Values and Preferences on the Use of Oral Pre-exposure Prophylaxis (PrEP) for HIV Prevention Among Multiple Populations: A Systematic Review of the Literature

Inequities in PrEP annualized pill-day coverage, United States, 2018-2022: a cross-sectional pharmacoequity analysis

INTRODUCTION

Pre-exposure prophylaxis (PrEP) is highly effective in reducing the risk of HIV acquisition, but the population-level impact of PrEP depends on the proportion of people with PrEP indications who use it (coverage) and how long they stay on it while at risk (persistence). We aimed to assess the extent to which PrEP persistence varied by race/ethnicity, sex and age.

METHODS

Previously reported methods and US commercial pharmacy data identified PrEP users and days covered. We calculated PrEP Days Covered (PDC) as the annual number of pills dispensed (i.e., pill-days) overall and by sex, race/ethnicity and age group. Statistical differences by demographic characteristics were calculated. To assess the potential impact of 2-1-1 PrEP dosing on median days of PrEP use, we compared 2018 and 2022 (pre- and post-US Public Health Service guideline for 2-1-1 dosing).

RESULTS

There were 225,180 PrEP users in 2018, and 459,984 in 2022. In 2022, the median PDC was 167 (IQR: 67, 308). There were 90 versus 180 median PDC for female and male users, respectively (difference of 90 PDC, 95% CI, 89.6-90.4). Among PrEP users with race/ethnicity data, the median PDC was higher for White non-Hispanic (NH) (290 days) than Hispanic (268 days) or Black NH (251 days) users. Older users had significantly more PDC than younger users (<16 years: 60 days; 16-29 years: 120 days; 30-64 years: 191 days). Residents of states with PrEP-Drug Assistance Programs (PrEP-DAP) or Medicaid expansion had higher median PrEP duration than states without programmes. Median days covered for 2018 (154 days) and 2022 (167 days) did not suggest that the addition of the 2-1-1 PrEP guideline was associated with fewer covered days.

CONCLUSIONS

PrEP programmes are often evaluated by enumerating people who used PrEP at any time during a year; our data indicate that significant differences in days of PrEP covered among users might mask further inequities in PrEP protection among women, and Black, Hispanic and younger people. Evaluations of PrEP equity should include a pharmacoequity component by assessing days covered as an additional indicator of PrEP equity.

Polymeric and lipidic nanoparticles in transforming anti-HIV combinational therapy: can they turn the tide?

The HIV-1 pandemic presents a multifaceted challenge across the globe, standing as the foremost public health crisis today. Global data on HIV-related morbidity and mortality are alarming. Effective HIV management hinges on minimizing transmission through highly active antiretroviral therapy (HAART), which relies on a combination of HAART and has been a cornerstone in HIV management. However, challenges such as low patient adherence, suboptimal drug pharmacokinetics, and side effects, potentially undermine the efficacy of existing treatment. Emerging nanotherapeutics, particularly lipidic and polymeric nanoparticles, have exhibited immense promise in addressing these concerns. These nanocarriers enhance targeted drug delivery, facilitate controlled release, and reduce toxicity. Notably, co-delivery strategies using nanoparticles enable the simultaneous transport of multiple drugs involved in HAART. But the question arises whether the exploration is enough to turn the tide. Hence, through this review, the authors have tried to explore and discuss the obstacles faced by the lipid and polymeric nanoparticles such as stability and encapsulation efficiency, and translating these innovations to clinical practice in detail and discussed the future potential of AI-driven nanomedicine.

A Qualitative Study Exploring How the Perspectives and Experiences of Cisgender Black Women Inform Their Readiness to Consider Pre-Exposure Prophylaxis for HIV Prevention

Attention to increasing pre-exposure prophylaxis (PrEP) use among cisgender Black women (CBW) in the southern United States (U.S.) is necessary to achieve national 2030 Ending the HIV Epidemic (EHE) goals. Qualitative exploration of CBW's readiness to use PrEP is necessary to discern whether practical solutions to addressing PrEP uptake within this HIV-vulnerable population are feasible. Focus group discussions (n = 5) and key informant interviews (n = 3) in two EHE jurisdictions in Houston and Austin, Texas were used to explore how perspectives and lived experiences may serve as facilitators and/or barriers to PrEP readiness among 20 CBW. Codes highlighted facilitators and barriers to PrEP readiness. Facilitators involved positive experiences with the healthcare system, high perceived HIV vulnerability, and prioritizing PrEP as self-care. Barriers encompassed concerns with sexual relationship dynamics, mental health implications, and access to humane treatment within the healthcare system. High perceived vulnerability of HIV acquisition is related to an awareness that CBW may not know the entirety of their partner's sexual activities. Findings indicate precursors of PrEP readiness and challenge the notion that CBW have low perceived vulnerability of acquiring HIV.

"Any time because I am ready": Willingness to use long-acting injectable HIV PrEP among female barmaids in Dar es Salaam, Tanzania

Background

Human immunodeficiency virus (HIV) is still a major global public health problem. Sub-Saharan Africa remains the most severely affected, accounting for 69% of the people living with HIV worldwide. Currently, Pre-Exposure Prophylaxis [PrEP] pills are offered but are highly affected by non-adherence. Long-acting injectable PrEP has the potential to improve adherence.

Objective

This study aimed to explore awareness and willingness to use long-acting injectable HIV pre-exposure prophylaxis among users and non-PrEP user female barmaids in Ubungo municipality in Dar es Salaam, Tanzania.

Methods

This phenomenological study used in-depth interviews to collect data. A total of 17 study participants were purposively selected. Audio-recorded interviews were transcribed verbatim and translated into English. A thematic approach was used to identify patterns in the data. Key themes were coded using NVivo14 and then summarized into key findings.

Findings

The findings revealed that participants who were PrEP pill users and non-users were aware of PrEP pills. Few of the PrEP pill users were aware of the long-acting injectable PrEP. The majority of both users and non-users of PrEP pills were willing to use the long-acting injectable PrEP. A few PrEP non-users expressed fear for PrEP, citing safety, and insisted on continuous condom use.

Conclusion

The majority of participants are aware of and willing to use long-acting injectable PrEP when made available. The initiation of HIV long-acting injectable PrEP has the potential to increase protection options among female barmaids who are a population at risk of HIV infection.

Postpartum women's prospective acceptability of long-acting HIV prevention approaches in Kenya: A qualitative study

Background

New long-acting pre-exposure prophylaxis (LA-PrEP) options offer an alternative to daily oral PrEP, which poses difficulties for adherence, especially during pregnancy and postpartum. Yet, limited data exist on LA-PrEP acceptability among pregnant and postpartum women. We aimed to evaluate its acceptability and identify strategies to enhance it.

Methods

We conducted an exploratory qualitative study with postpartum women in five public health facilities in Kisumu and Siaya Counties, Kenya. In-depth interviews (IDIs) were conducted with women expressing high, low, and mixed LA-PrEP interest throughout pregnancy and postpartum. Inductive and deductive content analysis was used, and themes of acceptability were explored using the Theoretical Framework of Acceptability (TFA).

Results

We conducted 70 IDIs with postpartum women between August 2023 and March 2024. The majority (62.9%) expressed consistently high interest in LA-PrEP. Most viewed LA-PrEP, especially every two-month injectables, as highly acceptable due to reduced pill burden, side effects, and dosing frequency. Concerns were raised regarding injectable PrEP safety for the baby during pregnancy and suitability of using the vaginal ring during delivery. Participants emphasized the importance of education on the safety of these methods during pregnancy and breastfeeding, and strategies for improving adherence, such as mobile reminders. Overall, women preferred LA-PrEP options over daily oral PrEP for convenience, effectiveness, and privacy, with healthcare provider education seen as crucial.

Discussion

We found high acceptability of LA-PrEP options among postpartum women with experience taking PrEP during pregnancy. The findings reveal diverse preferences and key factors influencing acceptability, including safety, discretion, and convenience.

Assessing the Landscape for PrEP Provisions in Prisons: A Systematic Review

This systematic review aims to review awareness and willingness for PrEP use in the prison complex and the factors influencing PrEP uptake among people incarcerated in state or federal prisons. We searched MEDLINE (OVID), EMBASE, and Scopus for relevant articles. Qualitative or quantitative studies focusing on incarcerated population, and outcome measures such as knowledge, willingness, or influencing factors for PrEP uptake were included. A narrative method was used to summarise the findings. Inmates' knowledge of PrEP was very low. Inmates who were briefly introduced to PrEP showed a favourable attitude and willingness toward it. However, low-risk perception of HIV, fear of stigma, jail policies, low priority to health overall, appointment issues, transportation problems, depression, substance misuse, and budgetary limitations after release were perceived as barriers to its uptake and continuation. PrEP is a much-needed HIV prevention strategy for the incarcerated population. However, removing the structural and social obstacles to sustained adherence is imperative.

Rationale and design of a randomized clinical trial of integrated eHealth for PrEP and medications for opioid use disorders for women in the criminal legal system. The Athena study

BACKGROUND

Women involved in the criminal legal system have elevated rates of opioid use disorder, which is treatable, and HIV, which is preventable with pre-exposure prophylaxis (PrEP). There are significant social and structural barriers to integrated delivery of PrEP and medications for opioid use disorder (MOUD), limiting women's ability to access these life-saving interventions. In a two parallel-arm randomized controlled trial, we are assessing an innovative eHealth delivery model that integrates PrEP with MOUD and is tailored to meet the specific needs of women involved in the criminal legal system.

