1
|
Ngure K, Browne EN, Reddy K, Friedland BA, van der Straten A, Palanee-Phillips T, Nakalega R, Gati B, Kalule HN, Siziba B, Soto-Torres L, Nair G, Garcia M, Celum C, Roberts ST. Correlates of Adherence to Oral and Vaginal Pre-exposure Prophylaxis (PrEP) Among Adolescent Girls and Young Women (AGYW) Participating in the MTN-034/REACH Trial. AIDS Behav 2024:10.1007/s10461-024-04382-3. [PMID: 38852114 DOI: 10.1007/s10461-024-04382-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/15/2024] [Indexed: 06/10/2024]
Abstract
We evaluated correlates of adherence to PrEP, including daily oral tenofovir disoproxil fumarate in combination emtricitabine (oral FTC/TDF) and the monthly dapivirine ring (ring)among adolescent girls and young women (AGYW) in the MTN-034/REACH study. We enrolled 247 AGYW aged 16-21 years in South Africa, Uganda and Zimbabwe (ClinicalTrials.gov: NCT03074786). Participants were randomized to the order of oral FTC/TDF or ring use for 6 months each in a crossover period, followed by a 6-month choice period. We assessed potential adherence correlates-individual, interpersonal, community, study, and product-related factors-quarterly via self-report. We measured biomarkers of adherence monthly; high adherence was defined as > 4 mg dapivirine released from returned rings or intracellular tenofovir diphosphate levels ≥ 700 fmol/punch from dried blood spots (DBS). We tested associations between correlates and objective measures of high adherence using generalized estimating equations. High adherence to oral FTC/TDF was significantly associated with having an older primary partner (p = 0.04), not having exchanged sex in the past 3 months (p = 0.02), and rating oral FTC/TDF as highly acceptable (p = 0.003). High ring adherence was significantly associated with unstable housing (p = 0.01), disclosing ring use to a male family member (p = 0.01), and noting a social benefit from study participation (p = 0.03). All associations were moderate, corresponding to about 6%-10% difference in the proportion with high adherence. In our multinational study, correlates of adherence among African AGYW differed for oral FTC/TDF and the ring, highlighting the benefit of offering multiple PrEP options.
Collapse
Affiliation(s)
- Kenneth Ngure
- School of Public Health, Jomo Kenyatta University of Agriculture and Technology, Box 19704-00202, Nairobi, Kenya.
- Department of Global Health, University of Washington, Seattle, USA.
| | - Erica N Browne
- Women's Global Health Imperative (WGHI), RTI International, Berkeley, CA, USA
| | - Krishnaveni Reddy
- Wits RHI, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | | | - Ariane van der Straten
- Department of Medicine, Center for AIDS Prevention Studies, University of California, San Francisco, USA
- ASTRA Consulting, Kensington, CA, USA
| | - Thesla Palanee-Phillips
- Wits RHI, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Rita Nakalega
- Makerere University - Johns Hopkins University Research Collaboration, Kampala, Uganda
| | - Brenda Gati
- Makerere University - Johns Hopkins University Research Collaboration, Kampala, Uganda
| | - Hadijah N Kalule
- Makerere University - Johns Hopkins University Research Collaboration, Kampala, Uganda
| | - Bekezela Siziba
- University of Zimbabwe Clinical Trials Research Centre, Harare, Zimbabwe
| | - Lydia Soto-Torres
- National Institute of Allergy and Infectious Diseases, National Institutes of Health, Rockville, MD, USA
| | | | | | - Connie Celum
- Department of Global Health, University of Washington, Seattle, USA
- Department of Medicine, University of Washington, Seattle, WA, USA
- Department of Epidemiology, University of Washington, Seattle, WA, USA
| | - Sarah T Roberts
- Women's Global Health Imperative (WGHI), RTI International, Berkeley, CA, USA
| |
Collapse
|
2
|
Milford C, Ramlal H, Mofokeng R, Rambally Greener L, Nel A, Smit J, Malherbe M. Self-reported removal and expulsion of the dapivirine vaginal ring: qualitative reports from female ring users and their male partners in the Ring Study (IPM 027). BMC Public Health 2024; 24:1458. [PMID: 38822304 PMCID: PMC11140940 DOI: 10.1186/s12889-024-18795-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2023] [Accepted: 05/08/2024] [Indexed: 06/02/2024] Open
Abstract
