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Sandfort TGM, Kreniske P, Mbeda C, Reynolds D, Tshabalala G, Madiwati B, Ogendo A, Dominquez K, Panchia R, Gondwe D, Hamilton EL, Guo X, Cummings V. Interest in I-PrEP and Willingness to Participate in Clinical Trials Among Men and Transfeminine Persons Who have Sex with Men in Sub-Saharan Africa: Quantitative and Qualitative Findings from HPTN 075. AIDS Behav 2024; 28:2361-2377. [PMID: 38761334 PMCID: PMC11199096 DOI: 10.1007/s10461-024-04334-x] [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: 03/27/2024] [Indexed: 05/20/2024]
Abstract
This study explored interest in injectable PrEP (I-PrEP) and willingness to participate in clinical trials testing new biomedical HIV prevention strategies among men and transfeminine persons who have sex with men (MSM & TGP), using data collected in the HIV Prevention Trials Network (HPTN) 075 study, which took place at sites in Kenya, Malawi, and South Africa. Data result from a survey among 267 18-44 years old HIV negative participants, complemented with semi-structured interviews with 80 purposively recruited persons. Correlations coefficients were calculated to identify demographic and psychosocial factors associated with interest in I-PrEP. Qualitative interviews were analyzed using concept-driven and subsequent data-driven coding. Most surveyed participants expressed an interest in I-PrEP. Quantitatively, only being interested in other HIV prevention measures was associated with interest in I-PrEP. Qualitatively, most participants preferred I-PrEP to O-PrEP and remained interested in I-PrEP despite barriers such as the somewhat invasive nature of the procedure and potential side effects of I-PrEP. Interest in I-PrEP was driven by the possibility of avoiding sexual or HIV stigma. Access to healthcare and altruism-such as assisting in the development of new HIV prevention methods-positively impacted willingness to participate in clinical trials. With I-PrEP favored by most participants, it is potentially a critical tool to prevent HIV infection among MSM & TGP in sub-Saharan Africa, with the mitigation of stigma as a major advance. Recruitment of MSM & TGP in biobehavioral clinical trials seems feasible, with altruistic reasons and receiving I-PrEP and free medical care as major motivators.
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Affiliation(s)
- Theodorus G M Sandfort
- HIV Center for Clinical and Behavioral Studies, Department of Psychiatry, New York State Psychiatric Institute and Columbia University, 1051 Riverside Drive, Unit 15, New York, NY, 10032, USA.
| | - Philip Kreniske
- Community Health and Social Sciences Department, Graduate School of Public Health and Health Policy, City University of New York (CUNY), New York, USA
| | - Calvin Mbeda
- Kenya Medical Research Institute (KEMRI) CDC, Kisumu, Kenya
| | | | - Gugulethu Tshabalala
- Perinatal HIV Research Unit, University of the Witwatersrand, Soweto, South Africa
| | | | - Arthur Ogendo
- Kenya Medical Research Institute (KEMRI) CDC, Kisumu, Kenya
| | | | - Ravindre Panchia
- Perinatal HIV Research Unit, University of the Witwatersrand, Soweto, South Africa
| | - Daniel Gondwe
- College of Medicine-Johns Hopkins Research Project, Blantyre, Malawi
| | | | - Xu Guo
- Vaccine and Infectious Disease Division, Fred Hutchinson Cancer Research Center, Seattle, WA, USA
| | - Vanessa Cummings
- Department of Pathology, Johns Hopkins University School of Medicine, Baltimore, MD, USA
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Rousseau E, Sikkema KJ, Julies RF, Mazer K, O'Malley G, Heffron R, Morton JF, Johnson R, Celum C, Baeten JM, Bekker L. Exploring adolescent girls and young women's PrEP-user profiles: qualitative insights into differentiated PrEP delivery platform selection and engagement in Cape Town, South Africa. J Int AIDS Soc 2024; 27:e26254. [PMID: 38695101 PMCID: PMC11063778 DOI: 10.1002/jia2.26254] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2023] [Accepted: 04/15/2024] [Indexed: 05/04/2024] Open
Abstract
INTRODUCTION Adolescent girls and young women (AGYW), a priority population for HIV prevention in Africa, show high interest but difficulty in sustained effective use of pre-exposure prophylaxis (PrEP). With ongoing PrEP scale-up focused on increasing access, it is important to understand what influences AGYW's choice of PrEP delivery platforms. METHODS The POWER implementation study in Cape Town provided PrEP between 2017 and 2020 to AGYW (16-25 years) from four differentiated delivery platforms: mobile clinic, government facility, courier delivery or community-based youth club. Healthcare providers at government and mobile clinics provided PrEP (initiation and refills) as part of comprehensive, integrated sexual and reproductive health services. Courier and youth club platforms provided light-touch PrEP refill services incorporating rapid HIV self-testing. We conducted in-depth interviews with a purposive sample of AGYW who had ≥3 months of PrEP-use and accessed ≥2 PrEP delivery platforms. The thematic analysis explored AGYW's preferences, decision-making and habits related to PrEP access to inform market segmentation. RESULTS We interviewed 26 AGYW (median age 20) PrEP-users between November 2020 and March 2021. AGYW PrEP-users reported accessing different services with, 24 accessing mobile clinics, 17 courier delivery, 9 government health facilities and 6 youth clubs for their PrEP refills. Qualitative findings highlighted four potential behavioural profiles. The "Social PrEP-user" preferred PrEP delivery in peer spaces, such as youth clubs or adolescent-friendly mobile clinics, seeking affirmation and social support for continued PrEP use. The "Convenient PrEP-user" favoured PrEP delivery at easily accessible locations, providing quick (courier) or integrated contraception-PrEP refill visits (mobile and government clinic). The "Independent PrEP-user" preferred PrEP delivery that offered control over delivery times that fit into their schedule, such as the courier service. The "Discreet PrEP-user" highly valued privacy regarding their PrEP use (courier delivery) and avoided delivery options where unintentional disclosure was evident (youth club). Comfort with HIV self-testing had minimal influence on PrEP delivery choice. CONCLUSIONS Market segmentation of AGYW characterizes different types of PrEP-users and has the potential to enhance tailored messaging and campaigns to reach specific segments, with the aim of improving sustained PrEP use and HIV prevention benefits.
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Affiliation(s)
- Elzette Rousseau
- Desmond Tutu HIV CentreUniversity of Cape TownCape TownSouth Africa
| | - Kathleen J. Sikkema
- Department of Sociomedical SciencesMailman School of Public HealthColumbia UniversityNew York CityNew YorkUSA
| | - Robin F. Julies
- Department of PsychologyUniversity of the Western CapeCape TownSouth Africa
| | - Katelyn Mazer
- Department of EpidemiologyFielding School of Public HealthUniversity of CaliforniaLos AngelesCaliforniaUSA
| | - Gabrielle O'Malley
- Department of Global HealthMedicine and EpidemiologyUniversity of WashingtonSeattleWashingtonUSA
| | - Renee Heffron
- Department of MedicineHeersink School of MedicineUniversity of Alabama at BirminghamBirminghamAlabamaUSA
| | - Jennifer F. Morton
- Department of Global HealthMedicine and EpidemiologyUniversity of WashingtonSeattleWashingtonUSA
| | - Rachel Johnson
- Department of Global HealthMedicine and EpidemiologyUniversity of WashingtonSeattleWashingtonUSA
| | - Connie Celum
- Department of Global HealthMedicine and EpidemiologyUniversity of WashingtonSeattleWashingtonUSA
| | - Jared M. Baeten
- Department of Global HealthMedicine and EpidemiologyUniversity of WashingtonSeattleWashingtonUSA
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Kebede S, Brazier E, Freeman AM, Muwonge TR, Choi JY, de Waal R, Poda A, Cesar C, Munyaneza A, Kasozi C, Pasayan MKU, Althoff KN, Shongo A, Low N, Ekouevi D, Veloso VG, Ross J. Preexposure prophylaxis availability among health facilities participating in the global International epidemiology Databases to Evaluate AIDS (IeDEA) consortium. AIDS 2024; 38:751-756. [PMID: 38133656 PMCID: PMC10939841 DOI: 10.1097/qad.0000000000003824] [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] [Indexed: 12/23/2023]
Abstract
BACKGROUND While recognized as a key HIV prevention strategy, preexposure prophylaxis (PrEP) availability and accessibility are not well documented globally. We aimed to describe PrEP drug registration status and the availability of PrEP services across HIV care sites participating in the International epidemiology Databases to Evaluate AIDS (IeDEA) research consortium. METHODS We used country-level PrEP drug registration status from the AIDS Vaccine Advocacy Coalition and data from IeDEA surveys conducted in 2014, 2017 and 2020 among participating HIV clinics in seven global regions. We used descriptive statistics to assess PrEP availability across IeDEA sites serving adult patients in 2020 and examined trends in PrEP availability among sites that responded to all three surveys. RESULTS Of 199 sites that completed the 2020 survey, PrEP was available in 161 (81%). PrEP availability was highest at sites in North America (29/30; 97%) and East Africa (70/74; 95%) and lowest at sites in Central (10/20; 50%) and West Africa (1/6; 17%). PrEP availability was higher among sites in countries where PrEP was officially registered (146/161; 91%) than where it was not (14/32; 44%). Availability was higher at health centers (109/120; 90%) and district hospitals (14/16; 88%) compared to regional/teaching hospitals (36/63). Among the 94 sites that responded to all three surveys, PrEP availability increased from 47% in 2014 to 60% in 2017 and 76% in 2020. CONCLUSION PrEP availability has substantially increased since 2014 and is now available at most IeDEA sites. However, PrEP service provision varies markedly across global regions.
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Affiliation(s)
- Samuel Kebede
- Department of Medicine, New York University Grossman School of Medicine, New York, NY, USA
| | - Ellen Brazier
- Institute for Implementation Science in Population Health, City University of New York, New York, NY, USA
- Graduate School of Public Health and Health Policy, City University of New York, New York, NY, USA
| | | | | | - Jun Yong Choi
- Division of Infectious Diseases, Department of Internal Medicine, Yonsei University College of Medicine, Seoul, South Korea
| | - Renee de Waal
- Centre for Infectious Disease Epidemiology and Research, University of Cape Town, Cape Town, South Africa
| | - Armel Poda
- Hôpital de Jour, Service des Maladies Infectieuses, CHU Sourô Sanou, Bobo-Dioulasso, Burkina Faso
| | | | | | | | | | - Keri N Althoff
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Alisho Shongo
- School of Public Health, University of Kinshasa, Kinshasa, Democratic Republic of Congo
| | - Nicola Low
- Institute of Social and Preventive Medicine, Bern, Switzerland
| | | | - Valdiléa G. Veloso
- Instituto Nacional de Infectologia Evandro Chagas, Rio de Janerio, Brazil
| | - Jonathan Ross
- Department of Medicine, Albert Einstein College of Medicine, Bronx, NY, USA
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Little KM, Hanif H, Anderson SM, Clark MR, Gustafson K, Doncel GF. Preferences for Long-Acting PrEP Products Among Women and Girls: A Quantitative Survey and Discrete Choice Experiment in Eswatini, Kenya, and South Africa. AIDS Behav 2024; 28:936-950. [PMID: 37971614 PMCID: PMC10896879 DOI: 10.1007/s10461-023-04202-0] [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: 09/28/2023] [Indexed: 11/19/2023]
Abstract
While oral pre-exposure prophylaxis (PrEP) can substantially reduce HIV risk, there are important barriers to uptake and adherence. We explored preferences for long-acting injectable and implantable PrEP among women and girls in Eswatini, Kenya, and South Africa. We conducted an online quantitative survey and discrete choice experiment (DCE) among adolescent girls (15-17), young women (18-29), and adult women (30-49). Participants completed a survey about their demographics and behavior and a DCE with 5 attributes (format, insertion location, number of insertions, dual-protection, and palpability). We recruited 1236 respondents (Eswatini = 420; Kenya = 350; South Africa = 493) in May 2022. Most participants were sexually active (72%), nearly 29% of whom reported recently engaging in transactional sex. 46% had heard of oral PrEP, but of those, only 16% reported having ever used it. Product format and dual-protection were significant predictors of product choice. Relative to a 2-month injection, participants had 1.76 times the odds (95% CI 1.08-2.04) of choosing a 6-month injectable, and 1.70 the odds (95% CI 1.06-1.92) of choosing a 12-month removable implant. Compared to a single-indication product, respondents had 2.46 times the odds (95% CI 1.04-2.68) of preferring a product also protecting against pregnancy, and 2.81 the odds (95% CI 1.04-3.05) of choosing a product that also protected against STIs. Adolescent girls and women in these countries showed strong preferences for longer-acting PrEP product formats, as well as those offering dual-protection. Introduction of long-acting options could improve PrEP uptake and reduce HIV burdens in east and southern African settings.
