PrEP Use, Sexual Behaviour, and PrEP Adherence Among Men who have Sex with Men Living in Wales Prior to and During the COVID-19 Pandemic

Impacts of the COVID-19 Pandemic on the HIV Care Continuum and Associated Factors in High-Income Nations: A Mixed-Methods Systematic Review

The COVID-19 pandemic has significantly impacted the HIV care continuum (HCC), presenting challenges while also driving positive transformations globally. This study examines the impact of the COVID-19 pandemic on HCC in high-income countries, aiming to identify barriers and facilitators to care delivery amidst global health challenges. This study employs JBI mixed-methods systematic review methodology. The search strategy included CINAHL, OVID-Medline, CAB Direct, and OVID-Embase databases and manual citation review. After systematic screening and data extraction, quality assessment was performed, and integrated findings were presented. A systematic search of online databases retrieved 20,305 records, with 14,600 unique records screened after removing duplicates; 607 full-text articles were reviewed, and 88 studies meeting eligibility criteria were included in the final analysis. The COVID-19 pandemic has disrupted various aspects of the HIV care continuum, posing challenges in testing, prevention, appointments, adherence, linkage to care, viral suppression, and treatment engagement. However, the pandemic has also spurred positive changes, notably through the widespread adoption of telemedicine, enhancing access to care and support services. Efforts to mitigate structural barriers, enhance access to care, and promote ART adherence are essential to ensure continuity of care and mitigate long-term consequences. Tailored interventions for vulnerable populations and addressing disparities in care access are crucial for fostering equitable HIV care delivery.

HIV Pre-Exposure Prophylaxis (PrEP) Users' Experiences of PrEP Access, Sexual Behaviour, and Well-Being During the COVID-19 Pandemic: A Welsh Qualitative Study

BACKGROUND

HIV Pre-Exposure Prophylaxis (PrEP) has been available in Wales since 2017. The coronavirus disease (COVID-19) pandemic impacted UK sexual health services, leading to a reduction in service provision. There is a lack of research on the experiences of PrEP users during this time.

OBJECTIVE

We aimed to explore the experiences of PrEP users in Wales following the introduction of COVID-19 pandemic measures.

METHODS

We conducted a secondary data analysis of two prior interview studies (DO-PrEP and UPrEP). Data collection was undertaken between May 2020 and February 2021 using remote interviewing. Semi-structured interviews were conducted. Participants were ≥18 years of age, residents of Wales, current or previous PrEP users, and men who have sex with men (MSM). Reflexive thematic analysis was conducted.

RESULTS

A total of 32 interviews were included in the analysis. Themes include the following: (1) PrEP use during COVID-19, (2) sexual behaviour and relationship changes following COVID-19 restrictions, (3) NHS service provision during the COVID-19 pandemic, and (4) wider contextual effects of the pandemic. Participants reported a change in PrEP use (pausing or switching to event-based PrEP). Participants reported reduced access to clinics and appointments. Support for changing to event-based PrEP was varied. Social isolation resulted in varied responses to lockdown rules, especially in later lockdowns.

CONCLUSION

This study provides patient perspectives on the challenges the COVID-19 pandemic posed to PrEP use and access. It offers insights into the broader support needs around PrEP use when an individual's circumstances change. Flexible models of PrEP provision, which can be adapted to the patient's needs, will be essential as PrEP delivery extends into the wider community.

PATIENT AND PUBLIC CONTRIBUTION

Both the DO-PrEP and UPrEP studies received input from various stakeholders in the design of the topic guides for the study; these included public lay members, PrEP users, PrEP providers, and individuals involved with HIV advocacy and policy.

Prevalence and factors associated with uptake of pre-exposure prophylaxis amongst women vulnerable to HIV who received HIV antibodies in Antibody Mediated Prevention HVTN703/HPTN081 trial in Harare, Zimbabwe: a cross-sectional study

Introduction

There is limited evidence on pre-exposure prophylaxis (PrEP) uptake post-trial participation for women vulnerable to HIV. This study investigates the prevalence and factors associated with PrEP uptake post-participation in an HIV prevention trial.

Methods

Former Antibody Mediated Prevention (AMP) study participants were invited to the three AMP clinical research sites in Zimbabwe after at least a year of exiting the study. The AMP study evaluated the safety and efficacy of Vaccine Research Center 01 broadly neutralising monoclonal antibody in reducing acquisition of HIV-1 infection in women in sub-Saharan Africa. Participants vulnerable to HIV were enrolled and risk reduction counselling was done throughout study participation. In a cross-sectional study, semi-structured interview administered questionnaires were completed. The primary outcome was uptake of PrEP after the study exit.

