Same-day prescribing of daily oral pre-exposure prophylaxis for HIV prevention

Oral pre-exposure prophylaxis (PrEP) receipt and persistence among opioid-dependent people who inject drugs initiating PrEP for HIV prevention

BACKGROUND

The opioid crisis in the United States has led to climbing overdose rates, alongside HIV outbreaks among people who inject drugs (PWID). One area of the pre-exposure prophylaxis (PrEP) cascade that has received little attention is the persistence of PrEP, especially among PWID. To address this gap, this study examined the receipt, persistence, and factors associated with PrEP persistence among opioid-dependent PWID.

METHODS

Between December 2020 and July 2022, we enrolled 100 opioid-dependent PWID. Eligible participants received a 90-day PrEP prescription from a community-based syringe services program and were followed up at 3 and 6 months. We assessed sociodemographic characteristics, PrEP use, and behaviors related to sex and drug use. We evaluated persistence on PrEP by calculating how many times each participant continued to pick up their PrEP prescription. To identify factors associated with persistence on PrEP, we used a multivariable ordinal logistic regression.

RESULTS

On average, participants were in their early 40s (mean age: 44.5, SD: 10.0 years), male (63.0 %), and unemployed (89.0 %). The majority (64.0 %) reported injecting drugs at least once per week in the past month, and 79.0 % had never used PrEP before. A total of 60 participants picked-up PrEP at least once during the 6-month follow-up period, with 42 (70.0 %) retrieving it only once, 16 (26.7 %) twice, and 2 (3.3 %) picking it up three times. In the multivariable model, unemployment (aOR = 7.819; 95 % CI: 1.538-39.751) and prior PrEP use (aOR = 3.381; 95 % CI: 1.210-9.443) were associated with higher persistence on PrEP, whereas participants who injected drugs once a week or less (aOR = 0.039; 95 % CI: 0.008-0.182) or more than once a week in the past month (aOR = 0.098; 95 % CI: 0.029-0.329) were less likely to consistently retrieve PrEP.

CONCLUSIONS

Despite a high willingness to use PrEP among opioid-dependent, PrEP-naïve PWID in general, the adoption and persistence of PrEP were low in this study. Given that PWID represent a marginalized group at significant risk for HIV, these findings highlight the urgent need for comprehensive strategies to enhance the PrEP continuum of care by addressing the unique and diverse needs of this subgroup.

Pre-exposure Prophylaxis: Clinical Considerations for Overcoming Barriers to Uptake and Persistence

ABSTRACT

Pre-exposure prophylaxis (PrEP) is the administration of antiretroviral medications before HIV exposure to prevent HIV infection. PrEP or biomedical prevention is an essential part of the ending the HIV epidemic strategy. Currently, there are 4 guideline-approved dosing approaches to PrEP, which include 2 oral formulations and 1 long-acting injectable. Unfortunately, most individuals who would benefit from PrEP do not receive a prescription, and even fewer initiate and continue PrEP. Barriers to PrEP uptake and persistence are complex and extend along a socio-ecologic framework from individual through structural. In this article, we highlight the barriers to PrEP care among priority populations, discuss evidence-based solutions, and offer multilevel considerations for clinicians, researchers, and community members to increase access, uptake, and persistence in PrEP care for all.

Rapid ART, Rapid PrEP, and Status Neutral Implementation in Ryan White-Funded Clinics: Results From a Multisite Survey

BACKGROUND

Ending the HIV Epidemic strategies include rapid ART Initiation (R-ART), rapid pre-exposure prophylaxis (R-PrEP), and status neutral approaches (status neutral), but implementation across heterogeneous settings in the United States is not well characterized.

SETTING

Ryan White (RW)-funded HIV treatment clinics located in select Ending the HIV Epidemic priority areas in the United States.

METHODS

Clinics were sent a survey to assess experiences offering R-ART, R-PrEP, and status neutral (collectively called "rapid START"). Primary outcomes were rapid START adoption and characteristics of implementing vs. nonimplementing clinics. Secondary outcomes included perceptions, barriers, and facilitators of R-ART and R-PrEP.

RESULTS

The response rate was 48% (40 of 83). The 40 respondents represented 57 clinics who reported providing HIV-related services to more than 70,000 individuals annually. R-ART uptake was 85% (range 43%-100%), status neutral 65% (range 57%-75%), and R-PrEP 60% (range 0%-88%). No rural-identifying organizations reported offering R-ART or R-PrEP compared with 96% and 76% of urban-identifying organizations, respectively. Positive perceptions of acceptability, appropriateness, and feasibility for R-ART and R-PrEP were high among all levels of implementation and strongest among those offering R-ART and R-PrEP. The most frequent barriers to R-ART were provider- and clinic-level and for R-PrEP were system-level (lack of insurance coverage) followed by patient-, provider-, and clinic-level issues.

CONCLUSION

This survey of diverse RW-funded clinics shows high uptake of R-ART and significant if less consistent uptake of R-PrEP and status neutral. Future research should focus on identifying broadly implementable strategies to expand adoption along with tailored approaches, especially in areas with lower health care access.

Policymaker Perspectives on Implementation Determinants of Rapid ART and Same-Day PrEP in Seven Priority Jurisdictions for Ending the HIV Epidemic: A Multisite Qualitative Study

BACKGROUND

Although rapid antiretroviral therapy (ART) and same-day pre-exposure prophylaxis models (henceforth "rapid START") are feasible, acceptable, and cost-effective in various contexts, significant barriers have hindered their broader implementation and scalability in the United States. Ryan White-funded clinics are cornerstones for HIV services, yet strategies are urgently needed to facilitate equitable rapid START adoption across contexts. This study aimed to identify common factors influencing rapid START to inform strategies applicable throughout jurisdictional settings.

