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Mujugira A, Karungi B, Nakyanzi A, Bagaya M, Nsubuga R, Sebuliba T, Nampewo O, Naddunga F, Birungi JE, Sapiri O, Nyanzi KR, Bambia F, Muwonge T, Gandhi M, Haberer JE. Peer-Delivered HIV Self-Testing, Sexually Transmitted Infection Self-Sampling, and Pre-exposure Prophylaxis for Transgender Women in Uganda: A Randomized Trial. J Acquir Immune Defic Syndr 2024; 97:125-132. [PMID: 39250646 PMCID: PMC11384309 DOI: 10.1097/qai.0000000000003471] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2023] [Accepted: 04/22/2024] [Indexed: 09/11/2024]
Abstract
BACKGROUND Peer-delivered HIV self-testing (HIVST) and sexually transmitted infection self-sampling (STISS) may promote adherence to oral pre-exposure prophylaxis (PrEP), but no studies have analyzed this approach among transgender women (TGW) in sub-Saharan Africa. SETTING The Peer study was a cluster randomized trial in Uganda (October 2020-July 2022; NCT04328025). METHODS Ten TGW peer groups, each with 1 TGW peer and 8 TGW, were randomized 1:1 to receive quarterly in-clinic HIV testing with PrEP refills as standard-of-care (SOC) or SOC plus monthly peer delivery of oral-fluid HIVST, STISS, and PrEP refills (intervention). Participants were followed for 12 months. The primary outcome was PrEP adherence. RESULTS We screened 85 TGW and enrolled 82 (41 per arm). The median age was 22 years (interquartile range [IQR] 20-24). Twelve-month retention was 88% (72/82). At the 3, 6, 9, and 12-month clinic visits, 10%, 5%, 5%, and 0% of TGW in the intervention arm had TFV-DP levels ≥700 fmol/punch, versus 7%, 15%, 7%, and 2% in the SOC arm, respectively (P = 0.18). At all visits, any detectable TFV-DP levels were significantly higher in SOC than the peer delivery group (P < 0.04). PrEP adherence was associated with sex work (incidence rate ratio 6.93; 95% CI: 2.33 to 20.60) and >10 years of schooling (incidence rate ratio 2.35; 95% CI: 1.14 to 4.84). There was a strong correlation between tenofovir detection in dried blood spots and urine (P < 0.001). No HIV seroconversions occurred. CONCLUSIONS Peer-delivered HIVST and STISS did not increase low levels of oral PrEP adherence among TGW in Uganda. Long-acting PrEP formulations should be considered for this population.
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Affiliation(s)
- Andrew Mujugira
- Research Department, The Infectious Diseases Institute Limited, Makerere University, Kampala, Uganda
- Department of Global Health, University of Washington, Seattle, WA
| | | | - Agnes Nakyanzi
- Research Department, The Infectious Diseases Institute Limited, Makerere University, Kampala, Uganda
| | - Monica Bagaya
- Research Department, The Infectious Diseases Institute Limited, Makerere University, Kampala, Uganda
| | - Rogers Nsubuga
- Research Department, The Infectious Diseases Institute Limited, Makerere University, Kampala, Uganda
| | - Timothy Sebuliba
- Research Department, The Infectious Diseases Institute Limited, Makerere University, Kampala, Uganda
| | - Olivia Nampewo
- Research Department, The Infectious Diseases Institute Limited, Makerere University, Kampala, Uganda
| | - Faith Naddunga
- Research Department, The Infectious Diseases Institute Limited, Makerere University, Kampala, Uganda
| | - Juliet E Birungi
- Research Department, The Infectious Diseases Institute Limited, Makerere University, Kampala, Uganda
| | - Oliver Sapiri
- Research Department, The Infectious Diseases Institute Limited, Makerere University, Kampala, Uganda
| | - Kikulwe R Nyanzi
- Research Department, The Infectious Diseases Institute Limited, Makerere University, Kampala, Uganda
| | - Felix Bambia
- Research Department, The Infectious Diseases Institute Limited, Makerere University, Kampala, Uganda
| | - Timothy Muwonge
- Research Department, The Infectious Diseases Institute Limited, Makerere University, Kampala, Uganda
| | - Monica Gandhi
- Department of Medicine, University of California San Francisco, San Francisco, CA
| | - Jessica E Haberer
- Harvard Medical School, Boston, MA; and
- Center for Global Health, Massachusetts General Hospital, Boston, MA
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Zhang Y, Johnson CC, Nguyen VTT, Ong JJ. Role of HIV self-testing in strengthening HIV prevention services. Lancet HIV 2024:S2352-3018(24)00187-5. [PMID: 39332440 DOI: 10.1016/s2352-3018(24)00187-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2024] [Revised: 07/15/2024] [Accepted: 07/17/2024] [Indexed: 09/29/2024]
Abstract
HIV self-testing, which has been increasingly available since 2016, can substantially enhance the uptake of HIV testing, especially for key populations. Clinical trials have explored the application of self-testing in various HIV prevention strategies, including post-exposure prophylaxis (PEP), pre-exposure prophylaxis (PrEP), and voluntary medical male circumcision. Research indicates that self-testing can facilitate PrEP initiation and improve adherence and continuation. However, evidence on the effectiveness of linkage to PrEP post HIV self-testing is mixed, underscoring the need to further understand contextual factors and optimal implementation strategies. Studies on linking voluntary medical male circumcision post HIV self-testing show no statistically significant difference compared with standard voluntary medical male circumcision demand creation strategies. There is a shortage of trials examining the role of self-testing in PrEP reinitiation, PEP initiation, or PEP follow-up. Evidence for the use of HIV prevention models that support self-testing is accumulating, but there is a need for further research in different contexts and among different populations to assess its value when scaled up to contribute to reducing HIV infections globally.
