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Scott RK, Deyarmond M, Marwitz S, Huang JC, Moriarty P, Visconti AJ, Beverley J, Elion R, Coleman M, Hull SJ. Implementation of an Educational Intervention to Improve HIV Pre-Exposure Prophylaxis Services for Women in an Urban Sexual Health Clinic. AIDS Patient Care STDS 2023; 37:447-457. [PMID: 37713289 PMCID: PMC10623070 DOI: 10.1089/apc.2023.0107] [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: 09/17/2023] Open
Abstract
To test the hypothesis that implementation of a multicomponent, educational HIV pre-exposure prophylaxis (PrEP) intervention to promote universal PrEP services for cisgender women (subsequently "women") in sexual and reproductive health centers would improve the proportion of women screened, offered, and prescribed PrEP, we implemented a multicomponent, educational intervention in a Washington D.C. Department of Health-sponsored sexual health clinic. The clinic serves a patient population with high-potential exposure to HIV. The intervention included clinic-wide PrEP trainings, an electronic health record prompt for PrEP counseling by providers, and educational videos in the waiting room. We collected preimplementation data from March 22, 2018 to July 4, 2018, including 331 clinical encounters for 329 women. Between July 5, 2018 and July 1, 2019, there were 1733 clinical encounters for 1720 HIV-negative women. We used mixed methods to systematically assess intervention implementation using the Reach Effectiveness Adoption Implementation Maintenance framework. Additionally, we assessed the interventions' acceptability and feasibility among providers through semistructured interviews. The proportion of women screened by providers for PrEP (5.6% preimplementation to a mean of 89.2% of women during the implementation period, p < 0.01), offered (6.2 to 69.8%, p < 0.01), and prescribed PrEP (2.6 to 8.1%, p < 0.01) by providers increased significantly in the implementation period. Providers and clinic staff found the intervention both highly feasible and acceptable and demonstrated increased knowledge of PrEP and HIV prevention associated with the clinic-wide trainings. Our results demonstrate the effectiveness of a low-cost educational intervention to increase provision of integrated PrEP services in an urban sexual health clinic serving women with high-potential exposure to HIV. ClinicalTrials.gov ID NCT03705663.
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Affiliation(s)
- Rachel K. Scott
- Department of Women's and Infants' Services, MedStar Washington Hospital Center, Division of Women's Health Research, MedStar Health Research Institute, Washington, District of Columbia, USA
| | - Megan Deyarmond
- Georgetown University School of Medicine, Washington, District of Columbia, USA
| | - Shannon Marwitz
- Georgetown University School of Medicine, Washington, District of Columbia, USA
| | - Jim C. Huang
- Department of Business Management, National Sun Yat-sen University, Kaohsiung, Taiwan
| | - Patricia Moriarty
- Division of Women's Health Research, MedStar Health Research Institute, Washington, District of Columbia, USA
| | - Adam J. Visconti
- HIV/AIDS, Hepatitis, STD and TB Administration, DC Health, Washington, District of Columbia, USA
| | - Jason Beverley
- HIV/AIDS, Hepatitis, STD and TB Administration, DC Health, Washington, District of Columbia, USA
| | - Rick Elion
- HIV/AIDS, Hepatitis, STD and TB Administration, DC Health, Washington, District of Columbia, USA
| | - Megan Coleman
- Whitman Walker Health, Washington, District of Columbia, USA
| | - Shawnika J. Hull
- Department of Prevention and Community Medicine, George Washington University, Washington, District of Columbia, USA
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Prevalence and Risk Factors of PrEP Use Stigma Among Adolescent Girls and Young Women in Johannesburg, South Africa and Mwanza, Tanzania Participating in the EMPOWER Trial. AIDS Behav 2022; 26:3950-3962. [PMID: 35776254 PMCID: PMC9640431 DOI: 10.1007/s10461-022-03721-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/13/2022] [Indexed: 11/01/2022]
Abstract
Adolescent girls and young women (AGYW) in sub-Saharan Africa may benefit from pre-exposure prophylaxis (PrEP), yet stigma may limit PrEP acceptance and continuation. We examined factors associated with PrEP use stigma among 307 participants of the EMPOWER trial (2016-2018), an unblinded randomized controlled trial among HIV-negative, AGYW, aged 16-24, in South Africa and Tanzania. The 6-item, brief-PrEP use stigma scale (B-PSS) had high internal reliability. At the end of the trial, 34.2% of study participants reported any PrEP use stigma. Three latent classes were observed, reflecting low (46.9%), medium (31.9%), and high (21.2%) reported PrEP use stigma. Disclosure of PrEP use to sexual partner and belief that PrEP prevents HIV were associated with less reported PrEP use stigma. Conversely, participants who reported fear and shame about people living with HIV were more likely to report PrEP use stigma. Our validated tool and findings will enable practitioners to identify AGYW at high risk of PrEP use stigma who may benefit from additional support.Pan African clinical trials registry PACTR202006754762723, 5 April 2020, retrospectively registered.