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Affiliation(s)
- Kristen M Little
- Population Services International, 1120 19th Street NW, Suite 600, Washington, DC, 20036, USA.
| | - Homaira Hanif
- Eastern Virginia Medical School, CONRAD, Norfolk, VA, USA
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Kawuma S, Katwesigye R, Walusaga H, Akatukunda P, Nangendo J, Kabugo C, Kamya MR, Semitala FC. Determinants to Continuation on Hiv Pre-exposure Propylaxis Among Female Sex Workers at a Referral Hospital in Uganda: a Mixed Methods Study Using Com-b Model. RESEARCH SQUARE 2024:rs.3.rs-3914483. [PMID: 38405703 PMCID: PMC10889058 DOI: 10.21203/rs.3.rs-3914483/v1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/27/2024]
Abstract
Background Female sex workers (FSWs) have the highest HIV prevalence in Uganda. Pre exposure prophylaxis (PrEP) has been recommended as part of the HIV combination prevention strategy, with improved patient initiation, but continuation on the service is low. We evaluated PrEP continuation among FSWs and explored potential determinants of PrEP continuation within a public referral hospital in Urban Uganda. Methods An explanatory sequential mixed method study was conducted at Kiruddu National referral hospital in Uganda. Secondary data on social demographic characteristics and follow up outcomes of at least one year was collected for all FSWs who were initiated PrEP between May 2020 and April 2021.We used Kaplan-Meier survival analysis to evaluate continuation on PrEP from time of initiation and follow-up period. The capability, opportunity, and motivation to change behaviour model was used to explore perspectives and practices of FSWs (n = 24) and health care providers (n = 8) on continuation on PrEP among FSWs, using semi structured interviews. The qualitative data was deductively coded and analyzed thematically, categorizing the themes related to PrEP continuation as facilitators and barriers. Results Of the 292 FSWs initiated on PrEP during this period, 101 (34.6) % were active on PrEP, 137 (46.9%) were lost to follow-up, 45 (15.4%) were no longer eligible to continue PrEP, eight (2.7%) were transferred out and one (0.3%) had died. Median survival time on PrEP was 15 months (Interquartile range IQR, 3-21). The continuation rates on PrEP at six (6) and 12 months were, 61.1% and 53.1%, respectively. Facilitators of PrEP continuation included awareness of risk associated with sex work, integration of PrEP with other HIV prevention services, presence of PrEP Peer support and use of Drop-in centers. The barriers included low community awareness about PrEP, high mobility of sex workers, substance abuse, and the unfavorable daytime clinic schedules. Conclusion Continuation on PrEP remains low among FSWs. Interventions for PrEP continuation should address barriers such as low community awareness on PrEP, substance abuse and restrictive health facility policies for scale of the PrEP program among FSWs in Uganda. Integration of PrEP with other services and scale up of community PrEP delivery structures may improve its continuation.
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Olakunde BO, Folala-Anoemuah Y, Ujam C, Ndukwe CD, Olaifa Y, Yahaya HB, Bello H, Ogundipe A. Awareness and uptake of oral pre-exposure prophylaxis among adolescent and young key populations in Nigeria: a secondary data analysis of the 2020 Integrated Biological & Behavioural Surveillance Survey. AIDS Care 2024; 36:146-152. [PMID: 37683258 DOI: 10.1080/09540121.2023.2254547] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2022] [Accepted: 08/25/2023] [Indexed: 09/10/2023]
Abstract
Oral pre-exposure prophylaxis (PrEP) is a critical intervention for HIV prevention among key populations (KP) in Nigeria. However, little is known about its coverage among adolescent and young key populations (AYKP). Using the 2020 Integrated Biological & Behavioural Surveillance Survey conducted among KP, including female sex workers (FSW), men who have sex with men (MSM), people who inject drugs (PWID), and transgender people (TG), we assessed the awareness and uptake of PrEP among AYKP (15-24 years) in Nigeria. We performed weighted descriptive statistics and logistic regression analyses. Of the 6882 AYKP included in this study, 36.1% were aware of PrEP, ranging from 47.9% in MSM to 19.8% in FSW. Compared with FSW, MSM (aOR = 3.7, 95%CI = 3.22-4.35) and TG (aOR = 2.6, 95%CI = 2.18-2.98) had significant higher odds of PrEP awareness. Among those aware of PrEP, 24.5% had ever taken PrEP. The uptake of PrEP varied by KP group: TG (28.1%), MSM (25.3%), PWID (18.0%), and FSW (14.4%). MSM (aOR = 2.6, 95%CI = 1.72-4.07) and TG (aOR = 2.7, 95%CI = 1.71-4.14) had significant higher odds of PrEP uptake relative to FSW. The awareness and uptake of PrEP among AYKP in Nigeria is low. This calls for more awareness creation about PrEP addressing the barriers that limit its uptake.
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Affiliation(s)
- Babayemi O Olakunde
- Department of Community Prevention and Care Services, National Agency for the Control of AIDS, Abuja, Nigeria
- Center for Translation and Implementation Research, University of Nigeria Nsukka, Enugu, Nigeria
| | - Yinka Folala-Anoemuah
- Department of Community Prevention and Care Services, National Agency for the Control of AIDS, Abuja, Nigeria
| | - Chukwugozie Ujam
- Department of Community Prevention and Care Services, National Agency for the Control of AIDS, Abuja, Nigeria
| | - Chinwedu D Ndukwe
- Department of Community Prevention and Care Services, National Agency for the Control of AIDS, Abuja, Nigeria
- African Institute of Health Policy and Health Systems, Abakaliki, Nigeria
| | - Yewande Olaifa
- Department of Community Prevention and Care Services, National Agency for the Control of AIDS, Abuja, Nigeria
| | - Hidayat B Yahaya
- Department of Community Prevention and Care Services, National Agency for the Control of AIDS, Abuja, Nigeria
| | - Hasiya Bello
- Department of Community Prevention and Care Services, National Agency for the Control of AIDS, Abuja, Nigeria
| | - Alex Ogundipe
- Department of Community Prevention and Care Services, National Agency for the Control of AIDS, Abuja, Nigeria
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Kansiime S, Hansen CH, Hayes R, Ruzagira E. Developing HIV risk prediction tools in four African settings. Trop Med Int Health 2023; 28:720-730. [PMID: 37496465 PMCID: PMC10947046 DOI: 10.1111/tmi.13916] [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] [Indexed: 07/28/2023]
Abstract
OBJECTIVE HIV risk prediction tools are a critical component of efforts to end the HIV pandemic. We aimed to create and validate tools for identifying individuals at highest risk of prevalent and incident HIV in an African setting. METHODS We used Logistic regression and Poisson regression to determine risk factors for HIV prevalence and incidence in a multi-country HIV vaccine trial preparedness cohort study among individuals at high risk of HIV, and used the identified factors to create and validate tools that predict HIV risk. We also assessed the performance of the VOICE risk score in predicting HIV incidence among women in the cohort. RESULTS The prevalent HIV prediction tool created had good predictive ability [area under the curve (AUC) = 0.70, 95% CI 0.66-0.74]. It included the following participant variables: age, sex, recreational drug use, unprotected male-to-male anal sex, a sexual partner who had other partners, transactional sex and having a partner who was a long-distance truck driver/miner. It was not possible to create a valid HIV incidence prediction tool. Participants with high VOICE risk scores (≥7) had slightly higher HIV incidence but this tool performed poorly within our study (AUC = 0.58, 95% CI 0.51-0.64: Harrell's concordance index = 0.59). CONCLUSION We created a prevalent HIV prediction tool that could be used to increase efficiency in diagnosis of HIV and linkage to care in sub-Saharan Africa. Existing incident HIV prediction tools may need modification to include context-specific predictors such as calendar period, participant occupation, study site, before adoption in settings different from those in which they were developed.
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Affiliation(s)
- Sheila Kansiime
- Medical Research Council/Uganda Virus Research Council and London School of Hygiene and Tropical Medicine, Uganda Research UnitEntebbeUganda
- Medical Research Council International Statistics and Epidemiology Group, London School of Hygiene & Tropical MedicineLondonUK
| | - Christian Holm Hansen
- Medical Research Council/Uganda Virus Research Council and London School of Hygiene and Tropical Medicine, Uganda Research UnitEntebbeUganda
- Medical Research Council International Statistics and Epidemiology Group, London School of Hygiene & Tropical MedicineLondonUK
| | - Richard Hayes
- Medical Research Council International Statistics and Epidemiology Group, London School of Hygiene & Tropical MedicineLondonUK
| | - Eugene Ruzagira
- Medical Research Council/Uganda Virus Research Council and London School of Hygiene and Tropical Medicine, Uganda Research UnitEntebbeUganda
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Ferrand RA, Kranzer K. Bending the HIV epidemic curve: can prevention cascades show us how? Lancet Glob Health 2023; 11:e999-e1000. [PMID: 37349046 DOI: 10.1016/s2214-109x(23)00223-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2023] [Accepted: 05/05/2023] [Indexed: 06/24/2023]
Affiliation(s)
- Rashida A Ferrand
- The Health Research Unit Zimbabwe, Biomedical Research and Training Institute, Harare, Zimbabwe; Department of Clinical Research, London School of Hygiene and Tropical Medicine, London, UK
| | - Katharina Kranzer
- The Health Research Unit Zimbabwe, Biomedical Research and Training Institute, Harare, Zimbabwe; Department of Clinical Research, London School of Hygiene and Tropical Medicine, London, UK; Department of Infectious Diseases and Tropical Medicine, Ludwig-Maximilians-Universität, Munich, Germany; German Center for Infection Research, Munich, Germany.
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Dietrich JJ, Ahmed N, Tshabalala G, Wu M, Mulaudzi M, Hornschuh S, Atujuna M, Muhumuza R, Ssemata AS, Stranix-Chibanda L, Nematadzira T, Bekker LG, Martinson N, Seeley J, Fox J. A qualitative study to explore daily versus on-demand oral pre-exposure prophylaxis (PrEP) in young people from South Africa, Uganda and Zimbabwe. PLoS One 2023; 18:e0287627. [PMID: 37384792 PMCID: PMC10310032 DOI: 10.1371/journal.pone.0287627] [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: 07/04/2021] [Accepted: 06/12/2023] [Indexed: 07/01/2023] Open
Abstract
BACKGROUND Adolescents in sub-Saharan Africa (SSA) remain vulnerable to HIV infection. While pre-exposure prophylaxis (PrEP) is highly effective in preventing HIV transmission as a daily or on-demand regimen, tailored approaches are necessary. The Combined HIV Adolescent PrEP and Prevention Study (CHAPS) is a mixed-methods research program investigating the acceptability and feasibility of implementing daily and on-demand PrEP among young people in SSA. It also aims to determine an on-demand dosing schedule for insertive sex. For this paper, we explored preferences for daily versus on-demand PrEP amongst adolescents as part of CHAPS. METHODS Purposive sampling was used to recruit participants from Soweto and Cape Town (South Africa), Wakiso district (Uganda) and Chitungwiza (Zimbabwe). At the time of the study in 2018/2019, Uganda had not rolled out PrEP to the general population; in Zimbabwe, PrEP for young people was only available at selected sites with one located within the study recruitment area. In South Africa, PrEP was made available to selected high-risk groups. We conducted 60 in-depth interviews and 24 group discussions amongst young people aged 13-24 without HIV in South Africa, Uganda, and Zimbabwe. All in-depth interviews and group discussions were audio-recorded, transcribed verbatim and translated to English. Data were analysed using framework analysis. The main themes were centered around preferences for daily and on-demand PrEP. RESULTS Reasons for on-demand preferences included stigma, pill fatigue, adherence and side effects. Reasons for daily PrEP preferences included factors related to sexual risk behaviour, continuous protection against incidents of unintentional exposure, and the increased efficacy of a daily dose. Participants at all sites preferring daily PrEP identified the same reasons, with more males than females citing inadvertent blood contact or perceived increased efficacy. Similarly, participants at all sites preferring on-demand PrEP gave the same reasons for their preferences for on-demand PrEP; the exception was South Africans who did not mention the hope of having fewer side effects by not taking daily PrEP. Additionally, more males than females cited intermittent sex as a reason for opting for on-demand PrEP. CONCLUSIONS Our study is the first known to explore and describe youth preferences for daily versus on-demand PrEP. While the choice is clear-cut, the reasons cited in the different options provide invaluable insights into their decisions, and the actual and perceived facilitators and barriers to access to PrEP. Further education is needed amongst young people, not only about PrEP but also in other areas of comprehensive sexuality education. Exploring all options of HIV prevention is crucial to provide a tailored, one-size-does-not-fit-all approach to adolescent care in SSA to reduce and, the continued and increasing risk of this preventable infection.
