Acceptability of oral versus rectal HIV preexposure prophylaxis among men who have sex with men and transgender women in Peru

Awareness and willingness to use pre-exposure prophylaxis for HIV prevention among men who have sex with men in Rwanda: findings from a web-based survey

Introduction

Pre-exposure Prophylaxis (PrEP) is a daily pill aimed at reducing HIV transmission risk when taken as prescribed. It's highly recommended for high-risk Men who have sex with Men (MSM). This study aimed to assess PrEP awareness and willingness to use it among Rwandan MSM, a critical aspect given PrEP's proven effectiveness. The findings are expected to inform policy decisions and further advance the implementation of PrEP strategies.

Methods

This is a cross-sectional study design that utilized a web-based survey conducted between April and June 2019 to assess awareness and willingness to use PrEP among sexually active MSM in Rwanda. A snowball sampling technique was used to recruit participants via social media such as WhatsApp and e-mail. Eligibility criteria included being sexually active, aged ≥18 years, self-identifying as MSM, residing in Rwanda, self-reported engagement in receptive or insertive anal sex in the last 12 months, and self-reported HIV-negative serostatus. We assessed two primary outcomes: PrEP awareness (having ever heard of PrEP) and willingness to use PrEP within one month of completing the survey. Multivariable logistic regression was performed to identify participant characteristics associated with PrEP awareness and willingness to use it.

Results

Out of 521 participants, the majority (73%) demonstrated awareness of PrEP. Factors linked to PrEP awareness included residing outside the capital, Kigali, being in the 18-29 age group, having higher education levels, perceiving a benefit from PrEP, and engaging in vaginal sex with a woman while using a condom in the last year. Additionally, 96% of participants expressed a strong willingness to use PrEP.

Conclusion

Rwandan MSM exhibits a high level of PrEP awareness, notably associated with factors like location, age, education, perceived benefits, and condom use. The study also revealed a strong willingness to use PrEP, indicating promising prospects for its adoption among this group. These findings highlight the need for targeted awareness campaigns, personalized interventions, and comprehensive sexual health education to promote PrEP adoption and strengthen HIV prevention efforts among Rwandan MSM.

Awareness and Willingness to Use HIV Infection Pre-Exposure Prophylaxis among Rwandan Men Who Have Sex with Men: Findings from a Web-based Survey

Introduction

Pre-exposure Prophylaxis (PrEP) is a daily pill intended to reduce the risk of acquiring Human Immunodeficiency Virus (HIV) when taken as prescribed. It is strongly recommended for Men who have sex with Men (MSM) at high risk of HIV transmission to minimize infection risk. Despite its proven effectiveness, there is a lack of information about awareness and willingness to use PrEP among Rwandan MSM. In the context of HIV acquisition, the purpose of this study was to ascertain the awareness and willingness to use PrEP among high-risk Rwandan MSM. The findings of this research will provide valuable perspectives to mold policy and direct the effective execution of PrEP within the country.

Method

This is a cross-sectional study design that utilized a web-based survey conducted between April and June 2019 to assess awareness and willingness to use PrEP among sexually active MSM in Rwanda. A snowball sampling technique was used to recruit participants who were contacted via social medial such as WhatsApp and e-mail. To be eligible, participants were supposed to be sexually active, aged ≥18 years, self-identify as MSM, residence in Rwanda, self-reported engagement in receptive or insertive anal sex in the last 12 months, and self-reported HIV-negative sero-status. We assessed two primary outcomes: PrEP awareness (having ever heard of PrEP) and willingness to use PrEP within one month of completing the survey. Multivariable logistic regression was performed to identify participant characteristics associated with PrEP awareness and willingness to use it.

Results

Among the 521 participants included in the analysis, 63% were aged below 24 years. The majority (73%) demonstrated awareness of PrEP. Factors associated with PrEP awareness included residing outside of the capital, Kigali, as opposed to living in Kigali (adjusted odds ratio [aOR] 2.35, 95% confidence interval [CI] 1.40-3.97), being in the age groups 18-24 years (aOR 2.28, 95% CI: 1.03-5.01) or 25-29 years (aOR 3.06, 95% CI 1.35-6.93) compared to those aged 30 or older, having higher education levels, such as completing secondary education (aOR 1.76, 95% CI 1.01-3.06) or university education (aOR 2.65, 95% CI 1.18-5.96) in contrast to having no education. Lastly, perceiving a benefit from PrEP (aOR 9.52, 95% CI 4.27-21.22), and engaging in vaginal sex with a woman using a condom in the last 12 months (aOR 1.82, 95% CI 1.14-2.91) versus not. Impressively, 96% of participants expressed a strong willingness to use PrEP.

Conclusion

Among Rwandan MSM, there is a high level of awareness of PrEP, notably associated with factors such as residing outside Kigali, younger age, higher education, perceived benefits of PrEP and condom use during vaginal sex in the past year. Furthermore, a significant portion of participants demonstrated an intense desire to use PrEP, suggesting promising possibilities for its extensive implementation among this group of people. The findings from this study emphasize the importance of implementing highly focused awareness campaigns, personalized intervention, and comprehensive sexual health education programs in order to enhance the adoption of PrEP and bolster HIV prevention initiatives among the Rwandan population of MSM.

Why do men who have sex with men practice condomless sex? A systematic review and meta-synthesis

Background

Despite a large amount of behavioral interventions to reduce human immunodeficiency virus (HIV)-related high-risk sexual behaviors, consistent condom use remains suboptimal among men who have sex with men (MSM). However, current databases are lack of synthesized evidence to explain why MSM practiced condomless sex.

Objective

Our study aims to conduct a systematic review and meta-synthesis of 39 eligible qualitative studies to explore the barriers to condom use among MSM.

Methods

A systematic review and meta-synthesis of qualitative studies (1994–2021). On March 4, 2021, a comprehensive search was conducted in 14 electronic databases. The study was conducted based on the Joanna Briggs Institute’s recommendations.

Results

Thematic analysis produced six synthesized themes, which were classified into three levels according to the Social-ecology Model. Individual level barriers to condom use included physical discomfort, lack of HIV/STI-related knowledge and substance use; interpersonal-level barrier was mainly the condom stigma, namely regarding using condom as symbols of distrust or HIV/sexually transmitted infections (STIs) prevention, or as violating traditional cognition of sex, or as an embarrassing topic; environmental/structural-level barriers included situational unavailability, unaffordability of condoms and power imbalance in the sexual relationship.

