Barriers and Facilitators to HIV Pre-Exposure Prophylaxis Uptake, Adherence, and Persistence Among Transgender Populations in the United States: A Systematic Review

Intentions to Use PrEP Among a National Sample of Transgender and Gender-Expansive Youth and Emerging Adults: Examining Gender Minority Stress, Substance Use, and Gender Affirmation

Transgender and gender-expansive young people, ages 13-24 years, experience disproportionate HIV risk yet are among those with the lowest US PrEP uptake rates (< 10%). Factors influencing PrEP outcomes for this population are poorly understood. This study examines the effects of gender minority stressors, gender affirmation, and heavy substance use on their PrEP outcomes using data from the CDC's 2018 START study (N = 972). A conceptual model integrating the gender minority stress and gender affirmation models was developed, mapping relevant START items onto it. Structural equation modeling (Mplus-8.9) was used to examine factors related to their PrEP intentions. Most participants were 18-24 (68%), trans-female (46%), white (45%), and reported heavy substance use (40%). Medical discrimination increased internalized transphobia (b = 0.097, SE = 0.034, p = 0.005) and perceived stigma (b = 0.087, SE = 0.034, p = 0.010). Family rejection increased perceived stigma (b = 0.181, SE = 0.032, p < 0.001) and heavy substance use (b = 0.260, SE = 0.053, p < 0.001). Perceived stigma also increased heavy substance use (b = 0.106, SE = 0.037, p = 0.004). Perceived stigma (b=-0.085, SE = 0.027, p = 0.002) and heavy substance use (b=-0.161, SE = 0.031, p < 0.001) decreased PrEP intentions, while gender affirmation increased them (b = 0.045, SE = 0.019, p = 0.020). A 1-point increase in gender affirmation reduced heavy substance use risk by -0.179 (SE = 0.030, p < 0.001) in the presence of family rejection and by -0.074 (SE = 0.041, p = 0.074) when perceived stigma was present. This study underscores heavy substance use as a potential barrier to PrEP uptake for transgender/gender-expansive youth. Future research could explore how gender affirmation acts as a protective factor against the negative impact of family rejection and perceived stigma on heavy substance behaviors among these populations.

Preferences for longer acting pre-exposure prophylaxis in transgender and gender expansive texans: centering gender affirming hormone therapy

The prevalence of HIV is higher in the transgender population than in the general population, and pre-exposure prophylaxis (PrEP) is an effective biomedical HIV prevention strategy for the prevention of HIV. However, the transgender and gender-expansive community faces several challenges to PrEP uptake and adherence. This community-based participatory study was conducted to understand preferences for long-acting PrEP modalities better. Data were collected virtually with an adapted version of the World Café Conversation method and in-depth interviews. A total of 33 transgender and gender-diverse individuals participated in either a World Café conversation or an individual interview about preferences for long-acting PrEP. All qualitative data were transcribed and coded for themes. Two themes emerged: (1) challenges related to long-acting PrEP for transgender and gender-expansive individuals and (2) bundling long-acting PrEP and gender-affirming hormone therapy. To improve access and adherence, HIV prevention needs to be included as part of gender-affirming hormone therapy to align with patients' health priorities.

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

INTRODUCTION

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

PrEP Use Among Black Transgender Women: A Qualitative Study on Barriers to PrEP Use and the Power and Promise of Community

Black transgender women (TW) have disproportionately low uptake and use of HIV pre-exposure prophylaxis (PrEP), despite high vulnerability to HIV. Community and peer support may be important intervention targets to improve PrEP use among Black TW. We conducted qualitative interviews with 42 Black TW in the midwestern United States to understand Black TW's experiences with PrEP and explore barriers to PrEP use and the ways peers and Black trans communities may support PrEP use. Using inductive thematic analysis, we identified three primary themes. First, many Black TW see themselves as PrEP advocates and look out for other Black TW. Second, participants described a desire to support the broader Black trans community thrive. Finally, participants described the importance of supporting Black TW involved in sex work, including by supporting the use of PrEP. Data from this study show that, despite numerous health care and structural-level barriers, Black TW play a vital role in supporting PrEP use among other Black TW and supporting their communities. Our results highlight the promise of community-driven interventions among Black TW in supporting PrEP use.

Pre-Exposure Prophylaxis Awareness and Demand Creation: Overlooked Populations and Opportunities to Move Forward

BACKGROUND

Pre-exposure prophylaxis (PrEP) for HIV prevention has been available since 2012, but uptake remains disappointing and inequitable. Furthermore, there is little evidence on the effectiveness of interventions to increase PrEP demand among priority populations in the United States. The objectives of this article were to describe how consumer perceptions of PrEP vary by distinct population groups and identify gaps in PrEP awareness, knowledge, and interest.

METHODS

We synthesized evidence-based interventions to improve demand for PrEP in populations heavily burdened by HIV. The focus centered on consumer factors, how people's awareness of PrEP, especially people who are likely to benefit, influences PrEP uptake.

RESULTS

Awareness and equity in PrEP use among vulnerable populations in the United States remain low because of both demand-side obstacles and accessibility challenges. Designing an effective package of interventions to increase demand for PrEP involves integrating strategies that address awareness, knowledge, interest/motivation, and access.

CONCLUSIONS

The underutilization of PrEP among the 1.2 million individuals who could benefit from it highlights the need for effective demand creation to reduce disparities. To effectively increase awareness of the benefits of PrEP requires consideration of the characteristics of the target population and the structural inequalities that contribute to PrEP-related disparities. Demand creation activities can increase awareness, correct misconceptions, provide knowledge, and help people decide whether PrEP is a good fit for them. The utilization of implementation science frameworks is essential to address demand generation and supply-side barriers to PrEP use.

Preferences and willingness for starting daily, on-demand, and long-acting injectable HIV pre-exposure prophylaxis among transfeminine persons in the US, 2022-2023

BACKGROUND

There remains limited information concerning US transfeminine persons preferences across varying PrEP options. We examined PrEP option willingness, preferences, and associated factors among a US nationwide sample of transfeminine persons.

METHODS

Sexually active transfeminine persons age 15 + were recruited online between June 2022-October 2023 through social media advertisements. Transfeminine persons not diagnosed with HIV were asked about willingness to initiate, and ranked preference, of three PrEP options- daily oral (DO), on-demand, and long-acting injectable (LA-PrEP). Log-binomial models were used to examine PrEP modality willingness and associated sociodemographic and behavioral characteristics.

RESULTS

Among 2657 transfeminine persons not currently using PrEP, 51% reported willingness to start at least one PrEP option. The highest willingness was reported for on-demand PrEP (42.6%), followed by DO (38.1%) and LA PrEP (27.1%). LA PrEP was ranked the most preferred PrEP option among transfeminine persons who reported willingness to start multiple PrEP options (43%, 277/651). Willingness to start on-demand PrEP was higher among participants who were 15-24 years, resided in the South, did not have health insurance, had more than one sex partners and reported prior awareness of on-demand PrEP. Willingness to use DO and LA PrEP was higher among those who had both private and public insurance, reported condomless anal sex, had more than one sex partners and had used non-injection illicit drugs. Additional factors for DO and LA PrEP willingness was residing in the South and prior awareness of LA PrEP, respectively.

CONCLUSIONS

Among transfeminine persons, the highest willingness was reported for on-demand PrEP; and LA PrEP was ranked the most preferred option among those who reported willingness to try multiple options. Offering a variety of PrEP options, informed by an understanding of individual preferences and socio-demographic and behavioral differences, can increase overall PrEP uptake and help meet diverse needs of the transfeminine community.

PrEP Disparities Among Transgender Feminine, Transgender Masculine, Nonbinary, and Gender Expansive Youth and Young Adults in the United States

This study assessed disparities in pre-exposure prophylaxis (PrEP) use among transgender and gender expansive youth and young adults (N = 477) between 15 and 24 years old in the CARES (ATN 149) and TechStep (ATN 160) study protocols within the National Adolescent Medicine Trials Network for HIV/AIDS Interventions (ATN). Structural equation modeling was used to test mediation pathways between gender identity and PrEP uptake among the full sample and stratified by sex assigned at birth. Lifetime PrEP uptake was higher among those assigned male at birth (26%) versus assigned female at birth (9%), explained by greater structural and behavioral risks and perceived need for PrEP, especially among trans women. Among those assigned female at birth, PrEP uptake was higher among trans men (12%) than nonbinary participants (6%). Our findings characterize key structural and behavioral drivers of PrEP use and highlight the need to reduce barriers to healthcare for trans youth, particularly in the South.