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Affiliation(s)
- Janan Janine Dietrich
- Perinatal HIV Research Unit, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
- Health Systems Research Unit, South African Medical Research Council, Bellville, South Africa
- African Social Sciences Unit of Research and Evaluation (ASSURE), Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Nadia Ahmed
- Mortimer Market Centre, Central North West London NHS Trust, London, United Kingdom
- Desmond Tutu HIV Centre, University of Cape Town, Cape Town, South Africa
| | - Gugulethu Tshabalala
- Perinatal HIV Research Unit, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Minju Wu
- Harvard College, Cambridge, MA, United States of America
| | - Mamakiri Mulaudzi
- Perinatal HIV Research Unit, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Stefanie Hornschuh
- Perinatal HIV Research Unit, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Millicent Atujuna
- Desmond Tutu HIV Centre, University of Cape Town, Cape Town, South Africa
| | - Richard Muhumuza
- Medical Research Council/Uganda Virus Research Institute and London School of Hygiene & Tropical Medicine Uganda Research Unit, Entebbe, Uganda
| | - Andrew Sentoogo Ssemata
- Medical Research Council/Uganda Virus Research Institute and London School of Hygiene & Tropical Medicine Uganda Research Unit, Entebbe, Uganda
- Department of Global Health and Development, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Lynda Stranix-Chibanda
- University of Zimbabwe Clinical Trials Research Centre, Faculty of Medicine and Health Sciences, Harare, Zimbabwe
| | - Teacler Nematadzira
- University of Zimbabwe Clinical Trials Research Centre, Faculty of Medicine and Health Sciences, Harare, Zimbabwe
| | - Linda-Gail Bekker
- Desmond Tutu HIV Centre, University of Cape Town, Cape Town, South Africa
| | - Neil Martinson
- Perinatal HIV Research Unit, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Janet Seeley
- Medical Research Council/Uganda Virus Research Institute and London School of Hygiene & Tropical Medicine Uganda Research Unit, Entebbe, Uganda
- Department of Global Health and Development, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Julie Fox
- King’s College London, London, United Kingdom
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Nagai H, Adiibokah E, Tagoe H, Tun W, Pilgrim NA, Ankomah A, Rahman YAA, Addo SA, Atuahene SK, Essandoh E, Maher S, Kowalski M. Policymakers' and healthcare providers' perspectives on the introduction of oral pre-exposure prophylaxis for key populations in Ghana. BMC Public Health 2023; 23:1065. [PMID: 37277772 DOI: 10.1186/s12889-023-15871-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2022] [Accepted: 05/11/2023] [Indexed: 06/07/2023] Open
Abstract
BACKGROUND Key populations (KPs) such as female sex workers (FSWs), men who have sex with men (MSM), people who inject drugs (PWID), and their partners contribute more than a quarter (27.5%) of new HIV infection in Ghana. Oral pre-exposure prophylaxis (PrEP) can substantially reduce HIV acquisition among this group. While the available research indicates KPs willingness to take PrEP in Ghana, little is known about the position of policymakers and healthcare providers on the introduction of PrEP for KPs. METHODS Qualitative data were collected from September to October 2017 in the Greater Accra (GA) and Brong-Ahafo (BA) regions of Ghana. Key informant interviews were conducted with 20 regional and national policymakers and supplemented with In-depth Interviews with 23 healthcare providers to explore their level of support for PrEP and their perspectives on challenges and issues to consider for oral PrEP implementation in Ghana. Thematic content analysis was used to unearth the issues emerging from the interviews. RESULTS Policymakers and healthcare providers in both regions expressed strong support for introducing PrEP for KPs. Key concerns regarding oral PrEP introduction included potential for behavioral disinhibition, non-adherence and side effects of medication, cost and long-term financial implications, and stigma related to HIV and key populations. Participants stressed the need to integrate PrEP into existing services and the provision of PrEP should start with high risk groups like sero-discordant couples, FSWs and MSM. CONCLUSIONS Policymakers and providers recognize the value of PrEP in cubing new HIV infections but have concerns about disinhibition, non-adherence, and cost. Therefore, the Ghana health service should roll-out a range of strategies to address their concerns including: sensitization with providers to mitigate underlying stigma towards KPs, particularly MSM, integration of PrEP into existing services, and innovative strategies to improve continued use of PrEP.
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Affiliation(s)
- Henry Nagai
- JSI Research & Training Institute, Inc, Accra, Ghana
| | | | - Henry Tagoe
- JSI Research & Training Institute, Inc, Accra, Ghana.
| | | | | | | | | | | | | | | | - Sean Maher
- JSI Research & Training Institute, Inc, Boston, USA
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11
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Haberer JE, Mujugira A, Mayer KH. The future of HIV pre-exposure prophylaxis adherence: reducing barriers and increasing opportunities. Lancet HIV 2023:S2352-3018(23)00079-6. [PMID: 37178710 DOI: 10.1016/s2352-3018(23)00079-6] [Citation(s) in RCA: 10] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2022] [Revised: 03/19/2023] [Accepted: 03/27/2023] [Indexed: 05/15/2023]
Abstract
The effectiveness of HIV pre-exposure prophylaxis (PrEP) hinges on adherence, which has been restricted by multifaceted barriers. Uptake of PrEP has been impeded by poor access resulting from high costs, provider uncertainty, discrimination, stigma, and poor understanding within the health-care community and the public of who can benefit from PrEP. Other important barriers to adherence and persistence over time relate to individuals (eg, depression) and their community, partners, and family (eg, poor support), and their effects vary substantially with each person, population, and setting. Despite these challenges, key opportunities for improving PrEP adherence exist, including novel delivery systems, tailored individual interventions, mobile health and digital health interventions, and long-acting formulations. Objective monitoring strategies will help to improve adherence interventions and alignment of PrEP use with the need for HIV prevention (ie, prevention-effective adherence). The future of PrEP adherence lies in person-centred approaches to service delivery that meet the needs of individuals while creating supportive environments and facilitating health-care access and delivery.
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Affiliation(s)
- Jessica E Haberer
- Center for Global Health, Massachusetts General Hospital, Boston, MA, USA; Department of Medicine, Harvard Medical School, Boston, MA, USA.
| | - Andrew Mujugira
- Infectious Diseases Institute, Makerere University, Kampala, Uganda; Department of Global Health, University of Washington, Seattle, WA, USA
| | - Kenneth H Mayer
- Department of Medicine, Harvard Medical School, Boston, MA, USA; The Fenway Institute, Boston, MA, USA; Department of Medicine, Beth Israel Deaconess Medical Center, Boston, MA, USA
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12
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Fleischman J, Kachale F, Mhuriro F, Mugambi M, Ncube G, Ndwiga A, Nyirenda R, Carter A, Rodrigues J, Segal K. Catalyzing action on HIV/SRH integration: lessons from Kenya, Malawi, and Zimbabwe to spur investment. Glob Health Action 2022; 15:2029335. [PMID: 35323105 PMCID: PMC8956310 DOI: 10.1080/16549716.2022.2029335] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
The HIV pandemic has long revealed the inequities and fault lines in societies, one of the most tenacious being the pandemic's disproportionate impact on adolescent girls and young women. In east and southern Africa, renewed global action is needed to invigorate an effective yet undervalued approach to expanding HIV prevention and improving women's health: integration of quality HIV and sexual and reproductive health (SRH) services. The urgency of advancing effective integration of these services has never been clearer or more pressing. In this piece, national health officials from Kenya, Malawi, and Zimbabwe and global health professionals have joined together in a call to catalyze actions by development partners in support of national strategies to integrate HIV and SRH information and services. This agenda is especially vital now because these adolescent girls and young women are falling through the cracks due to the cascading effects of COVID-19 and disruptions in both SRH and HIV services. In addition, the scale-up of pre-exposure prophylaxis (PrEP) has been anemic for this population. Examining the opportunities and challenges of HIV/SRH integration implemented recently in three countries - Kenya, Malawi, and Zimbabwe - provides lessons to spur integration and investments there and in other nations in the region, aimed at improving health outcomes for adolescent girls and young women and curbing the global HIV epidemic. While gaps remain between strong national integration policies and program implementation, the experiences of these countries show opportunities for expanded, quality integration. This commentary draws on a longer comparative analysis of findings from rapid landscaping analyses in Kenya, Malawi, and Zimbabwe, which highlighted cross-country trends and context-specific realities around HIV/SRH integration.
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Affiliation(s)
- Janet Fleischman
- Center for Innovation in Global Health, Georgetown University Medical Center, Washington, DC, USA
| | - Fannie Kachale
- Department of Reproductive Health, Ministry of Health, Lilongwe, Malawi
| | - Fatima Mhuriro
- Reproductive Health Unit, Ministry of Health and Child Care, Harare, Zimbabwe
| | | | - Getrude Ncube
- Department of AIDS/TB, Ministry of Health and Child Care, Harare, Zimbabwe
| | - Albert Ndwiga
- Department of Family Health, Ministry of Health, Nairobi, Kenya
| | - Rose Nyirenda
- Department of HIV/AIDS, Ministry of Health, Lilongwe, Malawi
| | - Anna Carter
- Center for Innovation in Global Health, Georgetown University Medical Center, Washington, DC, USA
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13
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Health system opportunities and challenges for PrEP implementation in Kenya: A qualitative framework analysis. PLoS One 2022; 17:e0259738. [PMID: 36206224 PMCID: PMC9543691 DOI: 10.1371/journal.pone.0259738] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2021] [Accepted: 10/25/2021] [Indexed: 11/06/2022] Open
Abstract
Background As pre-exposure prophylaxis (PrEP) scales up in sub-Saharan Africa, governments and implementers need to understand how to best manage national programs. Kenya’s national PrEP program offers an opportunity to review elements of program success within the health system and evaluate the utility of a national implementation framework. We explored health system considerations for PrEP implementation to understand how Kenya’s national PrEP implementation priorities align with those of PrEP service providers, peer educators, and program or county managers. Methods We conducted twelve key informant interviews (KII) and nine focus group discussions (FGDs) with PrEP program and county managers (n = 12), peer educators (n = 44), and PrEP service providers (n = 48). We recruited participants across a variety of cadres and experiences with PrEP programs. KIIs and FGDs focused on PrEP service delivery and program implementation. Data were collected by trained study staff, audio recorded, translated into English, and transcribed. We used framework analysis methods to systematically apply Kenya’s 2017 National PrEP Implementation Framework to the data and summarized findings according to the seven Implementation Framework domains. Results All respondents emphasized the important role of communication, coordination, training, and leadership in PrEP implementation. PrEP service providers and program and county managers highlighted the importance of efficient data collection and utilization, and improved resource allocation. Commodity security and research, while key elements of the PrEP Implementation Framework, were less commonly discussed, and research was less prioritized by respondents. Respondents highlighted the importance of coordinated PrEP service delivery across sites and programs to improve overall client experiences. Conclusion In the context of a nationally-scaled PrEP program, PrEP service providers, peer educators, and program and county managers value strong leadership, close coordination of services across sites, and expedient use of data to improve strategies and services. Kenya’s PrEP Implementation Framework aligns closely with the priorities of individuals involved in PrEP service delivery and management, and provides a comprehensive overview of health system considerations for effective implementation of a PrEP program at scale.
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14
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Lyons CE, Stokes-Cawley OJ, Simkin A, Bowring AL, Mfochive Njindam I, Njoya O, Bissek AZK, Tamoufe U, Georges S, Kakanou FZ, Turpin G, Levitt D, Billong SC, Mishra S, Baral S. Modeling the potential impact of pre-exposure prophylaxis for HIV among men who have sex with men in Cameroon. BMC Infect Dis 2022; 22:751. [PMID: 36163000 PMCID: PMC9513877 DOI: 10.1186/s12879-022-07738-z] [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: 04/14/2022] [Accepted: 09/14/2022] [Indexed: 11/26/2022] Open
Abstract
Background Men who have sex with men (MSM) are consistently burdened by HIV at higher levels than other adults. While HIV prevention programs for MSM are growing in coverage and quality, HIV incidence remains high. In response, pre-exposure prophylaxis (PrEP) was introduced in 2019 to support HIV risk reduction among MSM in Cameroon. Understanding how PrEP initiation programs will change the HIV prevalence among MSM in Cameroon is important to developing effective programs. Methods This study uses a mathematical model to simulate population-level HIV transmission among MSM in the cities of Yaoundé and Douala, Cameroon. PrEP is incorporated into the model at rates that equal 25%, 50%, or 75% coverage after twenty years to assess the potential effects on HIV prevalence among MSM, requiring annual initiation rates of 2.5%, 6.8%, and 17.2% for Yaoundé and 2.2%, 5.6%, and 13.4% for Douala, respectively. The data utilized for this model are from a cross sectional study which recruited MSM through respondent-driven sampling of MSM in two major cities in Cameroon: Yaoundé and Douala. Results The model estimated an HIV prevalence of 43.2% among MSM, annual HIV diagnoses of 300 per 10,000 MSM and antiretroviral therapy (ART) coverage of 53.9% in Yaoundé. In Douala, estimated prevalence is 26.5% among MSM, 167 per 10,000 MSM annual diagnoses and ART coverage of 72.0%. Standalone PrEP interventions aimed at 50% coverage at the end of a 20-year program would reduce the prevalence from 43.2% to 35.4% in Yaoundé and from 26.5 to 20.1% in Douala. Combining PrEP with a 10% increase in HIV testing would decrease the number of MSM living with HIV and unaware of their status from 9.8 to 6.0% in Yaoundé and from 8.7 to 4.6% in Douala. Conclusions PrEP would be beneficial in reducing prevalence even at varying initiation and coverage levels. Combination of PrEP and increased HIV testing further decreased the number of undiagnosed MSM. This study supports the utility of implementing PrEP as part of comprehensive HIV prevention programming among MSM in Cameroon. Supplementary Information The online version contains supplementary material available at 10.1186/s12879-022-07738-z.