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Velloza J, Khoza N, Scorgie F, Chitukuta M, Mutero P, Mutiti K, Mangxilana N, Nobula L, Bulterys MA, Atujuna M, Hosek S, Heffron R, Bekker L, Mgodi N, Chirenje M, Celum C, Delany‐Moretlwe S. The influence of HIV-related stigma on PrEP disclosure and adherence among adolescent girls and young women in HPTN 082: a qualitative study. J Int AIDS Soc 2020; 23:e25463. [PMID: 32144874 PMCID: PMC7060297 DOI: 10.1002/jia2.25463] [Citation(s) in RCA: 112] [Impact Index Per Article: 28.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2019] [Revised: 01/02/2020] [Accepted: 01/27/2020] [Indexed: 11/16/2022] Open
Abstract
Introduction Stigma and disclosure concerns have been key barriers to oral pre‐exposure prophylaxis (PrEP) adherence for African adolescent girls and young women (AGYW) in efficacy trials. We aimed to understand the impact of these factors among African AGYW in an open‐label PrEP study. Methods HPTN 082 was an open‐label PrEP study among AGYW (ages 16 to 24) in Harare, Zimbabwe, and Cape Town and Johannesburg, South Africa from 2016 to 2018. Women starting PrEP were randomized to standard adherence support (counselling, two‐way SMS, monthly adherence clubs) or standard support plus drug‐level feedback. Serial in‐depth interviews were conducted among 67 AGYW after 13‐week and 26‐week study visits to explore experiences of stigma, disclosure and PrEP adherence. We analysed data by coding transcripts and memo‐writing and diagramming to summarize themes. Results AGYW described stigma related to sexual activity (e.g. “people say I'm a prostitute”) and being perceived to be living with HIV because of taking antiretrovirals (e.g. “my husband's friends say I'm HIV infected”). Participants who anticipated stigma were reluctant to disclose PrEP use and reported adherence challenges. Disclosure also resulted in stigmatizing experiences. Across all sites, negative descriptions of stigma and disclosure challenges were more common in the first interview. In the second interview, participants often described disclosure as an “empowering” way to combat community‐level PrEP stigma; many said that they proactively discussed PrEP in their communities (e.g. became a “community PrEP ambassador”), which improved their ability to take PrEP and encourage others to use PrEP. These empowering disclosure experiences were facilitated by ongoing HPTN 082 study activities (e.g. counselling sessions, adherence clubs) in which they could discuss PrEP‐related stigma, disclosure and PrEP adherence issues. Conclusions Stigma and disclosure challenges were initial concerns for African AGYW newly initiating PrEP but many were empowered to disclose PrEP use over their first six months of PrEP use, which helped them cope with stigma and feel more able to take PrEP regularly. PrEP programmes can foster disclosure through community and clinic‐based discussion, adherence clubs and activities normalizing sexual behaviour and PrEP use, which can reduce stigma and improve PrEP adherence and thus effectiveness.