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Affiliation(s)
- Ying Zhang
- School of Translational Medicine, Faculty of Medicine, Nursing and Health Sciences, Monash University, Melbourne, VIC, Australia; Melbourne Sexual Health Centre, Alfred Health, Carlton, VIC, Australia
| | - Cheryl C Johnson
- Global HIV, Hepatitis and STI Programmes, World Health Organization, Geneva, Switzerland
| | | | - Jason J Ong
- School of Translational Medicine, Faculty of Medicine, Nursing and Health Sciences, Monash University, Melbourne, VIC, Australia; Melbourne Sexual Health Centre, Alfred Health, Carlton, VIC, Australia; Department of Clinical Research, Faculty of Infectious and Tropical Diseases, London School of Hygiene & Tropical Medicine, London, UK.
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3
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Mujugira A, Nakyanzi A, Bagaya M, Mugisha J, Kamusiime B, Nalumansi A, Kasiita V, Ssebuliba T, Nampewo O, Nsubuga R, Muwonge TR, Bukenya M, Gandhi M, Wyatt MA, Ware NC, Haberer JE. Integrated PrEP and STI Services for Transgender Women in Uganda: Qualitative Findings from a Randomized Trial. AIDS Behav 2024:10.1007/s10461-024-04469-x. [PMID: 39222182 DOI: 10.1007/s10461-024-04469-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/14/2024] [Indexed: 09/04/2024]
Abstract
Tenofovir alafenamide fumarate (F/TAF) pre-exposure prophylaxis (PrEP) is understudied in sub-Saharan Africa. The Tandika PrEP study was a randomized trial that evaluated same-day F/TAF initiation, the impact of drug-level feedback on PrEP adherence, and integrated PrEP and sexually transmitted infection (STI) services for HIV-negative transgender women (TGW) in Uganda (NCT04491422). From April 2022-February 2023, a qualitative sub-study of 30 in-depth interviews explored (1) perspectives on same-day initiation of F/TAF PrEP, (2) experiences of urine tenofovir testing and drug-level feedback, and (3) descriptions of self-collection of samples for STI testing. Qualitative data were analyzed using an inductive content analytic approach. Integrated PrEP/STI services were valued by TGW because the convenience of urine testing motivated adherence and allowed for tenofovir and STI detection. (1) Preferred characteristics: F/TAF-based PrEP was easy to take and not readily identifiable as an HIV-related medication, resulting in less stigma than the better-known tenofovir disoproxil fumarate (F/TDF). Weight gain associated with F/TAF use was viewed positively by TGW as a symbol of health and prosperity in African settings. (2) Adherence motivation: PrEP adherence was motivated by a desire not to disappoint healthcare workers; TGW reciprocated adherence support and drug-level feedback by taking PrEP. (3) Facilitating adherence and STI care: Urine testing enhanced STI detection and treatment. Utilization of urine for tenofovir and STI testing motivated the uptake of HIV/STI care, emphasizing the importance of integrated PrEP and STI services. Integrating PrEP/STI services into differentiated delivery models could increase prevention uptake in this vulnerable population.
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Affiliation(s)
- Andrew Mujugira
- Infectious Diseases Institute, Makerere University, P.O. Box 22418, Kampala, Uganda.
- Department of Global Health, University of Washington, Seattle, WA, USA.
| | - Agnes Nakyanzi
- Infectious Diseases Institute, Makerere University, P.O. Box 22418, Kampala, Uganda
| | - Monica Bagaya
- Infectious Diseases Institute, Makerere University, P.O. Box 22418, Kampala, Uganda
| | - Jackson Mugisha
- Infectious Diseases Institute, Makerere University, P.O. Box 22418, Kampala, Uganda
| | - Brenda Kamusiime
- Infectious Diseases Institute, Makerere University, P.O. Box 22418, Kampala, Uganda
| | - Alisaati Nalumansi
- Infectious Diseases Institute, Makerere University, P.O. Box 22418, Kampala, Uganda
| | - Vicent Kasiita
- Infectious Diseases Institute, Makerere University, P.O. Box 22418, Kampala, Uganda
| | - Timothy Ssebuliba
- Infectious Diseases Institute, Makerere University, P.O. Box 22418, Kampala, Uganda
| | - Olivia Nampewo
- Infectious Diseases Institute, Makerere University, P.O. Box 22418, Kampala, Uganda
| | - Rogers Nsubuga
- Infectious Diseases Institute, Makerere University, P.O. Box 22418, Kampala, Uganda
| | - Timothy R Muwonge
- Infectious Diseases Institute, Makerere University, P.O. Box 22418, Kampala, Uganda
| | | | - Monica Gandhi
- Department of Medicine, University of California San Francisco, San Francisco, USA
| | - Monique A Wyatt
- Department of Medicine, Brigham and Women's Hospital, Boston, MA, USA
- Harvard Global, Cambridge, MA, USA
| | - Norma C Ware
- Harvard Global, Cambridge, MA, USA
- Department of Global Health and Social Medicine, Harvard Medical School, Boston, MA, USA
| | - Jessica E Haberer
- Center for Global Health, Massachusetts General Hospital, Boston, USA
- Harvard Medical School, Boston, USA
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Garcia C, Rehman N, Matos-Silva J, Deng J, Ghandour S, Huang Z, Mbuagbaw L. Interventions to Improve Adherence to Oral Pre-exposure Prophylaxis: A Systematic Review and Network Meta-analysis. AIDS Behav 2024; 28:2534-2546. [PMID: 38814406 DOI: 10.1007/s10461-024-04365-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/30/2024] [Indexed: 05/31/2024]
Abstract
For people at risk of HIV infection, pre-exposure prophylaxis (PrEP) can reduce the risk of infection in anticipation of exposure to HIV. The effectiveness of PrEP relies upon a user's adherence to their PrEP regimen. We sought to assess the effect of PrEP adherence interventions compared to usual care or another intervention for people at risk of HIV. We searched electronic databases from 2010 onwards for randomized controlled trials (RCTs) involving persons at risk of HIV randomized to an adherence promoting intervention vs usual care or another intervention. We used network meta-analyses to compare PrEP adherence for all participant populations. Certainty of evidence was assessed using Confidence in Network Meta-Analysis (CINeMA). 21 trials (N = 4917) were included in qualitative analysis (19 in network meta-analyses (N = 4101)). HIV self-testing interventions with adherence feedback elements improved adherence compared to usual care (risk ratio (RR): 1.83, 95%CI 1.19, 2.82). In contrast, HIV self-testing alone was inferior to HIV self-testing with adherence feedback (RR: 0.58, 95%CI 0.37-0.92). Reminders alone also were inferior to HIV self-testing with adherence feedback on adherence (RR: 0.53, 95%CI 0.34-0.84) and had similar effects on adherence as usual care (RR: 0.98, 95%CI: 0.86-1.11). Interventions with only one component were inferior for adherence than those with two components (RR: 0.74, 95%CI 0.62-0.88) and those with three components (RR: 0.78, 95%CI 0.65-0.93). The certainty of evidence was moderate for HIV self-testing plus adherence feedback and interventions with two or three components. When designing future PrEP adherence interventions, we recommend strategies with more than one but no more than three components.
