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Heck CJ, Dam A, Yohannes K, Deacon J, Kripke K, Meyers K, Poku O, Obermeyer C, Wiant S, Quigee D, Larson M, Malati C, Sobieszczyk ME, Torres-Rueda S, Castor D. Lessons learnt from daily oral PrEP delivery to inform national planning for PrEP ring introduction for women in low-income and middle-income countries: a qualitative inquiry of international stakeholders. BMJ Glob Health 2024; 9:e014709. [PMID: 38770814 PMCID: PMC11085820 DOI: 10.1136/bmjgh-2023-014709] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2023] [Accepted: 04/16/2024] [Indexed: 05/22/2024] Open
Abstract
INTRODUCTION Some African countries plan to introduce and scale-up new long-acting pre-exposure prophylaxis methods (LA-PrEP), like the monthly dapivirine vaginal ring (PrEP ring) and injectable cabotegravir. National costed implementation plans, roadmaps for successful product implementation, are often overlooked. International stakeholders engaged in oral PrEP planning, introduction and scale-up are an information resource of lessons learned to advise LA-PrEP planning. We consulted such international stakeholders and synthesised oral PrEP lessons to inform the development of a costed rollout plan template for LA-PrEP. METHODS From selected global health organisations (five international nongovernmental, four donor, four university/research and two multilateral), we interviewed 27 representatives based in America, Europe, Asia and Africa about strategic content and approaches for LA-PrEP policy, programming and implementation. We conducted a thematic analysis of the interview data for implementation considerations. RESULTS From the consultations, we identified six implementation themes for LA-PrEP introduction and scale-up: (1) ethically increasing choice and avoiding coercion; (2) de-stigmatising PrEP by focusing on preference rather than risk-based eligibility; (3) integrating LA-PrEP into services that are more woman-oriented, couple-oriented and family-oriented, and providing private spaces for LA-PrEP delivery; (4) de-medicalising delivery of relatively safe products (eg, PrEP ring); (5) constructing multilevel, nuanced communication strategies to address measured and perceived product efficacy and effectiveness; and (6) devising product-agnostic, modular approaches to service delivery. Despite the widespread emphasis on integration, few stakeholders offered empirical examples of successful integration approaches and frameworks. CONCLUSIONS Lessons learnt from stakeholder participants suggest standardised and modular processes can improve efficiencies in LA-PrEP planning and implementation. Tiered communication strategies addressing product efficacy and effectiveness will improve clients' and providers' efficacy in making informed decisions. Integration is important for LA-PrEP delivery, but data on empirical integration approaches and frameworks is minimal: further research in this discipline is needed.
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Affiliation(s)
- Craig J Heck
- Columbia University Mailman School of Public Health, New York, New York, USA
- Columbia University Irving Medical Center, New York, New York, USA
| | - Anita Dam
- United States Agency for International Development, Washington, District of Columbia, USA
| | - Kibret Yohannes
- University of Virginia School of Medicine, Charlottesville, Virginia, USA
| | | | | | - Kathrine Meyers
- Columbia University Irving Medical Center, New York, New York, USA
| | - Ohemaa Poku
- New York State Psychiatric Institute, New York, New York, USA
| | | | - Sarah Wiant
- Columbia University Irving Medical Center, New York, New York, USA
| | - Daniela Quigee
- Columbia University Irving Medical Center, New York, New York, USA
| | | | - Christine Malati
- United States Agency for International Development, Washington, District of Columbia, USA
| | | | | | - Delivette Castor
- Columbia University Mailman School of Public Health, New York, New York, USA
- Columbia University Irving Medical Center, New York, New York, USA
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Golden MR, Soge OO, Mills M, Berzkalns A, Cannon C, Ramchandani M, Dombrowski JC, Karmarkar EN, Chow EJ, Gov JP, Swenson P, Greninger AL. Asymptomatic and Subclinical Mpox: An Association With Modified Vaccinia Ankara Vaccine. Sex Transm Dis 2024; 51:342-347. [PMID: 38301634 DOI: 10.1097/olq.0000000000001939] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2024]
Abstract
BACKGROUND How often mpox causes asymptomatic infections, particularly among persons who have received the Modified Vaccinia Ankara (MVA) vaccine, is unknown. METHODS We performed mpox polymerase chain reaction testing on rectal and pharyngeal specimens collected from symptomatic and asymptomatic patients at a sexual health clinic in Seattle, WA, between May 2022 and May 2023. Analyses evaluated the prevalence of asymptomatic or subclinical infection and, among persons with polymerase chain reaction-positive tests, the association of MVA vaccination status with the symptomatic infection. RESULTS The study population included 1663 persons tested for mpox during 2353 clinic visits. Ninety-three percent of study participants were cisgender men and 96% were men who have sex with men. A total of 198 symptomatic patients (30%) had a first mpox-positive test during 664 visits. Eighteen patients (1.1%) tested during 1689 visits had asymptomatic or subclinical mpox based on a positive rectal or pharyngeal test done in the absence of testing done because of clinical suspicion for mpox. Fourteen (78%) of 18 persons with asymptomatic/subclinical mpox and 53 (26%) of 198 persons with symptomatic mpox had received at least 1 dose of the MVA vaccine ( P < 0.0001). Controlling for calendar month, study subjects who received 1 and 2 doses of MVA vaccine were 4.4 (95% confidence interval, 1.3-15) and 11.9 (3.6-40) times more likely to have asymptomatic versus symptomatic mpox, respectively, than persons who were unvaccinated. CONCLUSIONS Asymptomatic mpox is uncommon. Modified Vaccinia Ankara vaccination is associated with an asymptomatic/subclinical infection among persons with mpox.