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Affiliation(s)
| | - Nomhle Khoza
- Wits Reproductive Health & HIV Institute (Wits RHI)JohannesburgSouth Africa
| | - Fiona Scorgie
- Wits Reproductive Health & HIV Institute (Wits RHI)JohannesburgSouth Africa
| | - Miria Chitukuta
- Clinical Trials Research CentreUniversity of Zimbabwe College of Health SciencesHarareZimbabwe
| | - Prisca Mutero
- Clinical Trials Research CentreUniversity of Zimbabwe College of Health SciencesHarareZimbabwe
| | - Kudzai Mutiti
- Clinical Trials Research CentreUniversity of Zimbabwe College of Health SciencesHarareZimbabwe
| | | | - Lumka Nobula
- Desmond Tutu HIV FoundationCape TownSouth Africa
| | | | | | - Sybil Hosek
- Stroger H. Hospital of Cook CountyChicagoILUSA
| | | | - Linda‐Gail Bekker
- Faculty of Health SciencesInstitute of Infectious Disease and Molecular MedicineUniversity of Cape TownCape TownSouth Africa
| | - Nyaradzo Mgodi
- Clinical Trials Research CentreUniversity of Zimbabwe College of Health SciencesHarareZimbabwe
| | - Mike Chirenje
- Clinical Trials Research CentreUniversity of Zimbabwe College of Health SciencesHarareZimbabwe
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Velloza J, Heffron R, Amico KR, Rowhani-Rahbar A, Hughes JP, Li M, Dye BJ, Celum C, Bekker LG, Grant RM. The Effect of Depression on Adherence to HIV Pre-exposure Prophylaxis Among High-Risk South African Women in HPTN 067/ADAPT. AIDS Behav 2020; 24:2178-2187. [PMID: 31955360 DOI: 10.1007/s10461-020-02783-8] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
Oral pre-exposure prophylaxis (PrEP) is highly efficacious but low adherence undermines effectiveness. Depression, common in African women, may be a barrier to consistent PrEP use. We aimed to assess the relationship between depression, psychosocial mediators, and PrEP adherence among South African women. We analyzed data from 174 South African women in HPTN 067, an open-label oral PrEP trial conducted from 2011 to 2013. Participants were followed for 24 weeks. PrEP adherence was measured via Wisepill™ and weekly self-report interview data. We considered participants "adherent" at week 24 if Wisepill™ and interviews indicated that ≥ 80% of expected doses were taken in the prior month. Elevated depressive symptoms were assessed using the 20-item Center for Epidemiological Studies-Depression (CES-D) scale. We used marginal structural models to estimate the effect of elevated symptoms at baseline on PrEP adherence at week 24 and to assess whether the direct effect changed meaningfully after accounting for mediating effects of stigma, social support, and PrEP optimism. High PrEP adherence occurred less often among women with elevated depressive symptoms (N = 35; 44.3%) compared with those without (N = 52; 54.7%; adjusted relative risk [aRR]: 0.79; 95% confidence interval [CI] 0.63-0.99). The effect of elevated depressive symptoms on PrEP adherence persisted in models accounting for the mediating influence of stigma (aRR: 0.74; 95% CI 0.51-0.97) and PrEP optimism (aRR: 0.75; 95% CI 0.55-0.99). We also found a direct effect of similar magnitude and direction when accounting for social support as the mediating variable, although this adjusted relative risk estimate was not statistically significant (aRR: 0.77; 95% CI 0.57-1.03). Depressive symptoms were common and associated with lower PrEP adherence among South African women. Future work is needed to determine whether depression services integrated with PrEP delivery could improve PrEP effectiveness among African women.
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Affiliation(s)
- Jennifer Velloza
- Department of Epidemiology, University of Washington, Seattle, WA, USA.
- Department of Global Health, University of Washington, Seattle, WA, USA.
- International Clinical Research Center, University of Washington, 325 Ninth Avenue, Box 359927, Seattle, WA, 98104, USA.