METHODS

The Network for Implementation Science in HIV examined the current implementation of rapid START among diverse Ryan White Part A-D-funded organizations across seven Ending the HIV Epidemic jurisdictions across the United States. Semistructured interviews (n = 13) were administered from March 2023 to August 2024, with HIV leadership across jurisdictions to identify rapid START implementation determinants and strategies to catalyze rapid START delivery. Data were deductively analyzed using the Consolidated Framework for Implementation Research.

RESULTS

Prominent barriers to rapid ART implementation across settings included provider/patient hesitancy and awareness gaps, siloed care systems, and funding complexities. Prominent implementation facilitators included learning collaboratives, technology integration, and clear contracting language. Key constraints to same-day pre-exposure prophylaxis implementation included funding inequities and suboptimal client/patient awareness, whereas enablers included integrated care models, availability of starter packs, and medication-assistance programs.

CONCLUSIONS

Several consistent key barriers and facilitators spanned multiple Ending the HIV Epidemic jurisdictions despite contextual differences (eg, Medicaid expansion). Collaborative efforts between system leaders and service providers were universally characterized as essential for equitable adoption and penetration of rapid START models.

Outcomes of a pilot randomized clinical trial testing brief interventions to increase HIV pre-exposure prophylaxis uptake among rural people who inject drugs attending syringe services programs

Background

Kentucky is one of seven states with high, sustained rural HIV transmission tied to injection drug use. Expanding access to pre-exposure prophylaxis (PrEP) has been endorsed as a key HIV prevention strategy; however, uptake among people who inject drugs (PWID) has been negligible in rural areas. Syringe services programs (SSPs) have been implemented throughout Kentucky's Appalachian region, providing an important opportunity to integrate PrEP services.

Objectives

The primary objective was to examine preliminary efficacy and effect sizes of the study interventions on PrEP initiation among HIV-negative PWID.

Design

Parallel group randomized controlled trial.

Methods

Eighty participants were enrolled from two rural SSP locations in southeastern Kentucky. Following informed consent, participants completed a baseline interview, and were randomized to the intervention comparators. The primary endpoint was PrEP initiation, measured by dispensed PrEP prescription, within the 6-month study period. Analyses employed intent-to-treat (ITT) and per protocol approaches.

Results

In total, 77/80 enrollees (96.2%) completed at least one session of their assigned intervention, regardless of trial arm. Seventy (87.5%) were linked to the embedded PrEP provider for the initial clinical visit; 38 (47.5%) completed a follow-up clinical visit with the provider, 22 (27.5%) were issued a prescription, and 7 (8.8%) initiated PrEP during the study period. We observed a 12.1% difference (14.6% vs 2.5%; ITT) and 12.8% difference (15.4% vs 2.6%; per protocol) in the primary outcome (PrEP initiation), in favor of the experimental intervention.

Conclusion

This pilot trial established proof of concept for integrated PrEP care within SSPs in rural areas, and demonstrated a clinically meaningful difference in PrEP initiation between interventions, which warrants examination in a larger trial. Rates of early care discontinuation indicate a need for ongoing patient engagement strategies and implementation support for community SSPs.

Trial registration

Prospective registration with ClinicalTrials.gov, NCT05037513 (registered August 5, 2021).

Effective preexposure prophylaxis in young women and girls, a key population for HIV prevention

PURPOSE OF REVIEW

Although there is substantial momentum to scale up preexposure prophylaxis (PrEP) for HIV prevention in adolescent girls and young women (AGYW) at risk of HIV acquisition, this key population has demonstrated difficulty in sustained PrEP use. Despite being a user-controlled and discreet prevention option, effective oral PrEP use requires a series of complex daily decisions in the life of the PrEP user. In this review, we describe how the number of decisions AGYW have to execute for effective and continued PrEP use may potentially be reduced by providing simplified, integrated, differentiated sexual and reproductive health services that include PrEP, and introducing a choice of PrEP products, including less frequently dosed, longer acting and/or multipurpose prevention technology (MPT) products.

RECENT FINDINGS

PrEP uptake and effective use are enhanced when AGYW experience PrEP service delivery channels as convenient, integrated with their other sexual and reproductive health needs and matching their experiences (including limited autonomy) and lifestyle. Longer acting or less frequently dosed PrEP products or MPTs may reduce the cognitive burden associated with prevention decision-making and is, therefore, likely more suitable for the majority of AGYW who struggle with daily pill adherence.

SUMMARY

In the scaling up of HIV prevention for AGYW, implementers are encouraged to consider both PrEP products and PrEP delivery outlet preferences. Understanding and responding to AGYW's different needs will allow for preferred PrEP delivery outlets and choice in PrEP products, leading to a greater likelihood of effective PrEP use in this key population.

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).

Outcomes of an Emergency Department Program to Identify and Link Patients at Increased Risk for Acquiring HIV Infection to Outpatient HIV Prevention Services: The HIV PreventED Program

BACKGROUND

Emergency departments (EDs) provide care to patients at increased risk for acquiring HIV, and for many of them, the ED serves as their sole point of entry into the healthcare system. We implemented the HIV PreventED Program to increase access to HIV prevention services for ED patients.

SETTING

ED in Oakland, CA with an annual census of 57,000 visits.

METHODS

This cross-sectional study evaluated the first 9 months of the HIV PreventED Program. In this program, a navigator surveyed adult ED patients who tested HIV negative to determine their risk for acquiring HIV infection, incorporating HIV prevention counseling into their assessments. Patients at higher risk for acquiring HIV were referred to outpatient prevention services, if interested. The primary outcome measure was the number and proportion of ED patients at higher risk for acquiring HIV who followed up for outpatient prevention services.

