| | - Susan Morrison
- Department of Global Health, University of Washington, Seattle, USA
| | - Harald Haugen
- Department of Global Health, University of Washington, Seattle, USA
| | - Andrew Mujugira
- Infectious Diseases Institute, Makerere University, Kampala, Uganda
| | - Jessica E Haberer
- Harvard Medical School - Massachusetts General Hospital, Boston, USA
| | - Norma C Ware
- Department of Global Health and Social Medicine, Harvard Medical School, Boston, USA
| | - Monique A Wyatt
- Department of Global Health and Social Medicine, Harvard Medical School, Boston, USA.,Harvard Global, Cambridge, USA
| | - Mark A Marzinke
- Department of Medicine, Johns Hopkins University, Baltimore, USA
| | - Lisa M Frenkel
- Seattle Children's Research Center, Seattle, USA.,Department of Laboratory Medicine, University of Washington, Seattle, USA.,Department of Pediatrics, University of Washington, Seattle, USA
| | - Connie Celum
- Department of Epidemiology, University of Washington, Seattle, USA.,Department of Global Health, University of Washington, Seattle, USA.,Department of Medicine, University of Washington, Seattle, USA
| | - Jared M Baeten
- Department of Epidemiology, University of Washington, Seattle, USA.,Department of Global Health, University of Washington, Seattle, USA.,Department of Medicine, University of Washington, Seattle, USA
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Heffron R, Ngure K, Odoyo J, Bulya N, Tindimwebwa E, Hong T, Kidoguchi L, Donnell D, Mugo NR, Bukusi EA, Katabira E, Asiimwe S, Morton J, Morrison S, Haugen H, Mujugira A, Haberer JE, Ware NC, Wyatt MA, Marzinke MA, Frenkel LM, Celum C, Baeten JM. Pre-exposure prophylaxis for HIV-negative persons with partners living with HIV: uptake, use, and effectiveness in an open-label demonstration project in East Africa. Gates Open Res 2018; 1:3. [PMID: 29355231 PMCID: PMC5757790 DOI: 10.12688/gatesopenres.12752.2] [Citation(s) in RCA: 55] [Impact Index Per Article: 9.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/29/2018] [Indexed: 01/06/2023] Open
Abstract
Background: Pre-exposure prophylaxis (PrEP) can provide high protection against HIV infection and is a recommended intervention for HIV-negative persons with substantial HIV risk. Demonstration projects conducted in diverse settings worldwide illustrate practical examples of how PrEP can be delivered. This manuscript presents estimates of effectiveness and patterns of PrEP use within a two-year demonstration project of PrEP for HIV-negative members of heterosexual HIV serodiscordant couples in East Africa. Methods: The PrEP delivery model integrated PrEP into HIV treatment services, prioritizing PrEP use for HIV-negative partners within serodiscordant couples before and during the first 6 months after the partner living with HIV initiated antiretroviral therapy (ART). We measured PrEP uptake through pharmacy records and adherence to PrEP through medication event monitoring system (MEMS) bottle caps and quantification of tenofovir in plasma among a random sample of participants. We estimated HIV infections prevented using a counterfactual cohort simulated from the placebo arm of a previous PrEP clinical trial. Results: We enrolled 1,010 HIV serodiscordant couples that were naïve to ART and PrEP. Ninety-seven percent of HIV-negative partners initiated PrEP. Objective measures suggest high adherence: 71% of HIV-negative participants took ≥80% of expected doses, as recorded via MEMS, and 81% of plasma samples had tenofovir detected. Four incident HIV infections were observed (incidence rate=0.24 per 100 person-years), a 95% reduction (95% CI 86-98%, p<0.0001) in HIV incidence, relative to estimated HIV incidence for the population in the absence of PrEP integrated into HIV treatment services. Conclusions: PrEP uptake and adherence were high and incident HIV was rare in this PrEP demonstration project for African HIV-negative individuals whose partners were known to be living with HIV. Delivery of PrEP to HIV-negative partners within HIV serodiscordant couples was feasible and should be prioritized for wide-scale implementation.