The Situated Vulnerabilities and Resiliencies Framework: a call for integrated strategies to address global HIV inequities for transgender, non-binary, and gender diverse populations

Transgender, non-binary, and gender diverse (trans) populations are burdened by the risk of HIV acquisition. Achieving global UNAIDS 95-95-95 targets by 2030 among trans populations requires conceptual frameworks to understand HIV epidemic drivers and optimise effective strategies to curb HIV inequities in trans populations. The Situated Vulnerabilities and Resiliencies Framework describes and explains HIV inequities in these populations. The HIV epidemic among trans populations is situated in multilevel biopsychosocial contexts, and these populations are made vulnerable to HIV through fundamental causes and conditions that render them at risk for risk. Key considerations include pathways that are linked to sex and gender, all-population and trans-specific exposures, developmental context, syndemic dynamics, and intersectionality. The framework highlights the need to deploy integrated strategies and interventions that are neutral to HIV status and grounded in health and human rights, work with trans communities, and use strengths-based approaches leveraging situated resiliencies (ie, salutogenic factors such as collective agency and trans kinships) to reduce pervasive stigma and advance HIV equity in trans populations.

Knowledge and Barriers to HIV Pre-exposure Prophylaxis in Southern California

Despite the proven effectiveness of human immunodeficiency virus (HIV) pre-exposure prophylaxis (PrEP), its use remains low in high-incidence areas. This study examined knowledge and barriers to PrEP among individuals at risk in Southern California. From September 2022 to April 2023, we recruited adult men who have sex with men, residing in San Bernardino and Riverside counties, who were not living with HIV and not using PrEP. Recruitment occurred through targeted online advertisements and clinic-distributed materials. Statistical analyses explored associations between demographic factors and barriers to PrEP. While 81% had heard of PrEP, nearly half were unaware of HIV testing requirements or of its availability for uninsured individuals. Uninsured participants were significantly less comfortable discussing sexual health with providers (OR: 0.19, 95% CI [0.05, 0.68]). Addressing misinformation, reducing provider stigma, and expanding access for uninsured individuals are essential for increasing PrEP use.

Pre-exposure prophylaxis uptake among Black/African American men who have sex with other men in Midwestern, United States: a systematic review

Introduction

Black/African American men who have sex with other men (BMSM) are disproportionately affected by HIV, experience significant disparities in HIV incidence, and face significant barriers to accessing HIV treatment and care services, including pre-exposure prophylaxis (PrEP). Despite evidence of individual and structural barriers to PrEP use in the Midwest, no review has synthesized this finding to have a holistic view of PrEP uptake and barriers. This review examines patterns of, barriers to, and facilitators of PrEP uptake among BMSM in the Midwest, United States (US).

Methods

Five databases (CINAHL Plus, PUBMED, PsycINFO, SCOPUS, and Web of Science) were searched in March 2023. We included studies that focused on BMSM in the Midwestern states; only empirical studies (either quantitative or qualitative or both) were considered. We synthesized the qualitative data and teased out some of the factors inhibiting or facilitating PrEP uptake among BMSM.

Results

We screened 850 articles, and only 22 (quantitative: 12; qualitative: 8; mixed methods: 2) met our set eligibility criteria. Most of the studies were conducted in Chicago. Most BMSM use oral than injectable PrEP. Uptake of PrEP ranged from 3.0 to 62.8%, and the majority reported a prevalence of less than 15%. The barriers include PrEP awareness, PrEP access, PrEP stigma, side effects, PrEP preference, socioeconomic status, medical insurance and support, partner trust, trust in the health system, and precautions with sexual partners. The identified PrEP facilitators include PrEP use until HIV is eradicated, friend influence, experience with dating men living with HIV, safety, phobia for HIV, disdain for condoms, and power to make decisions.

Conclusion

Our review summarized patterns of, barriers to, and facilitators of PrEP uptake among BMSM in the Midwest, United States. The low PrEP uptake of BMSM was primarily attributed to mistrust in the health system and low socioeconomic status. Multimodal and multilevel strategies are needed to improve PrEP uptake among BMSM, including improving the marketing of PrEP to BMSM and removing financial barriers to accessing PrEP service.

Assessment Tools for Evaluating Pharmacy Students' Knowledge on HIV Prophylaxis: A Scoping Review

OBJECTIVES

This study aimed to identify and evaluate instruments used to measure pharmacy students' knowledge of HIV prophylaxis, focusing on both preexposure prophylaxis (PrEP) and postexposure prophylaxis.

METHODS

A systematic literature search was conducted using PubMed, Virtual Health Library, Web of Science, Scopus, ScienceDirect, and Embase. Article screening was performed independently by 2 reviewers. Studies assessing pharmacy students' knowledge of HIV prophylaxis were included.

FINDINGS

Eight studies involving 1,797 students, mostly from the U.S., were identified. All had a cross-sectional design, with only one assessing knowledge retention. Six assessment tools focused on PrEP, one on PEP, and one on both. While confidence in PrEP was evident, significant gaps were found in PEP awareness, prophylaxis access, and prescribing guidelines.

SUMMARY

There is a notable shortage of assessment tools for PEP. Further research is needed to develop validated instruments for measuring knowledge and addressing educational gaps. Longitudinal studies with pre- and post-tests are crucial to evaluate educational interventions and enhance pharmacy students' preparedness for HIV prophylaxis.

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

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

Review protocol for a systematic review and meta-analysis on HIV inequities in transgender and non-binary populations

INTRODUCTION

Global disparities in HIV prevalence among transgender women are well documented. However, current epidemiological literature on HIV disparities demonstrates gaps in research that include the diversity within transgender populations-for example, transgender men and non-binary trans people across global regions. This systematic review and meta-analysis protocol aims to summarise global HIV inequities among all transgender and non-binary (trans) populations. The objectives of this review are to estimate pooled HIV prevalence and prevention outcomes (pre-exposure prophylaxis and antiretroviral therapy) and differences by gender identity, global regions and self-report versus lab-confirmed findings among trans adults worldwide.

METHODS AND ANALYSIS

We will conduct a systematic review of all studies on HIV outcomes among trans youth and adults (aged 15+ years) published between 2000 and 2024, following the Preferred Reporting Items for Systematic Review and Meta-Analysis Prereporting guidelines. We will use Covidence software for the title and abstract screening, full-text review and data abstraction processes. We will summarise the study's descriptive statistics and conduct meta-analyses of extracted data points to calculate and synthesise pooled findings and effect size. Specifically, we will use the Mantel-Haenszel method with random effects to model our meta-analyses and the DerSimonian and Laird Q test for heterogeneity testing. We will conduct a narrative synthesis on the areas of research that have been conducted to improve HIV prevention and treatment among trans populations and summarise their findings. Subgroup analyses by gender identity, global regions and self-report versus lab-confirmed findings will be conducted.

ETHICS AND DISSEMINATION

Ethics approval is not applicable for this review since we will not be collecting primary data. The results will be disseminated through peer-reviewed publications and conference presentations.

PROSPERO REGISTRATION NUMBER

The protocol is registered in the International Prospective Register of Systematic Reviews database (PROSPERO ID: CRD42022357285).

Long-Acting Injectable Pre-Exposure Prophylaxis Perceptions and Preferences Among Transgender and Nonbinary Young Adults in the United States

Long-acting injectable pre-exposure prophylaxis for HIV prevention (LAI-PrEP) was approved for use in the United States in 2021, yet little is known about perceptions of LAI-PrEP among transgender and nonbinary young adults, a group that faces substantial barriers to HIV prevention. We investigated US transgender and nonbinary young adults' perceptions of and attitudes toward LAI-PrEP and how perceived advantages and disadvantages of LAI-PrEP related to the PrEP continuum of care. We conducted semi-structured interviews with 31 transgender and nonbinary young adults who reported oral PrEP use or were PrEP-eligible. We analyzed responses using both a deductive RADaR approach, to identify LAI-PrEP perceptions relevant to the PrEP continuum of care, and an inductive thematic analysis to explore key themes. In this study, all PrEP-experienced and most PrEP-naïve participants indicated an interest in LAI-PrEP, citing advantages over daily oral medication (e.g., fewer adherence challenges). Three key themes emerged: (1) Some participants linked perceived advantages of LAI-PrEP to experiences with gender-affirming care (e.g., familiarity with needles via hormone use). (2) Participants weighed trade-offs and contextual factors that influenced their LAI-PrEP preferences (e.g., interest contingent on whether location for receiving injection was geographically accessible). (3) Participants envisaged alternative delivery methods that could enhance LAI-PrEP acceptability and uptake (e.g., home injection). HIV prevention programs should incorporate the insights of transgender and nonbinary young adults to ensure that emerging HIV prevention technologies are accessible and responsive to the needs and concerns of people of all gender modalities.

