PrEP in the Context of Other HIV Risk Reduction Strategies Among Men Who Have Sex with Men: Results from the Flash! PrEP in Europe Survey

Combination HIV prevention covers a range of biomedical, behavioral, and socio-structural interventions. Despite the growing availability of pre-exposure prophylaxis (PrEP), it is not always accessible in European Centre for Disease Prevention and Control reporting countries and may not meet the needs of all at-risk populations. Based on the Flash! PrEP in Europe data, multiple correspondence analysis and hierarchical clustering were used to identify patterns in HIV prevention strategies among 9980 men who have sex with men (MSM). PrEP interest was evaluated among four identified clusters: (A) "high condom use, sometimes Treatment as Prevention (TasP)"; (B) "mix of methods, infrequent condom use"; (C) "high condom use, tendency to choose partners based on serological status" and (D) "moderate use of condoms mixed with other prevention strategies". Clusters B and D had higher PrEP interest. These results suggest that MSM use a range of behavioral and biomedical risk reduction strategies that are often combined. On-demand PrEP may meet the needs of MSM who infrequently use condoms and other prevention methods.

"Yes, I'm interested in taking PrEP!": PrEP interest among women respondents to the European community-based survey "Flash! PrEP in Europe"

The World Health Organization recommends pre-exposure prophylaxis (PrEP) for all populations at substantial risk of HIV infection, including women. However, data regarding PrEP interest among women is lacking, particularly in Europe. Factors associated with interest in using PrEP were assessed among women respondents to the Flash! PrEP in Europe (FPIE) survey. This community-based cross-sectional study, conducted in 12 European countries, aimed to assess PrEP knowledge and interest. “High objective risk” (HOR) was assessed using established risk criteria following EACS and CDC guidelines. Factors associated with interest in using PrEP were assessed in univariable and multivariable logistic regression models. Among 678 women, 12.5% (n = 85) were considered at HOR, 46.8% (n = 317) indicated prior PrEP knowledge and 18.0% (n = 122) reported interest in using PrEP. Among women at HOR, 40.0% (n = 34) were interested in PrEP. Factors significantly associated with PrEP interest in the final multivariable model were: younger age (18–29 years) (aOR 1.91[95CI: 1.07; 3.41]), bad self-perceived financial status (1.84[1.09; 3.11]), migrant status (south to north) (2.87[1.05; 7.89]), single or dating relationship status (1.93[1.23; 3.03]), sexual abuse history (1.86[1.17; 2.97]), “rather high”/ “high” self-perceived HIV risk (3.21[1.32; 7.81]), and HOR (2.49[1.42; 4.35]). These results show that women at HOR and those who perceived themselves to be at high risk are interested in using PrEP. There is a critical need for targeted information and improved access to PrEP to increase uptake of this HIV prevention tool to meet PrEP interest among women.

Implementation and evaluation of an educational intervention for safer injection in people who inject drugs in Europe: a multi-country mixed-methods study

BACKGROUND

Harm reduction (HR) interventions are essential to reduce human immunodeficiency virus (HIV) and hepatitis C virus (HCV) transmission in people who inject drugs (PWID). Preliminary testing of the Individually Tailored Support and Education for Safer Injection (ITSESI) evidence-based educational intervention for PWID was performed in France in 2011. We created the Eurosider project to implement and evaluate ITSESI at a wider European level, with a view to its future pan-European diffusion.

METHODS

We performed a mixed-methods study involving quantitative (a 6-month before-after study with PWID) and qualitative (focus groups with field workers) components. The study was conducted in 2018-2019 with 307 eligible PWID participating in four existing HR programmes in Bulgaria, Greece, Portugal, and Romania. ITSESI consists in trained field workers observing PWID injection practices and providing an educational exchange. For the present study, PWID participants were allocated to either the control group (i.e., they continued receiving only the current HR services) or the intervention group (i.e., current HR services plus ITSESI). We used the RE-AIM QuEST framework to assess the effectiveness of ITSESI and its acceptability by field workers. Effectiveness was defined as a reduction in both syringe sharing - the highest HIV/HCV transmission risk practice - and in cutaneous abscesses. We used a multivariable mixed logit model to analyse both effectiveness outcomes and to provide adjusted odds ratios (aOR) and 95% confidence intervals (CI). Field workers' acceptability of the intervention was described using a thematic analysis of the qualitative data.

