Perceived barriers to pre-exposure prophylaxis use among HIV-negative men who have sex with men in Tijuana, Mexico: A latent class analysis

Exploring Barriers and Facilitators That Influence Uptake of Oral Pre-Exposure Prophylaxis Among Men Who Have Sex With Men in Bulawayo, Zimbabwe: Key Stakeholder's Perspectives

The world has been on the path to ending HIV and AIDS as a global threat by 2030; despite these efforts, the rate of new HIV infections among men who have sex with men remains very high. This study sought to explore the perceptions of key stakeholders on the potential barriers and facilitators of pre-exposure prophylaxis use among this key population. An exploratory, descriptive (through interviews) qualitative study was conducted on 10 key informants who were purposively selected and snowballed based on their knowledge and experience toward pre-exposure prophylaxis programming among men who have sex with men. The interviews were recorded, transcribed verbatim, coded, and thematically analyzed on MAXQDA. Stated barriers were stigma, lack of information, wrong messaging around pre-exposure prophylaxis, hearing negative things about the pills, the burden of taking pills daily, negative attitudes from health care providers, non-friendly health care facilities, pre-exposure prophylaxis not being affordable, and lack of flexibility and privacy from public hospitals. Identified facilitators were correct messaging on pre-exposure prophylaxis, long-lasting injectable pre-exposure prophylaxis, improved packaging, de-stigmatization, more friendly facilities, differentiated service approach, community groups, engagement, and partnership. To address these barriers and leverage the facilitators, it is imperative to have accessible, affordable services, non-judgmental health care providers, and peer support networks to empower men who have sex with men to make informed decisions regarding their sexual and reproductive health. Continued efforts to remove barriers and promote facilitators are crucial for maximizing the potential of pre-exposure prophylaxis as an effective HIV prevention tool among this population.

Oral Pre-Exposure Prophylaxis Accessibility, Knowledge, Barriers, and Facilitators Among Men Who Have Sex With Men in Bulawayo, Zimbabwe

Great strides have been made globally toward ending HIV and AIDS as a threat by 2030, although the rate of new HIV infections among men who have sex with men remains very high. Due to their risk of getting HIV and AIDS, utilization of pre-exposure prophylaxis (PrEP) can potentially reduce the risk of HIV transmission among this population. This study sought to analyze the accessibility, knowledge, and potential barriers and facilitators to assessing PrEP by men who have sex with men. The quantitative method was conducted on 65 men who have sex with men through questionnaires loaded on Kobo Collect. Chi-square test, odds ratios, and logistic regression were used to associate different demographic characteristics with knowledge and significance of barriers in PrEP access using STATA 15. A hotspot map of PrEP and locations was created using QGIS. About 84% of respondents accessed pills from friendly facilities. The remaining accessed them from public hospitals, namely Mpilo and United Bulawayo Hospitals. Over 90% of the respondents were found to be highly knowledgeable. Notably, barriers included lack of information, fear of side effects, pills not accessible, pill taste, odor and size, stigma, and lack of protection from other sexually transmitted infections. Facilitators were educated about PrEP, the existence of friendly health facilities, making pills available at all times, partner support, increased number of friendly health facilities and support groups. Maximizing the potential of PrEP as an efficient HIV-prevention intervention among this population requires ongoing efforts to remove barriers and promote facilitators.

Oral Pre-exposure Prophylaxis Uptake and Acceptability Among Men Who Have Sex With Men: A Scoping Review of the Literature

Despite the global effort to end the human immunodeficiency virus (HIV) and acquired immunodeficiency syndrome (AIDS) epidemic as a global threat by 2030, the rate of new HIV infections worldwide remains unacceptably high among men who have sex with men, hence the need to use pre-exposure prophylaxis (PrEP) to reduce the risk of HIV infection. This population has an increased risk of getting HIV; thus, it is imperative to assess the uptake and acceptability of PrEP. This study investigated the willingness, availability, accessibility, and knowledge and identified barriers and facilitators to using PrEP among this population. A scoping literature review search was conducted on research papers published in English and focused on men who have sex with men and their use of PrEP. These were independently screened and coded. Of about 1,202 literature sources, 55 were included in the study. Findings reported that the uptake and acceptability of PrEP were influenced by knowledge and perception of being high-risk. Generally, PrEP uptake and understanding were high in North America, Latin America, and Europe and low in Asia and Africa. Low uptake and acceptability have been largely attributed to fear of side effects, societal stigma, cost, and perception of not being at risk. Noted facilitators to PrEP use include education, availability of free pills, support groups, and friendly health care facilities. Health intervention programs to increase the use of PrEP must be backed by appropriate legal and regulatory frameworks.