Engagement in the HIV Pre-Exposure Prophylaxis Care Cascade in a Statewide Sample of Transgender and Nonbinary Individuals

Although literature regarding HIV prevention among transgender and nonbinary (TNB) people has grown considerably, important gaps remain, particularly in relation to the HIV pre-exposure prophylaxis (PrEP) care cascade. Additional research is needed to understand when and why TNB people exit the PrEP care cascade to inform interventions to better support these populations. Moreover, most studies have focused on transgender women, though transgender men and nonbinary people also experience a disproportionate prevalence of HIV relative to cisgender populations. This study addresses these gaps by exploring engagement in the PrEP care cascade among a statewide convenience sample of 659 transgender women, transgender men, and nonbinary people, and analyzing how gender identity impacts participant likelihood to continue along the cascade. Data come from the 2018 Michigan Trans Health Study and include self-report data on demographics, sexual behavior, and PrEP awareness, information receipt, referral, initiation, and retention. Participants who self-reported vaginal/front hole or anal sex and did not use barriers (n = 318) were considered eligible for PrEP. Only 21.13% of those eligible for PrEP received information about PrEP, 8.18% were referred to PrEP, and 1.57% initiated PrEP use. A significantly greater proportion of transfeminine and participants who identified with multiple/other genders reported receiving PrEP information than those who identified as transmasculine or nonbinary [χ2 (3, n = 311) =11.34, p = .01]. No other significant gender differences were observed. Providers serving TNB individuals must recognize the diversity of individuals who qualify for information on PrEP, provide trans-affirming care when offering PrEP prescriptions, and consider situating PrEP opportunities in TNB serving spaces to reduce access barriers.

Factors associated with self-reported suboptimal antiretroviral adherence and limited retention in care among people living with HIV who attend a large ART clinic in Panama City, Panama

BACKGROUND

The prevalence of HIV in Panama is estimated to be 1.0%; only 71% of individuals on antiretroviral treatment (ART) were virally suppressed in 2022. This study aimed to describe the prevalence of suboptimal adherence (≥1 missed doses in previous four weeks) and limited retention in HIV care (≥1 missed HIV care appointments in previous 12 months) among adults (aged ≥18 years) who attended the most populous urban ART Clinic in Panama City.

METHODS

In this cross-sectional study, participants completed a self-administered questionnaire. Univariable and bivariable analyses were used to describe the prevalence of suboptimal adherence and limited retention in HIV care. Multivariable logistic regression identified factors associated with suboptimal adherence at p<0.05.

RESULTS

We included 375 participants (209 identified as men, 158 as women, 8 another gender). Of those who responded, 37.3% (n = 125/335) reported suboptimal adherence: 28.6% (n = 53/185) of men, 49.0% (n = 71/145) women, 20.0% (n = 1/5) another gender; p<0.01; 18.6% (n = 69/371) reported limited retention in care:13.6% (n = 28/206) men, 24.2% (n = 38/157) women, 37.5% (n = 3/8) another gender, p = 0.01. In multivariable analyses, suboptimal adherence was associated with gender (49.0%women vs. 28.6% men, AOR = 1.86, 95%CI:0.97-3.57), depressive symptoms:46.2% severe symptoms vs. 28.1% minimal-mild, AOR = 2.19,95%CI:0.96-5.04), and lifetime intimate partner emotional violence (IPV) 48.2% vs.no emotional IPV 32.2%, OR = 1.96,95%CI:1.15-2.90, and lifetime physical IPV 46.9% vs.no physical IPV 32.6%, OR = 1.82, 95%CI:1.15-2.90. In unadjusted analyses, limited retention in care was associated with gender (24.2%women vs.13.6% men OR = 2.03, 95%CI:1.18-3.49), difficulty paying rent/mortgage/utilities (22.6% vs.14.9% no difficulty paying, OR = 1.67,95%CI = 0.98-2.83); no variables were associated in the multivariable model.

CONCLUSIONS

This study found high prevalence of suboptimal ART adherence and limited retention in care, especially among women; these factors were associated with severe depressive symptoms, as well as lifetime emotional and physical IPV. These results show the need for integrated mental health and IPV intervention for all individuals, including focused support for women.

Barriers and Facilitators Along the PrEP Continuum of Care Among Latinx Sexual Minoritized Men and Transgender Women: A Systematic Review

Latinx cisgender sexually minoritized men (SMM) and transgender women (TW) in the U.S. are disproportionately affected by HIV. Although pre-exposure prophylaxis (PrEP) is a highly effective strategy for HIV prevention, rates of PrEP use among Latinx SMM and TW remain suboptimal. The main purpose of this systematic review was to (1) describe engagement in the various stages of the PrEP care continuum among Latinx SMM and TW, and (2) identify multilevel determinants that function as barriers or facilitators to engagement in the PrEP continuum of care for Latinx SMM and TW. This review was conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-Analysis Statement (PRISMA). Five databases (MEDLINE, CINAHL, PsycINFO, Embase, Scopus) were searched to examine the available qualitative, quantitative, and mixed method studies relevant to the research question. A total of 56 studies were included, with the majority focusing on SMM and being cross-sectional in design. Barriers included PrEP knowledge, risk perception, intersecting stigma, and structural conditions. Community resources, social support, and PrEP navigation services facilitated engagement in the PrEP continuum of care. This review highlights the complex factors that influence PrEP care engagement among Latinx SMM and TW. These findings call for comprehensive, multilevel approaches to address inequities disparities in PrEP care engagement among these groups.

Transgender Latinas' Perspectives on HIV PrEP Uptake, Condom Use, and Medically Supervised Gender-Affirming Hormone Therapy: Insights From ChiCAS Qualitative Interviews

There is a dearth of HIV prevention behavioral interventions for transgender Latinas, despite this population's HIV risk. ChiCAS (Chicas Creando Acceso a la Salud) is an intervention to increase PrEP, condom, and gender-affirming hormone therapy (GAHT) use among transgender Latinas. To inform future work, semistructured interviews were conducted postintervention with 28 ChiCAS participants. Thematic analysis with inductive coding was used. Six themes emerged: (1) health-related priorities include sexual health and avoiding discrimination; (2) safe and collaborative community is of high importance; (3) interactive education with time for sharing stories and discussion was valued; (4) PrEP uptake was facilitated through awareness and health care navigation; (5) accessing GAHT depends on cost, clinic location, and individual goals; (6) ChiCAS could be improved with more PrEP/GAHT details and social connection. Interventions with goals similar to those of ChiCAS should prioritize building community, PrEP and GAHT education tailored to participants' needs, and emphasize health care options available locally.

Telehealth Models for PrEP Delivery: A Systematic Review of Acceptability, Implementation, and Impact on the PrEP Care Continuum in the United States

Pre-exposure prophylaxis (PrEP) is pivotal in curbing HIV transmission and is integral to the national plan to end the HIV epidemic in the United States (US). Nonetheless, widespread PrEP adoption faces barriers. Telehealth delivery models for PrEP, or telePrEP, can enhance PrEP access and adherence by providing flexible care remotely. This study presents a systematic review of telePrEP programs in the US, aiming to describe model characteristics and summarize clinical, implementation, and equity outcomes. We reviewed studies published from 2012 to 2023. We included articles that described telePrEP systems in the US and measured PrEP care continuum outcomes (awareness, initiation, uptake, adherence) or acceptability of the intervention by program users. Eight articles describing six distinct telePrEP initiatives met our inclusion criteria. Studies described models implemented in community-based, academic, and commercial settings, with most programs using a direct-to-client telePrEP model. Across studies, clients reported high acceptability of the telePrEP programs, finding them easy to use, convenient, and helpful as a tool for accessing HIV prevention services. No programs were offering injectable PrEP at the time these studies were conducted. Data was limited in measuring PrEP retention rates and the reach of services to underserved populations, including Black and Latinx communities, transgender individuals, and cis-gender women. Findings underscore the potential of telePrEP to bolster the reach of PrEP care and address structural barriers to access. As telehealth models for PrEP care gain prominence, future research should concentrate on refining implementation strategies, enhancing equity outcomes, and expanding services to include injectable PrEP.

