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Ngure K, Browne EN, Reddy K, Friedland BA, van der Straten A, Palanee-Phillips T, Nakalega R, Gati B, Kalule HN, Siziba B, Soto-Torres L, Nair G, Garcia M, Celum C, Roberts ST. Correlates of Adherence to Oral and Vaginal Pre-exposure Prophylaxis (PrEP) Among Adolescent Girls and Young Women (AGYW) Participating in the MTN-034/REACH Trial. AIDS Behav 2024; 28:2990-3000. [PMID: 38852114 DOI: 10.1007/s10461-024-04382-3] [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: 05/15/2024] [Indexed: 06/10/2024]
Abstract
We evaluated correlates of adherence to PrEP, including daily oral tenofovir disoproxil fumarate in combination emtricitabine (oral FTC/TDF) and the monthly dapivirine ring (ring)among adolescent girls and young women (AGYW) in the MTN-034/REACH study. We enrolled 247 AGYW aged 16-21 years in South Africa, Uganda and Zimbabwe (ClinicalTrials.gov: NCT03074786). Participants were randomized to the order of oral FTC/TDF or ring use for 6 months each in a crossover period, followed by a 6-month choice period. We assessed potential adherence correlates-individual, interpersonal, community, study, and product-related factors-quarterly via self-report. We measured biomarkers of adherence monthly; high adherence was defined as > 4 mg dapivirine released from returned rings or intracellular tenofovir diphosphate levels ≥ 700 fmol/punch from dried blood spots (DBS). We tested associations between correlates and objective measures of high adherence using generalized estimating equations. High adherence to oral FTC/TDF was significantly associated with having an older primary partner (p = 0.04), not having exchanged sex in the past 3 months (p = 0.02), and rating oral FTC/TDF as highly acceptable (p = 0.003). High ring adherence was significantly associated with unstable housing (p = 0.01), disclosing ring use to a male family member (p = 0.01), and noting a social benefit from study participation (p = 0.03). All associations were moderate, corresponding to about 6%-10% difference in the proportion with high adherence. In our multinational study, correlates of adherence among African AGYW differed for oral FTC/TDF and the ring, highlighting the benefit of offering multiple PrEP options.
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Affiliation(s)
- Kenneth Ngure
- School of Public Health, Jomo Kenyatta University of Agriculture and Technology, Box 19704-00202, Nairobi, Kenya.
- Department of Global Health, University of Washington, Seattle, USA.
| | - Erica N Browne
- Women's Global Health Imperative (WGHI), RTI International, Berkeley, CA, USA
| | - Krishnaveni Reddy
- Wits RHI, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | | | - Ariane van der Straten
- Department of Medicine, Center for AIDS Prevention Studies, University of California, San Francisco, USA
- ASTRA Consulting, Kensington, CA, USA
| | - Thesla Palanee-Phillips
- Wits RHI, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Rita Nakalega
- Makerere University - Johns Hopkins University Research Collaboration, Kampala, Uganda
| | - Brenda Gati
- Makerere University - Johns Hopkins University Research Collaboration, Kampala, Uganda
| | - Hadijah N Kalule
- Makerere University - Johns Hopkins University Research Collaboration, Kampala, Uganda
| | - Bekezela Siziba
- University of Zimbabwe Clinical Trials Research Centre, Harare, Zimbabwe
| | - Lydia Soto-Torres
- National Institute of Allergy and Infectious Diseases, National Institutes of Health, Rockville, MD, USA
| | | | | | - Connie Celum
- Department of Global Health, University of Washington, Seattle, USA
- Department of Medicine, University of Washington, Seattle, WA, USA
- Department of Epidemiology, University of Washington, Seattle, WA, USA
| | - Sarah T Roberts
- Women's Global Health Imperative (WGHI), RTI International, Berkeley, CA, USA
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Rachman BE, Khairunisa SQ, Wungu CDK, Asmarawati TP, Rusli M, Bramantono, Arfijanto MV, Hadi U, Kameoka M, Nasronudin. Low clinical impact of HIV drug resistance mutations in oral pre-exposure prophylaxis: a systematic review and meta-analysis. AIDS Res Ther 2024; 21:37. [PMID: 38844950 PMCID: PMC11155065 DOI: 10.1186/s12981-024-00627-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2024] [Accepted: 05/29/2024] [Indexed: 06/10/2024] Open
Abstract
INTRODUCTION Despite the widespread use of pre-exposure prophylaxis (PrEP) in preventing human immunodeficiency virus (HIV) transmission, scant information on HIV drug resistance mutations (DRMs) has been gathered over the past decade. This review aimed to estimate the pooled prevalence of pre-exposure prophylaxis and its two-way impact on DRM. METHODS We systematically reviewed studies on DRM in pre-exposure prophylaxis according to the Preferred Reporting Items for Systematic Reviews and Meta-Analysis 2020 guidelines. PubMed, Cochrane, and SAGE databases were searched for English-language primary studies published between January 2001 and December 2023. The initial search was conducted on 9 August 2021 and was updated through 31 December 2023 to ensure the inclusion of the most recent findings. The registration number for this protocol review was CRD42022356061. RESULTS A total of 26,367 participants and 562 seroconversion cases across 12 studies were included in this review. The pooled prevalence estimate for all mutations was 6.47% (95% Confidence Interval-CI 3.65-9.93), while Tenofovir Disoproxil Fumarate/Emtricitabine-associated drug resistance mutation prevalence was 1.52% (95% CI 0.23-3.60) in the pre-exposure prophylaxis arm after enrolment. A subgroup analysis, based on the study population, showed the prevalence in the heterosexual and men who have sex with men (MSM) groups was 5.53% (95% CI 2.55-9.40) and 7.47% (95% CI 3.80-12.11), respectively. Notably, there was no significant difference in the incidence of DRM between the pre-exposure prophylaxis and placebo groups (log-OR = 0.99, 95% CI -0.20 to 2.18, I2 = 0%; p = 0.10). DISCUSSION Given the constrained prevalence of DRM, the World Health Organization (WHO) advocates the extensive adoption of pre-exposure prophylaxis. Our study demonstrated no increased risk of DRM with pre-exposure prophylaxis (p > 0.05), which is consistent with these settings. These findings align with the previous meta-analysis, which reported a 3.14-fold higher risk in the pre-exposure prophylaxis group than the placebo group, although the observed difference did not reach statistical significance (p = 0.21). CONCLUSIONS Despite the low prevalence of DRM, pre-exposure prophylaxis did not significantly increase the risk of DRM compared to placebo. However, long-term observation is required to determine further disadvantages of extensive pre-exposure prophylaxis use. PROSPERO Number: CRD42022356061.
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Affiliation(s)
- Brian Eka Rachman
- Subspeciality Program in Internal Medicine, Faculty of Medicine, Airlangga University, Surabaya, Indonesia
- Institute of Tropical Disease, Airlangga University, Surabaya, Indonesia
| | | | - Citrawati Dyah Kencono Wungu
- Institute of Tropical Disease, Airlangga University, Surabaya, Indonesia
- Department of Physiology and Medical Biochemistry, Faculty of Medicine, Airlangga University, Surabaya, Indonesia
| | - Tri Pudy Asmarawati
- Division of Tropical and Infectious Diseases, Department of Internal Medicine, Faculty of Medicine, Airlangga University, Surabaya, Indonesia
| | - Musofa Rusli
- Division of Tropical and Infectious Diseases, Department of Internal Medicine, Faculty of Medicine, Airlangga University, Surabaya, Indonesia
| | - Bramantono
- Division of Tropical and Infectious Diseases, Department of Internal Medicine, Faculty of Medicine, Airlangga University, Surabaya, Indonesia
| | - M Vitanata Arfijanto
- Division of Tropical and Infectious Diseases, Department of Internal Medicine, Faculty of Medicine, Airlangga University, Surabaya, Indonesia
| | - Usman Hadi
- Division of Tropical and Infectious Diseases, Department of Internal Medicine, Faculty of Medicine, Airlangga University, Surabaya, Indonesia
| | - Masanori Kameoka
- Department of Public Health, Kobe University Graduate School of Health Sciences, 7-10-2 Tomogaoka, Suma-Ku, Kobe, Hyogo, 654-0142, Japan.
- Center for Infectious Diseases, Kobe University Graduate School of Medicine, Hyogo, Japan.
| | - Nasronudin
- Institute of Tropical Disease, Airlangga University, Surabaya, Indonesia
- Division of Tropical and Infectious Diseases, Department of Internal Medicine, Faculty of Medicine, Airlangga University, Surabaya, Indonesia
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Roche SD, Were D, Crawford ND, Tembo A, Pintye J, Bukusi E, Ngure K, Ortblad KF. Getting HIV Pre-exposure Prophylaxis (PrEP) into Private Pharmacies: Global Delivery Models and Research Directions. Curr HIV/AIDS Rep 2024; 21:116-130. [PMID: 38517671 PMCID: PMC11129962 DOI: 10.1007/s11904-024-00696-y] [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: 02/28/2024] [Indexed: 03/24/2024]
Abstract
PURPOSE OF REVIEW To provide an overview of the current state of HIV pre-exposure prophylaxis (PrEP) delivery via private sector pharmacies globally, to discuss the context-specific factors that have influenced the design and implementation of different pharmacy-based PrEP delivery models in three example settings, and to identify future research directions. RECENT FINDINGS Multiple high- and low-income countries are implementing or pilot testing PrEP delivery via private pharmacies using a variety of delivery models, tailored to the context. Current evidence indicates that pharmacy-based PrEP services are in demand and generally acceptable to clients and pharmacy providers. Additionally, the evidence suggests that with proper training and oversight, pharmacy providers are capable of safely initiating and managing clients on PrEP. The delivery of PrEP services at private pharmacies also achieves similar levels of PrEP initiation and continuation as traditional health clinics, but additionally reach individuals underserved by such clinics (e.g., young men; minorities), making pharmacies well-positioned to increase overall PrEP coverage. Implementation of pharmacy-based PrEP services will look different in each context and depend not only on the state of the private pharmacy sector, but also on the extent to which key needs related to governance, financing, and regulation are addressed. Private pharmacies are a promising delivery channel for PrEP in diverse settings. Countries with robust private pharmacy sectors and populations at HIV risk should focus on aligning key areas related to governance, financing, and regulation that have proven critical to pharmacy-based PrEP delivery while pursuing an ambitious research agenda to generate information for decision-making. Additionally, the nascency of pharmacy-based PrEP delivery in both high- and low-and-middle-income settings presents a prime opportunity for shared learning and innovation.
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Affiliation(s)
- Stephanie D Roche
- Public Health Sciences Division, Fred Hutchinson Cancer Center, 1100 Fairview Ave N, Seattle, WA, 98109, USA.
| | | | - Natalie D Crawford
- Behavioral, Social, and Health Education Sciences, Rollins School of Public Health, Emory University, Atlanta, GA, USA
| | - Angela Tembo
- Ezintsha, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Jillian Pintye
- School of Nursing, University of Washington, Seattle, USA
- Department of Global Health, University of Washington, Seattle, USA
| | - Elizabeth Bukusi
- Department of Global Health, University of Washington, Seattle, USA
- Department of Obstetrics and Gynecology, University of Washington, Seattle, USA
- Centre for Microbiology Research, Kenya Medical Research Institute, Nairobi, Kenya
| | - Kenneth Ngure
- Department of Global Health, University of Washington, Seattle, USA
- School of Public Health, Jomo Kenyatta University of Agriculture and Technology, Nairobi, Kenya
| | - Katrina F Ortblad
- Public Health Sciences Division, Fred Hutchinson Cancer Center, 1100 Fairview Ave N, Seattle, WA, 98109, USA
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Zhang M, Tseng AS, Anguzu G, Barnabas RV, Davis JL, Mujugira A, Flaxman AD, Ross JM. Modeled estimates of HIV-serodifferent couples in tuberculosis-affected households in four sub-Saharan African countries. PLOS GLOBAL PUBLIC HEALTH 2024; 4:e0002609. [PMID: 38696500 PMCID: PMC11065259 DOI: 10.1371/journal.pgph.0002609] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/11/2023] [Accepted: 03/20/2024] [Indexed: 05/04/2024]
Abstract
Household-based tuberculosis (TB) contact evaluation may be an efficient strategy to reach people who could benefit from oral pre-exposure prophylaxis (PrEP) because of the epidemiological links between HIV and TB. This study estimated the number of HIV serodifferent couples in TB-affected households and potential HIV acquisitions averted through their PrEP use in 4 TB-HIV high-burden countries. We conducted a model-based analysis set in Ethiopia, Kenya, South Africa, and Uganda using parameters from population-based household surveys, systematic literature review and meta-analyses, and estimates from the Global Burden of Diseases, Injuries, and Risk Factors Study 2019. We parameterized the nonlinear relationship between the proportion of serodifferent couples among people living with HIV and population-level HIV prevalence using Markov chain Monte Carlo methods. We integrated all parameters in a mathematical model and propagated uncertainty using a Monte Carlo approach. We estimated the HIV prevalence among adults aged 15-49 living in TB-affected households to be higher than in the general population in all 4 countries. The proportion of serodifferent couples among all couples in TB-affected households was also higher than in the general population (South Africa: 20.7% vs. 15.7%, Kenya: 15.7% vs. 5.7%, Uganda: 14.5% vs. 6.0%, Ethiopia: 4.1% vs. 0.8%). We estimated that up to 1,799 (95% UI: 1,256-2,341) HIV acquisitions in South Africa could be prevented annually by PrEP use in serodifferent couples in TB-affected households, 918 (95% UI: 409-1,450) in Kenya, 686 (95% UI: 505-871) in Uganda, and 408 (95% UI: 298-522) in Ethiopia. As couples in TB-affected households are more likely to be serodifferent than couples in the general population, offering PrEP during household TB contact evaluation may prevent a substantial number of HIV acquisitions.
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Affiliation(s)
- Meixin Zhang
- Institute for Health Metrics and Evaluation, University of Washington, Seattle, Washington, United States of America
| | - Ashley S. Tseng
- Department of Epidemiology, University of Washington, Seattle, Washington, United States of America
- Department of Global Health, University of Washington, Seattle, Washington, United States of America
| | - Godwin Anguzu
- PART Fellowship, Makerere University, Kampala, Uganda
- Department of Social Science Research Institute, Duke University, Durham, North Carolina, United States of America
| | - Ruanne V. Barnabas
- Division of Infectious Diseases, Massachusetts General Hospital, Boston, Massachusetts, United States of America
- Department of Medicine, Harvard Medical School, Boston, Massachusetts, United States of America
| | - J. Lucian Davis
- Department of Epidemiology of Microbial Diseases, Yale School of Public Health, New Haven, Connecticut, United States of America
- Center for Methods in Implementation and Prevention Science, Yale School of Public Health, New Haven, Connecticut, United States of America
- Pulmonary, Critical Care, and Sleep Medicine Section, Yale School of Medicine, New Haven, Connecticut, United States of America
| | - Andrew Mujugira
- Department of Global Health, University of Washington, Seattle, Washington, United States of America
- Infectious Diseases Institute, Makerere University, Kampala, Uganda
| | - Abraham D. Flaxman
- Institute for Health Metrics and Evaluation, University of Washington, Seattle, Washington, United States of America
- Department of Global Health, University of Washington, Seattle, Washington, United States of America
- Department of Health Metrics Sciences, University of Washington, Seattle, Washington, United States of America
| | - Jennifer M. Ross
- Division of Allergy and Infectious Diseases, Department of Medicine, University of Washington, Seattle, Washington, United States of America
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Wyatt MA, Pisarski EE, Nalumansi A, Kasiita V, Kamusiime B, Nalukwago GK, Thomas D, Muwonge TR, Mujugira A, Heffron R, Ware NC. How PrEP delivery was integrated into public ART clinics in central Uganda: A qualitative analysis of implementation processes. PLOS GLOBAL PUBLIC HEALTH 2024; 4:e0002916. [PMID: 38452111 PMCID: PMC10919847 DOI: 10.1371/journal.pgph.0002916] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/31/2023] [Accepted: 01/08/2024] [Indexed: 03/09/2024]
Abstract
Tailored delivery strategies are important for optimizing the benefit and overall reach of PrEP in sub-Saharan Africa. An integrated approach of delivering time-limited PrEP in combination with ART to serodifferent couples encourages PrEP use in the HIV-negative partner as a bridge to sustained ART use. Although PrEP has been delivered in ART clinics for many years, the processes involved in integrating PrEP into ART services are not well understood. The Partners PrEP Program was a stepped-wedge cluster randomized trial of integrated PrEP and ART delivery for HIV serodifferent couples in 12 public health facilities in central Uganda (Clinicaltrials.gov NCT03586128). Using qualitative data, we identified and characterized key implementation processes that explain how PrEP delivery was integrated into existing ART services in the Partners PrEP Program. In-depth interviews were conducted with a purposefully-selected sub-sample of 83 members of 42 participating serodifferent couples, and with 36 health care providers implementing integrated delivery. High quality training, technical supervision, and teamwork were identified as key processes supporting providers to implement PrEP delivery. Interest in the PrEP program was promoted through the numerous ways health care providers made integrated ART and PrEP meaningful for serodifferent couples, including tailored counseling messages, efforts to build confidence in integrated delivery, and strategies to create demand for PrEP. Couples in the qualitative sample responded positively to providers' efforts to promote the integrated strategy. HIV-negative partners initiated PrEP to preserve their relationships, which inspired their partners living with HIV to recommit to ART adherence. Lack of disclosure among couples and poor retention on PrEP were identified as barriers to implementation of the PrEP program. A greater emphasis on understanding the meaning of PrEP for users and its contribution to implementation promises to strengthen future research on PrEP scale up in sub-Saharan Africa.
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Affiliation(s)
- Monique A. Wyatt
- Department of Global Health and Social Medicine, Harvard Medical School, Boston, Massachusetts, United States of America
- Harvard Global, Cambridge, Massachusetts, United States of America
| | - Emily E. Pisarski
- Department of Global Health and Social Medicine, Harvard Medical School, Boston, Massachusetts, United States of America
| | | | - Vicent Kasiita
- Infectious Diseases Institute, Makerere University, Kampala, Uganda
| | - Brenda Kamusiime
- Infectious Diseases Institute, Makerere University, Kampala, Uganda
| | | | - Dorothy Thomas
- Department of Global Health, University of Washington, Seattle, Washington, United States of America
| | | | - Andrew Mujugira
- Infectious Diseases Institute, Makerere University, Kampala, Uganda
- Department of Global Health, University of Washington, Seattle, Washington, United States of America
| | - Renee Heffron
- Department of Global Health, University of Washington, Seattle, Washington, United States of America
- Department of Medicine, University of Alabama at Birmingham, Birmingham, Alabama, United States of America
| | - Norma C. Ware
- Department of Global Health and Social Medicine, Harvard Medical School, Boston, Massachusetts, United States of America
- Department of Medicine, Brigham and Women’s Hospital, Boston, Massachusetts, United States of America
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Pitchford K, Shangani S, Dawson C, Masa R, Heron K. Community Health Care Providers' Perspectives on Human Immunodeficiency Virus Pre-Exposure Prophylaxis Use Among Black Women in Eastern Virginia. AIDS Patient Care STDS 2024; 38:123-133. [PMID: 38471092 DOI: 10.1089/apc.2023.0199] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/14/2024] Open
Abstract
The most at-risk population among women for human immunodeficiency virus (HIV) diagnosis in the United States are Black women, accounting for 61% of all new HIV cases. Pre-exposure prophylaxis (PrEP) is a safe and effective HIV prevention method for people at risk of HIV acquisition. Although disproportionately affected by HIV, Black women's knowledge, perceived benefits, and uptake of PrEP remain low. The socioecological model (SEM) may be useful for understanding why there is a low uptake of PrEP among Black women. The current study used the SEM to explore provider perspectives on the barriers and facilitators of PrEP uptake among Black women in Eastern Virginia. Semistructured interviews were conducted with a total sample of 15 community health care providers. Barriers of PrEP uptake at the societal (e.g., PrEP advertisements focus on gay men), community/organizational (e.g., time constraints in the workplace), interpersonal (e.g., perceived monogamy), and individual (e.g., unmet basic needs) levels were identified. Providers also identified facilitators of PrEP uptake at the societal (e.g., PrEP advertisements that target women), community/organizational (e.g., PrEP education), interpersonal (e.g., HIV-positive partner), and individual (e.g., PrEP awareness and perceived susceptibility to HIV) levels. These findings highlight unique barriers to accessing and taking PrEP for Black women in the United States, and potential factors that could facilitate PrEP use. Both barriers and facilitators may be important targets for interventions to improve PrEP uptake. Future research focused on improving PrEP uptake among Black women in the United States should consider multi-level interventions that target barriers and facilitators to reduce rates of HIV infections.