BACKGROUND/AIMS The dapivirine vaginal ring is a self-administered, women-initiated, discreet, long-acting HIV-1 prevention option for women. It was found to be safe and effective in healthy HIV-negative women who adhered to product use instructions, and has been approved for use in women aged 18 and older in some African countries. A qualitative study was conducted to explore participants' and their male partners' discussions on accidental/purposeful vaginal ring removals during The Ring Study (IPM 027 clinical trial). METHODS Data were collected via in-depth interviews and focus group discussions with female trial participants and their male partners, from seven research centres in South Africa and Uganda. Data were thematically analysed using NVivo. RESULTS More participants reported purposeful ring removals than accidental expulsions. Various factors influenced purposeful ring removal - including individual (discomfort during use/sex and to clean it), partner (to show them, because of discomfort during sex, to test if partners could feel it, and concerns of harm), organisational (doctor's request), and socio-cultural (rumours about sickness and infertility). Some described their own ring use removal, others discussed why other participants removed their rings. CONCLUSIONS Vaginal ring adherence is critical to improve and support product efficacy. Counselling on vaginal anatomy, vaginal ring insertion and importance of adherence is important to minimise vaginal ring removal. Couples counselling is also important to facilitate support and long-term vaginal ring adherence behaviour. Understanding factors influencing vaginal ring adherence is important for tailoring and targeting messages to support correct and consistent vaginal ring use as it is made available to the public.
Collapse
Affiliation(s)
- Cecilia Milford
- Wits MRU (MatCH Research Unit), Department of Obstetrics and Gynaecology, Faculty of Health Sciences, University of the Witwatersrand, Commercial City Building, 40 Dr AB Xuma Street, Durban, 4001, South Africa.
- CAPRISA (Centre for the AIDS Programme of Research in South Africa), University of KwaZulu-Natal, Durban, South Africa.
| | - Hariska Ramlal
- Wits MRU (MatCH Research Unit), Department of Obstetrics and Gynaecology, Faculty of Health Sciences, University of the Witwatersrand, Commercial City Building, 40 Dr AB Xuma Street, Durban, 4001, South Africa
| | - Rorisang Mofokeng
- Wits MRU (MatCH Research Unit), Department of Obstetrics and Gynaecology, Faculty of Health Sciences, University of the Witwatersrand, Commercial City Building, 40 Dr AB Xuma Street, Durban, 4001, South Africa
| | - Letitia Rambally Greener
- Wits MRU (MatCH Research Unit), Department of Obstetrics and Gynaecology, Faculty of Health Sciences, University of the Witwatersrand, Commercial City Building, 40 Dr AB Xuma Street, Durban, 4001, South Africa
| | - Annaléne Nel
- IPM South Africa NPC, an affiliate of The Population Council, Inc., New York, NY, USA
| | - Jennifer Smit
- Wits MRU (MatCH Research Unit), Department of Obstetrics and Gynaecology, Faculty of Health Sciences, University of the Witwatersrand, Commercial City Building, 40 Dr AB Xuma Street, Durban, 4001, South Africa
| | - Mariëtte Malherbe
- IPM South Africa NPC, an affiliate of The Population Council, Inc., New York, NY, USA
| |
Collapse
|
3
|
Heck CJ, Dam A, Yohannes K, Deacon J, Kripke K, Meyers K, Poku O, Obermeyer C, Wiant S, Quigee D, Larson M, Malati C, Sobieszczyk ME, Torres-Rueda S, Castor D. Lessons learnt from daily oral PrEP delivery to inform national planning for PrEP ring introduction for women in low-income and middle-income countries: a qualitative inquiry of international stakeholders. BMJ Glob Health 2024; 9:e014709. [PMID: 38770814 PMCID: PMC11085820 DOI: 10.1136/bmjgh-2023-014709] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2023] [Accepted: 04/16/2024] [Indexed: 05/22/2024] Open
Abstract