RESULTS

In this study, 1233 patients who tested HIV negative were assessed by the navigator and received ED-based HIV prevention counseling. Of these, 193 (15.7%) were identified at higher risk and offered an outpatient referral for prevention services, of which 104 accepted (53.9%), 23 (11.9%) attended the referral, and 13 (6.7%) were prescribed preexposure prophylaxis (PrEP). The median time to linkage was 28 days (interquartile range 15-41 days).

CONCLUSION

A navigator focused on providing ED-based HIV prevention counseling and linkage to outpatient services is feasible. Strategies to more efficiently identify ED patients at higher risk for HIV acquisition, such as automated identification of risk data from the electronic health record, and policies to improve follow-up and the receipt of PrEP, such as same-day PrEP initiation, should be prospectively evaluated.

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.

Advancing the community plan to end the HIV Epidemic in Philadelphia: a qualitative descriptive evaluation of low-threshold PrEP services in sexual health clinics

BACKGROUND

Pre-exposure prophylaxis (PrEP) is an effective HIV prevention method and a key component of Philadelphia's Community Plan to End the HIV Epidemic (EHE). However, significant barriers to accessing PrEP exist among people at risk for HIV. Low-threshold models for PrEP services that minimize barriers to entry and service engagement could help bolster access to PrEP through community-based clinics. This study aimed to describe the initial implementation of low-threshold PrEP services in three sexual health clinics funded by the Philadelphia Department of Public Health and explore strategies for delivering low-threshold PrEP services.

METHODS

We conducted three focus groups with staff (i.e., providers, prevention navigators, and administrative staff, N = 21) at each of three participating PDPH-funded sexual health clinics from November 2021 to January 2022. Discussion topics included details about the PrEP delivery process, clinic strengths and assets, resource gaps, and PrEP implementation goals. Follow-up interviews with staff members (N = 8) between March 2022 and May 2022 focused on identifying successful strategies for PrEP delivery and adaptations needed to optimize low-threshold PrEP service delivery. Rapid qualitative methods and the Consolidated Framework for Implementation Science were used to analyze data from focus groups and interviews.

RESULTS

Participants collaborated to create process maps that visualized the steps involved in delivering PrEP services within their respective settings. These maps highlighted several stages in PrEP service delivery, such as connecting individuals to services, providing prevention navigation, conducting clinical encounters, and ensuring follow-up care. Participants described effective strategies for implementing PrEP, which included integrating and co-locating services on-site, strengthening staffing resources and capacity, and addressing barriers experienced by clients.

CONCLUSIONS

Lessons from the implementation of low-threshold PrEP service delivery in Philadelphia can guide ongoing local adaptations and future scale-up of these models to improve access to PrEP and advance the goals of the EHE initiative.

Acute HIV Diagnosis After Initiation of Pre-exposure Prophylaxis in a Young Adult Patient: A Case Report

Oral pre-exposure prophylaxis (PrEP) in the prevention of human immunodeficiency virus (HIV) infection is highly effective, yet the majority of sexually active adolescents and young adults (AYAs) at highest risk for HIV infection, particularly AYA males who have sex with males, have not been prescribed this medication. Provider hesitancy in prescribing PrEP to at-risk AYA patients is often associated with concerns about patient nonadherence and its effect on inducing HIV medication resistance. This case report has two aims. First, to outline the clinical course for an AYA patient prescribed PrEP for 3 months and then found to have HIV with an M184V resistance mutation and subsequently started on HIV treatment. And second, to illustrate how the benefits of PrEP initiation outweigh its risks by presenting clinical data on resistance patterns to PrEP medications. The patient eventually achieved viral suppression within 5 months of starting HIV treatment which has been sustained up to 2 years. This case illustrates that M184V resistance mutations, although rarely associated with PrEP, are unlikely to impact options for HIV treatment. Providers should recommend and prescribe oral PrEP to AYA patients at risk for HIV infection without concern for nonadherence leading to HIV medication resistance.

Client Perspectives on the Development of a Rapid PrEP Initiative at a Sexual Health Center in New Orleans, Louisiana

Uptake of PrEP remains suboptimal, especially in the Southern United States. Same-day or "Rapid PrEP Initiatives" (RPIs) in sexual health centers (SHCs) could facilitate access and overcome barriers to PrEP. We studied the adaptation of an RPI from Denver, Colorado to an SHC in New Orleans, Louisiana. Through focus group discussions (FGDs) with local SHC staff and PrEP providers, we developed a preliminary RPI model. In 5 FGDs with SHC clients referred for or taking PrEP, we gathered adaptation recommendations and feedback on model acceptability, feasibility, and utility. Providers and clients voiced unanimous support for the RPI. Clients favored the ease of same-day PrEP initiation and emphasized a desire for navigational support, financial counseling, and integration of PrEP care with their other clinical needs. Clients recommended that SHC providers discuss PrEP and HIV with all patients, regardless of providers' perception of risk. Next steps include small-scale implementation and evaluation.

Same-Day Initiation of Oral Pre-Exposure Prophylaxis is High Among Adolescent Men Who Have Sex With Men and Transgender Women in Brazil

PURPOSE

This study analyzed the sociodemographic and behavioral characteristics of adolescent men who have sex with men (aMSM) and transgender women (aTGW) initiating oral pre-exposure prophylaxis (PrEP) in human immunodeficiency virus (HIV) prevention clinics.

