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Eubanks A, Coulibaly B, Dembélé Keita B, Anoma C, Dah TTE, Mensah E, Maradan G, Bourrelly M, Mora M, Riegel L, Rojas Castro D, Yaya I, Spire B, Laurent C, Sagaon-Teyssier L. Rate and Predictors of Ineffective HIV Protection in African Men Who Have Sex with Men Taking Pre-Exposure Prophylaxis. AIDS Behav 2022; 26:3524-3537. [PMID: 35469111 DOI: 10.1007/s10461-022-03692-8] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/11/2022] [Indexed: 11/30/2022]
Abstract
We investigated the rate and predictors of ineffective HIV protection in men who have sex with men (MSM) taking pre-exposure prophylaxis (PrEP) in a prospective cohort study from November 2017 to November 2020 in Mali, Côte d'Ivoire, Burkina Faso, and Togo. MSM had to be 18 years or older and at high risk of HIV infection to participate. They also received a comprehensive sexual health prevention package, including PrEP, in community-based clinics as part of the cohort study. Using socio-behavioral/clinical data, HIV protection during their most recent anal intercourse with a male partner was categorized as effective or ineffective (i.e., incorrect PrEP adherence and no condom use). Seventeen percent (500/2839) of intercourses were ineffectively protected for the 520 study participants. Predictors of ineffective HIV protection included being an event-driven user with financial difficulties, having a high alcohol misuse score, and not being a member of a community association. PrEP programs in West Africa must be tailored to socially vulnerable MSM who struggle to adopt PrEP.
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Affiliation(s)
- August Eubanks
- Aix Marseille Univ, INSERM, IRD, SESSTIM, Sciences Economiques & Sociales de la Santé & Traitement de L'Information Médicale, ISSPAM, Marseille, France.
| | | | | | | | - Ter Tiero Elias Dah
- Association African Solidarité, Ouagadougou, Burkina Faso
- Institut National de Santé Publique, Centre Muraz, Bobo-Dioulasso, Burkina Faso
| | | | - Gwenaëlle Maradan
- Aix Marseille Univ, INSERM, IRD, SESSTIM, Sciences Economiques & Sociales de la Santé & Traitement de L'Information Médicale, ISSPAM, Marseille, France
- ORS PACA, Observatoire Régional de la santé Provence-Alpes-Côte d'Azur, Marseille, France
| | - Michel Bourrelly
- Aix Marseille Univ, INSERM, IRD, SESSTIM, Sciences Economiques & Sociales de la Santé & Traitement de L'Information Médicale, ISSPAM, Marseille, France
- Coalition Plus, Community-Based Research Laboratory, Pantin, France
| | - Marion Mora
- Aix Marseille Univ, INSERM, IRD, SESSTIM, Sciences Economiques & Sociales de la Santé & Traitement de L'Information Médicale, ISSPAM, Marseille, France
| | - Lucas Riegel
- Coalition Plus, Community-Based Research Laboratory, Pantin, France
| | - Daniela Rojas Castro
- Aix Marseille Univ, INSERM, IRD, SESSTIM, Sciences Economiques & Sociales de la Santé & Traitement de L'Information Médicale, ISSPAM, Marseille, France
- Coalition Plus, Community-Based Research Laboratory, Pantin, France
| | - Issifou Yaya
- TransVIHMI, Univ Montpellier, INSERM, Montpellier, IRD, France
| | - Bruno Spire
- Aix Marseille Univ, INSERM, IRD, SESSTIM, Sciences Economiques & Sociales de la Santé & Traitement de L'Information Médicale, ISSPAM, Marseille, France
| | | | - Luis Sagaon-Teyssier
- Aix Marseille Univ, INSERM, IRD, SESSTIM, Sciences Economiques & Sociales de la Santé & Traitement de L'Information Médicale, ISSPAM, Marseille, France
- ARCAD Santé PLUS, Bamako, Mali
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52
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Manguro GO, Musau AM, Were DK, Tengah S, Wakhutu B, Reed J, Plotkin M, Luchters S, Gichangi P, Temmerman M. Increased condom use among key populations using oral PrEP in Kenya: results from large scale programmatic surveillance. BMC Public Health 2022; 22:304. [PMID: 35164707 PMCID: PMC8842980 DOI: 10.1186/s12889-022-12639-6] [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: 06/13/2021] [Accepted: 01/24/2022] [Indexed: 11/29/2022] Open
Abstract
Background Female sex workers (FSW) and men having sex with men (MSM) in Kenya have high rates of HIV infection. Following a 2015 WHO recommendation, Kenya initiated national scale-up of pre-exposure prophylaxis (PrEP) for all persons at high-risk. Concerns have been raised about PrEP users' potential changes in sexual behaviors such adopting condomless sex and multiple partners as a result of perceived reduction in HIV risk, a phenomenon known as risk compensation. Increased condomless sex may lead to unintended pregnancies and sexually transmitted infections and has been described in research contexts but not in the programmatic setting. This study looks at changes in condom use among FSW and MSM on PrEP through a national a scale-up program. Methods Routine program data collected between February 2017 and December 2019 were used to assess changes in condom use during the first three months of PrEP in 80 health facilities supported by a scale-up project, Jilinde. The primary outcome was self-reported condom use. Analyses were conducted separately for FSW and for MSM. Log-Binomial Regression with Generalized Estimating Equations was used to compare the incidence proportion (“risk”) of consistent condom use at the month 1, and month 3 visits relative to the initiation visit. Results At initiation, 69% of FSW and 65% of MSM reported consistent condom use. At month 3, this rose to 87% for FSW and 91% for MSM. MSM were 24% more likely to report consistent condom use at month 1 (Relative Risk [RR], 1.24, 95% Confidence Interval [CI], 1.18–1.30) and 40% more likely at month 3 (RR, 1.40, 95% CI, 1.33–1.47) compared to at initiation. FSW were 15% more likely to report consistent condom use at the month one visit (RR, 1.15, 95% CI, 1.13–1.17) and 27% more likely to report condom use on the month 3 visit (RR 1.27, 95% CI, 1.24–1.29). Conclusion Condom use increased substantially among both FSW and MSM. This may be because oral PrEP was provided as part of a combination prevention strategy that included counseling and condoms but could also be due to the low retention rates among those who initiated. Supplementary Information The online version contains supplementary material available at 10.1186/s12889-022-12639-6.
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Affiliation(s)
- Griffins O Manguro
- International Center for Reproductive Health Kenya, 3rd Avenue Nyali, P.O Box 91109-80103, Mombasa, Kenya. .,Faculty of Medicine and Health Sciences, Gent University, Gent, Belgium.
| | | | | | | | | | | | | | - Stanley Luchters
- Institute for Human Development, Aga Khan University, Nairobi, Kenya.,International Centre for Reproductive Health, Department of Obstetrics and Gynecology, Ghent University, Ghent, Belgium.,School of Population Health and Preventive Medicine, Monash University, Melbourne, Australia
| | - Peter Gichangi
- Technical University of Mombasa, Mombasa, Kenya.,Department of Public Health and Primary Care, Faculty of Medicine and Health Sciences, Ghent University, Ghent, Belgium
| | - Marleen Temmerman
- International Center for Reproductive Health Kenya, 3rd Avenue Nyali, P.O Box 91109-80103, Mombasa, Kenya.,Department of Public Health and Primary Care, Faculty of Medicine and Health Sciences, Ghent University, Ghent, Belgium.,Department of Obstetrics and Gynecology, The Aga Khan University, Nairobi, Kenya
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53
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Joseph Davey DL, Mvududu R, Mashele N, Lesosky M, Khadka N, Bekker LG, Gorbach P, Coates TJ, Myer L. Early pre-exposure prophylaxis (PrEP) initiation and continuation among pregnant and postpartum women in antenatal care in Cape Town, South Africa. J Int AIDS Soc 2022; 25:e25866. [PMID: 35138678 PMCID: PMC8826542 DOI: 10.1002/jia2.25866] [Citation(s) in RCA: 28] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2021] [Accepted: 12/14/2021] [Indexed: 11/24/2022] Open
Abstract
Introduction Pre‐exposure prophylaxis (PrEP) is a safe and effective prevention strategy to reduce women's risk of HIV in pregnancy and postpartum. Effective PrEP protection requires daily PrEP adherence, but little is known about maternal PrEP continuation and factors that influence PrEP use. Methods The PrEP in pregnancy and postpartum (PrEP‐PP) study enrolled consenting pregnant, HIV‐negative women at first antenatal care (ANC) visit with follow‐up through 12 months postpartum. Eligible and consenting women and girls ≥16 years received HIV prevention counselling and were offered PrEP. Interviewers collected socio‐demographic and behavioural data from participants at each visit. We analysed the proportion of women who initiated PrEP and the proportion who continued PrEP after 3 months with associated correlates by estimating the prevalence ratio adjusting for a priori confounders. Results Between August 2019 and October 2021, we enrolled 1201 pregnant women (median gestation 21 weeks; age 26 years); 84% of women initiated PrEP at their first ANC visit (n = 1014); 55% were married or cohabiting. Overall, 66% of women on PrEP returned for a repeat prescription at 1 month; 58% returned at 3 months (n = 493 of 844). Almost one‐half of women on PrEP reported a side effect at 1 month, mostly nausea/vomiting. Women on PrEP in the first and second trimesters had higher odds of reporting side effects (aOR 2.61; 95% CI 1.17–5.84) versus postpartum women. Women who reported side effects continued with PrEP less than those who did not report side effects (aPR = 0.87; 95% CI 0.77–0.97). Women with ≥1 previous pregnancy (aPR = 0.76; 95% CI 0.57–1.01) or were postpartum (aPR 0.85; 95% CI 0.75–0.97) were less likely to continue PrEP compared to women who were primigravid or pregnant. Women who reported having an HIV+ partner (aPR = 1.45; 95% CI 1.13–1.85) or high HIV risk perception (aPR = 1.20, 95% CI = 1.01–1.41) were more likely to continue on PrEP than those who had HIV‐negative partners or low risk perception. Conclusions PrEP initiation and early continuation were high in this setting, compared to other studies in women. Being postpartum and experiencing side effects were associated with lower PrEP continuation, presenting opportunities for counselling on early transient side effects. Interventions for postpartum women on PrEP are needed.