Results

From February 2022 to August 2022, out of 434 participants enrolled in the AMP study, a total of 298 were invited and 225 participated in the study; 28% made an attempt to access PrEP after study participation, 20% used PrEP at some point after study participation and 15% were on PrEP at the time of questionnaire administration. PrEP uptake was associated with new sexual partners after study participation and higher average number of sexual encounters in the previous month. Challenges faced in accessing PrEP included those related to the health facility, transport problems and stigma.

Conclusion

The majority (85%) of former AMP participants were not on PrEP at the time of questionnaire administration. We observed poor uptake of PrEP post-study exit among participants who had received risk reduction counselling through study duration. Measures to improve PrEP uptake should be considered on participants vulnerable to HIV when exiting HIV prevention trials.

Impact of the COVID-19 Pandemic on the PrEP Cascade at Two Veterans Affairs Healthcare Systems

Overall, fewer Veterans were eligible for PrEP in 2020, compared to 2019, and 2018 (Maryland Veterans Affairs Health Care System- MVAHCS-: n = 890 (2020), n = 1533 (2019); Washington DC Veterans Affairs Medical Center -DC VAMC- n = 1119 (2020), n = 1716 (2019)). While the proportion of Veterans engaged in PrEP out of those eligible for PrEP increased in 2020 compared to 2019 at both sites (MVAHCS: 5.73% (2020) vs. 3.39% (2019) p-value = 0.006; F = 7.58, and DC VAMC: 15.91% (2020) vs. 9.38% (2019) p-value < 0.001; F = 27.64), the absolute number of Veterans engaged in PrEP remained unchanged (MVAHCS n = 51 (2020) and n = 52 (2019); DC VAMC n = 178 (2020) and n = 161 (2019)). Engagement in PrEP was significantly lower among Black Veterans compared to White Veterans at the DC VAMC across all FY with a widening gap in 2020. Cisgender women were less likely to be engaged in PrEP compared to cisgender men at both sites and throughout all FY with a wider gender gap in 2020. There were no significant differences in retention in PrEP between FY.Anticipated improvements in linkage, engagement, and retention in PrEP in 2020 at the MVAHCS and DC VAMC may not have been seen due to the COVID-19 pandemic. Furthermore, engagement rates in PrEP remained low overall, particularly among Black Veterans and cisgender women. Novel PrEP delivery models are needed to engage these populations in PrEP following the COVID-19 pandemic. Interactive dashboards and tele-PrEP may have played a big role in sustained retention in PrEP at the VHA.

Dynamicity of HIV Pre-exposure Prophylaxis Usage Pattern and Association with Executed Adherence in MSM: An Implementation Study in Hong Kong

Pre-exposure prophylaxis (PrEP) use has been shown to be effective for HIV prevention in men who have sex with men (MSM). PrEP use coverage aside, maintenance of high PrEP adherence is crucial in ensuring the achievement of HIV prevention. In this PrEP implementation study in Hong Kong, we examined the patterns of PrEP use in MSM and evaluated their association with prevention-effective adherence for HIV prevention. In January 2020-June 2021 in Hong Kong, 312 recruited MSM (median 30 years old) were followed up for 1 year, with HIV and creatinine testing, consultation, and PrEP refill. No HIV breakthrough infection was observed. As a measure of prevention-effective adherence, executed adherence (EA) was expressed as the proportion of days with HIV risk that were protected by PrEP and/or condom in 6 months. In 65,585 diary entries of 215 MSM, the median proportion of EA achieved was 89% (IQR 84-93%). Three latent classes of PrEP users were identified by latent class analysis. Taking Class 1 "daily dominant PrEP" (n = 113, 53%) as reference, Class 2 "episodic PrEP" (n = 76, 35%) was adopted by MSM with less sexual activity, had less PrEP refill and lower EA level, while Class 3 "mixed PrEP schedule" (n = 26, 12%) MSM were more sexually active but with a similar EA level. The study findings showed varied and dynamic PrEP usage patterns in the real-world setting. Strategies for promoting adherence are needed to ensure the maintenance of high EA level among PrEP-using MSM especially those on episodic PrEP schedule.