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Affiliation(s)
- Kayla Pitchford
- The Virginia Consortium Program in Clinical Psychology, Old Dominion University, Norfolk, Virginia, USA
- Department of Psychology, Old Dominion University, Norfolk, Virginia, USA
| | - Sylvia Shangani
- Department of Community Health Sciences, School of Public Health, Boston University, Boston, Massachusetts, USA
- Social and Behavioral Sciences Department, Yale School of Public Health, New Haven, Connecticut, USA
| | - Charlotte Dawson
- The Virginia Consortium Program in Clinical Psychology, Old Dominion University, Norfolk, Virginia, USA
| | - Rainier Masa
- School of Social Work, University of North Carolina, Chapel Hill, North Carolina, USA
| | - Kristin Heron
- The Virginia Consortium Program in Clinical Psychology, Old Dominion University, Norfolk, Virginia, USA
- Department of Psychology, Old Dominion University, Norfolk, Virginia, USA
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Bunge K, Balkus JE, Fairlie L, Mayo AJ, Nakabiito C, Mgodi N, Gadama L, Matrimbira M, Chappell CA, Piper J, Chakhtoura N, Szydlo DW, Richardson B, Hillier SL. DELIVER: A Safety Study of a Dapivirine Vaginal Ring and Oral PrEP for the Prevention of HIV During Pregnancy. J Acquir Immune Defic Syndr 2024; 95:65-73. [PMID: 38055292 DOI: 10.1097/qai.0000000000003312] [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: 03/11/2023] [Accepted: 08/15/2023] [Indexed: 09/29/2023]
Abstract
BACKGROUND Pregnancy represents a period of high HIV acquisition risk. Safety data for the monthly dapivirine vaginal ring (DVR) during pregnancy are limited. Here, we report data from the first 2 cohorts of pregnant participants in MTN-042/DELIVER, a phase 3b, randomized, open-label safety trial of DVR and oral tenofovir disoproxil fumarate/emtricitabine (TDF/FTC). MTN-042 is being conducted in 3 cohorts beginning with later gestational ages when risks of drug exposure are less. METHODS Eligible pregnant individuals aged 18-40 years in Malawi, South Africa, Uganda, and Zimbabwe were randomized 2:1 to monthly DVR or daily TDF/FTC. Participants in cohort 1 initiated product use between 36 weeks 0 days (36 0/7 weeks) and 37 6/7 weeks gestation; participants in cohort 2 initiated product use between 30 0/7 and 35 6/7 weeks gestation. All participants continued product use until delivery or 41 6/7 weeks gestation. Pregnancy outcomes and complications were assessed and summarized using descriptive statistics and compared with local background rates obtained through a separate chart review. RESULTS One-hundred and fifty participants were enrolled into cohort 1 with 101 randomized to DVR and 49 to TDF/FTC. One-hundred and fifty-seven participants were enrolled into cohort 2 with 106 randomized to DVR and 51 to TDF/FTC. In both cohorts, pregnancy complications were rare and similar to local background rates. CONCLUSION In this first study of a long-acting HIV prevention agent in pregnancy, adverse pregnancy outcomes and complications were uncommon when DVR and TDF/FTC were used in the third trimester of pregnancy, suggesting a favorable safety profile for both prevention products.
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Affiliation(s)
- Katherine Bunge
- Department of Obstetrics, Gynecology, and Reproductive Sciences, University of Pittsburgh, Pittsburgh, PA
| | - Jennifer E Balkus
- Department of Epidemiology, University of Washington School of Public Health, Seattle, WA
| | - Lee Fairlie
- Wits RHI, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | | | - Clemensia Nakabiito
- Makerere University-Johns Hopkins University Research Collaboration, Kampala, Uganda
| | - Nyaradzo Mgodi
- University of Zimbabwe College of Health Sciences Clinical Trials Research Centre, Harare, Zimbabwe
| | - Luis Gadama
- Department of Obstetrics and Gynaecology, College of Medicine, University of Malawi, Blantyre, Malawi
| | - Moleen Matrimbira
- University of Zimbabwe College of Health Sciences Clinical Trials Research Centre, Harare, Zimbabwe
| | - Catherine Anne Chappell
- Department of Obstetrics, Gynecology, and Reproductive Sciences, University of Pittsburgh, Pittsburgh, PA
| | | | - Nahida Chakhtoura
- Eunice Kennedy Shriver National Institute of Child Health and Human Development, Bethesda, MD
| | - Daniel W Szydlo
- Statistical Center for HIV/AIDS Research and Prevention, Fred Hutchinson Cancer Center, Seattle, WA; and
| | - Barbra Richardson
- Departments of Biostatistics and Global Health, University of Washington, Seattle, WA
| | - Sharon L Hillier
- Department of Obstetrics, Gynecology, and Reproductive Sciences, University of Pittsburgh, Pittsburgh, PA
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Wairimu N, Malen RC, Reedy AM, Mogere P, Njeru I, Culquichicón C, McGowan M, Gao F, Baeten JM, Ngure K, Ortblad KF. Peer PrEP referral + HIV self-test delivery for PrEP initiation among young Kenyan women: study protocol for a hybrid cluster-randomized controlled trial. Trials 2023; 24:705. [PMID: 37925450 PMCID: PMC10625301 DOI: 10.1186/s13063-023-07734-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] [Received: 07/20/2023] [Accepted: 10/16/2023] [Indexed: 11/06/2023] Open
Abstract
BACKGROUND Oral HIV pre-exposure prophylaxis (PrEP) for HIV prevention is highly effective, but uptake remains low in Africa, especially among young women who are a priority population for HIV prevention services. HIV self-testing (HIVST) has been proven to increase HIV testing in diverse populations but has been underutilized to support linkage to HIV prevention services. Most young women who initiate PrEP in Africa do so through informal peer referral. We wanted to test a model of formalized peer referral enhanced with HIVST delivery among young Kenyan women. METHODS The Peer PrEP Trial is a two-arm hybrid effectiveness-implementation cluster-randomized controlled trial being conducted in central Kenya. Eligible participants (i.e., peer providers, n = 80) are women (≥ 16-24 years) refilling or initiating PrEP at public healthcare clinics who can identify at least four peers who could benefit from PrEP and not enrolled in another HIV study. Peer providers will be 1:1 randomized to (1) formal peer PrEP referral + HIVST delivery, where they will be encouraged to refer four peers (i.e., peer clients, ≥ 16-24 years) using educational materials and HIVST kits (two per peer client), or (2) informal peer PrEP referral, where they are encouraged to refer four peer clients using informal word-of-mouth referral. In both arms, peer providers will deliver a standard PrEP referral card with information on nearby public clinics delivering PrEP services. Peer providers will complete surveys at baseline and 3 months; peer clients will complete surveys at 3 months. Our primary outcome is PrEP initiation among peer clients, as reported by peer providers at 3 months. Secondary outcomes include PrEP continuation (any refilling), HIV testing (past 3 months), sexual behaviors (past month), and PrEP adherence (past month) among peer clients, as reported by both peer providers and clients at 3 months. Implementation outcomes will include participants' perceived acceptability, appropriateness, and feasibility of the intervention as well assessments of the intervention's fidelity and cost. DISCUSSION Evidence from this trial will help us understand how HIVST could support health systems by facilitating linkage to PrEP services among young women who could benefit in Kenya and similar settings. TRIAL REGISTRATION ClinicalTrials.gov NCT04982250. Registered on July 29, 2021.
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Affiliation(s)
- Njeri Wairimu
- Partners in Health and Research Development, Center for Clinical Research, Kenya Medical Research Institute, Nairobi, Kenya
| | - Rachel C Malen
- Public Health Sciences Division, Fred Hutchinson Cancer Center, Seattle, USA
| | - Adriana M Reedy
- Public Health Sciences Division, Fred Hutchinson Cancer Center, Seattle, USA
| | - Peter Mogere
- Partners in Health and Research Development, Center for Clinical Research, Kenya Medical Research Institute, Nairobi, Kenya
| | - Irene Njeru
- Partners in Health and Research Development, Center for Clinical Research, Kenya Medical Research Institute, Nairobi, Kenya
| | - Carlos Culquichicón
- Public Health Sciences Division, Fred Hutchinson Cancer Center, Seattle, USA
- Department of Epidemiology, University of Washington, Seattle, USA
| | - Maureen McGowan
- Heidelberg Institute of Global Health, Heidelberg University, Heidelberg, Germany
| | - Fei Gao
- Public Health Sciences Division, Fred Hutchinson Cancer Center, Seattle, USA
- Vaccine and Infectious Diseases Division, Fred Hutchinson Cancer Center, Seattle, USA
| | - Jared M Baeten
- Department of Global Health, University of Washington, Seattle, USA
- Department of Medicine, University of Washington, Seattle, USA
| | - Kenneth Ngure
- School of Public Health, Jomo Kenyatta University of Agriculture and Technology, Nairobi, Kenya
| | - Katrina F Ortblad
- Public Health Sciences Division, Fred Hutchinson Cancer Center, Seattle, USA.
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Phillips AN, Bansi-Matharu L, Shahmanesh M, Hargreaves JR, Smith J, Revill P, Sibanda E, Ehrenkranz P, Sikwese K, Rodger A, Lundgren JD, Gilks CF, Godfrey C, Cowan F, Cambiano V. Potential cost-effectiveness of community availability of tenofovir, lamivudine, and dolutegravir for HIV prevention and treatment in east, central, southern, and west Africa: a modelling analysis. Lancet Glob Health 2023; 11:e1648-e1657. [PMID: 37734807 DOI: 10.1016/s2214-109x(23)00383-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2023] [Revised: 07/23/2023] [Accepted: 08/04/2023] [Indexed: 09/23/2023]
Abstract
BACKGROUND Post-exposure prophylaxis (PEP) offers protection from HIV after condomless sex, but is not widely available in a timely manner in east, central, southern, and west Africa. To inform the potential pilot implementation of such an approach, we modelled the effect and cost-effectiveness of making PEP consisting of tenofovir, lamivudine, and dolutegravir (TLD) freely and locally available in communities without prescription, with the aim of enabling PEP use within 24 h of condomless sex. Free community availability of TLD (referred to as community TLD) might also result in some use of TLD as pre-exposure prophylaxis (PrEP) and as antiretroviral therapy for people living with HIV. METHODS Using an existing individual-based model (HIV Synthesis), we explicitly modelled the potential positive and negative effects of community TLD. Through the sampling of parameter values we created 1000 setting-scenarios, reflecting the uncertainty in assumptions and a range of settings similar to those seen in east, central, southern, and west Africa (with a median HIV prevalence of 14·8% in women and 8·1% in men). For each setting scenario, we considered the effects of community TLD. TLD PEP was assumed to have at least 90% efficacy in preventing HIV infection after condomless sex with a person living with HIV. FINDINGS The modelled effects of community TLD availability based on an assumed high uptake of TLD resulted in a mean reduction in incidence of 31% (90% range over setting scenarios, 6% increase to 57% decrease) over 20 years, with an HIV incidence reduction over 50 years in 91% of the 1000 setting scenarios, deaths averted in 55% of scenarios, reduction in costs in 92% of scenarios, and disability-adjusted life-years averted in 64% of scenarios with community TLD. Community TLD was cost-effective in 90% of setting scenarios and cost-saving (with disability-adjusted life-years averted) in 58% of scenarios. When only examining setting scenarios in which there was lower uptake of community TLD, community TLD is cost-effective in 92% of setting scenarios. INTERPRETATION The introduction of community TLD, enabling greater PEP access, is a promising approach to consider further in pilot implementation projects. FUNDING Bill & Melinda Gates Foundation to the HIV Modelling Consortium.
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Affiliation(s)
| | | | - Maryam Shahmanesh
- Institute for Global Health, University College London, London, UK; Africa Health Research Institute, KwaZulu-Natal, South Africa
| | | | - Jennifer Smith
- Institute for Global Health, University College London, London, UK
| | - Paul Revill
- Centre for Health Economics, University of York, York, UK
| | - Euphemia Sibanda
- CeSHHAR Zimbabwe, Harare, Zimbabwe; Liverpool School of Tropical Medicine, Liverpool, UK
| | | | | | - Alison Rodger
- Institute for Global Health, University College London, London, UK
| | - Jens D Lundgren
- Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
| | | | - Catherine Godfrey
- Office of the Global AIDS Coordinator, Department of State, Washington, DC, USA
| | - Frances Cowan
- CeSHHAR Zimbabwe, Harare, Zimbabwe; Liverpool School of Tropical Medicine, Liverpool, UK
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10
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Young AM, Saidi F, Phanga T, Tseka J, Bula A, Mmodzi P, Pearce LD, Maman S, Golin CE, Mutale W, Chi BH, Hill LM. Male partners' support and influence on pregnant women's oral PrEP use and adherence in Malawi. FRONTIERS IN REPRODUCTIVE HEALTH 2023; 5:1206075. [PMID: 37614700 PMCID: PMC10442580 DOI: 10.3389/frph.2023.1206075] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2023] [Accepted: 07/24/2023] [Indexed: 08/25/2023] Open
Abstract
Introduction Daily oral pre-exposure prophylaxis (PrEP) is a safe and effective HIV prevention method for pregnant and postpartum women, but adherence barriers exist. Understanding the role of male partners in supporting PrEP use may inform strategies to support PrEP adherence among pregnant and breastfeeding women. Methods To understand male partners' involvement in women's use of PrEP, we conducted in-depth interviews with pregnant women in Lilongwe, Malawi who had recently decided to use PrEP (n = 30) and their male partners (n = 20) in the context of a PrEP adherence trial. Women were purposively recruited to ensure variation in their partners' HIV status. Interviews were conducted in Chichewa using a semistructured guide. We followed a thematic approach to analyze the interview data. Results Most male partners were receptive to women using PrEP during pregnancy because it eased their fears of the woman and baby acquiring HIV. Men often played a key role in women's PrEP adherence by providing daily reminders and encouragement to adhere to their medication. The majority of women appreciated this support from the men as it lessened the burden of remembering to take their medications daily on their own and aided their adherence. However, several women who lacked male partner support spoke of wanting their partners to be more involved. Many men living with HIV found the mutual support beneficial for their antiretroviral therapy adherence, while men without HIV or with status unknown appreciated knowing that the family was protected. While most men were open to women continuing PrEP beyond the current study, some would only support it if women were still at risk for acquiring HIV. Conclusion In this study, male partners were strongly motivated to support the PrEP adherence of their female partners as a way of ensuring that the pregnant women and unborn babies were protected against HIV. Promoting disclosure and tangible support that arises organically among men may be helpful, but programs to enhance this support and identify ways to support women who do not receive support from their partners or do not wish to disclose their PrEP use to partners may be needed.
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Affiliation(s)
- Alinda M Young
- Department of Maternal and Child Health, University of North Carolina at Chapel Hill, Chapel Hill, NC, United States
- Women's Global Health Imperative at RTI International, Berkeley, CA, United States
| | - Friday Saidi
- UNC Project-Malawi, Lilongwe, Malawi
- Department of Obstetrics and Gynecology, School of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, NC, United States
| | | | | | | | | | - Lisa D Pearce
- Department of Sociology, University of North Carolina at Chapel Hill, Chapel Hill, NC, United States
| | - Suzanne Maman
- Department of Health Behavior, University of North Carolina at Chapel Hill, Chapel Hill, NC, United States
| | - Carol E Golin
- Department of Health Behavior, University of North Carolina at Chapel Hill, Chapel Hill, NC, United States
- Department of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, NC, United States
| | - Wilbroad Mutale
- Department of Health Policy, University of Zambia School of Public Health, Lusaka, Zambia
| | - Benjamin H Chi
- Department of Obstetrics and Gynecology, School of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, NC, United States
| | - Lauren M Hill
- Department of Health Behavior, University of North Carolina at Chapel Hill, Chapel Hill, NC, United States
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Ssempijja V, Ssekubugu R, Kigozi G, Nakigozi G, Kagaayi J, Ekstrom AM, Nalugoda F, Nantume B, Batte J, Kigozi G, Yeh PT, Nakawooya H, Serwadda D, Quinn TC, Gray RH, Wawer MJ, Grabowski KM, Chang LW, Hoog AV, Cobelens F, Reynolds SJ. Dynamics of Pre-Exposure (PrEP) Eligibility Because of Waxing and Waning of HIV Risk in Rakai, Uganda. J Acquir Immune Defic Syndr 2023; 93:143-153. [PMID: 36889304 PMCID: PMC10179981 DOI: 10.1097/qai.0000000000003182] [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: 03/10/2023]
Abstract
BACKGROUND We conducted a retrospective population-based study to describe longitudinal patterns of prevalence, incidence, discontinuation, resumption, and durability of substantial HIV risk behaviors (SHR) for pre-exposure prophylaxis (PrEP) eligibility. METHODS The study was conducted among HIV-negative study participants aged 15-49 years who participated in survey rounds of the Rakai Community Cohort Study between August 2011 and June 2018. Substantial HIV risk was defined based on the Uganda national PrEP eligibility as reporting sexual intercourse with >1 partner of unknown HIV status, nonmarital sex without a condom, having genital ulcers, or having transactional sex. Resumption of SHR meant resuming of SHR after stopping SHR, whereas persistence of SHR meant SHR on >1 consecutive visit. We used generalized estimation equations with log-binomial regression models and robust variance to estimate survey-specific prevalence ratios; Generalized estimation equations with modified Poisson regression models and robust variance to estimate incidence ratios for incidence, discontinuation, and resumption of PrEP eligibility. FINDINGS Incidence of PrEP eligibility increased from 11.4/100 person-years (pys) in the first intersurvey period to 13.9/100 pys (adjusted incidence rate ratios = 1.28; 95%CI = 1.10-1.30) and declined to 12.6/100 pys (adjusted incidence rate ratios = 1.06; 95%CI = 0.98-1.15) in the second and third intersurvey periods, respectively. Discontinuation rates of SHR for PrEP eligibility were stable (ranging 34.9/100 pys-37.3/100 pys; P = 0.207), whereas resumption reduced from 25.0/100 pys to 14.5/100 pys ( P < 0.001). PrEP eligibility episodes lasted a median time of 20 months (IQR = 10-51). INTERPRETATION Pre-exposure prophylaxis use should be tailored to the dynamic nature of PrEP eligibility. Preventive-effective adherence should be adopted for assessment of attrition in PrEP programs.
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Affiliation(s)
- Victor Ssempijja
- Clinical Monitoring Research Program Directorate, Frederick National Laboratory for Cancer Research, Frederick, MD
- Rakai Health Sciences Program, Entebbe, Uganda
| | | | | | | | | | - Anna Mia Ekstrom
- Department of Global Public Health, Karolinska Institute, Stockholm, Sweden
- Department of Infectious Diseases, South Central Hospital, Stockholm, Sweden
| | | | | | - James Batte
- Rakai Health Sciences Program, Entebbe, Uganda
| | | | - Ping Teresa Yeh
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD
| | | | - David Serwadda
- Rakai Health Sciences Program, Entebbe, Uganda
- Makerere University School of Public Health, Kampala, Uganda
| | - Thomas C. Quinn
- Division of Infectious Diseases, Department of Medicine, Johns Hopkins School of Medicine, Baltimore, MD
- Division of Intramural Research, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, MD
| | - Ronald H. Gray
- Rakai Health Sciences Program, Entebbe, Uganda
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD
| | - Maria J. Wawer
- Rakai Health Sciences Program, Entebbe, Uganda
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD
| | - Kate M. Grabowski
- Rakai Health Sciences Program, Entebbe, Uganda
- Department of Pathology, Johns Hopkins School of Medicine, Baltimore, MD
| | - Larry W. Chang
- Rakai Health Sciences Program, Entebbe, Uganda
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD
| | - Anja van't Hoog
- Amsterdam Institute for Global Health and Development, Amsterdam University Medical Centers, Amsterdam, the Netherlands; and
- Health Research and Training Consultancy, Utrecht, the Netherlands
| | - Frank Cobelens
- Amsterdam Institute for Global Health and Development, Amsterdam University Medical Centers, Amsterdam, the Netherlands; and
| | - Steven J. Reynolds
- Rakai Health Sciences Program, Entebbe, Uganda
- Division of Infectious Diseases, Department of Medicine, Johns Hopkins School of Medicine, Baltimore, MD
- Division of Intramural Research, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, MD
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12
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Lavoie MCC, Blanco N, Mwango LK, Nichols BE, Whittington A, Lindsay B, Adebayo O, Mujansi M, Tembo K, Hachaambwa L, Mumba D, Musonda B, Claassen CW. Addressing the Need for a Preexposure Prophylaxis Monitoring and Evaluation Implementation Guide: Experience From Zambia. GLOBAL HEALTH, SCIENCE AND PRACTICE 2023; 11:e2200396. [PMID: 37116937 PMCID: PMC10141438 DOI: 10.9745/ghsp-d-22-00396] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/25/2022] [Accepted: 02/23/2023] [Indexed: 04/30/2023]
Abstract
BACKGROUND The HIV care continuum comprises well-defined steps and indicators. In contrast, indicators along the preexposure prophylaxis (PrEP) cascade are still in the early stages of implementation. Monitoring and evaluation (M&E) of PrEP services is critical to optimizing PrEP uptake and adherence during periods of HIV risk. We provide an overview of global indicators for PrEP, describe the development process and outcomes of Zambia's 2022 National Pre-Exposure Prophylaxis (PrEP) Program Monitoring & Evaluation Implementation Guide, and discuss the guide's implications for other countries in sub-Saharan Africa. NATIONAL M&E GUIDE DEVELOPMENT PROCESS During the scale-up of PrEP, the Zambia Ministry of Health (MOH) and the National HIV/AIDS/STI/TB Council recognized the need for a national unified monitoring system to guide the effective implementation of PrEP services. Stakeholders from the MOH, civil society, professional organizations, funding agencies, and implementing partners developed the National Pre-Exposure Prophylaxis (PrEP) Program Monitoring & Evaluation Implementation Guide. This guide is aligned with the existing global indicators from the World Health Organization and the U.S. President's Emergency Plan for AIDS Relief and adapted to the country's needs, context, and health information systems. Zambia's experience in developing the guide has highlighted the importance of strengthening client-level monitoring systems for HIV prevention, ensuring flexibility of the PrEP monitoring system to accommodate PrEP delivery modalities and differentiated service delivery models, and training health workers to enhance PrEP services and deliver care PrEP services along the continuum to prevent HIV acquisition effectively. CONCLUSIONS Using a collaborative and consensus-based approach, Zambia developed its first national PrEP M&E implementation guide to provide standardized guidelines for optimizing the delivery, monitoring, and evaluation of PrEP service delivery. Zambia's experience can inform other countries in sub-Saharan Africa as they develop national M&E implementation approaches for PrEP.
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Affiliation(s)
- Marie-Claude C Lavoie
- Division of Global Health Sciences, Department of Epidemiology and Public Health, University of Maryland School of Medicine, Baltimore, MD, USA.