METHODS

We will recruit and enroll 250 women involved in the criminal legal system with opioid use disorder across two diverse settings (New Haven, CT and Birmingham, AL). Participants will be randomized to (a) the "Athena strategy," which includes a PrEP decision aid and integrated PrEP/MOUD delivery via eHealth; or (b) enhanced standard of care (SOC) that includes a decision aid-only. During 6-month follow-up, we will assess PrEP initiation as the primary clinical outcome and implementation outcomes that include acceptability, adoption, feasibility, fidelity, implementation cost, and sustainability.

DISCUSSION

Results could help determine if reducing the social and structural barriers to PrEP and MOUD for women involved in the criminal legal system will facilitate engagement in treatment and prevention services, thus alleviating health disparities.

TRIAL REGISTRATION

Clinicaltrials.gov (NCT05547048). Registered September 15, 2022. https://clinicaltrials.gov/study/NCT05547048?term=NCT05547048&rank=1 .

Staff and Providers' Perceptions of Patients' PrEP Candidacy, Acceptability, and Adherence in Methadone Clinic Settings

BACKGROUND

People who use drugs and patients in substance use treatment may be placed at high risk for HIV due to mixing sex and drugs, potential engagement in sex work, and injection drug use. However, pre-exposure prophylaxis (PrEP) adoption among these populations remains low. Methadone clinics, a main point of contact with the healthcare system for this population, are a missed opportunity to offer biomedical HIV prevention. Understanding provider and staff perceptions of patients' PrEP-related candidacy, acceptability, and adherence is a critical first step to informing PrEP implementation in substance use treatment settings.

METHODS

Thirty semistructured interviews were conducted at 2 methadone clinics in Northern New Jersey between January and April 2019. Participants included methadone counselors, medical providers, front desk staff, intake coordinators, and other clinic staff members.

RESULTS

Three major themes were identified: (1) provider and staff's perceptions of who would benefit most from PrEP, (2) perceptions of patients' acceptability of PrEP, and (3) perceptions of patients' ability to take a pill every day. Broadly, staff perceived younger patients to be better PrEP candidates than older patients, expressed cautious optimism that PrEP would be acceptable to their patient populations, and were mixed in terms of their perceptions of patients' ability to adhere to PrEP. Notably, staff largely did not mention patients who inject drugs as potential PrEP candidates, suggesting a missed opportunity.

CONCLUSION

To promote PrEP implementation in methadone clinics, staff and providers should receive training around screening for PrEP eligibility in order to maximize the benefits of PrEP for various subpopulations, especially those who inject. Importantly, discussions around sexual behavior and injection drug use must be approached in an open, non-stigmatizing manner. These findings can be used to inform future interventions to integrate PrEP services into substance use treatment settings.

A decade of PrEP: the evolution of HIV pre-exposure prophylaxis content and sentiments in South African print news media, 2012-2021

After nearly a decade of HIV pre-exposure prophylaxis (PrEP) rollout in sub-Saharan Africa, there has been limited study of PrEP messaging in news media. We selected twenty South African newspapers with the highest circulation volumes to retrieve articles published in 2012-2021 mentioning PrEP (N = 249). Using inductive content analysis, we developed a structured codebook to characterise PrEP-related content and sentiments, as well as their evolution over time, in the South African press. Many articles espoused favourable attitudes towards PrEP (52%), but a sizeable fraction espoused unfavourable attitudes (11%). Relative to PrEP-favourable articles, PrEP-unfavourable articles were significantly more likely to emphasise the drawbacks/consequences of PrEP use, including adherence/persistence requirements (52% vs. 24%, p = .007), cost (48% vs. 11%, p < .001), and risk compensation (52% vs. 5%, p < .001). Nevertheless, the presence of these drawbacks/consequences in print media largely declined over time. Key populations (e.g. adolescents, female sex workers) were frequently mentioned potential PrEP candidates. Despite message variations over time, prevention effectiveness and adherence/persistence requirements were the most widely cited PrEP benefits and drawbacks, respectively. Study findings demonstrate the dynamic nature of PrEP coverage in the South African press, likely in response to PrEP scale-up and real-world PrEP implementation during the study period.

Assessment of acceptance and associated factors of HIV pre-exposure prophylaxis among commercial female sex workers in drop-in centers selected sub-cities of Addis Ababa, Ethiopia

Background

Globally, female sex workers (FSWs) face high risk of HIV, particularly in regions like sub-Saharan Africa. In Ethiopia and Addis Ababa, the impact is significant. Implementing WHO-recommended measures, such as pre-exposure prophylaxis (PrEP), is crucial to reducing new HIV infections and addressing service access disparities among FSWs. Thus this study aimed to assess the acceptance of Pre-Exposure Prophylaxis (PrEP) among commercial female sex workers in selected sub-cities of Addis Ababa, Ethiopia, 2022.

Method

Institution-based cross-sectional study design was conducted on three randomly selected sub-cities of Addis Ababa from June 20 to July 30, 2022. All (358) commercial sex workers available during the study period were included. A structured, pretested, and interviewer-administered questionnaire was used to collect the data. Logistic regression was used to identify factors associated with acceptance of pre-exposure prophylaxis and statistical significance was determined at p-value <0.05. An odds ratio with a 95% confidence interval was used to measure association estimates.

Result

A total of 358 female sex workers responded, 67.9% (95% CI: 63.7, 73.2%) were willing to take pre-exposure prophylaxis. Acceptability of pre-exposure prophylaxis was significantly associated with the accessibility of pre-exposure prophylaxis at easily reachable areas (AOR3.786; 95%CI: 1.449, 9.894) and knowledge about pre-exposure prophylaxis (AOR 3.270; 95%CI: 1.336, 8.001).

Conclusion

Acceptability of pre-exposure prophylaxis among female sex workers was 67.9% which is low. Accessibility of pre-exposure prophylaxis is an easily reachable area and knowledge of about it could significantly affect its acceptability.

Awareness and willingness to use pre-exposure prophylaxis among the University of Zambia students: A cross-sectional study

Background and Aims

Despite a quick rollout of PrEP as a preventive method against Human Immunodeficiency Virus (HIV) infections in Zambia, adolescent and young adult populations have remained very vulnerable to HIV infection. This study assessed the awareness and willingness to use PrEP among University of Zambia (UNZA) students.

Methods

Three hundred forty-six students participated in this cross-sectional study at UNZA between March and June 2021. A previously validated questionnaire assessed willingness to use PrEP. We tested the hypothesized pathways between sexual risk behavior and willingness to use PrEP using the structural equation model. Multivariate logistic regression analysis was employed to determine factors associated with willingness to use PrEP. Variables with a p-value < 0.05 were considered statistically significant.

Results

Of the 346 students, 271 (78.3%) were aware of PrEP, and 59 (17.1%) of the participants were willing to use PrEP. Only 17 (4.9%) of the participants had used PrEP before. In the multivariable logistic regression model, students who were aware of PrEP compared to those who were not (AOR = 3.03, 95% CI: 1.10, 8.40, p) were more likely to be willing to use PrEP. Sexual risk behavior indirectly and positively affected willingness to use PrEP through awareness of PrEP.

Conclusion

Even though most students were aware of PrEP, the willingness to use this preventative measure is still low among UNZA students, resulting in low uptake. Therefore, concerted efforts are required to influence the willingness and uptake of PrEP, especially in high-risk age groups such as university students.

Behind Prep Decisions: Understanding User Patterns and Discontinuation Factors in Real-World

This study aimed to characterize the epidemiological aspects of PrEP use and barriers to accessing this prophylaxis. This cross-sectional study was conducted between January 2021 and April 2022, encompassing 140 PrEP users treated at the Testing and Counseling Center (CTA) in Campo Grande, Mato Grosso do Sul. Data on sociodemographic characteristics and factors associated with PrEP discontinuation were obtained using a standardized questionnaire. Most PrEP users were cisgender men (92.00%), predominantly white (51.00%), over 30 years of age (56.50%), homosexual-oriented (76.50%), and had a minimum of 12 years of education (77.50%). Approximately 60.00% admitted to inconsistent condom use in recent sexual encounters, primarily involving anal intercourse. Approximately 88.00% perceived themselves as at risk of contracting STIs in the upcoming year. Regarding new presentation forms, 54.00% indicated a willingness to use "on-demand PrEP," and 92.00% expressed interest in using "injectable PrEP." After 6 months of follow-up, 43.60% (95.00% CI: 35.50-52.00) discontinued PrEP use, primarily due to changes in sexual behavior (38.30%) and difficulties accessing healthcare services (21.28%). This study underscores the need to involve diverse key populations and highlights the significance of PrEP as an ongoing monitoring strategy for HIV/STI prevention in addition to the importance of incorporating new formulations such as daily oral PrEP into the Brazilian National Health System (SUS).