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Affiliation(s)
- Cristian Garcia
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON, Canada.
- Temerty Faculty of Medicine, University of Toronto, Toronto, ON, Canada.
| | - Nadia Rehman
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON, Canada
| | - Jéssyca Matos-Silva
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON, Canada
| | - Jiawen Deng
- Temerty Faculty of Medicine, University of Toronto, Toronto, ON, Canada
| | - Sara Ghandour
- Temerty Faculty of Medicine, University of Toronto, Toronto, ON, Canada
| | - Zhongyu Huang
- Temerty Faculty of Medicine, University of Toronto, Toronto, ON, Canada
| | - Lawrence Mbuagbaw
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON, Canada
- Department of Anesthesia, McMaster University, Hamilton, ON, Canada
- Department of Pediatrics, McMaster University, Hamilton, ON, Canada
- Biostatistics Unit, Father Sean O'Sullivan Research Centre, St Joseph's Healthcare, Hamilton, ON, Canada
- Division of Epidemiology and Biostatistics, Department of Global Health, Stellenbosch University, Cape Town, South Africa
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Lin B, Feng S, Liu J, Li K, Shi G, Zhong X. Using an interactive web application to identify pre-exposure prophylaxis adherence among men who have sex with men. Int J Clin Health Psychol 2024; 24:100490. [PMID: 39220117 PMCID: PMC11365445 DOI: 10.1016/j.ijchp.2024.100490] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2024] [Accepted: 07/31/2024] [Indexed: 09/04/2024] Open
Abstract
Background Men who have sex with men (MSM) are at a high risk for HIV infection. While pre-exposure prophylaxis (PrEP) is an effective oral preventive strategy, its success is largely dependent on consistent medication adherence. Objective The aim of this study was to develop the machine learning web application and evaluate the performance in predicting PrEP adherence. Methods The PrEP prospective cohort study of the MSM population conducted in Western China from 2019 to 2023, and we collected adherence data and personal characteristics data from 747 MSM. Predictor variables were screened and the performance of several machine learning methods in predicting nonadherent behaviors were compared. Results A total of 11 candidate variables were screened that predicted nonadherent behaviors. We developed and evaluated five machine learning models that performed well in predicting adherence. Attitudes of male sexual partners, self-efficacy, HIV testing, number of male sexual partners, and risk perception were the most important predictors of adherence. The optimal prediction model was displayed in a shiny web application for online calculation of the probability of occurrence of nonadherent behaviors among MSM. Conclusions Machine learning performed well in predicting nonadherent behaviors among MSM. An interactive and intuitive web application can help identify individuals who may have nonadherent behaviors, resulting in improved medication adherence and increased prevention efficacy.
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Affiliation(s)
- Bing Lin
- School of Public Health, Chongqing Medical University, Chongqing, PR China
- Research Center for Medicine and Social Development, Chongqing, PR China
| | - Shihan Feng
- School of Public Health, Chongqing Medical University, Chongqing, PR China
- Research Center for Medicine and Social Development, Chongqing, PR China
| | - Jiaxiu Liu
- School of Medical Informatics, Chongqing Medical University, Chongqing, PR China
| | - Kangjie Li
- School of Public Health, Chongqing Medical University, Chongqing, PR China
- Research Center for Medicine and Social Development, Chongqing, PR China
| | - Guiqian Shi
- School of Public Health, Chongqing Medical University, Chongqing, PR China
- Research Center for Medicine and Social Development, Chongqing, PR China
| | - Xiaoni Zhong
- School of Public Health, Chongqing Medical University, Chongqing, PR China
- Research Center for Medicine and Social Development, Chongqing, PR China
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Moschese D, Lazzarin S, Colombo ML, Caruso F, Giacomelli A, Antinori S, Gori A. Breakthrough Acute HIV Infections among Pre-Exposure Prophylaxis Users with High Adherence: A Narrative Review. Viruses 2024; 16:951. [PMID: 38932243 PMCID: PMC11209220 DOI: 10.3390/v16060951] [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: 04/30/2024] [Revised: 06/02/2024] [Accepted: 06/10/2024] [Indexed: 06/28/2024] Open
Abstract
Pre-exposure prophylaxis (PrEP) is a pivotal intervention among HIV prevention strategies. We aimed to narratively revise the topic of HIV acute infection in the setting of PrEP exposure with a focus on diagnostic options, clinical features, and future PrEP perspectives, with a particular focus on users with high adherence to PrEP. We searched the main databases (PubMed, Embase, and Scopus) with the keywords "PrEP" or "Pre-Exposure Prophylaxis" and "HIV" or "PLWH" and "breakthrough" or "acute infection" or "primary infection". We included all randomized clinical trials and non-experimental studies (both case reports and observational studies) ever published. In the present narrative review, we revise the diagnostic challenges related to HIV diagnosis in the setting of PrEP and the clinical characteristics and symptoms of breakthrough infections. We discuss the management of acute HIV infection during PrEP and the new challenges that arise from the use of long-acting drugs for PrEP. Our review underlines that although extremely rare, HIV seroconversions are still possible during PrEP, even in a context of high adherence. Efforts to promptly identify these events must be included in the PrEP follow-up in order to minimize the chance of overlooked HIV breakthrough infections and thus exposure to suboptimal concentrations of antiretrovirals.