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Affiliation(s)
- Carrie E Lyons
- Department of Epidemiology, Johns Hopkins School of Public Health, 615 N Wolfe St, Baltimore, MD, 21205, USA.
| | - Owen J Stokes-Cawley
- Department of Epidemiology, Johns Hopkins School of Public Health, 615 N Wolfe St, Baltimore, MD, 21205, USA
| | - Anna Simkin
- Centre for Urban Health Solutions, Li Ka Shing Knowledge Institute, St. Michael's Hospital, University of Toronto, Toronto, Canada
| | - Anna L Bowring
- Department of Epidemiology, Johns Hopkins School of Public Health, 615 N Wolfe St, Baltimore, MD, 21205, USA
| | - Iliassou Mfochive Njindam
- Department of Epidemiology, Johns Hopkins School of Public Health, 615 N Wolfe St, Baltimore, MD, 21205, USA
| | - Oudou Njoya
- Department of Internal Medicine and Specialties, Faculty of Medicine and Biomedical Sciences, University of Yaoundé I, Yaoundé, Cameroon
| | - Anne Zoung-Kanyi Bissek
- Department of Internal Medicine and Specialties, Faculty of Medicine and Biomedical Sciences, University of Yaoundé I, Yaoundé, Cameroon.,Division of Operations Research, Ministry of Health, Yaoundé, Cameroon
| | - Ubald Tamoufe
- Metabiota, Yaounde, Cameroon.,Johns Hopkins Cameroon Program, Yaounde, Cameroon
| | | | - Florence Zeh Kakanou
- Directorate of Epidemic, Pandemic and Disease Control, Ministry of Public Health, Yaoundé, Cameroon
| | - Gnilane Turpin
- Department of Epidemiology, Johns Hopkins School of Public Health, 615 N Wolfe St, Baltimore, MD, 21205, USA
| | | | - Serge Clotaire Billong
- Department of Public Health, Faculty of Medicine and Biomedical Sciences, University of Yaoundé I, Yaoundé, Cameroon.,Central Technical Group, National AIDS Control Committee, Yaoundé, Cameroon
| | - Sharmistha Mishra
- Centre for Urban Health Solutions, Li Ka Shing Knowledge Institute, St. Michael's Hospital, University of Toronto, Toronto, Canada
| | - Stefan Baral
- Department of Epidemiology, Johns Hopkins School of Public Health, 615 N Wolfe St, Baltimore, MD, 21205, USA
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15
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Abstract
INTRODUCTION Novel mechanisms of service delivery are needed to expand access to pre-exposure prophylaxis (PrEP) for HIV prevention. Providing PrEP directly through pharmacies could offer an additional option for reaching potential users. METHODS We conducted a systematic review of studies examining effectiveness, values and preferences of end users and health workers, and cost of PrEP initiation and continuation through pharmacies (pharmacy access). We searched PubMed, CINAHL, LILACS and EMBASE through 2 December 2020. We also searched clinical trial registries and recent HIV conference abstracts. Standardised methods were used to search, screen and extract data from included studies. RESULTS No studies met the inclusion criteria for the effectiveness review, for either PrEP initiation or continuation. However, six 'case studies' presenting non-comparative data from PrEP pharmacy programmes demonstrated feasibility of this model in the USA. Eleven studies reported values and preferences of end users and health workers. In the USA, Kenya and South Africa, potential PrEP clients generally supported pharmacy access, although some preferred clinics. One study of PrEP pharmacy clients found all would 'definitely recommend' the programme. Six studies found pharmacists were generally supportive of offering PrEP; one study including doctors found more limited favour, while one study of diverse Kenyan stakeholders found broad support. Three studies reported cost data indicating client willingness to pay in the USA and Kenya and initial sustainability of a clinic financial model in the USA. CONCLUSION Provision of PrEP through pharmacies has been demonstrated to be feasible in the USA and acceptable to potential end users and stakeholders in multiple settings. Limited evidence on effectiveness and requirements for laboratory testing and assurance of high-quality services may limit enthusiasm for this approach. Further research is needed to determine if pharmacy access is a safe and effective way to help achieve global HIV prevention goals. PROSPERO REGISTRATION NUMBER CRD42021231650.
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Affiliation(s)
- Caitlin E Kennedy
- Department of International Health, Johns Hopkins University Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Ping Teresa Yeh
- Department of International Health, Johns Hopkins University Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Kaitlyn Atkins
- Department of International Health, Johns Hopkins University Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Laura Ferguson
- Keck School of Medicine, Institute on Inequalities in Global Health, University of Southern California, Los Angeles, California, USA
| | - Rachel Baggaley
- Department of HIV, Viral Hepatitis, and STIs, World Health Organization, Geneva, Switzerland
| | - Manjulaa Narasimhan
- Department of Sexual and Reproductive Health and Research, World Health Organization, Geneva, Switzerland
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Gill K, Bekker LG. Dapivirine Vaginal Ring for HIV Prevention in Women in South Africa. Infect Dis (Lond) 2022. [DOI: 10.17925/id.2022.1.1.26] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
Young women remain disproportionately affected by the HIV epidemic in South Africa. Clinical trials have shown that the dapivirine vaginal ring (DVR) is safe and effective at reducing HIV infection in women. In March 2022, the South African Health Products Regulatory Authority approved the use of the DVR in women aged 18 years and older who are unable or unwilling to use oral pre-exposure prophylaxis, as an additional choice for preventing HIV in women at substantial risk. Modelling studies have suggested that the DVR could have a substantial impact if prioritized for women at substantial risk of HIV or women aged 22–29 years. The licensing of the DVR in South Africa is a milestone event that brings the first long-acting and woman-controlled HIV prevention method another step closer to reaching the people who need it. As South Africa prepares its introduction, it is critical to examine the unmet need for HIV prevention and to review the clinical trial data that led to the DVR's approval.
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Irungu EM, Musau M, Nyerere B, Dollah A, Kwach B, Owidi E, Wamoni E, Odoyo J, Mugo N, Bukusi E, Mugwanya K, Baeten JM. Using an on-site modular training approach to amplify prep service delivery in public health facilities in Kenya. PLOS GLOBAL PUBLIC HEALTH 2022; 2:e0000092. [PMID: 36962311 PMCID: PMC10021257 DOI: 10.1371/journal.pgph.0000092] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/29/2021] [Accepted: 12/22/2021] [Indexed: 11/18/2022]
Abstract
Delivery of oral PrEP, a potent HIV prevention intervention, has begun within public health systems in many countries in Africa. Training as many health providers as possible expeditiously is necessary to efficiently and rapidly scale up PrEP delivery among at risk populations and thereby realize the greatest impact of PrEP. We designed and implemented an innovative on-site modular training approach delivered in five two-hour modules. The modules could be covered in two consecutive days or be broken across several days enabling flexibility to accommodate health provider work schedules. We assessed knowledge gain comparing pre-and post-training test scores and determined monthly PrEP uptake for six months following the training intervention. We also evaluated the cost of this training approach and conducted key informant interviews to explore acceptability among health providers. Between January 2019 and December 2020, 2111 health providers from 104 health facilities were trained on PrEP. Of 1821 (83%) providers who completed both pre- and post-tests, 505 (28%) were nurses, 333 (18%) were HIV counsellors, 276 (15%) were clinical officers and 255 (14%) were lay providers. The mean score prior to and after training was 58% and 82% respectively (p <0.001). On average, health facilities initiated an average of 2.7 (SD 4.7) people on PrEP each month after the training, a number that did not decline over six months post-training (p = 0.62). Assuming Ministry of Health costs, the costs per provider trained was $16.27. Health providers expressed satisfaction with this training approach because it enabled many providers within a facility receive training. On-site modular training is an effective approach for improving PrEP education for health workers in public health facilities, It is also acceptable and low-cost. This method of training can be scaled up to rapidly amplify the number of health workers able to offer PrEP services.
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Affiliation(s)
- Elizabeth M Irungu
- Centre for Clinical Research, Kenya Medical Research Institute, Nairobi, Kenya
- Department of Global Health, University of Washington, Seattle, WA, United States of America
| | - Moses Musau
- Centre for Clinical Research, Kenya Medical Research Institute, Nairobi, Kenya
| | - Bernard Nyerere
- Centre for Microbiology Research, Kenya Medical Research Institute, Nairobi, Kenya
| | - Anabelle Dollah
- Centre for Microbiology Research, Kenya Medical Research Institute, Nairobi, Kenya
| | - Benn Kwach
- Centre for Microbiology Research, Kenya Medical Research Institute, Nairobi, Kenya
| | - Emmah Owidi
- Centre for Clinical Research, Kenya Medical Research Institute, Nairobi, Kenya
| | - Elizabeth Wamoni
- Centre for Clinical Research, Kenya Medical Research Institute, Nairobi, Kenya
| | - Josephine Odoyo
- Centre for Microbiology Research, Kenya Medical Research Institute, Nairobi, Kenya
| | - Nelly Mugo
- Centre for Clinical Research, Kenya Medical Research Institute, Nairobi, Kenya
- Department of Global Health, University of Washington, Seattle, WA, United States of America
| | - Elizabeth Bukusi
- Department of Global Health, University of Washington, Seattle, WA, United States of America
- Centre for Microbiology Research, Kenya Medical Research Institute, Nairobi, Kenya
- Obstetrics and Gynecology, University of Washington, Seattle, WA, United States of America
| | - Kenneth Mugwanya
- Department of Global Health, University of Washington, Seattle, WA, United States of America
| | - Jared M Baeten
- Department of Global Health, University of Washington, Seattle, WA, United States of America
- Epidemiology, University of Washington, Seattle, WA, United States of America
- Medicine, University of Washington, Seattle, WA, United States of America
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Nakamanya S, Kawuma R, Kibuuka D, Kusemererwa S, McCormack S, Ruzagira E, Seeley J. Assessing acceptability of pre-exposure prophylaxis (PrEP) among participants in an HIV vaccine preparedness study in southwestern Uganda. PLoS One 2022; 17:e0271104. [PMID: 35905052 PMCID: PMC9337655 DOI: 10.1371/journal.pone.0271104] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2022] [Accepted: 06/24/2022] [Indexed: 12/02/2022] Open
Abstract
BACKGROUND Daily oral pre-exposure prophylaxis (PrEP) use is highly effective against HIV infection. However, the uptake of PrEP among individuals at high-risk of HIV acquisition in sub-Saharan Africa varies because of availability and acceptability. We assessed the acceptability of PrEP among participants in a prospective HIV vaccine preparedness study in Masaka, southwestern Uganda. METHODS From November 2018 to August 2019, 20 participants (10 female) were purposively selected for in-depth interviews (IDIs) at 3 and 9 months' post-enrolment in the vaccine preparedness study. Four focus group discussions (FGD) (two among men) were conducted with 29 individuals categorized as: younger (18-24 years) men, younger (18-24 years) women, older (≥30 years) men, and older (≥30 years) women. Apart from IDI specific questions on recent life history including work experience, relationship history and places lived, topics for IDIs and FGDs included knowledge of HIV, perceptions of HIV risk (including own risk), knowledge of and use of PrEP. The Theoretical Framework of Acceptability was used to structure a thematic framework approach for data analysis. RESULTS Participants understood that PrEP was an oral pill taken daily by HIV negative individuals to prevent acquisition of HIV. Overall, interest in and acceptability of PrEP was high, more than half expressed positivity towards PrEP but were not ready to initiate taking it citing the burden of daily oral pill taking, related side effects, stigma and distrust of PrEP. Fourteen participants (from IDI and FGD) initiated PrEP, although some (one FGD and two IDI participants) stopped taking it due to side effects or perceived reduced risk. CONCLUSION We observed a keen interest in PrEP initiation among our study participants. However, a limited understanding of PrEP and associated concerns impeded uptake and sustained use. Hence, interventions are needed to address end-user challenges to increase uptake and support adherence.