Conclusion

This meta-synthesis offered in-depth understanding of condom use barriers for MSM and could guide the development of multifactorial interventions according to the identified barriers, especially targeting to reduce condom stigma, which has not been focused and intervened previously.

A qualitative assessment in acceptability and barriers to use pre-exposure prophylaxis (PrEP) among men who have sex with men: implications for service delivery in Vietnam

Background

HIV Pre-exposure prophylaxis (PrEP) is being considered for implementation among MSM nationwide in Vietnam. However, there may be concerns about potential obstacles for PrEP adherence among Vietnamese MSM. This study aims to assess the acceptability to use PrEP, potential barriers and facilitators, and the preferences for PrEP service accessibility and delivery among Vietnamese MSM.

Methods

Four focus group discussions (FGDs) were conducted with 30 HIV-negative MSM in January 2018 in Hanoi, Vietnam. FGDs explored MSM’s awareness regarding PrEP, perceived benefits and barriers of PrEP use, and willingness to use PrEP. FGDs were audio-recorded and transcribed verbatim. Content analysis was used.

Results

The mean age of participants was 23.9 years old. Most participants realized the advantages of PrEP given its efficacy in HIV risk reduction and expressed high motivation and interest to use PrEP in the future. PrEP was considered as a supplement alongside condoms. Common concerns about PrEP included side-effects, forgetting to take the pill daily, stigmatization due to using PrEP, negative attitudes toward PrEP from other MSM and accessibility of PrEP. Participants would prefer an injectable PrEP regime if available as it was seen as easier to adhere to. Concerns were also raised that PrEP usage could be interpreted as an indication of engaging in sexual risk behavior for HIV, potentially causing suspicion in love relationships or by family and friends. Participants preferred to receive PrEP in civil business organizations and MSM-friendly clinics, and recommended that pharmacy stores would not be suitable for PrEP implementation due to lack of trust and fear of fake drugs.

Conclusion

This study indicated a high level of willingness to use PrEP among MSM in Vietnam in combination with condom. Strategies to raise awareness of PrEP, reduce stigma towards PrEP, and improve the accessibility among MSM in Vietnam is needed. Existing MSM-friendly clinics were recommended to implement PrEP programs in Vietnam.

Willingness to Use Pre-Exposure Prophylaxis (PrEP) for HIV Prevention and PrEP Implementation Preferences Among Transgender Women in Malaysia

Introduction: Transgender women (TW) face one of the highest HIV burdens worldwide. In Malaysia, 12.4% of TW are HIV infected, ∼30-fold higher than in the Malaysian adult population. Pre-exposure prophylaxis (PrEP) is a highly effective HIV prevention strategy, however, little is known about TW's willingness to use PrEP or their preferences for receiving PrEP. This study examined the correlates of Malaysian TW's willingness to use PrEP and their attitudes and preferences related to delivery of PrEP and PrEP-related care. Methods: Between June and August 2017, 361 TW in Malaysia completed an online survey about their knowledge of and willingness to use PrEP for HIV prevention. Results: Only 20.2% of participants had ever previously heard of PrEP and none were currently taking PrEP. The majority (82.5%) expressed high willingness to take PrEP and most participants met the World Health Organization (WHO) indication for PrEP (82.3%). In the multivariate model, lifetime hormone use, prior postexposure prophylaxis use, and having completed a high school education were associated with higher willingness to use PrEP, while injection drug use, older age, and Chinese ethnicity were associated with lower PrEP willingness. Conclusion: TW in Malaysia are highly willing to use PrEP for HIV prevention. Differences in willingness to use PrEP identified by education, ethnicity, substance abuse, and age suggest different strategies may be needed to scale-up PrEP for this diverse community of TW.

HIV Prevention Method Preferences Within Sexual Partnerships Reported by HIV-Negative MSM and TW in Tijuana, Mexico

To assess the potential for decreased condom use as pre-exposure prophylaxis (PrEP) is scaled-up in Latin America, we examined HIV prevention method preferences (neither PrEP nor condoms, condoms only, PrEP only, or PrEP with condoms) within 1302 sexual partnerships reported by 397 HIV-negative men who have sex with men (MSM) and transgender women (TW) in Tijuana, Mexico. Using PrEP with condoms (56%) was preferred to using condoms only (24%), using PrEP only (17%), and using neither PrEP nor condoms (3%). Compared to using condoms only, using PrEP only was preferred within primary (adjusted odds ratio [AOR] = 4.13, 95% confidence interval [CI] 1.92, 8.90) and condomless sex practicing (AOR = 6.97, 95% CI 3.92, 12.40) partnerships, suggesting PrEP use may not displace condom use among MSM and TW in Tijuana and other similar settings.

Rectal Douching Practices Associated with Anal Intercourse: Implications for the Development of a Behaviorally Congruent HIV-Prevention Rectal Microbicide Douche

Tenofovir administration via rectal douching results in higher rectal-mucosa drug concentration than oral administration. Many who engage in receptive anal intercourse (RAI) use cleansing rectal douches. To inform development of a behaviorally-congruent tenofovir douche, 4751 individuals ≥ 18 years-old, born male, from all US states/territories, who engaged in anal intercourse responded to an online survey. Of those who reported RAI in the prior 3 months, 80% douched beforehand, 82% within 1 h, mean 2.9 consecutive applications; 27% douched afterwards, 83% within 1 h, mean 1.7 consecutive applications. Among multidose users, 78% applied doses within 2 min, and 76% retained liquid < 1 min. Most used tap water (89%) in an enema bottle (50%) or rubber bulb (43%), and douched for cleanliness (97%), to avoid smelling bad (65%), and to enhance pleasure (24%). 98% reported high likelihood of using an HIV-prevention douche. An ideal product will protect within a user's typical number of applications, within 1 h, and be dissolvable in tap water.

Expanding the Menu of HIV Prevention Options: A Qualitative Study of Experiences with Long-Acting Injectable Cabotegravir as PrEP in the Context of a Phase II Trial in the United States

Adherence challenges with oral pre-exposure prophylaxis have stimulated interest in alternate modes of administration including long-acting injections. We conducted 30 in-depth interviews with 26 male trial participants and 4 clinical providers in a Phase IIa study (ÉCLAIR) evaluating the use of long-acting cabotegravir (CAB-LA) injections in New York and San Francisco. Interviews exploring attitudes and experiences with CAB-LA were audiotaped, transcribed, and analyzed using thematic content analysis. Despite a high frequency of some level of side effects, almost all participants reported being interested in continuing with CAB-LA, versus a daily oral, due to its convenience and the perceived advantage of not worrying about adhering to pills. Providers reinforced the importance of CAB-LA as a prevention option and the need for guidelines to assist patient decision-making. Further research is needed on the acceptability of CAB-LA among men and women at higher risk for HIV in different settings.

