"You can't have a PrEP program without a PrEP Coordinator": Implementation of a PrEP panel management intervention

Lack of healthcare provider knowledge, capacity, and willingness to prescribe PrEP are barriers to PrEP delivery in clinical settings. We implemented the PrEP Optimization Intervention (PrEP-OI) combining a PrEP Coordinator with an online panel management tool to assist providers with PrEP uptake, persistence, and management in 12 San Francisco Department of Public Health Primary Care Clinics. Medical directors (N = 10) identified important factors to consider prior to implementation, including shortage of clinical space for coordinators, medical mistrust, language barriers, and limited lab hours, along with the need for education of providers and staff and patient outreach. Among 110 providers who completed a baseline survey, the majority had reservations in asking about sexual practices and having conversations about PrEP. Providers reported PrEP-OI increased their efficiency and capacity to manage PrEP patients, and served as a gateway to additional services. These results highlight the promise of a provider-based intervention to improve the PrEP continuum and maximize the impact of PrEP.

Virtual CROI 2020: Highlights of Epidemiology, Public Health, and Prevention Research

At the 2020 Conference on Retroviruses and Opportunistic Infections, held virtually as a result of the emerging COVID-19 pandemic, trends in the HIV epidemic were highlighted, with decreasing HIV incidence reported across several countries, although key regions remain heavily impacted, including the US South. Adolescent girls and young women, men who have sex with men (MSM), transgender persons, and people who inject drugs continue to experience a high burden of new infections. Sexually transmitted infections during pregnancy can lead to a number of adverse outcomes in infants; novel strategies to detect and treat these infections are needed. Innovative HIV testing strategies, including self-testing and assisted partner services, are expanding the reach of testing; however, linkage to care can be improved. Novel preexposure prophylaxis (PrEP) delivery strategies are increasing uptake of PrEP in different groups, although adherence and persistence remain a challenge. Use of on-demand PrEP is increasing among MSM in the US. Strategies are needed to address barriers to PrEP uptake and persistence among cis- and transgender women. Several novel regimens for postexposure prophylaxis show promise.

Feasibility of establishing an HIV vaccine preparedness cohort in a population of the Uganda Police Force: Lessons learnt from a prospective study

Background

Members of uniformed armed forces are considered to be at high risk for HIV infection and have been proposed as suitable candidates for participation in HIV intervention studies. We report on the feasibility of recruitment and follow up of individuals from the community of the Uganda Police Force (UPF) for an HIV vaccine preparedness study.

Methods

HIV-negative volunteers aged 18–49 years, were identified from UPF facilities situated in Kampala and Wakiso districts through community HIV counselling and testing. Potential volunteers were referred to the study clinic for screening, enrolment and quarterly visits for one year. HIV incidence, retention rates were estimated and expressed as cases per 100 person years of observation (PYO). Rate ratios were used to determine factors associated with retention using Poisson regression models.

Results

We screened 560 to enroll 500 volunteers between November 2015 and May 2016. One HIV seroconversion occurred among 431 PYO, for an incidence rate of 0.23/100 PYO (95% confidence interval [CI]: 0.03–1.64). Overall, retention rate was 87% at one year, and this was independently associated with residence duration (compared to <1 year, 1 to 5 years adjusted rate ratio (aRR) = 1.19, 95%CI: 1.00–1.44); and >5 years aRR = 1.34, 95%CI: 0.95–1.37); absence of genital discharge in the last 3 months (aRR = 1.97, 95% CI: 1.38–2.83, absence of genital ulcers (aRR = 1.90, 95%CI: 1.26–2.87, reporting of new sexual partner in the last month (aRR = 0.57, 95%CI: 0.45–0.71, being away from home for more than two nights (aRR = 1.27, 95%CI: 1.04–1.56, compared to those who had not travelled) and absence of knowledge on HIV prevention (aRR = 2.67, 95%CI: 1.62–4.39).

Conclusions

While our study demonstrates the feasibility of recruiting and retaining individuals from the UPF for HIV research, we did observe lower than anticipated HIV incidence, perhaps because individuals at lower risk of HIV infection may have been the first to come forward to participate or participants followed HIV risk reduction measures. Our findings suggest lessons for recruitment of populations at high risk of HIV infection.