METHODS

PrEP1519 is a prospective, multicenter, open-label PrEP demonstration cohort study of aMSM and aTGW aged 15-19 years living in three large Brazilian capital cities. For this analysis, we included adolescents who enrolled in PrEP1519 from February 2019 to August 2021. Adolescents who visited PrEP clinics were classified into four groups based on PrEP eligibility and on their decision to use PrEP: (1) ineligible for same-day PrEP initiation; (2) eligible for same-day PrEP initiation, initiated PrEP at first visit; (3) eligible for PrEP initiation, initiated PrEP after the first visit; and (4) eligible for same-day PrEP initiation but declined. The groups that were eligible for same-day PrEP initiation were compared using the Chi-square and Fisher's exact tests.

RESULTS

Of the 1,254 adolescents enrolled in the PrEP1519 study, 61 (4.9%) were considered ineligible for same-day PrEP initiation. Of the 1,193 eligible for same-day PrEP initiation, 1,113 (93.3%) initiated PrEP [1,054 initiated PrEP in the first visit (88.3%) and 59 in subsequent visits (4.9%)] and 80 (6.7%) did not. Despite 90% of the PrEP decliners reporting a low risk of HIV infection, most reported condomless anal sex in the past six months (70%).

DISCUSSION

Same-day PrEP initiation among aMSM and aTGW was high, highlighting that this strategy was important to promote PrEP initiation among adolescents with increased vulnerability to HIV in Brazil.

Evaluating the impact of point-of-care HIV viral load assessment on linkage to care in Baltimore, MD: a randomized controlled trial

BACKGROUND

Integration of a sensitive point-of-care (POC) HIV viral load (VL) test into screening algorithms may help detect acute HIV infection earlier, identify people with HIV (PWH) who are not virally suppressed, and facilitate earlier referral to antiretroviral therapy (ART), or evaluation for pre-exposure prophylaxis (PrEP). This report describes a randomized clinical trial sponsored by the Centers for Disease Control and Prevention (CDC): "Ending the HIV Epidemic Through Point-of-Care Technologies" (EHPOC). The study's primary aim is to evaluate the use of a POC HIV VL test as part of a testing approach and assess the impact on time to linkage to ART or PrEP. The study will recruit people in Baltimore, Maryland, including patients attending a hospital emergency department, patients attending an infectious disease clinic, and people recruited via community outreach. The secondary aim is to evaluate the performance characteristics of two rapid HIV antibody tests approved by the United States Food and Drug Administration (FDA).

METHODS

The study will recruit people 18 years or older who have risk factors for HIV acquisition and are not on PrEP, or PWH who are not taking ART. Participants will be randomly assigned to either the control arm or the intervention arm. Participants randomized to the control arm will only receive the standard-of-care (SOC) HIV screening tests. Intervention arm participants will receive a POC HIV VL test in addition to the SOC HIV diagnostic screening tests. Follow up will consist of an interim phone survey conducted at week-4 and an in-person week-12 visit. Demographic and behavioral information, and oral fluid and blood specimens will be collected at enrollment and at week-12. Survey data will be captured in a Research Electronic Data Capture (REDCap) database. Participants in both arms will be referred for either ART or PrEP based on their HIV test results.

DISCUSSION

The EHPOC trial will explore a novel HIV diagnostic technology that can be performed at the POC and provide viral assessment. The study may help inform HIV testing algorithms and contribute to the evidence to support same day ART and PrEP recommendations.

TRIAL REGISTRATION

NIH ClinicalTrials.gov NCT04793750. Date: 11 March 2021.

Barriers and Facilitators to Pre-Exposure Prophylaxis by Men Who Have Sex with Men and Community Stakeholders in Malaysia

BACKGROUND

Men who have sex with men (MSM) in Malaysia are disproportionately affected by HIV. Pre-exposure prophylaxis (PrEP) is an evidence-based HIV prevention strategy; yet, uptake remains low among Malaysian MSM, who have a limited understanding of barriers to PrEP.

METHODS

We employed the nominal group technique (NGT), a structured mixed-methods strategy to understand the barriers and facilitators to PrEP use among Malaysian MSM, combined with a qualitative focus group. Six virtual focus group sessions, three among MSM (n = 20) and three among stakeholders (n = 16), were conducted using a video-conferencing platform. Rank-ordering of barriers from NGT was recorded, and thematic analysis was conducted for content.

RESULTS

Similar barriers were reported by MSM and community stakeholders, with aggregated costs associated with PrEP care (e.g., consultation with a clinician, medication, laboratory testing) being the greatest barrier, followed by limited knowledge and awareness of PrEP. Additionally, the lack of access to PrEP providers, the complex clinical protocol for PrEP initiation and follow-up, and social stigma undermined PrEP delivery. Qualitative discussions identified potential new strategies to overcome these barriers, including expanded outreach efforts to reach hard-to-reach MSM, a 'one-stop' delivery model for PrEP services, a patient-centered decision aid to guide PrEP uptake, and easy access to LGBT-friendly PrEP providers.

CONCLUSION

Current barriers may be overcome through governmental subsidy for PrEP and evidence-informed shared decision aids to support both MSM and PrEP providers.

Brief Report: Refusal of Daily Oral PrEP: Implementation Considerations and Reported Likelihood of Using Various HIV Prophylaxis Products in a Diverse Sample of MSM

BACKGROUND

An important subgroup of gay, bisexual, and other men who have sex with men (MSM) with behavioral indications refuse daily oral pre-exposure prophylaxis (PrEP) when recommended by a provider. Emerging HIV prophylaxis products (eg, injectable, event-driven) offer more options to MSM who refuse daily PrEP. In this article, we assess reasons for refusal and likelihood to use various products among MSM who refused PrEP.