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Affiliation(s)
- Davide Moschese
- I Division of Infectious Diseases, ASST Fatebenefratelli Sacco, Luigi Sacco Hospital, 20157 Milan, Italy;
| | - Samuel Lazzarin
- Department of Biomedical and Clinical Sciences, Università degli Studi di Milano, 20133 Milan, Italy; (S.L.); (M.L.C.); (F.C.); (A.G.); (S.A.)
- III Infectious Diseases Unit, ASST Fatebenefratelli Sacco, Luigi Sacco Hospital, 20157 Milan, Italy
| | - Martina Laura Colombo
- Department of Biomedical and Clinical Sciences, Università degli Studi di Milano, 20133 Milan, Italy; (S.L.); (M.L.C.); (F.C.); (A.G.); (S.A.)
- III Infectious Diseases Unit, ASST Fatebenefratelli Sacco, Luigi Sacco Hospital, 20157 Milan, Italy
| | - Francesco Caruso
- Department of Biomedical and Clinical Sciences, Università degli Studi di Milano, 20133 Milan, Italy; (S.L.); (M.L.C.); (F.C.); (A.G.); (S.A.)
- II Infectious Diseases Unit, ASST Fatebenefratelli Sacco, Luigi Sacco Hospital, 20157 Milan, Italy
| | - Andrea Giacomelli
- Department of Biomedical and Clinical Sciences, Università degli Studi di Milano, 20133 Milan, Italy; (S.L.); (M.L.C.); (F.C.); (A.G.); (S.A.)
- III Infectious Diseases Unit, ASST Fatebenefratelli Sacco, Luigi Sacco Hospital, 20157 Milan, Italy
| | - Spinello Antinori
- Department of Biomedical and Clinical Sciences, Università degli Studi di Milano, 20133 Milan, Italy; (S.L.); (M.L.C.); (F.C.); (A.G.); (S.A.)
- III Infectious Diseases Unit, ASST Fatebenefratelli Sacco, Luigi Sacco Hospital, 20157 Milan, Italy
| | - Andrea Gori
- I Division of Infectious Diseases, ASST Fatebenefratelli Sacco, Luigi Sacco Hospital, 20157 Milan, Italy;
- Department of Biomedical and Clinical Sciences, Università degli Studi di Milano, 20133 Milan, Italy; (S.L.); (M.L.C.); (F.C.); (A.G.); (S.A.)
- II Infectious Diseases Unit, ASST Fatebenefratelli Sacco, Luigi Sacco Hospital, 20157 Milan, Italy
- Centre for Multidisciplinary Research in Health Science (MACH), Università degli Studi di Milano, 20122 Milan, Italy
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Ogello VA, Rono BK, Ngure K, Sedah E, Thuo NB, Musinguzi N, Baeten JM, Bukusi EA, Mugo NR, Haberer JE. Acceptability and feasibility of long-term, real-time electronic adherence monitoring of HIV pre-exposure prophylaxis (PrEP) use among young women in Kenya: A mixed methods study. PLoS One 2024; 19:e0299168. [PMID: 38451884 PMCID: PMC10919630 DOI: 10.1371/journal.pone.0299168] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2022] [Accepted: 02/05/2024] [Indexed: 03/09/2024] Open
Abstract
Real-time electronic adherence monitoring involves "smart" pill boxes that record and monitor openings as a proxy for pill taking and may be useful in understanding and supporting PrEP use; however, acceptability and/or feasibility for PrEP users is uncertain. We sought to understand the experiences of using a real-time electronic adherence monitor for PrEP delivery among young women in Kisumu and Thika, Kenya. We used the Wisepill device to monitor PrEP use among 18-24-year-old women for two years. Half of the participants were randomized to also receive SMS adherence reminders (daily or as needed for missed doses). We assessed acceptability quantitatively and qualitatively according to the four constructs of Unified Theory of Acceptance and Use of Technology (UTAUT): performance expectancy, effort expectancy, social influence, and facilitating conditions. We assessed feasibility by monitor functionality during periods of PrEP use. We analyzed quantitative data descriptively and compared by site and over time; qualitative data were analyzed inductively and deductively. The median age was 21 years (IQR 19-22), median education was 12 years (IQR 10-13), 182 (53%) had disclosed PrEP use, and 55 (16%) reported recent intimate partner violence. Most participants reported high levels of usefulness and high interest in using the monitor with few problems or worries reported throughout follow-up. Feasibility was high overall with some differences by site (96% functional monitor days in Kisumu vs 88% in Thika). Few monitors were reported lost (N = 29; 8%) or dysfunctional (N = 11; 3%). In qualitative interviews, electronic monitoring was perceived as useful because it supported privacy, confidentiality, easy storage, and PrEP adherence. Effort was generally considered low. Participants expressed some concern for stigma from monitor and/or PrEP use. Facilitating conditions involved the monitor size, color, and battery life. Overall, real-time electronic adherence monitoring was a highly acceptable and feasible approach to understand PrEP adherence among young women in a sub-Saharan African setting.