| | - Renee Heffron
- Department of Epidemiology, University of Washington, Seattle, WA, USA
- Department of Global Health, University of Washington, Seattle, WA, USA
| | | | | | - James P Hughes
- Fred Hutchinson Cancer Research Center, Seattle, WA, USA
- Department of Biostatistics, University of Washington, Seattle, WA, USA
| | - Maoji Li
- Fred Hutchinson Cancer Research Center, Seattle, WA, USA
| | | | - Connie Celum
- Department of Global Health, University of Washington, Seattle, WA, USA
| | - Linda-Gail Bekker
- The Desmond Tutu HIV Centre, University of Cape Town, Cape Town, South Africa
| | - Robert M Grant
- University of California at San Francisco, San Francisco, CA, USA
- Gladstone Institute of Virology and Immunology, University of California at San Francisco, San Francisco, CA, USA
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Özdemir HÖ, Tosun S, Kabadurmuş FNK, Özdemir D. The impact of socioeconomic factors on the healthcare costs of people living with HIV in Turkey. BMC Public Health 2020; 20:368. [PMID: 32197598 PMCID: PMC7082973 DOI: 10.1186/s12889-020-08469-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2019] [Accepted: 03/05/2020] [Indexed: 11/10/2022] Open
Abstract
Background This study addresses an important field within HIV research, the impact of socioeconomic factors on the healthcare costs of people living with HIV/AIDS (PLHIV). We aimed to understand how different socioeconomic factors could create diverse healthcare costs for PLHIV in Turkey. Methods Data were collected between January 2017 and December 2017. HIV-positive people attending the clinic who had been referred to the national ART programme from January 1992 until December 2017 were surveyed. The questionnaire collected socioeconomic data. The cost data for the same patients was taken from the electronic database Probel Hospital Information Management System (PHIMS) for the same period. The PHIMS data include costs for medication (highly active antiretroviral therapy or HAART), laboratory, pathology, radiology, polyclinic, examination and consultation, hospitalisation, surgery and intervention, blood and blood products, supplies and other costs. Data were analysed using STATA 14.2 to estimate the generalised linear model (GLM). Results The findings of our GLM indicate that age, gender, marital and parental status, time since diagnosis, employment, wealth status, illicit drug use and CD4 cell count are the factors significantly related to the healthcare cost of patients. We found that compared with people who have AIDS (CD4 cells < 200 cells/mm3), people who have a normal range of CD4 cells (≥ 500 cells/mm3) have $1046 less in expenditures on average. Compared to younger people (19–39 years), older people (≥ 55) have $1934 higher expenditures on average. Costs are $644 higher on average for married people and $401 higher on average for people who have children. Healthcare costs are $518 and $651 higher on average for patients who are addicted to drugs and who use psychiatric drug(s), respectively. Compared to people who were recently diagnosed with HIV, people who were diagnosed ≥10 years ago have $743 lower expenditures on average. Conclusion Our results suggest that in addition to immunological status, socioeconomic factors play a substantial role in the healthcare costs of PLHIV. The key factors influencing the healthcare costs of PLHIV are also critical for public policy makers, healthcare workers, health ministries and employment community programs.
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Affiliation(s)
- Hülya Özkan Özdemir
- Department of Clinical Microbiology and Infectious Diseases, University of Health Sciences, Bozyaka Education and Research Hospital, İzmir, Turkey
| | - Selma Tosun
- Department of Clinical Microbiology and Infectious Diseases, University of Health Sciences, Bozyaka Education and Research Hospital, İzmir, Turkey
| | | | - Durmuş Özdemir
- Department of Economics, Yaşar University, Üniversite Caddesi No: 37-39, 35040 Bornova, İzmir, Turkey.
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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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Davies N, Heffron R. Global and national guidance for the use of pre-exposure prophylaxis during peri-conception, pregnancy and breastfeeding. Sex Health 2018; 15:501-512. [PMID: 30447703 PMCID: PMC6790372 DOI: 10.1071/sh18067] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2018] [Accepted: 09/15/2018] [Indexed: 12/30/2022]
Abstract
Pre-exposure prophylaxis (PrEP) is a well-established biomedical HIV prevention strategy and recommended to reduce HIV risk during peri-conception, pregnancy and breastfeeding. Efforts are needed to translate global recommendations into national guidelines and implementation strategies. This article presents the current status of policy guidance for the use of PrEP during peri-conception, pregnancy and breastfeeding, with a particular focus on high prevalence countries, including those in sub-Saharan Africa. PrEP clinical guidelines released by ministries of health or other national-level health bodies, with a particular focus on recommendations for PrEP use during peri-conception, pregnancy and breastfeeding, were reviewed and summarised. Among countries with PrEP guidelines and/or policy, pregnancy is recognised as a period with increased HIV vulnerability, and some recommend PrEP use specifically during pregnancy. Only one country notes that PrEP is contraindicated during pregnancy, recognising a gap in complete safety data from women using PrEP throughout pregnancy. PrEP is not contraindicated as a peri-conception HIV prevention strategy in any country, but only three countries have specific guidance for peri-conception HIV prevention. Multiple barriers to the implementation of PrEP during pregnancy and breastfeeding are discussed, including barriers at the policy, health systems, social and personal levels. Although pregnancy is a period of heightened risk and fertility rates are high in many settings with high HIV burden, few PrEP policies have included guidance for PrEP use specific to peri-conception, pregnancy and breastfeeding periods. This gap can be overcome by the development or adoption of national clinical guidelines and implementation strategies from exemplary countries.