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Affiliation(s)
- Sarah Nakamanya
- Medical Research Council/Uganda Virus Research Institute (MRC/UVRI) and London School of Hygiene and Tropical Medicine (LSHTM) Uganda Research Unit, Entebbe, Uganda
- * E-mail:
| | - Rachel Kawuma
- Medical Research Council/Uganda Virus Research Institute (MRC/UVRI) and London School of Hygiene and Tropical Medicine (LSHTM) Uganda Research Unit, Entebbe, Uganda
| | - Denis Kibuuka
- Medical Research Council/Uganda Virus Research Institute (MRC/UVRI) and London School of Hygiene and Tropical Medicine (LSHTM) Uganda Research Unit, Entebbe, Uganda
| | - Sylvia Kusemererwa
- Medical Research Council/Uganda Virus Research Institute (MRC/UVRI) and London School of Hygiene and Tropical Medicine (LSHTM) Uganda Research Unit, Entebbe, Uganda
| | | | - Eugene Ruzagira
- Medical Research Council/Uganda Virus Research Institute (MRC/UVRI) and London School of Hygiene and Tropical Medicine (LSHTM) Uganda Research Unit, Entebbe, Uganda
- London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Janet Seeley
- Medical Research Council/Uganda Virus Research Institute (MRC/UVRI) and London School of Hygiene and Tropical Medicine (LSHTM) Uganda Research Unit, Entebbe, Uganda
- London School of Hygiene and Tropical Medicine, London, United Kingdom
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Bhavaraju N, Shears K, Schwartz K, Mullick S, Jeckonia P, Murungu J, Persaud U, Vij A, Torjesen K. Introducing the Dapivirine Vaginal Ring in Sub-Saharan Africa: What Can We Learn from Oral PrEP? Curr HIV/AIDS Rep 2021; 18:508-517. [PMID: 34910276 PMCID: PMC8671875 DOI: 10.1007/s11904-021-00577-8] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/04/2021] [Indexed: 11/30/2022]
Abstract
Purpose of review Clinical trials have found that the dapivirine vaginal ring (DVR) is safe to use and effective at reducing women’s risk of acquiring HIV infection. As countries prepare for the introduction of this novel long-acting, woman-controlled prevention method, an examination of key learnings from oral pre-exposure prophylaxis (PrEP) delivery will help programs leverage successful innovations and approaches to support DVR scale-up and expand the method mix for HIV prevention. Recent findings Intensive efforts over the past 5 years have yielded lessons on how to facilitate access to oral PrEP; expand service delivery for PrEP; address the knowledge, attitudes, and skills providers need to support PrEP initiation and effective use; develop messaging that builds community and partner support and combats stigma; and understand the cyclical nature of PrEP use. Summary Evidence from oral PrEP introduction and scale-up can help inform and expedite DVR introduction.
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Affiliation(s)
| | - Kathleen Shears
- FHI 360, 1825 Connecticut Avenue NW, Washington, DC 20009 USA
| | | | - Saiqa Mullick
- Wits Reproductive Health and HIV Institute, 8 Blackwood Avenue, Parktown, Johannesburg, South Africa
| | - Patriciah Jeckonia
- LVCT Health, Batian Lane, Off Argwings Kodhek Road, Hurlingam, Nairobi, Kenya
| | - Joseph Murungu
- Pangaea Zimbabwe AIDS Trust, 27 Rowland Square, Milton Park, Harare, Zimbabwe
| | - Udita Persaud
- United States Agency for International Development, 1300 Pennsylvania Avenue NW, Washington, DC 20523 USA
| | - Ashley Vij
- United States Agency for International Development, 1300 Pennsylvania Avenue NW, Washington, DC 20523 USA
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Rousseau E, Julies RF, Madubela N, Kassim S. Novel Platforms for Biomedical HIV Prevention Delivery to Key Populations - Community Mobile Clinics, Peer-Supported, Pharmacy-Led PrEP Delivery, and the Use of Telemedicine. Curr HIV/AIDS Rep 2021; 18:500-507. [PMID: 34708316 PMCID: PMC8549812 DOI: 10.1007/s11904-021-00578-7] [Citation(s) in RCA: 23] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/13/2021] [Indexed: 02/03/2023]
Abstract
PURPOSE OF REVIEW A gap exists between PrEP interest and PrEP uptake in key populations (KP) for HIV prevention that may be ascribed to PrEP delivery services not being acceptable. This review summarizes novel platforms for HIV prevention outside of the traditional health facilities environment. RECENT FINDINGS Mobile health clinics provide highly acceptable integrated, KP-focused services at convenient locations with the potential of high PrEP uptake. Telemedicine and health apps decongest health systems and allow for personal agency and informed decision-making on personal health. Pharmacy-led PrEP delivery provides de-medicalized, confidential PrEP services at extended hours in community locations, from trusted medical professionals. Peer-supported delivery encourages continued PrEP use. Community-based, differentiated and de-medicalized PrEP delivery can address uptake and continued use barriers in key populations. Future research should assess scalability, cost-effectiveness and sustainability of these PrEP delivery platforms, as well as focus on ways to simplify PrEP provision.
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Affiliation(s)
- E Rousseau
- Desmond Tutu HIV Centre, Institute of Infectious Diseases and Molecular Medicine, University of Cape Town, Cape Town, South Africa.
| | - R F Julies
- Desmond Tutu HIV Centre, Institute of Infectious Diseases and Molecular Medicine, University of Cape Town, Cape Town, South Africa
| | - N Madubela
- Desmond Tutu HIV Centre, Institute of Infectious Diseases and Molecular Medicine, University of Cape Town, Cape Town, South Africa
| | - S Kassim
- Desmond Tutu HIV Centre, Institute of Infectious Diseases and Molecular Medicine, University of Cape Town, Cape Town, South Africa
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21
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Roche SD, Odoyo J, Irungu E, Kwach B, Dollah A, Nyerere B, Peacock S, Morton JF, O'Malley G, Bukusi EA, Baeten JM, Mugwanya KK. A one-stop shop model for improved efficiency of pre-exposure prophylaxis delivery in public clinics in western Kenya: a mixed methods implementation science study. J Int AIDS Soc 2021; 24:e25845. [PMID: 34898032 PMCID: PMC8666585 DOI: 10.1002/jia2.25845] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2021] [Accepted: 10/28/2021] [Indexed: 11/08/2022] Open
Abstract
INTRODUCTION In public clinics in Kenya, separate, sequential delivery of the component services of pre-exposure prophylaxis (PrEP) (e.g. HIV testing, counselling, and dispensing) creates long wait times that hinder clients' ability and desire to access and continue PrEP. We conducted a mixed methods study in four public clinics in western Kenya to identify strategies for operationalizing a one-stop shop (OSS) model and evaluate whether this model could improve client wait time and care acceptability among clients and providers without negatively impacting uptake or continuation. METHODS From January 2020 through November 2020, we collected and analysed 47 time-and-motion observations using Mann-Whitney U tests, 29 provider and client interviews, 68 technical assistance reports, and clinic flow maps from intervention clinics. We used controlled interrupted time series (cITS) to compare trends in PrEP initiation and on-time returns from a 12-month pre-intervention period (January-December 2019) to an 8-month post-period (January-November 2020, excluding a 3-month COVID-19 wash-out period) at intervention and control clinics. RESULTS From the pre- to post-period, median client wait time at intervention clinics dropped significantly from 31 to 6 minutes (p = 0.02), while median provider contact time remained around 23 minutes (p = 0.4). Intervention clinics achieved efficiency gains by moving PrEP delivery to lower volume departments, moving steps closer together (e.g. relocating supplies; cross-training and task-shifting), and differentiating clients based on the subset of services needed. Clients and providers found the OSS model highly acceptable and additionally identified increased privacy, reduced stigma, and higher quality client-provider interactions as benefits of the model. From the pre- to post-period, average monthly initiations at intervention and control clinics increased by 6 and 2.3, respectively, and percent of expected follow-up visits occurring on time decreased by 18% and 26%, respectively; cITS analysis of PrEP initiations (n = 1227) and follow-up visits (n = 2696) revealed no significant difference between intervention and control clinics in terms of trends in PrEP initiation and on-time returns (all p>0.05). CONCLUSIONS An OSS model significantly improved client wait time and care acceptability without negatively impacting initiations or continuations, thus highlighting opportunities to improve the efficiency of PrEP delivery efficiency and client-centredness.
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Affiliation(s)
| | - Josephine Odoyo
- Centre for Microbiology ResearchKenya Medical Research InstituteNairobiKenya
| | | | - Benn Kwach
- Centre for Microbiology ResearchKenya Medical Research InstituteNairobiKenya
| | - Annabell Dollah
- Centre for Microbiology ResearchKenya Medical Research InstituteNairobiKenya
| | - Bernard Nyerere
- Centre for Microbiology ResearchKenya Medical Research InstituteNairobiKenya
| | - Sue Peacock
- Department of Global HealthUniversity of WashingtonSeattleWashingtonUSA
| | | | | | - Elizabeth A. Bukusi
- Department of Global HealthUniversity of WashingtonSeattleWashingtonUSA
- Centre for Microbiology ResearchKenya Medical Research InstituteNairobiKenya
- Department of Obstetrics and GynecologyUniversity of WashingtonSeattleWashingtonUSA
| | - Jared M. Baeten
- Department of Global HealthUniversity of WashingtonSeattleWashingtonUSA
- Department of Medicine, University of WashingtonSeattleWashingtonUSA
- Department of Epidemiology, University of WashingtonWashingtonSeattleUSA
- Gilead SciencesFoster CityCaliforniaUSA
| | - Kenneth K. Mugwanya
- Department of Global HealthUniversity of WashingtonSeattleWashingtonUSA
- Department of Epidemiology, University of WashingtonWashingtonSeattleUSA
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22
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Ddaaki W, Strömdahl S, Yeh PT, Rosen JG, Jackson J, Nakyanjo N, Kagaayi J, Kigozi G, Nakigozi G, Grabowski MK, Chang LW, Reynolds SJ, Nalugoda F, Ekström AM, Kennedy CE. Qualitative Assessment of Barriers and Facilitators of PrEP Use Before and After Rollout of a PrEP Program for Priority Populations in South-central Uganda. AIDS Behav 2021; 25:3547-3562. [PMID: 34240317 DOI: 10.1007/s10461-021-03360-3] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/19/2021] [Indexed: 12/19/2022]
Abstract
Uganda piloted HIV pre-exposure prophylaxis (PrEP) for priority populations (sex workers, fishermen, truck drivers, discordant couples) in 2017. To assess facilitators and barriers to PrEP uptake and adherence, we explored perceptions of PrEP before and experiences after rollout among community members and providers in south-central Uganda. We conducted 75 in-depth interviews and 12 focus group discussions. We analyzed transcripts using a team-based thematic framework approach. Partners, family, peers, and experienced PrEP users provided adherence support. Occupational factors hindered adherence for sex workers and fishermen, particularly related to mobility. Pre-rollout concerns about unskilled/untrained volunteers distributing PrEP and price-gouging were mitigated. After rollout, awareness of high community HIV risk and trust in PrEP effectiveness facilitated uptake. PrEP stigma and unexpected migration persisted as barriers. Community-initiated, tailored communication with successful PrEP users may optimize future engagement by addressing fears and rumors, while flexible delivery and refill models may facilitate PrEP continuation and adherence.