Psychological and Behavioural Within-participant Predictors of Adherence to Oral HIV Pre-Exposure Prophylaxis (PrEP)

Oral PrEP's effectiveness relies on adequate adherence during periods of substantial HIV risk. Since most PrEP users will miss doses, understanding predictors within participants can help to explain adherence. We used a cross-sectional, within-participant design with 67 gay, bisexual, and other men who have sex with men taking PrEP daily. Using a questionnaire, informed by the Information Motivation Behavioral Skills Model, participants were asked about an adherent and a non-adherent episode. PrEP non-adherence was associated with non-normality of the day (p < .001), being out of the home (p < .001), weekend days (p = .01), having company (p = .02), using substances (p = 0.02), not using reminders (p = .03), lower PrEP information (p = .04), lower behavioural skills (p < .001) and less positive affect (p = .002). PrEP adherence assessment could focus on situational variations, supporting the construction of alternative strategies to facilitate adherence in these situations.

Pre-exposure Prophylaxis Adherence Among Men Who Have Sex With Men: A Systematic Review and Meta-analysis

OBJECTIVES

The effectiveness and efficiency of pre-exposure prophylaxis (PrEP) in reducing the transmission of human immunodeficiency virus (HIV) among men who have sex with men (MSM) relies on how widely it is adopted and adhered to, particularly among high-risk groups of MSM. The meta-analysis aimed to collect and analyze existing evidence on various factors related to PrEP adherence in MSM, including demographic characteristics, sexual behaviors, substance use, and psychosocial factors.

METHODS

The meta-analysis followed the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines. The search included articles published between January 2018 and December 2022, obtained from the PubMed, ScienceDirect, and Scopus databases. The studies that were included in the analysis reported the proportion of MSM who demonstrated adherence to PrEP and underwent quality appraisal using the Newcastle-Ottawa Scale.

RESULTS

Of the 268 studies initially identified, only 12 met the inclusion criteria and were included in the final meta-analysis. The findings indicated that education (odds ratio [OR], 1.64; 95% confidence interval [CI], 1.12 to 2.40), number of sexual partners (OR, 1.16; 95% CI, 1.02 to 1.31), engaging in sexual activities with an human immunodeficiency virus-positive partner (OR, 1.59; 95% CI, 1.16 to 2.26), substance use (OR, 0.83; 95% CI, 0.70 to 0.99), and lower levels of depression (OR, 0.55; 95% CI, 0.37 to 0.82) were associated with higher rates of PrEP adherence among MSM.

CONCLUSIONS

Despite these findings, further research is necessary to investigate PrEP adherence more comprehensively. The findings of this meta-analysis can be utilized to inform interventions aimed at improving PrEP adherence among MSM and provide directions for future research in this area.

Impact of COVID-19 Confinement on Mental Health in Youth and Vulnerable Populations: An Extensive Narrative Review

The objective of this narrative review is to analyze the impact of COVID-19 on the mental health of particularly vulnerable groups. This information will allow a better understanding of the determining factors that influence the appearance and/or maintenance of mood disorders. To achieve the main objective of this study, a critical review was carried out in which primary sources such as scientific articles, secondary sources such as databases, and other appropriate reference indexes were considered. The results indicated that there was an increase in the diagnosis of mood disorders and the use of medication associated with these disorders, mainly during the period of reclusion that was declared worldwide in March 2020. In addition, risk factors such as loneliness, a lack of resilience, and a lack of adequate coping strategies negatively impacted these groups. The future consequences of this may be reflected over many years thereafter, and it is important that all data obtained from this point forward be considered by mental health professionals and the general population. This review can be a starting point for looking directly at the most vulnerable populations and considering both the resources available to them and the possible aftermath of a traumatic period in everyone’s lives.

Psychometric Properties of an Adapted Stigma Scale and Experiences of Stigma Associated with HIV Pre-exposure Prophylaxis Use Among Men Who have Sex with Men: A Mixed Methods Study

Stigma may influence the use of HIV pre-exposure prophylaxis (PrEP). However, there is an absence of robust measures for PrEP-related stigma. We describe an adaptation of a HIV stigma scale for use in PrEP users and experiences of PrEP users in Wales (UK) with regards to PrEP-related stigma. A mixed methods study was conducted where PrEP users completed questionnaire items about PrEP-related stigma and a subset were interviewed about their experiences of taking PrEP. We adapted items from the HIV stigma scale and assessed construct validity and internal consistency. We analysed interview data using a framework approach, with themes focussing on enacted and anticipated stigma in order to identify areas for scale refinement. Our measure had good psychometric properties but additional items may be useful (e.g. specific instances of enacted stigma, concerns around homonegativity). Further work is needed to develop this scale and validate it in a larger sample.