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

INTRODUCTION

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

METHODS

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

RESULTS

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

CONCLUSION

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

High PrEP acceptability and need for tailored implementation in Cambodian key populations: results from a qualitative assessment

The HIV epidemics in Cambodia is concentrated in key populations (KPs). Pre-exposure prophylaxis (PrEP) has been officially approved in the country since 2019. However, its use may still be controversial after a PrEP clinical trial was interrupted in Cambodia after being deemed unethical in 2004. In this context, it was necessary to evaluate PrEP acceptability and administration preferences of KPs in Cambodia, with a view to increasing roll-out and uptake. We conducted a qualitative study in 2022 comprising six focus groups and four semi-structured individual interviews with transgender women, men who have sex with men, male entertainment workers, venue-based female entertainment workers (FEW), street-based FEW, and PrEP users who participated in a PrEP pilot study that started in 2019. Overall, KPs positively perceived PrEP, with some reservations. They preferred daily, community-based PrEP to event-driven, hospital-based PrEP, and highlighted that injectable PrEP would be a potential option if it became available in Cambodia. We recommend (i) proposing different PrEP regimens and PrEP delivery-models to broaden PrEP acceptability and adherence in Cambodia (ii) increasing the number of community-based organisations and improving the services they offer, (iii) rolling out injectable PrEP when it becomes officially available, and (iv) improving PrEP side effects information.

Direct and vicarious exposure to healthcare discrimination and erasure among transgender and gender independent individuals: Testing the indirect effect of mistrust in healthcare on utilization behaviors

RATIONALE

Direct exposure to gender identity-related discrimination and erasure among the transgender and gender independent (TGI) population are associated with healthcare underutilization, which may further exacerbate the health disparities that exist between this population and cisgender individuals in the United States (U.S.). Although the impacts of direct exposure to healthcare discrimination and erasure may have on TGI individuals are known, exposure to such harm vicariously (i.e., through observation or report) is underexplored.

OBJECTIVE

The present study examined the relationships among direct and vicarious gender identity-related healthcare discrimination and erasure exposure and past-year healthcare utilization.

METHOD

Gender identity-based mistrust in healthcare was also assessed, as a mechanism through which direct and vicarious gender identity-related healthcare discrimination and erasure predict healthcare utilization behaviors among a sample (N = 385) of TGI adults in the U.S., aged 18 to 71 recruited online.

RESULTS

Results indicated direct lifetime and vicarious healthcare discrimination and erasure exposure significantly predicted past-year healthcare underutilization when participants anticipated encountering gender identity-related healthcare discrimination. Mediational analyses indicated that higher levels of exposure to direct lifetime and vicarious healthcare discrimination and erasure were related to higher levels of mistrust in healthcare, through which past-year underutilization was significantly related.

CONCLUSIONS

These findings are vital to informing healthcare practice and policy initiatives aimed at ensuring the barriers that deleteriously influence the accessibility of healthcare among TGI individuals are ameliorated.

HIV/Pre-Exposure Prophylaxis Knowledge and Acceptability of Rapid HIV Testing Among Transgender Adolescents in a Multidisciplinary Gender Clinic

Purpose

The objectives of this study were to assess the knowledge of HIV and pre-exposure prophylaxis (PrEP) in transgender adolescents and young adults (AYAs) and to test the acceptability of rapid HIV testing among transgender adolescents in a multidisciplinary gender clinic.

Methods

Participants enrolled on the same day as their mental health or medical appointment in a multidisciplinary gender clinic. They completed survey questions regarding HIV and PrEP knowledge and were also offered an optional same-day, rapid, fourth-generation HIV test. Participants who had an HIV test answered additional questions about their testing experience.

Results

We enrolled 61 participants; just over half (n=31) were assigned female at birth. Less than a third (n=20, 32.8%) scored 80% or above regarding HIV knowledge. Nearly half of the participants (n=29, 47.5%) were not interested in PrEP. Forty-one percent of participants chose to have a rapid HIV test; all were "satisfied" with the testing experience. There were no positive HIV results.

Conclusions

Transgender AYAs have gaps in their understanding of HIV acquisition and transmission. Rapid HIV testing in the setting of gender care is well received by those who desire testing and may be a way to increase knowledge of transgender AYA HIV status.

Facilitators and barriers to community pharmacy PrEP delivery: a scoping review

INTRODUCTION

Pre-exposure prophylaxis (PrEP) is an effective medication to reduce the risk of acquiring HIV. PrEP is available free of charge in the UK from sexual health clinics. Expanding PrEP delivery to community pharmacies holds promise and aligns with UK government goals to eliminate new cases of HIV by 2030. The aim of this scoping review was to describe the existing evidence about the barriers to and facilitators of community pharmacy oral PrEP delivery, for pharmacists and pharmacy clients, as aligned with the Capacity Opportunity, Motivation Behaviour (COM-B) Model.

METHODS

Five bibliographic and five review databases were searched from inception to August 2023. Literature of any study design was included if it discussed barriers and facilitators of community pharmacy PrEP delivery. Trial registrations, protocols and news articles were excluded.

RESULTS

A total of 649 records were identified, 73 full texts were reviewed and 56 met the inclusion criteria, predominantly from high-income/westernized settings. Most of the included literature was original research (55%), from the United States (77%) conducted during or after the year 2020 (63%). Barriers to PrEP delivery for pharmacists included lack of knowledge, training and skills (capability), not having the necessary facilities (opportunity), concern about the costs of PrEP and believing that PrEP use could lead to risk behaviours and sexually transmitted infections (motivation). Facilitators included staff training (capability), time, the right facilities (opportunity), believing PrEP could be a source of profit and could reduce new HIV acquisitions (motivation). For clients, barriers included a lack of PrEP awareness (capability), pharmacy facilities (opportunity) and not considering pharmacists as healthcare providers (motivation). Facilitators included awareness of PrEP and pharmacist's training to deliver it (capability), the accessibility of pharmacies (opportunity) and having an interest in PrEP (motivation).

DISCUSSION

To effectively enhance oral PrEP delivery in UK community pharmacies, the identified barriers and facilitators should be explored for UK relevance, addressed and leveraged at the pharmacy team, client and care pathway level.

CONCLUSIONS

By comprehensively considering all aspects of the COM-B framework, community pharmacies could become crucial providers in expanding PrEP accessibility, contributing significantly to HIV prevention efforts.

Intention to Use Different Formulations of Longer Acting HIV Pre-Exposure Prophylaxis Among Transgender and Gender Expansive Individuals: The Roles of Social Vulnerability and Medical Mistrust

In 2012, the Federal Drug Administration approved daily oral pre-exposure prophylaxis (PrEP) for HIV prevention in adults. Longer acting injectable PrEP (LA PrEP) has been approved and other formulations are in development. A successful LA PrEP rollout requires examining potential facilitators and barriers to PrEP uptake. Given that transgender and gender expansive (TGE) individuals experience more social vulnerability and higher levels of medical mistrust compared to other populations, examining the role of these two factors in LA PrEP uptake is important. This study, PrEP for ALL, is a community-based participatory research project in Texas that engaged TGE community members and organizational partners through a community advisory board. In total, 482 TGE individuals were recruited and responded to all relevant questions in an online survey, including their intentions to use three formulations: a monthly oral pill, a bimonthly intramuscular injection, and an annual subdermal implant. Multiple regression analysis was used to examine the influence of social vulnerability and medical mistrust on intention to use each LA PrEP formulation adjusting for other relevant factors. Findings suggest that individuals with higher levels of social vulnerability had greater intentions to use the monthly oral pill (β = 0.12, p = 0.009), the bimonthly intramuscular injection (β = 0.18, p < 0.001), and annual subdermal implant (β = 0.17, p < 0.001), whereas medical mistrust reduced intentions to use the bimonthly intramuscular injection (β = -0.18, p < 0.001) and annual subdermal implant (β = -0.11, p = 0.021). Improvements in gender-affirming clinical care are needed along with LA PrEP formulations that allow for greater autonomy and reduced clinical contact. Clinical Trial Registration number: NCT05044286.

