HIV Pre-exposure Prophylaxis Uptake and Continuation Among Key Populations in Cameroon: Lessons Learned From the CHAMP Program

Ensuring equitable access to quality HIV care for affected populations in complex sociocultural settings: Lessons from Nigeria

BACKGROUND

HIV infection remains one of the major diseases of public health importance globally with an estimated 40.4 million deaths and 39 million people living with the virus by 2022. About 40 countries are on track to achieve a 95% reduction in AIDS-related mortality by 2030. This progress is however challenged by sub-optimal progress among affected populations (AP), also known as key populations (AP). Society for Family Health (SFH), with about 3 decades of experiences in AP program present in this paper an account of key strategies and innovations in adapting its service provisioning efforts to rapidly changing socio-cultural and political barriers to service delivery among AP in northern Nigeria.

METHODS

SFH is an indigenous nonprofit, non-political, non-governmental organization in Nigeria that has pioneered HIV interventions among AP across most parts of Nigeria. SFH has successfully tailored its interventions to the unique cultural and religious diversity of Nigeria. The predominantly Islamic-orientated population in the northern part of the country and the Christian-oriented population in the southern part, which is culturally inclined to Western orientations, have all been considered in SFH's comprehensive approach instilling confidence in the effectiveness of its strategies. SFH implemented 3 key strategies to circumvent pervasive socio-cultural and political barriers that hindered successful AP program implementation in northern Nigeria by addressing structural barriers, systems barriers (service-provider and client-related barriers) and by deployment of innovations to optimize program performance. For the purposes of this retrospective cross-sectional study, deidentified routine aggregate program data was utilized to conduct secondary data analysis.

RESULTS

Between 2019 - 2023, SFH tested a total of 324,391 AP of whom 30,581 were found to be HIV positives yielding overall positivity rate of 9.4%. People who inject drugs (PWID) demonstrated sustained high positivity rate over the 5 years. About 80% of those initiated on treatment were female sex workers (FSW) and men who have sex with men (MSM) contributing to 41.8% and 38.5% respectively. Year on year, the number of AP receiving ART more than doubled in 2020 and grew by 85%, 43% and 30% in 2021, 2022 and 2023 respectively. There was progressive increase in VL testing coverage between Year 1 - Year 3 across all the three AP typologies and then steady decline between Year 4 - Year 5. Between Year 1 - Year 2 the viral load suppression was at 91% with remarkable improvement to 97% in Year 3 and Year 4 and at 99% in Year 5.

CONCLUSION

The implementation of people-centered, evidence-driven, culturally, and religiously sensitive program enabled SFH to reach a high number of AP in northern Nigeria. This helps improve equity in access to care by AP. There are specific program areas that need continuous improvement including strategies to reach MSM to avoid the evolution of new structural barriers; expansion of PWID programming to optimize all aspects of harm reduction; and sustained sensitization, education, and awareness creation among AP to improve uptake of PrEP and other prevention and care services.

Cost-effectiveness of health insurance among women engaged in transactional sex and impacts on HIV transmission in Cameroon: a mathematical model

INTRODUCTION

HIV prevalence disproportionately affects high-risk populations, particularly female sex workers in Africa. Women and girls engaging in transactional sex (WGTS) face similar health risks from unsafe practices, economic vulnerabilities and stigma. However, they are not recognised.

METHODS

Using existing literature and data from the POWER randomised controlled trial, we developed a deterministic compartmental model to assess HIV dynamics among WGTS, their sugar daddies and low-risk populations. We evaluated the cost-effectiveness of a new structural intervention to prevent HIV among WGTS in urban Cameroon by reducing the financial need to engage in transactional sex in the case of illness and injury shocks to the household. The intervention provided free healthcare to WGTS and their economic dependents through a zero-cost health insurance package. We explored the cost-effectiveness of this intervention considering various population coverage levels (0%, 25%, 50%, 75% and 100%). We calculated the incremental cost-effectiveness ratio (ICER) per disability-adjusted life-year (DALY) and HIV infections averted, employing both univariable and global sensitivity analyses. Probabilistic sensitivity analyses considered all parameters, including the insurance effect in reducing HIV, comparing simulated ICERs to willingness-to-pay thresholds. We also compared the health insurance strategy with expanding pre-exposure prophylaxis (PrEP) coverage. All costs were evaluated in 2023 UK pounds (£) using a 3% discount rate, with Cameroon's gross domestic product (GDP) per capita recorded at £1239.

RESULTS

Implementing health insurance coverage levels of 25%, 50%, 75% and 100% yielded ICERs/DALY averted of £2795 (£2483-£2824), £2541 (£2370-£2592), £2263 (£2156-£2316) and £1952 (£1891-£1998), respectively, compared with 0% coverage. Probabilistic sensitivity analysis indicated an ICER=£2128/DALY averted at 100% coverage, with 58% of simulations showing ICERs

CONCLUSION

A comprehensive health insurance scheme for women in Cameroon could significantly reduce HIV infections and DALYs, promoting a more inclusive and targeted healthcare policy for women at high risk of HIV.