Risk Behaviors Among Young Men Who Have Sex With Men in Bangkok: A Qualitative Study to Understand and Contextualize High HIV Incidence

The Bangkok Men Who Have Sex With Men (MSM) Cohort Study has shown high HIV incidence (8-12/100 person-years) among 18-21-year-old MSM. These data led to a further study using qualitative methods among young (18-24 years old) MSM in order to understand the factors driving the HIV epidemic among YMSM. We conducted eight focus group discussions and 10 key informant interviews among YMSM in Bangkok, Thailand. Sociodemographic and behavioral data were collected using a questionnaire. We audio-recorded, transcribed, and analyzed qualitative and questionnaire data using computer software. The categories relating to risk behavior were (1) the use of social networks for seeking sexual partners and the marketing promotions of MSM entertainment venues, (2) social influence by peers and older MSM, (3) easy access to high parties and group sex, (4) easy access to club drugs, (5) conceptions related to HIV risk, and (6) sexual preferences of YMSM. Increased HIV testing, same-sex education, and YMSM-specific HIV prevention efforts are urgently needed for YMSM in Bangkok.

Preference of Oral Tenofovir Disoproxil Fumarate/Emtricitabine Versus Rectal Tenofovir Reduced-Glycerin 1% Gel Regimens for HIV Prevention Among Cisgender Men and Transgender Women Who Engage in Receptive Anal Intercourse with Men

Oral pre-exposure prophylaxis (PrEP) can prevent HIV transmission. Yet, some may prefer not to take systemic daily medication. MTN-017 was a 3-period, phase 2 safety and acceptability study of microbicide gel applied rectally either daily or before and after receptive anal intercourse (RAI), compared to daily oral tablet. At baseline, cisgender men and transgender women who reported RAI (N = 187) rated the daily oral regimen higher in overall liking, ease of use, and likelihood of future use than the gel regimens. After trying all three, 28% liked daily oral the least. Gel did not affect sexual enjoyment (88%) or improved it (7-8%). Most partners had no reaction to gel use. Ease of gel use improved significantly between the first and the last few times of daily use. A rectal gel used before and after RAI may constitute an attractive alternative to daily tablet. Experience with product use may increase acceptability.

Acceptability of Daily Use of Free Oral Pre-exposure Prophylaxis (PrEP) Among Transgender Women Sex Workers in Shenyang, China

This study investigated the acceptability of daily use of free oral pre-exposure prophylaxis (PrEP) and associated factors among transgender women sex workers in Shenyang, China, following a briefing on PrEP. A total of 183 HIV negative or sero-status unknown participants completed the cross-sectional survey. The prevalence of acceptability of daily use of free oral PrEP was 61.2%. Adjusting for education level and monthly income, variables on negative attitudes toward PrEP (i.e., having concerns about the side-effects of PrEP) [Adjusted odds ratios (AOR): 0.26], perceived subjective norms (i.e., perceiving support from male partners to take PrEP) (AOR: 2.08), and perceived behavioral control (e.g., perceiving complete control over using PrEP) (AOR: 2.10-16.72) were significantly associated with acceptability of daily use of free oral PrEP. In addition, experiencing violence during sex work, perceived risk of contracting HIV from clients and probable anxiety were also significant. Future PrEP promotion campaigns should consider these factors.

The intention to use HIV-pre-exposure prophylaxis (PrEP) among men who have sex with men in Switzerland: testing an extended explanatory model drawing on the unified theory of acceptance and use of technology (UTAUT)

Aim

The aim of this study was to determine the intention to use pre-exposure prophylaxis (PrEP) when available and to identify predictors of the intention to use PrEP among men who have sex with men (MSM) living in Switzerland. The theoretical model drew on the Unified Theory of Acceptance and Use of Technology and considered additional variables related specifically to PrEP, HIV protection and the resources of MSM.

Subject and methods

For data collection, we used an anonymous, standardized self-administered online questionnaire. In 2015, we gathered a convenience sample of 556 HIV-negative MSM living in Switzerland. We analyzed the data using descriptive and bivariate statistics and used structural equation modeling to test the hypothesized model.

Results

Predictors of respondents’ moderate intention to use PrEP were performance expectancy, effort expectancy, perceived social influence, concerns about using PrEP, attitudes toward condom use, negative experiences of condom use and age. These variables were predicted by HIV protection-related aspects and resources.

Conclusion

The findings provide insights into the complex dynamic underlying the intention to use PrEP.

Awareness and willingness to use HIV pre-exposure prophylaxis among men who have sex with men in low- and middle-income countries: a systematic review and meta-analysis

Introduction: To facilitate provision of pre-exposure prophylaxis (PrEP) in low- and middle-income countries (LMIC), a better understanding of potential demand and user preferences is required. This review assessed awareness and willingness to use oral PrEP among men who have sex with men (MSM) in LMIC.

Methods: Electronic literature search of Cochrane library, Embase, PubMed, PsychINFO, CINHAL, Web of Science, and Google Scholar was conducted between July and September 2016. Reference lists of relevant studies were searched, and three authors contacted for additional data. Non-peer reviewed publications were excluded. Studies were screened for inclusion, and relevant data abstracted, assessed for bias, and synthesized.

Results: In total, 2186 records were identified, of which 23 studies involving 14,040 MSM from LMIC were included. The proportion of MSM who were aware of PrEP was low at 29.7% (95% CI: 16.9–44.3). However, the proportion willing to use PrEP was higher, at 64.4% (95% CI: 53.3–74.8). Proportions of MSM aware of PrEP was <50% in 11 studies and 50–70% in 3 studies, while willingness to use PrEP was <50% in 6 studies, 50–70% in 9 studies, and over 80% in 5 studies. Several factors affected willingness to use PrEP. At the individual domain, poor knowledge of PrEP, doubts about its effectiveness, fear of side effects, low perception of HIV risk, and the need to adhere or take medicines frequently reduced willingness to use PrEP, while PrEP education and motivation to maintain good health were facilitators of potential use. Demographic factors (education, age, and migration) influenced both awareness and willingness to use PrEP, but their effects were not consistent across studies. At the social domain, anticipated stigma from peers, partners, and family members related to sexual orientation, PrEP, or HIV status were barriers to potential use of PrEP, while partner, peer, and family support were facilitators of potential use. At the structural domain, concerns regarding attitudes of healthcare providers, quality assurance, data protection, and cost were determinants of potential use.