- Institute of Human Virology, University of Maryland School of Medicine, Baltimore, MD, USA
- Center for International Health Education and Biosecurity, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Natalie Blanco
- Institute of Human Virology, University of Maryland School of Medicine, Baltimore, MD, USA
- Center for International Health Education and Biosecurity, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Linah K Mwango
- Center for International Health Education and Biosecurity-Zambia, Lusaka, Zambia
| | - Brooke E Nichols
- Department of Global Health, School of Public Health, Boston University, Boston, Massachusetts, USA
| | - Anna Whittington
- Institute of Human Virology, University of Maryland School of Medicine, Baltimore, MD, USA
- Center for International Health Education and Biosecurity, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Brianna Lindsay
- Institute of Human Virology, University of Maryland School of Medicine, Baltimore, MD, USA
- Center for International Health Education and Biosecurity, University of Maryland School of Medicine, Baltimore, MD, USA
| | | | - Morley Mujansi
- Maryland Global Initiatives Corporation Zambia, Lusaka, Zambia
| | - Kalima Tembo
- Maryland Global Initiatives Corporation Zambia, Lusaka, Zambia
| | - Lottie Hachaambwa
- Institute of Human Virology, University of Maryland School of Medicine, Baltimore, MD, USA
- Center for International Health Education and Biosecurity, University of Maryland School of Medicine, Baltimore, MD, USA
- Center for International Health Education and Biosecurity-Zambia, Lusaka, Zambia
| | - Daliso Mumba
- National HIV/AIDS/STI/TB Council, Lusaka, Zambia
| | | | - Cassidy W Claassen
- Division of Global Health Sciences, Department of Epidemiology and Public Health, University of Maryland School of Medicine, Baltimore, MD, USA
- Institute of Human Virology, University of Maryland School of Medicine, Baltimore, MD, USA
- Center for International Health Education and Biosecurity, University of Maryland School of Medicine, Baltimore, MD, USA
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13
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Smith J, Bansi-Matharu L, Cambiano V, Dimitrov D, Bershteyn A, van de Vijver D, Kripke K, Revill P, Boily MC, Meyer-Rath G, Taramusi I, Lundgren JD, van Oosterhout JJ, Kuritzkes D, Schaefer R, Siedner MJ, Schapiro J, Delany-Moretlwe S, Landovitz RJ, Flexner C, Jordan M, Venter F, Radebe M, Ripin D, Jenkins S, Resar D, Amole C, Shahmanesh M, Gupta RK, Raizes E, Johnson C, Inzaule S, Shafer R, Warren M, Stansfield S, Paredes R, Phillips AN. Predicted effects of the introduction of long-acting injectable cabotegravir pre-exposure prophylaxis in sub-Saharan Africa: a modelling study. Lancet HIV 2023; 10:e254-e265. [PMID: 36642087 PMCID: PMC10065903 DOI: 10.1016/s2352-3018(22)00365-4] [Citation(s) in RCA: 11] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2022] [Revised: 11/16/2022] [Accepted: 11/22/2022] [Indexed: 01/14/2023]
Abstract
BACKGROUND Long-acting injectable cabotegravir pre-exposure prophylaxis (PrEP) is recommended by WHO as an additional option for HIV prevention in sub-Saharan Africa, but there is concern that its introduction could lead to an increase in integrase-inhibitor resistance undermining treatment programmes that rely on dolutegravir. We aimed to project the health benefits and risks of cabotegravir-PrEP introduction in settings in sub-Saharan Africa. METHODS With HIV Synthesis, an individual-based HIV model, we simulated 1000 setting-scenarios reflecting both variability and uncertainty about HIV epidemics in sub-Saharan Africa and compared outcomes for each with and without cabotegravir-PrEP introduction. PrEP use is assumed to be risk-informed and to be used only in 3-month periods (the time step for the model) when having condomless sex. We consider three groups at risk of integrase-inhibitor resistance emergence: people who start cabotegravir-PrEP after (unknowingly) being infected with HIV, those who seroconvert while on PrEP, and those with HIV who have residual cabotegravir drugs concentrations during the early tail period after recently stopping PrEP. We projected the outcomes of policies of cabotegravir-PrEP introduction and of no introduction in 2022 across 50 years. In 50% of setting-scenarios we considered that more sensitive nucleic-acid-based HIV diagnostic testing (NAT), rather than regular antibody-based HIV rapid testing, might be used to reduce resistance risk. For cost-effectiveness analysis we assumed in our base case a cost of cabotegravir-PrEP drug to be similar to oral PrEP, resulting in a total annual cost of USD$144 per year ($114 per year and $264 per year considered in sensitivity analyses), a cost-effectiveness threshold of $500 per disability-adjusted life years averted, and a discount rate of 3% per year. FINDINGS Reflecting our assumptions on the appeal of cabotegravir-PrEP, its introduction is predicted to lead to a substantial increase in PrEP use with approximately 2·6% of the adult population (and 46% of those with a current indication for PrEP) receiving PrEP compared with 1·5% (28%) without cabotegravir-PrEP introduction across 20 years. As a result, HIV incidence is expected to be lower by 29% (90% range across setting-scenarios 6-52%) across the same period compared with no introduction of cabotegravir-PrEP. In people initiating antiretroviral therapy, the proportion with integrase-inhibitor resistance after 20 years is projected to be 1·7% (0-6·4%) without cabotegravir-PrEP introduction but 13·1% (4·1-30·9%) with. Cabotegravir-PrEP introduction is predicted to lower the proportion of all people on antiretroviral therapy with viral loads less than 1000 copies per mL by 0·9% (-2·5% to 0·3%) at 20 years. For an adult population of 10 million an overall decrease in number of AIDS deaths of about 4540 per year (-13 000 to -300) across 50 years is predicted, with little discernible benefit with NAT when compared with standard antibody-based rapid testing. AIDS deaths are predicted to be averted with cabotegravir-PrEP introduction in 99% of setting-scenarios. Across the 50-year time horizon, overall HIV programme costs are predicted to be similar regardless of whether cabotegravir-PrEP is introduced (total mean discounted annual HIV programme costs per year across 50 years is $151·3 million vs $150·7 million), assuming the use of standard antibody testing. With antibody-based rapid HIV testing, the introduction of cabotegravir-PrEP is predicted to be cost-effective under an assumed threshold of $500 per disability-adjusted life year averted in 82% of setting-scenarios at the cost of $144 per year, in 52% at $264, and in 87% at $114. INTERPRETATION Despite leading to increases in integrase-inhibitor drug resistance, cabotegravir-PrEP introduction is likely to reduce AIDS deaths in addition to HIV incidence. Long-acting cabotegravir-PrEP is predicted to be cost-effective if delivered at similar cost to oral PrEP with antibody-based rapid HIV testing. FUNDING Bill & Melinda Gates Foundation, National Institute of Allergy and Infectious Diseases of the National Institutes of Health.
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Affiliation(s)
- Jennifer Smith
- Institute for Global Health, University College London, London, UK
| | | | | | - Dobromir Dimitrov
- Public Health Sciences Division, Fred Hutchinson Cancer Center, Seattle, WA, USA
| | - Anna Bershteyn
- Department of Population Health, New York University Grossman School of Medicine, New York, NY, USA
| | | | | | - Paul Revill
- Centre for Health Economics, University of York, York, UK
| | - Marie-Claude Boily
- MRC Centre for Global Infectious Disease Analysis, School of Public Health, Imperial College London, London, UK
| | - Gesine Meyer-Rath
- Health Economics and Epidemiology Research Office (HE2RO), Department of Internal Medicine, School of Clinical Medicine, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | | | - Jens D Lundgren
- Department of Clinical Medicine, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
| | - Joep J van Oosterhout
- Partners in Hope, Lilongwe, Malawi; Department of Medicine, David Geffen School of Medicine, University of California, Los Angeles, CA, USA
| | - Daniel Kuritzkes
- Division of Infectious Diseases, Brigham and Women's Hospital, Boston, MA, USA; Department of Medicine, Harvard Medical School, Boston, MA, USA
| | - Robin Schaefer
- Global HIV, Hepatitis, and STIs Programmes, WHO, Geneva, Switzerland
| | - Mark J Siedner
- Department of Medicine, Harvard Medical School, Boston, MA, USA; Division of Infectious Diseases, Massachusetts General Hospital, Boston, MA, USA; Clinical Research Department, Africa Health Research Institute, Mtubatuba, South Africa
| | | | - Sinead Delany-Moretlwe
- Wits RHI, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Raphael J Landovitz
- Department of Medicine, David Geffen School of Medicine, University of California, Los Angeles, CA, USA; Center for Clinical AIDS Research and Education, University of California, Los Angeles, CA, USA
| | - Charles Flexner
- Johns Hopkins University School of Medicine and Bloomberg School of Public Health, Johns Hopkins University, Baltimore, MD, USA
| | - Michael Jordan
- Tufts Medical Center, Tufts University School of Medicine, Boston, MA, USA
| | - Francois Venter
- Ezintsha, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Mopo Radebe
- Regional Office for Africa, WHO, Gauteng, South Africa
| | - David Ripin
- Infectious Diseases Program, Clinton Health Access Initiative, New York, NY, USA
| | - Sarah Jenkins
- Infectious Diseases Program, Clinton Health Access Initiative, New York, NY, USA
| | - Danielle Resar
- Infectious Diseases Program, Clinton Health Access Initiative, New York, NY, USA
| | - Carolyn Amole
- Infectious Diseases Program, Clinton Health Access Initiative, New York, NY, USA
| | - Maryam Shahmanesh
- Institute for Global Health, University College London, London, UK; Clinical Research Department, Africa Health Research Institute, Mtubatuba, South Africa
| | - Ravindra K Gupta
- Clinical Research Department, Africa Health Research Institute, Mtubatuba, South Africa; Department of Medicine, University of Cambridge, Cambridge, UK
| | - Elliot Raizes
- US Department of Health and Human Services, Centers for Disease Control, Atlanta, GA, USA
| | - Cheryl Johnson
- Global HIV, Hepatitis, and STIs Programmes, WHO, Geneva, Switzerland
| | - Seth Inzaule
- Global HIV, Hepatitis, and STIs Programmes, WHO, Geneva, Switzerland
| | - Robert Shafer
- Department of Medicine, Stanford University, Palo Alto, CA, USA
| | | | - Sarah Stansfield
- Vaccine and Infectious Disease Division, Fred Hutchinson Cancer Center, Seattle, WA, USA
| | - Roger Paredes
- Department of Infectious Diseases, Irsi Caixa Institut de Recerca de la SIDA, Barcelona, Spain
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14
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Mataboge P, Nzenze S, Mthimkhulu N, Mazibuko M, Kutywayo A, Butler V, Naidoo N, Mullick S. Planning for decentralized, simplified prEP: Learnings from potential end users in Ga-Rankuwa, gauteng, South Africa. FRONTIERS IN REPRODUCTIVE HEALTH 2023; 4:1081049. [PMID: 36699142 PMCID: PMC9868940 DOI: 10.3389/frph.2022.1081049] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2022] [Accepted: 12/16/2022] [Indexed: 01/12/2023] Open
Abstract
Background In South Africa, youth experience challenges with oral Pre-Exposure Prophylaxis (PrEP) access and uptake. Taking services out of healthcare settings has the potential to increase reach and overcome these challenges. This paper presents young and older people's preferences for decentralized, simplified PrEP service delivery and new long-acting HIV prevention methods, in Ga-Rankuwa, South Africa. Methods Between May and August 2021, both PrEP user and non-user adolescent girls and young women (AGYW), pregnant AGYW, female sex workers, adolescent boys and young men (ABYM), and men who have sex with men (MSM) were recruited to participate in focus group discussions (FDGs) in Ga-Rankuwa, Gauteng. Twenty-two FGDs were conducted. Participants were asked about PrEP uptake, potential acceptability of long-acting HIV prevention products, provision of integrated, simplified, and decentralized services, and digital tools to facilitate access to PrEP and other SRH services. A qualitative approach using inductive thematic analysis was carried out to explore emerging themes on decentralized, simplified delivery and the acceptability of long-acting methods. Results Of the 109 participants included in the study approximately 45% (n = 50) were female, the median age was 23 years ± 5.3. A third (n = 37) were current or previous PrEP users, of which, 59.5% (n = 22) collected PrEP refills from the clinic. Decentralized, simplified service delivery was appealing; health facilities, pharmacies and institutions of learning were preferred as service points for PrEP and SRH services, and recreational spaces preferred for dissemination of health information and engagement. ABYM were more open to having recreational spaces as service points. Long-acting Cabotegravir was preferred over the Dapivirine Vaginal Ring due to concerns around perceived side-effects, efficacy, and comfort. Conclusion Providing long-acting PrEP methods through decentralized, simplified service delivery was appealing to this population. They provided practical locations for decentralized service provision to potentially increase their engagement with and uptake of HIV prevention and SRH services.
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Affiliation(s)
- Paballo Mataboge
- Faculty of Health Sciences, Wits Reproductive Health and HIV Institute (Wits RHI), University of the Witwatersrand, Johannesburg, South Africa
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15
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Phillips AN, Sibanda E, Sikwese K, Bansi-Matharu L, Cambiano V, Rodger A, Lundgren J, Shahmanesh M, Gilks C, Godfrey C, Ehrenkranz P, Hargreaves JR, Revill P, Cowan F. Enabling timely HIV postexposure prophylaxis access in sub-Saharan Africa. AIDS 2022; 36:1473-1475. [PMID: 35876709 DOI: 10.1097/qad.0000000000003258] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Affiliation(s)
| | | | - Kenly Sikwese
- African Community Advisory Board (AfroCAB-HIV), Lusaka, Zambia
| | | | | | | | - Jens Lundgren
- Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
| | | | | | - Catherine Godfrey
- Office of the Global AIDS Coordinator, Department of State, Washington, DC, USA
| | | | | | - Paul Revill
- Centre for Health Economics, University of York, UK
| | - Frances Cowan
- Liverpool School of Tropical Medicine, UK, and Harare, Zimbabwe
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Ngure K, Ortblad KF, Mogere P, Bardon AR, Thomas KK, Mangale D, Kiptinness C, Gakuo S, Mbaire S, Nyokabi J, Mugo NR, Baeten JM. Efficiency of 6-month PrEP dispensing with HIV self-testing in Kenya: an open-label, randomised, non-inferiority, implementation trial. Lancet HIV 2022; 9:e464-e473. [PMID: 35777410 DOI: 10.1016/s2352-3018(22)00126-6] [Citation(s) in RCA: 20] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2021] [Revised: 04/15/2022] [Accepted: 04/25/2022] [Indexed: 05/05/2023]
Abstract
BACKGROUND Oral pre-exposure prophylaxis (PrEP) for HIV prevention is highly effective and is being implemented at scale at health clinics throughout sub-Saharan Africa. However, barriers to clinic-based PrEP delivery remain. We aimed to establish the efficiency of semiannual PrEP clinic visits supplemented with interim home-based HIV self-testing (HIVST) versus standard of care for HIV testing, drug refilling, and adherence among PrEP users. METHODS This was a randomised, open-label, non-inferiority trial done at the Partners in Health and Research Development clinic in Thika, Kenya. Eligible participants were HIV-negative adults (≥18 years) at risk of acquiring HIV who had started PrEP at least 1 month before enrolment. Participants were randomly assigned (1:1:1) to 6-month PrEP dispensing plus interim blood-based HIVST (with biannual clinic visits), 6-month PrEP dispensing plus interim oral fluid-based HIVST (with biannual clinic visits), or standard of care PrEP delivery (3-month PrEP dispensing with quarterly clinic visits). The three coprimary outcomes, measured at 6 months, were HIV testing (any testing between enrolment and the 6-month visit), PrEP refilling, and PrEP adherence (detectable tenofovir diphosphate concentration in dried blood spots). All analyses were done according to the intention-to-treat principle. We used binomial regression models to estimate risk differences and one-sided 95% CIs. 6-month PrEP dispensing was considered non-inferior to standard of care if the lower limit bound of the one-sided 95% CI was greater than or equal to -10%. This study is registered with ClinicalTrials.gov, NCT03593629. FINDINGS Between May 28, 2018, and Feb 24, 2020, 495 participants were enrolled: 165 men and 130 women in HIV serodifferent couples and 200 singly enrolled women. 166 participants were randomly assigned to the standard of care group, 163 to the 6-month PrEP dispensing plus oral-fluid HIVST group, and 166 to the 6-month PrEP dispensing plus blood-based HIVST group. At 6 months, 274 (83%) of 329 participants in the combined 6-month PrEP dispensing group had tested for HIV compared with 140 (84%) of 166 participants in the standard of care group (risk difference -1·15%, 95% CI lower bound -6·89). Among participants in the combined 6-month PrEP dispensing group, 257 (78%) participants refilled PrEP compared with 134 (81%) participants in the standard of care group (-2·60%, -8·88), and 200 (61%) participants were adherent to PrEP compared with 95 (57%) participants in the standard of care group (2·37%, -5·05). No participants acquired HIV during the study. INTERPRETATION 6-month PrEP dispensing with HIVST for interim testing reduced the number of PrEP clinic visits in half without compromising HIV testing, retention, or adherence. FUNDING US National Institute of Mental Health.
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Affiliation(s)
- Kenneth Ngure
- Department of Community Health, Jomo Kenyatta University of Agriculture and Technology, Nairobi, Kenya; Department of Global Health, University of Washington, Seattle, WA, USA.
| | - Katrina F Ortblad
- Department of Global Health, University of Washington, Seattle, WA, USA; Public Health Sciences Division, Fred Hutchinson Cancer Center, Seattle, WA, USA
| | - Peter Mogere
- Center for Clinical Research, Kenya Medical Research Institute, Nairobi, Kenya
| | - Ashley R Bardon
- Department of Global Health, University of Washington, Seattle, WA, USA; Department of Epidemiology, University of Washington, Seattle, WA, USA
| | | | - Dorothy Mangale
- Department of Global Health, University of Washington, Seattle, WA, USA
| | | | - Stephen Gakuo
- Center for Clinical Research, Kenya Medical Research Institute, Nairobi, Kenya
| | - Sarah Mbaire
- Center for Clinical Research, Kenya Medical Research Institute, Nairobi, Kenya
| | - Jacinta Nyokabi
- Center for Clinical Research, Kenya Medical Research Institute, Nairobi, Kenya
| | - Nelly R Mugo
- Department of Global Health, University of Washington, Seattle, WA, USA; Center for Clinical Research, Kenya Medical Research Institute, Nairobi, Kenya
| | - 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; Gilead Sciences, Foster City, CA, USA
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Stewart J, Bukusi E, Sesay FA, Oware K, Donnell D, Soge OO, Celum C, Odoyo J, Kwena ZA, Scoville CW, Violette LR, Morrison S, Simoni J, McClelland RS, Barnabas R, Gandhi M, Baeten JM. Doxycycline post-exposure prophylaxis for prevention of sexually transmitted infections among Kenyan women using HIV pre-exposure prophylaxis: study protocol for an open-label randomized trial. Trials 2022; 23:495. [PMID: 35710444 PMCID: PMC9201793 DOI: 10.1186/s13063-022-06458-8] [Citation(s) in RCA: 15] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2022] [Accepted: 06/09/2022] [Indexed: 12/18/2022] Open
Abstract
BACKGROUND Women in Africa face disproportionate risk of human immunodeficiency virus (HIV) acquisition, accounting for more than half of new infections in Africa and similarly face a disproportionate burden of sexually transmitted infections (STIs). Very high STI prevalence is being observed globally, especially among people taking pre-exposure prophylaxis (PrEP) for HIV prevention. Doxycycline post-exposure prophylaxis (dPEP) has been proposed as an STI prevention strategy to reduce chlamydia, syphilis, and possibly gonorrhea, and trials are ongoing among cisgender men who have sex with men (MSM) and transgender women who are taking PrEP in high-income settings. We designed and describe here the first open-label trial to determine the effectiveness of dPEP to reduce STI incidence among cisgender women. METHODS We are conducting an open-label 1:1 randomized trial of dPEP versus standard of care (STI screening and treatment and risk-reduction counseling without dPEP) among 446 Kenyan women aged ≥ 18 and ≤ 30 years old women taking PrEP. Women are followed for 12 months, with quarterly STI testing, treatment, and adherence counseling. The primary trial outcome will be the combined incidence of Chlamydia trachomatis, Neisseria gonorrhoeae, and Treponema pallidum, compared between the randomized groups. We will also assess dPEP acceptability, tolerability, safety, impact on sexual behavior, adherence, and occurrence of antimicrobial resistance (AMR) in N. gonorrhoeae and C. trachomatis isolates. Finally, we will estimate cost per incident STI case and complications averted accounting for nonadherence and benefits relative AMR or side effects. DISCUSSION The results of this trial may have immediate implications for the global epidemic of STIs and sexual health. If effective, dPEP could put STI prevention into women's hands. While dPEP may be able to prevent STIs, it carries important risks that could counter its benefits; global debate about the balance of these potential risks and benefits requires data to inform policy and implementation and our study aims to fill this gap. TRIAL REGISTRATION ClinicalTrials.gov NCT04050540 .