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Affiliation(s)
- Vallery A. Ogello
- Center of Clinical Research, Kenya Medical Research Institute, Nairobi, Kenya
| | | | - Kenneth Ngure
- Department of Community Health, Jomo Kenyatta University of Agriculture and Technology, Nairobi, Kenya
- Department of Global Health, University of Washington, Seattle, Washington, United States of America
| | - Eric Sedah
- Center for microbiology research, Kenya Medical Research Institute, Kisumu, Kenya
| | - Nicholas B. Thuo
- Center of Clinical Research, Kenya Medical Research Institute, Nairobi, Kenya
| | | | - Jared M. Baeten
- Department of Global Health, University of Washington, Seattle, Washington, United States of America
- Gilead Sciences, Foster City, California, United States of America
| | - Elizabeth A. Bukusi
- Center for microbiology research, Kenya Medical Research Institute, Kisumu, Kenya
- Department of Global Health, University of Washington, Seattle, Washington, United States of America
| | - Nelly R. Mugo
- Center of Clinical Research, Kenya Medical Research Institute, Nairobi, Kenya
- Department of Global Health, University of Washington, Seattle, Washington, United States of America
| | - Jessica E. Haberer
- Center for Global Health, Massachusetts General Hospital, Boston, Massachusetts, United States of America
- Department of Medicine, Harvard Medical School, Boston, Massachusetts, United States of America
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8
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Nakiganda LJ, Bavinton BR, Poynten IM, Serwadda D, Bazaale JM, Grulich AE. Sexual pleasure and HIV-related worry in female sex workers on oral pre-exposure prophylaxis in south-western Uganda. Sex Health 2024; 21:SH23056. [PMID: 38267368 DOI: 10.1071/sh23056] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2023] [Accepted: 01/07/2024] [Indexed: 01/26/2024]
Abstract
BACKGROUND Female sex workers (FSWs) contribute disproportionately to HIV transmission in Uganda, and pre-exposure prophylaxis (PrEP) is effective in preventing HIV among cisgender women. Psychological factors are important for PrEP uptake, but few studies have examined psychosocial changes due to PrEP use in Uganda. METHODS In 2021, we recruited 524 FSWs in three Trans-African Highway towns and four fishing communities in south-western Uganda. We conducted structured interviews among women who were attending routine PrEP follow-up visits in six health units. Bivariable and multivariable modified regression using a robust covariance matrix estimator were used to identify factors associated with experiencing increased sexual pleasure and less worry about HIV because of PrEP. RESULTS Overall, 80.9% participants reported that sex was more pleasurable because of taking PrEP. There were statistical trends for sex being more pleasurable when taking PrEP or when having condomless sex with casual paying partners (aPR=1.19, 95% CI=1.07-1.32, P =0.001). Almost three-quarters of the participants (76.3%) were less worried about getting HIV because of PrEP. Condomless sex with casual paying partners (aPR=1.17, 95% CI=1.05-1.31, P =0.032, P =0.003) and being On PrEP for the past 1-2years (aPR=1.18, 95% CI=1.00-1.38, P =0.032) was significantly associated with HIV-related worry (aPR=1.17, 95% CI=1.05-1.31, P =0.032, P =0.003) Conclusions : We found a positive impact of PrEP in Ugandan FSWs on two key psychosocial dimensions: (1) more pleasurable sex; and (2) less worry about acquiring HIV. Interventions aiming to increase PrEP uptake may find it useful to focus on psychosocial dimensions.
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Affiliation(s)
| | - Benjamin R Bavinton
- Kirby Institute for Infection and Immunity in Society, UNSW Sydney, Sydney, NSW, Australia
| | - Isobel Mary Poynten
- Kirby Institute for Infection and Immunity in Society, UNSW Sydney, Sydney, NSW, Australia
| | - David Serwadda
- Rakai Health Sciences Program, Kalisizo, Uganda; and Makerere University School of Public Health, Kampala, Uganda
| | | | - Andrew E Grulich
- Kirby Institute for Infection and Immunity in Society, UNSW Sydney, Sydney, NSW, Australia
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9
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Sila J, Wagner AD, Abuna F, Dettinger JC, Odhiambo B, Ngumbau N, Oketch G, Sifuna E, Gómez L, Hicks S, John-Stewart G, Kinuthia J. An implementation strategy package (video education, HIV self-testing, and co-location) improves PrEP implementation for pregnant women in antenatal care clinics in western Kenya. FRONTIERS IN REPRODUCTIVE HEALTH 2023; 5:1205503. [PMID: 38045529 PMCID: PMC10690761 DOI: 10.3389/frph.2023.1205503] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2023] [Accepted: 10/20/2023] [Indexed: 12/05/2023] Open
Abstract
Background Pre-exposure prophylaxis (PrEP) is recommended by the World Health Organization and the Kenyan Ministry of Health for HIV prevention in pregnancy and postpartum for women at risk for HIV. Integration of PrEP into antenatal care is promising, but delivery gaps exist in the face of healthcare provider shortages in resource-limited settings. Methods Between May and November 2021, we conducted a difference-in-differences study (3 months pre-intervention data collection and 3 months post-intervention data collection) analyzing four intervention facilities, where the strategies were implemented, and four comparison facilities, where no strategies were implemented. We tested a combination of three implementation strategies-video-based PrEP information in the waiting bay, HIV self-testing, and dispensing of PrEP in the antenatal care rooms-to improve PrEP delivery. We compared absolute changes