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Affiliation(s)
- Dvora Leah Joseph Davey
- Department of Epidemiology, Fielding School of Public Health, University of California Los Angeles, Los Angeles, California, USA.,Division of Epidemiology and Biostatistics, School of Public Health and Family Medicine, University of Cape Town, Cape Town, South Africa.,The Desmond Tutu Health Foundation, University of Cape Town, Cape Town, South Africa
| | - Rufaro Mvududu
- Division of Epidemiology and Biostatistics, School of Public Health and Family Medicine, University of Cape Town, Cape Town, South Africa
| | - Nyiko Mashele
- Division of Epidemiology and Biostatistics, School of Public Health and Family Medicine, University of Cape Town, Cape Town, South Africa
| | - Maia Lesosky
- Division of Epidemiology and Biostatistics, School of Public Health and Family Medicine, University of Cape Town, Cape Town, South Africa
| | - Nehaa Khadka
- Department of Epidemiology, Fielding School of Public Health, University of California Los Angeles, Los Angeles, California, USA
| | - Linda-Gail Bekker
- The Desmond Tutu Health Foundation, University of Cape Town, Cape Town, South Africa
| | - Pamina Gorbach
- Department of Epidemiology, Fielding School of Public Health, University of California Los Angeles, Los Angeles, California, USA
| | - Thomas J Coates
- David Geffen School of Medicine, University of California Los Angeles, Los Angeles, California, USA
| | - Landon Myer
- Division of Epidemiology and Biostatistics, School of Public Health and Family Medicine, University of Cape Town, Cape Town, South Africa
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Witte SS, Filippone P, Ssewamala FM, Nabunya P, Bahar OS, Mayo-Wilson LJ, Namuwonge F, Damulira C, Tozan Y, Kiyingi J, Nabayinda J, Mwebembezi A, Kagaayi J, McKay M. PrEP acceptability and initiation among women engaged in sex work in Uganda: Implications for HIV prevention. EClinicalMedicine 2022; 44:101278. [PMID: 35128367 PMCID: PMC8808048 DOI: 10.1016/j.eclinm.2022.101278] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/27/2021] [Revised: 12/21/2021] [Accepted: 01/13/2022] [Indexed: 12/23/2022] Open
Abstract
BACKGROUND Women engaged in sex work (WESW) are disproportionately affected by HIV. In Uganda, HIV prevalence among WESW is estimated at 37%, accounting for 18% of all new infections in the country. WESW experience poverty, gender-based violence, and other issues that reduce their power and limit their ability to negotiate condom use. Female-controlled strategies, including pre-exposure prophylaxis (PrEP), may afford women more transmission protection, but barriers to access and use persist. This cross-sectional study examined baseline PrEP acceptability and initiation among WESW recently enrolled in a randomized clinical trial in Uganda to test the impact of a combination HIV risk reduction and economic empowerment intervention on sexual risk outcomes (clinicaltrials.gov, NCT03583541). METHODS A total of 542 WESW from 19 high HIV-prevalent geographical areas were enrolled in the Kyaterekera study between June 2019 and March 2020. Women were eligible for the study if they: (1) were age 18 or over; (2) reported engagement in transactional sex (a sex act in exchange for pay) in the past 30 days; and (3) reported engagement in one or more episodes of unprotected sex in the past 30 days. Women completed a baseline assessment, were tested for HIV and other sexually transmitted infections (STIs) at enrollment, and were connected with antiretroviral therapy (ART), STI treatment, or PrEP, based on need and interest. Descriptive statistics examined baseline data on PrEP acceptability and initiation. Independent variables (i.e. years in sex work, recent sexual coercion, perceived HIV and sex work stigmas, harmful alcohol use, barriers to medical care, and social support) were derived from the empirical literature and women's self-report. Bivariate analysis was performed to test associations between main effects of these variables. Using binomial logistic regression, predictive models were evaluated for two distinct outcomes-PrEP acceptability and PrEP initiation/uptake. FINDINGS At baseline, 59% of women (n = 322) tested HIV negative. Among WESW testing negative, 11% (n = 36) were already PrEP enrolled. Most women reported willingness to use PrEP (n = 317; 91%). Slightly over half of WESW not already on PrEP agreed to initiate PrEP (n = 158; 55%). Logistic regression models demonstrate that acceptability of or willingness to use PrEP was significantly associated with fewer years engaged in sex work (AOR= ·18, 95% CI 0·05-·66, p<·01) and greater perceived social support from family (AOR= 1·39, 95% CI 1·03 -1.88, p<·05). PrEP initiation was negatively associated with greater perceived social support from friends (AOR=·81, 95% CI ·68-0·97, p<·05) and positively associated with higher perceived stigma due to sex work among family members (AOR=2·20, 95% CI 1·15-4·22, p<·05). INTERPRETATION Despite endorsing PrEP use, many WESW remain reluctant to use it. This gap in prevention practice highlights the heart of a failing PrEP prevention cascade. Findings point to the important role family and friend support may play in destigmatizing sex work and PrEP use for women. Social and structural-level efforts are needed to improve educational messaging and to integrate positive messaging into health promotion campaigns for women and their families, while also working toward decriminalizing sex work. FUNDING This paper was made possible with funding from United States National Institute of Mental Health (Grant number: R01MH116768).
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Affiliation(s)
- Susan S. Witte
- Columbia University School of Social Work, 1255 Amsterdam Avenue, New York, NY 10027, United States
- Corresponding author.
| | - Prema Filippone
- Columbia University School of Social Work, 1255 Amsterdam Avenue, New York, NY 10027, United States
| | - Fred M. Ssewamala
- International Center for Child Health and Development (ICHAD), Washington University in St. Louis Brown School, 1 Brookings Drive, St. Louis, MO 63130, United States
| | - Proscovia Nabunya
- International Center for Child Health and Development (ICHAD), Washington University in St. Louis Brown School, 1 Brookings Drive, St. Louis, MO 63130, United States
| | - Ozge Sensoy Bahar
- International Center for Child Health and Development (ICHAD), Washington University in St. Louis Brown School, 1 Brookings Drive, St. Louis, MO 63130, United States
| | - Larissa Jennings Mayo-Wilson
- Department of Applied Health Science, Indiana University School of Public Health, 1025 E. 7TH Street, Bloomington, IN 47405, United States
| | - Flavia Namuwonge
- International Center for Child Health and Development (ICHAD), Washington University in St. Louis Brown School, 1 Brookings Drive, St. Louis, MO 63130, United States
| | - Christopher Damulira
- International Center for Child Health and Development (ICHAD), Washington University in St. Louis Brown School, 1 Brookings Drive, St. Louis, MO 63130, United States
| | - Yesim Tozan
- New York University School of Global Public Health, 708 Broadway, 4rd floor, New York, NY 10003, United States
| | - Joshua Kiyingi
- International Center for Child Health and Development (ICHAD), Washington University in St. Louis Brown School, 1 Brookings Drive, St. Louis, MO 63130, United States
| | - Josephine Nabayinda
- International Center for Child Health and Development (ICHAD), Washington University in St. Louis Brown School, 1 Brookings Drive, St. Louis, MO 63130, United States
| | | | - Joseph Kagaayi
- Rakai Health Sciences Program, P.O Box 279, Kalisizo, Uganda
| | - Mary McKay
- International Center for Child Health and Development (ICHAD), Washington University in St. Louis Brown School, 1 Brookings Drive, St. Louis, MO 63130, United States
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Thomas D, Mujugira A, Ortblad K, Namanda S, Kibuuka J, Nakitende M, Nambi F, Nakabugo L, Scoville C, Muwonge T, Heffron R. A pragmatic approach to identifying implementation barriers and facilitators for a novel pre-exposure prophylaxis (PrEP) delivery model at public facilities in urban Uganda. Implement Sci Commun 2022; 3:7. [PMID: 35090560 PMCID: PMC8795935 DOI: 10.1186/s43058-022-00254-w] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2021] [Accepted: 01/04/2022] [Indexed: 12/02/2022] Open
Abstract
Background Scalable HIV pre-exposure prophylaxis (PrEP) delivery models for resource-limited settings are critical for improving PrEP coverage and interrupting HIV transmission. This research uses technical assistance (TA) reports to evaluate implementation barriers and facilitators for a novel delivery model integrating PrEP and antiretroviral therapy (ART) delivery for HIV sero-different couples in public health facilities in Kampala, Uganda. Methods We used data from the Partners PrEP Program (PPP)—a stepped-wedge cluster randomized trial that is launching PrEP delivery through an integrated model of oral PrEP and antiretroviral therapy (ART) delivery for HIV sero-different couples at public health facilities in Kampala and Wakiso, Uganda (NCT03586128). Technical assistance teams, comprised of PPP program staff, conducted monthly TA visits to implementing facilities where they identified and addressed implementation challenges in collaboration with health facility staff. Findings were recorded in TA reports, a standardized form structured using the Consolidated Framework for Implementation Research (CFIR). We used a conceptual content analysis approach to evaluate TA reports completed from January to December 2019 and identify implementation barriers and facilitators. Results Among 39 reports from the 8 implementing facilities (~ 5 per facility), we identified 11 CFIR constructs. Key implementation facilitators included sensitizing and educating facility staff about PrEP (knowledge and beliefs about the innovation); establishing formal and informal feedback and accountability mechanisms (reflecting and evaluating); and empowering facility staff to address implementation challenges (self-efficacy). Key implementation barriers were related to ineffective recruitment and referral of sero-different couples to and from nearby facilities (cosmopolitanism) as well as stockouts of laboratory resources and testing supplies (available resources). Conclusions This analysis featured a robust implementation science framework to assess the relationship between early implementation determinants and outcomes of this innovative PrEP delivery model. Further, we have provided important descriptions of early implementation barriers and facilitators that will inform scale-up efforts for PrEP delivery within and beyond Uganda. Future work will refine the analysis of pragmatic program data, qualitatively investigate the identified key themes, and explore strategies for addressing implementation barriers. Supplementary Information The online version contains supplementary material available at 10.1186/s43058-022-00254-w.