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Affiliation(s)
| | | | - Margaret Mills
- Laboratory Medicine and Pathology, Washington, Seattle, WA
| | | | | | | | | | - Ellora N Karmarkar
- Department of Medicine, Division of Allergy and Infectious Diseases, University of Washington
| | | | - Jolene P Gov
- Laboratory Medicine and Pathology, Washington, Seattle, WA
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Ramchandani MS, Berzkalns A, Cannon CA, Dombrowski JC, Brown E, Chow EJ, Barash E, Pogosjans S, Smith D, Golden MR. Effectiveness of the Modified Vaccinia Ankara Vaccine Against Mpox in Men Who Have Sex With Men: A Retrospective Cohort Analysis, Seattle, Washington. Open Forum Infect Dis 2023; 10:ofad528. [PMID: 37942460 PMCID: PMC10629355 DOI: 10.1093/ofid/ofad528] [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: 08/01/2023] [Indexed: 11/10/2023] Open
Abstract
Background Data on modified Vaccinia Ankara (MVA) vaccine effectiveness against mpox in real-world settings are limited. Methods We performed a retrospective cohort analysis using Cox proportional hazards regression to estimate the association between vaccination and laboratory-confirmed mpox incidence. Study subjects included all men who have sex with men seen in a sexual health clinic in Seattle, Washington, between 1 January 2020 and 31 December 2022. Subjects' receipt of vaccine and diagnosis with mpox were ascertained from public health vaccine registry and surveillance data. Analyses were adjusted for demographic factors, human immunodeficiency virus (HIV) status, and sexual risk behaviors. Results The incidence of mpox per 100 person-years was 8.83 among patients with 0 doses, 3.32 among patients with 1 dose, and 0.78 among patients with 2 doses of MVA vaccine. Mpox diagnosis was significantly associated with age category 30-39 and 40-51 years, HIV positivity, syphilis diagnosis in the prior year, >10 sex partners in the last year, and having a clinic visit in the last year. In the multivariate model adjusting for these factors, vaccine effectiveness was 81% for 1 dose and 83% for 2 doses. Conclusions These data support the effectiveness of the MVA vaccine-including a single dose of the vaccine-in preventing mpox disease and highlight the appropriateness of risk factor-based prioritization of immunization early in the epidemic. The durability of MVA vaccine-induced immunity is unknown, and at-risk persons should receive 2 doses of MVA.
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Affiliation(s)
- Meena S Ramchandani
- Department of Medicine, University of Washington, Seattle, Washington, USA
- HIV/STI/HCV Program, Public Health–Seattle & King County, Seattle, Washington, USA
| | - Anna Berzkalns
- HIV/STI/HCV Program, Public Health–Seattle & King County, Seattle, Washington, USA
| | - Chase A Cannon
- Department of Medicine, University of Washington, Seattle, Washington, USA
- HIV/STI/HCV Program, Public Health–Seattle & King County, Seattle, Washington, USA
| | - Julia C Dombrowski
- Department of Medicine, University of Washington, Seattle, Washington, USA
- HIV/STI/HCV Program, Public Health–Seattle & King County, Seattle, Washington, USA
- Department of Epidemiology, University of Washington, Seattle, Washington, USA
| | - Elizabeth Brown
- Department of Biostatistics, University of Washington, Seattle, Washington, USA
| | - Eric J Chow
- Department of Medicine, University of Washington, Seattle, Washington, USA
- Department of Epidemiology, University of Washington, Seattle, Washington, USA
- Communicable Disease Epidemiology and Immunizations, Public Health–Seattle & King County, Seattle, Washington, USA
| | - Elizabeth Barash
- HIV/STI/HCV Program, Public Health–Seattle & King County, Seattle, Washington, USA
| | - Sargis Pogosjans
- Communicable Disease Epidemiology and Immunizations, Public Health–Seattle & King County, Seattle, Washington, USA
| | - Daniel Smith
- Communicable Disease Epidemiology and Immunizations, Public Health–Seattle & King County, Seattle, Washington, USA
| | - Matthew R Golden
- Department of Medicine, University of Washington, Seattle, Washington, USA
- HIV/STI/HCV Program, Public Health–Seattle & King County, Seattle, Washington, USA
- Department of Epidemiology, University of Washington, Seattle, Washington, USA
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