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Affiliation(s)
- Jenell Stewart
- Department of Global Health, University of Washington, Box 359931, 325 Ninth Ave, WA 98104 Seattle, USA
- Department of Medicine (Infectious Diseases), University of Washington, Seattle, USA
| | - Elizabeth Bukusi
- Department of Global Health, University of Washington, Box 359931, 325 Ninth Ave, WA 98104 Seattle, USA
- Kenya Medical Research Institute (KEMRI), Kisumu, Kenya
| | - Fredericka A. Sesay
- Department of Global Health, University of Washington, Box 359931, 325 Ninth Ave, WA 98104 Seattle, USA
- Department of Epidemiology, University of Washington, Seattle, USA
| | - Kevin Oware
- Kenya Medical Research Institute (KEMRI), Kisumu, Kenya
| | - Deborah Donnell
- Department of Global Health, University of Washington, Box 359931, 325 Ninth Ave, WA 98104 Seattle, USA
- Department of Biostatistics, University of Washington, Seattle, USA
| | - Olusegun O. Soge
- Department of Global Health, University of Washington, Box 359931, 325 Ninth Ave, WA 98104 Seattle, USA
- Department of Medicine (Infectious Diseases), University of Washington, Seattle, USA
- Department of Laboratory Medicine and Pathology, University of Washington, Seattle, USA
| | - Connie Celum
- Department of Global Health, University of Washington, Box 359931, 325 Ninth Ave, WA 98104 Seattle, USA
- Department of Medicine (Infectious Diseases), University of Washington, Seattle, USA
- Department of Epidemiology, University of Washington, Seattle, USA
| | | | | | - Caitlin W. Scoville
- Department of Global Health, University of Washington, Box 359931, 325 Ninth Ave, WA 98104 Seattle, USA
| | - Lauren R. Violette
- Department of Medicine (Infectious Diseases), University of Washington, Seattle, USA
- Department of Epidemiology, University of Washington, Seattle, USA
| | - Susan Morrison
- Department of Global Health, University of Washington, Box 359931, 325 Ninth Ave, WA 98104 Seattle, USA
| | - Jane Simoni
- Department of Psychology, University of Washington, Seattle, USA
| | - R. Scott McClelland
- Department of Global Health, University of Washington, Box 359931, 325 Ninth Ave, WA 98104 Seattle, USA
- Department of Medicine (Infectious Diseases), University of Washington, Seattle, USA
- Department of Epidemiology, University of Washington, Seattle, USA
| | - Ruanne Barnabas
- Department of Global Health, University of Washington, Box 359931, 325 Ninth Ave, WA 98104 Seattle, USA
- Department of Medicine (Infectious Diseases), University of Washington, Seattle, USA
- Department of Epidemiology, University of Washington, Seattle, USA
| | - Monica Gandhi
- Department of Medicine, Division of HIV, Infectious Diseases, and Global Medicine, University of California San Francisco, San Francisco, USA
| | - Jared M. Baeten
- Department of Global Health, University of Washington, Box 359931, 325 Ninth Ave, WA 98104 Seattle, USA
- Department of Medicine (Infectious Diseases), University of Washington, Seattle, USA
- Department of Epidemiology, University of Washington, Seattle, USA
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Phillips AN, Bershteyn A, Revill P, Bansi-Matharu L, Kripke K, Boily MC, Martin-Hughes R, Johnson LF, Mukandavire Z, Jamieson L, Meyer-Rath G, Hallett TB, Ten Brink D, Kelly SL, Nichols BE, Bendavid E, Mudimu E, Taramusi I, Smith J, Dalal S, Baggaley R, Crowley S, Terris-Prestholt F, Godfrey-Faussett P, Mukui I, Jahn A, Case KK, Havlir D, Petersen M, Kamya M, Koss CA, Balzer LB, Apollo T, Chidarikire T, Mellors JW, Parikh UM, Godfrey C, Cambiano V. Cost-effectiveness of easy-access, risk-informed oral pre-exposure prophylaxis in HIV epidemics in sub-Saharan Africa: a modelling study. Lancet HIV 2022; 9:e353-e362. [PMID: 35489378 PMCID: PMC9065367 DOI: 10.1016/s2352-3018(22)00029-7] [Citation(s) in RCA: 17] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2021] [Revised: 01/27/2022] [Accepted: 01/28/2022] [Indexed: 02/07/2023]
Abstract
BACKGROUND Approaches that allow easy access to pre-exposure prophylaxis (PrEP), such as over-the-counter provision at pharmacies, could facilitate risk-informed PrEP use and lead to lower HIV incidence, but their cost-effectiveness is unknown. We aimed to evaluate conditions under which risk-informed PrEP use is cost-effective. METHODS We applied a mathematical model of HIV transmission to simulate 3000 setting-scenarios reflecting a range of epidemiological characteristics of communities in sub-Saharan Africa. The prevalence of HIV viral load greater than 1000 copies per mL among all adults (HIV positive and negative) varied from 1·1% to 7·4% (90% range). We hypothesised that if PrEP was made easily available without restriction and with education regarding its use, women and men would use PrEP, with sufficient daily adherence, during so-called seasons of risk (ie, periods in which individuals are at risk of acquiring infection). We refer to this as risk-informed PrEP. For each setting-scenario, we considered the situation in mid-2021 and performed a pairwise comparison of the outcomes of two policies: immediate PrEP scale-up and then continuation for 50 years, and no PrEP. We estimated the relationship between epidemic and programme characteristics and cost-effectiveness of PrEP availability to all during seasons of risk. For our base-case analysis, we assumed a 3-monthly PrEP cost of US$29 (drug $11, HIV test $4, and $14 for additional costs necessary to facilitate education and access), a cost-effectiveness threshold of $500 per disability-adjusted life-year (DALY) averted, an annual discount rate of 3%, and a time horizon of 50 years. In sensitivity analyses, we considered a cost-effectiveness threshold of $100 per DALY averted, a discount rate of 7% per annum, the use of PrEP outside of seasons of risk, and reduced uptake of risk-informed PrEP. FINDINGS In the context of PrEP scale-up such that 66% (90% range across setting-scenarios 46-81) of HIV-negative people with at least one non-primary condomless sex partner take PrEP in any given period, resulting in 2·6% (0·9-6·0) of all HIV negative adults taking PrEP at any given time, risk-informed PrEP was predicted to reduce HIV incidence by 49% (23-78) over 50 years compared with no PrEP. PrEP was cost-effective in 71% of all setting-scenarios, and cost-effective in 76% of setting-scenarios with prevalence of HIV viral load greater than 1000 copies per mL among all adults higher than 2%. In sensitivity analyses with a $100 per DALY averted cost-effectiveness threshold, a 7% per year discount rate, or with PrEP use that was less well risk-informed than in our base case, PrEP was less likely to be cost-effective, but generally remained cost-effective if the prevalence of HIV viral load greater than 1000 copies per mL among all adults was higher than 3%. In sensitivity analyses based on additional setting-scenarios in which risk-informed PrEP was less extensively used, the HIV incidence reduction was smaller, but the cost-effectiveness of risk-informed PrEP was undiminished. INTERPRETATION Under the assumption that making PrEP easily accessible for all adults in sub-Saharan Africa in the context of community education leads to risk-informed use, PrEP is likely to be cost-effective in settings with prevalence of HIV viral load greater than 1000 copies per mL among all adults higher than 2%, suggesting the need for implementation of such approaches, with ongoing evaluation. FUNDING US Agency for International Development, US President's Emergency Plan for AIDS Relief, and Bill & Melinda Gates Foundation.
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Affiliation(s)
| | - Anna Bershteyn
- Department of Population Health, New York University Grossman School of Medicine, New York, NY, USA
| | - Paul Revill
- Centre for Health Economics, University of York, York, UK
| | | | | | - Marie-Claude Boily
- Department of Infectious Disease Epidemiology, Imperial College London, London, UK; MRC Centre for Global Infectious Disease Analysis, School of Public Health, Imperial College London, London, UK
| | | | - Leigh F Johnson
- Centre for Infectious Disease Epidemiology and Research, University of Cape Town, Cape Town, South Africa
| | - Zindoga Mukandavire
- Centre for Data Science and Artificial Intelligence, Emirates Aviation University, Dubai, United Arab Emirates
| | - Lise Jamieson
- Health Economics and Epidemiology Research Office (HE2RO), Department of Internal Medicine, School of Clinical Medicine, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa; Department of Medical Microbiology, Amsterdam University Medical Centre, Amsterdam, Netherlands
| | - Gesine Meyer-Rath
- Health Economics and Epidemiology Research Office (HE2RO), Department of Internal Medicine, School of Clinical Medicine, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa; Department of Global Health, School of Public Health, Boston University, Boston, MA, USA
| | - Timothy B Hallett
- Department of Infectious Disease Epidemiology, Imperial College London, London, UK; MRC Centre for Global Infectious Disease Analysis, School of Public Health, Imperial College London, London, UK
| | | | | | - Brooke E Nichols
- Health Economics and Epidemiology Research Office (HE2RO), Department of Internal Medicine, School of Clinical Medicine, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa; Department of Medical Microbiology, Amsterdam University Medical Centre, Amsterdam, Netherlands; Department of Global Health, School of Public Health, Boston University, Boston, MA, USA
| | - Eran Bendavid
- Department of Medicine, Stanford University, Stanford, CA, USA
| | - Edinah Mudimu
- Department of Decision Sciences, University of South Africa, Pretoria, South Africa
| | | | - Jennifer Smith
- Institute for Global Health, University College London, London, UK
| | - Shona Dalal
- World Health Organisation, Geneva, Switzerland
| | | | - Siobhan Crowley
- The Global Fund to Fight AIDS, Tuberculosis and Malaria, Geneva, Switzerland
| | | | - Peter Godfrey-Faussett
- Joint UN Programme on HIV/AIDS, Geneva, Switzerland; London School of Hygiene & Tropical Medicine, London, UK
| | - Irene Mukui
- Drugs for Neglected Diseases Initiative, Nairobi, Kenya
| | | | - Kelsey K Case
- Department of Infectious Disease Epidemiology, Imperial College London, London, UK
| | - Diane Havlir
- Department of Medicine, University of California, San Francisco, CA, USA
| | - Maya Petersen
- Divisions of Biostatistics and Epidemiology, School of Public Health, University of California, Berkeley, CA, USA
| | - Moses Kamya
- Department of Medicine, Makerere University, Kampala, Uganda; Infectious Diseases Research Collaboration, Kampala, Uganda
| | - Catherine A Koss
- Department of Medicine, University of California, San Francisco, CA, USA
| | - Laura B Balzer
- Department of Biostatistics and Epidemiology, School of Public Health and Health Sciences, University of Massachusetts, Amherst, MA, USA
| | | | | | - John W Mellors
- Department of Medicine, Division of Infectious Diseases, University of Pittsburgh, Pittsburgh, PA, USA
| | - Urvi M Parikh
- Department of Medicine, Division of Infectious Diseases, University of Pittsburgh, Pittsburgh, PA, USA
| | - Catherine Godfrey
- Office of the Global AIDS Coordinator, Department of State, Washington, DC, USA
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Velloza J, Poovan N, Ndlovu N, Khoza N, Morton JF, Omony J, Mkwanazi E, Grabow C, Donnell D, Munthali R, Baeten JM, Hosek S, Celum C, Delany-Moretlwe S. Adaptive HIV pre-exposure prophylaxis adherence interventions for young South African women: Study protocol for a sequential multiple assignment randomized trial. PLoS One 2022; 17:e0266665. [PMID: 35417485 PMCID: PMC9007385 DOI: 10.1371/journal.pone.0266665] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2021] [Accepted: 03/11/2022] [Indexed: 12/02/2022] Open
Abstract
INTRODUCTION Pre-exposure prophylaxis (PrEP) is a highly effective HIV prevention strategy and is recommended for populations at risk of HIV, including adolescent girls and young women (AGYW) in HIV endemic settings. However, PrEP continuation and high adherence remain challenges to its impact. Existing PrEP adherence interventions can be time- and cost-intensive. Widescale PrEP delivery will require the identification of layered PrEP support strategies for AGYW with diverse prevention needs. We describe the design of a sequential multiple assignment randomized trial (SMART) to evaluate a PrEP adherence support model using scalable, stepped interventions in AGYW in South Africa. METHODS "PrEP SMART" is a randomized trial in Johannesburg, South Africa, enrolling AGYW who are between 18 and 25 years of age, sexually active, newly initiating PrEP, and have regular access to a mobile phone. Participants are randomized 1:1 to standard-of-care PrEP counseling with either two-way SMS or WhatsApp group adherence support. Adherence is assessed at three months using tenofovir diphosphate (TFV-DP) levels from dried blood spots collected at month 2 to categorize participants as "responders" (TFV-DP ≥500 fmol/punch) or "non-responders" (TFV-DP <500 fmol/punch). AGYW defined as 'non-responders' undergo a secondary 1:1 randomization to either quarterly drug-level feedback counseling or monthly issue-focused counseling, in addition to their first-level intervention. The primary outcome is PrEP adherence at nine months (TFV-DP ≥700 fmol/punch). We will assess the effect of our two initial interventions on TFV-DP levels among responders, assess the effect of our intensified interventions on TFV-DP levels among non-responders, and identify the optimal sequence of adherence interventions through nine months. TRIAL REGISTRATION ClinicalTrials.gov, NCT04038060. Registered on 30 July 2019.
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Affiliation(s)
- Jennifer Velloza
- Department of Global Health, University of Washington, Seattle, WA, United States of America
| | - Nicole Poovan
- Wits Reproductive Health & HIV Institute (Wits RHI), Faculty of Health Sciences, University of The Witwatersrand, Johannesburg, South Africa
| | - Nontokozo Ndlovu
- Wits Reproductive Health & HIV Institute (Wits RHI), Faculty of Health Sciences, University of The Witwatersrand, Johannesburg, South Africa
| | - Nomhle Khoza
- Wits Reproductive Health & HIV Institute (Wits RHI), Faculty of Health Sciences, University of The Witwatersrand, Johannesburg, South Africa
| | - Jennifer F. Morton
- Department of Global Health, University of Washington, Seattle, WA, United States of America
| | - Jeanne Omony
- Wits Reproductive Health & HIV Institute (Wits RHI), Faculty of Health Sciences, University of The Witwatersrand, Johannesburg, South Africa
| | - Edwin Mkwanazi
- Wits Reproductive Health & HIV Institute (Wits RHI), Faculty of Health Sciences, University of The Witwatersrand, Johannesburg, South Africa
| | - Cole Grabow
- Department of Global Health, University of Washington, Seattle, WA, United States of America
| | - Deborah Donnell
- Department of Global Health, University of Washington, Seattle, WA, United States of America
- Vaccine and Infectious Disease Division, Fred Hutchinson Cancer Research Center, Seattle, WA, United States of America
| | - Richard Munthali
- Wits Reproductive Health & HIV Institute (Wits RHI), Faculty of Health Sciences, University of The Witwatersrand, Johannesburg, South Africa
| | - Jared M. Baeten
- Department of Global Health, University of Washington, Seattle, WA, United States of America
- Department of Epidemiology, University of Washington, Seattle, WA, United States of America
- Department of Medicine, University of Washington, Seattle, WA, United States of America
| | - Sybil Hosek
- Department of Psychiatry, Stroger Hospital of Cook County, Chicago, IL, United States of America
| | - Connie Celum
- Department of Global Health, University of Washington, Seattle, WA, United States of America
- Department of Epidemiology, University of Washington, Seattle, WA, United States of America
- Department of Medicine, University of Washington, Seattle, WA, United States of America
| | - Sinead Delany-Moretlwe
- Wits Reproductive Health & HIV Institute (Wits RHI), Faculty of Health Sciences, University of The Witwatersrand, Johannesburg, South Africa
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20
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Zhang J, Li C, Xu J, Hu Z, Rutstein SE, Tucker JD, Ong JJ, Jiang Y, Geng W, Wright ST, Cohen MS, Shang H, Tang W. Discontinuation, suboptimal adherence, and reinitiation of oral HIV pre-exposure prophylaxis: a global systematic review and meta-analysis. Lancet HIV 2022; 9:e254-e268. [PMID: 35364026 PMCID: PMC9124596 DOI: 10.1016/s2352-3018(22)00030-3] [Citation(s) in RCA: 76] [Impact Index Per Article: 38.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2021] [Revised: 01/19/2022] [Accepted: 01/26/2022] [Indexed: 12/26/2022]
Abstract
BACKGROUND Poor adherence to oral HIV pre-exposure prophylaxis (PrEP) diminishes its clinical and public health benefits. This study synthesises evidence regarding discontinuation, adherence, and reinitiation of PrEP among geographically diverse PrEP users. METHODS We did a systematic review and meta-analysis evaluating studies published in MEDLINE, Embase, and Cochrane Central Register of Controlled Trials from inception to Dec 18, 2020. We included longitudinal studies that presented data for PrEP discontinuation, defined as investigator-reported loss to follow-up or participant self-reported PrEP stoppage. Data were extracted from published reports and assessed for risk of bias. We used a random-effects meta-analysis to pool estimates of discontinuation and I2 and τ2 to evaluate heterogeneity. This study is registered with PROSPERO, CRD42020155675. FINDINGS We identified 4129 records, of which 59 articles were included (n=43 917 participants). 41·0% (95% CI 18·8-63·5) of participants discontinued PrEP within 6 months, with the highest rates in observational studies. The discontinuation rate in sub-Saharan Africa (47·5%, 95% CI: 29·4-66·4%) was higher than in other regions (p<0·001). Discontinuation rates were lower in studies with adherence interventions than in those without (24·7% vs 36·7%, p=0·015). Gay or bisexual men who have sex with men and transgender women offered daily or non-daily dosing options had lower discontinuation rates than those offered daily dosing alone (21·6% vs 31·5%; p<0·001). The pooled suboptimal adherence within 6 months was 37·7% (95% CI 8·4-66·9). Among people who discontinued PrEP, 47·3% (95% CI 31·5-63·2) reinitiated PrEP within 1 year of PrEP initiation. The included studies had poor quality in terms of study design, with a moderate risk of bias. INTERPRETATION Strategies to encourage reinitiating PrEP for new or persistent risk should be a focus of future PrEP implementation strategies. FUNDING National Institutes of Health and Nature Science Foundation of China.
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Affiliation(s)
- Jing Zhang
- The NHC Key Laboratory of AIDS Immunology and National Clinical Research Center for Laboratory Medicine of the First Affiliated Hospital of China Medical University
- Key Laboratory of AIDS Immunology, Chinese Academy of Medical Sciences
- Key Laboratory of AIDS Immunology of Liaoning Province
- Collaborative Innovation Center for Diagnosis and Treatment of Infectious Diseases
| | - Chunyan Li
- Department of Health Behavior of University of North Carolina
| | - Junjie Xu
- The NHC Key Laboratory of AIDS Immunology and National Clinical Research Center for Laboratory Medicine of the First Affiliated Hospital of China Medical University
- Key Laboratory of AIDS Immunology, Chinese Academy of Medical Sciences
- Key Laboratory of AIDS Immunology of Liaoning Province
- Collaborative Innovation Center for Diagnosis and Treatment of Infectious Diseases
| | - Zhili Hu
- The NHC Key Laboratory of AIDS Immunology and National Clinical Research Center for Laboratory Medicine of the First Affiliated Hospital of China Medical University
- Key Laboratory of AIDS Immunology, Chinese Academy of Medical Sciences
- Key Laboratory of AIDS Immunology of Liaoning Province
- Collaborative Innovation Center for Diagnosis and Treatment of Infectious Diseases
| | | | - Joseph D. Tucker
- Department of Medicine of University of North Carolina
- University of North Carolina Project-China
- Faculty of Infectious and Tropical Diseases of London School of Hygiene and Tropical Medicine
| | - Jason J Ong
- Faculty of Infectious and Tropical Diseases of London School of Hygiene and Tropical Medicine
- Monash University
| | - Yongjun Jiang
- The NHC Key Laboratory of AIDS Immunology and National Clinical Research Center for Laboratory Medicine of the First Affiliated Hospital of China Medical University
- Key Laboratory of AIDS Immunology, Chinese Academy of Medical Sciences
- Key Laboratory of AIDS Immunology of Liaoning Province
- Collaborative Innovation Center for Diagnosis and Treatment of Infectious Diseases
| | - Wenqing Geng
- The NHC Key Laboratory of AIDS Immunology and National Clinical Research Center for Laboratory Medicine of the First Affiliated Hospital of China Medical University
- Key Laboratory of AIDS Immunology, Chinese Academy of Medical Sciences
- Key Laboratory of AIDS Immunology of Liaoning Province
- Collaborative Innovation Center for Diagnosis and Treatment of Infectious Diseases
| | | | | | - Hong Shang
- The NHC Key Laboratory of AIDS Immunology and National Clinical Research Center for Laboratory Medicine of the First Affiliated Hospital of China Medical University
- Key Laboratory of AIDS Immunology, Chinese Academy of Medical Sciences
- Key Laboratory of AIDS Immunology of Liaoning Province
- Collaborative Innovation Center for Diagnosis and Treatment of Infectious Diseases
| | - Weiming Tang
- Department of Medicine of University of North Carolina
- University of North Carolina Project-China
- Dermatology Hospital of Southern Medical University
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21
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Joseph Davey DL, Mvududu R, Mashele N, Lesosky M, Khadka N, Bekker LG, Gorbach P, Coates TJ, Myer L. Early pre-exposure prophylaxis (PrEP) initiation and continuation among pregnant and postpartum women in antenatal care in Cape Town, South Africa. J Int AIDS Soc 2022; 25:e25866. [PMID: 35138678 PMCID: PMC8826542 DOI: 10.1002/jia2.25866] [Citation(s) in RCA: 31] [Impact Index Per Article: 15.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2021] [Accepted: 12/14/2021] [Indexed: 11/24/2022] Open
Abstract
Introduction Pre‐exposure prophylaxis (PrEP) is a safe and effective prevention strategy to reduce women's risk of HIV in pregnancy and postpartum. Effective PrEP protection requires daily PrEP adherence, but little is known about maternal PrEP continuation and factors that influence PrEP use. Methods The PrEP in pregnancy and postpartum (PrEP‐PP) study enrolled consenting pregnant, HIV‐negative women at first antenatal care (ANC) visit with follow‐up through 12 months postpartum. Eligible and consenting women and girls ≥16 years received HIV prevention counselling and were offered PrEP. Interviewers collected socio‐demographic and behavioural data from participants at each visit. We analysed the proportion of women who initiated PrEP and the proportion who continued PrEP after 3 months with associated correlates by estimating the prevalence ratio adjusting for a priori confounders. Results Between August 2019 and October 2021, we enrolled 1201 pregnant women (median gestation 21 weeks; age 26 years); 84% of women initiated PrEP at their first ANC visit (n = 1014); 55% were married or cohabiting. Overall, 66% of women on PrEP returned for a repeat prescription at 1 month; 58% returned at 3 months (n = 493 of 844). Almost one‐half of women on PrEP reported a side effect at 1 month, mostly nausea/vomiting. Women on PrEP in the first and second trimesters had higher odds of reporting side effects (aOR 2.61; 95% CI 1.17–5.84) versus postpartum women. Women who reported side effects continued with PrEP less than those who did not report side effects (aPR = 0.87; 95% CI 0.77–0.97). Women with ≥1 previous pregnancy (aPR = 0.76; 95% CI 0.57–1.01) or were postpartum (aPR 0.85; 95% CI 0.75–0.97) were less likely to continue PrEP compared to women who were primigravid or pregnant. Women who reported having an HIV+ partner (aPR = 1.45; 95% CI 1.13–1.85) or high HIV risk perception (aPR = 1.20, 95% CI = 1.01–1.41) were more likely to continue on PrEP than those who had HIV‐negative partners or low risk perception. Conclusions PrEP initiation and early continuation were high in this setting, compared to other studies in women. Being postpartum and experiencing side effects were associated with lower PrEP continuation, presenting opportunities for counselling on early transient side effects. Interventions for postpartum women on PrEP are needed.