in the proportion of antenatal attendees screened for PrEP (PrEP penetration), the proportion receiving all PrEP-specific steps in a visit (HIV testing, risk screening, and PrEP counseling) (PrEP fidelity), and client PrEP knowledge, client satisfaction, and waiting time and service time (a priori outcomes); post hoc, we compared the proportion offered PrEP (PrEP offer) and completing HIV testing. We measured provider perceptions of the acceptability and appropriateness of the implementation strategies. Results We observed significant improvements in PrEP penetration, PrEP offer, satisfaction, and knowledge (p < 0.05) and improvements in fidelity that trended towards significance (p = 0.057). PrEP penetration increased 5 percentage points (p = 0.008), PrEP fidelity increased 8 percentage points (p = 0.057), and PrEP offer increased 4 percentage points (p = 0.003) in intervention vs. comparison facilities. Client PrEP knowledge increased by 1.7 out of 6 total points (p < 0.001) and client satisfaction increased by 0.7 out of 24 total points (p = 0.003) in intervention vs. comparison facilities. We observed no changes in service time (0.09-min decrease; p = 0.435) and a small increase in waiting time (0.33-min increase; p = 0.005). HIV testing among those eligible did not change (1.5 percentage point decrease, p = 0.800). Providers felt the implementation strategies were acceptable and appropriate (median acceptability: 20/20; median appropriateness: 19.5/20). However, absolute levels of each step of the PrEP cascade remained suboptimal. Conclusions An implementation strategy package with video information, HIV self-testing, and co-location of medication dispensing enhanced PrEP delivery across several implementation outcomes and client satisfaction, while not substantially increasing wait time or decreasing provider-client contact time. Clinical trial registration ClinicalTrials.gov , identifier, NCT04712994.
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Affiliation(s)
- Joseph Sila
- Research & Programs, Kenyatta National Hospital, Nairobi, Kenya
| | - Anjuli D. Wagner
- Department of Global Health, University of Washington, Seattle, WA, United States
| | - Felix Abuna
- Research & Programs, Kenyatta National Hospital, Nairobi, Kenya
| | - Julia C. Dettinger
- Department of Global Health, University of Washington, Seattle, WA, United States
| | - Ben Odhiambo
- Research & Programs, Kenyatta National Hospital, Nairobi, Kenya
| | - Nancy Ngumbau
- Research & Programs, Kenyatta National Hospital, Nairobi, Kenya
| | - George Oketch
- Research & Programs, Kenyatta National Hospital, Nairobi, Kenya
| | - Enock Sifuna
- Research & Programs, Kenyatta National Hospital, Nairobi, Kenya
| | - Laurén Gómez
- Department of Global Health, University of Washington, Seattle, WA, United States
| | - Sarah Hicks
- Department of Epidemiology, University of Washington, Seattle, WA, United States
| | - Grace John-Stewart
- Department of Global Health, University of Washington, Seattle, WA, United States
- Department of Epidemiology, University of Washington, Seattle, WA, United States
- Departments of Pediatrics & Medicine, University of Washington, Seattle, WA, United States
| | - John Kinuthia
- Research & Programs, Kenyatta National Hospital, Nairobi, Kenya
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10
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Pintye J, Kinuthia J, Abuna F, Anderson PL, Dettinger JC, Gomez L, Haberer JE, Marwa MM, Ngumbau N, Omondi P, Odhiambo B, Stern J, Watoyi S, Baeten JM, John-Stewart G. HIV pre-exposure prophylaxis initiation, persistence, and adherence during pregnancy through the postpartum period. AIDS 2023; 37:1725-1737. [PMID: 37289583 PMCID: PMC10527305 DOI: 10.1097/qad.0000000000003617] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/10/2023]
Abstract
OBJECTIVE We evaluated pre-exposure prophylaxis (PrEP) initiation, persistence, and adherence measured via tenofovir-diphosphate (TFV-DP) concentrations in dried blood spots (DBS) among women offered PrEP during pregnancy. METHODS We prospectively analyzed data from participants in the PrIMA Study (NCT03070600) who were offered PrEP during the second trimester and followed through 9 months postpartum. At follow-up visits (monthly in pregnancy; 6 weeks, 6 months, 9 months postpartum), self-reported PrEP use was assessed, and DBS were collected for quantifying TFV-DP concentrations. RESULTS In total, 2949 participants were included in the analysis. At enrollment, median age was 24 years [interquartile range IQR) 21-29], gestational age 24 weeks (IQR 20-28), and 4% had a known partner living with HIV. Overall, 405 (14%) participants initiated PrEP in pregnancy with higher frequency among those with risk factors for HIV acquisition, including >2 lifetime sexual partners, syphilis during pregnancy, forced sex, and intimate partner violence ( P < 0.05). At 9 months postpartum, 58% of PrEP initiators persisted with PrEP use, of which 54% self-reported not missing any PrEP pills in the last 30 days. Among DBS randomly selected from visits where participants persisted with PrEP ( n = 427), 50% had quantifiable TFV-DP. Quantifiable TFV-DP was twice as likely in pregnancy than postpartum [adjusted risk ratio (aRR) = 1.90, 95% confidence interval (CI) 1.40-2.57, P < 0.001]. Having a partner known to be living with HIV was the strongest predictor of PrEP initiation, persistence, and quantifiable TFV-DP ( P < 0.001). CONCLUSIONS PrEP persistence and adherence waned postpartum, though over half of PrEP initiators persisted through 9-months postpartum. Interventions should prioritize increasing knowledge of partner HIV status and sustaining adherence in the postpartum period.
