Strategies to support HIV literacy in the roll-out of pre-exposure prophylaxis in Scotland: findings from qualitative research with clinical and community practitioners

Examining oral pre-exposure prophylaxis (PrEP) literacy among participants in an HIV vaccine trial preparedness cohort study

BACKGROUND

PrEP literacy is influenced by many factors including the types of information available and how it is interpreted. The level of PrEP literacy may influence acceptability and uptake.

METHODS

We conducted 25 in-depth interviews in a HIV vaccine trial preparedness cohort study. We explored what participants knew about PrEP, sources of PrEP knowledge and how much they know about PrEP. We used the framework approach to generate themes for analysis guided by the Social Ecological Model and examined levels of PrEP literacy using the individual and interpersonal constructs of the SEM.

RESULTS

We found that PrEP awareness is strongly influenced by external factors such as social media and how much participants know about HIV treatment and prevention in the local community. However, while participants highlighted the importance of the internet/social media as a source of information about PrEP they talked of low PrEP literacy in their communities. Participants indicated that their own knowledge came as a result of joining the HIV vaccine trial preparedness study. However, some expressed doubts about the effectiveness of the drug and worried about side effects. Participants commented that at the community level PrEP was associated with being sexually active, because it was used to prevent the sexual transmission of HIV. As a result, some participants commented that one could feel judged by the health workers for asking for PrEP at health facilities in the community.

CONCLUSION

The information collected in this study provided an understanding of the different layers of influence around individuals that are important to address to improve PrEP acceptability and uptake. Our findings can inform strategies to address the barriers to PrEP uptake, particularly at structural and community levels.

TRIAL REGISTRATION

https://clinicaltrials.gov/ct2/show/NCT04066881.

Does the Ring Work? Perceptions and Understanding of the Efficacy of a Dapivirine Vaginal Ring for HIV Prevention Amongst Women in a Placebo-Controlled Trial

As demonstrated by the Phase III clinical trial, MTN-020/ASPIRE, the monthly dapivirine vaginal ring is well tolerated and reduces the risk of HIV-1 as a woman-initiated prevention option. This analysis uses data from the follow-on MTN-032/Assessment of ASPIRE and HOPE Adherence (AHA) qualitative study to understand how perceptions (or misperceptions) of ring efficacy may have influenced behavior during ASPIRE, and affected intention to use the ring in future ring projects, specifically HOPE, the planned open-label extension study. Single in-depth interviews (n = 98) and 12 focus group discussions (n = 89) were conducted with women at seven sites in Malawi, South Africa, Uganda and Zimbabwe. Eligibility included participation in the ASPIRE active arm, and ring use for ≥ 3 months or at least 1 month if seroconversion occurred. Interviews were audio-recorded, transcribed into English, coded in Dedoose and thematically analyzed. Demographic and behavioral questionnaire data were summarized in Stata. Most AHA participants perceived the ring to be effective, and described simply trusting it or having confidence in it because they, or other participants in risky situations, remained HIV-uninfected. Participants described ring efficacy after receiving ASPIRE results as a binary assessment: the ring worked or not. Many did not remember exact efficacy percentages because of lack of comprehension or memory but recalled key details about age differences. The majority expressed interest in future ring use. There is a need to investigate improved ways of explaining placebo-controlled trials and efficacy to women in Sub-Saharan Africa. Now that ring efficacy, is known, these benefits must be well communicated, and understood by end-users and key stakeholders. Engagement with end-users to construct effective messages and to develop tools to measure understanding of partial efficacy will be essential.

‘We go where we know’: Reflections from Mobilizing for PrEP and Sexual Health (MobPrESH) – A peer-led PrEP education programme across England, for and by women and non-binary people

Background:

Pre-exposure prophylaxis is a highly effective method of HIV prevention but few women know about it, have access to it, or see it as relevant to them. In 2019, grassroots organization PrEPster piloted a peer-led intervention, MobPrESH (Mobilizing for Pre-Exposure prophylaxis (PrEP) and Sexual Health), across three sites in England, to mobilize for PrEP and sexual health with communities of women and non-binary people most affected by HIV, including Black women and non-binary people, people of colour, migrants, and transgender (trans) women.

Objectives:

We aimed to explore the accessibility, feasibility, acceptability, and ‘fidelity’ of MobPrESH, from the perspectives of peer mobilizers and project staff.

Methods:

We conducted focus group discussions and qualitative interviews with nine peer mobilizers (most identified as Black cisgender (cis) women) and six project staff (including Black and white cis women and non-binary people). We analysed data thematically, iteratively, and inductively, informed by concepts of reproductive and social justice.

Results:

We present findings in five thematic areas: connecting and relating to situate sexual health discussions, navigating silence and stigma, connecting within and across communities, competing pressures and structural hostilities, and resources and continuity. Community knowledge-building about PrEP is a slow, iterative process that needs investment and creation of trusted spaces that centre communities’ needs and concerns. Peer mobilizers and the communities they engaged with had competing demands in their lives, and knowledge-raising about PrEP was impacted by intersecting stigmas, discrimination, and oppressions around HIV status, racism, misogyny, transphobia, homophobia, and anti-sex worker rhetoric.

Conclusions:

Peer-led PrEP interventions require funding and foregrounding, particularly for women and non-binary people who are Black, trans, migrants, and people of colour, situated relative to their wider health needs, life pressures, and priorities. This requires concurrent challenge of the racist and patriarchal structures that continue to obscure the sexual and reproductive health needs of racially minoritized and marginalized women and non-binary people.

Risk perception, safer sex practices and PrEP enthusiasm: barriers and facilitators to oral HIV pre-exposure prophylaxis in Black African and Black Caribbean women in the UK

OBJECTIVES

UK Black African/Black Caribbean women remain disproportionately affected by HIV. Although oral pre-exposure prophylaxis (PrEP) could offer them an effective HIV prevention method, uptake remains limited. This study examined barriers and facilitators to PrEP awareness and candidacy perceptions for Black African/Black Caribbean women to help inform PrEP programmes and service development.

METHODS

Using purposive sampling through community organisations, 32 in-depth, semi-structured interviews were conducted with Black African/Black Caribbean women living in London and Glasgow between June and August 2018. Participants (aged 19-63) included women of varied HIV statuses to explore perceptions of sexual risk and safer sex, sexual health knowledge and PrEP attitudes. A thematic analysis guided by the Social Ecological Model was used to explore how PrEP perceptions intersected with wider safer sex understandings and practices.

RESULTS

Four key levels of influence shaping safer sex notions and PrEP candidacy perceptions emerged: personal, interpersonal, perceived environment and policy. PrEP-specific knowledge was low and some expressed distrust in PrEP. Many women were enthusiastic about PrEP for others but did not situate PrEP within their own safer sex understandings, sometimes due to difficulty assessing their own HIV risk. Many felt that PrEP could undermine intimacy in their relationships by disrupting the shared responsibility implicit within other HIV prevention methods. Women described extensive interpersonal networks that supported their sexual health knowledge and shaped their interactions with health services, though these networks were influenced by prevailing community stigmas.

CONCLUSIONS

Difficulty situating PrEP within existing safer sex beliefs contributes to limited perceptions of personal PrEP candidacy. To increase PrEP uptake in UK Black African/Black Caribbean women, interventions will need to enable women to advance their knowledge of PrEP within the broader context of their sexual health and relationships. PrEP service models will need to include trusted 'non-sexual health-specific' community services such as general practice.