METHODS

MSM who reported anal sex without condoms or PrEP and refused daily oral PrEP in the past 6 months were recruited through clinics, community venues, and online in Atlanta, Chicago, and Raleigh-Durham. Men were asked their main reason for recently refusing daily PrEP and likelihood of using various PrEP options in the future. Bivariate and multivariable regression models were used to estimate associations.

RESULTS

MSM (n = 93; 70% Black, 48% age 18-29 years) reported their main reason for refusing daily PrEP were potential side effects (35%), a daily pill regimen (22%), and not having enough information (18%). Reported likelihood of using PrEP products was 58% for penile gel, 54% for event-driven oral, 52% for injectable, and 50% for daily PrEP. MSM who reported daily regimen as the main reason for refusing PrEP had greater odds of likelihood to use an injectable [adjusted odds ratio (AOR) = 5.21, 95% confidence interval (CI): 1.32 to 20.52]. Younger men (18-29 vs 30+ years) had greater odds of likelihood to use condoms (AOR = 3.40, 95% CI: 1.15 to 10.04) and daily PrEP (AOR = 2.76, 95% CI: 1.06 to 7.16); there were no product preference differences by race.

CONCLUSION

Most men who refused daily PrEP indicated likelihood of using some form of PrEP in the future.

Pre-exposure prophylaxis in the era of emerging methods for men who have sex with men in the USA: the HIV Prevention Cycle of Care model

Expanding on previous work, we present an HIV Prevention Cycle of Care model to facilitate understanding of the complexity of issues involved in pre-exposure prophylaxis implementation for gay, bisexual, and other men who have sex with men (MSM) in the USA, including individual, client-provider, and overarching issues such as health equity, stigma, and prevention nomenclature. The HIV prevention cycle of care applies to MSM who test negative for HIV. The Prevention Cycle of Care model includes seven steps: prevention knowledge, prevention self-awareness and preferences, prevention motivation, health-care access and cost, provider issues, adherence and persistence, and periodic reassessment and adjustment. HIV prevention is complex in an era of emerging multiple modalities, and more research is needed to successfully implement pre-exposure prophylaxis options over time and across diverse communities of MSM who are sexually active.

Same-day initiation of oral pre-exposure prophylaxis among gay, bisexual, and other cisgender men who have sex with men and transgender women in Brazil, Mexico, and Peru (ImPrEP): a prospective, single-arm, open-label, multicentre implementation study

BACKGROUND

Although gay, bisexual, and other cisgender men who have sex with men (MSM) and transgender women have the highest HIV burden in Latin America, pre-exposure prophylaxis (PrEP) implementation is poor. We aimed to assess the feasibility of same-day oral PrEP delivery in Brazil, Mexico, and Peru.

METHODS

Implementation PrEP (ImPrEP) was a prospective, single-arm, open-label, multicentre PrEP implementation study conducted in Brazil (14 sites), Mexico (four sites), and Peru (ten sites). MSM and transgender women were eligible to participate if they were aged 18 years or older, HIV-negative, and reported one or more prespecified criteria. Enrolled participants received same-day initiation of daily oral PrEP (tenofovir disoproxil fumarate [300 mg] coformulated with emtricitabine [200 mg]). Follow-up visits were scheduled at week 4 and quarterly thereafter. We used logistic regression models to identify factors associated with early loss to follow-up (not returning after enrolment), PrEP adherence (medication possession ratio ≥0·6), and long-term PrEP engagement (attending three or more visits within 52 weeks). This study is registered at the Brazilian Registry of Clinical Trials, U1111-1217-6021.

FINDINGS

From Feb 6, 2018, to June 30, 2021, 9979 participants were screened and 9509 were enrolled (Brazil n=3928, Mexico n=3288, and Peru n=2293). 543 (5·7%) participants were transgender women, 8966 (94·3%) were cisgender men, and 2481 (26·1%) were aged 18-24 years. There were 12 185·25 person-years of follow-up. 795 (8·4%) of 9509 participants had early loss to follow-up, 6477 (68·1%) of 9509 were adherent to PrEP, and 5783 (70·3%) of 8225 had long-term PrEP engagement. Transgender women (adjusted odds ratio 1·60, 95% CI 1·20-2·14), participants aged 18-24 years (1·80, 1·49-2·18), and participants with primary education (2·18, 1·29-3·68) had increased odds of early loss to follow-up. Transgender women (0·56, 0·46-0·70), participants aged 18-24 years (0·52, 0·46-0·58), and those with primary education (0·60, 0·40-0·91) had lower odds of PrEP adherence. Transgender women (0·56, 0·45-0·71), participants aged 18-24 years (0·56, 0·49-0·64), and those with secondary education (0·74, 0·68-0·86) had lower odds of long-term PrEP engagement. HIV incidence was 0·85 per 100 person-years (95% CI 0·70-1·03) and was higher for transgender women, participants from Peru, those aged 18-24 years, Black and mixed-race participants, and participants who were non-adherent to PrEP.

INTERPRETATION

Same-day oral PrEP is feasible for MSM and transgender women in Latin America. Social and structural determinants of HIV vulnerability need to be addressed to fully achieve the benefits of PrEP.

FUNDING

Unitaid, WHO, and Ministries of Health in Brazil, Mexico, and Peru.

TRANSLATIONS

For the Portuguese and Spanish translations of the abstract see Supplementary Materials section.

Drug use typology, demographic covariates, and associations with condomless anal sex: A latent class analysis among a U.S. national cohort of men who have sex with men

BACKGROUND

Prior research has shown that men who have sex with men (MSM) who use drugs are at increased risk of sexually transmitted infections (STI) and Human Immunodeficiency Virus (HIV). Often, MSM who use drugs use multiple substances at once and research has indicated that certain substances are used in combination more frequently. As a vulnerable population, it is important to understand the various ways in which this population uses drugs in order to structure prevention, harm reduction, and treatment programs to their needs.