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23
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Matambanadzo P, Busza J, Mafaune H, Chinyanganya L, Machingura F, Ncube G, Steen R, Phillips A, Cowan FM. "It went through the roof": an observation study exploring the rise in PrEP uptake among Zimbabwean female sex workers in response to adaptations during Covid-19. J Int AIDS Soc 2021; 24 Suppl 6:e25813. [PMID: 34713613 PMCID: PMC8554216 DOI: 10.1002/jia2.25813] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2021] [Accepted: 08/19/2021] [Indexed: 11/24/2022] Open
Abstract
Introduction Sisters with a Voice (Sisters), a programme providing community‐led differentiated HIV prevention and treatment services, including condoms, HIV testing, pre‐exposure prophylaxis (PrEP) and antiretroviral therapy linkage for sex workers, reached over 26,000 female sex workers (FSW) across Zimbabwe in 2020. Zimbabwe's initial Covid “lockdown” in March 2020 and associated movement restrictions interrupted clinical service provision for 6 weeks, particularly in mobile clinics, triggering the adaptation of services for the Covid‐19 context and a scale up of differentiated service delivery (DSD) models. PrEP service delivery decentralized with shifts from clinical settings towards community/home‐based, peer‐led PrEP services to expand and maintain access. We hypothesize that peer‐led community‐based provision of PrEP services influenced both demand and supply‐side determinants of PrEP uptake. We observed the effect of these adaptations on PrEP uptake among FSW accessing services in Sisters in 2020. Methods New FSW PrEP initiations throughout 2020 were tracked by analysing routine Sisters programme data and comparing it with national PrEP initiation data for 2020. We mapped PrEP uptake among all negative FSW attending services in Sisters alongside Covid‐19 adaptations and shifts in the operating environment throughout 2020: prior to lockdown (January–March 2020), during severe restrictions (April–June 2020), subsequent easing (July–September 2020) and during drug stockouts that followed (October–December 2020). Results and discussion PrEP uptake in 2020 occurred at rates <25% (315 initiations or fewer) per month prior to the emergence of Covid‐19. In response to Covid‐19 restrictions, DSD models were scaled up in April 2020, including peer demand creation, community‐based delivery, multi‐month dispensing and the use of virtual platforms for appointment scheduling and post‐PrEP initiation support. Beginning May 2020, PrEP uptake increased monthly, peaking at an initiation rate of 51% (n = 1360) in September 2020. Unexpected rise in demand coincided with national commodity shortages between October and December 2020, resulting in restriction of new initiations with sites prioritizing refills. Conclusions Despite the impact of Covid‐19 on the Sisters Programme and FSW mobility, DSD adaptations led to a large increase in PrEP initiations compared to pre‐Covid levels demonstrating that a peer‐led, community‐based PrEP service delivery model is effective and can be adopted for long‐term use.
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Affiliation(s)
| | - Joanna Busza
- Centre for Evaluation, London School of Hygiene and Tropical Medicine, London, UK
| | - Haurovi Mafaune
- Centre for Sexual Health and HIV/AIDS Research Zimbabwe, Harare, Zimbabwe
| | | | | | - Getrude Ncube
- AIDS and TB Unit, Ministry of Health and Child Care, Harare, Zimbabwe
| | - Richard Steen
- Department of Public Health, Erasmus Medical Centre, Rotterdam, The Netherlands
| | - Andrew Phillips
- Institute for Global Health, University College London, London, UK
| | - Frances Mary Cowan
- Centre for Sexual Health and HIV/AIDS Research Zimbabwe, Harare, Zimbabwe.,Department of International Public Health, Liverpool School of Tropical Medicine, Liverpool, UK
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24
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Rousseau E, Katz AWK, O’Rourke S, Bekker LG, Delany-Moretlwe S, Bukusi E, Travill D, Omollo V, Morton JF, O’Malley G, Haberer JE, Heffron R, Johnson R, Celum C, Baeten JM, van der Straten A. Adolescent girls and young women's PrEP-user journey during an implementation science study in South Africa and Kenya. PLoS One 2021; 16:e0258542. [PMID: 34648589 PMCID: PMC8516266 DOI: 10.1371/journal.pone.0258542] [Citation(s) in RCA: 66] [Impact Index Per Article: 22.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2021] [Accepted: 09/29/2021] [Indexed: 11/19/2022] Open
Abstract
Successful scale-up of PrEP for HIV prevention in African adolescent girls and young women (AGYW) requires integration of PrEP into young women's everyday lives. We conducted interviews and focus group discussions with 137 AGYW PrEP users aged 16-25 from South Africa and Kenya. Individual and relational enablers and disablers were explored at key moments during their PrEP-user journey from awareness, initiation and early use through persistence, including PrEP pauses, restarts, and discontinuation. PrEP uptake was facilitated when offered as part of an integrated sexual reproductive health service, but hampered by low awareness, stigma and misconceptions about PrEP in the community. Daily pill-taking was challenging for AGYW due to individual, relational and structural factors and PrEP interruptions (intended or unintended) were described as part of AGYW's PrEP-user journey. Disclosure, social support, adolescent-friendly health counseling, and convenient access to PrEP were reported as key enablers for PrEP persistence.
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Affiliation(s)
- Elzette Rousseau
- Desmond Tutu HIV Centre, University of Cape Town, Cape Town, South Africa
| | - Ariana W. K. Katz
- RTI International, Women’s Global Health Imperative (WGHI), Berkeley, CA, United States of America
| | - Shannon O’Rourke
- RTI International, Women’s Global Health Imperative (WGHI), Berkeley, CA, United States of America
| | - Linda-Gail Bekker
- Desmond Tutu HIV Centre, University of Cape Town, Cape Town, South Africa
| | | | | | - Danielle Travill
- Wits RHI, University of the Witwatersrand, Johannesburg, South Africa
| | | | - Jennifer F. Morton
- International Clinical Research Center, University of Washington, Seattle, WA, United States of America
| | - Gabrielle O’Malley
- International Clinical Research Center, University of Washington, Seattle, WA, United States of America
| | - Jessica E. Haberer
- Harvard Medical School, Harvard University, Boston, MA, United States of America
- Centre for Global Health, Massachusetts General Hospital, Boston, MA, United States of America
| | - Renee Heffron
- International Clinical Research Center, University of Washington, Seattle, WA, United States of America
| | - Rachel Johnson
- International Clinical Research Center, University of Washington, Seattle, WA, United States of America
| | - Connie Celum
- International Clinical Research Center, University of Washington, Seattle, WA, United States of America
| | - Jared M. Baeten
- International Clinical Research Center, University of Washington, Seattle, WA, United States of America
- Gilead Sciences, Inc., Seattle, WA, United States of America
| | - Ariane van der Straten
- Centre for AIDS Prevention Studies, Department of Medicine, University of California, San Francisco, CA, United States of America
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25
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Irungu EM, Odoyo J, Wamoni E, Bukusi EA, Mugo NR, Ngure K, Morton JF, Mugwanya KK, Baeten JM, O'Malley G. Process evaluation of PrEP implementation in Kenya: adaptation of practices and contextual modifications in public HIV care clinics. J Int AIDS Soc 2021; 24:e25799. [PMID: 34496148 PMCID: PMC8425783 DOI: 10.1002/jia2.25799] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2021] [Accepted: 08/03/2021] [Indexed: 11/16/2022] Open
Abstract
Introduction In Africa, oral pre‐exposure prophylaxis (PrEP) is largely provided via over‐burdened public HIV care clinics. Successfully incorporating PrEP services into these clinics may require adaptations to practices outlined in national implementation guidelines and modifications to routine existing service delivery. We aimed to describe adaptations made by public HIV clinics in Kenya to integrate PrEP delivery into existing services. Methods The Partners Scale‐Up Project aimed to catalyse integration of PrEP in 25 public HIV care clinics. Between May and December 2018, we conducted qualitative interviews with health providers and documented clinic observations in technical assistance (TA) reports to understand the process of PrEP service integration. We analysed 36 health provider interview transcripts and 25 TA reports to identify clinic‐level adaptations to activities outlined in Kenyan Ministry of Health PrEP guidelines and modifications made to existing service delivery practices to successfully incorporate PrEP services. Identified adaptations were reported using the expanded framework for reporting adaptations and modifications (FRAME). Results All clinics (n = 25) performed HIV testing, HIV risk assessment, PrEP education and adherence counselling as stipulated in the guidelines. Most clinics initiated clients on PrEP without creatinine testing if otherwise healthy. While monthly refill appointments are recommended, a majority of clinics issued PrEP users two to three months of pills at a time. Clinics also implemented practices that had not been specified in the guidelines including incorporating PrEP‐related topics into routine health talks, calling clients with missed PrEP appointments, discussing PrEP service delivery in regular staff meetings, ‘fast‐tracking’ PrEP clients and dispensing PrEP in clinic rooms rather than at clinic‐based pharmacies. PrEP initiation numbers were highest among clinics that did not require creatinine testing, conducted peer on‐the‐job PrEP training and those that discussed PrEP delivery in their routine meetings. Above‐average continuation was observed among clinics that discussed PrEP in their routine meetings, dispensed PrEP in clinic rooms and offered PrEP at nonregular hours. Conclusions Health providers in public HIV care clinics instituted practices and made innovative adaptations to PrEP delivery to reduce barriers for clients and staff. Encouraging clinic level adaptations to national implementation guidelines will facilitate scale‐up of PrEP delivery.
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Affiliation(s)
- Elizabeth M Irungu
- Department of Global Health, University of Washington, Seattle, Washington, USA.,Centre for Clinical Research, Kenya Medical Research Institute, Nairobi, Kenya
| | - Josephine Odoyo
- Centre for Microbiology Research, Kenya Medical Research Institute, Nairobi, Kenya
| | - Elizabeth Wamoni
- Centre for Clinical Research, Kenya Medical Research Institute, Nairobi, Kenya
| | - Elizabeth A Bukusi
- Department of Global Health, University of Washington, Seattle, Washington, USA.,Department of Obstetrics and Gynecology, University of Washington, Seattle, Washington, USA.,Centre for Microbiology Research, Kenya Medical Research Institute, Nairobi, Kenya
| | - Nelly R Mugo
- Department of Global Health, University of Washington, Seattle, Washington, USA.,Centre for Clinical Research, Kenya Medical Research Institute, Nairobi, Kenya
| | - Kenneth Ngure
- Department of Global Health, University of Washington, Seattle, Washington, USA.,School of Public Health, Jomo Kenyatta University of Agriculture and Technology, Nairobi, Kenya
| | - Jennifer F Morton
- Department of Global Health, University of Washington, Seattle, Washington, USA
| | - Kenneth K Mugwanya
- Department of Global Health, University of Washington, Seattle, Washington, USA
| | - Jared M Baeten
- Department of Global Health, University of Washington, Seattle, Washington, USA.,Department of Epidemiology, University of Washington, Seattle, Washington, USA.,Department of Medicine, University of Washington, Seattle, Washington, USA.,Gilead Sciences, Foster City, CA, USA
| | - Gabrielle O'Malley
- Department of Global Health, University of Washington, Seattle, Washington, USA
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26
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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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27
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Were DK, Musau A, Atkins K, Shrestha P, Reed J, Curran K, Mohan D. Health system adaptations and considerations to facilitate optimal oral pre-exposure prophylaxis scale-up in sub-Saharan Africa. Lancet HIV 2021; 8:e511-e520. [PMID: 34265282 DOI: 10.1016/s2352-3018(21)00129-6] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2021] [Revised: 06/06/2021] [Accepted: 06/08/2021] [Indexed: 12/26/2022]
Abstract
Following WHO's 2015 recommendation, countries in sub-Saharan Africa have progressively scaled up oral pre-exposure prophylaxis (PrEP) as part of combination HIV prevention. PrEP has potential to significantly reduce new HIV infections in sub-Saharan Africa if it is widely available, accessible, and effectively used. Initial scale-up efforts have generated progress, drawing lessons from existing HIV interventions, such as antiretroviral therapy and biomedical prevention. However, beset by unprepared health systems, scale-up has been slow, resulting in suboptimal coverage among priority groups at higher risk of HIV acqusition. Using the WHO health system building blocks framework, this Review synthesises literature on essential considerations for PrEP scale-up in sub-Saharan Africa, highlighting the importance of health system adaptability and responsiveness.
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Affiliation(s)
| | | | - Kaitlyn Atkins
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Prakriti Shrestha
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | | | | | - Diwakar Mohan
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
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28
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Chabata ST, Hensen B, Chiyaka T, Mushati P, Musemburi S, Dirawo J, Busza J, Floyd S, Birdthistle I, Hargreaves JR, Cowan FM. The impact of the DREAMS partnership on HIV incidence among young women who sell sex in two Zimbabwean cities: results of a non-randomised study. BMJ Glob Health 2021; 6:bmjgh-2020-003892. [PMID: 33906844 PMCID: PMC8088246 DOI: 10.1136/bmjgh-2020-003892] [Citation(s) in RCA: 19] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2020] [Revised: 03/06/2021] [Accepted: 03/16/2021] [Indexed: 12/24/2022] Open
Abstract
INTRODUCTION Young women who sell sex (YWSS) in Zimbabwe remain at high risk of HIV infection. Effective HIV prevention strategies are needed. Through support to access a combination of evidence-based interventions, including oral pre-exposure prophylaxis (PrEP), the Determined, Resilient, Empowered, AIDS-free, Mentored and Safe (DREAMS) partnership aimed to reduce new HIV infections among adolescent girls and young women by 40% over 24 months. METHODS Non-randomised 'plausibility' evaluation, powered to detect a 40% HIV incidence difference between DREAMS and non-DREAMS sites. Two large cities with DREAMS funding were included, and four smaller non-DREAMS towns for comparison. In all sites, YWSS were enrolled to a cohort through peer-referral. Women were followed up for 24 months. HIV seroconversion was the primary outcome, with secondary outcomes identified through a theory of change. Outcomes were compared between YWSS recruited in DREAMS cities and non-DREAMS towns, adjusting for individual-level confounders and HIV prevalence at enrolment. RESULTS From April to July 2017, 2431 women were enrolled, 1859 of whom were HIV negative at enrolment; 1019 of these women (54.8%) were followed up from March to May 2019 and included in endline analysis. Access to clinical services increased, but access to socioeconomic interventions promoted by DREAMS was limited. A total of 79 YWSS HIV seroconverted, with HIV incidence among YWSS in DREAMS cities lower (3.1/100 person-years) than in non-DREAMS towns (5.3/100 person-years). In prespecified adjusted analysis, HIV incidence was lower in DREAMS cities but with weak statistical evidence (adjusted rate ratio (RR)=0.68; 95% CI 0.40 to 1.19; p=0.18). Women in DREAMS cities were more likely to report ever and ongoing PrEP use, consistent condom use, fewer sexual partners and less intimate partner violence. CONCLUSION It is plausible that DREAMS lowered HIV incidence among YWSS in two Zimbabwean cities, but our evaluation provides weak statistical evidence for impact and suggests any reduction in incidence was lower than the anticipated 40% decline. We identified changes to some important 'pathways to impact' variables, including condom use.
