InterPrEP: internet-based pre-exposure prophylaxis with generic tenofovir disoproxil fumarate/emtrictabine in London - analysis of pharmacokinetics, safety and outcomes

A modeling study of pre-exposure prophylaxis to eliminate HIV in Taiwan by 2030

BACKGROUND

The necessity of pre-exposure prophylaxis (PrEP) for ending the global AIDS epidemic by 2030 remains controversial. In Taiwan, the HIV epidemic predominantly affects young, sexually active men who have sex with men (MSM). This study aimed to model the impact and cost-effectiveness of a high-coverage oral emtricitabine/tenofovir PrEP program in Taiwan from an HIV elimination perspective.

METHODS

We applied stochastic and risk/age-structured deterministic modeling to assess the impact of PrEP scale-up on the basic reproduction number (R0) and the trajectory of the HIV epidemic in Taiwan, respectively. Both models were parameterized using the national HIV registry and cascade data. Cost-effectiveness was evaluated from a societal perspective.

RESULTS

Here we show that an intensive HIV test-and-treat strategy targeting HIV-positive individuals alone would substantially decrease HIV transmission but is not sufficient to eliminate the HIV epidemic among MSM at the estimated mixing level. In contrast, a PrEP program covering 50% of young, sexually active, high-risk, HIV-negative MSM would suppress HIV's R0 below 1, facilitating its elimination. It would also reduce HIV incidence to levels below the World Health Organization's HIV elimination threshold (1/1000 person-years) by 2030 and is highly cost-saving, yielding a benefit-cost ratio of 7.16. The program's effectiveness and cost-effectiveness remain robust even under conditions of risk compensation (i.e., no condom use among PrEP users), imperfect adherence (75%), or low-level emtricitabine/tenofovir resistance (1%).

CONCLUSION

Our findings strongly support scaling up PrEP for young, sexually active, high-risk, HIV-negative MSM as a critical strategy to end the HIV epidemic in Taiwan and globally.

Therapeutic drug monitoring of tenofovir disoproxil and emtricitabine in oral HIV pre-exposure prophylaxis (PrEP) users who have undergone gastrointestinal surgery

OBJECTIVES

Oral HIV pre-exposure prophylaxis (PrEP) is highly effective in preventing HIV, but its efficacy depends on adequate absorption of drug, which may decrease following gastrointestinal surgery.

METHODS

Clinicians across eight Genito-urinary Medicine clinics in the United Kingdom submitted data on PrEP users with history of gastrointestinal surgery who were referred to a national complex PrEP multi-disciplinary team between June 2021 and April 2023. Anonymised data were submitted on demographics, surgical history, PrEP regimen, and results of therapeutic drug monitoring (TDM) and HIV screening tests. Descriptive analyses were performed in SPSS version 29.

RESULTS

Nine cases described cis-gender men-who-have-sex-with-men (MSM) with median age of 47.4 years (IQR = 43 - 56.5) taking tenofovir disoproxil (TDF)/emtricitabine (FTC) daily (n = 8) or event-based (n = 1) as PrEP. Median time between PrEP initiation and TDM was 53 days (IQR = 8.5-1705). The mean (±SD) trough concentration of tenofovir (TFV) and FTC were 90.2 ± 27.7 ng/mL and 76.0 ± 45.9 ng/mL, respectively. All patients had a negative HIV test at follow-up.

CONCLUSIONS

Plasma trough concentrations of TFV observed in our cohort taking TDF/FTC were above the expected concentrations associated with PrEP efficacy as previously described in the literature, suggesting that PrEP can be safely given in this population, with TDM used for reassurance.

Public Health Implications of Adapting HIV Pre-exposure Prophylaxis Programs for Virtual Service Delivery in the Context of the COVID-19 Pandemic: Systematic Review

BACKGROUND

The novel coronavirus disease COVID-19 caused by SARS-CoV-2 threatens to disrupt global progress toward HIV epidemic control. Opportunities exist to leverage ongoing public health responses to mitigate the impacts of COVID-19 on HIV services, and novel approaches to care provision might help address both epidemics.

OBJECTIVE

As the COVID-19 pandemic continues, novel approaches to maintain comprehensive HIV prevention service delivery are needed. The aim of this study was to summarize the related literature to highlight adaptations that could address potential COVID-19-related service interruptions.