Examining the Effects of PrEP Use on Sexual Behaviors and Sexually Transmitted Infections Among Chinese Men who have Sex with Men: A Cross-Sectional Study

Men who have sex with men (MSM) is a high-risk population for HIV and sexually transmitted infections (STIs). Pre-exposure prophylaxis (PrEP) is effective in HIV prevention. This study aims to examine the differences in sexual behaviors, STI prevalence and HIV/STI testing across subgroups of MSM with various PrEP use. Data were collected via a cross-sectional survey in an MSM community in Xi'an, Shaanxi, from 2022.01 to 2022.09. Participants were categorized as 'PrEP-naïve and unwilling to use', 'PrEP-naïve but willing to use', and 'current or former PrEP users'. Shannon index was used to assess sexual act diversity and multivariate logistic regression analyzed factors associated with PrEP use. Of the 1,131 MSM participants, 23.52% were PrEP-naïve and unwilling, 64.98% were PrEP-naïve but willing, and 11.49% were current or former PrEP users. The PrEP-naïve but willing group had the highest recent STI testing rates at 73.06% and showed greater sexual act diversity (Shannon index 1.61). This group also had the highest syphilis rates (7.49% vs. 6.47% and2.54%, p < 0.01). Younger age (18-30: OR = 0.39 (0.18-0.85); 31-40: OR = 0.43 (0.20-0.96)) and lower education (high school/vocational: OR = 0.15 (0.04-0.58); associate degree: OR = 0.21 (0.06-0.71)) were factors that negatively influenced PrEP use. Current or former PrEP users had the highest oropharyngeal gonorrhea (14.39% vs. 9.68% and 5.80%, p < 0.01) and overall gonorrhea rates (20.86% vs. 17.17% and 8.37%, p < 0.001). 'PrEP-naïve but willing' participants consistently demonstrated high-risk sexual behavior, increased STI testing, and more diverse sexual acts, whereas PrEP users had the highest STI prevalence.

An Examination of Perceptions among Black Women on Their Awareness of and Access to Pre-Exposure Prophylaxis (PrEP)

Cisgender Black women (CBW) experience 67% of new HIV diagnoses among women in the South. Progress toward ending the HIV epidemic requires researchers to explore perceptions of factors related to the decision to initiate pre-exposure prophylaxis (PrEP) among CBW. Qualitative methods were used to explore how social and structural constructs influence individual decisions to use PrEP among 20 CBW through focus groups. The thematic data analysis identified how facilitators and barriers to PrEP uptake aligned with an external locus of control (LOC) [e.g., media influences on understanding of PrEP] or an internal LOC (e.g., awareness of personal vulnerability to HIV). Several participants highlighted that their PrEP knowledge was rooted in an external LOC, such as media campaigns. A participant stated, 'But even with the commercial, it wasn't representation for me.' Another participant described her personal HIV vulnerability in her sexual relationship as an internal LOC, stating, 'Not ignorance, it's maybe just not accepting the true reality of this can be contracted even from someone that you believe that you trust.' Due to gaps in media marketing, healthcare providers should be aware that some female patients may perceive that PrEP is not for them. Provider-led sexual health discussions are urgently needed to bridge the gap between PrEP eligibility and initiation.

Increasing pre-exposure prophylaxis (PrEP) in primary care: A study protocol for a multi-level intervention using the multiphase optimization strategy (MOST) framework

BACKGROUND

In the United States, over 1.2 million people are living with HIV. This disease disproportionately affects men who have sex with men (MSM), people of color, youth and young adults, and transgender individuals. Pre-exposure prophylaxis (PrEP) is an effective HIV prevention method. Barriers exist for both primary care providers (PCPs) to prescribe PrEP and prevent patients from initiating PrEP.

METHODS

This study, MOST: PrEP, follows the multiphase optimization strategy (MOST) framework. The purpose is to identify a multi-level intervention among patients and PCPs to increase PrEP prescriptions in primary care. First, feedback will be obtained from providers and patients via focus groups, then, suggestions related to the context-specific (provider and individual level) factors of intervention component delivery will be incorporated. Subsequently, a rigorous experiment will be conducted using a 24 factorial design focusing on priority populations for PrEP initiation. Provider components include computer-based simulation training and a best practice alert. Patient components include a tailored PrEP educational video and HIV risk assessment. Finally, the facilitators and barriers to implementing the intervention components will be qualitatively examined.

CONCLUSION

In this protocol paper, we describe the one of the first known multilevel MOST optimization trial in healthcare. Intervention components are to be delivered to patients and providers in a large healthcare system, based in an HIV Ending the Epidemic priority jurisdiction. If effective, this multi-level approach could be disseminated to providers and patients in other large healthcare systems to make a significant impact on HIV prevention.

Social, economic, and physical side effects impact PrEP uptake and persistence among transgender women in Peru

INTRODUCTION

Oral pre-exposure prophylaxis (PrEP) for HIV-1 infection is over 99% effective in protecting against HIV acquisition when used consistently and appropriately. However, PrEP uptake and persistent use remains suboptimal, with a substantial gap in utilization among key populations who could most benefit from PrEP. In Latin America specifically, there is poor understanding of barriers to PrEP uptake and persistence among transgender (trans) women.

METHODS

In April-May 2018, we conducted qualitative interviews lasting 25-45 min as part of an end-of-project evaluation of TransPrEP, a pilot RCT that examined the impact of a social network-based peer support intervention on PrEP adherence among trans women in Lima, Peru. Participants in the qualitative evaluation, all adult trans women, included individuals who either (1) screened eligible to participate in the TransPrEP pilot, but opted not to enroll (n = 8), (2) enrolled, but later withdrew (n = 6), (3) were still actively enrolled at the time of interview and/or successfully completed the study (n = 16), or (4) were study staff (n = 4). Interviews were audio recorded and transcribed verbatim. Codebook development followed an immersion/crystallization approach, and coding was completed using Dedoose.

RESULTS

Evaluation participants had a mean age of 28.2 years (range 19-47). When describing experiences taking PrEP, participant narratives highlighted side effects that spanned three domains: physical side effects, such as prolonged symptoms of gastrointestinal distress or somnolence; economic challenges, including lost income due to inability to work; and social concerns, including interpersonal conflicts due to HIV-related stigma. Participants described PrEP use within a broader context of social and economic marginalization, with a focus on daily survival, and how PrEP side effects negatively contributed to these stressors. Persistence was, in some cases, supported through the intervention's educational workshops.

CONCLUSION

This research highlights the ways that physical, economic, and social side effects of PrEP can impact acceptability and persistence among trans women in Peru, amplifying and layering onto existing stressors including economic precarity. Understanding the unique experiences of trans women taking PrEP is crucial to informing tailored interventions to improve uptake and persistence.

Variations in HIV Prevention Coverage in Subpopulations of Australian Gay and Bisexual Men, 2017-2021: Implications for Reducing Inequities in the Combination Prevention Era

Using repeated behavioural surveillance data collected from gay and bisexual men (GBM) across Australia, we assessed trends in HIV prevention coverage (the level of 'safe sex' achieved in the population by the use of effective prevention methods, including condoms, pre-exposure prophylaxis [PrEP] and having an undetectable viral load). We stratified these trends by age, country of birth/recency of arrival, sexual identity, and the proportion of gay residents in the participant's suburb. Among 25,865 participants with casual male partners, HIV prevention coverage increased from 69.8% in 2017 to 75.2% in 2021, lower than the UNAIDS target of 95%. Higher levels of coverage were achieved among older GBM (≥ 45 years), non-recently-arrived migrants, and in suburbs with ≥ 10% gay residents. The lowest levels of prevention coverage (and highest levels of HIV risk) were recorded among younger GBM (< 25 years) and bisexual and other-identified participants. Younger, recently-arrived, and bisexual GBM were the most likely to use condoms, while PrEP use was concentrated among gay men, 25-44-year-olds, and in suburbs with more gay residents. The use of undetectable viral load was most common among participants aged ≥ 45 years. Our analysis shows that high HIV prevention coverage can be achieved through a mixture of condom use, PrEP use, and undetectable viral load, or by emphasising PrEP use. In the Australian context, younger, bisexual and other-identified GBM should be prioritised for enhanced access to effective HIV prevention methods. We encourage other jurisdictions to assess the level of coverage achieved by combination prevention, and variations in uptake.

Understanding the Acceptability of Broadly Neutralizing Antibodies for HIV Prevention Among At-Risk Populations and Feasibility Considerations for Product Introduction in India: Protocol for a Qualitative Study

BACKGROUND

Acceptability and preference research play a crucial role in the design, evaluation, and implementation of any new prevention product in any geographical setting. They also play a critical role in the development of clinical guidelines and policies. A wide range of acceptability studies have been conducted in diverse general and key populations for various new HIV prevention products worldwide. As clinical development strategies are being developed for clinical studies of broadly neutralizing antibodies (bNAbs) as potential HIV prevention products, appropriately tailoring them to address the type of HIV epidemic at hand would be critical for efficient uptake within in-country public health systems and decrease adoption and adherence challenges. Accomplishing this will require comprehensive acceptability and feasibility studies to inform multisectoral efforts that increase access to these products and national policies supportive of access to health care for those in most need. Thus, it is both opportune and important to undertake focused efforts toward informing product development strategies.

OBJECTIVE

This study aims to understand preferences for product attributes and key behavioral factors influencing adoption and uptake of bNAb prevention products among end-users including female sex workers, men who have sex with men, transgender women, people who inject drugs, and adolescent girls and young women in India and understand the key health system and programmatic perspectives toward the introduction of bNAb prevention products from health service providers and policy makers in India.