Conclusions: This review found that despite low levels of awareness of PrEP, MSM in LMIC are willing to use it if they are supported appropriately to deal with a range of individual, social, and structural barriers.

Willingness to use pre-exposure prophylaxis for HIV prevention among men who have sex with men in Malaysia: Findings from an online survey

Objective

We examined willingness to use pre-exposure prophylaxis (PrEP) for HIV prevention among men who have sex with men (MSM) in Malaysia.

Methods

An online survey of 990 MSM was conducted between March and April 2016. Eligibility criteria included being biological male, Malaysian citizen, 18 years of age or above, identifying as MSM, and being HIV negative or unknown status. Participants’ demographics, sexual and drug use behaviors, attitudes towards PrEP, and preferences regarding future access to PrEP were collected. Bivariate analysis and logistic regression were performed to determine factors associated with willingness to use PrEP.

Results

Fewer than half of participants (44%) knew about PrEP before completing the survey. Overall, 39% of the sample were willing to take PrEP. Multivariate logistic regression indicated that Malay men (AOR: 1.73, 95% CI:1.12, 2.70), having 2 or more male anal sex partners in the past 6 months (AOR: 1.98, 95% CI: 1.29, 3.05), previous knowledge of PrEP (AOR: 1.40, 95%CI: 1.06, 1.86), lack of confidence in practising safer sex (AOR: 1.36, 95% CI: 1.02, 1.81), and having ever paid for sex with a male partner (AOR: 1.39, 95% CI: 1.01, 1.91) were independently associated with greater willingness to use PrEP, while men who identified as heterosexual were less willing to use PrEP (AOR, 0.36, 95% CI: 0.13, 0.97). Majority of participants preferred to access PrEP at affordable cost below 100 Malaysian Ringgit (USD25) per month from community based organisations followed by private or government hospitals.

Conclusions

Overall, MSM in Malaysia reported a relatively low level of willingness to use PrEP, although willingness was higher among those previously aware of PrEP. There is a need to provide PrEP at affordable cost, increase demand and awareness of PrEP, and to provide access to this preventative medication via diverse, integrated and tailored sexual health services.

Willingness to use HIV pre-exposure prophylaxis among gay men, other men who have sex with men and transgender women in Myanmar

INTRODUCTION

HIV pre-exposure prophylaxis (PrEP) has emerged as a key component of contemporary HIV combination prevention strategies. To explore the local suitability of PrEP, country-specific acceptability studies are needed to inform potential PrEP implementation. In the context of Myanmar, in addition to resource constraints, HIV service access by gay men, other men who have sex with men, and transgender women (GMT) continues to be constrained by legislative and community stigma and marginalization. We aimed to determine PrEP acceptability among GMT in Myanmar and explore the factors associated with willingness to use PrEP.

METHODS

GMT were recruited in Yangon and Mandalay through local HIV prevention outreach programmes in November and December 2014. Quantitative surveys were administered by trained peer educators and collected data on demographics, sexual risk, testing history and PrEP acceptability. A modified six-item PrEP acceptability scale classified self-reported HIV undiagnosed GMT as willing to use PrEP. Multivariable logistic regression identified factors associated with willingness to use PrEP.

RESULTS

Among 434 HIV undiagnosed GMT, PrEP awareness was low (5%). PrEP acceptability was high, with 270 (62%) GMT classified as willing to use PrEP. GMT recruited in Mandalay (adjusted odds ratio (aOR) = 1.79; 95%CI = 1.05-3.03), who perceived themselves as likely to become HIV positive (aOR = 1.82; 95%CI = 1.10-3.02), who had more than one recent regular partner (aOR = 2.94; 95%CI = 1.41-6.14), no regular partners (aOR = 2.05; 95%CI = 1.10-3.67), more than five casual partners (aOR = 2.05; 95%CI = 1.06-3.99) or no casual partners (aOR = 2.25; 95%CI = 1.23-4.11) were more likely to be willing to use PrEP. The association between never or only occasionally using condoms with casual partners and willingness to use PrEP was marginally significant (aOR = 2.02; 95%CI = 1.00-4.10). GMT who reported concern about side effects and long-term use of PrEP were less likely (aOR = 0.35; 95%CI = 0.21-0.59) to be willing to use PrEP.

CONCLUSIONS

This is the first study to assess PrEP acceptability in Myanmar. Findings suggest PrEP is an acceptable prevention option among GMT in Myanmar, providing they are not required to pay for it. Implementation/demonstration projects are needed to explore the feasibility and cost-effectiveness of PrEP as a prevention option for GMT in Myanmar.

Values and Preferences on the Use of Oral Pre-exposure Prophylaxis (PrEP) for HIV Prevention Among Multiple Populations: A Systematic Review of the Literature

Daily oral pre-exposure prophylaxis (PrEP) is the use of antiretroviral drugs by HIV-negative people to prevent HIV infection. WHO released new guidelines in 2015 recommending PrEP for all populations at substantial risk of HIV infection. To prepare these guidelines, we conducted a systematic review of values and preferences among populations that might benefit from PrEP, women, heterosexual men, young women and adolescent girls, female sex workers, serodiscordant couples, transgender people and people who inject drugs, and among healthcare providers who may prescribe PrEP. A comprehensive search strategy reviewed three electronic databases of articles and HIV-related conference abstracts (January 1990-April 2015). Data abstraction used standardised forms to categorise by population groups and relevant themes. Of 3068 citations screened, 76 peer-reviewed articles and 28 conference abstracts were included. Geographic coverage was global. Most studies (N = 78) evaluated hypothetical use of PrEP, while 26 studies included individuals who actually took PrEP or placebo. Awareness of PrEP was low, but once participants were presented with information about PrEP, the majority said they would consider using it. Concerns about safety, side effects, cost and effectiveness were the most frequently cited barriers to use. There was little indication of risk compensation. Healthcare providers would consider prescribing PrEP, but need more information before doing so. Findings from a rapidly expanding evidence base suggest that the majority of populations most likely to benefit from PrEP feel positively towards it. These same populations would benefit from overcoming current implementation challenges with the shortest possible delay.

MTN-017: A Rectal Phase 2 Extended Safety and Acceptability Study of Tenofovir Reduced-Glycerin 1% Gel

Background

Human immunodeficiency virus (HIV) disproportionately affects men who have sex with men (MSM) and transgender women (TGW). Safe and acceptable topical HIV prevention methods that target the rectum are needed.

