Sexual and Gender Minority Individuals' Interest in Sexual Health Services at Collective Sex Venues in New York City

HIV post-exposure prophylaxis in community settings and by lay health workers or through task sharing: a systematic review of effectiveness, case studies, values and preferences, and costs

INTRODUCTION

Post-exposure prophylaxis (PEP) for HIV prevention has been inadequately promoted, provided and used. Expanded access and task sharing could increase the HIV prevention impact of PEP, but scientific evidence to inform programmatic and policy decisions has not been synthesized.

METHODS

To inform World Health Organization guidelines, we conducted a systematic review of studies examining the provision of PEP in community settings, and by trained lay health workers or through task sharing. We searched CINAHL, PsycINFO, PubMed, EMBASE and scientific conferences for studies published between January 2012 and October 2023. We screened abstracts and extracted data in duplicate. The effectiveness review included randomized controlled trials and comparative observational studies; risk of bias was assessed using Cochrane Collaboration and Evidence Project tools, and the certainty of the evidence was assessed using GRADE. We also summarized implementation case studies, values and preferences studies, and cost and cost-effectiveness studies.

RESULTS

For provision of PEP in community settings, we identified one effectiveness study, three case studies, one values and preferences study, and one cost study. Very low certainty evidence from one study in Kenya and Uganda suggested that PEP uptake, when offered as part of a dynamic prevention package, was highest in the community setting (vs. outpatient or antenatal care settings). For provision of PEP by trained lay health workers or task sharing, we identified three effectiveness studies, two case studies, four values and preferences studies, and one cost study. Very low certainty evidence from Kenya, Uganda and the United States suggested that engagement of lay providers or pharmacists increased PEP uptake and completion and decreased HIV acquisition. Studies from six countries found most health workers supported PEP provision by non-specialist providers. One modelling study suggested community-based provision may be cost-effective or cost-saving in Africa.

DISCUSSION

Evidence on expanding PEP access through community delivery or task sharing is limited but generally suggests positive outcomes, feasibility, acceptability and cost-effectiveness of these approaches. Indirect evidence from HIV treatment and pre-exposure prophylaxis further supports these approaches.

CONCLUSIONS

Programmes should be expanded to include community delivery and task sharing to dispense, distribute, provide and monitor PEP.

Impact of COVID-19 and Mpox on Sexual Practices and Disease Mitigation Strategies Over Time Among Men Who Have Sex With Men Affiliated With Collective Sex Venues

BACKGROUND

The COVID-19 pandemic and subsequent multinational mpox outbreak significantly disrupted sexual health care delivery, particularly impacting men who have sex with men (MSM). This study investigated these public health emergencies in relation to perceptions, attitudes, and sexual practices among MSM affiliated with a collective sex venue (CSV).

METHODS

Electronic surveys were sent to clientele of a high-volume CSV between June 2021 and November 2022 across 3 time periods defined as pre-Omicron, post-Omicron, and mpox. Data collection encompassed sociodemographics, health care access, sexually transmitted infection/HIV status, COVID-19 testing, and sexual behaviors. Multivariable regression analyses identified factors associated with self-reported COVID-19 testing and positivity, and mpox exposure.

RESULTS

Among 1135 responses, demographics were largely cisgender MSM and predominantly White. Increased self-reported COVID-19 positivity was associated with having more sex partners and frequenting bathhouses for meeting sex partners. Confidence in COVID-19 mitigation strategies decreased post-Omicron. Factors linked to mpox exposure included younger age, increased sex partners, sexually transmitted infection positivity, and lower confidence in mitigation strategies.

DISCUSSION

These findings underscore the intersectionality between sexual behaviors and public health responses to COVID-19 and mpox among MSM communities affiliated with a CSV. Decreased confidence in mitigation strategies and changes in sexual behaviors during public health emergencies underscore the need for targeted interventions and messaging. Collaboration between health departments and CSVs can facilitate responses to current and future public health threats and interventions.

Updated guidelines on HIV post-exposure prophylaxis: continued efforts towards increased accessibility

INTRODUCTION

HIV transmission is ongoing in both high- and low-resource settings. Post-exposure prophylaxis (PEP) remains an important tool in preventing HIV; however, PEP is significantly underutilized. The multitude of barriers to PEP implementation include low patient and provider awareness and acceptability, limited access to treatment and prevention services, and high rates of stigma. The World Health Organization (WHO) recently released updated guidance on the delivery of HIV PEP. This commentary aims to highlight the salient changes, evaluate how such recommendations can overcome the existing barriers to PEP implementation and discuss strategies needed to put the updated guidance into practice.

DISCUSSION

The 2024 WHO PEP guidelines continue a trend towards increasing access to PEP. Most notably, the WHO now provides strong recommendations that: (1) PEP be delivered in community settings (e.g. pharmacies, police stations and online platforms), and (2) PEP delivery and monitoring be done via task sharing involving non-specialist health workers (e.g. pharmacists or community health workers). The guidelines also emphasize that the PEP encounter is an important educable moment whereby a transition to pre-exposure prophylaxis among individuals at continued risk for HIV infection should be discussed. The decentralization of PEP delivery has the potential to overcome numerous barriers to PEP implementation, reduce time to initiation and support adherence with the 28-day course. To translate the recommendations into delivery programmes, however, much more work is needed. Detailed templates can help overcome the heterogeneity of both the community settings in which PEP can now be provided and the populations (e.g. survivors of sexual assault, healthcare workers, sex workers, etc.) among whom PEP may be indicated. Training of the workforce will be essential, which should include, as emphasized by the WHO, training in trauma-based care. Novel formulations of and delivery mechanisms for PEP are also emerging, and how such iterations can synergize with decentralized PEP delivery programmes remains to be seen.

CONCLUSIONS

The updated WHO PEP guidelines make major strides towards increasing access to PEP. Realization of such aims will require ongoing evaluation and support given the heterogeneity in who benefits most from PEP.