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Affiliation(s)
- Dvora Leah Joseph Davey
- Department of Epidemiology, Fielding School of Public Health, University of California Los Angeles, Los Angeles, California, USA.,Division of Epidemiology and Biostatistics, School of Public Health and Family Medicine, University of Cape Town, Cape Town, South Africa.,The Desmond Tutu Health Foundation, University of Cape Town, Cape Town, South Africa
| | - Rufaro Mvududu
- Division of Epidemiology and Biostatistics, School of Public Health and Family Medicine, University of Cape Town, Cape Town, South Africa
| | - Nyiko Mashele
- Division of Epidemiology and Biostatistics, School of Public Health and Family Medicine, University of Cape Town, Cape Town, South Africa
| | - Maia Lesosky
- Division of Epidemiology and Biostatistics, School of Public Health and Family Medicine, University of Cape Town, Cape Town, South Africa
| | - Nehaa Khadka
- Department of Epidemiology, Fielding School of Public Health, University of California Los Angeles, Los Angeles, California, USA
| | - Linda-Gail Bekker
- The Desmond Tutu Health Foundation, University of Cape Town, Cape Town, South Africa
| | - Pamina Gorbach
- Department of Epidemiology, Fielding School of Public Health, University of California Los Angeles, Los Angeles, California, USA
| | - Thomas J Coates
- David Geffen School of Medicine, University of California Los Angeles, Los Angeles, California, USA
| | - Landon Myer
- Division of Epidemiology and Biostatistics, School of Public Health and Family Medicine, University of Cape Town, Cape Town, South Africa
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22
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Jia KM, Eilerts H, Edun O, Lam K, Howes A, Thomas ML, Eaton JW. Risk scores for predicting HIV incidence among adult heterosexual populations in sub-Saharan Africa: a systematic review and meta-analysis. J Int AIDS Soc 2022; 25:e25861. [PMID: 35001515 PMCID: PMC8743366 DOI: 10.1002/jia2.25861] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2021] [Accepted: 12/06/2021] [Indexed: 11/24/2022] Open
Abstract
Introduction Several HIV risk scores have been developed to identify individuals for prioritized HIV prevention in sub‐Saharan Africa. We systematically reviewed HIV risk scores to: (1) identify factors that consistently predicted incident HIV infection, (2) review inclusion of community‐level HIV risk in predictive models and (3) examine predictive performance. Methods We searched nine databases from inception until 15 February 2021 for studies developing and/or validating HIV risk scores among the heterosexual adult population in sub‐Saharan Africa. Studies not prospectively observing seroconversion or recruiting only key populations were excluded. Record screening, data extraction and critical appraisal were conducted in duplicate. We used random‐effects meta‐analysis to summarize hazard ratios and the area under the receiver‐operating characteristic curve (AUC‐ROC). Results From 1563 initial search records, we identified 14 risk scores in 13 studies. Seven studies were among sexually active women using contraceptives enrolled in randomized‐controlled trials, three among adolescent girls and young women (AGYW) and three among cohorts enrolling both men and women. Consistently identified HIV prognostic factors among women were younger age (pooled adjusted hazard ratio: 1.62 [95% confidence interval: 1.17, 2.23], compared to above 25), single/not cohabiting with primary partners (2.33 [1.73, 3.13]) and having sexually transmitted infections (STIs) at baseline (HSV‐2: 1.67 [1.34, 2.09]; curable STIs: 1.45 [1.17; 1.79]). Among AGYW, only STIs were consistently associated with higher incidence, but studies were limited (n = 3). Community‐level HIV prevalence or unsuppressed viral load strongly predicted incidence but was only considered in 3 of 11 multi‐site studies. The AUC‐ROC ranged from 0.56 to 0.79 on the model development sets. Only the VOICE score was externally validated by multiple studies, with pooled AUC‐ROC 0.626 [0.588, 0.663] (I2: 64.02%). Conclusions Younger age, non‐cohabiting and recent STIs were consistently identified as predicting future HIV infection. Both community HIV burden and individual factors should be considered to quantify HIV risk. However, HIV risk scores had only low‐to‐moderate discriminatory ability and uncertain generalizability, limiting their programmatic utility. Further evidence on the relative value of specific risk factors, studies populations not restricted to “at‐risk” individuals and data outside South Africa will improve the evidence base for risk differentiation in HIV prevention programmes. PROSPERO Number CRD42021236367
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Affiliation(s)
- Katherine M Jia
- MRC Centre for Global Infectious Disease Analysis, School of Public Health, Imperial College London, London, UK
| | - Hallie Eilerts
- Department of Population Health, The London School of Hygiene and Tropical Medicine, London, UK
| | - Olanrewaju Edun
- MRC Centre for Global Infectious Disease Analysis, School of Public Health, Imperial College London, London, UK
| | - Kevin Lam
- MRC Centre for Global Infectious Disease Analysis, School of Public Health, Imperial College London, London, UK
| | - Adam Howes
- Department of Mathematics, Imperial College London, London, UK
| | - Matthew L Thomas
- Joint Centre for Excellence in Environmental Intelligence, University of Exeter & Met Office, Exeter, UK
| | - Jeffrey W Eaton
- MRC Centre for Global Infectious Disease Analysis, School of Public Health, Imperial College London, London, UK
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23
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Mwongeli N, Wagner AD, Dettinger JC, Pintye J, Brown Trinidad S, Awuor M, Kimemia G, Ngure K, Heffron RA, Baeten JM, Mugo N, Bukusi EA, Kinuthia J, Kelley MC, John-Stewart GC, Beima-Sofie KM. " PrEP Gives the Woman the Control": Healthcare Worker Perspectives on Using pre-Exposure Prophylaxis (PrEP) During Pregnancy and Postpartum in Kenya. J Int Assoc Provid AIDS Care 2022; 21:23259582221111068. [PMID: 35776525 PMCID: PMC9251967 DOI: 10.1177/23259582221111068] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
Background: Pregnant and postpartum women in high HIV prevalent regions are at increased HIV risk. Oral pre-exposure prophylaxis (PrEP) can decrease HIV incidence reducing infant HIV infections. Understanding healthcare worker (HCW) beliefs about PrEP prior to national roll-out is critical to supporting PrEP scale-up. Methods: We conducted 45 semi-structured interviews among a range of HCW cadres with and without PrEP provision experience purposively recruited from four clinics in Kenya to compare their views on prescribing PrEP during pregnancy and postpartum. Interviews were analysed using a conventional content analysis approach to identify key influences on PrEP acceptability and feasibility. Results: All HCWs perceived PrEP as an acceptable and feasible HIV prevention strategy for pregnant and postpartum women. They believed PrEP meets women’s needs as an on-demand, female-controlled prevention strategy that empowers women to take control of their HIV risk. HCWs highlighted their role in PrEP delivery success while acknowledging how their knowledge gaps, concerns and perceived PrEP implementation challenges may hinder optimal PrEP delivery. Conclusion: HCWs supported PrEP provision to pregnant and postpartum women. However, counseling tools to address risk perceptions in this population and strategies to reduce HCW knowledge gaps, concerns and perceived implementation barriers are required.
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Affiliation(s)
| | - Anjuli D Wagner
- Department of Global Health, 7284University of Washington, Seattle, WA, USA
| | - Julia C Dettinger
- Department of Global Health, 7284University of Washington, Seattle, WA, USA
| | - Jillian Pintye
- Department of Global Health, 7284University of Washington, Seattle, WA, USA.,School of Nursing, 7284University of Washington, Seattle, WA, USA
| | - Susan Brown Trinidad
- Department of Bioethics and Humanities, 7284University of Washington, Seattle, WA, USA
| | - Merceline Awuor
- 7284University of Washington Kenya (UW-Kenya), Nairobi, Kenya
| | - Grace Kimemia
- Population Dynamic and Reproductive Health, 107883African Population and Health Research Center, Nairobi, Kenya
| | - Kenneth Ngure
- Department of Global Health, 7284University of Washington, Seattle, WA, USA.,Department of Community Health, 118985Jomo Kenyatta University of Agriculture and Technology, Juja, Kenya
| | - Renee A Heffron
- Department of Global Health, 7284University of Washington, Seattle, WA, USA.,Department of Epidemiology, 7284University of Washington, Seattle, WA, USA
| | - Jared M Baeten
- Department of Global Health, 7284University of Washington, Seattle, WA, USA.,Department of Epidemiology, 7284University of Washington, Seattle, WA, USA.,Department of Medicine, 7284University of Washington, Seattle, WA, USA.,2158Gilead Sciences, Foster City, USA
| | - Nelly Mugo
- Department of Global Health, 7284University of Washington, Seattle, WA, USA.,Partners in Health Research and Development, Thika, Kenya.,185955Centre for Clinical Research, Kenya Medical Research Institute (KEMRI), Nairobi, Kenya
| | - Elizabeth A Bukusi
- Department of Global Health, 7284University of Washington, Seattle, WA, USA.,185955Centre for Clinical Research, Kenya Medical Research Institute (KEMRI), Nairobi, Kenya.,Department of Obstetrics and Gynecology, 7284University of Washington, Seattle, WA, USA
| | - John Kinuthia
- 285569Kenyatta National Hospital, Nairobi, Kenya.,Department of Global Health, 7284University of Washington, Seattle, WA, USA
| | - Maureen C Kelley
- The Ethox Centre and 575097Wellcome Centre for Ethics & Humanities, Nuffield Department of Population Health, University of Oxford, Oxford, UK
| | - Grace C John-Stewart
- Department of Global Health, 7284University of Washington, Seattle, WA, USA.,Department of Epidemiology, 7284University of Washington, Seattle, WA, USA.,Department of Medicine, 7284University of Washington, Seattle, WA, USA.,Department of Pediatrics, 7284University of Washington, Seattle, WA, USA
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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: 70] [Impact Index Per Article: 23.3] [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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Rousseau E, Bekker LG, Julies RF, Celum C, Morton J, Johnson R, Baeten JM, O'Malley G. A community-based mobile clinic model delivering PrEP for HIV prevention to adolescent girls and young women in Cape Town, South Africa. BMC Health Serv Res 2021; 21:888. [PMID: 34454505 PMCID: PMC8403426 DOI: 10.1186/s12913-021-06920-4] [Citation(s) in RCA: 29] [Impact Index Per Article: 9.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2020] [Accepted: 08/19/2021] [Indexed: 01/06/2023] Open
Abstract
BACKGROUND Daily doses of pre-exposure prophylaxis (PrEP) can reduce the risk of acquiring HIV by more than 95 %. In sub-Saharan Africa, adolescent girls and young women (AGYW) are at disproportionately high risk of acquiring HIV, accounting for 25 % of new infections. There are limited data available on implementation approaches to effectively reach and deliver PrEP to AGYW in high HIV burden communities. METHODS We explored the feasibility and acceptability of providing PrEP to AGYW (aged 16-25 years) via a community-based mobile health clinic (CMHC) known as the Tutu Teen Truck (TTT) in Cape Town, South Africa. The TTT integrated PrEP delivery into its provision of comprehensive sexual and reproductive health services (SRHS). We analyzed data from community meetings and in-depth interviews with 30 AGYW PrEP users to understand the benefits and challenges of PrEP delivery in this context. RESULTS A total of 585 young women started PrEP at the TTT between July 2017 - October 2019. During in-depth interviews a subset of 30 AGYW described the CMHC intervention for PrEP delivery as acceptable and accessible. The TTT provided services at times and in neighborhood locations where AGYW organically congregate, thus facilitating service access and generating peer demand for PrEP uptake. The community-based nature of the CMHC, in addition to its adolescent friendly health providers, fostered a trusting provider-community-client relationship and strengthened AGYW HIV prevention self-efficacy. The integration of PrEP and SRHS service delivery was highly valued by AGYW. While the TTT's integration in the community facilitated acceptability of the PrEP delivery model, challenges faced by the broader community (community riots, violence and severe weather conditions) also at times interrupted PrEP delivery. CONCLUSIONS PrEP delivery from a CMHC is feasible and acceptable to young women in South Africa. However, to effectively scale-up PrEP it will be necessary to develop diverse PrEP delivery locations and modalities to meet AGYW HIV prevention needs.
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Affiliation(s)
- Elzette Rousseau
- Desmond Tutu Health Foundation, University of Cape Town, Cape Town, South Africa.
| | - Linda-Gail Bekker
- Desmond Tutu Health Foundation, University of Cape Town, Cape Town, South Africa
| | - Robin F Julies
- Desmond Tutu Health Foundation, University of Cape Town, Cape Town, South Africa
| | - Connie Celum
- Department of Global Health, University of Washington, Seattle, USA
| | - Jennifer Morton
- Department of Global Health, University of Washington, Seattle, USA
| | - Rachel Johnson
- Department of Global Health, University of Washington, Seattle, USA
| | - Jared M Baeten
- Department of Global Health, University of Washington, Seattle, USA
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26
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Claassen CW, Mumba D, Njelesani M, Nyimbili D, Mwango LK, Mwitumwa M, Mubanga E, Mulenga LB, Chisenga T, Nichols BE, Hendrickson C, Chitembo L, Okuku J, O'Bra H. Initial implementation of PrEP in Zambia: health policy development and service delivery scale-up. BMJ Open 2021; 11:e047017. [PMID: 34244265 PMCID: PMC8273462 DOI: 10.1136/bmjopen-2020-047017] [Citation(s) in RCA: 20] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
INTRODUCTION Daily pre-exposure prophylaxis (PrEP) for HIV prevention is highly effective, but not yet widely deployed in sub-Saharan Africa. We describe how Zambia developed PrEP health policy and then successfully implemented national PrEP service delivery. POLICY DEVELOPMENT Zambia introduced PrEP as a key strategy for HIV prevention in 2016, and established a National PrEP Task Force to lead policy advocacy and development. The Task Force was composed of government representatives, regulatory agencies, international donors, implementation partners and civil society organisations. Following an implementation pilot, PrEP was rolled out nationally using risk-based criteria alongside a national HIV prevention campaign. NATIONAL SCALE-UP In the first year of implementation, ending September 2018, 3626 persons initiated PrEP. By September 2019, the number of people starting PrEP increased by over sixfold to 23 327 persons at 728 sites across all ten Zambian provinces. In the first 2 years, 26 953 clients initiated PrEP in Zambia, of whom 31% were from key and priority populations. Continuation remains low at 25% and 11% at 6 and 12 months, respectively. LESSONS LEARNT Risk-based criteria for PrEP ensures access to those most in need of HIV prevention. Healthcare worker training in PrEP service delivery and health needs of key and priority populations is crucial. PrEP expansion into primary healthcare clinics and community education is required to reach full potential. Additional work is needed to understand and address low PrEP continuation. Finally, a task force of key stakeholders can rapidly develop and implement health policy, which may serve as a model for countries seeking to implement PrEP.
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Affiliation(s)
- Cassidy W Claassen
- Center for International Health, Education, and Biosecurity, University of Maryland School of Medicine, Baltimore, Maryland, USA
- Adult Infectious Diseases Center, University Teaching Hospital, Lusaka, Zambia
- Division of Infectious Diseases, Department of Medicine, University of Zambia School of Medicine, Lusaka, Zambia
| | - Daliso Mumba
- National HIV/AIDS/STI/TB Council, Lusaka, Zambia
- Ministry of Health, Lusaka, Zambia
| | | | - Derrick Nyimbili
- Chemonics Global Health Supply Chain Program-Procurement and Supply Management, Lusaka, Zambia
| | | | - Mundia Mwitumwa
- Adult Infectious Diseases Center, University Teaching Hospital, Lusaka, Zambia
- Division of Infectious Diseases, Department of Medicine, University of Zambia School of Medicine, Lusaka, Zambia
| | | | - Lloyd B Mulenga
- Adult Infectious Diseases Center, University Teaching Hospital, Lusaka, Zambia
- Division of Infectious Diseases, Department of Medicine, University of Zambia School of Medicine, Lusaka, Zambia
- Ministry of Health, Lusaka, Zambia
| | | | - Brooke E Nichols
- Department of Global Health, Boston University School of Public Health, Boston, Massachusetts, USA
- Health Economics and Epidemiology Research Office, Wits University, Johannesburg-Braamfontein, South Africa
| | - Cheryl Hendrickson
- Health Economics and Epidemiology Research Office, Wits University, Johannesburg-Braamfontein, South Africa
| | | | - Jackson Okuku
- U.S. Centers for Disease Control and Prevention, Lusaka, Zambia
| | - Heidi O'Bra
- U.S. Agency for International Development, Lusaka, Zambia
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27
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Fonner VA, Ntogwisangu J, Hamidu I, Joseph J, Fields J, Evans E, Kilewo J, Bailey C, Goldsamt L, Fisher CB, O'Reilly KR, Ruta T, Mbwambo J, Sweat MD. "We are in this together:" dyadic-level influence and decision-making among HIV serodiscordant couples in Tanzania receiving access to PrEP. BMC Public Health 2021; 21:720. [PMID: 33853559 PMCID: PMC8045366 DOI: 10.1186/s12889-021-10707-x] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2020] [Accepted: 03/24/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND A substantial number of new HIV infections in sub-Saharan Africa occur within stable couples. Biomedical prevention (pre-exposure prophylaxis, PrEP) and treatment (antiretroviral therapy, ART) can provide benefits to sexual partners and can be used to prevent infection within HIV serodiscordant couples. However, research is typically focused on individuals, not dyads, even when the intervention may directly or indirectly impact sexual partners. Gaps remain in understanding best practices for recruitment, informed consent, and intervention implementation in studies involving HIV prevention and treatment among heterosexual serodiscordant couples. This qualitative study was undertaken to understand and describe decision-making and dyadic-level influence among members of serodiscordant couples regarding (1) participation in a dyadic-based research study involving HIV self-testing and access to PrEP, and (2) utilization of PrEP and ART. METHODS This qualitative study was nested within an observational cohort study assessing the acceptability of home-based couples' HIV self-testing and uptake of dyadic care for serodiscordant couples involving facilitated referral for HIV-positive partners and access to PrEP for HIV-negative partners. Semi-structured in-depth interviews were conducted among a subset of study participants (n = 22) as well as individuals involved in serodiscordant relationships who chose not to participate (n = 9). Interviews focused on couples' decision-making regarding study participation and dyadic-level influence on medication use. Interviews were transcribed verbatim and translated from Kiswahili into English. Data were analyzed using thematic analysis. RESULTS Three major themes were identified: (1) HIV as "two people's secret" and the elevated role of partner support in serodiscordant relationships; (2) the intersectional role of HIV-status and gender on decision-making; (3) the relational benefits of PrEP, including psychosocial benefits for the couple that extend beyond prevention. CONCLUSIONS The study found that couples made joint decisions regarding study participation and uptake of HIV-related medication. Relational autonomy and dyadic-level influence should be considered within research and programs involving HIV serodiscordant couples.
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Affiliation(s)
- Virginia A Fonner
- Medical University of South Carolina, Department of Psychiatry and Behavioral Sciences, Division of Global and Community Health, Charleston, SC, USA.
| | - Jacob Ntogwisangu
- Department of Psychiatry and Mental Health, Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania
| | - Isihaka Hamidu
- Department of Psychiatry and Mental Health, Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania
| | - Juliet Joseph
- Medical University of South Carolina, College of Medicine, Charleston, SC, USA
| | - Joshua Fields
- Medical University of South Carolina, College of Medicine, Charleston, SC, USA
| | - Evans Evans
- Department of Psychiatry and Mental Health, Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania
| | - Jordan Kilewo
- Department of Psychiatry and Mental Health, Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania
| | - Claire Bailey
- Medical University of South Carolina, Department of Psychiatry and Behavioral Sciences, Division of Global and Community Health, Charleston, SC, USA
| | - Lloyd Goldsamt
- New York University, Rory Meyers College of Nursing, New York, NY, USA
| | - Celia B Fisher
- Fordham University, Department of Psychology and Center for Ethics Education, Bronx, NY, USA
| | - Kevin R O'Reilly
- Medical University of South Carolina, Department of Psychiatry and Behavioral Sciences, Division of Global and Community Health, Charleston, SC, USA
| | - Theonest Ruta
- Department of Psychiatry and Mental Health, Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania
| | - Jessie Mbwambo
- Department of Psychiatry and Mental Health, Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania
| | - Michael D Sweat
- Medical University of South Carolina, Department of Psychiatry and Behavioral Sciences, Division of Global and Community Health, Charleston, SC, USA
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28
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Bekker LG, Brown B, Joseph-Davey D, Gill K, Moorhouse M, Delany-Moretlwe S, Myer L, Orrell C, Rebe K, Venter WF, Wallis CL. Southern African guidelines on the safe, easy and effective use of pre-exposure prophylaxis: 2020. South Afr J HIV Med 2020; 21:1152. [PMID: 33354364 PMCID: PMC7736681 DOI: 10.4102/sajhivmed.v21i1.1152] [Citation(s) in RCA: 21] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2020] [Accepted: 08/14/2020] [Indexed: 12/28/2022] Open
Abstract
No abstract available.