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The Vaginal Microbiome and its Potential to Impact Efficacy of HIV Pre-exposure Prophylaxis for Women. Curr HIV/AIDS Rep 2018; 14:153-160. [PMID: 28812207 DOI: 10.1007/s11904-017-0362-z] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
PURPOSE OF REVIEW This review describes existing evidence addressing the potential modulation of pre-exposure prophylaxis (PrEP) products, specifically 1% tenofovir (TFV) gel and oral tenofovir-based PrEP, by vaginal dysbiosis and discusses future considerations for delivering novel, long-acting PrEP products to women at high risk for vaginal dysbiosis and HIV. RECENT FINDINGS We describe results from analyses investigating the modification of PrEP efficacy by vaginal dysbiosis and studies of biological mechanisms that could render PrEP ineffective in the presence of specific microbiota. A secondary analysis from the CAPRISA-004 cohort demonstrated that there is no effect of the 1% TFV gel in the presence of non-Lactobacillus dominant microbiota. Another recent analysis comparing oral tenofovir-based PrEP efficacy among women with and without bacterial vaginosis in the Partners PrEP Study found that oral PrEP efficacy is not modified by bacterial vaginosis. Gardnerella vaginalis, commonly present in women with vaginal dysbiosis, can rapidly metabolize TFV particularly when it is locally applied and thereby prevent TFV integration into cells. Given that vaginal dysbiosis appears to modulate efficacy for 1% TFV gel but not for oral tenofovir-based PrEP, vaginal dysbiosis is potentially less consequential to HIV protection from TFV in the context of systemic drug delivery and high product adherence. Vaginal dysbiosis may undermine the efficacy of 1% TFV gel to protect women from HIV but not the efficacy of oral PrEP. Ongoing development of novel ring, injectable, and film-based PrEP products should investigate whether vaginal dysbiosis can reduce efficacy of these products, even in the presence of high adherence.
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Bailey JL, Molino ST, Vega AD, Badowski M. A Review of HIV Pre-Exposure Prophylaxis: The Female Perspective. Infect Dis Ther 2017; 6:363-382. [PMID: 28600755 PMCID: PMC5595773 DOI: 10.1007/s40121-017-0159-9] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2017] [Indexed: 11/01/2022] Open
Abstract
When taken consistently, pre-exposure prophylaxis (PrEP) against human immunodeficiency virus (HIV) with once daily tenofovir disoproxil fumarate-emtricitabine (TDF-FTC) has been shown to safely reduce the incidence of HIV infection in high-risk individuals by more than 90%. Yet, according to the Centers for Disease Control and Prevention, there were about 2.1 million new cases of HIV reported worldwide in 2015. Undoubtedly, there is significant room for improvement to prevent the transmission of HIV. Research to date has been heavily focused on the high-risk men who have sex with men (MSM) population, yet, many women worldwide remain at high risk of HIV transmission. PrEP offers women a protection method that is discrete, does not require partner consent, and may be compatible with both contraception or conception as desired. However, women often remain under-represented in HIV prevention literature and are reported to have lower real-world uptake in comparison to men. Furthermore, clinical trials that do focus on the female population demonstrate mixed efficacy results that highlight the adherence challenges in this population. It is essential to identify factors that contribute to PrEP non-adherence as well as barriers to preventative treatment. This review will discuss the clinical evidence behind PrEP in women, current barriers to use afflicting this population, pharmacotherapy considerations for the female patient, alternative and future agents, and the current real-world application of PrEP.
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Affiliation(s)
- Jennifer L Bailey
- Notre Dame of Maryland University School of Pharmacy, Baltimore, MD, USA.
