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Ntabadde K, Kagaayi J, Ssempijja V, Feng X, Kairania R, Lubwama J, Ssekubugu R, Yeh PT, Ssekasanvu J, Tobian AAR, Kennedy CE, Mills LA, Alamo S, Kreniske P, Santelli J, Nelson LJ, Reynolds SJ, Chang LW, Nakigozi G, Grabowski MK. Pre-exposure prophylaxis (PrEP) knowledge, use, and discontinuation among Lake Victoria fisherfolk in Uganda: a cross-sectional population-based study. MEDRXIV : THE PREPRINT SERVER FOR HEALTH SCIENCES 2024:2024.03.29.24305076. [PMID: 38585794 PMCID: PMC10996747 DOI: 10.1101/2024.03.29.24305076] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 04/09/2024]
Abstract
Background There are limited population-level data on the pre-exposure prophylaxis (PrEP) care continuum in eastern Africa. Here, we assessed the PrEP care continuum following PrEP rollout in a Ugandan community with ~40% HIV seroprevalence. Methods We used cross-sectional population-based data collected between September 3 and December 19, 2018 from a Lake Victoria fishing community in southern Uganda to measure levels of self-reported PrEP knowledge, ever use, and discontinuation following 2017 PrEP rollout via a U.S. President's Emergency Plan for AIDS Relief (PEPFAR)-supported phased implementation program. Our analysis included HIV-seronegative persons reporting having ever received an HIV test result. We examined associations between demographic, behavioral, and health utilization factors with each outcome using age-adjusted modified Poisson regression. Results There were 1,401 HIV-seronegative participants, of whom 1,363 (97.3%) reported ever receiving an HIV test result. Median age was 29 years (IQR: 23-36), and 42.3% (n=577) were women. Most (85.5%; n=1,166) participants reported PrEP knowledge, but few (14.5%; n=197) reported ever using PrEP. Among 375 (47.7%) men and 169 (29.3%) women PrEP-eligible at time of survey, 18.9% (n=71) and 27.8% (n=47) reported ever using PrEP, respectively. Over half (52.3%, n=103) of those who had ever used PrEP, self-reported current use. Conclusion In this Lake Victoria fishing community, there were low levels of PrEP use despite high levels of PrEP awareness and eligibility, particularly among men. Efforts that enhance awareness of HIV risk and increase PrEP accessibility may help increase PrEP use among HIV-seronegative persons in African settings with high HIV burden.
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Affiliation(s)
| | - Joseph Kagaayi
- Rakai Health Sciences Program, Kalisizo, Uganda
- Makerere University School of Public Health, Kampala, Uganda
| | - Victor Ssempijja
- Rakai Health Sciences Program, Kalisizo, Uganda
- Clinical Monitoring Research Program Directorate, Frederick National Laboratory for Cancer Research, Frederick, MD, USA
| | - Xinyi Feng
- Department of Pathology, Johns Hopkins School of Medicine, Baltimore, MD, USA
| | | | | | | | - Ping Teresa Yeh
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | | | - Aaron A R Tobian
- Department of Pathology, Johns Hopkins School of Medicine, Baltimore, MD, USA
| | - Caitlin E. Kennedy
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Lisa A. Mills
- United States Centers for Disease Control and Prevention, Uganda, Division of Global HIV & TB, Kampala Uganda
| | - Stella Alamo
- United States Centers for Disease Control and Prevention, Uganda, Division of Global HIV & TB, Kampala Uganda
| | - Philip Kreniske
- Community Health and Social Sciences Department, Graduate School of Public Health and Health Policy, City University of New York (CUNY)
| | - John Santelli
- Department of Population and Family Health and Pediatrics, Columbia University Mailman School of Public Health, New York, New York, USA
| | - Lisa J. Nelson
- United States Centers for Disease Control and Prevention, Uganda, Division of Global HIV & TB, Kampala Uganda