Methods

MTN-017 was a phase 2, 3-period, randomized sequence, open-label, expanded safety and acceptability crossover study comparing rectally applied reduced-glycerin (RG) 1% tenofovir (TFV) and oral emtricitabine/TFV disoproxil fumarate (FTC/TDF). In each 8-week study period participants were randomized to RG-TFV rectal gel daily, or RG-TFV rectal gel before and after receptive anal intercourse (RAI; or at least twice weekly in the event of no RAI), or daily oral FTC/TDF.

Results

MSM and TGW (n = 195) were enrolled from 8 sites in the United States, Thailand, Peru, and South Africa with mean age of 31.1 years (range 18-64). There were no differences in ≥grade 2 adverse event rates between daily gel (incidence rate ratio [IRR], 1.09; P = .59) or RAI gel (IRR, 0.90; P = .51) compared to FTC/TDF. High adherence (≥80% of prescribed doses assessed by unused product return and Short Message System reports) was less likely in the daily gel regimen (odds ratio [OR], 0.35; P < .001), and participants reported less likelihood of future daily gel use for HIV protection compared to FTC/TDF (OR, 0.38; P < .001).

Conclusions

Rectal application of RG TFV gel was safe in MSM and TGW. Adherence and product use likelihood were similar for the intermittent gel and daily oral FTC/TDF regimens, but lower for the daily gel regimen.

Clinical Trials Registration

NCT01687218.

High Willingness to Use HIV Pre-Exposure Prophylaxis Among Transgender Women in Argentina

Purpose: In Argentina, transgender women face a disproportionately high prevalence of HIV infection (34%). Although not currently approved in Argentina, pre-exposure prophylaxis (PrEP) may offer a potential effective HIV prevention tool for this population. In this study, we assessed the willingness to use PrEP among transgender women in Argentina. Methods: Data were drawn from a nationwide cross-sectional survey conducted among transgender women in 2013. Using multivariable logistic regression, we assessed the prevalence of and factors associated with willingness to use PrEP among transgender women with negative or unknown HIV status. Results: This study included 337 transgender women (278 HIV negative and 59 with unknown HIV status), most of whom had a history of sex work involvement (81.8%). Overall, 301 (89.3%) expressed willingness to use PrEP. In a multivariable analysis, having casual sexual partners was positively associated with willingness to use PrEP (adjusted odds ratio [AOR]=4.26, 95% confidence interval [CI] 1.73-10.51), while discrimination by healthcare workers was negatively associated (AOR=0.33, 95% CI 0.12-0.88). Conclusion: We found high levels of willingness to use PrEP among transgender women in Argentina, suggesting that there is high perception of HIV risk in this population. However, discrimination by healthcare workers was a strong negative correlate of willingness to use PrEP, suggesting that multilevel interventions that address gender-based stigma in healthcare settings will be critical for the success of PrEP as an HIV prevention strategy in this population.

Rectal Douching Prevalence and Practices Among Peruvian Men Who have Sex with Men and Transwomen: Implications for Rectal Microbicides

Peruvian men who have sex with men (MSM) and transwomen (TW) could benefit from a rectal microbicide (RM) formulated as a rectal douche to prevent HIV infection. However, little is known about rectal douching practices among Peruvian MSM and TW, information necessary to inform RM douche development and future uptake. Using a self-administered interview, we examined the prevalence of and factors associated with rectal douching among a convenience sample of 415 Peruvian MSM and 68 TW. In the previous 6 months, 18 % of participants reported rectal douching using pre-filled commercial kits or plastic bottles or enema bags filled with water, water/soap or saltwater. Multivariate logistic analysis found that "equally insertive and receptive" or "exclusively/mainly receptive" sex roles were associated with douche use. Rectal douching among Peruvian MSM and TW is similar to reports from other studies and supports the potential uptake of a douche-formulated RM in these populations.

Towards a fair consideration of PrEP as part of combination HIV prevention in Latin America

INTRODUCTION

Despite progress in scaling up antiretroviral treatment, HIV prevention strategies have not been successful in significantly curbing HIV incidence in Latin America. HIV prevention interventions need to be expanded to target the most affected key populations with a combination approach, including new high impact technologies. Oral pre-exposure prophylaxis (PrEP) is recommended as additional prevention choice for individuals at higher risk of infection and could become a cost-effective prevention tool. We discuss the barriers and solutions for a fair consideration of PrEP as part of combination HIV prevention strategies in Latin America.

DISCUSSION

Although demonstration projects are ongoing or being planned in a number of countries, to date no Latin American country has implemented a public PrEP programme. The knowledge of policymakers about PrEP implementation needs to be strengthened, and programmatic guidance and cost estimate tools need to be developed to support adequate planning. Despite high levels of awareness among health providers, especially if engaged in HIV or key population care, willingness to prescribe PrEP is still low due to the lack of national policies and guidelines. Key populations, especially men who have sex with men, transgender women and sex workers, have been engaged in demonstration projects, and qualitative research shows high awareness and willingness to use PrEP, especially if accessible in the public sector for free or at affordable price. Concerns of safety, adherence, effectiveness and risk compensation need to be addressed through targeted social communication strategies to improve PrEP knowledge and stimulate demand. Alliance among policymakers, civil society and representatives from key populations, healthcare providers and researchers will be critical for the design and successful implementation of PrEP demonstration projects of locally adapted delivery models. The use of mechanisms of joint negotiation and procurement of antiretrovirals could reduce costs and significantly increase the cost-effectiveness of PrEP.

CONCLUSIONS

PrEP is an additional prevention tool and should be implemented in combination and synergy with other prevention interventions. PrEP programmes should target high-risk individuals from key populations for higher cost-effectiveness. Demonstration projects may generate strategic information for and lead to the implementation of full-scale PrEP programmes.

Acceptability of Three Novel HIV Prevention Methods Among Young Male and Transgender Female Sex Workers in Puerto Rico

Sex workers need HIV-prevention methods they can control and incorporate easily in their work. We studied the acceptability of three methods: HIV self-test use with clients, oral pre-exposure prophylaxis (PrEP), and rectal microbicide gel. Four male and eight transgender female (TGF) sex workers in Puerto Rico completed a baseline survey with a quantitative measure of likelihood of use. From them, one male and four TGF also completed a 12-week study of rectal microbicide placebo gel use prior to receptive anal intercourse with male clients and evaluated via qualitative in-depth interviews and follow-up quantitative assessments how each method could be incorporated into their work. Most were interested in a rectal microbicide gel and able to use it covertly with clients. Challenges to using the HIV self-test with clients included the potential for both breach of confidentiality and confronting violent situations. Participants also expressed interest in oral PrEP, but raised concerns about side effects.

