No one left behind: how are we doing in the roll-out of PrEP as part of combination HIV prevention?

Multi-dimensional mismatch and barriers for promoting PrEP among men who have sex with men in China: a cross sectional survey from the Demand-side

BACKGROUND

Men who have sex with men (MSM) is a key population for preventing HIV in China, yet pre-exposure prophylaxis (PrEP) is not widely accepted in this population. The objective of this manuscript was to assessed the barriers in the acknowledgement and uptake focusing the demand side.

METHODS

An online questionnaire survey was conducted from December 2018 to January 2019. All participants were required to scan two-dimensional code which was the online crowdsourcing survey platform to complete the electronic questionnaire anonymously.

RESULTS

Among 1915 MSM from thirty-four cities of China, 512 (26.7%) versus 1617 (84.4%) had an objective or subjective need of PrEP, respectively. One hundred and six (5.5%) reported affordability and only 23 (1.2%) had ever taken it. Age, living alone and occupation were associated with the objective needs. Age, income, sexual behavior were associated with actual usage. The participants who they had objective need to use PrEP are the population which we should focus on.

CONCLUSION

A wide disconnect exists among the objective need, willingness, affordability and uptake of PrEP. Cost was the most prevalent barrier, accounting for 78.22% of individuals who needed and wished for PrEP but finally failed to receive it. The findings might facilitate optimizing future allocation of resources to better promote PrEP in Chinese MSM.

Socio-behavioral correlates of pre-exposure prophylaxis use and correct adherence in men who have sex with men in West Africa

BACKGROUND

Multiple barriers compromise pre-exposure prophylaxis (PrEP) engagement (i.e., use and adherence) in men who have sex with men (MSM). In low/middle-income countries, little is known about PrEP engagement in this population. In West Africa, the CohMSM-PrEP study was one of the rare interventions providing PrEP to MSM. We estimated PrEP use and correct adherence rates in CohMSM-PrEP, together with associated factors over time.  METHODS: CohMSM-PrEP recruited MSM in four community-based clinics in Mali, Côte d'Ivoire, Burkina Faso, and Togo. Quarterly follow-up included collecting socio-behavioral data, and providing a comprehensive HIV prevention package, PrEP (daily or event-driven), and peer educator (PE)-led counselling. Using repeated measures, multivariate generalized estimating equations models were used to identify factors associated with self-reported i) PrEP use and ii) correct PrEP adherence during participants' most recent anal intercourse (defined as four pills/week for daily users and 2 + 1 + 1 for event-driven users).

RESULTS

Five hundred twenty participants were included with a median follow-up time of 12 months (IQR 6-21). Of the 2839 intercourses declared over the follow-up period, PrEP use was self-reported for 1996 (70%), and correct PrEP adherence for 1461 (73%) of the latter. PrEP use was higher in participants who also attended participating clinics outside of scheduled visits (adjusted odds ratio (aOR) [95% Confidence Interval, CI], p-value; 1.32[1.01-1.71], 0.040), and in those who practiced condomless anal sex (1.86[1.54-2.24], < 0.001). Correct adherence was higher in those who often contacted PE outside of scheduled visits (2.16[1.01-4.64], 0.047) and in participants who adopted receptive/versatile sexual positions with stable partners (1.36[1.03-1.81], 0.030). Instead, after an interaction effect between financial situation and regimen was tested, it was lower in event-driven users with a difficult/very difficult financial situation (comfortable/just making ends meet & daily, 4.19[2.56-6.86], < 0.001; difficult/very difficult & daily, 6.47[4.05-10.30], < 0.001; comfortable/just making ends meet & event-driven, 1.63[1.22-2.17], 0.001), and in participants who felt alone (0.76[0.58-0.99], 0.042).

CONCLUSIONS

Community-based clinic attendance and PE contact outside of scheduled visits were both associated with higher PrEP engagement, but some socially and economically marginalized participants struggled with adherence. As scale-up continues in West Africa, we recommend implementing community-based interventions and providing extra support for vulnerable users to ensure adequate PrEP engagement.