HIV pre-exposure prophylaxis programme preferences among sexually active HIV-negative transgender and gender diverse adults in the United States: a conjoint analysis

INTRODUCTION

Current implementation efforts have failed to achieve equitable HIV pre-exposure prophylaxis (PrEP) provision for transgender and gender-diverse (trans) populations. We conducted a choice-based conjoint analysis to measure preferences for key attributes of hypothetical PrEP delivery programmes among a diverse online sample predominantly comprised of transmasculine and nonbinary individuals in the United States.

METHODS

Between April 2022 and June 2022, a national online survey with an embedded conjoint analysis experiment was conducted among 304 trans individuals aged ≥18 years in the United States to assess five PrEP programme attributes: out-of-pocket cost; dispensing venue; frequency of visits for PrEP-related care; travel time to PrEP provider; and ability to bundle PrEP-related care with gender-affirming hormone therapy services. Participants responded to five questions, each of which presented two PrEP programme scenarios and one opt-out option per question and selected their preferred programme in each question. We used hierarchical Bayes estimation and multinomial logistic regression to measure part-worth utility scores for the total sample and by respondents' PrEP status.

RESULTS

The median age was 24 years (range 18-56); 75% were assigned female sex at birth; 54% identified as transmasculine; 32% as nonbinary; 14% as transfeminine. Out-of-pocket cost had the highest attribute importance score (44.3%), followed by the ability to bundle with gender-affirming hormone therapy services (18.7%). Minimal cost-sharing ($0 out-of-pocket cost) most positively influenced the attribute importance of cost (average conjoint part-worth utility coefficient of 2.5 [95% CI 2.4-2.6]). PrEP-experienced respondents preferred PrEP delivery in primary care settings (relative utility score 4.7); however, PrEP-naïve respondents preferred pharmacies (relative utility score 5.1).

CONCLUSIONS

Participants preferred programmes that offered PrEP services without cost-sharing and bundled with gender-affirming hormone therapy services. Bolstering federal regulations to cover PrEP services and prioritizing programmes to expand low-barrier PrEP provision are critical to achieving equitable PrEP provision. Community-engaged implementation research conducted by and in close collaboration with trans community stakeholders and researchers are needed to streamline the design of patient-centred PrEP programmes and develop implementation strategies that are salient to the diverse sexual health needs of trans patients.

HIV Pre-exposure Prophylaxis (PrEP) Care in Belgium: A mixed-methods Study on PrEP Users' Experiences and Service Delivery Preferences

In Belgium, HIV pre-exposure prophylaxis (PrEP) services are mainly provided through specialised HIV clinics. To optimise PrEP uptake and retention in care, we require insights into users' perspectives on PrEP care. We aimed to elicit experiences with, and preferences for, PrEP service delivery among PrEP users in Belgium, including willingness to involve their family physician (FP) in PrEP care. We adopted a sequential mixed-methods design. We used a web-based longitudinal study among 326 PrEP users that consisted of two questionnaires at six-month intervals, and complemented this with 21 semi-structured interviews (September 2020-January 2022). We conducted descriptive analyses and logistic regression to examine factors associated with willingness to involve their FP in PrEP care. Interviews were analysed using thematic analysis. Survey respondents reported high satisfaction with care received in HIV clinics [median score 9 (IQR 8-10), 10='very satisfied']. Interviews revealed the importance of regular HIV/STI screening, and the expertise and stigma-free environment of HIV clinics. Yet, they also contextualised service delivery barriers reported in the questionnaire, including the burden of cost and challenges integrating PrEP visits into their private and professional lives. Although 63.8% (n = 208/326) of baseline respondents preferred attending an HIV clinic for PrEP follow-up, 51.9% (n = 108/208) of participants in the follow-up questionnaire reported to be willing to have their FP involved in PrEP care. Participants reporting trust in FPs' PrEP and sexual health expertise, or who didn't feel judged by their FP, were more likely to be willing to involve them in PrEP care. Therefore, we recommend a differentiated PrEP service delivery approach, including involving FPs, to make PrEP care more client-centred.

Determinants of HIV Pre-Exposure Prophylaxis (PrEP) Retention among Transgender Women: A Sequential, Explanatory Mixed Methods Study

Transgender women (TW) face inequities in HIV and unique barriers to PrEP, an effective biomedical intervention to prevent HIV acquisition. To improve PrEP retention among TW, we examined factors related to retention using a two-phase, sequential explanatory mixed methods approach. In Phase I, we used data from a trial of 170 TW who were provided oral PrEP to examine predictors of 24-week retention. In Phase II, we conducted 15 in-depth interviews with PrEP-experienced TW and used thematic analysis to explain Phase I findings. In Phase I, more participants who were not retained at 24 weeks reported sex work engagement (18% versus 7%) and substantial/severe drug use (18% versus 8%). In Phase II, participants reported drug use as a barrier to PrEP, often in the context of sex work, and we identified two subcategories of sex work. TW engaged in "non-survival sex work" had little difficulty staying on PrEP, while those engaged in "survival sex work" struggled to stay on PrEP. In Phase I, fewer participants not retained at 24 weeks reported gender-affirming hormone therapy (GAHT) use (56% versus 71%). In Phase II, participants prioritized medical gender affirmation services over PrEP but also described the bidirectional benefits of accessing GAHT and PrEP. TW who engaged in "survival sex work" experience barriers to PrEP retention (e.g., unstable housing, drug use) and may require additional support to stay in PrEP care.

Barriers and facilitators to pre-exposure prophylaxis uptake among Black/African American men who have sex with other men in Iowa: COM-B model analysis

Background

In Iowa, men who have sex with men (MSM) accounted for 54% of persons with HIV in 2022 and Non-Hispanic Black/African Americans were over 10 times more likely to be diagnosed with HIV than Non-Hispanic white Iowans. To address this disparity in HIV incidence and prevalence, the United States (US) government ending the HIV epidemic (EHE) initiative seeks to expand pre-exposure prophylaxis (PrEP) coverage across the United States. Recent data showed that PrEP coverage is suboptimal in Iowa (a rural state), and Black Iowans were less likely to engage with PrEP services.

Objectives

Using capability, opportunity, motivation and behavior (COM-B) model for behavior change, this study sought to identify the key barriers and facilitators to PrEP uptake among Black/African American MSM in small urban areas in Iowa.

Design

This was a phenomenological study aimed to explore subjective views of Black MSM on PrEP use.

Methods

In-depth semistructured interviews were conducted with 12 Black MSM aged 20-42 years in two small urban counties. Broad themes identified from the interview transcripts were analyzed inductively and mapped onto the COM-B constructs deductively.

Results

Results showed that barriers to PrEP uptake were closely associated with five (of six) COM-B subcomponents: physical capability, psychological capability, social opportunity, reflective motivation, and automatic motivation. The thematized barriers were (1) lack of medical insurance; (2) limited PrEP awareness; (3) PrEP stigma; (4) fear of distrust among partners; (5) anticipated side effects; and (6) doubt about PrEP effectiveness. Similarly, facilitators to PrEP uptake were aligned with four subcomponents of COM-B model: physical capability, psychological capability, social opportunity, and physical opportunity. The thematized facilitators were (1) increased PrEP awareness; (2) PrEP access without discrimination; (3) state provision of PrEP to uninsured; and (4) physicians buy-in and recommendation. No motivation-related facilitators were reported.

Conclusion

To reduce the current disparity in HIV incidence and to achieve the EHE goals of expanding PrEP coverage in Iowa, efforts should be directed toward the provision of low-cost or free PrEP services, healthcare providers' training on cultural competence, and the development of culturally appropriate strategies to deliver PrEP to the Black MSM community.