| | - Suzanne T Molino
- University of Illinois Hospital and Health Sciences System, Chicago, IL, USA
| | - Ana D Vega
- University of Maryland Medical Center, Baltimore, MD, USA
| | - Melissa Badowski
- College of Pharmacy, University of Illinois at Chicago, Chicago, IL, USA
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Cáceres CF, Borquez A, Klausner JD, Baggaley R, Beyrer C. Implementation of pre-exposure prophylaxis for human immunodeficiency virus infection: progress and emerging issues in research and policy. J Int AIDS Soc 2016; 19:21108. [PMID: 27760685 PMCID: PMC5071779 DOI: 10.7448/ias.19.7.21108] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2016] [Revised: 06/30/2016] [Accepted: 07/12/2016] [Indexed: 01/02/2023] Open
Abstract
BACKGROUND In this article, we present recent evidence from studies focused on the implementation, effectiveness and cost-effectiveness of pre-exposure prophylaxis (PrEP) for HIV infection; discuss PrEP scale-up to date, including the observed levels of access and policy development; and elaborate on key emerging policy and research issues to consider for further scale-up, with a special focus on lower-middle income countries. DISCUSSION The 2015 WHO Early Release Guidelines for HIV Treatment and Prevention reflect both scientific evidence and new policy perspectives. Those guidelines present a timely challenge to health systems for the scaling up of not only treatment for every person living with HIV infection but also the offer of PrEP to those at substantial risk. Delivery and uptake of both universal antiretroviral therapy (ART) and PrEP will require nation-wide commitment and could reinvigorate health systems to develop more comprehensive "combination prevention" programmes and support wider testing linked to both treatments and other prevention options for populations at highest risk who are currently not accessing services. Various gaps in current health systems will need to be addressed to achieve strategic scale-up of PrEP, including developing prioritization strategies, strengthening drug regulations, determining cost and funding sources, training health providers, supporting user adherence and creating demand. CONCLUSIONS The initial steps in the scale-up of PrEP globally suggest feasibility, acceptability and likely impact. However, to prevent setbacks in less well-resourced settings, countries will need to anticipate and address challenges such as operational and health systems barriers, drug cost and regulatory policies, health providers' openness to prescribing PrEP to populations at substantial risk, demand and legal and human rights issues. Emerging problems will require creative solutions and will continue to illustrate the complexity of PrEP implementation.
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Affiliation(s)
- Carlos F Cáceres
- Center for Interdisciplinary Studies in Sexuality, AIDS and Society, Universidad Peruana Cayetano Heredia, Lima, Peru;
| | - Annick Borquez
- Division of Global Public Health, University of California, San Diego, CA, USA
| | - Jeffrey D Klausner
- David Geffen School of Medicine, University of California, Los Angeles, CA, USA
- Fielding School of Public Health, University of California, Los Angeles, CA, USA
| | - Rachel Baggaley
- HIV Department, World Health Organization, Geneva, Switzerland
| | - Chris Beyrer
- Center for Public Health and Human Rights, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, MA, USA
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Spence P, Nel A, van Niekerk N, Derrick T, Wilder S, Devlin B. Post-use assay of vaginal rings (VRs) as a potential measure of clinical trial adherence. J Pharm Biomed Anal 2016; 125:94-100. [PMID: 27016673 PMCID: PMC4873601 DOI: 10.1016/j.jpba.2016.03.023] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2015] [Revised: 03/07/2016] [Accepted: 03/10/2016] [Indexed: 01/06/2023]
Abstract
Simulated use of dapivirine VRs showed no content changes after storage at RT or −20 °C. On average, about 4 mg of dapivirine is released in vivo after 28 days of VR use. Both in vivo and in vitro drug release conform to the Higuchi equation. Residual ring data should be used in conjunction with other PK measures for modeling adherence.
Adherence measurement for microbicide use within the clinical trial setting remains a challenge for the HIV prevention field. This paper describes an assay method used for determining residual dapivirine levels in post-use vaginal rings from clinical trials conducted with the Dapivirine Vaginal Matrix Ring-004 developed by the International Partnership for Microbicides to prevent male to female HIV transmission. Post-use assay results from three Ring-004 clinical trials showed that of the 25 mg drug load, approximately 4 mg of dapivirine is released from the matrix ring over a 28-day use period. Data obtained by both in vitro and in vivo studies indicate that dapivirine is released according to a diffusion mechanism, as determined by conformance of both data sets to the Higuchi equation. This, coupled with the low variability associated with batch production over two manufacturing sites and 20 batches of material, provides evidence that post-use ring analysis can contribute to the assessment of adherence to ring use. Limitations of this method include the potential of intra-participant and inter-participant variability and uncertainty associated with measuring the low amount of dapivirine actually released relative to the drug load. Therefore, residual drug levels should not serve as the only direct measurement for microbicide adherence in vaginal ring clinical trials but should preferably be used as part of a multi-pronged approach towards understanding and assessing adherence to vaginal ring use.