Tennessee Pharmacists' Opinions on Barriers and Facilitators to Initiate PrEP: A Qualitative Study

Pre-exposure prophylaxis (PrEP) is recommended to prevent the transmission of the human immunodeficiency virus (HIV). Although an effective treatment, the uptake in the United States remains low. Pharmacists are well-positioned to initiate the conversation with patients about PrEP, but few studies exist exploring their unique roles. The objective of this study was to characterize Tennessee pharmacists’ perceptions about access to PrEP. A qualitative study was used to gather the data that consisted of virtual Focus Groups over four months in 2021 from practicing Tennessee pharmacists. Emails were sent to all Tennessee licensed pharmacists to recruit them to participate in the study. Recruitment continued until Thematic Saturation was obtained. The corpus of data was audio-recorded, transcribed, and analyzed by the research team. Thematic Analysis revealed two themes: (1) Barriers to accessing PrEP; (2) Potential solutions to address barriers identified. These findings highlighted barriers and identified solutions to improve access to PrEP in Tennessee; additional financial assistance programs and marketing programs targeting patients and providers are needed to enhance PrEP access.

Changing the PrEP Narrative: A Call to Action to Increase PrEP Uptake among Women

Although the incidence of new cases of human immunodeficiency virus (HIV) has decreased in the past decade, in 2018 more than 7000 women with HIV were diagnosed in the United States (US). Globally, per recent reports, 48% of the new HIV infections were among women. There is still no vaccine to prevent HIV transmission. However, pre-exposure prophylaxis (PrEP) was approved in 2012 by the Food and Drug Administration, providing a powerful tool to block HIV infection and help prevent the subsequent development of acquired immunodeficiency syndrome (AIDS). The uptake of PrEP has been slow globally and among the most vulnerable populations in the US, even though the Centers for Disease Control (CDC) recommended its use in high-risk populations, including women. Furthermore, women represent one-quarter of people living with HIV in the US; however, PrEP is underutilized in this group. Thus, it is imperative to make women’s voices heard through conducting more research, ensuring sufficient access to PrEP, and enhancing knowledge about PrEP as a viable prevention strategy for women. This article aims to promote women’s health by changing the narrative, providing key information on empowering women, and increasing the usage of PrEP.

Low willingness to pay for pre-exposure prophylaxis (PrEP) among men who have sex with men (MSM) in China

Background

Pre-exposure prophylaxis (PrEP) is recommended as an HIV prevention strategy for key populations, in particular men who have sex with men (MSM). However, the willingness to pay market rate for PrEP is largely unknown. This study aimed to investigate the willingness to pay for PrEP and its associated factors among MSM living in Mainland China.

Methods

A cross-sectional survey was conducted among 689 MSM who were recruited through a gay-friendly health consulting service center in Chengdu, China during 2018–2019. We collected information on participants’ willingness to pay for PrEP and its potential correlates (e.g., PrEP awareness and acceptability, perceived risk of HIV infection) using a structured questionnaire. Univariate and multivariate logistic regression were used for data analyses.

Results

Only 14.1% of respondents indicated they would not pay any money for PrEP, around half (49.3%) would like to pay $14–84 per month, and very few (6.8%) would like to pay ≥283 per month (market rate). We found that PrEP awareness (unadjusted odds ratio (ORu) = 1.41; 95% CI: 1.01–1.97), acceptability (ORu =1.20; 95% CI: 1.07–1.34), perceived PrEP adherence (ORu =1.23; 95% CI: 1.08–1.41), and perceived PrEP benefit in reducing condom use (ORu =1.29; 95% CI: 1.07–1.55) were all associated with participants’ willingness to pay the market rate for PrEP. Other facilitators of PrEP pay willingness included full disclosure of sexual orientation to health professionals, high HIV literacy, and a high degree of HIV disclosure with sex partners.

Conclusions

The overall willingness to pay for the market rate of PrEP was low among this urban sample of Chinese MSM. Programs aiming to promote PrEP pay willingness should provide enhanced counseling to improve PrEP-related cognition, deliver accurate HIV/PrEP information to increase health literacy, and decrease stigma towards sexual minorities to develop trust with health professionals.