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Affiliation(s)
- Linda-Gail Bekker
- Desmond Tutu HIV Centre, Institute of Infectious Disease and Molecular Medicine, University of Cape Town, Cape Town, South Africa
| | | | - Dvora Joseph-Davey
- Department of Epidemiology, University of California, Los Angeles, United States of America
- Division of Epidemiology and Biostatistics, School of Public Health and Family Medicine, University of Cape Town, Cape Town, South Africa
| | - Kathrine Gill
- Desmond Tutu HIV Centre, Institute of Infectious Disease and Molecular Medicine, University of Cape Town, Cape Town, South Africa
| | - Michelle Moorhouse
- Wits Reproductive Health and HIV Research Unit, University of the Witwatersrand, Johannesburg, South Africa
| | - Sinead Delany-Moretlwe
- Wits Reproductive Health and HIV Research Unit, University of the Witwatersrand, Johannesburg, South Africa
| | - Landon Myer
- Division of Epidemiology and Biostatistics, School of Public Health and Family Medicine, University of Cape Town, Cape Town, South Africa
| | - Catherine Orrell
- Desmond Tutu HIV Centre, Institute of Infectious Disease and Molecular Medicine, University of Cape Town, Cape Town, South Africa
- Department of Medicine, University of Cape Town, Cape Town, South Africa
| | - Kevin Rebe
- Life Vincent Pallotti Hospital, Cape Town, South Africa
- Department of Medicine and Infectious Diseases, University of Cape Town, Cape Town, South Africa
| | - W.D. Francois Venter
- Ezintsha, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Carole L. Wallis
- BARC-SA, Speciality Molecular Division, Lancet Laboratories, Johannesburg, South Africa
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Pretorius C, Schnure M, Dent J, Glaubius R, Mahiane G, Hamilton M, Reidy M, Matse S, Njeuhmeli E, Castor D, Kripke K. Modelling impact and cost-effectiveness of oral pre-exposure prophylaxis in 13 low-resource countries. J Int AIDS Soc 2020; 23:e25451. [PMID: 32112512 PMCID: PMC7048876 DOI: 10.1002/jia2.25451] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2019] [Accepted: 01/14/2020] [Indexed: 11/07/2022] Open
Abstract
INTRODUCTION Oral pre-exposure prophylaxis (PrEP) provision is a priority intervention for high HIV prevalence settings and populations at substantial risk of HIV acquisition. This mathematical modelling analysis estimated the impact, cost and cost-effectiveness of scaling up oral PrEP in 13 countries. METHODS We projected the impact and cost-effectiveness of oral PrEP between 2018 and 2030 using a combination of the Incidence Patterns Model and the Goals model. We created four PrEP rollout scenarios involving three priority populations-female sex workers (FSWs), serodiscordant couples (SDCs) and adolescent girls and young women (AGYW)-both with and without geographic prioritization. We applied the model to 13 countries (Eswatini, Ethiopia, Haiti, Kenya, Lesotho, Mozambique, Namibia, Nigeria, Tanzania, Uganda, Zambia and Zimbabwe). The base case assumed achievement of the Joint United Nations Programme on HIV/AIDS 90-90-90 antiretroviral therapy targets, 90% male circumcision coverage by 2020 and 90% efficacy and adherence levels for oral PrEP. RESULTS In the scenarios we examined, oral PrEP averted 3% to 8% of HIV infections across the 13 countries between 2018 and 2030. For all but three countries, more than 50% of the HIV infections averted by oral PrEP in the scenarios we examined could be obtained by rollout to FSWs and SDCs alone. For several countries, expanding oral PrEP to include medium-risk AGYW in all regions greatly increased the impact. The efficiency and impact benefits of geographic prioritization of rollout to AGYW varied across countries. Variations in cost-effectiveness across countries reflected differences in HIV incidence and expected variations in unit cost. For most countries, rolling out oral PrEP to FSWs, SDCs and geographically prioritized AGYW was not projected to have a substantial impact on the supply chain for antiretroviral drugs. CONCLUSIONS These modelling results can inform prioritization, target-setting and other decisions related to oral PrEP scale-up within combination prevention programmes. We caution against extensive use given limitations in cost data and implementation approaches. This analysis highlights some of the immediate challenges facing countries-for example, trade-offs between overall impact and cost-effectiveness-and emphasizes the need to improve data availability and risk assessment tools to help countries make informed decisions.
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Affiliation(s)
| | | | - Juan Dent
- The Palladium Group, Washington, DC, USA
| | | | | | | | | | | | - Emmanuel Njeuhmeli
- United States Agency for International Development (USAID), Mbabane, Eswatini
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Muwonge TR, Nsubuga R, Brown C, Nakyanzi A, Bagaya M, Bambia F, Katabira E, Kyambadde P, Baeten JM, Heffron R, Celum C, Mujugira A, Haberer JE. Knowledge and barriers of PrEP delivery among diverse groups of potential PrEP users in Central Uganda. PLoS One 2020; 15:e0241399. [PMID: 33112907 PMCID: PMC7592843 DOI: 10.1371/journal.pone.0241399] [Citation(s) in RCA: 21] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2020] [Accepted: 10/13/2020] [Indexed: 01/29/2023] Open
Abstract
BACKGROUND Scale-up of oral pre-exposure prophylaxis (PrEP) for HIV prevention in Uganda began with serodiscordant couples (SDC) and has expanded to other most at-risk populations (MARPs). We explored knowledge, acceptability, barriers and facilitators of PrEP use among potential PrEP users in four MARPs (SDC; men who have sex with men [MSM]; female sex workers [FSW], and fisher folk). METHODS We administered quantitative surveys to potential PrEP users in multiple settings in Central Uganda at baseline and approximately 9 months after healthcare worker (HCW) training on PrEP. RESULTS The survey was completed by 250 potential PrEP users at baseline and 125 after HCW training; 55 completed both surveys. For these 250 participants, mean age was 28.5 years (SD 6.9), 47% were male and 6% were transgender women, with approximately even distribution across MARPs and recruitment locations (urban, peri-urban, and rural). Most (65%) had not heard about PrEP. After HCW training, 24% of those sampled were aware of PrEP, and the proportion of those who accurately described PrEP as "antiretrovirals to be used before HIV exposure" increased from 54% in the baseline survey to 74% in the second survey (p<0.001). The proportion of participants who reported HCW as a source of PrEP information increased after training (59% vs 91%, p<0.001). In both surveys, nearly all participants indicated they were willing to take PrEP if offered. The most common anticipated barriers to PrEP were stigma, transportation, accessibility, busy schedules, and forgetfulness. Closeness to home was a common facilitator for all participant categories. CONCLUSIONS Initial awareness of PrEP was low, but PrEP knowledge and interest increased among diverse MARPs after HCW training. Demand creation and HCW training will be critical for increasing PrEP awareness among key populations, with support to overcome barriers to PrEP use. These findings should encourage the acceleration of PrEP rollout in Uganda.
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Affiliation(s)
- Timothy R. Muwonge
- Infectious Diseases Institute Makerere University, Kampala, Uganda
- * E-mail: ,
| | - Rogers Nsubuga
- Infectious Diseases Institute Makerere University, Kampala, Uganda
| | - Charles Brown
- Infectious Diseases Institute Makerere University, Kampala, Uganda
| | - Agnes Nakyanzi
- Infectious Diseases Institute Makerere University, Kampala, Uganda
| | - Monica Bagaya
- Infectious Diseases Institute Makerere University, Kampala, Uganda
| | - Felix Bambia
- Infectious Diseases Institute Makerere University, Kampala, Uganda
| | - Elly Katabira
- Department of Medicine, College of Health Sciences, Makerere University, Kampala, Uganda
| | - Peter Kyambadde
- Most At-Risk Populations Initiative, Kampala, Uganda
- STD/AIDS Control Program Ministry of Health, Kampala, Uganda
| | - Jared M. Baeten
- Department of Global Health, Medicine, and Epidemiology, University of Washington, Seattle, Washington, United States of America
| | - Renee Heffron
- Department of Global Health, Medicine, and Epidemiology, University of Washington, Seattle, Washington, United States of America
| | - Connie Celum
- Department of Global Health, Medicine, and Epidemiology, University of Washington, Seattle, Washington, United States of America
| | - Andrew Mujugira
- Infectious Diseases Institute Makerere University, Kampala, Uganda
| | - Jessica E. Haberer
- Department of General Internal Medicine, Massachusetts General Hospital Global Health, Boston, Massachusetts, United States of America
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Musinguzi N, Kidoguchi L, Mugo NR, Ngure K, Katabira E, Celum CL, Baeten JM, Heffron R, Haberer JE. Adherence to recommendations for ART and targeted PrEP use among HIV serodiscordant couples in East Africa: the "PrEP as a bridge to ART" strategy. BMC Public Health 2020; 20:1621. [PMID: 33115478 PMCID: PMC7594426 DOI: 10.1186/s12889-020-09712-3] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2020] [Accepted: 10/15/2020] [Indexed: 01/29/2023] Open
Abstract
BACKGROUND PrEP use should be aligned with periods of risk for HIV acquisition. For HIV serodiscordant couples, PrEP can be used as a bridge until the partner living with HIV takes antiretroviral therapy (ART) long enough to achieve viral suppression (the "PrEP as a Bridge to ART" strategy). However, adherence to this strategy is unknown. METHODS In a demonstration project in Kenya and Uganda, HIV-uninfected partners of serodiscordant couples were advised to take PrEP until the partner living with HIV took ART for ≥ 6 months. PrEP discontinuation was then recommended unless there were concerns about ART adherence, immediate fertility intentions, or outside partners with unknown HIV/ART status. Electronic adherence monitoring and socio-behavioral questionnaire data were used in logistic regression models to explore completion of this strategy and continuation of PrEP beyond recommendations to stop its use. RESULTS Among 833 serodiscordant couples, 436 (52%) HIV-uninfected partners completed ≥ 6 months of PrEP as a bridge to ART. Strategy completion was associated with older age (aOR per 5 years = 1.1; p = 0.008) and having fewer children (aOR = 0.9; p = 0.019). Of the 230 participants encouraged to stop PrEP according to strategy recommendations, 170 (74%) did so. PrEP continuation among the remaining 60 participants was associated with more education (aOR = 1.1; p = 0.029), a preference for PrEP over ART (aOR = 3.6; p = 0.026), comfort with managing their serodiscordant relationship (aOR = 0.6; p = 0.046), and believing PrEP makes sex safe (aOR = 0.5; p = 0.026). CONCLUSION Half of participants completed the PrEP as a bridge to ART strategy and the majority stopped PrEP as recommended. These findings suggest that targeting PrEP to periods of risk is a promising approach; however, tailoring counseling around aligning PrEP use and HIV risk will be important for optimal strategy implementation.
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Affiliation(s)
- Nicholas Musinguzi
- grid.33440.300000 0001 0232 6272Global Health Collaborative, Mbarara University of Science and Technology, P. O Box 434, Mbarara, Uganda
| | - Lara Kidoguchi
- grid.34477.330000000122986657Department of Medicine, University of Washington, Seattle, USA
| | - Nelly R. Mugo
- grid.33058.3d0000 0001 0155 5938Centres for Clinical Research, Kenya Medical Research Institute, Nairobi, Kenya ,grid.34477.330000000122986657Department of Global Health, University of Washington, Seattle, USA
| | - Kenneth Ngure
- grid.411943.a0000 0000 9146 7108School of Public Health, Jomo Kenyatta University of Agriculture and Technology Nairobi, Nairobi, Kenya
| | - Elly Katabira
- grid.11194.3c0000 0004 0620 0548Infectious Disease Institute, Makerere University, Kampala, Uganda
| | - Connie L. Celum
- grid.34477.330000000122986657Department of Medicine, University of Washington, Seattle, USA ,grid.34477.330000000122986657Department of Global Health, University of Washington, Seattle, USA ,grid.34477.330000000122986657Department of Epidemiology, University of Washington, Seattle, USA
| | - Jared M. Baeten
- grid.34477.330000000122986657Department of Medicine, University of Washington, Seattle, USA ,grid.34477.330000000122986657Department of Global Health, University of Washington, Seattle, USA ,grid.34477.330000000122986657Department of Epidemiology, University of Washington, Seattle, USA
| | - Renee Heffron
- grid.34477.330000000122986657Department of Global Health, University of Washington, Seattle, USA ,grid.34477.330000000122986657Department of Epidemiology, University of Washington, Seattle, USA
| | - Jessica E. Haberer
- grid.32224.350000 0004 0386 9924Massachusetts General Hospital and Harvard Medical School, Boston, USA
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Ngure K, Velloza J, Patel RC, Mugo NR, Bukusi EA, Haberer JE, Odoyo J, Celum C, Baeten JM, Heffron R. Alignment of PrEP use and effective contraceptive use among East African women in HIV serodiscordant partnerships. Int J STD AIDS 2020; 31:1263-1271. [PMID: 32998640 DOI: 10.1177/0956462420951501] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Women who have a prevention mindset may opt for concurrent use of oral pre-exposure prophylaxis (PrEP) and all forms of contraception; we therefore assessed how contraception may influence PrEP use or vice versa. We analyzed data from Kenyan and Ugandan HIV-uninfected non-pregnant women in sero-discordant partnerships who were participating in the Partners Demonstration Project. Using multivariable generalized estimating equation models, we estimated the associations between effective contraceptive use and 1) PrEP dispensation 2) high effective PrEP use. Among the 311 women (93.1% of all those followed in the Partners Demonstration Project) median age was 29 years (interquartile range [IQR] 24.0-35.0) and 115 (37.0%) reported using effective contraception at baseline. All the women initiated PrEP during the study and moderately high PrEP adherence was recorded at 73.1% of visits over an average 7.5 months following PrEP dispensation. Women (14.8%) consistently used an effective contraceptive throughout study follow-up. PrEP dispensation was more frequent among those concurrently using effective contraception, (adjusted relative risk [aRR] = 1.19; 95% confidence interval [CI] = 1.08-1.32) and contraceptive use was more common among those on PrEP (aRR = 1.63; 95% CI = 1.18-2.25). Among East African women at high risk of HIV infection, PrEP dispensation was more frequent among women using effective contraception, indicating that family planning outlets may be efficient locations to deliver PrEP.
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Affiliation(s)
- Kenneth Ngure
- Department of Community Health, Jomo Kenyatta University of Agriculture and Technology, Nairobi, Kenya.,Department of Global Health, University of Washington, Seattle, WA, USA
| | - Jennifer Velloza
- Department of Global Health, University of Washington, Seattle, WA, USA
| | - Rena C Patel
- Department of Global Health, University of Washington, Seattle, WA, USA.,Department of Medicine, University of Washington, Seattle, WA, USA
| | - Nelly R Mugo
- Department of Global Health, University of Washington, Seattle, WA, USA.,Center for Clinical Research, Kenya Medical Research Institute, Nairobi, Kenya
| | - Elizabeth A Bukusi
- Department of Global Health, University of Washington, Seattle, WA, USA.,Center for Microbiology Research, Kenya Medical Research Institute, Nairobi, Kenya.,Department of Obstetrics and Gynecology, University of Washington, Seattle, WA, USA
| | - Jessica E Haberer
- Center for Global Health, Massachusetts General Hospital, Boston, MA, USA.,Department of Medicine, Harvard Medical School, Boston, MA, USA
| | - Josephine Odoyo
- Center for Microbiology Research, Kenya Medical Research Institute, Nairobi, Kenya
| | - Connie Celum
- Department of Global Health, University of Washington, Seattle, WA, USA.,Department of Medicine, University of Washington, Seattle, WA, USA.,Department of Epidemiology, University of Washington, Seattle, WA, USA
| | - Jared M Baeten
- Department of Global Health, University of Washington, Seattle, WA, USA.,Department of Medicine, University of Washington, Seattle, WA, USA.,Department of Epidemiology, University of Washington, Seattle, WA, USA
| | - Renee Heffron
- Department of Global Health, University of Washington, Seattle, WA, USA.,Department of Epidemiology, University of Washington, Seattle, WA, USA
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Kagaayi J, Batte J, Nakawooya H, Kigozi B, Nakigozi G, Strömdahl S, Ekström AM, Chang LW, Gray R, Reynolds SJ, Komaketch P, Alamo S, Serwadda D. Uptake and retention on HIV pre-exposure prophylaxis among key and priority populations in South-Central Uganda. J Int AIDS Soc 2020; 23:e25588. [PMID: 32785976 PMCID: PMC7421540 DOI: 10.1002/jia2.25588] [Citation(s) in RCA: 37] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2019] [Revised: 04/28/2020] [Accepted: 07/01/2020] [Indexed: 11/19/2022] Open
Abstract
INTRODUCTION Pre-exposure prophylaxis (PrEP) programmes have been initiated in sub-Saharan Africa to prevent HIV acquisition in key populations at increased risk. However, data on PrEP uptake and retention in high-risk African communities are limited. We evaluated PrEP uptake and retention in HIV hyperendemic fishing villages and trading centres in south-central Uganda between April 2018 and March 2019. METHODS PrEP eligibility was assessed using a national risk screening tool. Programme data were used to evaluate uptake and retention over 12 months. Multivariable modified Poisson regression estimated adjusted prevalence ratios (aPR) and 95% Confidence intervals (CIs) of uptake associated with covariates. We used Kaplan-Meier analysis to estimate retention and multivariable Cox regression to estimate adjusted relative hazards (aRH) and 95% CIs of discontinuation associated with covariates. RESULTS AND DISCUSSION Of the 2985 HIV-negative individuals screened; 2750 (92.1 %) were eligible; of whom 2,536 (92.2%) accepted PrEP. Male (aPR = 0.91, 95% CI = 0.85 to 0.97) and female (aPR = 0.85, 95% CI = 0.77 to 0.94) fisher folk were less likely to accept compared to HIV-discordant couples. Median retention was 45.4 days for both men and women, whereas retention was higher among women (log rank, p < 0.001) overall. PrEP discontinuation was higher among female sex workers (aRH = 1.42, 95% CI = 1.09 to 1.83) and female fisher folk (aRH = 1.99, 95% CI = 1.46 to 2.72), compared to women in discordant couples. Male fisher folk (aRH = 1.37, 95% CI = 1.07 to 1.76) and male truck drivers (aRH = 1.49, 95% CI = 1.14 to 1.94) were more likely to discontinue compared to men in discordant couples. Women 30 to 34 years tended to have lower discontinuation rates compared to adolescents 15 to 19 years (RH = 0.78 [95% CI = 0.63 to 0.96]). CONCLUSIONS PrEP uptake was high, but retention was very low especially among those at the highest risk of HIV: fisher folk, sex workers and truck drivers and adolescent girls. Research on reasons for PrEP discontinuation could help optimize retention.
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Affiliation(s)
- Joseph Kagaayi
- Rakai Health Sciences Program, Kalisizo, Uganda
- Makerere University School of Public Health, Kampala, Uganda
| | - James Batte
- Rakai Health Sciences Program, Kalisizo, Uganda
| | | | | | | | - Susanne Strömdahl
- Department of Global Public Health and Karolinska University Hospital, Department of Infectious Diseases, Karolinska Institutet, Stockholm, Sweden
- Department of Medical Sciences, Section of Infectious Diseases, Uppsala University, Stockholm, Sweden
| | - Anna Mia Ekström
- Department of Global Public Health and Karolinska University Hospital, Department of Infectious Diseases, Karolinska Institutet, Stockholm, Sweden
| | - Larry W Chang
- Rakai Health Sciences Program, Kalisizo, Uganda
- Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
- Johns Hopkins School of Medicine, Baltimore, MD, USA
| | - Ron Gray
- Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Steven J Reynolds
- Rakai Health Sciences Program, Kalisizo, Uganda
- Johns Hopkins School of Medicine, Baltimore, MD, USA
- Division of Intramural Research, NIAID/NIH, Bethesda, MD, USA
| | | | - Stella Alamo
- Centers for Disease Control and Prevention, Kampala, Uganda
| | - David Serwadda
- Rakai Health Sciences Program, Kalisizo, Uganda
- Makerere University School of Public Health, Kampala, Uganda
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Wanga V, Baeten JM, Bukusi EA, Mugo NR, Asiimwe S, Ngure K, Mujugira A, Muwonge T, Odoyo JB, Haberer JE, Celum C, Heffron R. Sexual Behavior and Perceived HIV Risk Among HIV-Negative Members of Serodiscordant Couples in East Africa. AIDS Behav 2020; 24:2082-2090. [PMID: 31925607 DOI: 10.1007/s10461-019-02773-5] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
HIV risk perception may influence the use of HIV prevention interventions. Using data from HIV-negative adults enrolled in a study of pre-exposure prophylaxis (PrEP) and antiretroviral therapy for HIV-serodiscordant couples in Kenya and Uganda, we examined associations between: (1) condom use and risk perception and (2) risk perception and PrEP adherence. Two-thirds of HIV-negative partners reported condomless sex with their HIV-positive partner or another partner in the month prior to study enrollment. Compared to those who reported no condomless sex, participants who reported condomless sex during the month prior to study visit had fivefold higher odds of reporting "high risk" vs "no risk" perception (36.3 versus 10.9%: aOR 4.9, 95% CI 3.4-6.9). Reporting condomless sex in the most recent sex act was associated with increased odds of perceiving some HIV risk (aOR for high risk = 7.3, 95% CI 4.9-10.8; aOR for moderate risk = 4.8, 95% CI 3.5-6.7; aOR for low risk = 3.5, 95% CI 2.7-4.6). We found no significant association between risk perception and PrEP adherence. Sexual behavior aligned with perceived HIV risk, which can facilitate an HIV-negative individual's decisions about PrEP use.