METHODS

A multisite study will be conducted in Delhi, Mumbai, and Chennai to capture the differences in perspectives among diverse end-users and key informants across the country. The study will use a multimethods design using focus group discussions, in-depth interviews, simulated behavioral experiments, and key informant interviews. A total of 30 focus group discussions, 45 in-depth interviews, 15 simulated behavioral experiments sessions, and 15 key informant interviews will be conducted across 3 sites.

RESULTS

The data collected and analyzed will enable insights on which specific product attributes matter the most to the populations and why some attributes are less preferred; contextual drivers of preferences and choices at individual, interpersonal, social, and structural levels; and relative positioning of bNAb products among other potential HIV prevention products. Insights from the health service providers and policy makers will provide a critical understanding of the need perception of the potential product in the existing product landscape and what additional efforts and resources are required for potential introduction, delivery, and uptake of the bNAb products in the Indian context.

CONCLUSIONS

Insights generated from the abovementioned objectives will represent perspectives of populations of interest across geographies in India, will provide an overview of the acceptability of bNAb products and the feasibility of their introduction in this region, and will inform product development strategies.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

DERR1-10.2196/47700.

Dimensional Reduction in Barriers and Facilitators to Pre-exposure Prophylaxis (PrEP) Uptake Willingness for Full-Service Sex Workers

Full-Service Sex Workers (FSSWs) face heightened risk of acquiring HIV, yet exhibit relatively low adoption of pre-exposure prophylaxis (PrEP)-an antiviral that substantially reduces HIV acquisition risk. Little work examines barriers and facilitators to PrEP uptake willingness among FSSWs. This study aimed to identify the distinct components of barriers and facilitators to PrEP uptake willingness for FSSWs. Here, we subjected 19 PrEP barriers and facilitators identified in the literature to a principal component analysis (PCA) among a sample of 83 FSSWs. Preliminary statistics supported factorability of data. PCA revealed three distinct components of barriers and facilitators that explained 62.80% of the total variance in survey responses. We labeled these components Behavioral and Social Concerns (α = 0.93), Access and Affordability (α = 0.67), and Biologically Based Health Concerns (α = 0.79). This study shows promise for future clinical and research utility of these factors and provides a basis for future psychometric studies of barriers and facilitators to PrEP uptake willingness among FSSWs.

Adverse effects of daily oral pre-exposure prophylaxis in men who have sex with men and transgender women: a systematic review and meta-analysis

The adverse effects of oral pre-exposure prophylaxis (PrEP) using tenofovir disoproxil fumarate are barriers to PrEP initiation and continuation. Although serious effects are rare and predictable, evidence for this assessment among men who have sex with men (MSM) and transgender women (TGW) is still limited. This study assesses the adverse effects of daily oral PrEP in MSM and TGW. This is a systematic review and meta-analysis of clinical trials and cohort studies on the use of daily oral PrEP selected from the PubMed/MEDLINE, Embase, LILACS, and Cochrane CENTRAL databases. Data extraction included adverse effects and changes in renal and hepatic markers. Random effects models were used to summarize the risk of adverse effects throughout the study. Heterogeneity was assessed using the Cochran's Q test and the inconsistency test (I2). The risk of bias and the certainty of the evidence were assessed using the Cochrane Collaboration recommendations. The search identified 653 references. Of these, 10 were selected. All studies assessed the eligibility of renal and hepatic markers. The use of daily oral PrEP was not associated with grade 3 or 4 adverse events (RR = 0.99; 95%CI: 0.83-1.18; I2 = 26.1%), any serious adverse event (RR = 1.04; 95%CI: 0.58-1.87; I2 = 88.4%), grade 3+4 creatinine level (RR = 0.66; 95%CI: 0.24-1.84; I2 = 79.9%), and grade 3 or 4 hypophosphatemia (RR = 0.56; 95%CI: 0.15-2.10). The certainty of the evidence ranged from high to moderate for the outcomes analyzed. Daily oral PrEP is safe and well tolerated by MSM and TGW. Adverse effects were minimal and evenly distributed between intervention and control.

Pre-Exposure Prophylaxis Care Continuum for HIV Risk Populations: An Umbrella Review of Systematic Reviews and Meta-Analyses

Pre-exposure prophylaxis (PrEP) is an effective biomedical strategy for HIV prevention. This umbrella review is aimed at providing a comprehensive summary of the current status of each stage of the PrEP care cascade. A systematic literature search was conducted in PubMed, Embase, and Cochrane. Additionally, a Measurement Tool to Assess Systematic Reviews 2 (AMSTAR-2) tool and Preferred Reporting Items for Systematic Review and Meta-Analysis (PRISMA) checklist were used to evaluate their methodological and reporting quality, respectively. A total of 30 systematic reviews met the inclusion criteria. According to the results of methodological quality assessment, 3 reviews were rated as low, while 27 as critically low. Furthermore, the results of the reporting quality evaluation revealed a mean score of 23.03 for the included reviews. Across all the reviews, awareness of PrEP was generally moderate in all populations, and the acceptability was even higher compared with awareness. Unfortunately, the PrEP uptake among different groups was even less optimal, although the adherence was almost above moderate, and several barriers that hindered the utilization of PrEP were identified, and the most common are as follows: cost, stigma, lack of knowledge, mistrust, low risk perception, and more. Although PrEP has proven to be an effective prevention method to date, the promotion of PrEP failed to achieve the anticipated outcome. To reinforce the generalization of and use of PrEP, and effectively control HIV transmission, it is urgent to identify the underlying causes of low uptake rates so that efficient interventions can be implemented.

"It's already in your body and it's preventing": a qualitative study of African female adolescent's acceptability and preferences for proxy HIV prevention methods in Cape Town, South Africa

BACKGROUND

Advances in biomedical HIV prevention will soon offer young women a choice of HIV prevention methods, including various pre-exposure prophylaxis (PrEP) modalities such as daily oral pills, dapivirine vaginal ring, and long-acting injectable agents. By understanding preferences for contraceptive methods, we may draw analogies for the HIV prevention needs of young women. The UChoose Study was an open-label randomised cross-over study designed to evaluate the acceptability and preference for several contraceptive options as a proxy for HIV prevention methods that use similar types of administration. The study enrolled healthy HIV uninfected young women aged 15 to 19 years. At enrolment, participants were randomly assigned to a contraceptive method for a period of 16 weeks in the form of monthly Nuvaring® (vaginal ring), daily combined oral contraceptive (daily pills), or bi-monthly injectable contraceptive (injectable). After 16 weeks, participants crossed over to another contraceptive method, and those who had received the injectable and the daily pills received the vaginal ring for another 16 weeks, whereas those who had received the vaginal ring were able to choose between the injectable and daily pills, to ensure that all participants tried the vaginal ring-the least familiar option to the study population.

RESULTS

Thirty-three participants were purposively recruited to participate in seven focus group discussions (FGD) and completed a pre-survey for their assigned group. Our sample comprised 14 participants randomised to use of the vaginal ring and daily pills and 19 participants randomised to use of the vaginal ring and injectable. For most participants, their preferences for a prevention method were based primarily on their desire to avoid negative aspects of one method rather than their positive user experience with another method. Most participants expressed initial hesitancy for trying new contraception method products; however, a lack of familiarity was moderated by a strong interest in diverse user-controlled prevention methods. Participants valued methods that had infrequent dosing and simplified use requirements. The injection and vaginal ring were preferred over daily pills as a potential HIV prevention method.

CONCLUSION

Expanding the availability of diverse products could provide adolescents with multiple choices in HIV prevention for the uninitiated.

TRIAL REGISTRATION

ClinicalTrials.gov ( NCT02404038 ). Registered March 31, 2015-Registered.

Stakeholder perspectives on interventions to improve HIV pre-exposure prophylaxis uptake and continuation in Lesotho: A participant-ranked preferences study

Low uptake and high discontinuation remain major obstacles to realizing the potential of Pre-Exposure Prophylaxis (PrEP) in changing the trajectory of the HIV epidemic. We conducted a card sorting and ranking exercise with 155 local stakeholders to determine their views on the most important barriers and most promising interventions to achieving high PrEP coverage. Stakeholders were a purposive sample of PrEP policymakers and implementing partners (n = 7), healthcare providers (n = 51), and end-users (n = 97). End-users included adults who were currently using PrEP (n = 55), formerly using PrEP (n = 36), and those who were offered PrEP but declined (n = 6). Participants sorted pre-selected interventions and barriers to PrEP coverage into three piles-most, somewhat, and least important. Participants then ranked interventions and barriers in the "most important" piles in ascending order of significance. Ranked preferences were analyzed as voting data to identify the smallest set of candidates for which each candidate in the set would win in a two-candidate election against any candidate outside the set. Participants viewed a lack of PrEP awareness as the most important barrier to PrEP uptake for women, and a fear of HIV testing for men. Community-based HIV testing was ranked as the most promising intervention to improve PrEP uptake for both men and women. Perceived or experienced stigma was seen as an important barrier for PrEP continuation for both men and women, with an additional important barrier for men being daily activities that compete with the time needed to take a daily pill. Adherence counseling and multi-month PrEP prescriptions were seen as the most promising interventions to improve PrEP continuation. Our findings suggest community-based activities that generate PrEP demand (community-based HIV testing and mass media campaigns), reinforced with facility-based follow-up (counseling and multi-month prescription) could be promising interventions for PrEP programs that are aimed at the general adult population.