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

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

Uptake and Discontinuation of Pre-Exposure Prophylaxis Among Uninsured Transgender and Cisgender Women: A Public-Private Partnership Model in North Carolina

HIV pre-exposure prophylaxis (PrEP) remains underutilized among cis and trans women. The PrEP Initiative Program (PIP) is a novel public-private partnership implemented at 12 local clinics in North Carolina. PIP provides HIV/sexually transmitted infection (STI) testing and clinical and laboratory monitoring for PrEP to uninsured/underinsured clients. We sought to understand service-related differences among both cis and trans women enrolled in PIP, including STIs diagnoses, clinic type, sources of referral, services needed, and reasons for PrEP discontinuation. The Kaplan-Meier curves display retention on PrEP over the duration of the program. Since 2018, 142 women (cis n = 113; trans n = 29) enrolled, and 136 started PrEP. The majority were ages 25-34 years (31.7%) or 18-24 years (29.6%), Black (57.8%) or Latinx (24.7%). Approximately 20.6% of recipients reported at least one STI while enrolled. Overall, trans women requested fewer services than cis women. After accounting for the amount of time each patient was taking PrEP, there were higher rates of trans women diagnosed with syphilis than cis women. Rates of persons with other STIs were not notably different between trans and cis women. Clinic access varied by gender: 69% of trans women were enrolled at only one site. Trans women were retained significantly longer: The Kaplan-Meier adjusted median time to discontinuation was 560 and 238 days for trans and cis women, respectively. PIP successfully reached historically marginalized and uninsured cis and trans women who may benefit from PrEP. Further investigations into factors contributing to recruitment and retention of women in HIV prevention programs are needed.

Control groups for HIV prevention efficacy trials: what does the future hold?

PURPOSE OF REVIEW

Ending the HIV epidemic will require the development of additional effective immune-mediated and nonimmune-mediated means of HIV prevention. Evaluating novel interventions requires large, controlled trials demonstrating efficacy. Recent advances in the field of HIV prevention necessitate new approaches to efficacy trial design.

RECENT FINDINGS

Three classes of efficacy trial designs are possible: standard of prevention-controlled trials, active-controlled trials, and active-controlled trials augmented with external control data. Recent experience with these approaches provides lessons on considerations around and success of the designs. Additional experience and development is needed for the augmented active-controlled trial design.

SUMMARY

Efficacy trials of new HIV prevention interventions are feasible but require careful consideration, given the complexity and dynamic state of the prevention field. While standard of prevention-controlled efficacy trials are reasonable approaches for HIV vaccine and monoclonal antibody efficacy trials, trials of new antiretroviral agents may require active-controlled designs.

Improving HIV pre-exposure prophylaxis (PrEP) adherence and retention in care: Process evaluation and recommendation development from a nationally implemented PrEP programme

INTRODUCTION

HIV pre-exposure prophylaxis (PrEP), in which people take HIV medication to prevent HIV acquisition, underpins global HIV transmission elimination strategies. Effective prevention needs people to adhere to PrEP and remain in care during periods of risk, but this is difficult to achieve. We undertook a process evaluation of Scotland's PrEP programme to explore barriers and facilitators to PrEP adherence and retention in care and to systematically develop evidence-based, theoretically-informed recommendations to address them.

METHODS

We conducted semi-structured interviews and focus groups (09/2018-07/2019) with patients who identified as gay or bisexual men and were either using PrEP, had declined the offer of PrEP, had stopped PrEP, or had been assessed as ineligible for PrEP (n = 39 of whom n = 5 (13%) identified as trans, median age 31 years and interquartile range 14 years), healthcare professionals involved in PrEP provision (n = 54 including specialist sexual health doctors and nurses of various grades, PrEP prescribing general practitioners, health promotion officers, midwifes, and a PrEP clinical secretary), and clients (n = 9) and staff (n = 15) of non-governmental organisations with an HIV prevention remit across Scotland. We used thematic analysis to map key barriers and facilitators to priority areas that could enhance adherence and retention in care. We used implementation science analytic tools (Theoretical Domains Framework, Intervention Functions, Behaviour Change Technique Taxonomy, APEASE criteria) and expert opinion to systematically generate recommendations.

RESULTS

Barriers included perceived complexity of on-demand dosing, tendency for users to stop PrEP before seeking professional support, troublesome side-effects, limited flexibility in the settings/timings/nature of review appointments, PrEP-related stigma and emerging stigmas around not using PrEP. Facilitators included flexible appointment scheduling, reminders, and processes to follow up non-attenders. Examples of the 25 recommendations include: emphasising benefits of PrEP reviews and providing appointments flexibly within individualised PrEP care; using clinic systems to remind/recall PrEP users; supporting PrEP conversations among sexual partners; clear on-demand dosing guidance; encouraging good PrEP citizenship; detailed discussion on managing side-effects and care/coping planning activities.

CONCLUSIONS

PrEP adherence and retention in care is challenging, reducing the effectiveness of PrEP at individual and population levels. We identify and provide solutions to where and how collaborative interventions across public health, clinical, and community practice could address these challenges.

Barriers and facilitators to HIV pre-exposure prophylaxis uptake among transgender women in Colombia: A qualitative analysis using the COM-B model

Transgender women [TGW] in Colombia are disproportionately affected by HIV due to their low sociodemographic conditions, varied risk behaviours, difficulty accessing health services, and discrimination. Offering pre-exposure prophylaxis [PrEP] as part of a combination of prevention strategies is an appropriate option for this population to reduce their risk of HIV infection. However, little is known about how to implement a PrEP program for TGW in Colombia. Between June and October 2020, we conducted individual interviews with 16 TGW from four different cities in Colombia. The interviews assessed contextual influences, knowledge, skills, perceptions, and beliefs. We used qualitative thematic analysis to identify themes and the Capability, Opportunity, Motivation, and Behavior framework to further delineate barriers and possible interventions. After delineating the main themes across the three subdomains of the model, nine barriers were identified: one related to capability, knowledge, and perception of PrEP; six related to opportunity, which includes, family relations, sexual work environment, stable partner relations, interactions with healthcare workers, health service provision, and community interactions and opportunities; and two related to motivation, mental health, and concerns about medication side effects. Mapping barriers with interventions generated the following intervention functions: education, training, enablement, and environmental structure; and the following policy functions: communication/marketing, legislation, and changes in service provision. Examples of possible interventions are presented and discussed.

"Entre Nosotras:" a qualitative study of a peer-led PrEP project for transgender latinas

BACKGROUND

Uptake of HIV pre-exposure prophylaxis (PrEP) remains low among transgender people as compared to other subgroups, despite high rates of HIV acquisition. In California, Latinx people comprise 40% of the population and Latina transgender women experience some of the highest burden of HIV of any subgroup, indicating a critical need for appropriate services. With funding from the California HIV/AIDS Research Programs, this academic-community partnership developed, implemented, and evaluated a PrEP project that co-located HIV services with gender affirming care in a Federally Qualified Heath Center (FQHC). Trans and Latinx staff led intervention adaptation and activities.

METHODS

This paper engages qualitative methods to describe how a PrEP demonstration project- Triunfo- successfully engaged Spanish-speaking transgender Latinas in services. We conducted 13 in-depth interviews with project participants and five interviews with providers and clinic staff. Interviews were conducted in Spanish or English. We conducted six months of ethnographic observation of intervention activities and recorded field notes. We conducted thematic analysis.

RESULTS

Beneficial elements of the intervention centered around three intertwined themes: creating trusted space, providing comprehensive patient navigation, and offering social support "entre nosotras" ("between us women/girls"). The combination of these factors contributed to the intervention's success supporting participants to initiate and persist on PrEP, many of whom had previously never received healthcare. Participants shared past experiences with transphobia and concerns around discrimination in a healthcare setting. Developing trust proved foundational to making participants feel welcome and "en casa/ at home" in the healthcare setting, which began from the moment participants entered the clinic and continued throughout their interactions with staff and providers. A gender affirming, bilingual clinician and peer health educators (PHE) played a critical part in intervention development, participant recruitment, and patient navigation.

CONCLUSIONS

Our research adds nuance to the existing literature on peer support services and navigation by profiling the multifaced roles that PHE served for participants. PHE proved instrumental to empowering participants to overcome structural and other barriers to healthcare, successfully engaging a group who previously avoided healthcare in clinical settings.