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Affiliation(s)
- Sungai T Chabata
- Centre for Sexual Health and HIV/AIDS Research (CeSHHAR) Zimbabwe, Harare, Zimbabwe .,Department of Public Health, Erasmus MC, University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Bernadette Hensen
- Department of Clinical Research, London School of Hygiene & Tropical Medicine, London, UK
| | - Tarisai Chiyaka
- Centre for Sexual Health and HIV/AIDS Research (CeSHHAR) Zimbabwe, Harare, Zimbabwe
| | - Phillis Mushati
- Centre for Sexual Health and HIV/AIDS Research (CeSHHAR) Zimbabwe, Harare, Zimbabwe
| | - Sithembile Musemburi
- Centre for Sexual Health and HIV/AIDS Research (CeSHHAR) Zimbabwe, Harare, Zimbabwe
| | - Jeffrey Dirawo
- Centre for Sexual Health and HIV/AIDS Research (CeSHHAR) Zimbabwe, Harare, Zimbabwe
| | - Joanna Busza
- Centre for Evaluation, London School of Hygiene & Tropical Medicine, London, UK
| | - Sian Floyd
- Department of Infectious Disease Epidemiology, London School of Hygiene & Tropical Medicine, London, UK
| | - Isolde Birdthistle
- Department of Population Health, London School of Hygiene & Tropical Medicine, London, UK
| | - James R Hargreaves
- Centre for Evaluation, London School of Hygiene & Tropical Medicine, London, UK
| | - Frances M Cowan
- Centre for Sexual Health and HIV/AIDS Research (CeSHHAR) Zimbabwe, Harare, Zimbabwe.,Department of International Public Health, Liverpool School of Tropical Medicine, Liverpool, UK
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29
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Ayieko J, Petersen ML, Kabami J, Mwangwa F, Opel F, Nyabuti M, Charlebois ED, Peng J, Koss CA, Balzer LB, Chamie G, Bukusi EA, Kamya MR, Havlir DV. Uptake and outcomes of a novel community-based HIV post-exposure prophylaxis (PEP) programme in rural Kenya and Uganda. J Int AIDS Soc 2021; 24:e25670. [PMID: 34152067 PMCID: PMC8215805 DOI: 10.1002/jia2.25670] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2020] [Revised: 12/23/2020] [Accepted: 01/21/2021] [Indexed: 11/24/2022] Open
Abstract
INTRODUCTION Antiretroviral-based HIV prevention, including pre-exposure prophylaxis (PrEP), is expanding in generalized epidemic settings, but additional prevention options are needed for individuals with periodic, high-risk sexual exposures. Non-occupational post-exposure prophylaxis (PEP) is recommended in global guidelines. However, in Africa, awareness of and access to PEP for sexual exposures are limited. We assessed feasibility, acceptability, uptake and adherence in a pilot study of a patient-centred PEP programme with options for facility- or community-based service delivery. METHODS After population-level HIV testing with universal access to PrEP for persons at elevated HIV risk (SEARCH Trial:NCT01864603), we conducted a pilot PEP study in five rural communities in Kenya and Uganda between December 2018 and May 2019. We assessed barriers to PEP in the population and implemented an intervention to address these barriers, building on existing in-country PEP protocols. We used community leaders for sensitization. Test kits and medications were acquired through the Ministry of Health supply chain and healthcare providers based at the Ministry of Health clinics were trained on PEP delivery. Additional intervention components were (a)PEP availability seven days/week, (b)PEP hotline staffed by providers and (c)option for out-of-facility medication delivery. We assessed implementation using the Proctor framework and measured seroconversions via repeat HIV testing. Successful "PEP completion" was defined as self-reported adherence over four weeks of therapy with post-PEP HIV testing. RESULTS Community leaders were able to sensitize and mobilize for PEP. The Ministry of Health supplied test kits and PEP medications; after training, healthcare providers delivered the 28-day regimen with high completion rates. Among 124 persons who sought PEP, 66% were female, 24% were ≤25 years and 42% were fisherfolk. Of these, 20% reported exposure with a serodifferent partner, 72% with a new or existing relationship and 7% from transactional sex. 12% of all visits were conducted at out-of-facility community-based sites; 35% of participants had ≥1 out-of-facility visit. No serious adverse events were reported. Overall, 85% met the definition of PEP completion. There were no HIV seroconversions. CONCLUSIONS Among individuals with elevated-risk exposures in rural East African communities, patient-centred PEP was feasible, acceptable and provides a promising addition to the current prevention toolkit.
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Affiliation(s)
- James Ayieko
- Center for Microbiology ResearchKenya Medical Research InstituteNairobiKenya
| | - Maya L Petersen
- Department of BiostatisticsUniversity of CaliforniaBerkeleyCAUSA
| | - Jane Kabami
- Infectious Diseases Research CollaborationKampalaUganda
| | | | - Fred Opel
- Center for Microbiology ResearchKenya Medical Research InstituteNairobiKenya
| | - Marilyn Nyabuti
- Center for Microbiology ResearchKenya Medical Research InstituteNairobiKenya
| | | | - James Peng
- Department of MedicineUniversity of CaliforniaSan FranciscoCAUSA
| | - Catherine A Koss
- Department of MedicineUniversity of CaliforniaSan FranciscoCAUSA
| | - Laura B Balzer
- Department of Biostatistics and EpidemiologyUniversity of MassachusettsAmherstMAUSA
| | - Gabriel Chamie
- Department of MedicineUniversity of CaliforniaSan FranciscoCAUSA
| | - Elizabeth A Bukusi
- Center for Microbiology ResearchKenya Medical Research InstituteNairobiKenya
| | - Moses R Kamya
- Department of MedicineMakerere UniversityKampalaUganda
| | - Diane V Havlir
- Department of MedicineUniversity of CaliforniaSan FranciscoCAUSA
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30
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Pike C, Celum C, Bekker LG. Adolescent healthcare: I'm Lovin' it. South Afr J HIV Med 2020; 21:1147. [PMID: 33240538 PMCID: PMC7670027 DOI: 10.4102/sajhivmed.v21i1.1147] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
Affiliation(s)
- Carey Pike
- Desmond Tutu Health Foundation, Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa
| | - Connie Celum
- Department of Global Health, University of Washington, Seattle, United States of America.,Department of Medicine, University of Washington, Seattle, United States of America.,Department of Epidemiology, University of Washington, Seattle, United States of America
| | - Linda-Gail Bekker
- Desmond Tutu Health Foundation, Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa
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Bershteyn A, Sharma M, Akullian AN, Peebles K, Sarkar S, Braithwaite RS, Mudimu E. Impact along the HIV pre-exposure prophylaxis "cascade of prevention" in western Kenya: a mathematical modelling study. J Int AIDS Soc 2020; 23 Suppl 3:e25527. [PMID: 32602669 PMCID: PMC7325506 DOI: 10.1002/jia2.25527] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2019] [Revised: 04/09/2020] [Accepted: 04/27/2020] [Indexed: 12/15/2022] Open
Abstract
INTRODUCTION Over one hundred implementation studies of HIV pre-exposure prophylaxis (PrEP) are completed, underway or planned. We synthesized evidence from these studies to inform mathematical modelling of the prevention cascade for oral and long-acting PrEP in the setting of western Kenya, one of the world's most heavily HIV-affected regions. METHODS We incorporated steps of the PrEP prevention cascade - uptake, adherence, retention and re-engagement after discontinuation - into EMOD-HIV, an open-source transmission model calibrated to the demography and HIV epidemic patterns of western Kenya. Early PrEP implementation research from East Africa was used to parameterize prevention cascades for oral PrEP as currently implemented, delivery innovations for oral PrEP, and future long-acting PrEP. We compared infections averted by PrEP at the population level for different cascade assumptions and sub-populations on PrEP. Analyses were conducted over the 2020 to 2040 time horizon, with additional sensitivity analyses for the time horizon of analysis and the time when long-acting PrEP becomes available. RESULTS The maximum impact of oral PrEP diminished by over 98% across all prevention cascades, with the exception of long-acting PrEP under optimistic assumptions about uptake and re-engagement after discontinuation. Long-acting PrEP had the highest population-level impact, even after accounting for possible delays in product availability, primarily because its effectiveness does not depend on drug adherence. Retention was the most significant cascade step reducing the potential impact of long-acting PrEP. These results were robust to assumptions about the sub-populations receiving PrEP, but were highly influenced by assumptions about re-initiation of PrEP after discontinuation, about which evidence was sparse. CONCLUSIONS Implementation challenges along the prevention cascade compound to diminish the population-level impact of oral PrEP. Long-acting PrEP is expected to be less impacted by user uptake and adherence, but it is instead dependent on product availability in the short term and retention in the long term. To maximize the impact of long-acting PrEP, ensuring timely product approval and rollout is critical. Research is needed on strategies to improve retention and patterns of PrEP re-initiation.
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Affiliation(s)
- Anna Bershteyn
- Department of Population HealthNYU Grossman School of MedicineNew YorkNYUSA
- Institute for Disease ModelingBellevueWAUSA
| | - Monisha Sharma
- Institute for Disease ModelingBellevueWAUSA
- Department of Global HealthUniversity of WashingtonSeattleWAUSA
| | - Adam N Akullian
- Institute for Disease ModelingBellevueWAUSA
- Department of Global HealthUniversity of WashingtonSeattleWAUSA
| | - Kathryn Peebles
- Department of EpidemiologyUniversity of WashingtonSeattleWAUSA
| | | | | | - Edinah Mudimu
- Department of Decision SciencesUniversity of South AfricaPretoriaSouth Africa
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Chabata ST, Hensen B, Chiyaka T, Mushati P, Busza J, Floyd S, Birdthistle I, Hargreaves JR, Cowan FM. Condom use among young women who sell sex in Zimbabwe: a prevention cascade analysis to identify gaps in HIV prevention programming. J Int AIDS Soc 2020; 23 Suppl 3:e25512. [PMID: 32602611 PMCID: PMC7325503 DOI: 10.1002/jia2.25512] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2019] [Revised: 03/31/2020] [Accepted: 04/22/2020] [Indexed: 12/16/2022] Open
Abstract
INTRODUCTION Adolescent girls and young women (AGYW), including those who sell sex in sub-Saharan Africa, are especially vulnerable to HIV. Reaching them with effective prevention is a programmatic priority. The HIV prevention cascade can be used to track intervention coverage, and identify gaps and opportunities for programme strengthening. The aim of this study was to characterise gaps in condom use and identify reasons underlying these gaps among young women who sell sex (YWSS) in Zimbabwe using data from enrolment into an impact evaluation of the DREAMS programme. DREAMS provided a package of biomedical, social and economic interventions to AGYW aged 10 to 24 with the aim of reducing HIV incidence. METHODS In 2017, we recruited YWSS aged 18 to 24 using respondent-driven sampling in six sites across Zimbabwe. We measured knowledge about efficacy of, access to, and effective (consistent) use of condoms with the most recent three sexual partners, separately by whether YWSS self-identified as female sex workers (FSW) or not. Among YWSS without knowledge about efficacy of, not having access to, and not effectively using condoms, we described the potential reasons underlying the gaps in the condom cascade. To identify socio-demographic characteristics associated with effective condom use, we used logistic regression modelling. All analyses were RDS-II weighted and restricted to YWSS testing HIV-negative at enrolment. RESULTS We enrolled 2431 YWSS. Among 1842 (76%) YWSS testing HIV-negative, 66% (n = 1221) self-identified as FSW. 89% of HIV-negative YWSS demonstrated knowledge about efficacy of condoms, 80% reported access to condoms and 58% reported using condoms consistently with the three most recent sexual partners. Knowledge about efficacy of and effective use of condoms was similar regardless of whether or not YWSS self-identified as FSW, but YWSS self-identifying as FSW reported better access to condoms compared to those who did not (87% vs 68%; age- and site-adjusted (adjOR) = 2.69; 95% CI: 2.01 to 3.60; p < 0.001). Women who reported experiencing sexual violence in the past year and common mental disorder in the past week were less likely to use condoms consistently (43% vs. 60%; adjOR = 0.49; 95% CI: 0.35 to 0.68; p < 0.001) and (51% vs. 61%; adjOR = 0.76; 95% CI: 0.60 to 0.97; p = 0.029), respectively. CONCLUSIONS Despite high knowledge about efficacy of and access to condoms, there remain large gaps in self-reported consistent condom use among YWSS. Addressing the structural determinants of YWSS' inconsistent condom use, including violence, could reduce this gap. YWSS who do not self-identify as FSW have less access to condoms and may require additional programmatic intervention.