METHODS

Data for this analysis were taken from a cohort of geographically diverse U.S. national sample of cisgender men who have sex with men (n = 6111). After assessing prevalence of drug use in the sample, we used iterative latent class analysis to determine substance use classes for 10 substances. After a model was selected, class assignments were examined for association with mean number of insertive and receptive condomless anal sex (CAS) partners in the past three months.

RESULTS

The final model indicated six latent classes: class 1 = "cannabis use" (n = 1,996), class 2 = "diverse use" (n = 299), class 3 = "cocaine and inhalant use" (n = 421), class 4 = "methamphetamine, GHB, and inhalant use" (n = 345), class 5 = "no use" (n = 2431), class 6 = "sedative use" (n = 619). Age, race, annual income, residence in EHE jurisdictions, past history of houselessness, and past history of incarceration was significantly associated with membership in some classes. In outcome modeling, participants best assigned to Class 4 had the highest mean number of insertive (Mean = 9.70, 95% CI: 5.92 - 13.47) and receptive (Mean = 8.71, 95% CI: 6.75 - 10.66) condomless anal sex (CAS) partners in the prior three months.

CONCLUSION

The six heterogenous classes may indicate discrete typologies of use behavior corresponding to different settings or activities, which may themselves differ by regional HIV incidence trends and participant demographics. Programs seeking to address substance use among MSM may be well served to tailor toward these divergent clusters of substance use.

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.

Factors associated with long-term HIV pre-exposure prophylaxis engagement and adherence among transgender women in Brazil, Mexico and Peru: results from the ImPrEP study

Introduction

The HIV epidemic continues to disproportionately impact Latin‐American transgender women (TGW). We assessed factors associated with long‐term pre‐exposure prophylaxis (PrEP) engagement and adherence among TGW enrolled in the Implementation of PrEP (ImPrEP) study, the largest PrEP demonstration study in Latin America.

Methods

HIV‐negative TGW aged ≥18 years reporting 1+eligibility criteria in the 6 months prior to enrolment (e.g. sex partner known to be living with HIV, condomless anal sex [CAS], transactional sex or having a sexually transmitted infection [STI]) who could safely take PrEP were enrolled. Follow‐up visits were conducted at 4 weeks and then quarterly. We conducted logistic regression to identify factors associated with long‐term PrEP engagement (3+ follow‐up visits in 52 weeks) and complete self‐reported adherence (no missed pills in the past 30 days) during follow‐up. For both outcomes, we constructed multivariable models controlling for country, socio‐demographics, sexual behaviour, substance use, STIs and self‐reported adherence at 4 weeks (long‐term engagement outcome only).

Results

From March 2018 to June 2021, ImPrEP screened 519 TGW, enrolled 494 (Brazil: 190, Mexico: 66 and Peru: 238) and followed them for 52 weeks. At baseline, 27.5% of TGW were aged 18–24 years, 67.8% were mixed‐race and 31.6% had >secondary education. Most, 89.9% reported CAS, 61.9% had >10 sex partners and 71.9% reported transactional sex. HIV incidence was 1.82 cases per 100 person‐years (95% confidence interval [CI]: 0.76–4.38). Almost half of TGW (48.6%) had long‐term PrEP engagement, which was positively associated with reporting complete adherence at week 4 (aOR:2.94 [95%CI:1.88–4.63]) and was inversely associated with reporting CAS with unknown‐HIV partner (aOR:0.52 [95%CI:0.34–0.81]), migration (aOR:0.54 [95%CI:0.34–0.84]), and being from Mexico (aOR:0.28 [95%CI:0.14–0.53]). Self‐reported adherence was associated with TGW aged >34 (aOR:1.61 [95%CI:1.10–2.34]) compared to those aged 25–34 and those with >secondary education (aOR:1.55 [95%CI:1.10–2.19]) and was lower among TGW from Peru (aOR:0.29 [95%CI:0.21–0.41]) or reporting PrEP‐related adverse effects (aOR:0.63 [95%CI:0.42–0.92]).

Conclusions

Although TGW were willing to enrol in ImPrEP, long‐term PrEP engagement and complete self‐reported adherence were limited, and HIV incidence remained relatively high. A successful HIV prevention agenda should include trans‐specific interventions supporting oral PrEP and exploring long‐acting PrEP strategies for TGW.

Nurse Practitioner-Led Integrated Rapid Access to HIV Prevention for People Who Inject Drugs (iRaPID): Protocol for a Pilot Randomized Controlled Trial

BACKGROUND

The ongoing volatile opioid epidemic remains a significant public health concern, alongside continued outbreaks of HIV and hepatitis C virus among people who inject drugs. The limited access to and scale-up of medications for opioid use disorder (MOUD) among people who inject drugs, coupled with multilevel barriers to pre-exposure prophylaxis (PrEP) uptake, makes it imperative to integrate evidence-based risk reduction and HIV prevention strategies in innovative ways. To address this need, we developed an integrated rapid access to HIV prevention program for people who inject drugs (iRaPID) that incorporates same-day PrEP and MOUD for this population.

OBJECTIVE

The primary objective of this pilot study is to assess the feasibility and acceptability of the program and evaluate its preliminary efficacy on PrEP and MOUD uptake for a future randomized controlled trial (RCT). We also aim to explore information on the implementation of the program in a real-world setting using a type I hybrid implementation trial design.