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Affiliation(s)
- Dorothy Thomas
- Department of Global Health, University of Washington, Ninth and Jefferson Building, HMC 359927, 325 Ninth Avenue, Seattle, WA, 98104-2499, USA
| | - Andrew Mujugira
- Department of Global Health, University of Washington, Ninth and Jefferson Building, HMC 359927, 325 Ninth Avenue, Seattle, WA, 98104-2499, USA.,Infectious Diseases Institute, Makerere University, Kampala, Uganda
| | - Katrina Ortblad
- Public Health Science Division, Fred Hutchinson Cancer Research Center, 1100 Fairview Ave N, Seattle, WA, 98109, USA
| | - Sylvia Namanda
- Infectious Diseases Institute, Makerere University, Kampala, Uganda
| | - Joseph Kibuuka
- Infectious Diseases Institute, Makerere University, Kampala, Uganda
| | - Mai Nakitende
- Infectious Diseases Institute, Makerere University, Kampala, Uganda
| | - Florence Nambi
- Infectious Diseases Institute, Makerere University, Kampala, Uganda
| | | | - Caitlin Scoville
- Department of Global Health, University of Washington, Ninth and Jefferson Building, HMC 359927, 325 Ninth Avenue, Seattle, WA, 98104-2499, USA
| | - Timothy Muwonge
- Infectious Diseases Institute, Makerere University, Kampala, Uganda
| | - Renee Heffron
- Department of Global Health, University of Washington, Ninth and Jefferson Building, HMC 359927, 325 Ninth Avenue, Seattle, WA, 98104-2499, USA. .,Department of Epidemiology, University of Washington, Ninth and Jefferson Building, HMC 359927, 325 Ninth Avenue, Seattle, WA, 98104-2499, USA.
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56
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Makhakhe NF, MeyerWeitz A, Sliep Y. Motivating factors associated with oral pre-exposure prophylaxis use among female sex workers in South Africa. J Health Psychol 2022; 27:2820-2833. [PMID: 34991407 DOI: 10.1177/13591053211072674] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
To explore the motivating factors that encourage female sex workers to take oral PrEP, despite the challenges that come with adherence. The 39 participants in this study consisted of female sex workers, peer educators, a counselor, and a researcher. Participants took PrEP as an expression of self-love. Some participants described PrEP as empowering because they could independently prevent HIV. They were also motivated by parenting, hope and future aspirations. It is important for future PrEP interventions to incorporate behavioral strategies that appeal to the user's personal and deeper motivations for living.
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Mantsios A, Muraleetharan O, Donastorg Y, Perez M, Gomez H, Shembilu C, Beckham SW, Karver TS, Davis W, Likindikoki S, Mbwambo J, Barrington C, Kerrigan D. "She is the one who knows": A qualitative exploration of oral and injectable PrEP as part of a community empowerment approach to HIV prevention among female sex workers in the Dominican Republic and Tanzania. PLOS GLOBAL PUBLIC HEALTH 2022; 2:e0000981. [PMID: 36712835 PMCID: PMC9880901 DOI: 10.1371/journal.pgph.0000981] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
Despite documented interest among female sex workers (FSW), uptake of oral pre-exposure prophylaxis (PrEP) for HIV prevention has been low. Recent trials and regulatory approval of long-acting injectable (LAI) PrEP offer new hope for the potential of this biomedical intervention. We examined FSW's PrEP-related interest and preferences regarding both oral and LAI PrEP situating these dynamics within their specific social and occupational realities. We conducted this work using qualitative methods across two distinct contexts by conducting 40 in-depth interviews with FSW in Tanzania and the Dominican Republic. Textual data was coded using iterative thematic content analysis. Analytic summaries were developed and reviewed to identify recurring themes. We systematically organized themes within each country and then compared across settings. Women in both settings expressed strong interest in PrEP seeing it as an important option to protect themselves in their work. Most participants preferred LAI PrEP due to expectations of reduced stigma and concerns about daily pill adherence and side effects. Occupational factors such as alcohol use, overnight dates with clients, and fear of violence from clients were identified as barriers to daily oral PrEP. LAI PrEP was seen as having the potential to reduce stress related to oral PrEP. Women who preferred pills discussed fear of needles, skepticism about the injections, and others relayed that taking a daily pill would not be challenging for them. There was a pre-dominant sentiment that women know best whether they are better suited for oral or LAI PrEP. Participants stressed the importance of FSW understanding both options to ensure informed decision-making around PrEP and described community-led peer education as key to delivering trusted information. Community empowerment approaches led by FSW which address structural and psychosocial constraints and promote safe work environments may facilitate equitable access and uptake of PrEP among FSW across settings.
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Affiliation(s)
- Andrea Mantsios
- Public Health Innovation & Action, New York, New York, United States of America
- * E-mail:
| | - Ohvia Muraleetharan
- Yale School of Public Health, New Haven, Connecticut, United States of America
| | - Yeycy Donastorg
- Department of Health Policy, Instituto Dominicano de Dermatologia y Cirugia de Piel, Santo Domingo, Dominican Republic
| | - Martha Perez
- Department of Health Policy, Instituto Dominicano de Dermatologia y Cirugia de Piel, Santo Domingo, Dominican Republic
| | - Hoisex Gomez
- Department of Health Policy, Instituto Dominicano de Dermatologia y Cirugia de Piel, Santo Domingo, Dominican Republic
| | - Catherine Shembilu
- Department of Psychiatry, Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania
| | - S. Wilson Beckham
- Department of Health, Behavior and Society, Johns Hopkins University, Baltimore, Maryland, United States of America
| | - Tahilin Sanchez Karver
- Department of Health, Behavior and Society, Johns Hopkins University, Baltimore, Maryland, United States of America
| | - Wendy Davis
- Department of Prevention and Community Health, George Washington University, Washington, DC, United States of America
| | - Samuel Likindikoki
- Department of Psychiatry, Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania
| | - Jessie Mbwambo
- Department of Psychiatry, Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania
| | - Clare Barrington
- Department of Health Behavior, University of North Carolina, Chapel Hill, North Carolina, United States of America
| | - Deanna Kerrigan
- Department of Prevention and Community Health, George Washington University, Washington, DC, United States of America
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58
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Moran A, Mashele N, Mvududu R, Gorbach P, Bekker LG, Coates TJ, Myer L, Joseph Davey D. Maternal PrEP Use in HIV-Uninfected Pregnant Women in South Africa: Role of Stigma in PrEP Initiation, Retention and Adherence. AIDS Behav 2022; 26:205-217. [PMID: 34287756 PMCID: PMC8294266 DOI: 10.1007/s10461-021-03374-x] [Citation(s) in RCA: 23] [Impact Index Per Article: 11.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/09/2021] [Indexed: 11/29/2022]
Abstract
Pregnant women in sub-Saharan Africa are at high risk of HIV acquisition and require effective methods to prevent HIV. In a cohort of pregnant women offered Pre-exposure prophylaxis (PrEP), we evaluate the relationship between internalized and anticipated stigma and PrEP initiation at first antenatal visit, 3-month continuation and adherence using multivariable logistic regression. High internalized and anticipated PrEP stigma are associated with lower PrEP care initiation at first antenatal visit (aOR internalized stigma = 0.06; 95% CI = 0.03–0.11 and aOR anticipated stigma = 0.55; 95% CI = 0.31–1.00) compared to women with low reported stigma, after controlling for covariates. Women whose partners have not been tested for HIV or whose serostatus remains unknown have 1.6-times odds of PrEP retention at 3-months compared to women whose partners have been tested (aOR = 1.60; 95% CI = 1.02–2.52) after adjusting for covariates. PrEP counseling and maternal PrEP interventions must consider individual- and relational-level interventions to overcome anticipated PrEP stigma and other barriers to PrEP initiation and adherence.