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Affiliation(s)
- Patrick Spence
- International Partnership for Microbicides, 8401 Colesville Road, Suite 200, Silver Spring 20910, MD, USA.
| | - Annalene Nel
- International Partnership for Microbicides, 63 Main Road, Paarl 7645, South Africa
| | - Neliëtte van Niekerk
- International Partnership for Microbicides, 63 Main Road, Paarl 7645, South Africa
| | - Tiffany Derrick
- International Partnership for Microbicides, 8401 Colesville Road, Suite 200, Silver Spring 20910, MD, USA
| | - Susan Wilder
- Genentech USA, Inc., 1 DNA Way, South San Francisco 94080-4990, CA, USA
| | - Bríd Devlin
- International Partnership for Microbicides, 8401 Colesville Road, Suite 200, Silver Spring 20910, MD, USA
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Schwartz SR, West N, Phofa R, Yende N, Sanne I, Bassett J, Van Rie A. Acceptability and preferences for safer conception HIV prevention strategies: a qualitative study. Int J STD AIDS 2015; 27:984-92. [PMID: 26384950 DOI: 10.1177/0956462415604091] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2015] [Accepted: 08/11/2015] [Indexed: 11/16/2022]
Abstract
Safer conception strategies to reduce the HIV transmission risk include antiretroviral therapy for HIV-positive partners, pre-exposure prophylaxis for HIV-negative partners, condomless sex limited to fertile periods, and home-based self-insemination. Resistance to taking treatment or cultural concerns may limit uptake of strategies and intervention success. Understanding the acceptability and preferences between different approaches is important to optimise service delivery. Between February and July 2013, 42 adults (21 HIV-positive and 21 HIV-negative) receiving primary care at Witkoppen Health and Welfare Centre in Johannesburg, South Africa, participated in focus group discussions or in-depth interviews. Themes were analysed using a grounded theory approach. Acceptability of antiretroviral-based strategies varied. Concerns over side effects, antiretroviral treatment duration and beliefs that treatment is only for the sick were common barriers; however, desperation for a child was noted as a facilitator for uptake. HIV-negative men and HIV-positive women had favourable attitudes towards self-insemination, though paternity and safety concerns were raised. Self-insemination was generally preferred over pre-exposure prophylaxis by HIV-negative men, and antiretroviral-based strategies were preferred by couples with HIV-negative female partners, despite concerns raised about condomless sex while virally suppressed. Knowledge about the fertile window was low. A strong counselling component will be required for effective uptake and adherence to safer conception services.
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Affiliation(s)
- Sheree R Schwartz
- Department of Epidemiology, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA Department of Epidemiology, Johns Hopkins School of Public Health, Baltimore, MD, USA
| | - Nora West
- Witkoppen Health and Welfare Centre, Johannesburg, South Africa
| | - Rebecca Phofa
- Witkoppen Health and Welfare Centre, Johannesburg, South Africa
| | | | - Ian Sanne
- Clinical HIV Research Unit, Department of Medicine, University of the Witwatersrand, Johannesburg, South Africa Right to Care, Johannesburg, South Africa
| | - Jean Bassett
- Witkoppen Health and Welfare Centre, Johannesburg, South Africa
| | - Annelies Van Rie
- Department of Epidemiology, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
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Maisel K, Chattopadhyay S, Moench T, Hendrix C, Cone R, Ensign LM, Hanes J. Enema ion compositions for enhancing colorectal drug delivery. J Control Release 2015; 209:280-7. [PMID: 25937321 PMCID: PMC4458383 DOI: 10.1016/j.jconrel.2015.04.040] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2015] [Revised: 04/12/2015] [Accepted: 04/29/2015] [Indexed: 10/23/2022]
Abstract