Effectiveness, Acceptability, and Feasibility of a Telehealth HIV Pre-Exposure Prophylaxis Care Intervention Among Young Cisgender Men and Transgender Women Who Have Sex With Men: Protocol for a Randomized Controlled Trial

BACKGROUND

Despite its promise for HIV prevention, the uptake of pre-exposure prophylaxis (PrEP) has been slow, and there have been substantial inequities in PrEP access. Young men who have sex with men and transgender women of color are most in need of PrEP and least likely to have that need fulfilled. PrEP telehealth care, which provides remote PrEP care via electronic communication, seems well suited to address several of the challenges of PrEP provision, including discomfort with stigmatizing and difficult-to-access health care systems, transportation challenges, and privacy concerns, and address disparities in PrEP access. Research suggests that PrEP telehealth care has promise and is a favored option for many prospective recipients of PrEP. However, despite growing attention to telehealth approaches as an avenue for increasing access to PrEP amidst the COVID-19 pandemic, there have been no published randomized controlled trials (RCTs) on PrEP telehealth care to date, making it difficult to draw strong conclusions about the advantages or disadvantages of telehealth compared with usual PrEP care. We developed PrEPTECH, a telehealth intervention that focuses specifically on alleviating issues of stigma, access, cost, and confidentiality for young people with risk factors for HIV infection who are seeking PrEP care. Leveraging data from the 2017 observational pilot study, we redesigned and enhanced PrEPTECH.

OBJECTIVE

This study aims to assess the effectiveness, acceptability, and feasibility of a telehealth HIV PrEP care intervention, PrEPTECH, in increasing PrEP uptake.

METHODS

This is the protocol for an RCT of young cisgender men and transgender women who have sex with men in 4 regions within the United States: the San Francisco Bay Area, California; Los Angeles County, California; Miami-Dade County, Florida; and Broward County, Florida. Participants in the intervention arm received access to a web-based telehealth program, PrEPTECH, which offers a fully web-based pathway to PrEP, whereas those in the control arm received access to a dynamic web page containing publicly available informational resources about PrEP. Follow-up data collection occurred at 3 and 6 months. An analysis will be conducted on outcomes, including PrEP initiation, persistence, adherence, coverage, and medication prescription, as well as PrEPTECH acceptability and feasibility.

RESULTS

The study was funded in 2019 and received institutional review board approval in 2020. The PrEPTECH intervention was developed over the next 1.5 years. Study recruitment was launched in February 2022 and completed in September 2022, with 229 participants recruited in total. Data collection was completed in April 2023.

CONCLUSIONS

The results of this RCT will offer valuable evidence regarding the effectiveness, acceptability, and feasibility of telehealth HIV PrEP care interventions among young cisgender men and transgender women who have sex with men.

TRIAL REGISTRATION

ClinicalTrials.gov NCT04902820; https://clinicaltrials.gov/ct2/show/NCT04902820.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

PRR1-10.2196/47932.

Cost-Effectiveness of Anti-retroviral Adherence Interventions for People Living with HIV: A Systematic Review of Decision Analytical Models

BACKGROUND

Although safe and effective anti-retrovirals (ARVs) are readily available, non-adherence to ARVs is highly prevalent among people living with human immunodeficiency virus/acquired immunodeficiency syndrome (PLWHA). Different adherence-improving interventions have been developed and examined through decision analytic model-based health technology assessments. This systematic review aimed to review and appraise the decision analytical economic models developed to assess ARV adherence-improvement interventions.

METHODS

The review protocol was registered on PROSPERO (CRD42022270039), and reporting followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) checklist. Relevant studies were identified through searches in six generic and specialized bibliographic databases, i.e. PubMed, Embase, NHS Economic Evaluation Database, PsycINFO, Health Economic Evaluations Database, tufts CEA registry and EconLit, from their inception to 23 October 2022. The cost-effectiveness of adherence interventions is represented by the incremental cost-effectiveness ratio (ICER). The quality of studies was assessed using the quality of the health economics studies (QHES) instrument. Data were narratively synthesized in the form of tables and texts. Due to the heterogeneity of the data, a permutation matrix was used for quantitative data synthesis rather than a meta-analysis.

RESULTS

Fifteen studies, mostly conducted in North America (8/15 studies), were included in the review. The time horizon ranged from a year to a lifetime. Ten out of 15 studies used a micro-simulation, 4/15 studies employed Markov and 1/15 employed a dynamic model. The most commonly used interventions reported include technology based (5/15), nurse involved (2/15), directly observed therapy (2/15), case manager involved (1/15) and others that involved multi-component interventions (5/15). In 1/15 studies, interventions gained higher quality-adjusted life years (QALYs) with cost savings. The interventions in 14/15 studies were more effective but at a higher cost, and the overall ICER was well below the acceptable threshold mentioned in each study, indicating the interventions could potentially be implemented after careful interpretation. The studies were graded as high quality (13/15) or fair quality (2/15), with some methodological inconsistencies reported.

CONCLUSION

Counselling and smartphone-based interventions are cost-effective, and they have the potential to reduce the chronic adherence problem significantly. The quality of decision models can be improved by addressing inconsistencies in model selection, data inputs incorporated into models and uncertainty assessment methods.

Engaging Latino sexual minority men in PrEP and behavioral health care: multilevel barriers, facilitators, and potential implementation strategies

Latino sexual minority men (LSMM) are affected by HIV and behavioral health disparities. Evidence-based HIV-prevention and behavioral health (BH) services are not sufficiently scaled up to LSMM. The current study identified multilevel barriers and facilitators to LSMM's use of HIV-prevention and BH services. LSMM (N = 290) in South Florida, a US HIV epicenter, completed a battery of measures potentially associated with pre-exposure prophylaxis (PrEP) and BH treatment use. Stochastic search variable selection (SSVS) followed by multiple linear regression analyses identified variables associated with engagement in PrEP and BH treatment. Multilevel determinants of PrEP and BH treatment engagement were identified, with most identified determinants being at the relational level (e.g., stigma, discrimination based on income and immigration status, personal recommendation for treatment). Individual (e.g., knowledge, self-efficacy) and structural (e.g., financial stress) determinants were also identified. Accordingly, modifiable leverage points to enhance the reach of PrEP and BH treatment to LSMM include educating and enhancing the perceived relevance of services, de-stigmatizing and normalizing via peer examples, bolstering self-efficacy, and building trust.

Associations Between Sexual History Documentation in Electronic Health Records and Referral to Pre-Exposure Prophylaxis Navigator on Prescription of Pre-Exposure Prophylaxis at a Multi-Site Federally Qualified Health Center

This cross-sectional study examined the relationships between sexual history screening (SHS) and referrals to a pre-exposure prophylaxis (PrEP) navigator (non-clinical staff member who assists patients in overcoming structural barriers to PrEP) on the proportion of days covered by PrEP for adult patients at a federally qualified health center. Patients' sociodemographics, PrEP prescriptions, referral to a PrEP navigator, and SHS data were extracted from the electronic health record (EHR). The analytic sample was 214 adult patients who were human immunodeficiency virus (HIV) negative and taking PrEP to prevent infection from January 2016 to December 2019. Mixed-effects negative binomial models were conducted accounting for clustering by patients' primary care providers. Documentation of SHS was associated with a higher proportion of days covered by PrEP (incidence rate ratio = 1.44, 95% confidence interval: 1.17-1.77). There was no significant effect of having a referral to the PrEP navigator on the proportion of days covered by PrEP, nor did having a referral to the PrEP navigator moderate the relationship between having SHS documented in the EHR and the proportion of days covered by PrEP. This study is the first to investigate the relationship between having sexual history documented in the EHR, referrals to a PrEP navigator, and their combined effect on the proportion of days covered by PrEP. Results of this study provide foundational evidence for future studies examining SHS as an opportunity to improve PrEP access and adherence and indicate the need for additional research exploring the value of PrEP navigators as an implementation strategy to overcome social and structural barriers to care.