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Affiliation(s)
- Renee Heffron
- Department of Epidemiology, University of Washington, Seattle, USA.,Department of Global Health, University of Washington, Seattle, USA
| | - Kenneth Ngure
- College of Health Sciences, Jomo Kenyatta University of Agriculture and Technology, Nairobi, Kenya
| | - Josephine Odoyo
- Centres for Microbiology Research , Kenya Medical Research Institute, Nairobi, Kenya
| | - Nulu Bulya
- Infectious Diseases Institute, Makerere University, Kampala, Uganda
| | | | - Ting Hong
- Department of Global Health, University of Washington, Seattle, USA
| | - Lara Kidoguchi
- Department of Global Health, University of Washington, Seattle, USA
| | - Deborah Donnell
- Department of Global Health, University of Washington, Seattle, USA.,Vaccine and Infectious Disease Division, Fred Hutchinson Cancer Research Center, Seattle, USA
| | - Nelly R Mugo
- Department of Global Health, University of Washington, Seattle, USA.,Centres for Clinical Research, Kenya Medical Research Institute, Nairobi, Kenya
| | - Elizabeth A Bukusi
- Department of Global Health, University of Washington, Seattle, USA.,Centres for Microbiology Research , Kenya Medical Research Institute, Nairobi, Kenya.,Department of Obstetrics and Gynecology, University of Washington, Seattle, USA
| | - Elly Katabira
- Infectious Diseases Institute, Makerere University, Kampala, Uganda
| | | | - Jennifer Morton
- Department of Global Health, University of Washington, Seattle, USA
| | - Susan Morrison
- Department of Global Health, University of Washington, Seattle, USA
| | - Harald Haugen
- Department of Global Health, University of Washington, Seattle, USA
| | - Andrew Mujugira
- Infectious Diseases Institute, Makerere University, Kampala, Uganda
| | - Jessica E Haberer
- Harvard Medical School - Massachusetts General Hospital, Boston, USA
| | - Norma C Ware
- Department of Global Health and Social Medicine, Harvard Medical School, Boston, USA
| | - Monique A Wyatt
- Department of Global Health and Social Medicine, Harvard Medical School, Boston, USA.,Harvard Global, Cambridge, USA
| | - Mark A Marzinke
- Department of Medicine, Johns Hopkins University, Baltimore, USA
| | - Lisa M Frenkel
- Seattle Children's Research Center, Seattle, USA.,Department of Laboratory Medicine, University of Washington, Seattle, USA.,Department of Pediatrics, University of Washington, Seattle, USA
| | - Connie Celum
- Department of Epidemiology, University of Washington, Seattle, USA.,Department of Global Health, University of Washington, Seattle, USA.,Department of Medicine, University of Washington, Seattle, USA
| | - Jared M Baeten
- Department of Epidemiology, University of Washington, Seattle, USA.,Department of Global Health, University of Washington, Seattle, USA.,Department of Medicine, University of Washington, Seattle, USA
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Brief Report: PrEP Use During Periods of HIV Risk Among East African Women in Serodiscordant Relationships. J Acquir Immune Defic Syndr 2017; 77:41-45. [PMID: 29016523 DOI: 10.1097/qai.0000000000001561] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Pre-exposure prophylaxis (PrEP) is efficacious for African women at risk for HIV, but data on adherence outside clinical trials are sparse. We describe the persistence and execution of PrEP use among women participating in a large open-label PrEP demonstration project, particularly during periods of HIV risk. SETTING AND METHODS Three hundred ten HIV-uninfected women in HIV serodiscordant couples in Kenya and Uganda were offered and accepted PrEP. Electronic monitoring caps were used to measure daily PrEP adherence. Time on PrEP while at risk for HIV (when the HIV-infected partner was on antiretroviral therapy <6 months) and weekly adherence while on PrEP were calculated and compared among older and younger (<25 years old) women. RESULTS As defined above, women were at risk for HIV for an average of 361 days; 54% took PrEP during their entire risk period and 24% stopped but restarted PrEP during their risk period. While on PrEP, women took ≥6 doses/wk for 78% of weeks [67% of weeks for women aged <25 years, 80% of weeks for women aged ≥25 years (P < 0.001)], and ≥4 doses for 88% of weeks [80% for those <25, 90% for those ≥25, (P < 0.001)]. Compared with historical, risk-matched controls, HIV incidence was reduced 93% (95% confidence interval: 77% to 98%) for all women and 91% (95% confidence interval: 29% to 99%) among women aged <25 years. CONCLUSION Women, including young women, in HIV-serodiscordant couples took PrEP successfully over sustained periods of risk. Although young women had lower adherence than older women, they achieved strong protection, which suggests that women can align PrEP use to periods of risk and imperfect adherence can still provide substantial benefit.