METHODS

Using a type I hybrid implementation trial design, we are pilot testing the nurse practitioner-led iRaPID program while exploring information on its implementation in a real-world setting. Specifically, we will assess the feasibility and acceptability of the iRaPID program and evaluate its preliminary efficacy on PrEP and MOUD uptake in a pilot RCT. The enrolled 50 people who inject drugs will be randomized (1:1) to either iRaPID or treatment as usual (TAU). Behavioral assessments will occur at baseline, and at 1, 3, and 6 months. Additionally, we will conduct a process evaluation of the delivery and implementation of the iRaPID program to collect information for future implementation.

RESULTS

Recruitment began in July 2021 and was completed in August 2022. Data collection is planned through February 2023. The Institutional Review Boards at Yale University and the University of Connecticut approved this study (2000028740).

CONCLUSIONS

This prospective pilot study will test a nurse practitioner-led, integrated HIV prevention program that incorporates same-day PrEP and MOUD for people who inject drugs. This low-threshold protocol delivers integrated prevention via one-stop shopping under the direction of nurse practitioners. iRaPID seeks to overcome barriers to delayed PrEP and MOUD initiation, which is crucial for people who inject drugs who have had minimal access to evidence-based prevention.

TRIAL REGISTRATION

ClinicalTrials.gov NCT04531670; https://clinicaltrials.gov/ct2/show/NCT04531670.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

DERR1-10.2196/42585.

Clinical Considerations in the Selection of Preexposure Prophylaxis for HIV Prevention in Canada

According to the Public Health Agency of Canada, approximately 62,050 people were living with HIV in Canada in 2018, and of those, 13% were undiagnosed. Currently, no single strategy provides complete protection or is universally effective across all demographic groups at risk for HIV. However, HIV preexposure prophylaxis (PrEP) is the newest HIV prevention strategy that shows promise. To date, two products have received an indication for PrEP by Health Canada: emtricitabine/tenofovir disoproxil fumarate (Truvada®; FTC/TDF) and emtricitabine/tenofovir alafenamide (Descovy®; FTC/TAF). Despite the high efficacy of these PrEP intervention methods, access to PrEP in Canada remains low. Identifying and addressing barriers to PrEP access, especially in high-risk groups, are necessary to reduce HIV transmission in Canada. While guidelines published by the Center for Disease Control and Prevention (CDC) include FTC/TAF information, the efficacy of FTC/TAF for PrEP has not yet been considered in Canada's clinical practice guidelines. Thus, the current paper reviews data regarding the use of FTC/TDF and FTC/TAF for PrEP, which may be useful for Canadian healthcare providers when counseling and implementing HIV prevention methods. The authors highlight these data in relation to various at-risk populations and review ongoing clinical trials investigating novel PrEP agents. Overall, FTC/TDF PrEP is effective for many populations, including men who have sex with men, transgender women, heterosexuals with partners living with HIV, and people who use drugs. While there is fewer data reported on the efficacy of FTC/TAF to date, recent clinical trials have demonstrated noninferiority of FTC/TAF in comparison to FTC/TDF. Notably, as studies have shown that FTC/TAF maintains renal function and bone mineral density to a greater extent than FTC/TDF, FTC/TAF may be a safer option for patients experiencing renal and/or bone dysfunction, for those at risk of renal and bone complications, and for those who develop FTC/TDF-related adverse events.

Acceptability and feasibility of leveraging community-based HIV counselling and testing platforms for same-day oral PrEP initiation among adolescent girls and young women in Eastern Cape, South Africa

INTRODUCTION

Community-based delivery of HIV pre-exposure prophylaxis (PrEP) to South African adolescent girls and young women's (AGYW) could increase access but needs evaluation. We integrated PrEP services via home-based services and pop-up tents into existing community-based HIV testing services (CB-HTS) in Eastern Cape Province, South Africa.

METHODS

After accessing CB-HTS via a "pop-up" tent or home-based services, HIV-negative AGYW aged 16-25 years were invited to complete a baseline questionnaire and referred for PrEP services at a community-based PrEP site co-located with pop-up HTS tents. A 30-day supply of PrEP was dispensed. PrEP uptake, time-to-initiation, cohort characteristics and first medication refill within 90 days were measured using descriptive statistics.

RESULTS

Of the 1164 AGYW who tested for HIV, 825 (74.3%) completed a questionnaire and 806 (97.7%) were referred for community-based PrEP. Of those, 624 (77.4%) presented for PrEP (482/483 [99.8%] from pop-up HTS and 142/323 [44.0%] from home-based HTS), of which 603 (96.6%) initiated PrEP. Of those initiating PrEP following home-based HTS, 59.1% initiated within 0-3 days, 25.6% within 4-14 days and 15.3% took ≥15 days to initiate; 100% of AGYW who used pop-up HTS initiated PrEP the same day. Among AGWY initiating PrEP, 37.5% had a detectable sexually transmitted infection (STI). Although AGYW reported a low self-perception of HIV risk, post-hoc application of HIV risk assessment measures to available data classified most study participants as high risk for HIV acquisition. Cumulatively, 329 (54.6%) AGYW presented for a first medication refill within 90 days of accepting their first bottle of PrEP.

CONCLUSIONS

Leveraging CB-HTS platforms to provide same-day PrEP initiation and refill services was acceptable to AGYW. A higher proportion of AGYW initiated PrEP when co-located with CB-HTS sites compared to those referred following home-based HTS, suggesting that proximity of CB-HTS and PrEP services facilitates PrEP uptake among AGYW. The high prevalence of STIs among those initiating PrEP necessitates the integration of STI and HIV prevention programs for AGYW. Eligibility for PrEP initiation should not be required among AHYW in high HIV burden communities. Community-based service delivery will be crucial to maintaining access to PrEP services during the COVID-19 pandemic and future health and humanitarian emergencies.