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Key Words

• HIV
• Health economics
• Health insurance
• Mathematical modelling

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MESH Headings

• Humans
• Cameroon/epidemiology
• HIV Infections/prevention & control
• HIV Infections/transmission
• HIV Infections/economics
• HIV Infections/epidemiology
• Cost-Benefit Analysis
• Female
• Sex Workers/statistics & numerical data
• Insurance, Health/economics
• Models, Theoretical
• Adult

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Grants

• MRC/ESRC
• Dr Aurélia Lépine

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Affiliation(s)

Kasim Allel University College London, London, UK Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
Henry Cust University College London, London, UK Duke University, Durham, North Carolina, USA
Iliassou Mfochive John Hopkins Cameroon Program, Yaounde, Cameroon
Sandie Szawlowski University College London, London, UK
Emile Nitcheu John Hopkins Cameroon Program, Yaounde, Cameroon
Eric Defo Tamgno John Hopkins Cameroon Program, Yaounde, Cameroon
Stephanie Moyoum John Hopkins Cameroon Program, Yaounde, Cameroon
Julienne Noo John Hopkins Cameroon Program, Yaounde, Cameroon
Serge Billong University of Yaounde, Yaoundé, Cameroon
Ubald Tamoufe John Hopkins Cameroon Program, Yaounde, Cameroon
Aurelia Lepine University College London, London, UK

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Determinants of Intention to Use HIV Pre-exposure Prophylaxis and Condom Use Among a Sample of Cisgender Female Sex Workers Working Mostly Outdoors in Madrid, Spain

There is scant knowledge regarding pre-exposure prophylaxis (PrEP) use among female sex workers (FSWs) in Europe. Spain recognized FSWs as a population at high risk of acquiring HIV and granted them subsidized access to PrEP when the medication first became nationally available in 2019. Nevertheless, FSWs represented just 0.2% of PrEP users in 2022. A total of 102 HIV-negative FSWs reached through field activities of local NGOs located in Madrid were interviewed between January and March 2022. Participants were selected through convenience sampling over a fixed recruitment period. FSWs completed a 73-item survey with questions about individual, occupational, social, and structural determinants. The objective of this study was to identify (1) the prevalence of intention to use oral PrEP and its determinants, and (2) the prevalence of inconsistent condom use, which is the risk factor that qualifies FSWs for subsidized PrEP in the national health system, and its determinants. Importantly, the study sample overrepresented street-based FSWs (71.6%). A quarter (25.5%) of the study participants used condoms inconsistently. PrEP awareness was low (9.8%), but intention to use PrEP was high (72.5%). Intention to use oral PrEP was significantly associated with feeling protected against HIV by taking PrEP and perceiving insufficient protection by condom use alone. Inconsistent condom use was significantly associated with frequent heroin/cocaine use, having clients who inject drugs, and willingness to take PrEP despite it not protecting 100% against HIV infection. FSWs, in this specific sample, are likely to benefit from targeted PrEP awareness campaigns and implementation projects that prioritize those who use drugs and are more likely to engage in condomless sex.

Qualitative focus group discussions exploring PrEP method and service delivery preferences among female sex workers and their managers in four Zambian provinces

Objectives

To describe the experiences of oral HIV pre-exposure prophylaxis (PrEP) use, preferences comparing oral PrEP to future long-acting PrEP products (the dapivirine vaginal ring (PrEP ring) and injectable cabotegravir (CAB PrEP)), and service provision preferences among female sex workers (FSWs) and their managers.

Methods

Qualitative formative focus group discussions were conducted in two urban (Copperbelt, Lusaka) and two rural (Central, Luapula) provinces in Zambia. Consenting participants included 43 FSWs and 36 sex work managers. Eligible participants self-identified as FSWs or sex work managers, were 18 years or older and spoke English, Nyanja or Bemba.

Results

FSWs had a median age of 28 years and 60% reported ever using oral PrEP. Among potential future HIV prevention options, most FSWs preferred longer acting PrEP methods, mainly CAB PrEP over the PrEP ring. This preference was consistent across provinces. Many FSWs had personal oral PrEP experience and appreciated the high effectiveness but conveyed that the realities of daily use, including pill visibility, and attributed side effects did not meet their needs. FSWs and managers also identified frequent stigma and misinformation-related barriers to PrEP access and use at community and facility levels. Most FSWs and managers agreed that informing non-paying or long-term partners of PrEP use was acceptable. Participants offered recommendations for greater sensitisation and peer-led services or service extension through trusted figures in the community.