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Chi BH, Rosenberg NE, Mweemba O, Powers KA, Zimba C, Maman S, Kasaro M, Mollan KR, Stringer JS, Mutale W. Involving both parents in HIV prevention during pregnancy and breastfeeding. Bull World Health Organ 2017; 96:69-71. [PMID: 29403103 PMCID: PMC5791874 DOI: 10.2471/blt.17.200139] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2017] [Revised: 10/26/2017] [Accepted: 11/10/2017] [Indexed: 11/27/2022] Open
Affiliation(s)
- Benjamin H Chi
- Schools of Medicine and Public Health, University of North Carolina at Chapel Hill, Campus Box 7577, MBRB 4300C, Chapel Hill, North Carolina, United States of America
| | - Nora E Rosenberg
- Schools of Medicine and Public Health, University of North Carolina at Chapel Hill, Campus Box 7577, MBRB 4300C, Chapel Hill, North Carolina, United States of America
| | - Oliver Mweemba
- School of Public Health, University of Zambia, Lusaka, Zambia
| | - Kimberly A Powers
- Schools of Medicine and Public Health, University of North Carolina at Chapel Hill, Campus Box 7577, MBRB 4300C, Chapel Hill, North Carolina, United States of America
| | - Chifundo Zimba
- Schools of Medicine and Public Health, University of North Carolina at Chapel Hill, Campus Box 7577, MBRB 4300C, Chapel Hill, North Carolina, United States of America
| | - Suzanne Maman
- Schools of Medicine and Public Health, University of North Carolina at Chapel Hill, Campus Box 7577, MBRB 4300C, Chapel Hill, North Carolina, United States of America
| | - Margaret Kasaro
- Schools of Medicine and Public Health, University of North Carolina at Chapel Hill, Campus Box 7577, MBRB 4300C, Chapel Hill, North Carolina, United States of America
| | - Katie R Mollan
- Schools of Medicine and Public Health, University of North Carolina at Chapel Hill, Campus Box 7577, MBRB 4300C, Chapel Hill, North Carolina, United States of America
| | - Jeffrey Sa Stringer
- Schools of Medicine and Public Health, University of North Carolina at Chapel Hill, Campus Box 7577, MBRB 4300C, Chapel Hill, North Carolina, United States of America
| | - Wilbroad Mutale
- School of Public Health, University of Zambia, Lusaka, Zambia
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Brief Report: Context Matters: PrEP Adherence is Associated With Sexual Behavior Among HIV Serodiscordant Couples in East Africa. J Acquir Immune Defic Syndr 2017; 76:488-492. [PMID: 28961676 DOI: 10.1097/qai.0000000000001548] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Short message service (SMS) surveys are a promising tool for understanding whether preexposure prophylaxis (PrEP) adherence aligns with risk for HIV acquisition-a concept known as prevention-effective adherence. METHODS The Partners Demonstration Project was an open-label study of integrated PrEP and antiretroviral therapy (ART) delivery among high-risk HIV serodiscordant couples in East Africa. HIV-uninfected partners were offered PrEP until their HIV-infected partner had taken ART for ≥6 months. At 2 study sites, HIV-uninfected partners were offered enrollment into the Partners Mobile Adherence to PrEP (PMAP) substudy based on ongoing PrEP use, personal cell phone ownership, and ability to use SMS. SMS surveys asked about PrEP adherence and sexual activity in the previous 24 hours; these surveys were sent daily for the 7 days before and 7 days after routine study visits in the Partners Demonstration Project. RESULTS The PMAP substudy enrolled 373 HIV-uninfected partners; 69% were men and mean age