HIV Incidence Among Individuals Accessing Pre-Exposure Prophylaxis in Jackson, Mississippi

Although pre-exposure prophylaxis (PrEP) is an efficacious biomedical intervention, the effectiveness of same-day PrEP programs has not been widely studied. We utilized data from three of the four largest PrEP providers in Mississippi from September 2018 to September 2021 linked to the Mississippi State Department of Health's Enhanced HIV/AIDS reporting system. HIV diagnosis was defined as testing newly positive for HIV at least 2 weeks after the initial PrEP visit. We calculated the cumulative incidence and incidence rate of HIV per 100 person-years (PY). Person-time was calculated as time from the initial PrEP visit to (1) HIV diagnosis or (2) December 31, 2021 (HIV surveillance data end date). We did not censor individuals if they discontinued PrEP to obtain an estimate of PrEP effectiveness rather than efficacy. Among the 427 clients initiating PrEP during the study period, 2.3% [95% confidence interval (CI): 0.9-3.8] subsequently tested positive for HIV. The HIV incidence rate was 1.18 per 100 PY (95% CI: 0.64-2.19) and median time to HIV diagnosis after the initial PrEP visit was 321 days (95% CI: 62-686). HIV incidence rates were highest among transgender and nonbinary individuals [10.35 per 100 PY (95% CI: 2.59-41.40)] compared with cisgender men and women, and among people racialized as Black [1.45 per 100 PY (95% CI: 0.76-2.80)] compared with White and other racialized groups. These findings indicate a need for more clinical and community interventions that support PrEP persistence and restarts among those at high risk of HIV acquisition.

Mapping Community-Engaged Implementation Strategies with Transgender Scientists, Stakeholders, and Trans-Led Community Organizations

PURPOSE OF REVIEW

Pre-exposure prophylaxis (PrEP) represents one of the most effective methods of prevention for HIV, but remains inequitable, leaving many transgender and nonbinary (trans) individuals unable to benefit from this resource. Deploying community-engaged PrEP implementation strategies for trans populations will be crucial for ending the HIV epidemic.

RECENT FINDINGS

While most PrEP studies have progressed in addressing pertinent research questions about gender-affirming care and PrEP at the biomedical and clinical levels, research on how to best implement gender-affirming PrEP systems at the social, community, and structural levels remains outstanding. The science of community-engaged implementation to build gender-affirming PrEP systems must be more fully developed. Most published PrEP studies with trans people report on outcomes rather than processes, leaving out important lessons learned about how to design, integrate, and implement PrEP in tandem with gender-affirming care. The expertise of trans scientists, stakeholders, and trans-led community organizations is essential to building gender-affirming PrEP systems.

Sources of Information about Pre-Exposure Prophylaxis (PrEP) and Associations with PrEP Stigma, Intentions, Provider Discussions, and Use in the United States

The amount and type of information individuals receive about HIV pre-exposure prophylaxis (PrEP) may influence PrEP uptake. We surveyed 331 HIV-negative sexual and gender minorities who have sex with men at a Midwestern Pride festival in 2018 (Mage = 32, 68% White, 87% cisgender men) to assess sources and perceived tone of PrEP information and associated outcomes. Most participants (88%) had heard about PrEP. The most common sources were the internet (70%), social media (59%), and friends (54%). Messages from health campaigns were perceived as most positive and those from religious institutions as least positive. Sources differed based on demographics. Controlling for indications for PrEP use, those who heard about PrEP from health campaigns and those who heard more positive messages reported lower levels of PrEP stigma, βs = -0.27--0.23, ps < .05. Non-users who heard about PrEP from the internet had stronger intentions to use PrEP, β = 0.28, p < .05. Those who heard about PrEP from sexual partners and health campaigns were more likely to discuss PrEP with providers, PRs = 1.60-1.80, ps < .01. Finally, those who heard about PrEP from friends and partners were more likely to use PrEP, PRs = 2.01-2.24, ps < .05. Leveraging sexual partners, social network members, and health campaigns are promising avenues to advance PrEP implementation.

Intersecting Sexual Behavior and Gender Identity Stigmas Among Transgender Women in the United States: Burden and Associations with Sexual Health

In the United States, a context of multiple marginalization shapes sexual health disparities experienced by transgender women. Using data from 396 transgender women with negative or unknown HIV status, we performed exploratory factor analysis on responses to gender identity and sexual behavior stigma items and regressed sexual health outcomes on extracted factors via modified Poisson regression with robust variance estimation. Overall, 97.2% of participants endorsed ≥ 1 gender identity stigma; 67.2% endorsed ≥ 1 sexual behavior stigma; and 66.9% endorsed ≥ 1 of each. Extracted factors included gender-identity social stigma, reflecting experiences related to family, fearfulness in public, and verbal harassment (α = 0.68); gender-identity institutional stigma/violence, reflecting experiences related to healthcare, police interactions, and interpersonal violence (α = 0.73); and global sexual behavior stigma, reflecting experiences related to family, friends, and healthcare, as well as police interactions, fearfulness in public, verbal harassment, and interpersonal violence (α = 0.83). Gender-identity social stigma was significantly, positively associated with testing for HIV and testing for sexually transmitted infections. Gender-identity institutional stigma/violence and global sexual behavior stigma were both significantly, positively associated with condomless anal sex, sex work, testing for HIV, testing for sexually transmitted infections, and use of HIV pre-exposure prophylaxis. Stigma-mitigation remains critical to improve quality of life and sexual health for transgender women in the United States.

Inclusion of Transgender and Gender Diverse People in Phase III Trials: Examples from HIV Pharmacologic Prevention Studies

Although at least 25 million adults are transgender worldwide, few phase III clinical trials have enrolled transgender and gender diverse (TGD) people. HIV is the only therapeutic area to include TGD people intentionally in phase III randomized clinical trials during the development of certain newer HIV pharmacologic prevention interventions. Pharmacologic assessments for HIV prevention efficacy in TGD populations are important, as there may be specific considerations for product use and potential interactions with hormone therapies. Herein, we summarize ongoing and completed phase III HIV trials that included TGD people as part of the study population, we examine investigators' strategies for recruiting and engaging TGD priority populations in these phase III trials, and we comment on the implications of these studies for prioritizing TGD populations in clinical pharmacology research within the phase III clinical trial landscape.

The Use of HIV Pre- and Postexposure Prophylaxis Among a Web-Based Sample of HIV-Negative and Unknown Status Cisgender and Transgender Sexual Minority Men: Cross-sectional Study

BACKGROUND

HIV disproportionately affects sexual minority men (SMM) in the United States.

OBJECTIVE

We sought to determine past HIV postexposure prophylaxis (PEP) use and current and prior pre-exposure prophylaxis (PrEP) use among a web-based sample of cisgender and transgender men who have sex with men.

METHODS

In 2019, HIV-negative and unknown status SMM (n=63,015) were recruited via geosocial networking apps, social media, and other web-based venues to participate in a brief eligibility screening survey. Individuals were asked about past PEP use and current and prior PrEP use. We examined associations of demographics, socioeconomic indicators, and recent club drug use with PEP and PrEP use, as well as the association between past PEP use and current and prior PrEP use using generalized linear models and multinomial logistic regression. Statistical significance was considered at P<.001, given the large sample size; 99.9% CIs are reported.

RESULTS

Prior PEP use was reported by 11.28% (7108/63,015) of the participants, with current or prior PrEP use reported by 21.95% (13,832/63,015) and 8.12% (5118/63,015), respectively. Nearly half (3268/7108, 46%) of the past PEP users were current PrEP users, and another 39.9% (2836/7108) of the participants who reported past PEP use also reported prior PrEP use. In multivariable analysis, past PEP use was associated with current (relative risk ratio [RRR] 23.53, 99.9% CI 14.03-39.46) and prior PrEP use (RRR 52.14, 99.9% CI 29.39-92.50). Compared with White men, Black men had higher prevalence of past PEP use and current PrEP use, Latino men had higher prevalence of PEP use but no significant difference in PrEP use, and those identifying as another race or ethnicity reported higher prevalence of past PEP use and lower current PrEP use. Past PEP use and current PrEP use were highest in the Northeast, with participants in the Midwest and South reporting significantly lower PEP and PrEP use. A significant interaction of Black race by past PEP use with current PrEP use was found (RRR 0.57, 99.9% CI 0.37-0.87), indicating that Black men who previously used PEP were less likely to report current PrEP use. Participants who reported recent club drug use were significantly more likely to report past PEP use and current or prior PrEP use than those without recent club drug use.

CONCLUSIONS

PrEP use continues to be the predominant HIV prevention strategy for SMM compared with PEP use. Higher rates of past PEP use and current PrEP use among Black SMM are noteworthy, given the disproportionate burden of HIV. Nonetheless, understanding why Black men who previously used PEP are less likely to report current PrEP use is an important avenue for future research.