Rectal 1% Tenofovir Gel Use Associates with Altered Epidermal Protein Expression

Rectal use of a 1% tenofovir (TFV) gel is currently being evaluated for HIV prevention. While careful assessment of mucosal safety of candidate microbicides is a primary concern, tools to assess mucosal toxicity are limited. Mass spectrometry-based proteomics is a sensitive and high-throughput technique that can provide in-depth information on inflammation processes in biological systems. In this study, we utilized a proteomics approach to characterize mucosal responses in study participants involved in a phase 1 clinical trial of a rectal TFV-based gel. Project Gel was a phase 1 randomized (1:1), double-blind, multisite, placebo-controlled trial in which 24 participants received rectal TFV or a universal placebo [hydroxyethyl cellulose (HEC)] over a course of 8 daily doses. Rectal mucosal swabs were collected after 0, 1, and 8 doses and were analyzed by label-free tandem mass spectrometry. Differential protein expression was evaluated using a combination of paired (time-effects) and unpaired (across study arm) t-tests, and multivariate [least absolute shrinkage and selection operator (LASSO)] modeling. Within the TFV arm, 7% (17/249, p < .05) and 10% (25/249, p < .05) of total proteins changed after 1 and 8 daily applications of TFV gel, respectively, compared to 3% (7/249, p < .05) and 6% (16/249, p < .05) in the HEC arm. Biofunctional analysis associated TFV use with a decrease in epidermal barrier proteins (adj. p = 1.21 × 10⁻¹⁰). Multivariate modeling identified 13 proteins that confidently separated TFV gel users (100% calibration and 96% cross-validation accuracy), including the epithelial integrity factors (FLMNB, CRNN, CALM), serpins (SPB13, SPB5), and cytoskeletal proteins (VILI, VIME, WRD1). This study suggested that daily rectal applications of a 1% TFV gel may be associated with mucosal proteome changes involving epidermal development. Further assessment of more extended use of TFV-gel is recommended to validate these initial associations.

Antiretroviral pre-exposure prophylaxis preferences among men who have sex with men in Vietnam: results from a nationwide cross-sectional survey

Background: The HIV/AIDS epidemic in Vietnam is concentrated in subgroups of the population, including men who have sex with men (MSM). Pre-exposure prophylaxis (PrEP) is a viable strategy for HIV prevention, but knowledge about and preferences for PrEP delivery among Vietnamese MSM are not well understood. Methods: In 2015, an online survey was conducted with recruitment via social networking websites for MSM and peer recruitment. A description of daily oral, long-acting injectable, and rectal microbicide formulations of PrEP was provided to participants. Participants were asked about their prior awareness of and interest in PrEP, and ranked their most preferred PrEP modality. Multivariable logistic regression models were used to assess factors associated with having heard of PrEP and preference for each PrEP modality. Results: Of 548 participants who answered demographic and PrEP-related questions, 26.8% had previously heard of PrEP and most (65.7%) endorsed rectal microbicides as their most preferred PrEP delivery modality. Commonly-cited perceived barriers to uptake of PrEP included concern about side-effects, perception about being HIV positive, and family or friends finding out about their sexual behaviour. In multivariable models, older participants less often endorsed rectal microbicides (adjusted odds ratio (AOR) 0.95 per year, 95% confidence interval (CI) 0.91-0.99) and more often endorsed long-acting injectables (AOR 1.08 per year, 95% CI 1.03 to 1.14) as their preferred PrEP modality. Participants who were willing to pay more for PrEP less often endorsed rectal microbicides (AOR 0.81, 95% CI 0.72-0.92) and more often endorsed long-acting injectables (AOR 1.17, 95% CI 1.01-1.35) and daily oral pills (AOR 1.16, 95% CI 1.00-1.35) as their preferred form of PrEP. Conclusions: A variety of PrEP modalities were acceptable to MSM in Vietnam, but low knowledge of PrEP may be a barrier to implementation.

Early Adopters: Correlates of HIV Chemoprophylaxis Use in Recent Online Samples of US Men Who Have Sex with Men

To date, little data on pre-exposure prophylaxis (PrEP) users outside of the clinical trial setting are available. A repeated cross-sectional survey of one of the largest social and sexual networking websites for men who have sex with men (MSM) in the United States was conducted in August 2013 (Wave 1) and January 2014 (Wave 2). Multivariable logistic regression models were used to assess factors associated with having heard of and having taken post-exposure prophylaxis (PEP) and PrEP in Wave 1 (N = 4043) and Wave 2 (N = 2737) separately. In Wave 1, 147 (3.6 %) and 61 (1.5 %) reported using PEP and PrEP, respectively, compared to 119 (4.4 %) and 62 (2.3 %) in Wave 2. Higher-risk sexual behaviors were associated with having taken PEP and PrEP, and previous PEP use was associated with having taken PrEP. Understanding factors that are associated with early use of PrEP may help inform wider utilization of PrEP by at risk MSM.

Project Gel a Randomized Rectal Microbicide Safety and Acceptability Study in Young Men and Transgender Women

OBJECTIVES

The purpose of Project Gel was to determine the safety and acceptability of rectal microbicides in young men who have sex with men (MSM) and transgender women (TGW) at risk of HIV infection.

METHODS

MSM and TGW aged 18-30 years were enrolled at three sites; Pittsburgh, PA; Boston, MA; and San Juan, PR. Stage 1A was a cross-sectional assessment of sexual health and behavior in MSM and TGW. A subset of participants from Stage 1A were then enrolled in Stage 1B, a 12-week evaluation of the safety and acceptability of a placebo rectal gel. This was followed by the final phase of the study (Stage 2) in which a subset of participants from Stage 1B were enrolled into a Phase 1 rectal safety and acceptability evaluation of tenofovir (TFV) 1% gel.

RESULTS

248 participants were enrolled into Stage 1A. Participants' average age was 23.3 years. The most common sexually transmitted infection (STIs) at baseline were Herpes simplex (HSV)-2 (16.1% by serology) and rectal Chlamydia trachomatis (CT) (10.1% by NAAT). 134 participants were enrolled into Stage 1B. During the 12 week period of follow-up 2 HIV, 5 rectal CT, and 5 rectal Neisseria gonorrhea infections were detected. The majority of adverse events (AEs) were infections (N = 56) or gastrointestinal (N = 46) and were mild (69.6%) or moderate (28.0%). Of the participants who completed Stage 1B, 24 were enrolled into Stage 2 and randomized (1:1) to receive TFV or placebo gel. All participants completed Stage 2. The majority of AEs were gastrointestinal (N = 10) and of mild (87.2%) or moderate (10.3%) severity.