INTRODUCTION Some African countries plan to introduce and scale-up new long-acting pre-exposure prophylaxis methods (LA-PrEP), like the monthly dapivirine vaginal ring (PrEP ring) and injectable cabotegravir. National costed implementation plans, roadmaps for successful product implementation, are often overlooked. International stakeholders engaged in oral PrEP planning, introduction and scale-up are an information resource of lessons learned to advise LA-PrEP planning. We consulted such international stakeholders and synthesised oral PrEP lessons to inform the development of a costed rollout plan template for LA-PrEP. METHODS From selected global health organisations (five international nongovernmental, four donor, four university/research and two multilateral), we interviewed 27 representatives based in America, Europe, Asia and Africa about strategic content and approaches for LA-PrEP policy, programming and implementation. We conducted a thematic analysis of the interview data for implementation considerations. RESULTS From the consultations, we identified six implementation themes for LA-PrEP introduction and scale-up: (1) ethically increasing choice and avoiding coercion; (2) de-stigmatising PrEP by focusing on preference rather than risk-based eligibility; (3) integrating LA-PrEP into services that are more woman-oriented, couple-oriented and family-oriented, and providing private spaces for LA-PrEP delivery; (4) de-medicalising delivery of relatively safe products (eg, PrEP ring); (5) constructing multilevel, nuanced communication strategies to address measured and perceived product efficacy and effectiveness; and (6) devising product-agnostic, modular approaches to service delivery. Despite the widespread emphasis on integration, few stakeholders offered empirical examples of successful integration approaches and frameworks. CONCLUSIONS Lessons learnt from stakeholder participants suggest standardised and modular processes can improve efficiencies in LA-PrEP planning and implementation. Tiered communication strategies addressing product efficacy and effectiveness will improve clients' and providers' efficacy in making informed decisions. Integration is important for LA-PrEP delivery, but data on empirical integration approaches and frameworks is minimal: further research in this discipline is needed.
Collapse
Affiliation(s)
- Craig J Heck
- Columbia University Mailman School of Public Health, New York, New York, USA
- Columbia University Irving Medical Center, New York, New York, USA
| | - Anita Dam
- United States Agency for International Development, Washington, District of Columbia, USA
| | - Kibret Yohannes
- University of Virginia School of Medicine, Charlottesville, Virginia, USA
| | | | | | - Kathrine Meyers
- Columbia University Irving Medical Center, New York, New York, USA
| | - Ohemaa Poku
- New York State Psychiatric Institute, New York, New York, USA
| | | | - Sarah Wiant
- Columbia University Irving Medical Center, New York, New York, USA
| | - Daniela Quigee
- Columbia University Irving Medical Center, New York, New York, USA
| | | | - Christine Malati
- United States Agency for International Development, Washington, District of Columbia, USA
| | | | | | - Delivette Castor
- Columbia University Mailman School of Public Health, New York, New York, USA
- Columbia University Irving Medical Center, New York, New York, USA
| |
Collapse
|
4
|
Camfield C, Evans YN, Kumbhakar RG. HIV preexposure prophylaxis in adolescents and young adults: an update. Curr Opin Pediatr 2024:00008480-990000000-00178. [PMID: 38655797 DOI: 10.1097/mop.0000000000001357] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 04/26/2024]
Abstract
PURPOSE OF REVIEW This review provides an update of evidence for HIV preexposure prophylaxis (PrEP), including efficacy and safety of newly available medications. It discusses barriers to care that are unique to adolescents and young adults as well as interventions that may help increase uptake, adherence, and retention in care. RECENT FINDINGS Tenofovir alafenamide-emtricitabine and cabotegravir are both newly approved medications for the prevention of HIV and are well tolerated and effective for adolescents. These medications, along with tenofovir disoproxil-emtricitabine, offer a variety of PrEP options to choose from. SUMMARY Adolescents and young adults have many options when it comes to HIV prevention, but barriers persist in terms of uptake and adherence to PrEP and retention in care. Technology-based interventions, provider education, navigation support, and multiple access options are all tools to help increase PrEP use in young people.