| | - Steven J. Reynolds
- Rakai Health Sciences Program, Kalisizo, Uganda
- Division of Intramural Research, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, Maryland, USA
- Division of Infectious Diseases, School of Medicine, Johns Hopkins University, Baltimore, Maryland, USA
| | - Larry William Chang
- Rakai Health Sciences Program, Kalisizo, Uganda
- Division of Infectious Diseases, School of Medicine, Johns Hopkins University, Baltimore, Maryland, USA
| | | | - M. Kate Grabowski
- Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
- Rakai Health Sciences Program, Kalisizo, Uganda
- Department of Pathology, Johns Hopkins School of Medicine, Baltimore, MD, 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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Kakande ER, Ayieko J, Sunday H, Biira E, Nyabuti M, Agengo G, Kabami J, Aoko C, Atuhaire HN, Sang N, Owaranganise A, Litunya J, Mugoma EW, Chamie G, Peng J, Schrom J, Bacon MC, Kamya MR, Havlir DV, Petersen ML, Balzer LB. A community-based dynamic choice model for HIV prevention improves PrEP and PEP coverage in rural Uganda and Kenya: a cluster randomized trial. J Int AIDS Soc 2023; 26:e26195. [PMID: 38054535 PMCID: PMC10698808 DOI: 10.1002/jia2.26195] [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: 05/08/2023] [Accepted: 11/17/2023] [Indexed: 12/07/2023] Open
Abstract
INTRODUCTION Optimizing HIV prevention may require structured approaches for providing client-centred choices as well as community-based entry points and delivery. We evaluated the effect of a dynamic choice model for HIV prevention, delivered by community health workers (CHWs) with clinician support, on the use of biomedical prevention among persons at risk of HIV in rural East Africa. METHODS We conducted a cluster randomized trial among persons (≥15 years) with current or anticipated HIV risk in 16 villages in Uganda and Kenya (SEARCH; NCT04810650). The intervention was a client-centred HIV prevention model, including (1) structured client choice of product (pre-exposure prophylaxis [PrEP] or post-exposure prophylaxis [PEP]), service location (clinic or out-of-clinic) and HIV testing modality (self-test or rapid test), with the ability to switch over time; (2) a structured assessment of patient barriers and development of a personalized support plan; and (3) phone access to a clinician 24/7. The intervention was delivered by CHWs and supported by clinicians who oversaw PrEP and PEP initiation and monitoring. Participants in control villages were referred to local health facilities for HIV prevention services, delivered by Ministry of Health staff. The primary outcome was biomedical prevention coverage: a proportion of 48-week follow-up with self-reported PrEP or PEP use. RESULTS From May to July 2021, we enrolled 429 people (212 intervention; 217 control): 57% women and 35% aged 15-24 years. Among intervention participants, 58% chose PrEP and 58% chose PEP at least once over follow-up; self-testing increased from 52% (baseline) to 71% (week 48); ≥98% chose out-of-facility service delivery. Among 413 (96%) participants with the primary outcome ascertained, average biomedical prevention coverage was 28.0% in the intervention versus 0.5% in the control: a difference of 27.5% (95% CI: 23.0-31.9%, p<0.001). Impact was larger during periods of self-reported HIV risk: 36.6% coverage in intervention versus 0.9% in control, a difference of 35.7% (95% CI: 27.5-43.9, p<0.001). Intervention effects were seen across subgroups defined by sex, age group and alcohol use. CONCLUSIONS A client-centred dynamic choice HIV prevention intervention, including the option to switch between products and CHW-based delivery in the community, increased biomedical prevention coverage by 27.5%. However, substantial person-time at risk of HIV remained uncovered.