CONCLUSIONS

In this study we were able to enroll a sexually active population of young MSM and TGW who were willing to use rectal microbicides. TFV gel was safe and acceptable and should be further developed as an alternative HIV prevention intervention for this population.

TRIAL REGISTRATION

ClinicalTrials.gov NCT01283360.

Mucosal Topical Microbicide Candidates Exert Influence on the Subsequent SIV Infection and Survival by Regulating SIV-Specific T-Cell Immune Responses

OBJECTIVE

To determine whether mucosal topical microbicides have any influence on disease progression during subsequent simian immunodeficiency virus (SIV) infection.

DESIGN

A 2-phase study was performed in primate monkeys. The first phase mimicked microbicide efficacy studies; the second phase served to determine the disease progression in a productive infection model.

METHODS

During the first phase, monkeys were intrarectally pretreated with tenofovir, sifuvirtide (SFT), or maraviroc-formulated microbicides and then challenged with low-dose SHIV-1157ipd3N4. Second, all monkeys were rechallenged with a single high dose of SIVmac239 to generate productive infections. The survival rate, viral loads, CD4(+) T-cell counts, and SIV-specific T-cell responses were determined during the 104-week following up.

RESULTS

Repeated rectal challenges did not result in productive infection in all groups, evidenced by undetectable viral loads with occasional viral blips during the first phase of this study. All monkeys were productively infected after the high-dose rechallenge with SIVmac239. Two groups, including maraviroc-treated and tenofovir-treated groups, experienced 100% mortality during the 104-week following up. In contrast, the SFT-treated group showed significantly higher survival, and only 25% died at week 95. Interestingly, SIV-specific T-cell responses were also significantly higher in the SFT group. Transcriptomic analyses evidenced immune imprint in immune system among different microbicide-treated groups.

CONCLUSIONS

This study provides preliminary but important evidence for the influence of prophylactically applied microbicides on disease progression of subsequent SIV infection and suggests that the long-term immune safety concern for microbicides should be also considered in the effort to develop effective microbicides.

Hypothetical Rectal Microbicide Acceptability and Factors Influencing It among Men Who Have Sex with Men in Tianjin, China

Objectives

To measure potential acceptability of rectal microbicides and to explore factors likely to affect their acceptability among men who have sex with men (MSM).

Methods

Cross-sectional and retrospective surveys were conducted in this study. A questionnaire and a scale were used to measure the acceptability score for physical and functional characteristics of hypothetical rectal microbicides. We also evaluated the involvement of other factors such as sexual behaviors, social context, etc.

Results

MSMs we interviewed showed a high acceptability to rectal microbicides, indicated by the mean acceptability score of 2.92 (SD, 0.54, scale of 1–4). The results also suggested that microbicides were preferred in a cream form that can moisten and lubricate the rectum, prevent HIV infection and go unnoticed by their partners. Multivariate analysis showed that the microbicides acceptability varied significantly by education level (β = 0.135; P = 0.028), having casual partners (β = 0.174; P = 0.007), frequency of lubricant use (β = 0.134; P = 0.031), history of HIV test (β = 0.129; P = 0.036), willingness to use lubricant (β = 0.126; P = 0.045), locus of control by partners regarding STI infection (β = 0.168; P = 0.009).

Conclusions

A positive response to rectal microbicides among MSMs was found in our study, suggesting that rectal microbicides might have a potential market in MSMs and they might play an important role in HIV/STIs prevention as a supplement. Further studies may be considered to combine the acceptability study with clinical research together to understand the true feelings of MSMs when they use the products.

Perceptions among Dutch men who have sex with men and their willingness to use rectal microbicides and oral pre-exposure prophylaxis to reduce HIV risk--a preliminary study

Oral pre-exposure prophylaxis (PrEP) with antiretroviral (ARV) tablets and topical PrEP or microbicides containing ARV drugs could help to reduce HIV incidence. These methods hold promise for men who have sex with men (MSM) who are at higher risk of acquiring HIV. This mixed-methods study in the Netherlands explored perceptions of MSM and their willingness to use oral PrEP and rectal microbicides (RM) if made available. Recruited through social media (Facebook and Twitter), 108 MSM completed online questionnaires. Seven of them consented to discuss the survey results in semi-structured interviews. Survey participants preferred a RM that could be applied before and after anal intercourse (60.8%) to daily oral PrEP (20.3%). This preference was based on anticipated user friendliness, hypothetically fewer expected adverse events, and perceptions that RM would be less likely to be confused with ARVs for treatment. Those who preferred oral PrEP had stronger beliefs in the effectiveness of pills, perceived its use as easy, and viewed not requiring sexual partner awareness as advantages. No predictive factors were found for the choice of one prevention method over the other. Although Dutch MSM perceive both oral and topical PrEP positively, many barriers exist to the introduction of these products in the Netherlands. These include lack of regulatory approval of oral PrEP, no proven efficacy as yet for RM, and strong HIV stigma within the MSM population. In-depth qualitative research is needed to further explore the perceptions of MSM to inform implementation of programmes should these HIV prevention methods become available.

HIV risk and preventive interventions in transgender women sex workers

Worldwide, transgender women who engage in sex work have a disproportionate risk for HIV compared with natal male and female sex workers. We reviewed recent epidemiological research on HIV in transgender women and show that transgender women sex workers (TSW) face unique structural, interpersonal, and individual vulnerabilities that contribute to risk for HIV. Only six studies of evidence-based prevention interventions were identified, none of which focused exclusively on TSW. We developed a deterministic model based on findings related to HIV risks and interventions. The model examines HIV prevention approaches in TSW in two settings (Lima, Peru and San Francisco, CA, USA) to identify which interventions would probably achieve the UN goal of 50% reduction in HIV incidence in 10 years. A combination of interventions that achieves small changes in behaviour and low coverage of biomedical interventions was promising in both settings, suggesting that the expansion of prevention services in TSW would be highly effective. However, this expansion needs appropriate sustainable interventions to tackle the upstream drivers of HIV risk and successfully reach this population. Case studies of six countries show context-specific issues that should inform development and implementation of key interventions across heterogeneous settings. We summarise the evidence and knowledge gaps that affect the HIV epidemic in TSW, and propose a research agenda to improve HIV services and policies for this population.