Knowledge and willingness to use pre-exposure prophylaxis among men who have sex with men in Northeastern Brazil

Few studies evaluate knowledge and willingness to use pre-exposure prophylaxis (PrEP) among men who have sex with men (MSM) in middle-income countries. Brazil added PrEP to public drug formularies in December 2017, but little is known about local knowledge and attitudes about PrEP among MSM outside metropolitan areas in Southern Brazil. The cross-sectional HIV Surveillance Survey Project in Brazil estimates HIV and STD prevalence among MSM in 12 state capitals. Among 32 participants at the Salvador, Bahia study site, we used qualitative interviews to assess knowledge, willingness, and barriers to PrEP use among MSM; few MSM had previous knowledge of PrEP and were willing to use PrEP. Clinical, behavioural, social, and structural factors influencing participants' knowledge and willingness to take PrEP included concerns about efficacy and side effects, access to culturally congruent services for MSM, and stigma. Some participants reported that learning about PrEP online positively influenced their willingness to use PrEP. Participants' opinions about PrEP's contribution to risk compensation varied. Interventions to provide culturally congruent care and destigmatise PrEP for MSM at high risk for HIV acquisition, particularly those conducted collaboratively with Brazil's civil society movement, may enhance the public health effort to expand access to PrEP in Brazil.

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

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

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

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

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

Online-to-offline models in HIV service delivery

PURPOSE OF REVIEW

Half the world's population has access to Internet and technologies, and utilization is near-ubiquitous among providers and key populations. Despite being so well connected; identifying, reaching and linking vulnerable populations to HIV clinical services remains a global challenge. This review highlights the emerging online-to-offline (O2O) models, their potential in scaling up services, and evaluating impact, and implications for future research.

RECENT FINDINGS

Globally, four major types of O2O models have been implemented, primarily in the West and Asia, especially among MSM and transgender women. These models have varying levels of impact in terms of reach, engagement, participation, linkage, and ability to track and monitor participants, and assess outcomes. Those integrated with offline sites enable seamless transition, dramatically reduce the O2O linkage time and demonstrate high linkage success (>73%). O2O models are ideal for at-risk, stigmatized, criminalized populations and for scaling-up biomedical prevention interventions such as preexposure and postexposure prophylaxis.

SUMMARY

O2O models represent novel and powerful solutions to reverse the pandemic and could help fill significant programmatic gaps in tracking individuals through HIV cascades. Providers, especially in resource-limited settings, could choose between a variety of current approaches highlighted in this review and employ no-cost or cost-effective technologies to transform their traditional models and leverage O2O models.

HIV Pre-Exposure Prophylaxis and Postexposure Prophylaxis in Japan: Context of Use and Directions for Future Research and Action

Biomedical HIV prevention strategies are playing an increasingly prominent role in addressing HIV epidemics globally, but little is known about their use in Japan, where persistent HIV disparities and a recently stable, but not declining, national epidemic indicate the need for evolving approaches. We conducted an ethnographic study to determine the context of pre-exposure prophylaxis (PrEP) and postexposure prophylaxis (PEP) use and to identify directions for future research and action in Japan. We used data from observational fieldwork in the Kansai region and Tokyo Metropolitan Area (n = 178 persons observed), qualitative interviews (n = 32), documents and web-based data sources (n = 321), and email correspondences (n = 9) in the period 2013-2016. Drug approvals by Japan's regulatory agencies, insurance coverage for medications, and policies by healthcare institutions and government agencies were the main factors affecting PrEP and PEP legality, use, and awareness. Awareness and the observable presence of PrEP and PEP were very limited, particularly at the community level. PrEP and PEP held appeal for Japanese scientists and activists, and for study participants who represented various other stakeholder groups; however, significant concerns prevented open endorsements. Japanese health officials should prioritize a national discussion, weigh empirical evidence, and strongly consider formal approval of antiretroviral (ARV) medications for use in PrEP and both occupational and nonoccupational PEP. Once approved, social marketing campaigns can be used to advertise widely and increase awareness. Future research would benefit from theoretical grounding in a diffusion of innovations framework. These findings can inform current and future ARV-based prevention strategies at a critical time in the international conversation.