Impact of COVID-19 on the Belgian HIV epidemic: slowdown of HIV transmission and testing and adaptation of care

BACKGROUND

To gain insight into the impact of the COVID-19 pandemic and containment measures on the HIV epidemic and services, this study aims to describe HIV trends in 2020 and compare them with previous years.

METHODS

Belgian national HIV surveillance data 2017-2020 were analysed for trends in HIV testing, HIV diagnoses, VL measurements, ART uptake and PrEP purchase. Descriptive statistics from 2020 are compared to annual averages from 2017 to 2019 (proportional difference, %).

RESULTS

In 2020, 725 HIV infections were diagnosed in Belgium (- 21.5% compared to 2019). The decline was most pronounced during the first lockdown in April-May but also present in July-December. The number of HIV tests performed decreased by 17.6% in 2020, particularly in March-May and October-December (- 57.5% in April and -25.4% in November 2020 compared to monthly 2017-19 numbers). Diagnosis of acute HIV infections decreased by 47.1% in 2020 (n = 27) compared to 2019 (n = 51). Late HIV diagnoses decreased by 24.7% (95% CI [- 40.7%; -9.7%]) in 2020 compared to 2019. Of patients in care in 2019, 11.8% interrupted HIV care in 2020 compared to 9.1% yearly in the 3 previous years. The number of HIV patients with VL monitoring per month dropped in March-May 2020, whilst proportions of VL suppression and ART coverage remained above 86% and 98.5% respectively in 2020. PrEP purchases, number of purchasers and starters dropped during April-May 2020 (respectively - 45.7%, - 47.4%, - 77.9% in April compared to February 2020).

CONCLUSIONS

The significant decrease in HIV diagnoses in Belgium in 2020 coincided with the COVID-19 pandemic and following containment measures, particularly in April-May during the first lockdown. A slowdown of HIV transmission due to reduced HIV risk exposure is suggested by the halving in diagnosis of acute HIV infections in March-December 2020 compared to the previous year, and the adaptive decrease in PrEP use and PrEP initiation from April onwards. Despite a slight increase in HIV care interruptions, the indicators of quality of HIV care remained stable. Access to prevention, testing and care for all people living with HIV and at risk of acquiring HIV is a priority during and after times of pandemic.

Characterizing the Impact of the COVID-19 Pandemic on HIV PrEP care: A Review and Synthesis of the Literature

The global COVID-19 pandemic and associated lockdown measures have caused disruptions to sexual health services and created additional barriers to the continuity of HIV pre-exposure prophylaxis (PrEP) among key populations. This review provides an examination of the influences of the pandemic on engagement in the PrEP care continuum. Using the PRISMA guideline, 46 studies were included in this review and the synthesis. Most of the studies were conducted in high-income settings through quantitative analysis. A majority of studies examining the changes in PrEP use suggested a decline or discontinuation in PrEP uptake during the pandemic. The most common reasons for stopping using PrEP were perceived barriers to PrEP-related care, having reduced sexual behaviors and fewer sexual partners, and reduced perceived risk of HIV infection. Limited studies documenting an increase in PrEP uptake were all in specific PrEP optimizing programs. During the pandemic, there is also an emerging trend of switching to on-demand PrEP from daily oral PrEP. Future studies should understand the mechanism of strategies that facilitated the improvements during the pandemic. PrEP implementation programs should consider alternative PrEP modalities and provide consistent and comprehensive knowledge about correct information.

Between- and Within-Individual Sociodemographic and Psychological Determinants of PrEP Adherence Among Men Who have Sex with Men Prescribed a Daily PrEP Regimen in Wales

We investigated the determinants of daily PrEP use and coverage of condomless anal sex (CAS) by PrEP among men who have sex with men in Wales, UK. We measured PrEP use by electronic monitors and CAS by secure online surveys. We defined PrEP use based on daily medication cap openings and coverage as CAS episodes preceded by ≥ 3 days of PrEP use and followed by ≥ 2 days of PrEP use. We included 57 participants (5463 observations). An STI diagnosis was associated with lower PrEP use but also lower PrEP coverage. Older adults had higher PrEP use. A belief that other PrEP users took PrEP as prescribed was associated with lower PrEP coverage. An STI diagnosis is an important cue for an intervention, reflecting episodes of high-risk sexual behaviour and low PrEP coverage. Other results provide a basis for the development of an evidence-informed intervention for promoting coverage of PrEP.

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.