RESULTS

Of the 307 PWID, 55% received ITSESI. Syringe sharing and cutaneous abscesses decreased during follow-up in the intervention group (from 25 to 16% and from 27 to 14%, respectively). Reductions were smaller in the control group (from 29 to 24% and from 23 to 18%, respectively). The multivariable analyses confirmed the effect of the intervention on both of these outcomes (aOR [95% CI]: 0.38 [0.17, 0.85]) and (aOR [95% CI]: 0.38 [0.16, 0.90], respectively). Our qualitative data on acceptability showed the feasibility of involving field workers as proactive research partners in making ITSESI more accessible and acceptable across Europe.

CONCLUSIONS

We demonstrated both the effectiveness of ITSESI in reducing syringe sharing and cutaneous abscesses in four European countries, and a high level of intervention acceptability by field workers. Our findings provide important insights into how ITSESI can be adapted for pan-European implementation.

PrEP Interest Among Men Who Have Sex with Men in the Netherlands: Covariates and Differences Across Samples

Despite increased availability of pre-exposure prophylaxis (PrEP), PrEP uptake has remained low. To promote uptake, factors related to PrEP interest among relevant target populations warrant investigation. The aim of this study was to provide an analysis of PrEP interest among men who have sex with men (MSM) in the Netherlands, while taking study recruitment strategies into account. We recruited 154 MSM from an LGBT research panel (AmsterdamPinkPanel) and 272 MSM from convenience sampling. Both samples were part of the Flash! PrEP in Europe Survey and were compared on their PrEP interest, usage intentions, and sexual behavior. We conducted logistic regression analyses to discover variables associated with PrEP interest and intentions. Participants from the AmsterdamPinkPanel were less likely to use PrEP, had less knowledge of PrEP, and were less interested in PrEP than participants from convenience sampling. Significant covariates of PrEP interest were being single, more prior PrEP knowledge, sexual risk behaviors, such as not having used a condom during last sex and having ever used drugs in a sexual context, and not participating in the AmsterdamPinkPanel. Adding the recruitment strategy to the regression increased explained variance on top of predictors already described in the literature. Increased sexual risk behavior is related to increased PrEP interest and it helps to identify PrEP target groups. Recruitment strategies have a substantial impact on findings regarding PrEP interest and usage intentions. This study emphasizes the importance of using multiple strategies for recruiting participants to obtain a more comprehensive view of MSM's attitudes toward PrEP.

Implementation research to evaluate an educational intervention for people who inject drugs

Objective

In the context of disseminating harm reduction (HR) programmes in Europe, the Eurosider project aims to study the transferability of an effective educational intervention for people who inject drugs (PWID) to four European countries (Bulgaria, Greece, Portugal and Romania). This intervention, entitled Individually-Tailored Support and Education for Safer Injection (ITSESI), has been shown to reduce HIV-Hepatitis C Virus (HCV) risk practices by offering educational supervision during all phases of the injection sequence, from pre- to post-injection.

Methods

The project employs mixed methods and implementation science. The exploratory first step used qualitative interviews and other available data in each country. The second step consists in implementing and evaluating the intervention using a 6-month study conducted among 300 PWID enrolled in the 4 countries. They are interviewed at baseline and at 6 months. The third step will consist in designing, promoting and disseminating all the tools necessary to transfer ITSESI at the European level.

Results

Results from the exploratory phase highlighted two main determining factors for the feasibility of implementing ITSESI: funding and a repressive legal context. Preliminary results from a quantitative analysis of data from the second step will provide a baseline description of the 300 PWID.

Discussion

Findings to date indicate that an exploratory phase is crucial to adapt and transfer the intervention to local contexts and to evaluate it. More globally, the Eurosider project will 1) help understand each local context to adapt the intervention accordingly; 2) assess the feasibility and effectiveness of ITSESI in different contexts; 3) promote and disseminate tools and training to implement the intervention at the European level.

Key messages

People who inject drugs in European countries report HIV-HCV risk practices and adequate prevention should be provided. The implementation of an innovative educational intervention for people who inject drugs may be one response but requires to take into account contextual factors: funding and repressive drug policy.