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Affiliation(s)
- Sungai T Chabata
- Centre for Sexual Health and HIV/AIDS Research (CeSHHAR) ZimbabweHarareZimbabwe
| | - Bernadette Hensen
- Faculty of Infectious and Tropical DiseasesLondon School of Hygiene and Tropical MedicineLondonUnited Kingdom
| | - Tarisai Chiyaka
- Centre for Sexual Health and HIV/AIDS Research (CeSHHAR) ZimbabweHarareZimbabwe
| | - Phillis Mushati
- Centre for Sexual Health and HIV/AIDS Research (CeSHHAR) ZimbabweHarareZimbabwe
| | - Joanna Busza
- Faculty of Public Health and PolicyLondon School of Hygiene and Tropical MedicineLondonUnited Kingdom
| | - Sian Floyd
- Faculty of Epidemiology and Population HealthLondon School of Hygiene and Tropical MedicineLondonUnited Kingdom
| | - Isolde Birdthistle
- Faculty of Epidemiology and Population HealthLondon School of Hygiene and Tropical MedicineLondonUnited Kingdom
| | - James R Hargreaves
- Faculty of Public Health and PolicyLondon School of Hygiene and Tropical MedicineLondonUnited Kingdom
| | - Frances M Cowan
- Centre for Sexual Health and HIV/AIDS Research (CeSHHAR) ZimbabweHarareZimbabwe
- Faculty of Clinical Sciences and International Public HealthLiverpool School of Tropical MedicineLiverpoolUnited Kingdom
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Begnel ER, Escudero J, Mugambi M, Mugwanya K, Kinuthia J, Beima-Sofie K, Dettinger JC, Baeten JM, John-Stewart G, Pintye J. High pre-exposure prophylaxis awareness and willingness to pay for pre-exposure prophylaxis among young adults in Western Kenya: results from a population-based survey. Int J STD AIDS 2020; 31:454-459. [PMID: 32208816 DOI: 10.1177/0956462420912141] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
We conducted a population-level short message service (SMS)-based survey among individuals aged 18–34 years in six HIV high-burden counties in Western Kenya to assess pre-exposure prophylaxis (PrEP) awareness, acceptability of non-facility PrEP delivery, and willingness to pay for PrEP. In January 2019, anonymous data were collected using mSurvey Inc., Nairobi, Kenya, which sends SMS messages via mobile provider networks to a ‘general audience’ pool of subscribers ≥18 years. Subscribers’ demographic information was matched to Kenyan census data by age, gender, and county. Of the 3825 individuals who received the survey, 2617 (68%) opened the survey and 2498/2617 (95%) completed all questions. Overall, 84% had ever heard of PrEP, of whom 59% demonstrated understanding of PrEP; understanding was greater among men than women (64% versus 55%, p < 0.001). Among participants who understood PrEP (n = 1249), 38% reported pharmacies (informal or formal) as the preferred venue to obtain PrEP. Over half (61%) were willing to pay for PrEP and 78% reported that the maximum amount they were willing to pay for a one-month supply was <5 USD. High awareness of PrEP in high HIV prevalence settings in Kenya suggests effective public health messaging. Willingness to pay and preference for pharmacy access suggest that non-facility PrEP delivery may be useful.
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Affiliation(s)
- Emily R Begnel
- Department of Global Health, University of Washington, Seattle, WA, USA
| | - Jaclyn Escudero
- Department of Global Health, University of Washington, Seattle, WA, USA
| | - Melissa Mugambi
- Department of Global Health, University of Washington, Seattle, WA, USA
| | - Kenneth Mugwanya
- Department of Global Health, University of Washington, Seattle, WA, USA
| | - John Kinuthia
- Department of Global Health, University of Washington, Seattle, WA, USA.,Department of Obstetrics/Gynecology, Kenyatta National Hospital, Nairobi, Kenya
| | | | - Julia C Dettinger
- Department of Global Health, University of Washington, Seattle, WA, USA
| | - Jared M Baeten
- Department of Global Health, University of Washington, Seattle, WA, USA.,Department of Epidemiology, University of Washington, Seattle, WA, USA.,Department of Medicine, University of Washington, Seattle, WA, USA
| | - Grace John-Stewart
- Department of Global Health, University of Washington, Seattle, WA, USA.,Department of Epidemiology, University of Washington, Seattle, WA, USA.,Department of Medicine, University of Washington, Seattle, WA, USA.,Department of Pediatrics, University of Washington, Seattle, WA, USA
| | - Jillian Pintye
- Department of Global Health, University of Washington, Seattle, WA, USA
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Social representations of the prevention of heterosexual transmission of HIV among young Africans from five countries, 1997-2014. PLoS One 2020; 15:e0227878. [PMID: 32142515 PMCID: PMC7059925 DOI: 10.1371/journal.pone.0227878] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2019] [Accepted: 12/31/2019] [Indexed: 01/29/2023] Open
Abstract
HIV prevention has evolved dramatically since the 1990s. The ABC trilogy (abstinence, be faithful, use a condom) has expanded to incorporate a range of biomedical prevention strategies, including voluntary medical male circumcision, pre- and post-exposure prophylaxis, and treatment-as-prevention, and to accommodate structural and combination prevention approaches. This study examines how young Africans from five epidemiologically and socio-culturally diverse countries (Swaziland, Kenya, Nigeria, Burkina Faso and Senegal) made sense of the evolving prevention of sexual transmission of HIV between 1997 and 2014. It uses a distinctive data source: 1,343 creative narratives submitted to HIV-themed scriptwriting competitions by young people aged 10–24. The study triangulates between analysis of quantifiable characteristics of the narratives, thematic qualitative analysis, and narrative-based approaches. Over time, HIV prevention themes become less prominent. Condoms are represented less often from 2008, though representations become more favourable. Biomedical prevention is all but absent through 2014. While prevention strategies may be described as effective in narratorial commentary, they are rarely depicted as preventing HIV, but are evoked instead in moralistic cautionary tales or represented as ineffective. Over time, an increasing proportion of protagonists are female. One in five narratives acknowledge structural drivers of HIV, but these are generally either disempowering or condemn characters for failing to prevent HIV in the face of often overwhelming structural challenges. In the context of combination prevention, there is a need to disseminate an empowering cultural narrative that models successful use of HIV prevention strategies despite structural constraints and avoids blaming and stigma.
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Wu Y, Xie L, Meng S, Hou J, Fu R, Zheng H, He N, Meyers K. Mapping Potential Pre-Exposure Prophylaxis Users onto a Motivational Cascade: Identifying Targets to Prepare for Implementation in China. LGBT Health 2019; 6:250-260. [PMID: 31170020 DOI: 10.1089/lgbt.2018.0256] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
Purpose: China recently commenced several pre-exposure prophylaxis (PrEP) projects, but little work has characterized potential users. This study describes awareness of, intention to use, and uptake of PrEP in a sample of men who have sex with men (MSM), a key population experiencing high rates of HIV in China. Methods: Through a cross-sectional survey administered to 708 MSM in four cities, we mapped respondents onto a Motivational PrEP Cascade. We conducted bivariable and multivariable analysis to examine factors associated with progression through the Cascade. Results: Among 45.6% of MSM who were PrEP eligible, 36% were in Contemplation, 9% were in PrEParation, 2% were in PrEP Action and Initiation, and none reached Maintenance and Adherence. We found no association between individual risk factors and progression through the Cascade. In multivariable analysis, friends' positive attitudes toward PrEP, more frequent sexually transmitted infection testing, and higher scores on the perceived PrEP benefits scale were positively associated with entering PrEP Contemplation. Having higher condom use self-efficacy was associated with decreased odds of entering PrEP Contemplation. Having sex with men and women in the past 6 months, having heard of PrEP from medical providers, and knowing a PrEP user were positively associated with entering PrEParation. Conclusion: We found a high proportion of MSM who were PrEP eligible and identified several intervention targets to prepare for PrEP introduction in China: community education to increase accurate knowledge, gain-framed messaging for PrEP and sexual health, and provider trainings to build MSM-competent services that can support shared decision-making for PrEP initiation.
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Affiliation(s)
- Yumeng Wu
- 1 Aaron Diamond AIDS Research Center, The Rockefeller University, New York, New York
| | - Lu Xie
- 2 Institute of HIV/AIDS, The First Hospital of Changsha, Changsha, China
| | - Siyan Meng
- 3 School of Public Health, Fudan University, Shanghai, China
| | - Jianhua Hou
- 4 Center for Infectious Diseases, Beijing You'an Hospital, Capital Medical University, Beijing, China
| | - Rong Fu
- 5 Guangzhou Center for Disease Control and Prevention, Guangzhou, China
| | - Huang Zheng
- 6 Shanghai CSW & MSM Center, Shanghai, China
| | - Na He
- 3 School of Public Health, Fudan University, Shanghai, China
| | - Kathrine Meyers
- 1 Aaron Diamond AIDS Research Center, The Rockefeller University, New York, New York
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Mayer CM, Owaraganise A, Kabami J, Kwarisiima D, Koss CA, Charlebois ED, Kamya MR, Petersen ML, Havlir DV, Jewell BL. Distance to clinic is a barrier to PrEP uptake and visit attendance in a community in rural Uganda. J Int AIDS Soc 2019; 22:e25276. [PMID: 31037845 PMCID: PMC6488759 DOI: 10.1002/jia2.25276] [Citation(s) in RCA: 30] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2018] [Accepted: 03/14/2019] [Indexed: 01/26/2023] Open
Abstract
INTRODUCTION Geographic and transportation barriers are associated with poorer HIV-related health outcomes in sub-Saharan Africa, but data on the impact of these barriers on prevention interventions are limited. We estimated the association between distance to clinic and other transportation-related barriers on pre-exposure prophylaxis (PrEP) uptake and initial clinic visit attendance in a rural community in southwestern Uganda enrolled in the ongoing SEARCH study (NCT01864603). METHODS Community-wide HIV testing was conducted and offered to adult (≥15 years) participants in Ruhoko. Participants were eligible for PrEP based on an empiric risk score, having an HIV-discordant partner, or self-referral at either the community health campaign or during home-based testing from March to April 2017. We collected data from PrEP-eligible households on GPS-measured distance to clinic, walking time to clinic and road difficulty. A sample of participants was also asked to identify their primary barriers to PrEP use with a semi-quantitative questionnaire. We used multivariable logistic regression to evaluate the association between transportation barriers and (1) PrEP uptake among PrEP-eligible individuals and (2) four-week clinic visit attendance among PrEP initiators. RESULTS Of the 701 PrEP-eligible participants, 272 (39%) started PrEP within four weeks; of these, 45 (17%) were retained at four weeks. Participants with a distance to clinic of ≥2 km were less likely to start PrEP (aOR 0.34; 95% CI 0.15 to 0.79, p = 0.012) and less likely to be retained on PrEP once initiated (aOR 0.29; 95% CI 0.10 to 0.84; p = 0.024). Participants who were deemed eligible during home-based testing and did not have the option of same-day PrEP start were also substantially less likely to initiate PrEP (aOR 0.16, 95% CI 0.07 to 0.37, p < 0.001). Of participants asked to name barriers to PrEP use (N = 98), the most frequently cited were "needing to take PrEP every day" (N = 18) and "low/no risk of getting HIV" (N = 18). Transportation-related barriers, including "clinic is too far away" (N = 6) and "travel away from home" (N = 4) were also reported. CONCLUSIONS Distance to clinic is a significant predictor of PrEP uptake and four-week follow-up visit attendance in a community in rural Uganda. Interventions that address geographic and transportation barriers may improve PrEP uptake and retention in sub-Saharan Africa.
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Affiliation(s)
| | | | - Jane Kabami
- Infectious Diseases Research CollaborationKampalaUganda
| | | | | | | | | | | | - Diane V Havlir
- University of California San FranciscoSan FranciscoCAUSA
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