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Affiliation(s)
| | | | - Helen Sunday
- Infectious Diseases Research CollaborationKampalaUganda
| | - Edith Biira
- Infectious Diseases Research CollaborationKampalaUganda
| | | | | | - Jane Kabami
- Infectious Diseases Research CollaborationKampalaUganda
- Department of MedicineMakerere University College of Health SciencesKampalaUganda
| | | | | | - Norton Sang
- Kenya Medical Research InstituteNairobiKenya
| | | | | | | | - Gabriel Chamie
- Division of HIVInfectious Diseases, and Global MedicineUniversity of California San FranciscoSan FranciscoCaliforniaUSA
| | - James Peng
- Department of BiostatisticsUniversity of WashingtonSeattleWashingtonUSA
| | - John Schrom
- Division of HIVInfectious Diseases, and Global MedicineUniversity of California San FranciscoSan FranciscoCaliforniaUSA
| | - Melanie C. Bacon
- Department of Health and Human ServicesNational Institute of HealthBethesdaMarylandUSA
| | - Moses R. Kamya
- Infectious Diseases Research CollaborationKampalaUganda
- Department of MedicineMakerere University College of Health SciencesKampalaUganda
| | - Diane V. Havlir
- Division of HIVInfectious Diseases, and Global MedicineUniversity of California San FranciscoSan FranciscoCaliforniaUSA
| | - Maya L. Petersen
- Division of BiostatisticsUniversity of California BerkeleyBerkeleyCaliforniaUSA
| | - Laura B. Balzer
- Division of BiostatisticsUniversity of California BerkeleyBerkeleyCaliforniaUSA
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Nelson A, Bheemraj K, Dean SS, de Voux A, Hlatshwayo L, Mvududu R, Berkowitz N, Neumuller C, Jacobs S, Fourie S, Coates T, Bekker LG, Myer L, Davey DJ. Integration of HIV pre-exposure prophylaxis (PrEP) services for pregnant and breastfeeding women in eight primary care clinics: results of an implementation science study. RESEARCH SQUARE 2023:rs.3.rs-3648622. [PMID: 38045335 PMCID: PMC10690321 DOI: 10.21203/rs.3.rs-3648622/v1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/05/2023]
Abstract
Background Although HIV vertical transmission (VT) has declined significantly in sub-Saharan Africa, incident HIV infection in pregnant and postpartum women is estimated to account for roughly one-third of VT. Oral pre-exposure prophylaxis (PrEP) for pregnant and breastfeeding women (PBFW) is part of the recommended guidelines in South Africa since 2021; however, integration of PrEP services within antenatal (ANC) and postnatal care (PNC) remains limited. Methods Between March 2022 and September 2023, we evaluated the acceptability, feasibility and sustainability of integrating PrEP for PBFW in high-HIV prevalence clinics after training and mentoring health care providers (HCP). We used the Reach Effectiveness-Adoption Implementation Maintenance (RE-AIM) framework to evaluate the intervention. Acceptability and maintenance were defined as the proportion of PBFW without HIV who initiated PrEP and the proportion of women continuing PrEP at 3 months in ANC or PNC services. Feasibility was defined as the proportion of trained HCPs (HIV lay counsellors and nurses/ midwives) who provided PrEP according to national guidelines, measured through post-training surveys and in-service assessments. Sustainability was defined as number of facilities and providers that continued to provide PrEP for PBFW past the mentoring period. Results In 8 facilities providing ANC and PNC, we trained 224 HCP (127 nurses and 37 counsellors). Of those, we mentored 60 nurses, midwives and HIV counsellors working with PBFW, with 72% of nurse/midwives and 65% of counsellors scoring over 8/10 on the final mentoring assessment Overall, 12% (1493/12,614) of HIV-negative pregnant women started PrEP and 41% of those continued PrEP at 3-months. Among the HIV-negative breastfeeding women in postnatal care, 179/1315 (14%) initiated PrEP and 25% continued PrEP at 3-months. All 8 facilities continued providing PrEP 3-months after handover of the clinics. Conclusion Integration of PrEP services in ANC and services for breastfeeding women was feasible, acceptable and sustainable. Acceptability and PrEP continuation showed improvement over time. Barriers to the PrEP integration were observed including the lack of regular HIV testing of breastfeeding mothers and need for ART-trained nurses to prescribe PrEP. Enablers included motivated and dedicated staff.
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