Collapse
Affiliation(s)
- Caitlin Camfield
- Division of Adolescent Medicine, Department of Pediatrics, University of Washington & Seattle Children's Hospital
| | - Yolanda N Evans
- Division of Adolescent Medicine, Department of Pediatrics, University of Washington & Seattle Children's Hospital, Seattle, Washington, USA
| | - Raaka G Kumbhakar
- Division of Allergy and Infectious Diseases, Department of Medicine, University of Washington
| |
Collapse
|
5
|
Shi D, Ye T. Behavioral carry-over effect and power consideration in crossover trials. Biometrics 2024; 80:ujae023. [PMID: 38563531 PMCID: PMC10985791 DOI: 10.1093/biomtc/ujae023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2023] [Revised: 02/28/2024] [Accepted: 03/07/2024] [Indexed: 04/04/2024]
Abstract
A crossover trial is an efficient trial design when there is no carry-over effect. To reduce the impact of the biological carry-over effect, a washout period is often designed. However, the carry-over effect remains an outstanding concern when a washout period is unethical or cannot sufficiently diminish the impact of the carry-over effect. The latter can occur in comparative effectiveness research, where the carry-over effect is often non-biological but behavioral. In this paper, we investigate the crossover design under a potential outcomes framework with and without the carry-over effect. We find that when the carry-over effect exists and satisfies a sign condition, the basic estimator underestimates the treatment effect, which does not inflate the type I error of one-sided tests but negatively impacts the power. This leads to a power trade-off between the crossover design and the parallel-group design, and we derive the condition under which the crossover design does not lead to type I error inflation and is still more powerful than the parallel-group design. We also develop covariate adjustment methods for crossover trials. We evaluate the performance of cross-over design and covariate adjustment using data from the MTN-034/REACH study.
Collapse
Affiliation(s)
- Danni Shi
- Department of Biostatistics, University of Washington, Seattle, WA 98195, United States
| | - Ting Ye
- Department of Biostatistics, University of Washington, Seattle, WA 98195, United States
| |
Collapse
|
6
|
Wang Z. Novel diarylpyrimidine subtypes as HIV-1 nonnucleoside reverse transcriptase inhibitors with improved resistance profile. J Med Virol 2024; 96:e29553. [PMID: 38516803 DOI: 10.1002/jmv.29553] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2024] [Accepted: 03/06/2024] [Indexed: 03/23/2024]
Affiliation(s)
- Zhengqiang Wang
- Center for Drug Design, College of Pharmacy, University of Minnesota, Minneapolis, Minnesota, USA
| |
Collapse
|
7
|
Marrazzo J. Doxycycline Postexposure Prophylaxis for STIs in Women - Uncertain Benefit, Urgent Need. N Engl J Med 2023; 389:2389-2390. [PMID: 38118030 DOI: 10.1056/nejme2311948] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/22/2023]
|
8
|
Graybill LA, Chi BH. PrEParing for choice in a new era of HIV prevention. Lancet HIV 2023; 10:e757-e758. [PMID: 37898147 DOI: 10.1016/s2352-3018(23)00263-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2023] [Accepted: 10/11/2023] [Indexed: 10/30/2023]
Affiliation(s)
- Lauren A Graybill
- Department of Epidemiology, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Benjamin H Chi
- Department of Epidemiology, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA; Department of Obstetrics and Gynecology, School of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA.