Conclusions

Zambian FSWs and their managers preferred longer acting PrEP methods, particularly CAB PrEP, as part of comprehensive HIV prevention method choice, with little difference between provinces. PrEP programming led by FSW peers, managers or other trusted figures was recommended to address misinformation, sensitise partners and potentially deliver services to circumvent perceived stigma at health facilities.

Discontinuation of HIV oral pre-exposure prophylaxis: findings from programmatic surveillance within two general population HIV programs in Nigeria

BACKGROUND

As oral PrEP scales up in Nigeria, information about uptake, use pattern and client preference in a real-world, implementation setting is invaluable to guide refining service provision and incorporation of oral PrEP and other prevention measures into routine health services. To add to this body of knowledge, our study examines factors associated with discontinuation of PrEP among HIV negative individuals across two large scale programs in Nigeria.

METHODS

Using program implementation data from two large-scale HIV projects in Akwa Ibom and Cross River states in Nigeria between January 2020 and July 2021, we used logistic regression to explore factors associated with early discontinuation (i.e., stopping PrEP within one month of starting) among HIV-negative individuals who initiated PrEP in the programs.

RESULTS

Of a total of 26,325 clients; 22,034 (84%) discontinued PrEP within the first month. The odds of PrEP discontinuation were higher among clients who enrolled in community-based distribution sites (aOR 2.72; 95% C.I: 2.50-2.96) compared to those who enrolled in program-supported facilities and never married (aOR 1.76; 95% C.I: 1.61-1.92) compared to married clients. Clients who initiated PrEP because of high-risk sexual behaviour (aOR 1.15, 95% C.I 1.03-1.30) or inconsistent use or non-use of condoms (aOR 1.96, 95% C.I 1.60-2.41) had greater odds of discontinuing PrEPthan those who initiated PrEP because they were in a serodifferent relationship.

CONCLUSION

The behavioural and demographic factors associated with early discontinuation of PrEP suggest that risk stratification of pre-initiation and follow up counselling may be helpful in raising continuation rates. On the service delivery side, strategies to strengthen follow-up services provided by community-based distribution sites need to be introduced. Overall, the low continuation rate calls for a review of programmatic approaches in provision of PrEP services in Nigeria.

The Feasibility and Acceptability of Using Mobile Applications for HIV Testing, Prevention, and Treatment Among Adolescent Girls and Young Women in Cameroon: A Cross-Sectional Study

ABSTRACT

Adolescent girls and young women (AGYW) are vulnerable populations to HIV/AIDS. We conducted a cross-sectional survey among 637 AGYW in Cameroon to study the feasibility and willingness to use mobile applications (apps) for HIV testing, prevention, and treatment. We found that phone ownership is high among AGYW, where 93.9% ( n = 598) of them (median age: 22 years, interquartile range: 21-24 years) had access to a smartphone, 49.5% ( n = 315) frequently searched for health information, and 48.9% ( n = 312) frequently used health-related apps. AGYW's willingness to use mobile apps for HIV testing, prevention, and treatment were 87.9% ( n = 560), 84.4% ( n = 538), and 84.9% ( n = 541), respectively. The high willingness to use apps was associated with older age, HIV testing, and searching for health information on a phone. Barriers to willingness included having no internet access, concerns about internet cost and privacy, and lack of consistent access to a smartphone.

PrEPare_Morocco a successful community-based PrEP delivery demonstration program for men who have sex with men and female sex workers in Morocco

Pre-exposure prophylaxis (PrEP) is an effective HIV prevention tool, recommended for persons at substantial risk for HIV, such as female sex workers (FSW) and men who have sex with men (MSM). We present Morocco's and the Middle East/North Africa's first PrEP demonstration project. Our pilot aimed to assess the feasibility and acceptability of a community-based PrEP program for FSW and MSM in Morocco's highest HIV prevalence cities: Agadir, Marrakech, and Casablanca. From May to December 2017, 373 eligible participants engaged in a 5-9 month program with daily oral TDF/FTC and clinic visits. Of these, 320 initiated PrEP, with 119 retained until the study's end. We report an 86% PrEP uptake, 37% overall retention, and 78% retention after 3 months. No seroconversions occurred during follow-up. These results underscore PrEP's need and acceptability among MSM and FSW and demonstrate the effectiveness of a community-based PrEP program in Morocco. These findings informed Morocco's current PrEP program and hold potential for the wider region with similar challenges.