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Affiliation(s)
- Alexander Moran
- Department of Epidemiology, Fielding School of Public Health, University of California Los Angeles, 615 E Charles Young Drive S, Los Angeles, CA, 90095, USA.
| | - Nyiko Mashele
- Department of Biostatistics and Epidemiology, School of Public Health and Family Medicine, University of Cape Town, Cape Town, South Africa
| | - Rufaro Mvududu
- Department of Biostatistics and Epidemiology, School of Public Health and Family Medicine, University of Cape Town, Cape Town, South Africa
| | - Pamina Gorbach
- Department of Epidemiology, Fielding School of Public Health, University of California Los Angeles, 615 E Charles Young Drive S, Los Angeles, CA, 90095, USA
| | - Linda-Gail Bekker
- The Desmond Tutu HIV Centre, University of Cape Town, Cape Town, South Africa
| | - Thomas J Coates
- David Geffen School of Medicine, University of California Los Angeles, Los Angeles, CA, USA
| | - Landon Myer
- Department of Biostatistics and Epidemiology, School of Public Health and Family Medicine, University of Cape Town, Cape Town, South Africa
| | - Dvora Joseph Davey
- Department of Epidemiology, Fielding School of Public Health, University of California Los Angeles, 615 E Charles Young Drive S, Los Angeles, CA, 90095, USA
- Department of Biostatistics and Epidemiology, School of Public Health and Family Medicine, University of Cape Town, Cape Town, South Africa
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Mahomed S, Garrett N, Capparelli EV, Osman F, Harkoo I, Yende-Zuma N, Gengiah TN, Archary D, Samsunder N, Baxter C, Mkhize NN, Modise T, Carlton K, McDermott A, Moore PL, Karim QA, Barouch DH, Fast PE, Mascola JR, Ledgerwood JE, Morris L, Abdool Karim SS. OUP accepted manuscript. J Infect Dis 2022; 226:510-520. [PMID: 35134995 PMCID: PMC9417124 DOI: 10.1093/infdis/jiac041] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2021] [Accepted: 02/01/2022] [Indexed: 11/20/2022] Open
Abstract
Background Effective, long-acting prevention approaches are needed to reduce human immunodeficiency virus (HIV) incidence. We evaluated the safety and pharmacokinetics of VRC07-523LS and PGT121 administered subcutaneously alone and in combination as passive immunization for young women in South Africa. Methods CAPRISA 012A was a randomized, double-blinded, placebo-controlled, dose-escalation phase 1 trial. We enrolled 45 HIV-negative women into 9 groups and assessed safety, tolerability, pharmacokinetics, neutralization activity, and antidrug antibody levels. Pharmacokinetic modeling was conducted to predict steady-state concentrations for 12- and 24-weekly dosing intervals. Results VRC07-523LS and PGT121, administered subcutaneously, were safe and well tolerated. Most common reactogenicity events were injection site tenderness and headaches. Nine product-related adverse events were mild and transient. Median VRC07-523LS concentrations after 20 mg/kg doses were 9.65 μg/mL and 3.86 μg/mL at 16 and 24 weeks. The median week 8 concentration after the 10 mg/kg PGT121 dose was 8.26 μg/mL. Modeling of PGT121 at 20 mg/kg showed median concentrations of 1.37 μg/mL and 0.22 μg/mL at 16 and 24 weeks. Half-lives of VRC07-523LS and PGT121 were 29 and 20 days. Both antibodies retained neutralizing activity postadministration and no antidrug antibodies were detected. Conclusions Subcutaneous administration of VRC07-523LS in combination with optimized versions of PGT121 or other antibodies should be further assessed for HIV prevention.
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Affiliation(s)
- Sharana Mahomed
- Correspondence: Sharana Mahomed, MBChB, FC Path, Doris Duke Medical Research Institute, Nelson R. Mandela School of Medicine, University of KwaZulu-Natal, Private Bag X7, Congella, 4013, South Africa ()
| | - Nigel Garrett
- CAPRISA, Centre for the AIDS Programme of Research in South Africa, Durban, South Africa
- Department of Public Health Medicine, School of Nursing and Public Health, University of KwaZulu-Natal, Durban, South Africa
| | | | - Farzana Osman
- CAPRISA, Centre for the AIDS Programme of Research in South Africa, Durban, South Africa
| | - Ishana Harkoo
- CAPRISA, Centre for the AIDS Programme of Research in South Africa, Durban, South Africa
| | - Nonhlanhla Yende-Zuma
- CAPRISA, Centre for the AIDS Programme of Research in South Africa, Durban, South Africa
| | - Tanuja N Gengiah
- CAPRISA, Centre for the AIDS Programme of Research in South Africa, Durban, South Africa
| | - Derseree Archary
- CAPRISA, Centre for the AIDS Programme of Research in South Africa, Durban, South Africa
| | - Natasha Samsunder
- CAPRISA, Centre for the AIDS Programme of Research in South Africa, Durban, South Africa
| | - Cheryl Baxter
- CAPRISA, Centre for the AIDS Programme of Research in South Africa, Durban, South Africa
| | - Nonhlanhla N Mkhize
- National Institute for Communicable Diseases, a Division of the National Health Laboratory Service, Johannesburg, South Africa
- Antibody Immunity Research Unit, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Tandile Modise
- National Institute for Communicable Diseases, a Division of the National Health Laboratory Service, Johannesburg, South Africa
| | - Kevin Carlton
- Vaccine Research Centre, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, Maryland, USA
| | - Adrian McDermott
- Vaccine Research Centre, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, Maryland, USA
| | - Penny L Moore
- CAPRISA, Centre for the AIDS Programme of Research in South Africa, Durban, South Africa
- National Institute for Communicable Diseases, a Division of the National Health Laboratory Service, Johannesburg, South Africa
- Antibody Immunity Research Unit, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Quarraisha Abdool Karim
- CAPRISA, Centre for the AIDS Programme of Research in South Africa, Durban, South Africa
- Department of Epidemiology, Columbia University, New York, New York, USA
| | - Dan H Barouch
- Center for Virology and Vaccine Research, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
| | - Patricia E Fast
- International AIDS Vaccine Initiative, New York, New York, USA
- Pediatric Infectious Diseases, Stanford University School of Medicine, Palo Alto, California, USA
| | - John R Mascola
- Vaccine Research Centre, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, Maryland, USA
| | - Julie E Ledgerwood
- Vaccine Research Centre, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, Maryland, USA
| | - Lynn Morris
- CAPRISA, Centre for the AIDS Programme of Research in South Africa, Durban, South Africa
- National Institute for Communicable Diseases, a Division of the National Health Laboratory Service, Johannesburg, South Africa
- Antibody Immunity Research Unit, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Salim S Abdool Karim
- CAPRISA, Centre for the AIDS Programme of Research in South Africa, Durban, South Africa
- Department of Epidemiology, Columbia University, New York, New York, USA
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Nakamanya S, Kawuma R, Kibuuka D, Kusemererwa S, McCormack S, Ruzagira E, Seeley J. Assessing acceptability of pre-exposure prophylaxis (PrEP) among participants in an HIV vaccine preparedness study in southwestern Uganda. PLoS One 2022; 17:e0271104. [PMID: 35905052 PMCID: PMC9337655 DOI: 10.1371/journal.pone.0271104] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2022] [Accepted: 06/24/2022] [Indexed: 12/02/2022] Open
Abstract
BACKGROUND Daily oral pre-exposure prophylaxis (PrEP) use is highly effective against HIV infection. However, the uptake of PrEP among individuals at high-risk of HIV acquisition in sub-Saharan Africa varies because of availability and acceptability. We assessed the acceptability of PrEP among participants in a prospective HIV vaccine preparedness study in Masaka, southwestern Uganda. METHODS From November 2018 to August 2019, 20 participants (10 female) were purposively selected for in-depth interviews (IDIs) at 3 and 9 months' post-enrolment in the vaccine preparedness study. Four focus group discussions (FGD) (two among men) were conducted with 29 individuals categorized as: younger (18-24 years) men, younger (18-24 years) women, older (≥30 years) men, and older (≥30 years) women. Apart from IDI specific questions on recent life history including work experience, relationship history and places lived, topics for IDIs and FGDs included knowledge of HIV, perceptions of HIV risk (including own risk), knowledge of and use of PrEP. The Theoretical Framework of Acceptability was used to structure a thematic framework approach for data analysis. RESULTS Participants understood that PrEP was an oral pill taken daily by HIV negative individuals to prevent acquisition of HIV. Overall, interest in and acceptability of PrEP was high, more than half expressed positivity towards PrEP but were not ready to initiate taking it citing the burden of daily oral pill taking, related side effects, stigma and distrust of PrEP. Fourteen participants (from IDI and FGD) initiated PrEP, although some (one FGD and two IDI participants) stopped taking it due to side effects or perceived reduced risk. CONCLUSION We observed a keen interest in PrEP initiation among our study participants. However, a limited understanding of PrEP and associated concerns impeded uptake and sustained use. Hence, interventions are needed to address end-user challenges to increase uptake and support adherence.