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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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36
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Irungu EM, Baeten JM. PrEP rollout in Africa: status and opportunity. Nat Med 2020; 26:655-664. [PMID: 32405065 DOI: 10.1038/s41591-020-0872-x] [Citation(s) in RCA: 63] [Impact Index Per Article: 15.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2019] [Accepted: 04/06/2020] [Indexed: 12/14/2022]
Abstract
Following recommendations by the World Health Organization in 2015, and key clinical trials, countries in sub-Saharan Africa, the region with the highest burden of human immunodeficiency virus (HIV), developed policies that incorporate pre-exposure prophylaxis (PrEP) into national HIV-prevention strategies. By the end of 2019, more than one third of people receiving PrEP globally were in Africa. Crucial understandings gained from early rollout among at-risk populations, such as HIV-serodiscordant couples, adolescent girls and young women, female sex workers, and men who have sex with men, include the importance of strategies for maintaining persistent adherence to PrEP and novel approaches to making PrEP services accessible, simplified and efficient. This Perspective will discuss the current status of these programs and how to further widen their implementation.
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Affiliation(s)
- Elizabeth M Irungu
- College of Health Sciences, Jomo Kenyatta University of Agriculture and Technology, Nairobi, Kenya.,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.
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Ortblad KF, Stalter RM, Bukusi EA, Ngure K, Mujugura A, Celum C, Baeten JM, Heffron R. No Evidence of Sexual Risk Compensation Following PrEP Initiation Among Heterosexual HIV Serodiscordant Couples in Kenya and Uganda. AIDS Behav 2020; 24:1365-1375. [PMID: 31696370 PMCID: PMC7156350 DOI: 10.1007/s10461-019-02720-4] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
Recent studies among men who have sex with men suggest that sexual behaviors associated with risk of sexually transmitted infections increase following initiation of pre-exposure prophylaxis (PrEP) for HIV prevention. We used longitudinal data from HIV-uninfected participants (n = 1013) enrolled in an open-label study of PrEP delivered to Ugandan and Kenyan heterosexual HIV serodiscordant couples to understand the association between PrEP initiation and HIV risk-related sexual behaviors among these couples. In the month following PrEP initiation, the mean number of monthly sex acts within couples decreased from 7.9 to 6.9 (mean difference: - 1.1; 95% CI - 1.5, - 0.7) and the proportion of couples having condomless sex decreased from 65% to 32% (percentage point change: - 33%; 95% CI - 37%, - 30%); these behaviors then remained relatively constant over 2 years. We found no evidence of sexual risk compensation following PrEP initiation within African serodiscordant couples. However, roughly a third of couples continued to engage in condomless sex during follow up, emphasizing the importance of continued PrEP use to sustain HIV protection.
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Affiliation(s)
- Katrina F Ortblad
- Department of Global Health, University of Washington, 908 Jefferson St, 12th floor, Seattle, WA, 98104, USA.
| | - Randy M Stalter
- Department of Global Health, University of Washington, 908 Jefferson St, 12th floor, Seattle, WA, 98104, USA
- Department of Epidemiology, University of Washington, Seattle, USA
| | - Elizabeth A Bukusi
- Department of Global Health, University of Washington, 908 Jefferson St, 12th floor, Seattle, WA, 98104, USA
- Department of Obstetrics and Gynecology, University of Washington, Seattle, USA
- Centre for Microbiology Research, Kenya Medical Research Institute, Nairobi, Kenya
| | - Kenneth Ngure
- Department of Community Health, Jomo Kenyatta University of Agriculture and Technology, Nairobi, Kenya
| | - Andrew Mujugura
- Infectious Diseases Institute, Makerere University, Kampala, Uganda
| | - Connie Celum
- Department of Global Health, University of Washington, 908 Jefferson St, 12th floor, Seattle, WA, 98104, USA
- Department of Medicine, University of Washington, Seattle, USA
| | - Jared M Baeten
- Department of Global Health, University of Washington, 908 Jefferson St, 12th floor, Seattle, WA, 98104, USA
- Department of Epidemiology, University of Washington, Seattle, USA
- Department of Medicine, University of Washington, Seattle, USA
| | - Renee Heffron
- Department of Global Health, University of Washington, 908 Jefferson St, 12th floor, Seattle, WA, 98104, USA
- Department of Medicine, University of Washington, Seattle, USA
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38
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Irungu EM, Ngure K, Mugwanya KK, Awuor M, Dollah A, Ongolly F, Mugo N, Bukusi E, Wamoni E, Odoyo J, Morton JF, Barnabee G, Mukui I, Baeten JM, O'Malley G. "Now that PrEP is reducing the risk of transmission of HIV, why then do you still insist that we use condoms?" the condom quandary among PrEP users and health care providers in Kenya. AIDS Care 2020; 33:92-100. [PMID: 32207327 DOI: 10.1080/09540121.2020.1744507] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
Communication around condom use in the context of PrEP services presents a potential conundrum for patients and providers. Within the Partners Scale-Up Project, which supports integration of PrEP delivery in HIV care clinics, we interviewed 41 providers and 61 PrEP users and identified themes relating to condom messaging and use. Most providers counselled PrEP initiators to always use both PrEP and condoms, except when trying to conceive. However, others reported contexts and rationales for not emphasizing condom use. Providers reported that PrEP users were sometimes confused, even frustrated, with their insistence on using condoms in addition to PrEP. PrEP users generally regarded PrEP as a more feasible and desirable HIV prevention method than condoms, enabling increased sexual pleasure and conception, and reducing the conflict and stigma associated with condom use. Innovative approaches to condom counselling in PrEP programs are needed.
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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
| | - Kenneth Ngure
- Department of Global Health, University of Washington.,School of Public Health, Jomo Kenyatta University of Agriculture and Technology
| | | | - Merceline Awuor
- Centre for Microbiology Research, Kenya Medical Research Institute
| | - Annabelle Dollah
- Centre for Microbiology Research, Kenya Medical Research Institute
| | - Fernandos Ongolly
- Centre for Clinical 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
| | - Elizabeth Bukusi
- Department of Global Health, University of Washington.,Centre for Microbiology Research, Kenya Medical Research Institute
| | - Elizabeth Wamoni
- Centre for Clinical Research, Kenya Medical Research Institute, Nairobi, Kenya
| | - Josephine Odoyo
- Centre for Microbiology Research, Kenya Medical Research Institute
| | | | - Gena Barnabee
- Department of Global Health, University of Washington
| | | | - Jared M Baeten
- Department of Global Health, University of Washington.,Department of Epidemiology, University of Washington.,Department of Medicine, University of Washington
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Kinuthia J, Pintye J, Abuna F, Mugwanya KK, Lagat H, Onyango D, Begnel E, Dettinger J, Baeten JM, John-Stewart G. Pre-exposure prophylaxis uptake and early continuation among pregnant and post-partum women within maternal and child health clinics in Kenya: results from an implementation programme. Lancet HIV 2019; 7:e38-e48. [PMID: 31813837 DOI: 10.1016/s2352-3018(19)30335-2] [Citation(s) in RCA: 99] [Impact Index Per Article: 19.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2019] [Revised: 07/27/2019] [Accepted: 09/13/2019] [Indexed: 01/17/2023]
Abstract
BACKGROUND Pregnant women in settings with high HIV prevalence are at increased risk of HIV acquisition and subsequent vertical transmission. We implemented and evaluated a novel programme to provide pre-exposure prophylaxis (PrEP) in maternal and child health clinics in Kenya. METHODS In collaboration with Kisumu County Department of Health, we integrated PrEP delivery within 16 maternal and child health clinics in Kisumu County (Kenya). Women and girls older than 15 years seeking maternal and child health services who tested HIV negative at that visit or within a month and were willing to receive PrEP counselling were interviewed to assess for HIV behavioural risk factors and offered PrEP. Correlates of PrEP initiation and continuation were assessed using Poisson regression in univariate and multivariate analyses. Potential correlates included in our analyses were age, marital status, marriage type, whether pregnant or post partum, gestational age (if pregnant), and HIV risk factors in the previous 6 months. Reasons for the decision to discontinue after having decided to initiate PrEP were evaluated. Women who initiated PrEP were followed up 1 month, 3 months, and 6 months after initiation. FINDINGS Between Nov 20, 2017, and June 13, 2018, 9376 pregnant and post-partum women were assessed for behavioural risk factors and willingness to initiate PrEP. Overall, 2030 (21·7%) initiated PrEP, and 2027 had the status of their partner captured (153 [79·3%] of 193 women with partners living with HIV, 1178 [37·2%] of 3165 women with partners of unknown HIV status, and 696 [11·6%] of 5997 women with HIV-negative partners). Predictors of PrEP initiation in the multivariate analysis were: being younger than 24 years (adjusted prevalence ratio 1·14, 95% CI 1·02-1·28); having a partner living with HIV (6·96, 5·46-8·89) or of unknown HIV status (3·08, 2·50-3·81); gestational age of less than 26 weeks (1·22, 1·02-1·47); having been diagnosed or treated for a sexually transmitted infection (1·57, 1·20-2·06); having been forced to have sex (1·82, 1·38-2·42); having experienced intimate partner violence during the previous 6 months (1·65, 1·10-2·48); having shared needles while engaging in injection drug use (2·43, 1·69-3·50); and recurrent use of post-exposure prophylaxis (1·96, 1·36-2·82). Overall, 786 (38·7%) of 2030 women who initiated PrEP continued use after the first month, with 104 (68·0%) of 153 women who had a partner living with HIV continuing use. Having a partner living with HIV was the only predictor of PrEP continuation at 1 month in the multivariable model (1·98, 1·54-2·55). Frequent reasons for discontinuation were side effects and low HIV risk perception. No incident HIV infection was reported among women on PrEP. INTERPRETATION Many women attending maternal and child health clinics had risk factors for HIV and elected to use PrEP, indicating that routinely accessed maternal and child health clinics can be an effective platform for PrEP delivery for young women. As PrEP awareness rises, PrEP provision in routine clinical settings such as maternal and child health facilities might contribute to decreased HIV incidence among young women. FUNDING US Department of State.
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Affiliation(s)
- John Kinuthia
- Department of Global Health, University of Washington, Seattle, WA, USA; Department of Research & Programs, Kenyatta National Hospital, Nairobi, Kenya.
| | - Jillian Pintye
- Department of Global Health, University of Washington, Seattle, WA, USA
| | - Felix Abuna
- University of Washington-Kenya, Nairobi, Kenya
| | | | | | | | - Emily Begnel
- Department of Global Health, University of Washington, Seattle, WA, USA
| | - Julia 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
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Tugume L, Muwonge TR, Joloba EN, Isunju JB, Kiweewa FM. Perceived risk versus objectively measured risk of HIV acquisition: a cross-sectional study among HIV-negative individuals in Serodiscordant partnerships with clients attending an Urban Clinic in Uganda. BMC Public Health 2019; 19:1591. [PMID: 31783826 PMCID: PMC6884744 DOI: 10.1186/s12889-019-7929-0] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2019] [Accepted: 11/08/2019] [Indexed: 01/13/2023] Open
Abstract
Background Acceptability of Pre-exposure Prophylaxis (PrEP) could be hampered by low self-perceived risk for HIV acquisition. Moreover, discordance between risk perception and actual risk of HIV acquisition is likely to occur. We assessed congruence between the level of self- perceived and that of objectively scored risk of HIV acquisition among HIV-negative individuals in discordant relationships. Methods This was a cross-sectional study among a representative sample of HIV-negative adult males and females whose partners were receiving antiretroviral therapy for at least 3 months from the Infectious Diseases Institute Clinic in Kampala, Uganda. Perceived risk was measured based on self-report using a numerical rating scale whereas objective risk was measured using a validated risk score tool. Congruence between perceived risk and objectively scored risk was evaluated using descriptive statistics and validity measures. Incongruence between the two phenomena was further evaluated using univariate and multivariate regression analyses. Results HIV-negative partners evaluated in this study were mostly male (64%) with a median age of 41 years (IQR 35 to 50). Majority (76.3%) of the partners perceived themselves as low risk for HIV acquisition. Similarly, most (93.8%) were objectively scored as low risk. However, nearly three quarters (72.7%) of partners who were objectively scored as high risk perceived themselves as being at low risk and all were men. The sensitivity and specificity of perceived risk for detecting the objectively measured risk was 27.3 and 76.5% respectively; area under ROC curve = 0.52; 95%CI (0.38, 0.66). The proportion of participants at high risk of HIV acquisition who perceived their risk as low was greater among those whose partners had detectable viral load compared to participants whose partners had undetectable viral load (PR = 0.51; 95%CI 0.29 to 0.90). Conclusion Incongruence between perceived and objectively measured risk of HIV acquisition does occur especially among individuals whose partners had a detectable viral load. PrEP counselling for serodiscordant couples should focus on explaining the consequence of detectable viral load in the HIV-positive partner on HIV transmission risk.
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Affiliation(s)
- Lillian Tugume
- Makerere University College of Health Sciences, School of Public Health, Kampala, Uganda. .,Infectious Diseases Institute, Makerere University, Kampala, Uganda.
| | | | - Edith Nakku Joloba
- Makerere University College of Health Sciences, School of Public Health, Kampala, Uganda
| | - John Bosco Isunju
- Makerere University College of Health Sciences, School of Public Health, Kampala, Uganda
| | - Flavia Matovu Kiweewa
- Makerere University College of Health Sciences, School of Public Health, Kampala, Uganda.,Makerere University- John Hopkins University Research Collaboration, Kampala, Uganda
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41
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Abstract
Clinical studies have demonstrated that use of tenofovir disoproxil fumarate with or without emtricitabine as antiretroviral pre-exposure prophylaxis (PrEP) can decrease the risk of human immunodeficiency virus (HIV) acquisition when medication adherence is high. However, the potential for PrEP to promote antiretroviral resistance remains an important public health consideration. We performed a search of the medical literature to identify studies that address HIV drug resistance during PrEP use. In this review, we summarize findings about emergent drug resistance during clinical trials of PrEP, case reports of seroconversions in patients adherent to PrEP, and animal studies of PrEP effectiveness against drug-resistant viral strains. We also discuss the potential utility of novel PrEP formulations for protection against drug-resistant HIV, the impact of drug resistance on HIV treatment options, and mathematical models that estimate the potential contribution of PrEP to population-level drug resistance. Evidence suggests that selection for HIV drug resistance with PrEP use is infrequent and most likely to occur when PrEP is used during undiagnosed acute HIV infection. Breakthrough infections during PrEP use with high adherence are possible, but appear to be rare. The prevalence of drug-resistant HIV strains needs to be monitored as PrEP is scaled up. However, the benefit of a decreased HIV incidence with wider PrEP use is likely to outweigh the risk of harms from possible increases in the prevalence of HIV drug resistance.
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Affiliation(s)
- Kevin M Gibas
- Division of Infectious Diseases, Beth Israel Deaconess Medical Center, 110 Francis St. W/LMOB, Suite GB, Boston, MA, 02215, USA
| | - Polly van den Berg
- Division of Infectious Diseases, Beth Israel Deaconess Medical Center, 110 Francis St. W/LMOB, Suite GB, Boston, MA, 02215, USA
| | - Victoria E Powell
- Division of Infectious Diseases, Beth Israel Deaconess Medical Center, 110 Francis St. W/LMOB, Suite GB, Boston, MA, 02215, USA
| | - Douglas S Krakower
- Division of Infectious Diseases, Beth Israel Deaconess Medical Center, 110 Francis St. W/LMOB, Suite GB, Boston, MA, 02215, USA.
- The Fenway Institute, Fenway Health, Boston, MA, USA.
- Department of Population Medicine, Harvard Medical School, Boston, MA, USA.
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42
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Masyuko S, Mukui I, Njathi O, Kimani M, Oluoch P, Wamicwe J, Mutegi J, Njogo S, Anyona M, Muchiri P, Maikweki L, Musyoki H, Bahati P, Kyongo J, Marwa T, Irungu E, Kiragu M, Kioko U, Ogando J, Were D, Bartilol K, Sirengo M, Mugo N, Baeten JM, Cherutich P, PrEP Technical Working Group OBOT. Pre-exposure prophylaxis rollout in a national public sector program: the Kenyan case study. Sex Health 2019; 15:578-586. [PMID: 30408432 DOI: 10.1071/sh18090] [Citation(s) in RCA: 60] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2018] [Accepted: 09/29/2018] [Indexed: 12/20/2022]
Abstract
Background While advances have been made in HIV prevention and treatment, new HIV infections continue to occur. The introduction of pre-exposure prophylaxis (PrEP) as an additional HIV prevention option for those at high risk of HIV may change the landscape of the HIV epidemic, especially in sub-Saharan Africa, which bears the greatest HIV burden. METHODS This paper details Kenya's experience of PrEP rollout as a national public sector program. The process of a national rollout of PrEP guidance, partnerships, challenges, lessons learnt and progress related to national scale up of PrEP in Kenya, as of 2018, is described. National rollout of PrEP was strongly lead by the government, and work was executed through a multidisciplinary, multi-organisation dedicated team. This required reviewing available evidence, providing guidance to health providers, integration into existing logistic and health information systems, robust communication and community engagement. Mapping of the response showed that subnational levels had existing infrastructure but required targeted resources to catalyse PrEP provision. Rollout scenarios were developed and adopted, with prioritisation of 19 counties focusing on high incidence area and high potential PrEP users to maximise impact and minimise costs. RESULTS PrEP is now offered in over 900 facilities countrywide. There are currently over 14000 PrEP users 1 year after launching PrEP. CONCLUSIONS Kenya becomes the first African country to rollout PrEP as a national program, in the public sector. This case study will provide guidance for low- and middle-income countries planning the rollout of PrEP in response to both generalised and concentrated epidemics.
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Affiliation(s)
- Sarah Masyuko
- The National AIDS and STI Control Program, Ministry of Health, Afya Annex, Kenyatta National Hospital Grounds, Nairobi, Kenya
| | - Irene Mukui
- The National AIDS and STI Control Program, Ministry of Health, Afya Annex, Kenyatta National Hospital Grounds, Nairobi, Kenya
| | - Olivia Njathi
- Clinton Health Access Initiative, Timau Plaza, 3rd Floor, Argwings Kodhek Road, Nairobi, Kenya
| | - Maureen Kimani
- The National AIDS and STI Control Program, Ministry of Health, Afya Annex, Kenyatta National Hospital Grounds, Nairobi, Kenya
| | - Patricia Oluoch
- Centers for Disease Control, KEMRI Complex, Mbagathi Road off Mbagathi Way, Nairobi, Kenya
| | - Joyce Wamicwe
- The National AIDS and STI Control Program, Ministry of Health, Afya Annex, Kenyatta National Hospital Grounds, Nairobi, Kenya
| | - Jane Mutegi
- Jhpiego, Ring Road, 14 Riverside, Nairobi, Kenya
| | - Susan Njogo
- The National AIDS and STI Control Program, Ministry of Health, Afya Annex, Kenyatta National Hospital Grounds, Nairobi, Kenya
| | - Micah Anyona
- Jhpiego, Ring Road, 14 Riverside, Nairobi, Kenya
| | - Phillip Muchiri
- Clinton Health Access Initiative, Timau Plaza, 3rd Floor, Argwings Kodhek Road, Nairobi, Kenya
| | - Lucy Maikweki
- Population Services International, Lenana Road, Jumuia Place, Wing B, 2nd Floor, Nairobi, Kenya
| | - Helgar Musyoki
- The National AIDS and STI Control Program, Ministry of Health, Afya Annex, Kenyatta National Hospital Grounds, Nairobi, Kenya
| | - Prince Bahati
- International AIDS Vaccine Initiative, ABC Place, Building 2, 3rd Floor, Waiyaki Way, Nairobi, Kenya
| | | | - Tom Marwa
- Jhpiego, Ring Road, 14 Riverside, Nairobi, Kenya
| | - Elizabeth Irungu
- Kenya Medical Research Institute, Centre for Clinical Research Laboratories, Nairobi, Kenya
| | | | - Urbanus Kioko
- University of Nairobi, School of Economics, Nairobi, Kenya
| | - Justus Ogando
- Clinton Health Access Initiative, Timau Plaza, 3rd Floor, Argwings Kodhek Road, Nairobi, Kenya
| | - Dan Were
- Jhpiego, Ring Road, 14 Riverside, Nairobi, Kenya
| | - Kigen Bartilol
- The National AIDS and STI Control Program, Ministry of Health, Afya Annex, Kenyatta National Hospital Grounds, Nairobi, Kenya
| | - Martin Sirengo
- The National AIDS and STI Control Program, Ministry of Health, Afya Annex, Kenyatta National Hospital Grounds, Nairobi, Kenya
| | - Nelly Mugo
- Kenya Medical Research Institute, Centre for Clinical Research Laboratories, Nairobi, Kenya
| | - Jared M Baeten
- University of Washington, 510 San Juan Road, Seattle, WA 98195, USA
| | - Peter Cherutich
- Ministry of Health - Department of Preventive and Promotive Services, Cathedral Road, Nairobi, Kenya
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Hodges-Mameletzis I, Dalal S, Msimanga-Radebe B, Rodolph M, Baggaley R. Going global: the adoption of the World Health Organization's enabling recommendation on oral pre-exposure prophylaxis for HIV. Sex Health 2019; 15:489-500. [PMID: 30496718 DOI: 10.1071/sh18125] [Citation(s) in RCA: 43] [Impact Index Per Article: 8.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2018] [Accepted: 10/08/2018] [Indexed: 11/23/2022]
Abstract
In September 2015, the World Health Organization (WHO) launched evidence-based guidelines by recommending that any person at substantial HIV risk should be offered oral pre-exposure prophylaxis (PrEP) containing tenofovir disoproxil fumarate (TDF) as an additional prevention choice. Since 2017, PrEP medicines have also been listed in the WHO's Essential Medicines List, including TDF/emtricitabine (FTC) and TDF in combination with lamivudine (3TC). A descriptive policy review and analysis of countries adopting WHO's 2015 recommendation on oral PrEP was conducted. As of June 2018, we identified 35 countries that had some type of policy on oral PrEP, and an additional five countries where a specific policy on PrEP is currently pending. A total of 19 high-income countries (HICs) and 21 low- and middle-income countries (LMICs) have adopted or have a pending policy. Most countries that have adopted or pending PrEP are in the European (42.9%) or African (30.0%) region. TDF/FTC is the most commonly recommended PrEP drug in the guidelines reviewed, although seven countries, namely in sub-Saharan Africa (6/7), are also recommending the use of TDF/3TC for PrEP. In sum, by the end of 2018, at least 40 countries (20.6%) are anticipated to have adopted WHO's oral PrEP recommendation. Nonetheless, policy uptake does not reflect broader programmatic coverage of PrEP services, which remain limited across all settings, irrespective of income status. Enhancing global partnerships is needed to support and track ongoing policy adoption and to ensure that policy is translated into meaningful implementation of PrEP services.