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Affiliation(s)
| | - John Kinuthia
- University of Washington, Seattle, Washington, USA
- Kenyatta National Hospital, Nairobi, Kenya
| | | | | | | | - Laurén Gomez
- University of Washington, Seattle, Washington, USA
| | | | | | | | | | | | - Joshua Stern
- University of Washington, Seattle, Washington, USA
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11
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Heilmann E, Okuku J, Itoh M, Hines JZ, Prieto JT, Phiri M, Watala K, Nsofu C, Luhana-Phiri M, Vlahakis N, Kabongo M, Kaliki B, Minchella PA, Musonda B. Measuring Oral Pre-exposure Prophylaxis (PrEP) Continuation Through Electronic Health Records During Program Scale-Up Among the General Population in Zambia. AIDS Behav 2023; 27:2390-2396. [PMID: 36586011 PMCID: PMC11345677 DOI: 10.1007/s10461-022-03966-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/16/2022] [Indexed: 01/01/2023]
Abstract
HIV pre-exposure prophylaxis (PrEP) is being scaled-up in Zambia, but PrEP continuation data are limited by paper-based registers and aggregate reports. Utilization of Zambia's electronic health record (EHR) system, SmartCare, may address this gap. We analyzed individuals aged ≥ 15 years who initiated PrEP between October 2020 and September 2021 in four provinces in Zambia in SmartCare versus aggregate reports. We measured PrEP continuation using Kaplan-Meier survival analysis and Cox proportional hazards models. SmartCare captured 29% (16,791/58,010) of new PrEP clients; 49% of clients continued at one month, and 89% discontinued PrEP by February 2022. Women were less likely than men to discontinue PrEP (adjusted hazard ratio [aHR]: 0.89, 95% CI 0.86-0.92, z = - 6.99, p < 0.001), and PrEP clients aged ≥ 50 years were less likely to discontinue PrEP compared to clients 15-19 years (aHR: 0.53, 95% CI 0.48-0.58, z = - 13.04, p < 0.001). Zambia's EHR is a valuable resource for measuring individual-level PrEP continuation over time and can be used to inform HIV prevention programs.
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Affiliation(s)
- Elizabeth Heilmann
- PHI/CDC Global Health Fellowship Program, Public Health Institute, Oakland, CA, USA.
- Division of Global HIV & TB, Centers for Disease Control and Prevention, 351 Independence Avenue, Lusaka, Zambia.
| | - Jackson Okuku
- Division of Global HIV & TB, Centers for Disease Control and Prevention, 351 Independence Avenue, Lusaka, Zambia
| | - Megumi Itoh
- Division of Global HIV & TB, Centers for Disease Control and Prevention, 351 Independence Avenue, Lusaka, Zambia
| | - Jonas Z Hines
- Division of Global HIV & TB, Centers for Disease Control and Prevention, 351 Independence Avenue, Lusaka, Zambia
| | | | - Mutinta Phiri
- Lusaka Provincial Health Office, Ministry of Health, Lusaka, Zambia
| | - Kelvin Watala
- Southern Provincial Health Office, Ministry of Health, Choma, Zambia
| | - Chilufya Nsofu
- Western Provincial Health Office, Ministry of Health, Mongu, Zambia
| | | | - Natalie Vlahakis
- Centre for Infectious Disease Research in Zambia, Lusaka, Zambia
| | - Michael Kabongo
- Centre for Infectious Disease Research in Zambia, Lusaka, Zambia
| | - Boyd Kaliki
- Division of Global HIV & TB, Centers for Disease Control and Prevention, 351 Independence Avenue, Lusaka, Zambia
| | - Peter A Minchella
- Division of Global HIV & TB, Centers for Disease Control and Prevention, 351 Independence Avenue, Lusaka, Zambia
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12
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Self-reported and pill count measures of adherence to oral HIV PrEP among female sex workers living in South-Western Uganda. PLoS One 2022; 17:e0277226. [DOI: 10.1371/journal.pone.0277226] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2022] [Accepted: 10/23/2022] [Indexed: 11/12/2022] Open
Abstract
Background
Female sex workers (FSWs) in Uganda are at high risk of HIV infection. Scaling up oral pre-exposure prophylaxis (PrEP) will reduce HIV incidence if high levels of adherence are maintained. This study evaluates PrEP adherence using clinic-based pill counts and self-reported measures, and factors associated with protective levels of adherence.
Methods
Participants were sex workers who had been taking PrEP for at least 5 months and were attending routine follow-up visits for PrEP care in fishing communities and along the Trans-African Highway. Participants who had a pill count showing at least 85% use since their last clinic visit and those who reported taking their PrEP every day in the last 5 months were categorised as having ‘protective adherence’. Spearman’s correlation and weighted kappa assessed the relationship between pill count and self-reported measures. Bivariate and multivariate logistic regression was used to determine factors associated with protective adherence as measured by pill count.
Results
We recruited 524 FSWs, with a median age of 29 years (IQR 23–35). Participants were recruited from fishing communities and Trans-African Highway towns (n = 297, 56.7%, and n = 227, 43.0%). Nearly three quarters (n = 372, 71.0%) of women were estimated to have protective adherence based on pill count (i.e., a pill count of >85%) and 50.4% by self-report in last 3 months. There was a strong positive association between self-reported measures and pill count measures (rest = 0.6453, 95% CI = 0.5924–0.6927) and a moderate agreement between self-reported measures and pill count measures, κ = 0.544 (95%CI = 0.4869–0.6011, p < 0.001).
Factors associated with protective adherence included being aged 35 years or older (aOR = 2.40, 95% CI = 1.17–4.86), living in a fishing community (aOR = 1.45, 95% CI = 0.62–3.38), and having an STI in last 3 months (aOR = 1.64, 95% CI = 1.07–2.49).