Acceptability, feasibility and potential of an intervention using secret Facebook groups to complement existing HIV prevention strategies among female sex workers in Cameroon, a randomized pilot study

This randomized pilot project evaluated an intervention promoting health care literacy around HIV, pre-exposure prophylaxis (PrEP), and stigma reduction using private social media groups that complemented existing HIV prevention services among female sex workers (FSWs) in Cameroon. The intervention was 12 HIV and sexual health videos tailored to FSWs that were released over 8 weeks through a secret Facebook group platform. In-person surveys were administered before, after the intervention, and three months later. No HIV seroconversions were detected; all participants completed follow-up and agreed to recommend the intervention to a coworker. Although the intervention was assessed to be acceptable and feasible to implement, poor internet connectivity was a key barrier. In time-series analysis, the intervention group participants reported improved PrEP interest, PrEP knowledge, and condom use along with reduced PrEP and HIV-related stigma, but no impact on sex-work related stigma or social cohesion. Similar results occurred in the control group. Cross-contamination and small pilot study size might have hindered the ability to detect the differential impact of this intervention. As communications technology increases in Cameroon, it is essential to learn more about FSWs preferences on the use of social media platforms for HIV prevention strategies.

HIV Pre-Exposure Prophylaxis Uptake Among High-Risk Population in Sub-Saharan Africa: A Systematic Review and Meta-Analysis

Globally, 38.4 million people are affected by the human immunodeficiency virus (HIV) pandemic, and more than 2.5 million new HIV infections occur yearly. HIV pre-exposure prophylaxis (PrEP) has been widely recognized as a potential way to prevent new infections among risk population. There is a paucity of abridged evidence on the level and barriers to PrEP service uptake in sub-Saharan Africa (SSA). Therefore, we conducted a systematic review to synthesize existing evidence on PrEP uptake in SSA. Relevant studies were searched from major databases (PubMed and PsychInfo) and direct Google Scholar. Data were extracted and recorded using a pilot-tested template. Methodological rigor, heterogeneity and publication bias of studies were assessed to minimize the inclusion of erroneous findings. A random effect model was used for the meta-analysis followed by narrative metasynthesis. The protocol of this systematic review has been by registered PROSPERO (ID: CRD42022308855). A total of 1830 studies were retrieved, and 30 studies met inclusion criteria of the systematic review. People who heard about PrEP ranged from 23% to 98%. The pooled prevalence of willingness to use PrEP was 64.2% (95% confidence interval: 55.5-72.0). Fear of side effect, stigma, nonreceptive attitude, cost of pills, low awareness about PrEP, perceived reason about the effectiveness of PrEP, and lack of friendly services were the common barriers to PrEP uptake in Africa. In conclusion, comprehensive knowledge and willingness to use PrEP were low in SSA. The barriers to low PrEP service uptake are avoidable through comprehensive awareness creation and availing essential services to key population in Africa. Expanding educational messages to key population using friendly approaches and more accessible platforms, engaging stakeholders, and integrating PrEP service with routine health care are important to foster HIV prevention and control in the future.

Modeling the potential impact of pre-exposure prophylaxis for HIV among men who have sex with men in Cameroon

Background

Men who have sex with men (MSM) are consistently burdened by HIV at higher levels than other adults. While HIV prevention programs for MSM are growing in coverage and quality, HIV incidence remains high. In response, pre-exposure prophylaxis (PrEP) was introduced in 2019 to support HIV risk reduction among MSM in Cameroon. Understanding how PrEP initiation programs will change the HIV prevalence among MSM in Cameroon is important to developing effective programs.

Methods

This study uses a mathematical model to simulate population-level HIV transmission among MSM in the cities of Yaoundé and Douala, Cameroon. PrEP is incorporated into the model at rates that equal 25%, 50%, or 75% coverage after twenty years to assess the potential effects on HIV prevalence among MSM, requiring annual initiation rates of 2.5%, 6.8%, and 17.2% for Yaoundé and 2.2%, 5.6%, and 13.4% for Douala, respectively. The data utilized for this model are from a cross sectional study which recruited MSM through respondent-driven sampling of MSM in two major cities in Cameroon: Yaoundé and Douala.

Results

The model estimated an HIV prevalence of 43.2% among MSM, annual HIV diagnoses of 300 per 10,000 MSM and antiretroviral therapy (ART) coverage of 53.9% in Yaoundé. In Douala, estimated prevalence is 26.5% among MSM, 167 per 10,000 MSM annual diagnoses and ART coverage of 72.0%. Standalone PrEP interventions aimed at 50% coverage at the end of a 20-year program would reduce the prevalence from 43.2% to 35.4% in Yaoundé and from 26.5 to 20.1% in Douala. Combining PrEP with a 10% increase in HIV testing would decrease the number of MSM living with HIV and unaware of their status from 9.8 to 6.0% in Yaoundé and from 8.7 to 4.6% in Douala.

Conclusions

PrEP would be beneficial in reducing prevalence even at varying initiation and coverage levels. Combination of PrEP and increased HIV testing further decreased the number of undiagnosed MSM. This study supports the utility of implementing PrEP as part of comprehensive HIV prevention programming among MSM in Cameroon.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12879-022-07738-z.