High interest in a long-acting injectable formulation of pre-exposure prophylaxis for HIV in young men who have sex with men in NYC: a P18 cohort substudy

OBJECTIVE

In the context of continued high rates of condomless anal intercourse and HIV-1 infection, young men who have sex with men (YMSM) need additional effective and desirable HIV prevention tools. This study reports on the willingness of a racially-ethnically diverse cohort of YMSM to use a new biomedical prevention approach, a long-acting injectable pre-exposure prophylaxis (LAI-PrEP) agent.

METHODS

A cross-sectional study conducted between June-August 2013 recruited participants from an ongoing cohort study of YMSM in NYC. Participants included 197 YMSM, of whom 72.6% (n = 143) identified as men of color. Two outcomes were measured through computer-assisted self-interviews: 1) willingness to use long-acting injectable PrEP and 2) preference for route of administration of PrEP. In addition, concerns about perceived impacts of PrEP on health and risk behavior, access to health services, and stigma were investigated.

RESULTS

Over 80% (n = 159/197, p<0.001) of participants stated they would be willing to use LAI-PrEP. With regards to preference for mode of delivery 79.2% (n = 156/197, p<0.001) stated they would prefer an injection administered every three months over a daily pill or neither one.

CONCLUSIONS

This study is the first to explore acceptability of LAI-PrEP in the US. A significant majority of participants expressed willingness to use LAI and the majority preferred LAI-PrEP. LAI-PrEP holds great promise in that it could circumvent the adherence challenges associated with daily dosing, especially if nested within appropriate psycho-behavioral support. Medical providers whose patients include YMSM at high risk for HIV infection should note the positive attitudes toward PrEP, and specifically LAI-PrEP.

Interest in using rectal microbicides among Australian gay men is associated with perceived HIV vulnerability and engaging in condomless sex with casual partners: results from a national survey

OBJECTIVE

We assessed interest in using rectal microbicides to prevent HIV transmission among gay men in Australia.

METHODS

A national online survey was conducted in 2013. Interest in using rectal microbicides was measured on a seven-item scale (α=0.81). Factors independently associated with greater interest in using a microbicide were identified using multivariate logistic regression.

RESULTS

Data were collected from 1223 HIV-negative and untested men. Mean age was 31.3 years (SD=10.8, range 18-65); 77% were born in Australia and 25% reported any condomless anal sex with a casual partner in the previous 6 months. Overall, there was moderate interest in using rectal microbicides (M=3.33, range 1-5). In multivariate analysis, greater interest in using microbicides was independently associated with being born outside Australia (adjusted OR (AOR)=1.59; p=0.009), greater self-perceived likelihood of becoming HIV positive (AOR=3.40; p<0.001), less uncertainty about the efficacy of microbicides (AOR=0.65; p=0.009), any condomless anal sex with casual partners in the previous 6 months (AOR=1.78; p=0.03) and ever having received postexposure prophylaxis (AOR=1.53; p=0.04). Interest in using microbicides was not associated with age, number of male sex partners or the HIV status of regular male partners.

CONCLUSIONS

Interest in using rectal microbicides was associated with self-perceived vulnerability to HIV, engaging in sexual practices that increase the risk of HIV acquisition and less uncertainty about the efficacy of microbicides. There appears to be a group of men who would benefit from, and are highly motivated to use, a rectal microbicide product.

Provider attitudes toward oral preexposure prophylaxis for HIV prevention among high-risk men who have sex with men in Lima, Peru

Oral preexposure prophylaxis (PrEP) was the first biomedical intervention to demonstrate efficacy in preventing HIV infection among men who have sex with men (MSM). Healthcare providers' attitudes toward PrEP will be critical in translating this finding into effective public health rollout programs. In a convenience sample of 186 healthcare providers in Peru, we assessed knowledge, barriers, and attitudes to prescribe and monitor HIV PrEP for high-risk MSM and transgender women, the populations with the highest HIV incidence in this setting. A total of 57.5% reported awareness of PrEP, and awareness was independently associated with caring for more than 50 MSM (OR: 3.67, p<0.002). Lack of local guidelines, concern about increased high-risk behavior, antiretroviral drug resistance, and limited availability of antiretrovirals for HIV-infected individuals were the most common barriers to prescribing PrEP. Of all physicians 44.6% indicated that they would be likely to prescribe oral PrEP now; likelihood to prescribe was higher if PrEP were supported by local guidelines (70.3%, p<0.001), if more trials supported its effectiveness (68.5%, p<0.001), and if intermittent use were shown to be effective (62.2%, p=0.019). Physicians were more likely to prescribe PrEP now if they care for more than 50 MSM (OR: 6.62, p=0.010). Infectious disease specialists were less likely to prescribe PrEP (OR: 0.10, p=0.003) than nonspecialists. Successful large-scale implementation of PrEP in Peru will require focused educational campaigns to increase awareness and address concerns among healthcare providers.

Preparing for rectal microbicides: sociocultural factors affecting product uptake among potential South American users

OBJECTIVES

We examined views on rectal microbicides (RMs), a potential HIV prevention option, among men who have sex with men and transgender women in 3 South American cities.

METHODS

During September 2009 to September 2010, we conducted 10 focus groups and 36 in-depth interviews (n = 140) in Lima and Iquitos, Peru, and Guayaquil, Ecuador, to examine 5 RM domains: knowledge, thoughts and opinions about RM as an HIV prevention tool, use, condoms, and social concerns. We coded emergent themes in recorded and transcribed data sets and extracted representative quotes. We collected sociodemographic information with a self-administered questionnaire.

RESULTS

RM issues identified included limited knowledge; concerns regarding plausibility, side effects, and efficacy; impact on condom use; target users (insertive vs receptive partners); and access concerns.

CONCLUSIONS

Understanding the sociocultural issues affecting RMs is critical to their uptake and should be addressed prior to product launch.

Rectal pre-exposure prophylaxis (PrEP)

Rectal pre-exposure prophylaxis (PrEP) will be a critical component of HIV prevention products due to the prevalence of unprotected receptive anal intercourse among men who have sex with men and heterosexual couples. Given the biological considerations of this compartment and the complexity of HIV infection, design of a successful rectal microbicide product faces a number of challenges. Important information is being compiled to begin to address deficits in knowledge toward design of rectal PrEP products for men and women. Aspects of formulation development and preclinical and clinical evaluation of rectal products studied to date are summarized in this review. This article is based on a presentation at the "Product Development Workshop 2013: HIV and Multipurpose Prevention Technologies," held in Arlington, Virginia on February 21-22, 2013. It forms part of a special supplement to Antiviral Research.