METHODS

We performed a systematic review and searched six databases, OVID/Medline, Scopus, Cochrane Library, CINAHL, PsycINFO, and Embase, for studies published between January 1, 2010, and October 26, 2021, related to recent technology-based interventions for virtual service delivery. Search terms included "telemedicine," "telehealth," "mobile health," "eHealth," "mHealth," "telecommunication," "social media," "mobile device," and "internet," among others. Of the 6685 abstracts identified, 1259 focused on HIV virtual service delivery, 120 of which were relevant for HIV prevention efforts; 48 pertained to pre-exposure prophylaxis (PrEP) and 19 of these focused on evaluations of interventions for the virtual service delivery of PrEP. Of the 16 systematic reviews identified, three were specific to PrEP. All 35 papers were reviewed for outcomes of efficacy, feasibility, and/or acceptability. Limitations included heterogeneity of the studies' methodological approaches and outcomes; thus, a meta-analysis was not performed. We considered the evidence-based interventions found in our review and developed a virtual service delivery model for HIV prevention interventions. We also considered how this platform could be leveraged for COVID-19 prevention and care.

RESULTS

We summarize 19 studies of virtual service delivery of PrEP and 16 relevant reviews. Examples of technology-based interventions that were effective, feasible, and/or acceptable for PrEP service delivery include: use of SMS, internet, and smartphone apps such as iText (50% [95% CI 16%-71%] reduction in discontinuation of PrEP) and PrEPmate (OR 2.62, 95% CI 1.24-5.5.4); telehealth and eHealth platforms for virtual visits such as PrEPTECH and IowaTelePrEP; and platforms for training of health care workers such as Extension for Community Healthcare Outcomes (ECHO). We suggest a virtual service delivery model for PrEP that can be leveraged for COVID-19 using the internet and social media for demand creation, community-based self-testing, telehealth platforms for risk assessment and follow-up, applications for support groups and adherence/appointment reminders, and applications for monitoring.

CONCLUSIONS

Innovations in the virtual service provision of PrEP occurred before COVID-19 but have new relevance during the COVID-19 pandemic. The innovations we describe might strengthen HIV prevention service delivery during the COVID-19 pandemic and in the long run by engaging traditionally hard-to-reach populations, reducing stigma, and creating a more accessible health care platform. These virtual service delivery platforms can mitigate the impacts of the COVID-19 pandemic on HIV services, which can be leveraged to facilitate COVID-19 pandemic control now and for future responses.

A Comparison of Tenofovir Predose Concentrations in Generic Pre-exposure Prophylaxis Formulations: A Short Communication

BACKGROUND

There is extensive evidence to show that pre-exposure prophylaxis (PrEP) using tenofovir disoproxil fumarate (TDF)-based formulations dramatically reduces the risk of HIV acquisition among individuals without HIV infection. Here, the authors aim to compare tenofovir plasma predose concentrations in subjects taking PrEP daily versus on demand and using different TDF-based generic formulations.

METHODS

Subjects providing informed signed consent for the measurement of tenofovir plasma levels were included in the study. Predose drug concentrations were stratified according to PrEP administration and the type of TDF-based formulation. The control group consisted of patients with HIV infection who were matched for renal function and were administered branded TDF that was not combined with boosted-antiretroviral drugs.

RESULTS

The study consisted of 100 subjects (mean age, 39 ± 10 years; body weight, 77 ± 11 kg). A wide distribution in tenofovir predose concentrations was observed, with values ranging from 17 to 297 ng/mL (coefficient of variation 77%). No significant differences were noted in tenofovir predose concentrations between subjects who were administered PrEP daily (n = 75) or on demand (n = 25) [94 (35-255) versus 104 (37-287) ng/mL; P = 0.476]. Comparable tenofovir predose concentrations were found between patients with HIV infection (n = 220) who were administered branded TDF and those without HIV infection who were treated with 5 different generic TDF-based formulations with generics-to-branded ratios. These were always within the range of 80%-125% and were used to define bioequivalence.

CONCLUSIONS

The marketed generic formulations of TDF delivered tenofovir plasma predose concentrations comparable with those delivered by branded formulations.

Choosing event-driven and daily HIV pre-exposure prophylaxis - data from two European PrEP demonstration projects among men who have sex with men

INTRODUCTION

Daily and event-driven PrEP are both efficacious in reducing the risk for HIV infection. However, the practice of event-driven PrEP (edPrEP) is less well studied, in particular when provided as an alternative to daily PrEP. We studied regimen preferences and switches, and sexually transmitted infection (STI) incidence.