Expansion of HIV Preexposure Prophylaxis to 35 PEPFAR-Supported Early Program Adopters, October 2016-September 2018

The U.S. President's Emergency Plan for AIDS Relief (PEPFAR), the largest bilateral funder of human immunodeficiency virus (HIV) prevention and control programs worldwide, currently supports implementation of preexposure prophylaxis (PrEP) to reduce HIV incidence among persons at substantial risk for infection, including female sex workers, men who have sex with men (MSM), and transgender women (hereafter referred to as key populations). Recent estimates suggest that 54% of all global new HIV infections in 2018 occurred among key populations and their sexual partners (1). In 2016, PEPFAR began tracking initiation of PrEP by key populations and other groups at high risk (2). The implementation and scale-up of PrEP programs across 35 PEPFAR-supported country or regional programs* was assessed by determining the number of programs reporting any new PrEP clients during each quarter from October 2016 to September 2018. As of September 2018, only 15 (43%) PEPFAR-supported country or regional programs had implemented PrEP programs; however, client volume increased by 3,351% over the assessment period in 15 country or regional programs. Scale-up of PrEP among general population clients (5,255%) was nearly three times that of key population clients (1,880%). Among key populations, the largest increase (3,518%) occurred among MSM. Factors that helped drive the success of these PrEP early adopter programs included initiation of national, regional, and multilateral stakeholder meetings; engagement of ministries of health and community advocates; revision of HIV treatment guidelines to include PrEP; training for HIV service providers; and establishment of drug procurement policies. These best practices can help facilitate PrEP implementation, particularly among key populations, in other country or regional programs to reduce global incidence of HIV infection.

Cost-Effectiveness of a Statewide Pre-Exposure Prophylaxis Program for Gay, Bisexual, and Other Men Who Have Sex with Men

Pre-exposure prophylaxis (PrEP) is an effective tool for preventing HIV infection among men who have sex with men (MSM), but its cost-effectiveness has varied across settings. Using an agent-based model, we projected the cost-effectiveness of a statewide PrEP program for MSM in Rhode Island over the next decade. In the absence of PrEP, the model predicted an average of 830 new HIV infections over ten years. Scaling up the existing PrEP program to cover 15% of MSM with ten or more partners each year could reduce the number of new HIV infections by 33.1% at a cost of $184,234 per quality-adjusted life-year (QALY) gained. Expanded PrEP use among MSM at high risk for HIV infection has the potential to prevent a large number of new HIV infections but the high drug-related costs may limit the cost-effectiveness of this intervention.

US Guideline Criteria for Human Immunodeficiency Virus Preexposure Prophylaxis: Clinical Considerations and Caveats

Clinical guidelines for human immunodeficiency virus (HIV) preexposure prophylaxis (PrEP) developed by the US Centers for Disease Control and Prevention have been instrumental in the implementation of PrEP in medical practices throughout the country. However, the eligibility criteria contained within may inadvertently limit PrEP access for some patients. We describe the following key considerations and caveats related to these criteria: promotion of a selective vs universal approach to sexual health education involving PrEP; misalignment between criteria stated in the table and text boxes; problematic categorization and confounding of sexual orientation, gender identity, and risk behavior; underemphasis of network/community-level drivers of HIV transmission; oversimplification of serodiscordant risk; and lack of clarity surrounding the relevance of condoms to PrEP eligibility. We offer concrete recommendations to address the identified issues and strengthen future iterations of the guidelines, applying these recommendations in an alternative table of "criteria."

Moving Metaphors: Shifting Institutional Responsibilities and Evidentiary Boundaries in the Commissioning of Pre-Exposure Prophylaxis for HIV

In this article, we investigate how speakers in the U.K.'s House of Commons cited the same legislative context and medical research to arrive at contradictory conclusions regarding the Government's responsibility to fund pre-exposure prophylaxis (PrEP) as an HIV intervention. Because the Government had expressed that it would not comment on institutional responsibilities directly, given the likelihood of a legal challenge in response to the National Health Service withdrawing PrEP from the drug commissioning process, the Government's support of this decision could not be explicitly detailed. Our discourse analytic approach reveals how members of parliament adopted positions in the debate by using distinct metaphorical frames and lexical choices to linguistically encode assumptions that imply contrary interpretations of mutually agreed upon facts. This suggests that the concrete discursive practices used to cite evidence in policy-making discussions, regardless of the quality of the evidence, may have material consequences for evidence-based policy.