was 31 years. Participants completed 17,030 of 23,056 SMS surveys sent (74%) with a mean of 47 surveys per participant over 9.8 months of follow-up. While HIV-infected partner use of ART was <6 months, mean reported PrEP adherence was 92% on surveys concurrently reporting sex within the serodiscordant partnership, and 84% on surveys reporting no sex (P < 0.001). DISCUSSION SMS surveys provided daily assessment of concurrent PrEP adherence and sexual behavior. Higher PrEP adherence was temporally associated with increased risk for HIV acquisition.
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Alignment of adherence and risk for HIV acquisition in a demonstration project of pre-exposure prophylaxis among HIV serodiscordant couples in Kenya and Uganda: a prospective analysis of prevention-effective adherence. J Int AIDS Soc 2017; 20:21842. [PMID: 28741331 PMCID: PMC5577705 DOI: 10.7448/ias.20.1.21842] [Citation(s) in RCA: 62] [Impact Index Per Article: 8.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022] Open
Abstract
Introduction: Adherence is essential for pre-exposure prophylaxis (PrEP) to protect against HIV acquisition, but PrEP use need not be life-long. PrEP is most efficient when its use is aligned with periods of risk – a concept termed prevention-effective adherence. The objective of this paper is to describe prevention-effective adherence and predictors of adherence within an open-label delivery project of integrated PrEP and antiretroviral therapy (ART) among HIV serodiscordant couples in Kenya and Uganda (the Partners Demonstration Project). Methods: We offered PrEP to HIV-uninfected participants until the partner living with HIV had taken ART for ≥6 months (a strategy known as “PrEP as a bridge to ART”). The level of adherence sufficient to protect against HIV was estimated in two ways: ≥4 and ≥6 doses/week (per electronic monitoring). Risk for HIV acquisition was considered high if the couple reported sex with <100% condom use before six months of ART, low if they reported sex but had 100% condom use and/or six months of ART and very low if no sex was reported. We assessed prevention-effective adherence by cross-tabulating PrEP use with HIV risk and used multivariable regression models to assess predictors of ≥4 and ≥6 doses/week. Results: A total of 985 HIV-uninfected participants initiated PrEP; 67% were male, median age was twenty-nine years, and 67% reported condomless sex in the month before enrolment. An average of ≥4 doses and ≥6 doses/week were taken in 81% and 67% of participant-visits, respectively. Adherence sufficient to protect against HIV acquisition was achieved in 75–88% of participant-visits with high HIV risk. The strongest predictor of achieving sufficient adherence was reporting sex with the study partner who was living with HIV; other statistically significant predictors included no concerns about daily PrEP, pregnancy or pregnancy intention, females aged >25 years, older male partners and desire for relationship success. Predictors of not achieving sufficient adherence were no longer being a couple, delayed PrEP initiation, >6 months of follow-up, ART use >6 months by the partner living with HIV and problem alcohol use. Conclusions: Over three-quarters of participant-visits by HIV-uninfected partners in serodiscordant couples achieved prevention-effective adherence with PrEP. Greater adherence was observed during months with HIV risk and the strongest predictor of achieving sufficient adherence was sexual activity.