HIV Pre-Exposure Prophylaxis: What Do Pediatricians Need to Know?

Pediatricians and adolescent providers play an important role in the health and well-being of adolescents and young adults, including their sexual health. HIV remains an ongoing concern for young people, with 21% of new HIV diagnoses occurring in this age group. The use of antiretroviral therapy for pre-exposure prophylaxis (PrEP) to prevent transmission of HIV to people who are not infected has been proven safe and effective. PrEP can be considered as part of a comprehensive risk mitigation strategy for adolescents and young adults, with clear guidelines for baseline evaluation and ongoing management. [Pediatr Ann. 2022;51(5):e191-e195.].

PrEP Care Continuum Engagement Among Persons Who Inject Drugs: Rural and Urban Differences in Stigma and Social Infrastructure

Pre-exposure prophylaxis (PrEP) is a medication that prevents HIV acquisition, yet PrEP uptake has been low among people who inject drugs. Stigma has been identified as a fundamental driver of population health and may be a significant barrier to PrEP care engagement among PWID. However, there has been limited research on how stigma operates in rural and urban settings in relation to PrEP. Using in-depth semi-structured qualitative interviews (n = 57) we explore PrEP continuum engagement among people actively injecting drugs in rural and urban settings. Urban participants had more awareness and knowledge. Willingness to use PrEP was similar in both settings. However, no participant was currently using PrEP. Stigmas against drug use, HIV, and sexualities were identified as barriers to PrEP uptake, particularly in the rural setting. Syringe service programs in the urban setting were highlighted as a welcoming space where PWID could socialize and therefore mitigate stigma and foster information sharing.

Abandonment of HIV preexposure prophylaxis prescriptions at retail pharmacies-United States, 2019

We analyzed a national pharmacy database to estimate the annual number of persons who abandoned their PrEP prescription and assessed the associated factors. About 9% of persons prescribed PrEP abandoned it in 2019, and PrEP abandonment was associated with sex, age, insurance type, black race/ethnicity, and drug copayment amount.

Considerations for the Design of Pre-exposure Prophylaxis (PrEP) Interventions for Women: Lessons Learned from the Implementation of a Novel PrEP Intervention

Pre-exposure prophylaxis (PrEP) uptake among women in the United States has been low. To increase uptake, we developed a peer outreach and navigation PrEP intervention. Semi-structured qualitative interviews with 32 cisgender women and 3 transgender women were conducted to assess the intervention. We used a thematic approach to identify barriers to, and facilitators of the intervention. Facilitators included interest in PrEP, offer of health and social services, the intervention's women-focused approach, and peer outreach and navigation. Barriers were perceived HIV risk, concerns about medication side effects or interactions, housing insecurity and travel, co-occurring health-related conditions, and caregiving responsibilities. We recommend that future interventions consider packaging PrEP in local community settings, such as syringe exchange programs; include services such as food and housing assistance; use peers to recruit and educate women; integrate a culturally appropriate women's focus; and consider providing same-day PrEP.

Evaluation of an HIV Pre-Exposure Prophylaxis Referral System: From Sexual Health Center to Federally Qualified Health Center Pre-Exposure Prophylaxis Clinic

Innovative delivery strategies are needed to facilitate access to HIV pre-exposure prophylaxis (PrEP). The objective of this study was to evaluate a navigator-facilitated PrEP referral process from a sexual health center (SHC) to a co-located PrEP clinic as an alternative delivery model. Electronic health record (EHR) data were used to calculate the number of clients seen at the SHC in 2019. Charts were manually reviewed to determine whether a PrEP clinic referral was made and document type of referral method: face-to-face appointment scheduling with the navigator (warm handoff), EHR messaging to navigator to schedule the appointment at a later time (EHR message), or provision of navigator's contact information to the client (card only). In 2019, 2481 unique potentially PrEP-eligible clients were seen at the SHC; 220 (9%) received a PrEP referral. Of referred clients, median age was 30 years (interquartile range, 24-34), 182 (83%) were male, 89 (40%) were non-Hispanic Black, and 24 (11%) were Latinx. In total, 94/220 (43%) referred clients attended an initial PrEP visit with a provider, and the proportion attending by referral method was 81%, 36%, and 27% for warm handoff, EHR message, and card only, respectively (p < 0.0001). Despite co-location of these two clinics, there were significant drop-offs along the PrEP care continuum for this referral system. Warm handoff was the most effective referral method, but further efforts are needed to understand barriers to referral. Implementation of same-day PrEP services at SHCs is one potential solution to engaging additional clients.

Evidence of HIV pre-exposure or post-exposure prophylaxis (PrEP/PEP) among blood donors: a pilot study, England June 2018 to July 2019

Objective

Due to increased use of pre-exposure prohylaxis (PrEP) and its potential to affect HIV screening of blood donors, we undertook antiretroviral residual testing among HIV-negative male donors in England.

Methods

Residual plasma samples were obtainnd from 46 male donors confirmed positive for syphilis and 96 donors who were repeat reactive for HIV antibodies in screening but confirmed as HIV-negative by reference testing. These were tested for concentrations of tenofovir and emtricitabine by high-performance liquid chromatograhpy coupled with mass spectrometry.

Results

We found evidence of pre-exposure or post-exposure prophylaxis (PrEP/PEP) use in three male blood donors confirmed positive for syphilis (3 out of 46 screened, 6.5%). Two were estimated to have taken PrEP/PEP within a day of donating, and the third within 2 days. Two were new donors, whereas one had donated previously but acquired syphilis infection after his last donation.

Conclusions

Our findings indicate that a small proportion of blood donors have not been disclosing PrEP/PEP use and therefore donating in non-compliance to donor eligibility criteria.