Evaluation of factors associated with HIV self-testing Acceptability and Uptake among the MSM community in Nairobi, Kenya: A cross sectional study

BACKGROUND

Human Immunodeficiency Virus self-test (HIVST) refers to a process where a person collects his or her own specimen (blood or oral), performs a test and interprets the results. The interpretation of results can either be done in private or through support of a trusted partner. Self-test should be seen as screening and confirmatory tests are typically strongly encouraged.

STUDY OBJECTIVE

To determine facilitating factors for HIVST acceptability and uptake among men who have sex with men (MSM).

METHODS

A cross-sectional exploratory study design, targeting MSM in Nairobi was used. Adult men (aged 18-60 years) who reported to be actively engaging in anal or oral sex with men were eligible for the study. Purposive sampling was used to identify the sites where data was collected, snowballing technique was then employed to reach the respondents. Data was collected between July 2018 and June 2019. A total of 391 MSM respondent were recruited of whom 345 MSM completed the questionnaires. The missing data was handled through the listwise approach that omits those cases with the missing data and analyze the remaining data. We also excluded responses with inconsistencies in all confirmatory questions in the questionnaire.

RESULTS

Two-thirds (64.0%) of the participants were aged 18-24 years with 13.4% being married to women and 40.2% having tertiary level of education. Majority, 72.7% were unemployed and two-thirds (64.0%) of participants were young (18-24 years) and self reported as male sex workers (58.8). There were significant associations between willingness to undertake HIV self-tests and frequency of HIV testing as well as with previous knowledge about self-testing. Habitual HIV testers were more likely to have used the HIVST kit than the non-habitual testers. Willingness to undertake confirmatory test within one month of self-testing was associated with acceptability of HIVST. Most of the MSM preferred blood sample self-test kits as compared to oral self-test kits, believing that blood test will be more accurate than oral self-test. Other factors associated with HIVST included consistent use of protection regardless of HIV status, preference of "treatment buddies". High costs of the self-test kits and inadequate knowledge on the use of HIV self-test kits were the main hindrances to HIVST uptake.

CONCLUSIONS

This study has showed that age, habitual testing, self-care/partner care, as well as confirmatory testing and immediate introduction into care if found sero-positive were associated with the use of HIVST kit. This study contributes to the pool of knowledge of the characteristics of MSM that would adopt and embrace HIVST, and demonstrates that these MSM are self and partner care aware and conscious. The challenge however remains on how to encourage those that are not self/partner care aware to embrace HIV testing and particularly HIVST as routine practices. Future studies may need to explore potential motivators to self-testing among the young, elder MSM generations and the MSM with higher economic status in Kenya.

The Influencing Factors of HIV-Preventive Behavior Based on Health Belief Model among HIV-Negative MSMs in Western China: A Structural Equation Modeling Analysis

(1) Background: Men who have sex with other men (MSMs) are at high risk of being infected by the human immunodeficiency virus (HIV) in western China. Pre-exposure prophylaxis (PrEP) is an efficient way to prevent HIV transmission. However, adherence is the most vital determinant factor affecting PrEP effectiveness. We conducted a study based on the Health Belief Model to explore factors that predict adherence to PrEP among a cohort of 689 MSMs in western China. (2) Methods: We assessed perceived susceptibility, severity, benefits, barriers, self-efficacy, cues to action, and HIV-preventive behavior through a cross-sectional survey. (3) Results: PrEP self-efficacy was directly associated with PrEP behaviors (β = 0.221, p < 0.001), cues to action were directly associated with PrEP behaviors (β = 0.112, p < 0.001), perceived benefits were directly associated with PrEP behaviors (β = 0.101, p < 0.001), and perceived susceptibility was directly associated with PrEP behaviors (β = 0.117, p = 0.043). (4) Conclusion: Medication self-efficacy, perceived susceptibility, and cue to action structures are predictors of the MSMs’ HIV-preventive behavior in western China. These results will provide theoretical plans for promoting PrEP adherence in MSMs.

Metrics of sexual behavior stigma among cisgender men who have sex with men in Mexico: exploratory and confirmatory factor analyses

Cisgender gay, bisexual, and other men who have sex with men (MSM) in Mexico experience disparities in sexual health outcomes, perhaps most notably in HIV prevalence, HIV testing and status awareness, and condom use. Sexual behavior stigma, underpinned by socio-structural factors specific to Mexico (e.g., machismo), uniquely shapes these sexual health disparities. However, few reliable, valid measures are available to document, track, and ultimately mitigate sexual behavior stigma in this context. Exploratory and confirmatory factor analyses were performed on responses to a 13-item sexual behavior stigma scale from 15,681 MSM recruited online across Mexico. Associations with extracted factors were tested to assess construct validity. Three subscales were identified in exploratory factor analysis and validated in confirmatory factor analysis: "stigma from family and friends" (α = 0.65), "anticipated healthcare stigma" (α = 0.84), and "general social stigma" (α = 0.70). External construct validity was indicated through each subscale's strong association (all p < 0.001) with perceived community intolerance of MSM and perceived community discrimination toward people living with HIV. These subscales show promise as reliable, valid measures for assessing sexual behavior stigma among MSM in Mexico, and as tools for documenting and tracking sexual behavior stigma trends, comparing regional burdens of sexual behavior stigma, and tracking the progress of stigma-mitigation interventions among MSM in Mexico. Future research is needed to understand the extent to which each subscale is differentially associated with sexual (and other) health outcomes, which can inform the development and implementation of uniquely tailored stigma-mitigation, HIV-prevention, HIV-care, and other needed interventions for MSM in Mexico.