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HIV Incidence and Predictors of HIV Acquisition From an Outside Partner in Serodiscordant Couples in Lusaka, Zambia. J Acquir Immune Defic Syndr 2017; 76:123-131. [PMID: 28737591 PMCID: PMC5597474 DOI: 10.1097/qai.0000000000001494] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
OBJECTIVE Evaluate the incidence and predictors of HIV acquisition from outside partners in serodiscordant couples. METHODS Demographic, behavioral, and clinical exposures were measured quarterly in a cohort of serodiscordant cohabiting couples in Zambia from 1995 to 2012 (n = 3049). Genetic analysis classified incident infections as those acquired from the study partner (linked) or acquired from an outside partner (unlinked). Factors associated with time to unlinked HIV infection were evaluated using multivariable Cox proportional hazards regression stratified by sex. RESULTS There were 100 unlinked infections in couples followed for a median of 806 days. Forty-five infections occurred in women [1.85/100 couple-years; 95% confidence interval (CI): 1.35 to 2.47]. Risk of female unlinked infection (vs. nonseroconverting females) was associated with reporting being drunk weekly/daily vs. moderate/nondrinkers at baseline [adjusted hazard ratio (aHR) = 5.44; 95% CI: 1.03 to 28.73], genital ulcers (aHR = 6.09; 95% CI: 2.72 to 13.64), or genital inflammation (aHR = 11.92; 95% CI: 5.60 to 25.37) during follow-up adjusting for age, years cohabiting, income, contraceptive use, previous pregnancies, history of sexually transmitted infections, and condomless sex with study partner. Fifty-five infections occurred in men (1.82/100 couple-years; 95% CI: 1.37 to 2.37). Risk of male unlinked infection was associated with genital inflammation (aHR = 8.52; 95% CI: 3.82 to 19.03) or genital ulceration (aHR = 2.31; 95% CI: 2.05 to 8.89), reporting ≥1 outside sexual partner (aHR = 3.86; 95% CI: 0.98 to 15.17) during follow-up, and reporting being drunk weekly/daily vs. moderate/nondrinkers at baseline (aHR = 3.84; 95% CI: 1.28 to 11.55), controlling for age, income, circumcision status, and history of sexually transmitted infection. CONCLUSIONS Predictors of unlinked infection in serodiscordant relationships were alcohol use, genital inflammation, and ulceration. Causes of genital inflammation and ulceration should be screened for and treated in HIV-negative individuals. Counseling on risk of alcohol use and sex with outside partners should be discussed with couples where 1 or both are HIV-negative, including in counseling on use of pre-exposure prophylaxis to prevent HIV acquisition in the HIV-negative partner (when feasible and affordable).
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Mujugira A, Baeten JM, Kidoguchi L, Haberer J, Celum C, Donnell D, Ngure K, Bukusi EA, Mugo N, Asiimwe S, Odoyo J, Tindimwebwa E, Bulya N, Katabira E, Heffron R, for the Partners Demonstration Proj. High levels of viral suppression among East African HIV-infected women and men in serodiscordant partnerships initiating antiretroviral therapy with high CD4 counts and during pregnancy. AIDS Res Hum Retroviruses 2017. [PMID: 28899162 DOI: 10.1089/aid.2017.0020] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/14/2023] Open
Abstract
BACKGROUND People who are asymptomatic and feel healthy, including pregnant women, may be less motivated to initiate ART or achieve high adherence. We assessed whether ART initiation, and viral suppression 6, 12 and 24-months after ART initiation, were lower in HIV-infected members of serodiscordant couples who initiated during pregnancy or with higher CD4 counts. METHODS We used data from the Partners Demonstration Project, an open-label study of the delivery of integrated PrEP and ART (at any CD4 count) for HIV prevention among high-risk HIV serodiscordant couples in Kenya and Uganda. Differences in viral suppression (HIV RNA <400 copies/ml) among people initiating ART at different CD4 count levels (≤350, 351-500, and >500 cells/mm3) and during pregnancy were estimated using Poisson regression. RESULTS Of 865 HIV-infected participants retained after becoming eligible for ART during study follow-up, 95% initiated ART. Viral suppression 24-months after ART initiation was high overall (97%), and comparable among those initiating ART at CD4 counts >500, 351-500 and ≤350 cells/mm3 (96% vs 97% vs 97%; relative risk [RR] 0.98; 95% CI: 0.93-1.03 for CD4 >500 vs <350 and RR 0.99; 95% CI: (0.93-1.06) for CD4 351-500 vs ≤350). Viral suppression was as likely among women initiating ART primarily to prevent perinatal transmission as ART initiation for other reasons (p=0.9 at 6 months and p=0.5 at 12 months). CONCLUSIONS Nearly all HIV-infected partners initiating ART were virally suppressed by 24 months, irrespective of CD4 count or pregnancy status. These findings suggest that people initiating ART at high CD4 counts or due to pregnancy can adhere to ART as well as those starting treatment with symptomatic HIV disease or low CD4 counts.