Conclusion
Our findings indicate that PrEP-experienced FSWs attending clinical follow-up visits reported high protective levels of oral pre-exposure prophylaxis, as measured by both pill count and self-reported measures, and a moderate agreement between pill count and self-reported measures.
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13
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Budzyńska J, Patryn R, Kozioł I, Leśniewska M, Kopystecka A, Skubel T. Self-Testing as a Hope to Reduce HIV in Transgender Women—Literature Review. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2022; 19:ijerph19159331. [PMID: 35954695 PMCID: PMC9368376 DOI: 10.3390/ijerph19159331] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/19/2022] [Revised: 07/24/2022] [Accepted: 07/28/2022] [Indexed: 02/04/2023]
Abstract
So far, the rate of HIV-positive people who do not know their sero-status is about 14% and the percentage is higher among transgender women (TGW). They represent one of the most vulnerable groups to infection. HIV self-testing (HIVST) may be a way to reduce transmission of the virus. The aim of this analysis and in-depth review was to collect available data on factors that may influence the use and dissemination of HIVST among TGW. This review was conducted in accordance with PRISMA guidelines for systematic reviews and meta-analyses. All data from 48 papers were used. From the available literature, HIVST is a convenient and preferred method of testing due to its high confidentiality and possibility of being performed at home. However, there are barriers that limit its use, including marginalization of transgender people, stigma by medical personnel, lack of acceptance of sexual partners, and even cultural standards. Therefore, there is a need for activities that promote and inform on the possibility of using HIVST as well as enable easier access to it.
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Affiliation(s)
- Julia Budzyńska
- Students’ Scientific Group on Medical Law, Department of Humanities and Social Medicine, Medical University of Lublin, 20-059 Lublin, Poland; (I.K.); (M.L.); (A.K.); (T.S.)
- Correspondence:
| | - Rafał Patryn
- Department of Humanities and Social Medicine, Medical University of Lublin, 20-059 Lublin, Poland;
| | - Ilona Kozioł
- Students’ Scientific Group on Medical Law, Department of Humanities and Social Medicine, Medical University of Lublin, 20-059 Lublin, Poland; (I.K.); (M.L.); (A.K.); (T.S.)
| | - Magdalena Leśniewska
- Students’ Scientific Group on Medical Law, Department of Humanities and Social Medicine, Medical University of Lublin, 20-059 Lublin, Poland; (I.K.); (M.L.); (A.K.); (T.S.)
| | - Agnieszka Kopystecka
- Students’ Scientific Group on Medical Law, Department of Humanities and Social Medicine, Medical University of Lublin, 20-059 Lublin, Poland; (I.K.); (M.L.); (A.K.); (T.S.)
| | - Tomasz Skubel
- Students’ Scientific Group on Medical Law, Department of Humanities and Social Medicine, Medical University of Lublin, 20-059 Lublin, Poland; (I.K.); (M.L.); (A.K.); (T.S.)
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14
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Kiptinness C, Kuo AP, Reedy AM, Johnson CC, Ngure K, Wagner AD, Ortblad KF. Examining the Use of HIV Self-Testing to Support PrEP Delivery: a Systematic Literature Review. Curr HIV/AIDS Rep 2022; 19:394-408. [PMID: 35904695 PMCID: PMC9334974 DOI: 10.1007/s11904-022-00617-x] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/12/2022] [Indexed: 11/16/2022]
Abstract
Purpose of Review HIV self-testing (HIVST) has the potential to expand access to and uptake of HIV pre-exposure prophylaxis (PrEP) delivery. We conducted a systematic literature review to understand the evidence on HIVST use for PrEP delivery. Recent Findings After screening 1055 records, we included eight: three randomized trials and five values and preferences studies. None measured PrEP initiation. Most studies occurred in Sub-Saharan Africa (7/8) and included different populations. One trial found that HIVST use between quarterly clinic visits as part of an adherence package with biofeedback slightly increased adherence; the other two trials found that HIVST use between or in lieu of quarterly clinic visits had no significant or non-inferior effects on adherence. HIVST to support PrEP delivery was acceptable, feasible, and preferred. Summary HIVST use for PrEP continuation largely resulted in similar outcomes to standard-of-care delivery and was perceived acceptable and feasible. Further research is needed to optimize HIVST use within PrEP programming. Supplementary Information The online version contains supplementary material available at 10.1007/s11904-022-00617-x.
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Affiliation(s)
- Catherine Kiptinness
- Department of Public and Global Health, University of Nairobi, Nairobi, Kenya.,Department of Global Health, University of Washington, Seattle, WA, 98105, USA
| | - Alexandra P Kuo
- Department of Pharmacy, University of Washington, Seattle, WA, 98195, USA
| | - Adriana M Reedy
- Public Health Sciences Division, Fred Hutchinson Cancer Center, 1100 Fairview Ave N, Seattle, WA, 98109, USA
| | - Cheryl C Johnson
- Global HIV, Hepatitis and STI Programmes, World Health Organization, Geneva, Switzerland
| | - Kenneth Ngure
- Department of Pharmacy, University of Washington, Seattle, WA, 98195, USA.,Department of Community Health, Jomo Kenyatta University of Agriculture and Technology, Nairobi, Kenya.,Department of Global Health, University of Washington, Seattle, WA, 98105, USA
| | - Anjuli D Wagner
- Department of Pharmacy, University of Washington, Seattle, WA, 98195, USA.,Department of Global Health, University of Washington, Seattle, WA, 98105, USA
| | - Katrina F Ortblad
- Public Health Sciences Division, Fred Hutchinson Cancer Center, 1100 Fairview Ave N, Seattle, WA, 98109, USA.
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