Systematic review of the values and preferences regarding the use of injectable pre-exposure prophylaxis to prevent HIV acquisition

INTRODUCTION

Pre-exposure prophylaxis (PrEP) is an important HIV prevention option. Two randomized trials have provided efficacy evidence for long-acting injectable cabotegravir (CAB-LA) as PrEP. In considering CAB-LA as an additional PrEP modality for people at substantial risk of HIV, it is important to understand community response to injectable PrEP. We conducted a systematic review of values, preferences and perceptions of acceptability for injectable PrEP to inform global guidance.

METHODS

We searched nine databases and conference websites for peer-reviewed and grey literature (January 2010-September 2021). There were no restrictions on location. A two-stage review process assessed references against eligibility criteria. Data from included studies were organized by constructs from the Theoretical Framework of Acceptability.

RESULTS

We included 62 unique references. Most studies were observational, cross-sectional and qualitative. Over half of the studies were conducted in North America. Men who have sex with men were the most researched group. Most studies (57/62) examined injectable PrEP, including hypothetical injectables (55/57) or placebo products (2/57). Six studies examined CAB-LA specifically. There was overall interest in and often a preference for injectable PrEP, though there was variation within and across groups and regions. Many stakeholders indicated that injectable PrEP could help address adherence challenges associated with daily or on-demand dosing for oral PrEP and may be a better lifestyle fit for individuals seeking privacy, discretion and infrequent dosing. End-users reported concerns, including fear of needles, injection site pain and body location, logistical challenges and waning or incomplete protection.

DISCUSSION

Despite an overall preference for injectable PrEP, heterogeneity across groups and regions highlights the importance of enabling end-users to choose a PrEP modality that supports effective use. Like other products, preference for injectable PrEP may change over time and end-users may switch between prevention options. There will be a greater understanding of enacted preference as more end-users are offered anti-retroviral (ARV)-containing injectables. Future research should focus on equitable implementation, including real-time decision-making and how trained healthcare providers can support choice.

CONCLUSIONS

Given overall acceptability, injectable PrEP should be included as part of a menu of prevention options, allowing end-users to select the modality that suits their preferences, needs and lifestyle.

The relationship of PrEP beliefs to perceived personal, interpersonal and structural benefits and barriers to PrEP use in women who inject drugs

BACKGROUND

Women who inject drugs (WWID) have significant biological, behavioral, and gender-based barriers to accessing HIV prevention services, including Pre-Exposure Prophylaxis (PrEP) medication. Little is known about how beliefs about PrEP impact both perceived barriers and benefits of PrEP use and how they may be related to the decision-making process.

METHODS

Surveys were conducted with 100 female clients of a large syringe services program in Philadelphia, Pennsylvania. The sample was categorized into three groups based on mean PrEP beliefs scores using terciles: accurate beliefs, moderately accurate beliefs, and inaccurate beliefs. Oneway ANOVA tests were used to compare groups by perceived benefits and barriers to PrEP, drug use stigma, healthcare beliefs, patient self-advocacy, and intention to use PrEP.

RESULTS

Participants had a mean age of 39 years (SD 9.00), 66% reported being White, 74% finished high school, and 80% reported having been homeless within the past 6 months. Those with the most accurate PrEP beliefs reported highest intent to use PrEP and were more likely to agree that benefits of PrEP included it preventing HIV and helping them "feel in charge". Those with inaccurate beliefs were more likely to strongly agree that barriers, such as fear of reprisal from a partner, potential theft, or feeling they "might get HIV anyway", were reasons not to use PrEP.

CONCLUSIONS

Results indicate perceived personal, interpersonal and structural barriers to PrEP use are associated with accuracy of beliefs is, pointing to important intervention targets to increase uptake among WWID.

Women's perspectives on barriers to potential PrEP uptake for HIV prevention: HIV risk assessment, relationship dynamics and stigma

HIV remains a significant health issue for women, and multiple overlapping factors shape women's HIV-related risk. Pre-exposure prophylaxis (PrEP) offers critical advantages over other existing options, yet it remains significantly underused among women in the USA where limited work has explored women's opinions on barriers to potential PrEP use. Using open-ended text responses from a sample of women seeking care at a US urban family planning health centre, this study aimed to understand perceptions of factors affecting potential PrEP use. Three themes concerning key factors impacting potential PrEP use emerged: HIV risk assessment, relationship dynamics, and anticipated stigma. Women's assessment of HIV risk suggests that identifying women in clinical settings as having low self-perceived risk may overlook the complexity of how women determine HIV-related risk and prevention needs. Women frequently referenced relationship dynamics when considering PrEP and discussed anticipated partner reactions about use contributing to non-use. Fear or worry of stigma were expressed as motivations to not use PrEP. Study results highlight the importance of public health and health care professionals normalising PrEP as a strategy in women's HIV prevention and sexual health decision-making. Woman-centred PrEP education, screening and communication strategies reflective of their unique HIV-related risk context are needed.

Not as Clear Online? Active Visualization of How PrEP Works in the Body Improves Knowledge But Doesn't Change Behavior

Active visualization, the use of dynamic representation of internal processes, is associated with increased knowledge and adherence to ART among people living with HIV. The current pilot intervention study tested the effectiveness of an online visualization for HIV prevention among 146 at-risk youth. Youth were randomized to a standard PrEP briefing or an online visualization. PrEP knowledge, attitudes, and uptake were self-reported at baseline and 3-months. Knowledge of PrEP increased, but there were no changes in preferences or uptake. Active visualization delivered online may be a useful educational tool for PrEP but not for shifting youth's uptake.

Understanding Influences on Intention to Use Pre-exposure Prophylaxis (PrEP) Among African American Young Adults

Pre-exposure prophylaxis (PrEP), a potent medication for HIV prevention, shows promise for reducing HIV disparities. However, PrEP is not equitably utilized by all races and ethnicities in the USA. Its uptake is especially low among African Americans, who are disproportionately impacted by HIV. Understanding factors influencing low PrEP uptake among diverse priority groups of African American young adults beyond gender and sexual minority groups (e.g., cisgender heterosexual people) may increase PrEP uptake. Data were from the Afya project, a study examining the use of PrEP for HIV prevention among multiple priority groups of African American young adults at heightened HIV risk, using Theory of Reasoned Action/Theory of Planned Behavior (TRA/TPB) as a theoretical framework. Eleven focus groups (N = 63) were conducted in Louisville, Kentucky from June to November 2018 with African American young adult priority groups (18-29 years old): men who have sex with men, transgender women, and cisgender heterosexual men and women demonstrating heightened sexual risk. Data were analyzed using constructivist grounded theory techniques. PrEP awareness, knowledge, perceived HIV risk and perceived need for PrEP (behavioral beliefs) and adherence beliefs (control beliefs), opinions of others (subjective norms), and confidence in ability to adhere to PrEP (perceived behavior controls) influenced acceptability of PrEP (participants' attitudes) and, in turn, influenced intention to use PrEP either negatively or positively. Thus, understanding factors that create reticence to PrEP use provides useful insight for tailoring outreach interventions towards African American young adults to improve PrEP uptake.

Correlates of Dapivirine Vaginal Ring Acceptance among Women Participating in an Open Label Extension Trial

MTN-025/HOPE was an open-label trial of the dapivirine vaginal ring conducted in four African countries between 2016 and 2018. Women were first offered one ring monthly (at baseline, months 1 and 2), thereafter, transitioned to a more applicable real-world dispensation schedule, - 3 rings quarterly (at months 3, 6 and 9). Logistic regression analysis was used to assess correlates of ring acceptance at baseline and through follow-up. A total of 1456 women (median age 31 years) enrolled, 1342 (92.2%) accepted the ring at baseline and 1163 (79.9%) accepted the ring(s) at all visits. Changing ring dispensation from a monthly to a quarterly schedule had no negative effect on acceptance. Having a primary partner and him knowing about the ring being offered in HOPE, use of long-acting contraception (implants, injections, IUDs) or sterilization were associated with ring acceptance, along with prior strong intention to use the ring in the future. Efforts should consider these factors when rolling out the ring for HIV prevention.

Variations in Pre-exposure Prophylaxis (PrEP) Awareness and Healthcare Provider Interactions in a Nationally Representative Sample of American Men Aged 15-49 Years: A Cross-Sectional Study

Awareness of and discussions with a healthcare provider (HCP) around pre-exposure prophylaxis (PrEP), an effective HIV prevention method, are associated with PrEP uptake, yet few studies utilize representative samples or report on these outcomes using distinct behavioral risk subgroups. This cross-sectional study utilized responses given by men on the 2017-2019 National Survey of Family Growth, a nationally representative survey of Americans aged 15-49 years. Multiple logistic regression models were used to determine how respondents' sociodemographic characteristics and HIV risk behaviors were related to PrEP awareness and HCP discussions. PrEP awareness was low (29.40%) as was the proportion who reported ever discussing PrEP with an HCP (4.48%). Odds of being PrEP aware and discussing PrEP with an HCP varied significantly within sexual behavior subgroups based on sociodemographic and behavioral characteristics highlighting the differential risks within distinct behavioral subgroupings of men. Sexual behavior subgroupings should be considered when promoting PrEP awareness and discussions as HIV risk behaviors vary considerably and sexual identity alone may not sufficiently capture one's HIV risk.