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Affiliation(s)
- Andrew Mujugira
- Department of Global Health, University of Washington, Seattle, Washington
| | - Jared M. Baeten
- Department of Global Health, University of Washington, Seattle, Washington
- Department of Epidemiology, University of Washington, Seattle, Washington
- Department of Medicine, University of Washington, Seattle, Washington
| | - Lara Kidoguchi
- Department of Global Health, University of Washington, Seattle, Washington
| | | | - Connie Celum
- Department of Global Health, University of Washington, Seattle, Washington
- Department of Epidemiology, University of Washington, Seattle, Washington
- Department of Medicine, University of Washington, Seattle, Washington
| | - Deborah Donnell
- Department of Global Health, University of Washington, Seattle, Washington
| | - Kenneth Ngure
- Department of Global Health, University of Washington, Seattle, Washington
- School of Public Health, Jomo Kenyatta University of Agriculture and Technology, Juja, Kenya
| | - Elizabeth A. Bukusi
- Department of Global Health, University of Washington, Seattle, Washington
- Center for Microbiology Research, Kenya Medical Research Institute, Nairobi, Kenya
| | - Nelly Mugo
- Department of Global Health, University of Washington, Seattle, Washington
- Center for Clinical Research, Kenya Medical Research Institute, Nairobi, Kenya
| | | | - Josephine Odoyo
- Center for Microbiology Research, Kenya Medical Research Institute, Nairobi, Kenya
| | | | - Nulu Bulya
- Infectious Disease Institute, Makerere University, Kampala, Uganda
| | - Elly Katabira
- Infectious Disease Institute, Makerere University, Kampala, Uganda
| | - Renee Heffron
- Department of Global Health, University of Washington, Seattle, Washington
- Department of Epidemiology, University of Washington, Seattle, Washington
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Abstract
Health communication is a broad term that applies to the fundamental need for practitioners, policy makers, patients, and community members to understand one another around health promotion and health care issues. Whether in a consultation between nurse and patient, a health clinic director's engagement with the health ministry, or a community campaign for encouraging HIV testing, all have critical health communication elements. When people's needs are not perceived by them to be addressed or clients/patients do not understand what is being communicated, they are unmotivated to engage. Health communication may be deployed at multiple levels to encourage positive behavior change and affect HIV treatment outcomes. As countries move to treatment for all as soon as possible after testing, health communication can help address significant losses at each stage of the HIV continuum of care, thereby contributing to achieving the 90-90-90 global treatment goals. This JAIDS supplement presents compelling studies that are anchored on the health communication exigencies in highly diverse HIV and AIDS contexts in low and middle income settings. Our special focus is health communication needs and challenges within the HIV continuum of care. We introduce the supplement with thumbnails summaries of the work presented by an experienced array of public health, behavioral, and clinical scientists.
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