Latent Class Analysis of Sexual Behaviours and Attitudes to Sexually Transmitted Infections Among Gay and Bisexual Men Using PrEP

Gay and bisexual men (GBM) who use pre-exposure prophylaxis (PrEP) are at increased risk of sexually transmitted infections (STIs) compared to those who don't use PrEP. Since the implementation of PrEP in Australia, it is possible that attitudes towards STIs have shifted in line with changes in risk and transmission dynamics in the context of increased screening. As the extent to which GBM utilise STI prevention strategies likely depends on their attitudes towards STIs and STI prevention, the aims of this study were to use latent class analysis (LCA) to classify GBM using PrEP on the basis of their attitudes towards STIs and reported risk behaviours, and examine how these categorisations relate to risk of STI acquisition. 1225 GBM who were previously enrolled in a PrEP implementation study (The PrEPX Study) completed a survey focused on sexual behaviours and attitudes towards STIs 1 year post-study follow-up. Data on chlamydia, gonorrhoea and syphilis testing and positivity were available through a sentinel network of participating study clinics. Using LCA, participants were allocated into four classes; Class 1, "Some concern and lowest risk"; Class 2, "Low concern and lower risk"; Class 3, " High concern and higher risk"; and Class 4, "Low concern and highest risk". The majority (78%) of participants were classified into Class 3 or Class 4, two groups which were distinguished by highly disparate attitudes towards STIs but with a similar proportion of participants diagnosed with a bacterial STI in the last 12 months (48% and 57%, respectively). Findings suggest that attitudes towards STIs among GBM using PrEP in Australia vary considerably, and this will likely influence their receptivity to different STI prevention strategies.

Overlapping Key Populations and HIV Transmission in Tijuana, Mexico: A Modelling Analysis of Epidemic Drivers

Tijuana, Mexico, has a concentrated HIV epidemic among overlapping key populations (KPs) including people who inject drugs (PWID), female sex workers (FSW), their male clients, and men who have sex with men (MSM). We developed a dynamic HIV transmission model among these KPs to determine the extent to which their unmet prevention and treatment needs is driving HIV transmission. Over 2020-2029 we estimated the proportion of new infections acquired in each KP, and the proportion due to their unprotected risk behaviours. We estimate that 43.7% and 55.3% of new infections are among MSM and PWID, respectively, with FSW and their clients making-up < 10% of new infections. Projections suggest 93.8% of new infections over 2020-2029 will be due to unprotected sex between MSM or unsafe injecting drug use. Prioritizing interventions addressing sexual and injecting risks among MSM and PWID are critical to controlling HIV in Tijuana.

PrEP Awareness, Use, Intention to Use, and Information Source Among Geosocial Networking Application Users in Mexico in 2018-2019

Pre-exposure prophylaxis (PrEP) has limited availability across Latin America, though access is increasing. We explored PrEP uptake in Mexico via an online survey completed by Spanish-speaking, Hornet geosocial networking application (GSN app) users without HIV (n = 2020). Most (81.3%) had heard of PrEP, 3.5% were current users, and 34.2% intended to take PrEP within six months. Current PrEP use was associated with PrEP eligibility (aOR 26.07 [95%CI 13.05-52.09], p < 0.001), recent STI testing (aOR 3.79 [95%CI 1.10-13.11], p = 0.035), and recent chemsex (aOR 3.02 [95%CI 1.02-8.93], p = 0.046). Recent STI testing was associated with hearing about PrEP from a doctor (aOR 3.26 [95%CI 1.98-5.36], p < 0.001), and those who lived in large cities were less likely to have learned about PrEP via Hornet (aOR 0.52 [95%CI 0.32-0.85], p = 0.009). Interventions to increase PrEP uptake in Mexico should build upon existing health networks and utilize GSN apps for PrEP information dissemination, particularly in less populated areas.