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Affiliation(s)
- Sarah Nakamanya
- Medical Research Council/Uganda Virus Research Institute (MRC/UVRI) and London School of Hygiene and Tropical Medicine (LSHTM) Uganda Research Unit, Entebbe, Uganda
- * E-mail:
| | - Rachel Kawuma
- Medical Research Council/Uganda Virus Research Institute (MRC/UVRI) and London School of Hygiene and Tropical Medicine (LSHTM) Uganda Research Unit, Entebbe, Uganda
| | - Denis Kibuuka
- Medical Research Council/Uganda Virus Research Institute (MRC/UVRI) and London School of Hygiene and Tropical Medicine (LSHTM) Uganda Research Unit, Entebbe, Uganda
| | - Sylvia Kusemererwa
- Medical Research Council/Uganda Virus Research Institute (MRC/UVRI) and London School of Hygiene and Tropical Medicine (LSHTM) Uganda Research Unit, Entebbe, Uganda
| | | | - Eugene Ruzagira
- Medical Research Council/Uganda Virus Research Institute (MRC/UVRI) and London School of Hygiene and Tropical Medicine (LSHTM) Uganda Research Unit, Entebbe, Uganda
- London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Janet Seeley
- Medical Research Council/Uganda Virus Research Institute (MRC/UVRI) and London School of Hygiene and Tropical Medicine (LSHTM) Uganda Research Unit, Entebbe, Uganda
- London School of Hygiene and Tropical Medicine, London, United Kingdom
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61
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Understanding PrEP Acceptability Among Priority Populations: Results from a Qualitative Study of Potential Users in Central Uganda. AIDS Behav 2022; 26:2676-2685. [PMID: 35133529 PMCID: PMC9252941 DOI: 10.1007/s10461-022-03606-8] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/23/2022] [Indexed: 01/26/2023]
Abstract
Daily oral pre-exposure prophylaxis (PrEP) can safely and effectively prevent HIV acquisition in HIV-negative individuals. However, uptake of PrEP has been suboptimal in sub-Saharan Africa. The goal of this qualitative study was to identify facilitators of and barriers to PrEP acceptability among target users not taking PrEP. Fifty-nine individuals belonging to Ugandan priority populations participated in a single in-depth interview. Participants perceived themselves as being at high risk for HIV acquisition, and expressed interest in PrEP as an HIV prevention strategy. Two forms of stigma emerged as potential barriers to PrEP use: (1) misidentification as living with HIV; and (2) disclosure of membership in a priority population. Acceptability of PrEP was dampened for this sample of potential PrEP users due to anticipated stigmatization. Mitigating stigma should be a key component of effective PrEP delivery to reach UNAIDS goal of ending the AIDS epidemic by 2030.
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Chimoyi L, Chikovore J, Musenge E, Mabuto T, Chetty-Makkan CM, Munyai R, Nchachi T, Charalambous S, Setswe G. Understanding factors influencing utilization of HIV prevention and treatment services among patients and providers in a heterogeneous setting: A qualitative study from South Africa. PLOS GLOBAL PUBLIC HEALTH 2022; 2:e0000132. [PMID: 36962320 PMCID: PMC10021737 DOI: 10.1371/journal.pgph.0000132] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/30/2021] [Accepted: 11/29/2021] [Indexed: 12/16/2022]
Abstract
Despite advances made in HIV prevention and treatment interventions in South Africa, barriers to their utilization continue to exist. Understanding perspectives from patients and providers of healthcare can shed light on the necessary strategies to enhance uptake of HIV services. A cross-sectional qualitative study was conducted in July 2020 in Ekurhuleni District. Based on HIV prevalence estimates from a national survey, male condom use coverage and antiretroviral treatment (ART) initiation rates from routinely collected clinical data for 2012, we selected facilities from geographical areas with varying HIV prevalence and uptake of HIV services. In-depth interviews were conducted with adult (≥18 years) patients and healthcare workers in selected primary healthcare facilities. Thematic analysis was performed following a framework built around the social cognitive theory to describe behavioural, personal, and social/environmental factors influencing utilization of HIV services. Behavioural factors facilitating uptake of HIV services included awareness of the protective value of condoms, and the benefits of ART in suppressing viral load and preventing mother-to-child HIV transmission which was evident across geographical areas. Barriers in high prevalence areas included suboptimal condom use, fears of a positive HIV result, and anticipated HIV-related stigma while seeking healthcare services. Across the geographical areas, personal factors included ability to correctly use available services enhanced by knowledge acquired during counselling sessions and community-based health promotion activities. Further, social support from family reinforced engagement in care. Compared to low uptake areas, clinics in high uptake areas used care-facilitators, outreach teams and decanting programs to address the environmental barriers including staff shortages and long queues. Barriers at multiple levels prevent optimal utilization of HIV services, calling for strategies that target and address the different levels and tailored to needs of specific settings. Overall, improved delivery of HIV prevention or treatment interventions can be achieved through strengthening training of healthcare providers in facilities and communities and addressing negative sequelae from utilising services in low uptake areas.
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Affiliation(s)
- Lucy Chimoyi
- Implementation Research Division, The Aurum Institute, Johannesburg, South Africa
- School of Public Health, University of the Witwatersrand, Johannesburg, South Africa
| | - Jeremiah Chikovore
- Human and Social Capabilities Research Division, Human Sciences Research Council, Durban, South Africa
| | - Eustasius Musenge
- School of Public Health, University of the Witwatersrand, Johannesburg, South Africa
| | - Tonderai Mabuto
- Implementation Research Division, The Aurum Institute, Johannesburg, South Africa
| | - Candice M Chetty-Makkan
- Health Economics and Epidemiology Research Office (HE2RO), Johannesburg, South Africa
- Faculty of Health Sciences, Department of Internal Medicine, School of Clinical Medicine, University of the Witwatersrand, Johannesburg, South Africa
| | - Reuben Munyai
- Implementation Research Division, The Aurum Institute, Johannesburg, South Africa
| | - Tshegang Nchachi
- Implementation Research Division, The Aurum Institute, Johannesburg, South Africa
| | - Salome Charalambous
- Implementation Research Division, The Aurum Institute, Johannesburg, South Africa
- School of Public Health, University of the Witwatersrand, Johannesburg, South Africa
| | - Geoffrey Setswe
- Implementation Research Division, The Aurum Institute, Johannesburg, South Africa
- Department of Health Studies, University of South Africa, Pretoria, South Africa
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Bhavaraju N, Shears K, Schwartz K, Mullick S, Jeckonia P, Murungu J, Persaud U, Vij A, Torjesen K. Introducing the Dapivirine Vaginal Ring in Sub-Saharan Africa: What Can We Learn from Oral PrEP? Curr HIV/AIDS Rep 2021; 18:508-517. [PMID: 34910276 PMCID: PMC8671875 DOI: 10.1007/s11904-021-00577-8] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/04/2021] [Indexed: 11/30/2022]
Abstract
Purpose of review Clinical trials have found that the dapivirine vaginal ring (DVR) is safe to use and effective at reducing women’s risk of acquiring HIV infection. As countries prepare for the introduction of this novel long-acting, woman-controlled prevention method, an examination of key learnings from oral pre-exposure prophylaxis (PrEP) delivery will help programs leverage successful innovations and approaches to support DVR scale-up and expand the method mix for HIV prevention. Recent findings Intensive efforts over the past 5 years have yielded lessons on how to facilitate access to oral PrEP; expand service delivery for PrEP; address the knowledge, attitudes, and skills providers need to support PrEP initiation and effective use; develop messaging that builds community and partner support and combats stigma; and understand the cyclical nature of PrEP use. Summary Evidence from oral PrEP introduction and scale-up can help inform and expedite DVR introduction.
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Affiliation(s)
| | - Kathleen Shears
- FHI 360, 1825 Connecticut Avenue NW, Washington, DC 20009 USA
| | | | - Saiqa Mullick
- Wits Reproductive Health and HIV Institute, 8 Blackwood Avenue, Parktown, Johannesburg, South Africa
| | - Patriciah Jeckonia
- LVCT Health, Batian Lane, Off Argwings Kodhek Road, Hurlingam, Nairobi, Kenya
| | - Joseph Murungu
- Pangaea Zimbabwe AIDS Trust, 27 Rowland Square, Milton Park, Harare, Zimbabwe
| | - Udita Persaud
- United States Agency for International Development, 1300 Pennsylvania Avenue NW, Washington, DC 20523 USA
| | - Ashley Vij
- United States Agency for International Development, 1300 Pennsylvania Avenue NW, Washington, DC 20523 USA
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Derivation of an HIV Risk Score for African Women Who Engage in Sex Work. AIDS Behav 2021; 25:3292-3302. [PMID: 33861378 DOI: 10.1007/s10461-021-03235-7] [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: 03/13/2021] [Indexed: 10/21/2022]
Abstract
No tool exists to stratify HIV risk in contemporary African female sex worker (FSW) populations. Data from a cohort of HIV-negative FSWs in Mombasa, Kenya from 2010 to 2017 were used to conduct a survival analysis assessing predictors of HIV infection. Stepwise regression was used to construct a multivariable model that formed the basis for the score. Seventeen HIV infections occurred over 1247 person-years of follow-up contributed by 670 women. Using depot medroxyprogesterone acetate (DMPA), having a curable sexually transmitted infection (STI), and being married contributed points to the score. HIV incidence was 0.85/100 person-years in a lower-risk group and 3.10/100 person-years in a higher-risk group. In a cohort with overall HIV incidence < 1.50/100 person-years, this risk score identified a subgroup of FSWs with HIV incidence > 3.00/100 person-years, which is the threshold used by the World Health Organization for initiating pre-exposure prophylaxis (PrEP). If validated in an external population, this tool could be useful for targeted PrEP promotion among higher-risk FSWs.