Delivering drugs to the colorectum by enema has advantages for treating or preventing both local and systemic diseases. However, the properties of the enema itself are not typically exploited for improving drug delivery. Sodium ions are actively pumped out of the lumen of the colon, which is followed by osmotically-driven water absorption, so we hypothesized that this natural mechanism could be exploited to drive nanoparticles and drugs to the colorectal tissue surface. Here, we report that sodium-based, absorption-inducing (hypotonic) enemas rapidly transport hydrophilic drugs and non-mucoadhesive, mucus penetrating nanoparticles (MPP), deep into the colorectal folds to reach virtually the entire colorectal epithelial surface. In contrast, isotonic and secretion-inducing (hypertonic) vehicles led to non-uniform, poor surface coverage. Sodium-based enemas induced rapid fluid absorption even when moderately hyper-osmolal (~350 mOsm) compared to blood (~300 mOsm), which suggests that active sodium absorption plays a key role in osmosis-driven fluid uptake. We then used tenofovir, an antiretroviral drug in clinical trials for preventing HIV, to test the effects of enema composition on local and systemic drug delivery. We found that strongly hypotonic and hypertonic enemas caused rapid systemic drug uptake, whereas moderately hypotonic enemas with ion compositions similar to feces resulted in high local tissue levels with minimal systemic drug exposure. Similarly, moderately hypotonic enemas provided improved local drug retention in colorectal tissue, whereas hypertonic and isotonic enemas provided markedly reduced drug retention in colorectal tissue. Lastly, we found that moderately hypotonic enema formulations caused little to no detectable epithelial damage, while hypertonic solutions caused significant damage, including epithelial sloughing; the epithelial damage caused increased systemic drug absorption and penetration of MPP into colorectal tissue, a potential advantage in certain drug delivery applications. In summary, we illustrate that enema composition can be adjusted to maximize local versus systemic drug delivery, and that mildly hypotonic, sodium-based vehicles can provide uniform drug and MPP delivery in the colon that maximizes local drug concentrations.
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Affiliation(s)
- Katharina Maisel
- Center for Nanomedicine, Johns Hopkins University School of Medicine, 400N. Broadway, Baltimore, MD 21231 USA; Department of Biomedical Engineering, Johns Hopkins University School of Medicine, 720 Rutland Avenue, Baltimore, MD 21205 USA
| | - Sumon Chattopadhyay
- Center for Nanomedicine, Johns Hopkins University School of Medicine, 400N. Broadway, Baltimore, MD 21231 USA; Department of Chemical and Biomolecular Engineering, Johns Hopkins University, 3400 N. Charles Street, Baltimore, MD 21218 USA
| | - Thomas Moench
- Department of Biophysics, Johns Hopkins University, 3400 N. Charles Street, Baltimore, MD 21218 USA; ReProtect, Inc, 703 Stags Head Road, Baltimore, MD 21286 USA
| | - Craig Hendrix
- Department of Clinical Pharmacology, Johns Hopkins University School of Medicine, 600 N. Wolfe Street, Baltimore, MD 21287, USA
| | - Richard Cone
- Center for Nanomedicine, Johns Hopkins University School of Medicine, 400N. Broadway, Baltimore, MD 21231 USA; Department of Biophysics, Johns Hopkins University, 3400 N. Charles Street, Baltimore, MD 21218 USA
| | - Laura M Ensign
- Center for Nanomedicine, Johns Hopkins University School of Medicine, 400N. Broadway, Baltimore, MD 21231 USA; Department of Chemical and Biomolecular Engineering, Johns Hopkins University, 3400 N. Charles Street, Baltimore, MD 21218 USA; Department of Ophthalmology, The Wilmer Eye Institute, Johns Hopkins University School of Medicine, 400 N. Broadway, Baltimore, MD 21231, USA; Center for Cancer Nanotechnology Excellence, the Institute for NanoBioTechnology, Johns Hopkins University, 3400 N Charles Street, Baltimore, MD 21218, USA.
| | - Justin Hanes
- Center for Nanomedicine, Johns Hopkins University School of Medicine, 400N. Broadway, Baltimore, MD 21231 USA; Department of Biomedical Engineering, Johns Hopkins University School of Medicine, 720 Rutland Avenue, Baltimore, MD 21205 USA; Department of Chemical and Biomolecular Engineering, Johns Hopkins University, 3400 N. Charles Street, Baltimore, MD 21218 USA; Department of Ophthalmology, The Wilmer Eye Institute, Johns Hopkins University School of Medicine, 400 N. Broadway, Baltimore, MD 21231, USA; Center for Cancer Nanotechnology Excellence, the Institute for NanoBioTechnology, Johns Hopkins University, 3400 N Charles Street, Baltimore, MD 21218, USA; Departments of Neurosurgery, Oncology, and Pharmacology & Molecular Sciences, Johns Hopkins University School of Medicine, 600 N. Wolfe Street, Baltimore, MD 21287, USA.
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