Acceptability Assessment in HIV Prevention and Treatment Intervention and Service Delivery Research: A Systematic Review and Qualitative Analysis

We reviewed the literature on the assessment of acceptability of HIV prevention and treatment interventions and service delivery strategies. Following PRISMA guidelines, we screened 601 studies published from 2015 to 2020 and included 217 in our review. Of 384 excluded studies, 21% were excluded because they relied on retention as the sole acceptability indicator. Of 217 included studies, only 16% were rated at our highest tier of methodological rigor. Operational definitions of acceptability varied widely and failed to comprehensively represent the suggested constructs in current acceptability frameworks. Overall, 25 studies used formal quantitative assessments (including four adapted measures used in prior studies) and six incorporated frameworks of acceptability. Findings suggest acceptability assessment in recent HIV intervention and service delivery research lacks harmonization and rigor. We offer guidelines for best practices and future research, which are timely and critical in this era of informed choice and novel options for HIV prevention and treatment.

Missed opportunities for HIV pre-exposure prophylaxis among people with recent HIV infection: The French ANRS 95041 OMaPrEP study

OBJECTIVES

Our objective was to identify missed opportunities for the use of pre-exposure prophylaxis (PrEP) in people with recently acquired HIV, factors associated with PrEP knowledge, and reasons for not using PrEP.

DESIGN

This was a French national cross-sectional multicentre study enrolling people diagnosed with recent HIV (incomplete Western blot or negative HIV test in the previous 6 months) in 28 HIV clinical centres. Data were gathered using a self-administered questionnaire (SAQ).

METHOD

We analysed missed opportunities for PrEP use via a retrospective prep cascade. Factors associated with prior knowledge of PrEP and reasons for PrEP non-use among those who knew about PrEP were described using univariate and multivariate logistic regression models.

RESULTS

Of the 224 eligible patients, 185 completed the SAQ and 168 (91%) were eligible for PrEP. Of these, 90% reported seeing at least one physician during the previous year, 26% received information about PrEP, and 5% used PrEP. Factors independently associated with a higher probability of knowing about PrEP were being a man who has sex with men, being aged 25-30 years (vs older), undergoing HIV screening at least once every semester (vs less often; odds ratio [OR] 4.11; 95% confidence interval [CI] 2.00-8.45), and practicing chemsex (OR 3.19; 95% CI 1.12-9.10). Fear of side effects and a low perceived risk of HIV infection were the two most common reasons for not using PrEP (N = 40 [33.33%] and N = 34 [28.3%], respectively).

CONCLUSIONS

We found two gaps in the retrospective PrEP cascade: insufficient provision of PrEP information by healthcare providers (mainly general practitioners) and low PrEP acceptability by informed, eligible patients. More diverse healthcare providers need to be involved in PrEP prescription, and at-risk people need to be sensitized to the risk of HIV infection.

Cultural Repertoires and Situated Selections as an Alternative Framework to Hegemonic Masculinities: Findings From Eswatini

Since the 1980s studies on men have frequently utilized Connell's framework of hegemonic masculinities. We critically appraise this framework in the context of a population-based HIV pre-exposure prophylaxis study in Eswatini. Our findings highlight that men confidently show variation in their behavior and choices, which manifest across different men and within the same men acting in particular situations and over the life course. This led us to interrogate the hegemonic masculinities framework on the following grounds: Men's choices and behavior do not seem to fit the model of aspiring to a hegemonic ideal; the delineation of masculine traits as hegemonic or subordinate remain vague in terms of "responsibility," "fidelity," and "consideration for others"; the binary gender concept underpinning hegemonic masculinities seems outdated. Building on the work of Hirsch and Kachtan, we propose cultural repertoires as an alternative framework which also bridges the gender divide.

Awareness, Willingness and Use of HIV Pre-Exposure Prophylaxis Among Female Sex Workers Living in Dar-es-Salaam, Tanzania

Tanzania is in the final stages to roll out pre-exposure prophylaxis (PrEP) to Female Sex Workers (FSWs) so as to reduce new infections. PrEP demonstration projects support programming through gaining first experiences.We analyzed data from a cohort of 700 HIV negative FSWs in Dar-es-Salaam to determine proportions of FSWs who were aware, willing and used PrEP. We compared proportions at cohort enrolment and after 12 months. Logistic regression was used to determine factors associated with PrEP use. PrEP awareness increased from 67% to 97% after 12 months. Willingness was high at both time points (98% versus 96%). Only 8% (57/700) had used PrEP. Being married/cohabiting or separated/divorced/widowed and having sex with a HIV infected partner were independently associated with PrEP use. The PrEP program should focus on scaling up access as willingness to use PrEP is high.

The epidemiological impact and cost-effectiveness of key population-led PrEP delivery to prevent HIV among men who have sex with men in Thailand: A modelling study

Background

Although key populations (KPs), such as men-who-have-sex-with-men (MSM) are disproportionately affected by HIV, many prevention and treatment services are not easily accessible for KP members. To address the needs of KPs, Thailand established pre-exposure prophylaxis (PrEP) service delivery together with and led by KP members. This study determines the epidemiological impact and cost-effectiveness of key population-led (KP-led) PrEP.

Methods

We calibrated a compartmental deterministic HIV transmission model to the HIV epidemic among Thai MSM. Besides KP-led PrEP, we included other Thai service delivery models of PrEP (fee-based PrEP, the government PrEP program).Data on consistent PrEP use (5 years daily use, 95% effectiveness for preventing HIV) came from Thai PrEP delivery models. For the period 2015-2032, we ranged the number of PrEP starters (40,000-120,000), effectiveness of PrEP (45%-95%), and proportion of consistent users (10%-50%). The analysis started in 2015 when PrEP was introduced. A cost-effectiveness ratio of <160,000 Baht per quality-adjusted life year (QALY) over 40 years was cost-effective.

Findings

Without PrEP, 53,800 (interquartile range 48,700-59,700) new HIV infections are expected in 2015-2032. KP-led PrEP was found to have the strongest epidemiological impact of all delivery models averting 58% of infections compared to without PrEP. The epidemiological impact depends on the number of PrEP starters and proportion of consistent use. Although all PrEP service delivery models are cost-effective, KP-led PrEP is most cost-effective with incremental cost-effectiveness ratios of 28,000-37,300 Thai Baht per QALY.

Interpretation

Our model projects KP-led PrEP having the greatest epidemiological impact and being the most cost-effective service delivery model of PrEP in Thailand.

Funding

This study was supported by the US Agency for International Development and U.S. President's Emergency Plan for AIDS Relief through the Linkages Across the Continuum of HIV Services for Key Populations cooperative agreement (AID-OAA-A-14- 0045) managed by FHI 360.

Paying for PrEP: A qualitative study of cost factors that impact pre-exposure prophylaxis uptake in the US

BACKGROUND

Concerns about the actual and perceived costs of pre-exposure prophylaxis (PrEP) continue to be a major barrier to uptake among gay, bisexual and men who have sex with men (GBMSM) in the United States.

METHODS

We conducted semi-structured interviews with 25 GBMSM who presented for routine health care at a STD clinic in the northeastern United States. The cohort included GBMSM who were or were not currently taking PrEP and represented varied health care coverage and financial resources. We used a structured coding scheme to analyze transcripts and identify themes relevant to cost factors.

RESULTS

Participants shared their perspectives about PrEP and their experiences with accessing and paying for PrEP. Our findings suggest that health care coverage or financial assistance were essential to PrEP access but were not easily accessible to all people and did not always cover all costs. Therefore, paying for PrEP had to be balanced with other life expenses. Participants had multiple sources for information about PrEP cost and assistance from clinic and pharmacy staff helped reduce burden and resolve difficulties.

CONCLUSION

Addressing gaps in health care coverage, providing financial support, and improving the enrollment process in a financial assistance program may improve PrEP uptake.

PrEP service delivery preferences of black Cis-gender women living in the Southern United States

To assess PrEP service delivery preferences among Black cis-gender women living in urban and rural settings in Alabama, we conducted a cross-sectional discrete choice experiment survey. Discrete choice experiments included five attributes. Hierarchical Bayes (HB) modeling and latent class analyses (LCA) were used to evaluate attribute preferences. Among 795 Black cis-gender HIV-negative women, almost two-thirds lived in urban settings and reported having at least some college; about a third reported a household income less than $25,000 annually; and reported willingness to use PrEP. Respondents placed the greatest importance on PrEP medication formulation and healthcare facility. LCA showed the group with the highest rural proportion preferred for on-line visits. Black women in the Deep South had distinct preferences regarding PrEP service delivery. These findings can inform tailored interventions to improve PrEP uptake among Black cis-gender women across diverse settings in the South.

Health system opportunities and challenges for PrEP implementation in Kenya: A qualitative framework analysis

Background

As pre-exposure prophylaxis (PrEP) scales up in sub-Saharan Africa, governments and implementers need to understand how to best manage national programs. Kenya’s national PrEP program offers an opportunity to review elements of program success within the health system and evaluate the utility of a national implementation framework. We explored health system considerations for PrEP implementation to understand how Kenya’s national PrEP implementation priorities align with those of PrEP service providers, peer educators, and program or county managers.