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Hensen B, Machingura F, Busza J, Birdthistle I, Chabata S, Chiyaka T, Floyd S, Jamali G, Mushati P, Hargreaves J, Cowan F. How Can We Support the Use of Oral PrEP Among Young Women who Sell Sex? A PrEP Cascade Analysis. J Acquir Immune Defic Syndr 2021; 88:45-56. [PMID: 34050101 PMCID: PMC8357043 DOI: 10.1097/qai.0000000000002733] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2020] [Accepted: 04/19/2021] [Indexed: 11/27/2022]
Abstract
BACKGROUND We constructed self-reported pre-exposure prophylaxis (PrEP) cascades and explored factors associated with and barriers to PrEP use to inform efforts to support PrEP use among young women who sell sex. METHODS Using self-reported data from HIV-negative young women who sell sex enrolled into a cohort study using respondent-driven sampling in Zimbabwe, we constructed PrEP cascades assessing knowledge of, ever offered, ever used, and current PrEP use in 2017 and 2019. We used logistic regression to examine factors associated with PrEP use by 2019. Through qualitative interviews with 43 women enrolled in the cohort, we investigated barriers to PrEP use. RESULTS At enrollment, 50% of women had heard of PrEP, 12% had ever been offered PrEP, and 7% ever used PrEP. Over time, all cascade domains: 96% of women had heard of and 55% reported an active offer of PrEP. Among women retained in the study in 2019 (56%; n = 538), 34% ever took PrEP by 2019. PrEP use was associated with, at enrollment, reporting more clients in the past month (10+: 45% vs 1-3: 27% adjOR = 1.71 95% CI: 1.06 to 2.76), duration of selling sex (24% <2 years vs 38% 2-3 years; adjOR = 0.51 95% CI: 0.32 to 0.83), and having visited a female sex worker program in the past 12 months (55% vs 27%; adjOR = 2.92 95% CI: 1.91 to 4.46). Qualitative interviews revealed fear of disclosing sex work, HIV-related/ART-related stigma, and (opportunity) costs of accessing PrEP as barriers to use. CONCLUSION PrEP use was associated with factors known to increase HIV risk. Fear of stigma, disclosure, and supply-side barriers need to be addressed to increase women's ability to use PrEP.
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Affiliation(s)
- B. Hensen
- Faculty of Infectious and Tropical Diseases, London School of Hygiene and Tropical Medicine, London, United Kingdom;
| | - F. Machingura
- Centre for Sexual Health and HIV/AIDS Research (CeSHHAR) Zimbabwe, Harare, Zimbabwe;
| | - J. Busza
- Centre for Evaluation, London School of Hygiene and Tropical Medicine, London, United Kingdom;
| | - I. Birdthistle
- Faculty of Epidemiology and Population Health, London School of Hygiene and Tropical Medicine, London, United Kingdom; and
| | - S.T. Chabata
- Centre for Sexual Health and HIV/AIDS Research (CeSHHAR) Zimbabwe, Harare, Zimbabwe;
| | - T. Chiyaka
- Centre for Sexual Health and HIV/AIDS Research (CeSHHAR) Zimbabwe, Harare, Zimbabwe;
| | - S. Floyd
- Faculty of Epidemiology and Population Health, London School of Hygiene and Tropical Medicine, London, United Kingdom; and
| | - G. Jamali
- Centre for Sexual Health and HIV/AIDS Research (CeSHHAR) Zimbabwe, Harare, Zimbabwe;
| | - P. Mushati
- Centre for Sexual Health and HIV/AIDS Research (CeSHHAR) Zimbabwe, Harare, Zimbabwe;
| | - J. Hargreaves
- Centre for Evaluation, London School of Hygiene and Tropical Medicine, London, United Kingdom;
| | - F.M. Cowan
- Centre for Sexual Health and HIV/AIDS Research (CeSHHAR) Zimbabwe, Harare, Zimbabwe;
- Faculty of Clinical Sciences and International Public Health, Liverpool School of Tropical Medicine, Liverpool, United Kingdom.
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Were DK, Musau A, Atkins K, Shrestha P, Reed J, Curran K, Mohan D. Health system adaptations and considerations to facilitate optimal oral pre-exposure prophylaxis scale-up in sub-Saharan Africa. Lancet HIV 2021; 8:e511-e520. [PMID: 34265282 DOI: 10.1016/s2352-3018(21)00129-6] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2021] [Revised: 06/06/2021] [Accepted: 06/08/2021] [Indexed: 12/26/2022]
Abstract
Following WHO's 2015 recommendation, countries in sub-Saharan Africa have progressively scaled up oral pre-exposure prophylaxis (PrEP) as part of combination HIV prevention. PrEP has potential to significantly reduce new HIV infections in sub-Saharan Africa if it is widely available, accessible, and effectively used. Initial scale-up efforts have generated progress, drawing lessons from existing HIV interventions, such as antiretroviral therapy and biomedical prevention. However, beset by unprepared health systems, scale-up has been slow, resulting in suboptimal coverage among priority groups at higher risk of HIV acqusition. Using the WHO health system building blocks framework, this Review synthesises literature on essential considerations for PrEP scale-up in sub-Saharan Africa, highlighting the importance of health system adaptability and responsiveness.
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Affiliation(s)
| | | | - Kaitlyn Atkins
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Prakriti Shrestha
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | | | | | - Diwakar Mohan
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
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Claassen CW, Mumba D, Njelesani M, Nyimbili D, Mwango LK, Mwitumwa M, Mubanga E, Mulenga LB, Chisenga T, Nichols BE, Hendrickson C, Chitembo L, Okuku J, O'Bra H. Initial implementation of PrEP in Zambia: health policy development and service delivery scale-up. BMJ Open 2021; 11:e047017. [PMID: 34244265 PMCID: PMC8273462 DOI: 10.1136/bmjopen-2020-047017] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
INTRODUCTION Daily pre-exposure prophylaxis (PrEP) for HIV prevention is highly effective, but not yet widely deployed in sub-Saharan Africa. We describe how Zambia developed PrEP health policy and then successfully implemented national PrEP service delivery. POLICY DEVELOPMENT Zambia introduced PrEP as a key strategy for HIV prevention in 2016, and established a National PrEP Task Force to lead policy advocacy and development. The Task Force was composed of government representatives, regulatory agencies, international donors, implementation partners and civil society organisations. Following an implementation pilot, PrEP was rolled out nationally using risk-based criteria alongside a national HIV prevention campaign. NATIONAL SCALE-UP In the first year of implementation, ending September 2018, 3626 persons initiated PrEP. By September 2019, the number of people starting PrEP increased by over sixfold to 23 327 persons at 728 sites across all ten Zambian provinces. In the first 2 years, 26 953 clients initiated PrEP in Zambia, of whom 31% were from key and priority populations. Continuation remains low at 25% and 11% at 6 and 12 months, respectively. LESSONS LEARNT Risk-based criteria for PrEP ensures access to those most in need of HIV prevention. Healthcare worker training in PrEP service delivery and health needs of key and priority populations is crucial. PrEP expansion into primary healthcare clinics and community education is required to reach full potential. Additional work is needed to understand and address low PrEP continuation. Finally, a task force of key stakeholders can rapidly develop and implement health policy, which may serve as a model for countries seeking to implement PrEP.