Pre-exposure prophylaxis awareness, use, and intention to use in a regional sample of Latin American geosocial networking application users in 2018-2019

Pre-exposure prophylaxis (PrEP) access is increasing in Latin America. We explored PrEP use among Spanish-speaking, Hornet geosocial networking application users from Latin American countries with limited PrEP data via an online survey completed between December 2018 and February 2019. A total of 718 Hornet users from 10 countries were included, of whom 72.1% reported PrEP awareness. Few (5.6%) were currently taking PrEP, though 32.1% intended to take PrEP in the subsequent 6 months. PrEP awareness was lower in 18-25 year olds compared to 26+ (62.4% vs. 75.6%, aOR 0.67, [95% CI 0.46-0.97]), and higher among those living in larger versus smaller cities (74.4% vs. 58.8%, aOR 1.96, [95% CI 1.25-3.07]) or countries with at least partial versus no PrEP policy adoption (79.1% vs. 60.8%, aOR 2.20, [95% CI 1.56-3.12]). Intention to use PrEP was higher among PrEP-eligible respondents (51.8% vs. 29.6%, aOR 2.26, [95% CI 1.26-4.07]) and those recently tested for a sexually transmitted infection (35.4% vs. 25.5%, aOR 1.58, [95% CI 1.01-2.48]). Efforts to expand PrEP use in Latin America should focus on national PrEP policy adoption, and research should explore barriers to awareness and use among young men who have sex with men.

A comparison of the effectiveness of respondent-driven and venue-based sampling for identifying undiagnosed HIV infection among cisgender men who have sex with men and transgender women in Tijuana, Mexico

BACKGROUND

Efforts to increase HIV testing, diagnosis and care are critical to curbing HIV epidemics among cisgender men who have sex with men (MSM) and transgender women (TW) in low- and middle-income countries (LMIC). We compared the effectiveness of respondent-driven sampling (RDS) and venue-based sampling (VBS) for identifying previously undiagnosed HIV infection among MSM and TW in Tijuana, Mexico.

METHODS

Between March 2015 and December 2018, we conducted RDS within the social networks of MSM and TW and VBS at venues frequented by MSM and TW to socialize and meet sexual partners. Those reached by RDS/VBS who reported at least 18 years of age, anal sex with MSM or TW, and no previous HIV diagnosis were eligible for HIV testing.

RESULTS

Of those screened following recruitment via RDS (N = 1232; 98.6% MSM; 1.3% TW), 60.8% (749/1232) were eligible for HIV testing and 97.5% (730/749) were tested for HIV infection, which led to the identification of 36 newly diagnosed HIV infections (4.9%). Of those screened following recruitment via VBS (N = 2560; 95.2% MSM; 4.6% TW), 56.5% (1446/2560) were eligible for HIV testing and 92.8% (1342/1446) were tested for HIV infection, which led to the identification of 82 newly diagnosed HIV infections (6.1%). The proportion of new HIV diagnoses did not differ by recruitment method (ratio = 0.81, 95% confidence interval: 0.55 to 1.18). Compared to those recruited via RDS, those tested following recruitment via VBS were younger, more likely to identify as gay, and more likely to identify as TW. Compared to those recruited via VBS, those newly diagnosed with HIV infection following recruitment via RDS reported higher levels of internalized stigma and were more likely to report injection drug use and a history of deportation from the United States.

CONCLUSIONS

Despite RDS and VBS being equally effective for identifying undiagnosed HIV infection, each recruitment method reached different subgroups of MSM and TW in Tijuana. Our findings suggest that there may be benefits to using both RDS and VBS to increase the identification of previously undiagnosed HIV infection and ultimately support HIV care engagement among MSM and TW in Mexico and other similar LMIC.

Recent HIV Infection among men who have sex with men and transgender women in Tijuana

OBJECTIVE To characterize recent HIV infections among newly diagnosed men who have sex with men and transgender women in Tijuana. METHODS Limiting Antigen (LAg)-Avidity testing was performed to detect recent HIV infection within a cohort of newly-diagnosed men who have sex with men and transgender women in Tijuana. Logistic regression was used to determine characteristics associated with recent infection. A partial transmission network was inferred using HIV-1 pol sequences. Tamura-Nei 93 genetic distances were measured between all pairs of sequences, and the network was constructed by inferring putative transmission links (genetic distances ≤ 1.5%). We assessed whether recent infection was associated with clustering within the inferred network. RESULTS Recent infection was detected in 11% (22/194) of newly-diagnosed participants. Out of the participants with sequence data, 60% (9/15) with recent infection clustered compared with 31% (43/139) with chronic infection. Two recent infections belonged to the same cluster. In adjusted analyses, recent infection was associated with years of residence in Tijuana (OR = 1.5; 95%CI 1.01-1.09), cocaine use (past month) (OR = 8.50; 95%CI 1.99-28.17), and ever experiencing sexual abuse (OR = 2.85; 95%CI 1.03-7.85). DISCUSSION A total of 11% of men newly diagnosed with HIV who have sex with men and transgender women in Tijuana were recently infected. The general lack of clustering between participants with recent infection suggests continued onward HIV transmission rather than an outbreak within a particular cluster.