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Affiliation(s)
| | - Shona Dalal
- World Health Organization, Headquarters, Avenue Appia 20, 1202 Geneva, Switzerland
| | - Busisiwe Msimanga-Radebe
- World Health Organization, South Africa Country Office, 7th Floor Metro Park Building, 351 Francis Baard Street, Pretoria, 0002, South Africa
| | - Michelle Rodolph
- World Health Organization, Headquarters, Avenue Appia 20, 1202 Geneva, Switzerland
| | - Rachel Baggaley
- World Health Organization, Headquarters, Avenue Appia 20, 1202 Geneva, Switzerland
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PrEP Discontinuation and Prevention-Effective Adherence: Experiences of PrEP Users in Ugandan HIV Serodiscordant Couples. J Acquir Immune Defic Syndr 2019; 82:265-274. [PMID: 31609925 PMCID: PMC6812551 DOI: 10.1097/qai.0000000000002139] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Abstract
BACKGROUND Optimal adherence to oral pre-exposure prophylaxis (PrEP) for HIV prevention involves aligning consistent PrEP use with periods of risk to achieve prevention-effective adherence. Prevention-effective adherence is predicated on individuals discontinuing PrEP during periods without expected risk. For stable, serodiscordant couples, antiretroviral therapy (ART) adherence by the HIV-positive partner markedly decreases HIV transmission risk, potentially obviating the need for continued PrEP use; yet little is known about actual lived experiences of discontinuing PrEP. METHODS In-depth qualitative interviews were conducted with HIV-uninfected PrEP users in serodiscordant couples taking part in the Partners Demonstration Project at IDI-Kasangati, Kampala, Uganda. Open-ended interviews elicited information on the partnered relationship; understandings of PrEP; prevention strategies; and experiences of PrEP discontinuation. An inductive, thematic, content-analytic approach was used to analyze study data. RESULTS Uninfected partners experienced PrEP as a valued resource for preventing HIV acquisition. Despite ongoing ART use by HIV-positive partners for a period of time consistent with viral suppression, discontinuation of PrEP was experienced as a loss of protection and a corresponding increase in risk of HIV acquisition. Uninfected partners responded with strategies aimed at offsetting this subjective sense of increased risk, specifically: (1) changing sexual practices; (2) prioritizing fidelity in the relationship; (3) increasing reliance on condoms; and (4) seeking evidence of partners' ART adherence. CONCLUSIONS These experiences highlight the challenges PrEP users in serodiscordant couples face in discontinuing PrEP for prevention-effective adherence. Flexible interventions that support individuals during this transition may increase comfort with discontinuing PrEP when alternative prevention strategies provide protection, such as a partner's consistent adherence to ART.
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Abstract
BACKGROUND Low adherence can undermine the efficacy of daily oral pre-exposure prophylaxis (PrEP). Mental health conditions, particularly depression, could be associated with low PrEP adherence, especially for women. SETTING We analyzed data from 1013 Kenyan and Ugandan HIV-uninfected participants in the Partners Demonstration Project, an open-label study of PrEP delivered to HIV-uninfected members of serodiscordant couples. METHODS Participants completed quarterly visits over 2 years and were encouraged to use PrEP until their partners living with HIV had ≥6 months of antiretroviral therapy use (when viral suppression was expected). PrEP adherence was measured daily with electronic medication event monitoring system caps and dichotomized into low (<80% of expected bottle openings) and high adherence. Depression was assessed annually using the 16-item Hopkins Symptom Checklist screening tool; scores >1.75 indicate "probable depression." The association between probable depression and PrEP adherence was assessed separately for men and women using generalized estimating equations and marginal structural models. RESULTS At enrollment, 39 (11.7% of 334) women and 64 (9.4% of 679) men reported symptoms indicating probable depression, and these proportions decreased during follow-up (P < 0.001 for women and men). Probable depression was significantly associated with low PrEP adherence among women (adjusted risk ratio = 1.77; 95% confidence interval: 1.14 to 2.77; P = 0.01); there was no association between depression and adherence among men (P = 0.50). Marginal structural models and sensitivity analyses confirmed these findings. CONCLUSIONS Depression was relatively uncommon in this population and was an independent risk factor for low PrEP adherence among women. For PrEP programs targeting African women, integration of depression screening may improve PrEP effectiveness.
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Velloza J, Bacchetti P, Hendrix CW, Murnane P, Hughes JP, Li M, E. Curlin M, Holtz TH, Mannheimer S, Marzinke MA, Amico KR, Liu A, Piwowar-Manning E, Eshleman SH, Dye BJ, Gandhi M, Grant RM. Short- and Long-Term Pharmacologic Measures of HIV Pre-exposure Prophylaxis Use Among High-Risk Men Who Have Sex With Men in HPTN 067/ADAPT. J Acquir Immune Defic Syndr 2019; 82:149-158. [PMID: 31335588 PMCID: PMC6749964 DOI: 10.1097/qai.0000000000002128] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2019] [Accepted: 06/21/2019] [Indexed: 11/26/2022]
Abstract
BACKGROUND The effectiveness of oral emtricitabine (FTC)/tenofovir (TFV) disoproxil fumarate-based HIV pre-exposure prophylaxis (PrEP) depends on adherence. Pharmacologic measures help interpret patterns and predictors of PrEP adherence. SETTING We analyzed data from the subsample of men who have sex with men enrolled in HPTN 067/ADAPT in Bangkok, Thailand, and Harlem, NY, U.S. METHODS After a 5-week directly observed therapy period, participants were randomized to daily, time-driven, or event-driven PrEP. Follow-up occurred at weeks 4, 12, and 24 after randomization. Plasma and hair FTC/TFV levels indicated short- and long-term PrEP use, respectively. Electronic pill bottle data (Wisepill) were collected weekly. Pearson correlation coefficients between PrEP use measures were calculated; linear mixed models assessed predictors of plasma and hair drug concentrations. RESULTS Among 350 participants (median age: 31 years, interquartile range: 25-38), 49.7% were from Harlem, half had less than college education, and 21% reported heavy alcohol use. In multivariable models, being enrolled in Harlem, being in non-daily arms, and having less than college education were associated with lower hair FTC/TFV concentrations; heavy alcohol use was associated with higher concentrations. Similar results were found for plasma concentrations by site and arm, but older age and greater number of sex partners were associated with higher concentrations. Hair and plasma FTC/TFV concentrations were moderately correlated with Wisepill data (r ≥ 0.29) across visits. CONCLUSIONS In HPTN067, plasma, hair, and Wisepill data correlated with one another and served as complementary adherence measures. Site, arm, education, age, alcohol, and sexual behavior influenced patterns of adherence.
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Affiliation(s)
- Jennifer Velloza
- Department of Global Health, University of Washington, Seattle, WA
| | - Peter Bacchetti
- School of Medicine, University of California at San Francisco, San Francisco, CA
| | | | - Pamela Murnane
- School of Medicine, University of California at San Francisco, San Francisco, CA
| | - James P. Hughes
- Department of Global Health, University of Washington, Seattle, WA
- Fred Hutchinson Cancer Research Center, Seattle, WA
| | - Maoji Li
- Fred Hutchinson Cancer Research Center, Seattle, WA
| | - Marcel E. Curlin
- U.S. Centers for Disease Control and Prevention, Atlanta, GA
- Thailand MOPH–U.S. CDC Collaboration, Bangkok, Thailand
- Division of Infectious Disease, Oregon Health & Science University, Portland, OR
| | - Timothy H. Holtz
- U.S. Centers for Disease Control and Prevention, Atlanta, GA
- Thailand MOPH–U.S. CDC Collaboration, Bangkok, Thailand
| | | | | | - K. Rivet Amico
- Department of Health Behavior and Health Education, School of Public Health, University of Michigan, Ann Arbor, MI
| | - Albert Liu
- San Francisco Department of Public Health, San Francisco, CA
| | | | | | | | - Monica Gandhi
- School of Medicine, University of California at San Francisco, San Francisco, CA
| | - Robert M. Grant
- School of Medicine, University of California at San Francisco, San Francisco, CA
- Gladstone Institute of Virology and Immunology, University of California at San Francisco, San Francisco, CA
| | - HPTN 067/ADAPT Study Team
- Department of Global Health, University of Washington, Seattle, WA
- School of Medicine, University of California at San Francisco, San Francisco, CA
- Department of Medicine, Johns Hopkins University, Baltimore, MD
- Fred Hutchinson Cancer Research Center, Seattle, WA
- U.S. Centers for Disease Control and Prevention, Atlanta, GA
- Thailand MOPH–U.S. CDC Collaboration, Bangkok, Thailand
- Division of Infectious Disease, Oregon Health & Science University, Portland, OR
- Columbia University, New York, NY
- Department of Health Behavior and Health Education, School of Public Health, University of Michigan, Ann Arbor, MI
- San Francisco Department of Public Health, San Francisco, CA
- FHI 360, Durham, NC; and
- Gladstone Institute of Virology and Immunology, University of California at San Francisco, San Francisco, CA
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Hodges-Mameletzis I, Fonner VA, Dalal S, Mugo N, Msimanga-Radebe B, Baggaley R. Pre-Exposure Prophylaxis for HIV Prevention in Women: Current Status and Future Directions. Drugs 2019; 79:1263-1276. [PMID: 31309457 DOI: 10.1007/s40265-019-01143-8] [Citation(s) in RCA: 36] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
Pre-exposure prophylaxis (PrEP) is a promising intervention to prevent HIV acquisition, with benefits both to the individual and to population-level health. PrEP is an opportunity to complement ongoing public health efforts to eliminate HIV. For women, PrEP can also serve as a gateway to access sexual and reproductive health (SRH) services. Clinical efficacy of PrEP was initially reported in women using a 1% tenofovir vaginal gel in 2010, followed by an efficacy trial of oral PrEP using TDF/FTC in men who have sex with men (MSM). Since then, further trials have reported efficacy in oral PrEP containing tenofovir in women and heterosexual men, while the subsequent trials for women using tenofovir gel reported no efficacy, stemming from difficulties in achieving adequate adherence. In an effort to offer women additional choices to oral PrEP, alternative modalities are being tested in clinical research, including long-acting injectable formulations and intra-vaginal rings. In 2015, a meta-analysis of clinic trials and open-label extension studies led to the World Health Organization (WHO) strongly recommending the provision of oral PrEP containing tenofovir for any person at substantial risk of HIV infection, irrespective of gender or population group. Currently, PrEP services for women around the world, including those who are either pregnant or breastfeeding, remain limited. Outside sub-Saharan Africa, most PrEP programmes are focused on MSM. South Africa, Kenya, and the USA have the greatest utilization of oral PrEP by women. Yet, since 2012, of the estimated > 300,000 people globally who have initiated PrEP, a minority are women. In this narrative review, we examine the most recent literature on clinical and implementation PrEP research among women. We highlight the high burden of disease related to common sexually transmitted infections (STIs) in women, and the opportunity to integrate PrEP and other HIV prevention services, STI case management, and family planning services, as part of a more robust package of SRH services. Raising awareness on PrEP amongst women and their healthcare providers, minimizing gaps in access, and ensuring adherence and persistence of PrEP during periods of risk are critical issues if PrEP can have a meaningful impact on reducing HIV incidence in women globally.
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Affiliation(s)
| | | | - Shona Dalal
- World Health Organization, Geneva, Switzerland
| | - Nelly Mugo
- University of Washington/Kenya Medical Research Institute, Nairobi, Kenya
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Matthews LT, Jaggernath M, Kriel Y, Smith PM, O'Neil K, Haberer JE, Hendrix C, Baeten JM, Ware NC, Wirth K, Psaros C, Bangsberg DR, Smit JA. Protocol for a longitudinal study to evaluate the use of tenofovir-based PrEP for safer conception and pregnancy among women in South Africa. BMJ Open 2019; 9:e027227. [PMID: 31350241 PMCID: PMC6661571 DOI: 10.1136/bmjopen-2018-027227] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/13/2018] [Revised: 03/06/2019] [Accepted: 06/12/2019] [Indexed: 01/18/2023] Open
Abstract
INTRODUCTION Women who choose to conceive a baby with a partner living with HIV or a partner whose HIV serostatus is unknown in HIV-endemic settings need prevention strategies to mitigate HIV acquisition during conception and pregnancy. METHODS AND ANALYSIS We are conducting a single-arm longitudinal study offering oral tenofovirdisoproxil fumarate/emtricitabine (TDF/FTC) as pre-exposure prophylaxis (PrEP) for periconception use to 350 HIV-uninfected women in KwaZulu-Natal, South Africa. PrEP is offered as part of woman-centred safer conception programme that promotes couples-based HIV counselling and testing, antiretroviral therapy for partners who are HIV-infected, treatment for sexually transmitted infections and safer conception strategies, such as limiting condomless sex to peak fertility. We enrol HIV-uninfected women who are not currently pregnant, in a stable relationship (≥6 months) with a partner living with HIV or of unknown serostatus, and personal or partner plans for pregnancy in the next 12 months. We follow enrolled women for 12 months. Women who become pregnant are followed through pregnancy outcome, independent of their decisions regarding PrEP use. The primary objective of the study is to evaluate the uptake of and adherence to PrEP during the periconception period and pregnancy. Secondary outcomes include the uptake of other safer conception strategies. We also measure clinical outcomes including HIV seroconversion rates and pregnancy and infant outcomes. Finally, we will explore conduct and evaluate qualitative interviews in 25 participants to further inform our conceptual framework for periconception PrEP uptake and adherence among HIV-exposed women in South Africa. ETHICS AND DISSEMINATION The protocol has been approved by the Human Research Ethics Committee at the University of the Witwatersrand (Johannesburg, South Africa) and the Institutional Review Board of Partners Healthcare (Boston, Massachusetts, USA). Study findings will be made available to interested participants. Results will be presented to local health officials and stakeholders at meetings. Investigators will share the results at meetings and in manuscripts. De-identified quantitative data will be made available. TRIAL REGISTRATION NUMBER The protocol is registered with the South African Health Products Regulatory Agency (SAHPRA, formerly known as the Medicine Controls Council, MCC#20170131) and ClinicalTrials.gov (NCT03194308); Pre-results.
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Affiliation(s)
- Lynn T Matthews
- Department of Medicine, Division of Infectious Diseases, University of Alabama at Birmingham (UAB), Birmingham, Alabama, USA
- Department of Medicine, Division of Infectious Diseases, Massachusetts General Hospital, Boston, MA, USA
| | - Manjeetha Jaggernath
- Department of Gynecology and Obstetrics, Faculty of Health Sciences, MatCH Research Unit, University of Witwatersrand, Durban, South Africa
| | - Yolandie Kriel
- Department of Gynecology and Obstetrics, Faculty of Health Sciences, MatCH Research Unit, University of Witwatersrand, Durban, South Africa
| | - Patricia M Smith
- Department of Medicine, Division of Infectious Diseases, University of Alabama at Birmingham (UAB), Birmingham, Alabama, USA
| | - Kasey O'Neil
- Center for Global Health, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Jessica E Haberer
- Center for Global Health, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Craig Hendrix
- Division of Clinical Pharmacology, Johns Hopkins Medicine, Baltimore, Maryland, USA
| | - Jared M Baeten
- Department of Global Health, University of Washington, Seattle, Washington, USA
| | - Norma C Ware
- Department of Global Health and Social Medicine, Harvard Medical School, Boston, Massachusetts, USA
| | - Kathleen Wirth
- Department of Biostatistics, Harvard T.H. Chan School of Public Health, Boston, Massachusetts, USA
| | - Christina Psaros
- Department of Psychiatry, Massachusetts General Hospital, Boston, MA
| | - David R Bangsberg
- Dean's Office, Portland State University School of Public Health, Oregon Health and Science University, Portland, Oregon, USA
| | - Jennifer A Smit
- Department of Gynecology and Obstetrics, Faculty of Health Sciences, MatCH Research Unit, University of Witwatersrand, Durban, South Africa
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Tenofovir Plasma Concentration from Preexposure Prophylaxis at the Time of Potential HIV Exposure: a Population Pharmacokinetic Modeling and Simulation Study Involving Serodiscordant Couples in East Africa. Antimicrob Agents Chemother 2019; 63:AAC.00446-19. [PMID: 31182536 PMCID: PMC6658796 DOI: 10.1128/aac.00446-19] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2019] [Accepted: 06/03/2019] [Indexed: 01/26/2023] Open
Abstract
The Partners Demonstration Project was a prospective, open-label, implementation science-driven study of preexposure prophylaxis (PrEP) among heterosexual HIV serodiscordant couples in Kenya and Uganda. Adherence data were collected using the Medication Event Monitoring System (MEMS), and time of sexual activity was collected using the mobile phone short message service (SMS). Two plasma samples were collected at a single study visit. We integrated adherence, pharmacokinetics, and SMS data using a population pharmacokinetic (PopPK) model to simulate tenofovir plasma concentrations from PrEP at the time of sexual activity. In the first stage of this analysis, we used data from the current study to update a prior PopPK model of tenofovir (TFV) developed with data from the Partners PrEP Study (a phase III clinical trial). The second stage involved simulating plasma concentrations at the time of sexual activity using empirical Bayes estimates (EBEs) derived from the final model. In addition, EBEs from a previously published parent metabolite model of TFV (MTN-001, an open-label 3-way crossover study in healthy women) was used to simulate tenofovir diphosphate (TFV-DP) concentrations. We estimated percent PrEP "coverage" as the number of reported sexual events during which simulated concentrations were above an a priori threshold concentrations associated with a high degree of protection from HIV infection: plasma TFV of >40 ng/ml and peripheral blood mononuclear cell (PBMC) TFV-DP concentration of >36 fmol/million cells. The levels of coverage were 72% for TFV and 81% for TFV-DP. These levels are consistent with a high degree of protection against HIV acquisition in this study of a pragmatic delivery model for antiretroviral-based HIV prevention.
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Reza-Paul S, Lazarus L, Jana S, Ray P, Mugo N, Ngure K, Folayan MO, Durueke F, Idoko J, Béhanzin L, Alary M, Gueye D, Sarr M, Mukoma W, Kyongo JK, Bothma R, Eakle R, Dallabetta G, Presley J, Lorway R. Community Inclusion in PrEP Demonstration Projects: Lessons for Scaling Up. Gates Open Res 2019; 3:1504. [PMID: 31942537 PMCID: PMC6943951 DOI: 10.12688/gatesopenres.13042.2] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/24/2019] [Indexed: 12/23/2022] Open
Abstract
Pre-exposure prophylaxis (PrEP) has emerged as a new HIV prevention strategy. A series of demonstration projects were conducted to explore the use of PrEP outside of clinical trial settings. Learning from the failures in community consultation and involvement in early oral tenofovir trials, these PrEP projects attempted to better engage communities and create spaces for community involvement in the planning and roll out of these projects. We briefly describe the community engagement strategies employed by seven Bill & Melinda Gates Foundation-funded PrEP demonstration projects and the lessons these projects offer for community engagement in PrEP implementation.
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Affiliation(s)
- Sushena Reza-Paul
- Centre for Global Public Health, Rady Faculty of Health Sciences, Community Health Sciences, University of Manitoba, Winnipeg, Canada
- Ashodaya Samithi, Mysore, India
| | - Lisa Lazarus
- Centre for Global Public Health, Rady Faculty of Health Sciences, Community Health Sciences, University of Manitoba, Winnipeg, Canada
| | | | - Protim Ray
- Durbar Mahila Samanawaya Committee, Kolkata, India
| | - Nelly Mugo
- Center for Clinical Research, Kenya Medical Research Institute, Nairobi, Kenya
- Department of Global Health, University of Washington, Seattle, USA
| | - Kenneth Ngure
- Department of Community Health, Jomo Kenyatta University of Agriculture and Technology, Nairobi, Kenya
| | | | - Florita Durueke
- New HIV Vaccine and Microbicide Advocacy Society, Lagos, Nigeria
| | - John Idoko
- Department of Medicine, University of Jos, Jos, Nigeria
| | - Luc Béhanzin
- Centre de recherche du CHU de Québec, Université Laval, Quebec, Canada
- Dispensaire IST, Centre de santé communal de Cotonou 1, Cotonou, Benin
- École Nationale de Formation des Techniciens Supérieurs en Santé Publique et en Surveillance Épidémiologique, Université de Parakou, Parakou, Benin
| | - Michel Alary
- Centre de recherche du CHU de Québec, Université Laval, Quebec, Canada
- Département de médecine sociale et préventive, Université Laval, Quebec, Canada
- Institut national de santé publique du Québec, Quebec, Canada
| | - Daouda Gueye
- Institut de Recherche en Santé, de Surveillance Epidémiologique et de Formation (IRESSEF), Dakar, Senegal
| | | | | | | | - Rutendo Bothma
- Wits Reproductive Health and HIV Institute (WRHI), Johannesburg, South Africa
| | - Robyn Eakle
- Wits Reproductive Health and HIV Institute (WRHI), Johannesburg, South Africa
- Faculty of Public Health and Policy, London School of Hygiene and Tropical Medicine, London, UK
| | | | | | - Robert Lorway
- Centre for Global Public Health, Rady Faculty of Health Sciences, Community Health Sciences, University of Manitoba, Winnipeg, Canada
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