Global PrEP roll-out: recommendations for programmatic success

Pre-exposure prophylaxis (PrEP) is being adopted and rolled out in diverse regions, communities, and groups. Although it has been shown to be effective, in some settings PrEP roll-out has lagged, in part due to flawed messaging. Lessons can be learned and principles applied from marketing to highlight the potential pitfalls of current roll-out strategies focused on selective and siloed service provision. After exploration of the way PrEP is promoted in awareness messaging (the sell), marketed to select and often stigmatised groups (the brand), and offered as a special or non-integrated service (product placement), we propose that current strategies can ultimately slow roll-out and contribute to stigma surrounding PrEP use. We propose alternatives for programmes and ministries to consider as they develop long-term plans for HIV prevention. We propose that the sell should focus on protection or wellness framing, the branding should convey PrEP as appropriate for anyone in need, and the provision of PrEP should be placed in the context of other relevant and valued health services. As has been shown in some PrEP programmes, it is possible for programmes to adopt modern marketing strategies that are attractive to healthy clients and might promote an inclusive and holistic vision of biomedical prevention.

Knowledge and use of HIV pre-exposure prophylaxis among men who have sex with men in Berlin - A multicentre, cross-sectional survey

Background

HIV pre-exposure prophylaxis (PrEP) has likely contributed to large decreases in HIV incidence among men who have sex with men (MSM) in several major cities. Berlin has seen a smaller decline, and affordable PrEP has been accessible through formal channels in Germany only since autumn 2017. We aimed to investigate knowledge and use of PrEP among MSM in Berlin, and factors predictive of a desire to use PrEP and history of PrEP use.

Methods

Multicentre, paper-based, self-administered survey of adult MSM whose HIV status was negative or unknown at time of participation. Data were collected from 1 October 2017 to 2 April 2018.

Results

473 of 875 questionnaires were returned (response rate 54.1%; mean age 37.4 years, range 18–79). 90.0% of participants were aware of PrEP and, of these, 48.2% felt well informed about it. Among the 17.2% of participants reporting PrEP use, 59.3% indicated obtaining some or all of it from informal sources. 23.7% of those with no history of PrEP use reported having condomless anal intercourse (CAI) with two or more partners over the past six months. Worries about side effects, cost, not having a doctor who prescribes it, and a lack of information were the most frequently reported barriers to PrEP use. A desire to use PrEP and history of PrEP use were associated in our multivariable model with having multiple CAI partners. A history of PrEP use was associated with having a university degree, one or two parents born outside Germany, or friends living with HIV.

Conclusions

We found high awareness of PrEP among MSM in Berlin, but also a strong need for more education on its pros, cons and proper use. The frequency of informal PrEP use was also high, raising urgent individual and public health concerns. Policy makers need to consider recent calls to improve access to PrEP and PrEP education through regular health services.

Evolving Models and Ongoing Challenges for HIV Preexposure Prophylaxis Implementation in the United States

BACKGROUND

The use of preexposure prophylaxis (PrEP) for HIV prevention was approved by the Food and Drug Administration in 2012, but delivery to at-risk persons has lagged. This critical review analyzes the current state of PrEP implementation in the United States, by reviewing barriers and innovative solutions to enhance PrEP access and uptake.

SETTING

Clinical care settings, public health programs, and community-based organizations (CBOs).

METHODS

Critical review of recent peer-reviewed literature.

RESULTS

More than 100 papers were reviewed. PrEP is currently provided in diverse settings. Care models include sexually transmitted disease clinics, community health centers, CBOs, pharmacies, and private primary care providers (PCPs). Sexually transmitted disease clinics have staff trained in sexual health counseling and are linked to public health programs (eg, partner notification services), whereas PCPs and community health centers may be less comfortable counseling and feel time-constrained in managing PrEP. However, PCPs may be ideal PrEP providers, given their long-term relationships with patients, integrating PrEP into routine care. Collaborations with CBOs can expand PrEP care through adherence support and insurance navigation. Pharmacies can deliver PrEP, given their experience with medication dispensing and counseling, and may be more accessible for some patients, but to address other health concerns, liaisons with PCPs may be needed.

CONCLUSIONS

PrEP implementation in the United States is moving forward with the development of diverse models of delivery. Optimal scale-up will require learning about the best features of each model and providing choices to consumers that enhance engagement and uptake.