Methods

We conducted twelve key informant interviews (KII) and nine focus group discussions (FGDs) with PrEP program and county managers (n = 12), peer educators (n = 44), and PrEP service providers (n = 48). We recruited participants across a variety of cadres and experiences with PrEP programs. KIIs and FGDs focused on PrEP service delivery and program implementation. Data were collected by trained study staff, audio recorded, translated into English, and transcribed. We used framework analysis methods to systematically apply Kenya’s 2017 National PrEP Implementation Framework to the data and summarized findings according to the seven Implementation Framework domains.

Results

All respondents emphasized the important role of communication, coordination, training, and leadership in PrEP implementation. PrEP service providers and program and county managers highlighted the importance of efficient data collection and utilization, and improved resource allocation. Commodity security and research, while key elements of the PrEP Implementation Framework, were less commonly discussed, and research was less prioritized by respondents. Respondents highlighted the importance of coordinated PrEP service delivery across sites and programs to improve overall client experiences.

Conclusion

In the context of a nationally-scaled PrEP program, PrEP service providers, peer educators, and program and county managers value strong leadership, close coordination of services across sites, and expedient use of data to improve strategies and services. Kenya’s PrEP Implementation Framework aligns closely with the priorities of individuals involved in PrEP service delivery and management, and provides a comprehensive overview of health system considerations for effective implementation of a PrEP program at scale.

Current Perspectives on the Determinants of Acceptability of Pre-Exposure Prophylaxis and Nonoccupational Post-Exposure Prophylaxis among People at Risk for HIV: A Scoping Review

Pre-exposure prophylaxis (PrEP) and nonoccupational post-exposure prophylaxis (nPEP) were found to be effective HIV biomedical interventions. However, several barriers to acceptance of these interventions were discovered among populations at risk for HIV, and the Coronavirus Disease 2019 (COVID-19) pandemic may also exacerbate these. The current scoping review aims to update information in regards to facilitators and barriers for PrEP and nPEP acceptability among key populations collected in the past two years and to identify any existing knowledge gaps during the time of the COVID-19 pandemic. Of 1453 studies retrieved, 16 met the final inclusion criteria. The review synthesized a range of individual, PrEP-specific, psychosocial, and health system factors that may affect the acceptability of PrEP or nPEP. The conclusion from this scoping review is that more research is needed to enable a comprehensive understanding of the determinants of acceptability of PrEP and nPEP in the context of COVID-19, particularly among PWID and FSWs.

PrEP uptake and delivery setting preferences among clients visiting six healthcare facilities in Eswatini

Due to the high HIV incidence among the general population of Eswatini, pre-exposure prophylaxis (PrEP) for HIV-exposed individuals is recommended. However, little is known about PrEP uptake and preferences in PrEP delivery healthcare setting among the general population. We conducted a secondary analysis of a randomized trial that aimed to increase PrEP uptake. All clients eligible for PrEP in one of six public-sector healthcare facilities in Eswatini were included. PrEP uptake was stratified by initial reason for visit (e.g. outpatient). Preferences in PrEP delivery setting were collected among those clients who initiated PrEP. A total of 1782 clients had their HIV acquisition risk assessed. Of these, 72% (1277/1782) were considered at risk by healthcare providers and, among them, 40% (517/1277) initiated PrEP. Uptake was higher among clients visiting specifically to initiate PrEP (93%), followed by HIV testing visits (45.8%) and outpatient visits (40%). Among those who initiated PrEP, preferred delivery settings were outpatient services (31%), HIV testing services (26%), family planning (21%) and antenatal services (14%). Men or those at high risk of HIV acquisition were more likely to prefer HIV testing and outpatient services, while young women were more likely to visit and express a preference for antenatal and family planning services. Outpatient services and HIV testing services could be preferable choices for PrEP delivery integration, due to the high PrEP uptake and delivery setting preferences of the populations who use these services. Antenatal and family planning could also be considered with a view to targeting the youngest women.

Knowledgeable, aware / interested: Young black women's perceptions of pre-exposure prophylaxis

Purpose

HIV in the United States disproportionately affects young Black women. Pre-exposure prophylaxis (PrEP) is an effective HIV prevention option that has the potential to reduce HIV incidence among HIV-vulnerable populations. However, data regarding women's awareness, interest in starting, and feelings of acceptability or stigma about PrEP remains limited, particularly among adolescent and young Black women.

Materials and methods

A cross-sectional survey was conducted with 100 sexually active young Black women ages 13–24 years attending women's health clinics in Chicago, IL. Descriptive statistics were used to characterize the sample and determine more about what the PrEP needs and barriers are in this community. Associations were modeled using logistic regression and 95% confidence intervals for both bivariate and multivariable models.

Results

In our survey (N = 100), half of study participants (50%) expressed interest in starting PrEP in the next three months and a majority (80%) of young women were confident they could obtain PrEP. Pregnant young women were significantly more interested in starting PrEP than non-pregnant women [OR 2.3 95% CI (1.0, 5.4)], p = 0.05), however, this association did not remain significant in adjusted models.

Conclusions

This study provides a more complete understanding of awareness, interest in, and acceptability of PrEP among adolescent and young Black women attending women's health clinics. Findings indicate sustained interest in starting PrEP, reduced stigma, and increased awareness of PrEP among young Black women. These findings suggest that integrating PrEP into women's health clinics is a promising strategy to increase awareness and utilization of PrEP and decrease HIV transmission among youth at highest risk.

''Ask the way from those who have walked it before"-Grandmothers' roles in health-related decision making and HIV pre-exposure prophylaxis use among pregnant and breastfeeding women in sub-Saharan Africa

HIV acquisition among pregnant and breastfeeding women in sub-Saharan Africa and vertical transmission rates remain high despite established strategies for HIV prevention. During the MTN-041/MAMMA study, we explored the influence of grandmothers (mothers and mothers-in-law of pregnant and breastfeeding women) in eastern and southern Africa on the health-related decisions of pregnant and breastfeeding women and their potential to support use of HIV prevention products. To do this we used structured questionnaires and focus group discussions with three stakeholder groups: 1) grandmothers, 2) HIV-uninfected currently or recently pregnant or breastfeeding women and 3) male partners of currently or recently pregnant or breastfeeding women. A total of 23 focus group discussions comprising 68 grandmothers, 65 pregnant or breastfeeding women and 63 male partners were completed across four study sites. Grandmothers were described as important sources of information during pregnancy and breastfeeding playing both supportive and influencer roles due to personal maternal experience and generational knowledge. While pregnant and breastfeeding women were not keen to involve grandmothers in HIV prevention decision making, they were accepting of grandmothers' involvement in a supportive role. Grandmothers expressed willingness to support pre-exposure prophylaxis use and agreed with the other two stakeholder groups that this decision should be made by women themselves or together with partners. These novel data indicate potential for grandmothers' health related supportive roles to be extended to support decision-making and adherence to biomedical HIV prevention options, and possibly contribute to the decline in HIV acquisition among pregnant and breastfeeding women in these communities.

HIV-serodifferent couples' perspectives and practices regarding HIV prevention strategies: A mixed methods study

A substantial proportion of heterosexually acquired HIV infections in the U.S. occur between partners in primary relationships characterized by mixed HIV status. The U.S. Centers for Disease Control and Prevention have issued guidelines prioritizing HIV-serodifferent couples for primary HIV prevention, including treatment-as-prevention and pre-exposure prophylaxis (PrEP). Yet, very little research has been conducted to understand the perspectives and practices of HIV-serodifferent couples regarding HIV prevention strategies in the U.S. To help fill this gap, we conducted a mixed methods study with 27 mostly Black/African American and Latinx HIV-serodifferent heterosexual couples residing in New York City to explore their knowledge, attitudes, practices, and perspectives regarding combination HIV prevention, including condoms, PrEP and viral control. All couples expressed the desire to maintain viral suppression in the HIV-positive partner, which was not always achieved. There was considerable heterogeneity in the use of HIV prevention methods by couples; and several patterns emerged that were largely driven by gender and relationship dynamics. Female partners, in particular, expressed high levels of anxiety around transmission of HIV and thus desired multiple methods of protection. Healthcare providers should consider couples' psychosocial well-being, relationship quality, and other motivational factors when helping to tailor HIV preventative care for mixed-status couples.

Impact of daily, oral pre-exposure prophylaxis on the risk of bacterial sexually transmitted infections among cisgender women: a systematic review and narrative synthesis

Background: There are concerns that the use of pre-exposure prophylaxis (PrEP) may result in an increased incidence of sexually transmitted infections (STIs). Evidence for this is mixed and has mostly been based on reviews focussed on gay and bisexual men and transgender women, while none have summarised evidence in cisgender women. Methods: We conducted a systematic review to explore whether daily, oral PrEP use is associated with changes in bacterial STI occurrence (diagnoses or self-reported) and/or risk among HIV seronegative cisgender women (ciswomen). The quality of evidence was assessed using the Grading of Recommendations, Assessment, Development and Evaluation (GRADE) tool. Results: We included 11 full text articles in a narrative synthesis, with the studies published between 2012 and 2021. The studies were mostly based in Africa (n=7, 63.6%) and reported on 3168 ciswomen using PrEP aged 16-56 years. Studies had marked differences in variables, including measurements and definitions (e.g., STI type) and limited data available looking specifically at ciswomen, principally in studies with both male and female participants. The limited evidence suggests that PrEP use is not associated with increased STI rates in ciswomen generally; however, adolescent girls and young women in Sub Saharan Africa have a higher prevalence of bacterial STIs prior to PrEP initiation, compared to adult ciswomen and female sex workers. Conclusions: We suggest future PrEP research make efforts to include ciswomen as study participants and report stratified results by gender identity to provide adequate data to inform guidelines for PrEP implementation. PROSPERO registration: CRD42019130438.