| |
Collapse
|
9
|
Roberts ST, Mancuso N, Williams K, Nabunya HK, Mposula H, Mugocha C, Mvinjelwa P, Garcia M, Szydlo DW, Soto‐Torres L, Ngure K, Hosek S. How a menu of adherence support strategies facilitated high adherence to HIV prevention products among adolescent girls and young women in sub-Saharan Africa: a mixed methods analysis. J Int AIDS Soc 2023; 26:e26189. [PMID: 37936551 PMCID: PMC10630658 DOI: 10.1002/jia2.26189] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2023] [Accepted: 10/18/2023] [Indexed: 11/09/2023] Open
Abstract
INTRODUCTION Effective use of pre-exposure prophylaxis (PrEP) has been low among adolescent girls and young women (AGYW) in sub-Saharan Africa. The MTN-034/REACH trial offered AGYW a menu of adherence support strategies and achieved high adherence to both daily oral PrEP and the monthly dapivirine vaginal ring. Understanding how these strategies promoted product use could inform the design of adherence support systems in programmatic settings. METHODS REACH was a randomized crossover trial evaluating the safety of and adherence to the ring and oral PrEP among 247 HIV-negative AGYW (ages 16-21) in South Africa, Uganda and Zimbabwe from January 2019 to September 2021 (NCT03593655). Adherence support included monthly counselling sessions with drug-level feedback (DLF) plus optional daily short message service (SMS) reminders, weekly phone or SMS check-ins, peer support clubs, "peer buddies" and additional counselling. Counsellors documented adherence support choices and counselling content on standardized forms. Through focus groups, serial in-depth interviews (IDIs) and single IDIs (n = 119 total), we explored participants' experiences with adherence support and how it encouraged product use. RESULTS Participants received counselling at nearly all visits. DLF was provided at 54.3% of sessions and, across sites, 49%-68% received results showing high adherence for oral PrEP, and 73%-89% for the ring. The most popular support strategies were in-person clubs and weekly calls, followed by online clubs, additional counselling and SMS. Preferences differed across sites but were similar for both products. Qualitative results demonstrated that the REACH strategies supported adherence by providing information about HIV and PrEP, continually motivating participants, and supporting the development of behavioural skills and self-efficacy, aligning with the Information, Motivation, and Behavioural Skills (IMB) model. Effectiveness was supported by three foundational pillars: strong interpersonal relationships with counsellors; ongoing, easily accessible support and resources; and establishing trust in the counsellors and study products through counsellor relationships, peer-to-peer exchange and DLF. CONCLUSIONS Implementation programmes could support effective PrEP use by offering a small menu of counsellor- and peer-based support options that are youth-friendly and developmentally appropriate. The same menu options can support both ring and oral PrEP users, though content should be tailored to the individual products.
Collapse
Affiliation(s)
- Sarah T. Roberts
- Women's Global Health Imperative, RTI InternationalBerkeleyCaliforniaUSA
| | - Noah Mancuso
- Women's Global Health Imperative, RTI InternationalAtlantaGeorgiaUSA
| | - Kristin Williams
- Applied Public Health Research CenterRTI InternationalResearch Triangle ParkNorth CarolinaUSA
| | | | - Hlengiwe Mposula
- Wits Reproductive Health and HIV InstituteJohannesburgSouth Africa
| | - Caroline Mugocha
- University of Zimbabwe Clinical Trials Research CentreHarareZimbabwe
| | | | | | - Daniel W. Szydlo
- Statistical Center for HIV/AIDS Research and PreventionFred Hutchinson Cancer CenterSeattleWashingtonUSA
| | - Lydia Soto‐Torres
- Division of AIDSNational Institute of Allergy and Infectious Diseases, National Institutes of HealthBethesdaMarylandUSA
| | - Kenneth Ngure
- School of Public HealthJomo Kenyatta University of Agriculture and TechnologyNairobiKenya
- Department of Global HealthUniversity of WashingtonSeattleWashingtonUSA
| | - Sybil Hosek
- Center for Dissemination and Implementation ScienceUniversity of Illinois ChicagoChicagoIllinoisUSA
| |
Collapse
|