Demographic Differences in PrEP-Related Stereotypes: Implications for Implementation

Qualitative interviews about pre-exposure prophylaxis (PrEP) stereotypes were conducted with a subsample of 160 MSM who participated in a PrEP messaging study. Negative stereotypes about PrEP users were identified by 80 % of participants. Two types of stereotypes were most common: PrEP users are HIV-infected (and lying about it), and PrEP users are promiscuous and resistant to condom use. Participants' identification of these stereotype categories differed significantly by demographic factors (i.e., race/ethnicity, education). Expanding access to PrEP requires recognizing potential differences in the experience or anticipation of PrEP-related stereotypes that might impact willingness to discuss PrEP with providers, friends, or partners.

The preexposure prophylaxis revolution: from clinical trials to routine practice: implementation view from the USA

PURPOSE OF REVIEW

This article describes the use of tenofovir/emtricitabine (Truvada) as prevention for exposure to HIV [preexposure prophylaxis (PrEP)] infection in the USA. The use of PrEP and the challenges of implementation are very instructive as other countries adopt this intervention and it becomes a fundamental part of worldwide efforts for HIV prevention and much can be learned from the first 3 years in the USA.

RECENT FINDINGS

Randomized trials and demonstration projects have shown the benefits of PrEP for men and women who are at risk for HIV. Numerous studies have showed that the level of prevention is excellent when the drug is taken at least four times weekly, once adequate levels are obtained. However, adherence remains a critical issue as well as tailoring delivery models for specific populations. Six recent studies are discussed, that support excellent efficacy and significantly support PrEP as a means of prevention. These projects have shown high acceptance of PrEP with excellent adherence by individuals demonstrated by those at risk remaining free of HIV over extended periods of time.

SUMMARY

The USA faces three significant challenges in scaling up PrEP. The first challenge in implementation in the USA is to get individuals to recognize the actual risks that their behaviors represent and to engage with providers to address these issues. The second challenge is getting a population of providers to recognize the exact same issues and offer PrEP in a compassionate, nonjudgmental fashion. The third challenge is identifying the set of providers and locations to scale-up the response in a timely, cost-effective fashion.

The preexposure prophylaxis revolution; from clinical trials to programmatic implementation

PURPOSE OF REVIEW

An investment in preexposure prophylaxis (PrEP) delivery must have public health impact in reducing HIV infections. Sustainable delivery of PrEP requires policy, integration of services, and synergy with other existing HIV prevention programs. This review discusses key policy and programmatic considerations for implementation and scale up of PrEP in Africa.

RECENT FINDINGS

PrEP delivery has been delayed by concerns about adherence and delivery in 'real world' settings. Demonstration projects and clinical service delivery models are providing evidence of PrEP effectiveness with an impact much higher than that found in randomized clinical trials. Data confirm that PrEP uptake, adherence, and retention has been high, more so by persons who perceive themselves at high risk for HIV infection, and PrEP is well tolerated. PrEP delivery is more than dispensation of a pill and programs should address other risk drivers, which differ by population. In Africa, barriers to PrEP uptake and adherence include stigma among MSM and low HIV risk perception among young women. Additional data have provided insight into optimal points of service delivery, provider training requirements and quality assurance needs. Of the 2 million new HIV infections in 2014, 70% were in Africa. PrEP use is not lifelong, and use limited to periods of risk may be both effective and cost-effective for the continent.

SUMMARY

HIV prevention programs should determine strategies to identify those at substantial risk for HIV infection, formulate and deliver PrEP in combination with interventions that target social drivers of HIV vulnerability specific to each population. Policy guidance for optimal combination of interventions and service delivery avenues, clinical protocols, health infrastructure requirements are required. Cost-effectiveness and efficiency data are essential for policy guidance to navigate ethical questions over use of antiretroviral therapy for HIV-negative individuals when treatment coverage has not been attained in many parts of Africa. Countries need to invest in purposeful advocacy at both local and global forums. Failure to implement PrEP will be a failure to protect future generations.

[The health promotion programs for the children based at health promotion institutions]

The research carried out in the framework of the health promotion programs for the children made it possible to obtain characteristics of the patients admitted to health promotion facilities, identify the risk factors for the development of acute respiratory diseases, and substantiate the principles of the differentiated approach to the rehabilitation of such patients based at the institutions of this type taking into consideration the health group to which a concrete patient is referred and the risk factors of acute respiratory diseases. The feasibility and effectiveness of the addition of aromatherapy and treatment with the use of polarized light into the health promotion programs for the children presenting with acute respiratory diseases that they develop during the period of adaptation based at health promotion institutions are discussed.