Factors motivating female sex workers to initiate pre- exposure prophylaxis for HIV prevention in Zimbabwe

BACKGROUND

Female sex workers (FSWs) have a 26 times greater chance of HIV infection compared to the women in the general population. The World Health Organization recommends pre-exposure prophylaxis (PrEP) for population groups with an HIV incidence of 3% or higher and FSWs in southern Africa fit this criteria. This study sought to understand factors that motivate FSWs to initiate PrEP, in Harare, Zimbabwe.

METHODS

We purposively selected and recruited 20 FSWs to participate in the study in-order to gain an in-depth understanding of factors that motivate FSWs to initiate PrEP in Harare, Zimbabwe. We identified FSW who had been initiated on PrEP at a specialized clinic providing comprehensive sexual reproductive health (SRH) services for sex workers including HIV prevention options. We used a descriptive phenomenological approach to collect and analyze the data. Data was analyzed using Colaizzi's seven steps to analyze data.

FINDINGS

Two broad themes were identified as intrinsic and extrinsic motivators. The two broad themes each have several sub-themes. The sub-themes under intrinsic motivation were (i) Self- protection from HIV infection and (ii) condoms bursting. Six sub-themes were identified as external motivators for initiating PrEP, these included (i) occupational risk associated with sex work, (ii) increased chance of offering unprotected sex as a motivator to initiate PrEP, (iii) positive encouragement from others (iv) need to take care of the children and (v) prior participation in HIV prevention research studies and (vi) Gender Based Violence.

CONCLUSIONS

Understanding the factors that motivate FSWs to initiate PrEP is critical in developing contextually appropriate strategies to promote PrEP initiation and adherence strategies within specific and eligible populations for receiving PrEP according to the WHO guidelines (2015).

Determinants of Implementation for HIV Pre-exposure Prophylaxis Based on an Updated Consolidated Framework for Implementation Research: A Systematic Review

BACKGROUND

Delivery and use of HIV pre-exposure prophylaxis (PrEP) are suboptimal in the United States. Previous reviews of barriers and facilitators have not used an implementation science lens, limiting comprehensiveness and the link to implementation strategies. To summarize the state of the science, we systematically reviewed determinants of PrEP implementation using the updated Consolidated Framework for Implementation Research (CFIR 2.0).

SETTING

PrEP-eligible communities and delivery settings in the United States.

METHODS

In January 2021, we searched Ovid MEDLINE, PsycINFO, and Web of Science for peer-reviewed articles related to HIV/AIDS, interventions, implementation, and determinants or strategies. We identified 286 primary research articles published after 1999 about US-based PrEP implementation. Team members extracted discrete "mentioned" and "measured" determinants, coding each by setting, population, valence, measurement, and CFIR 2.0 construct.

RESULTS

We identified 1776 mentioned and 1952 measured determinants from 254 to 239 articles, respectively. Two-thirds of measured determinants were of PrEP use by patients as opposed to delivery by providers. Articles contained few determinants in the inner setting or process domains (ie, related to the delivery context), even among studies of specific settings. Determinants across priority populations also focused on individual patients and providers rather than structural or logistical factors.

CONCLUSION

Our findings suggest substantial knowledge in the literature about general patient-level barriers to PrEP use and thus limited need for additional universal studies. Instead, future research should prioritize identifying determinants, especially facilitators, unique to understudied populations and focus on structural and logistical features within current and promising settings (eg, pharmacies) that support integration of PrEP into clinical practice.

Assessing the Information-Motivation-Behavioral Skills Model to Predict Pre-exposure Prophylaxis Adherence Among Black Men Who have Sex with Men and Transgender Women in a Community Setting in New York City

The Information-Motivation-Behavioral Skills (IMB) Model has been used to understand adherence to medications and intentions to uptake pre-exposure prophylaxis (PrEP) to prevent HIV infection. In the current study, the IMB Model was used to understand factors that predict adherence to PrEP among a community-based cohort of 204 Black men who have sex with men (MSM) and transgender women (TGW) using structural equation modeling. PrEP motivation was directly associated with PrEP behavioral skills (β = 0.320, p = 0.009), and PrEP behavioral skills were directly associated with PrEP adherence (β = 0.416, p = 0.001). PrEP knowledge and PrEP motivation were not associated with PrEP adherence, directly or indirectly. The analysis identified intervenable factors that predicted PrEP adherence. Screening for motivation and behavioral skills could be used to identify where additional support to improve PrEP adherence is needed, or whether to offer alternative PrEP modalities or delivery strategies.

HIV pre-exposure prophylaxis: assessment of acceptability among members of HIV serodiscordant/serostatus unknown couples

BACKGROUND

Pre-exposure prophylaxis (PrEP) is effective in preventing HIV infection but is not yet widely available in resource-limited settings such as the Dominican Republic. We aimed to ascertain PrEP acceptability among people living with HIV in the Dominican Republic who are part of HIV serodiscordant partnerships and understand relationships between PrEP acceptability, HIV stigma, and intimate partner violence.Methods: A cross-sectional survey of people in care for HIV infection included acceptability-related questions and assessments of HIV stigma and intimate partner violence. We also explored the expected impact of PrEP on HIV disclosure rates and fertility intentions.Results: Of the 100 participants, 74% had been in their current partnership for >1 year; 38% had not disclosed to their partner; 29% reported condomless sex, and 23% reported sex with multiple partners. PrEP was highly acceptable with 84% of participants saying they were "very likely" to offer PrEP to their partner if available and 21% stating it would allow them to have more children. Of those who had not disclosed to their partner, 71% stated PrEP would help them do so. No relationship was found between PrEP acceptability, HIV stigma, and intimate partner violence. However, higher than expected rates of PrEP acceptability limited the power of these analyses.Conclusion: Pre-exposure prophylaxis was considered to be highly acceptable among people living with HIV in the Dominican Republic who are part of serodiscordant partnerships.

Race and Sexual Identity Differences in PrEP Continuum Outcomes Among Latino Men in a Large Chicago Area Healthcare Network

U.S. HIV incidence is threefold higher among Latino individuals than non-Latino Whites. Pre-exposure prophylaxis (PrEP) uptake remains low among Latino men. Most HIV studies view Latino communities as a monolithic group, ignoring racial and sexual diversity. This analysis examines PrEP-related outcomes including eligibility, first prescription, and second prescription across race and sexual identity in a sample of Latino cisgender men (n = 8271) who sought services from a healthcare network in Chicago in 2012-2019. Logistic regression was used to calculate adjusted odds ratios. Latino-only participants had lower odds of PrEP eligibility and first prescription compared to White-Latino participants. No other significant differences by race were detected. While bisexual participants had equivalent odds of PrEP eligibility, they had lower odds of first PrEP prescription compared to gay participants. Heterosexual participants also had lower odds of PrEP eligibility and initiation. Future research should address unique factors shaping PrEP-related outcomes among diverse Latino populations.

Cost-effectiveness and impact of pre-exposure prophylaxis to prevent HIV among men who have sex with men in Asia: A modelling study

INTRODUCTION

More than 70% of new HIV infections in Asia occurred in eight countries in 2020: Cambodia, China, India, Indonesia, Myanmar, Nepal, Thailand, and Vietnam-with a rising incidence among men who have sex with men (MSM). The World Health Organization (WHO) recommends pre-exposure prophylaxis (PrEP) for those at risk of acquiring HIV, yet wide-scale implementation of PrEP, on a daily or event-driven basis, has been limited in Asia.

METHODS

The Optima HIV model was applied to examine the impact of scaling-up PrEP over five-years to cover an additional 15% of MSM compared with baseline coverage, a target deemed feasible by regional experts. Based on behavioral survey data, we assume that covering 15% of higher-risk MSM will cover 30% of all sexual acts in this group. Scenarios to compare the impact of generic-brand daily dosing of PrEP with generic event-driven dosing (15 days a month) were modelled from the start of 2022 to the end of 2026. Cost-effectiveness of generic versus branded PrEP was also assessed for China, the only country with an active patent for branded, higher cost PrEP. The impact on new HIV infections among the entire population and cost per HIV-related disability-adjusted life year (DALY) averted were estimated from the beginning of 2022 to the end of 2031 and from 2022 to 2051.

RESULTS

If PrEP were scaled-up to cover an additional 15% of MSM engaging in higher-risk behavior from the beginning of 2022 to the end of 2026 in the eight Asian countries considered, an additional 100,000 (66,000-130,000) HIV infections (17%) and 300,000 (198,000-390,000) HIV-related DALYs (3%) could be averted over the 2022 to 2031 period. The estimated cost per HIV-related DALY averted from 2022 to 2031 ranged from US$600 for event-driven generic PrEP in Indonesia to US$34,400 for daily branded PrEP in Thailand. Over a longer timeframe from 2022 to 2051, the cost per HIV-related DALY averted could be reduced to US$100-US$12,700.

CONCLUSION

PrEP is a critical tool to further reduce HIV incidence in highly concentrated epidemics. Implementing PrEP in Asia may be cost-effective in settings with increasing HIV prevalence among MSM and if PrEP drug costs can be reduced, PrEP could be more cost-effective over longer timeframes.