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Affiliation(s)
- Cassidy W Claassen
- Center for International Health, Education, and Biosecurity, University of Maryland School of Medicine, Baltimore, Maryland, USA
- Adult Infectious Diseases Center, University Teaching Hospital, Lusaka, Zambia
- Division of Infectious Diseases, Department of Medicine, University of Zambia School of Medicine, Lusaka, Zambia
| | - Daliso Mumba
- National HIV/AIDS/STI/TB Council, Lusaka, Zambia
- Ministry of Health, Lusaka, Zambia
| | | | - Derrick Nyimbili
- Chemonics Global Health Supply Chain Program-Procurement and Supply Management, Lusaka, Zambia
| | | | - Mundia Mwitumwa
- Adult Infectious Diseases Center, University Teaching Hospital, Lusaka, Zambia
- Division of Infectious Diseases, Department of Medicine, University of Zambia School of Medicine, Lusaka, Zambia
| | | | - Lloyd B Mulenga
- Adult Infectious Diseases Center, University Teaching Hospital, Lusaka, Zambia
- Division of Infectious Diseases, Department of Medicine, University of Zambia School of Medicine, Lusaka, Zambia
- Ministry of Health, Lusaka, Zambia
| | | | - Brooke E Nichols
- Department of Global Health, Boston University School of Public Health, Boston, Massachusetts, USA
- Health Economics and Epidemiology Research Office, Wits University, Johannesburg-Braamfontein, South Africa
| | - Cheryl Hendrickson
- Health Economics and Epidemiology Research Office, Wits University, Johannesburg-Braamfontein, South Africa
| | | | - Jackson Okuku
- U.S. Centers for Disease Control and Prevention, Lusaka, Zambia
| | - Heidi O'Bra
- U.S. Agency for International Development, Lusaka, Zambia
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Ongolly FK, Dolla A, Ngure K, Irungu EM, Odoyo J, Wamoni E, Peebles K, Mugwanya K, Mugo NR, Bukusi EA, Morton J, Baeten JM, O’Malley G. "I Just Decided to Stop:" Understanding PrEP Discontinuation Among Individuals Initiating PrEP in HIV Care Centers in Kenya. J Acquir Immune Defic Syndr 2021; 87:e150-e158. [PMID: 33492024 PMCID: PMC8026512 DOI: 10.1097/qai.0000000000002625] [Citation(s) in RCA: 23] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2020] [Accepted: 12/30/2020] [Indexed: 12/19/2022]
Abstract
BACKGROUND Preexposure prophylaxis (PrEP) discontinuation rates in clinical trials and demonstration projects have been well characterized; however, little is known about discontinuation in routine public health settings in sub-Saharan Africa. Understanding discontinuation in nonstudy settings is important for establishing expectations for PrEP continuation in national programs and for facilitating effective PrEP scale-up. METHODS We conducted in-depth interviews with 46 individuals who had initiated PrEP at 25 HIV comprehensive care clinics (CCCs) in central and western Kenya and whose clinic records indicated they had discontinued. RESULTS Many of our study participants discontinued PrEP when their perceived risk decreased (eg, hiatus or end of a sexual relationship or partner known to be living with HIV became virally suppressed). Others reported discontinuation due to side effects, daily pill burden, preference for condoms, or their partner's insistence. Participant narratives frequently described facility level factors such as stigma-related discomforts with accessing PrEP at CCCs, inconvenient clinic location or operating hours, long wait times, and short refill dates as discouraging factors, suggesting actionable areas for improving PrEP access and continuation. CONCLUSION Clients frequently make intentional decisions to discontinue PrEP as they weigh different prevention options within the context of complex lives. Many clients will decide to discontinue PrEP when perceiving themselves to be at reduced risk and PrEP counseling must include provisions for addressing seasons of risk. PrEP will not be the right prevention method for everyone, or forever. Expanding PrEP access points and increasing sex-positive messaging may facilitate PrEP being a better option for many.
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Affiliation(s)
| | - Annabel Dolla
- Center for Microbiology Research, Kenya Medical Research Institute; Nairobi, Kenya
| | - Kenneth Ngure
- Department of Global Health, Seattle, Washington, USA
- Department of Community Health, Jomo Kenyatta University of Agriculture and Technology, Nairobi, Kenya
| | - Elizabeth M. Irungu
- Center for Clinical Research, Kenya Medical Research Institute; Nairobi, Kenya
| | - Josephine Odoyo
- Center for Microbiology Research, Kenya Medical Research Institute; Nairobi, Kenya
| | - Elizabeth Wamoni
- Center for Clinical Research, Kenya Medical Research Institute; Nairobi, Kenya
| | - Kathryn Peebles
- Department of Epidemiology, Medicine, Seattle, Washington, USA
- University of Washington, Seattle, Washington, USA
| | - Kenneth Mugwanya
- Department of Global Health, Seattle, Washington, USA
- University of Washington, Seattle, Washington, USA
| | - Nelly R. Mugo
- Center for Clinical Research, Kenya Medical Research Institute; Nairobi, Kenya
- Department of Global Health, Seattle, Washington, USA
| | - Elizabeth A. Bukusi
- Department of Global Health, Seattle, Washington, USA
- Department of Obstetrics and Gynecology, Seattle, Washington, USA
- Center for Microbiology Research, Kenya Medical Research Institute; Nairobi, Kenya
| | - Jennifer Morton
- Department of Global Health, Seattle, Washington, USA
- University of Washington, Seattle, Washington, USA
| | - Jared M. Baeten
- Department of Global Health, Seattle, Washington, USA
- Department of Epidemiology, Medicine, Seattle, Washington, USA
- University of Washington, Seattle, Washington, USA
- Center for Microbiology Research, Kenya Medical Research Institute; Nairobi, Kenya
| | - Gabrielle O’Malley
- Department of Global Health, Seattle, Washington, USA
- University of Washington, Seattle, Washington, USA
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Pre-exposure Prophylaxis Uptake Among Men Who Have Sex With Men Who Used nPEP: A Longitudinal Analysis of Attendees at a Large Sexual Health Clinic in Montréal (Canada). J Acquir Immune Defic Syndr 2021; 85:408-415. [PMID: 33136737 DOI: 10.1097/qai.0000000000002472] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Reducing HIV transmission using pre-exposure prophylaxis (PrEP) requires focussing on individuals at high acquisition risk, such as men who have sex with men with a history of nonoccupational post-exposure prophylaxis (nPEP). This study aims to characterize longitudinal trends in PrEP uptake and its determinants among nPEP users in Montréal. METHODS Eligible attendees at Clinique médicale l'Actuel were recruited prospectively starting in October 2000 (nPEP) and January 2013 (PrEP). Linking these cohorts, we characterized the nPEP-to-PrEP cascade, examined the determinants of PrEP uptake after nPEP consultation using a Cox proportional-hazard model, and assessed whether PrEP persistence differed by nPEP history using Kaplan-Meier curves. RESULTS As of August 2019, 31% of 2682 nPEP cohort participants had 2 or more nPEP consultations. Subsequent PrEP consultations occurred among 36% of nPEP users, of which 17% sought nPEP again afterward. Among 2718 PrEP cohort participants, 46% reported previous nPEP use. Among nPEP users, those aged 25-49 years [hazard ratio (HR) = 1.3, 95% confidence interval (CI): 1.1 to 1.7], with more nPEP episodes (HR = 1.4, 95% CI: 1.3 to 1.5), who reported chemsex (HR = 1.3, 95% CI: 1.1 to 1.7), with a sexually transmitted infection history (HR = 1.5; 95% CI: 1.3 to 1.7), and who returned for their first nPEP follow-up visit (HR = 3.4, 95% CI: 2.7 to 4.2) had higher rates of PrEP linkage. There was no difference in PrEP persistence between nPEP-to-PrEP and PrEP only participants. CONCLUSION Over one-third of nPEP users were subsequently prescribed PrEP. However, the large proportion of men who repeatedly use nPEP calls for more efficient PrEP-linkage services and, among those who use PrEP, improved persistence should be encouraged.
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70
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Zarwell M, John SA, Westmoreland D, Mirzayi C, Pantalone DW, Golub S, Nash D, Grov C. PrEP Uptake and Discontinuation Among a U.S. National Sample of Transgender Men and Women. AIDS Behav 2021; 25:1063-1071. [PMID: 33057893 PMCID: PMC7979462 DOI: 10.1007/s10461-020-03064-0] [Citation(s) in RCA: 21] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/08/2020] [Indexed: 10/23/2022]
Abstract
Pre-exposure prophylaxis (PrEP) has revolutionized HIV prevention efforts by effectively preventing the sexual transmission of HIV infection. Few studies have examined PrEP uptake and discontinuation among transgender individuals who are underserved in HIV prevention efforts. An online U.S. nationwide survey screened 294 HIV-negative transgender people for participation in a larger cohort study. We analyzed associations between demographic characteristics and PrEP use and discontinuation. We conducted thematic analyses of open-ended responses to identify reasons for PrEP discontinuation. Fifty-one participants (17.4%) reported ever receiving a PrEP prescription. Transgender men reported higher PrEP use than transgender women (χ2 = 18.06; p < 0.0001). PrEP discontinuation was reported by 49.0% of individuals who reported PrEP use. Reasons for PrEP discontinuation were related to side effects, insurance coverage, relationship status, and access to providers. HIV prevention efforts to increase PrEP should include mechanisms for PrEP uptake and re-initiation among transgender individuals.
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Affiliation(s)
- Meagan Zarwell
- Department of Public Health Sciences, University of North Carolina at Charlotte, Charlotte, NC, USA
| | - Steven A John
- Center for AIDS Intervention Research, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Drew Westmoreland
- Department of Community Health and Social Sciences, CUNY Graduate School of Public Health and Health Policy, The CUNY Institute for Implementation Science in Population Health (ISPH), City University of New York, 55 West 125th Street, Room 812, New York, NY, USA
| | - Chloe Mirzayi
- Department of Community Health and Social Sciences, CUNY Graduate School of Public Health and Health Policy, The CUNY Institute for Implementation Science in Population Health (ISPH), City University of New York, 55 West 125th Street, Room 812, New York, NY, USA
| | - David W Pantalone
- University of Massachusetts, Boston, MA, USA
- The Fenway Institute, Fenway Health, Boston, MA, USA
| | - Sarit Golub
- Hunter College and Graduate Center, The City University of New York, New York, NY, USA
| | - Denis Nash
- Department of Community Health and Social Sciences, CUNY Graduate School of Public Health and Health Policy, The CUNY Institute for Implementation Science in Population Health (ISPH), City University of New York, 55 West 125th Street, Room 812, New York, NY, USA
| | - Christian Grov
- Department of Community Health and Social Sciences, CUNY Graduate School of Public Health and Health Policy, The CUNY Institute for Implementation Science in Population Health (ISPH), City University of New York, 55 West 125th Street, Room 812, New York, NY, USA.