Are US jurisdictions prepared to dispense medical countermeasures through open points of dispensing? Findings from a national study

Communities will rely on open points of dispensing (PODs) for mass dispensing of medical countermeasures following a bioterrorism attack or a pandemic. US Cities Readiness Initiative (CRI) open POD preparedness is assessed using the Technical Assistance Review (TAR) but focuses on oral prophylaxis dispensing; mass vaccination readiness is not well measured. Non-CRI preparedness had not been studied. In 2013 an online questionnaire was sent to all 456 CRIs and a random sample of 500 non-CRIs to measure open POD preparedness and exercise participation. Hierarchical linear regression was used to describe factors associated with higher POD preparedness and exercise participation scores. In total, 257 subjects participated, for a 41% response rate. Almost all open PODs have existing written plans and/or a layout for each site (93.4%, n=240, and 87.0%, n=220). Only half (46.7%, n=120) have an alternative dispensing modality in place, and even fewer (42.6%, n=104) report having adequate staffing. Determinants of open POD preparedness were perceived preparedness, participation in more POD exercises, and more closed POD coverage. Most jurisdictions conducted a full-scale exercise and a staff notification drill (83.7%, n=215 for both). Fewer than half (40.5%, n=104) have conducted a vaccination clinic exercise. Determinants of increased POD exercises were perceived preparedness, years of work experience, community type (nontribal), and larger population. Because successful open POD deployment is critical, jurisdictions need to plan for mass vaccination, use of alternative dispensing modalities, and recruitment strategies to increase POD staffing.

Human Resource Challenges to Integrating HIV Pre-Exposure Prophylaxis (PrEP) into the Public Health System in Kenya: A Qualitative Study

Extensive planning will be necessary to integrate HIV pre-exposure prophylaxis (PrEP) into public health systems. In Bondo and Kisumu, Kenya, we conducted interviews with 16 district and provincial public health stakeholders and held consultations with 18 provincial and 23 national public health stakeholders on topics related to PrEP rollout. We coded interview transcripts and created memos summarizing responses. We documented consultation discussions through note taking. Human resource challenges identified included increased workload and insufficient personnel, the need for task shifting/sharing, training needs, infrastructural requirements, discrimination and stigma by staff towards at-risk clients, and providers' personal priorities about offering PrEP. These challenges paralleled current challenges related to integration of antiretroviral therapy (ART) and could be partially addressed prior to PrEP rollout. The recommendations for training staff are likewise grounded in lessons from ART and have practical application for program planners developing training curricula for PrEP delivery.

Turning the tide against AIDS by preventing new HIV infections initial experience with Minnesota's first PrEP clinic

During the last 30 years, there have been remarkable improvements in the treatment of patients with HIV. New drug regimens are both tolerable and easy to take, resulting in HIV viral suppression and markedly improved clinical outcomes. Viral suppression in patients with HIV significantly decreases the chance they will transmit the virus. Yet HIV transmission levels in the United States remain unacceptably high. Prevention efforts focused on HIV-negative persons who are at high risk for infection have led to the development of a pre-exposure prophylaxis (PrEP) strategy. This article provides an overview of PrEP and a review of the evidence for it, barriers to its use and how PrEP is being used in the United States and Minnesota. With concerted efforts by physicians, patients and public health authorities, PrEP could become a major tool in preventing transmission of the HIV virus.

Antiviral prophylaxis and isolation for the control of pandemic influenza

Before effective vaccines become available, antiviral drugs are considered as the major control strategies for a pandemic influenza. However, perhaps such control strategies can be severely hindered by the low-efficacy of antiviral drugs. For this reason, using antiviral drugs and an isolation strategy is included in our study. A compartmental model that allows for imported exposed individuals and asymptomatic cases is used to evaluate the effectiveness of control strategies via antiviral prophylaxis and isolation. Simulations show that isolation strategy plays a prominent role in containing transmission when antiviral drugs are not effective enough. Moreover, relatively few infected individuals need to be isolated per day. Because the accurate calculations of the needed numbers of antiviral drugs and the isolated infected are not easily available, we give two simple expressions approximating these numbers. We also derive an estimation for the total cost of these intervention strategies. These estimations obtained by a simple method provide a useful reference for the management department about the epidemic preparedness plans.