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71
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Crowell TA, Fast PE, Bekker LG, Sanders EJ. Involvement of African men and transgender women who have sex with men in HIV research: progress, but much more must be done. J Int AIDS Soc 2020; 23 Suppl 6:e25596. [PMID: 33000908 PMCID: PMC7527757 DOI: 10.1002/jia2.25596] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2020] [Accepted: 07/20/2020] [Indexed: 12/28/2022] Open
Affiliation(s)
- Trevor A Crowell
- U.S. Military HIV Research Program, Walter Reed Army Institute of Research, Silver Spring, MD, USA
- Henry M. Jackson Foundation for the Advancement of Military Medicine, Bethesda, MD, USA
| | - Patricia E Fast
- International AIDS Vaccine Initiative, New York, NY, USA
- School of Medicine, Stanford University, Palo Alto, CA, USA
| | - Linda-Gail Bekker
- Desmond Tutu HIV Centre, University of Cape Town, Cape Town, South Africa
| | - Eduard J Sanders
- KEMRI-Wellcome Trust Research Programme, Kilifi, Kenya
- Oxford University, Oxford, United Kingdom
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Wahome EW, Graham SM, Thiong’o AN, Mohamed K, Oduor T, Gichuru E, Mwambi J, van der Elst EM, Sanders EJ. Risk factors for loss to follow-up among at-risk HIV negative men who have sex with men participating in a research cohort with access to pre-exposure prophylaxis in coastal Kenya. J Int AIDS Soc 2020; 23 Suppl 6:e25593. [PMID: 33000889 PMCID: PMC7527770 DOI: 10.1002/jia2.25593] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2020] [Revised: 07/07/2020] [Accepted: 07/15/2020] [Indexed: 12/20/2022] Open
Abstract
INTRODUCTION Retention in preventive care among at-risk men who have sex with men (MSM) is critical for successful prevention of HIV acquisition in Africa. We assessed loss to follow-up (LTFU) rates and factors associated with LTFU in an HIV vaccine feasibility cohort study following MSM with access to pre-exposure prophylaxis (PrEP) in coastal Kenya. METHODS Between June 2017 and June 2019, MSM cohort participants attending a research clinic 20 km north of Mombasa were offered daily PrEP and followed monthly for risk assessment, risk reduction counselling and HIV testing. Participants were defined as LTFU if they were late by >90 days for their scheduled appointment. Participants who acquired HIV were censored at diagnosis. Cox proportional hazards models were used to estimate adjusted Hazard Ratio (aHR) of risk factors for LTFU. RESULTS AND DISCUSSION A total of 179 participants with a median age of 25.0 years (interquartile range [IQR]: 23.0 to 30.0) contributed a median follow-up time of 21.2 months (IQR: 6.5 to 22.1). Of these, 143 (79.9%) participants started PrEP and 76 (42.5%) MSM were LTFU, for an incidence rate of 33.7 (95% confidence interval [CI], 26.9 to 42.2) per 100 person-years. Disordered alcohol use (aHR: 2.3, 95% CI, 1.5 to 3.7), residence outside the immediate clinic catchment area (aHR: 2.5, 95% CI, 1.3 to 4.6 for Mombasa Island; aHR: 1.8, 95% CI, 1.0 to 3.3 for south coast), tertiary education level or higher (aHR: 2.3, 95% CI, 1.1 to 4.8) and less lead-in time in the cohort prior to 19 June 2017 (aHR: 3.1, 95% CI, 1.8 to 5.6 for zero to three months; aHR: 2.4, 95% CI, 1.2 to 4.7 for four to six months) were independent predictors of LTFU. PrEP use did not differ by LTFU status (HR: 1.0, 95% CI, 0.6 to 1.5). Psychosocial support for men reporting disordered alcohol use, strengthened engagement of recently enrolled participants and focusing recruitment on areas close to the research clinic may improve retention in HIV prevention studies involving MSM in coastal Kenya. CONCLUSIONS About one in three participants became LTFU after one year of follow-up, irrespective of PrEP use. Research preparedness involving MSM should be strengthened for HIV prevention intervention evaluations in coastal Kenya.
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Affiliation(s)
- Elizabeth W Wahome
- KEMRI/Wellcome Trust Research Programme Centre for Geographic Medicine Research–CoastKilifiKenya
| | - Susan M Graham
- KEMRI/Wellcome Trust Research Programme Centre for Geographic Medicine Research–CoastKilifiKenya
- Departments of Medicine, Epidemiology and Global HealthUniversity of WashingtonSeattleWAUSA
| | - Alexander N Thiong’o
- KEMRI/Wellcome Trust Research Programme Centre for Geographic Medicine Research–CoastKilifiKenya
| | - Khamisi Mohamed
- KEMRI/Wellcome Trust Research Programme Centre for Geographic Medicine Research–CoastKilifiKenya
| | - Tony Oduor
- KEMRI/Wellcome Trust Research Programme Centre for Geographic Medicine Research–CoastKilifiKenya
| | - Evans Gichuru
- KEMRI/Wellcome Trust Research Programme Centre for Geographic Medicine Research–CoastKilifiKenya
| | - John Mwambi
- KEMRI/Wellcome Trust Research Programme Centre for Geographic Medicine Research–CoastKilifiKenya
| | - Elise M van der Elst
- KEMRI/Wellcome Trust Research Programme Centre for Geographic Medicine Research–CoastKilifiKenya
- Department of Global HealthUniversity of AmsterdamAmsterdamthe Netherlands
| | - Eduard J Sanders
- KEMRI/Wellcome Trust Research Programme Centre for Geographic Medicine Research–CoastKilifiKenya
- Department of Global HealthUniversity of AmsterdamAmsterdamthe Netherlands
- Nuffield Department of MedicineUniversity of OxfordHeadingtonUnited Kingdom
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Abstract
Objective: The aim of this study was to appropriately plan for rollout and monitor impact of oral preexposure prophylaxis (PrEP). It is important to understand PrEP continuation and come to a consensus on how best to measure PrEP continuation. This study reviews data on PrEP continuation to document how it is reported, and to compare continuation over time and across populations. Design: A systematic review and meta-analysis. Methods: We searched MEDLINE, Embase and Global Health and reviewed abstracts from HIV conferences from 2017 to 2018 for studies reporting primary data on PrEP continuation. Findings were summarized along a PrEP cascade and continuation was presented by population at months 1, 6 and 12, with random-effects meta-analysis. Results: Of 2578 articles and 596 abstracts identified, 41 studies were eligible covering 22 034 individuals. Continuation data were measured and reported inconsistently. Results showed high discontinuation at month 1 and persistent discontinuation at later time points in many studies. Pooled continuation estimates were 66% at month 1 [n = 5348; 95% confidence interval (95% CI): 48–82], 63% at month 6 (n = 13 629; 95% CI: 48–77) and 71% at month 12 (n = 14 933; 95% CI: 60–81; higher estimate than previous timepoints due to inclusion of different studies). Adequate data were not available to reliably compare estimates across populations. Conclusion: This review found that discontinuation at one month was high, suggesting PrEP initiations may be a poor measure of effectiveness. Continuation declined further over time in many studies, indicating existing cross-sectional indicators may not be adequate to understand PrEP use patterns. Studies do not measure continuation consistently, and consensus is needed.
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74
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Calabrese SK. Understanding, Contextualizing, and Addressing PrEP Stigma to Enhance PrEP Implementation. Curr HIV/AIDS Rep 2020; 17:579-588. [PMID: 32965576 DOI: 10.1007/s11904-020-00533-y] [Citation(s) in RCA: 67] [Impact Index Per Article: 16.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/04/2020] [Indexed: 01/10/2023]
Abstract
PURPOSE OF REVIEW HIV pre-exposure prophylaxis (PrEP) is a safe and effective preventive intervention that could play a central role in ending the HIV epidemic. However, low uptake in general, and among certain social groups in particular, underscores the need to identify and address barriers to PrEP use. PrEP stigma has emerged as a key factor interfering with PrEP interest, uptake, and continuation. The purpose of this article is to describe and contextualize PrEP stigma and to offer recommendations on how to address it in future PrEP implementation initiatives. RECENT FINDINGS PrEP users are commonly stereotyped as sexually irresponsible, promiscuous, and immoral. These stereotypes and associated prejudice manifest at multiple levels and discourage PrEP interest and uptake, disrupt PrEP adherence, and motivate PrEP discontinuation. Intersecting forms of stigma may influence the nature, magnitude, and impact of PrEP stigma across social groups and otherwise hinder PrEP use. Current PrEP implementation strategies that narrowly focus on risk and target stigmatized groups with disproportionately high HIV incidence have yielded limited success and are counterproductive to the extent that they perpetuate stigma. Implementation strategies involving more inclusive messaging and further integration of PrEP within healthcare may help to reduce PrEP stigma and mitigate its impact, ultimately increasing PrEP use. PrEP stigma is a barrier to PrEP interest, uptake, and continuation that manifests at multiple levels. Understanding and addressing PrEP stigma requires consideration of its origins and intersections. Targeted, risk-focused implementation strategies perpetuate stigma and undermine use.
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Affiliation(s)
- Sarah K Calabrese
- Department of Psychological and Brain Sciences, The George Washington University, 2125 G Street NW, Washington, DC, 20052, USA. .,Department of Prevention and Community Health, The George Washington University, 950 New Hampshire Avenue NW, Washington, DC, 20052, USA.
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