METHODS

We analysed pooled data from two prospective cohort studies among MSM: Be-PrEP-ared, Belgium and AMPrEP, the Netherlands. In both projects, participants could choose between daily and edPrEP at three-monthly study visits, when they were also screened for sexually transmitted infections including hepatitis C (HCV). We assessed the proportion choosing each regimen, and the determinants of choosing edPrEP at baseline. Additionally, we compared the incidence rates (IRs) of HCV, syphilis and chlamydia or gonorrhoea between regimens using Poisson regression. The study period was from 3 August 2015 until 24 September 2018.

RESULTS AND DISCUSSION

We included 571 MSM, of whom 148 (25.9%) chose edPrEP at baseline. 31.7% of participants switched regimen at least once. After 28 months, 23.5% used edPrEP. Older participants (adjusted odds ratio (aOR) = 1.38 per 10 years, 95% confidence interval (CI) = 1.15 to 1.64) and those unemployed (aOR = 1.68, 95% CI = 1.03 to 1.75) were more likely to initially choose edPrEP. IR of HCV and syphilis did not differ between regimens, but the IR of chlamydia/gonorrhoea was higher among daily users (adjusted incidence rate ratio = 1.61, 95% CI = 1.35 to 1.94).

CONCLUSIONS

A quarter of participants chose edPrEP at baseline and at 28 months this proportion was similar. Although the IR of HCV and syphilis were similar in the two regimens, the lower incidence of chlamydia and gonorrhoea among edPrEP users may suggest that less frequent STI testing of this group could be considered.

Provision of Preexposure Prophylaxis at the Portuguese National Health Service and Uptake in the Lisbon Cohort of Men Who Have Sex with Men

We aimed to study the uptake of preexposure prophylaxis (PrEP) before and after its implementation in the Portuguese National Health Service (PNHS) among men who have sex with men (MSM). We studied 6164 participants in the Lisbon Cohort of MSM who participated between March 2014 and July 2019. 198 participants (3.2%) reported having recently used PrEP. Approximately one-third started PrEP after its implementation. PrEP uptake increased from 0.15% in 2014 to 5.36% in 2019. In their first use, 86 participants (70.5%) used it daily. How PrEP was obtained varied according to the timing of the first use: prescribed by a physician in Portugal (11.1% before vs 68.8% after implementation) and online (40.7% before vs 14.1% after). We observed an increase in the uptake and in the prescription by a physician, particularly after its implementation in the PNHS representing a change to a more equitable and safer way of using PrEP.

Socio-Sexual Experiences and Access to Healthcare Among Informal PrEP Users in the Netherlands

The aim of this qualitative study was to explore the experiences of informal PrEP users regarding access to PrEP and PrEP-related healthcare, community responses, sexual behavior and well-being. We interviewed 30 men who have sex with men (MSM) in semi-structured online interviews between March and August 2018. Interviews were analyzed using interpretive description. Informal PrEP users were well informed about the use of PrEP, but sometimes did not make use of renal testing. Participants reported a lack of PrEP knowledge among healthcare providers, which limited their access to PrEP and put them at risk, as they received incorrect information. Although some participants reported negative reactions from potential sex partners, most received positive reactions and were sometimes seen as more desirable sex partners. PrEP healthcare services should not only be accessible to formal PrEP users, but also to PrEP users who procure PrEP informally.

Low Tenofovir Plasma Exposure in HIV Oral Pre-exposure Prophylaxis Recipients with Gastrointestinal Disorders

Four pre-exposure prophylaxis (PrEP) users with gastro-intestinal disorders (sleeve gastrectomy, terminal ileitis, celiac disease or chronic diarrhea) and receiving oral tenofovir disoproxil fumarate/emtricitabine (TDF/FTC) were included. Despite a self-reported high adherence, trough plasma tenofovir concentrations (after a supervised intake) were significantly lower than those observed in PrEP recipients without gastrointestinal disorders [21 (±9.1) vs. 138 (±85) ng/mL]. PrEP users with gastrointestinal disorders may need increased TDF doses or alternative prophylactic measures.

First year of pre-exposure prophylaxis implementation in France with daily or on-demand tenofovir disoproxil fumarate/emtricitabine

BACKGROUND

In January 2016, the French Medicine Agency initiated a Temporary Recommendation for Use (TRU) to allow the use of oral intake of tenofovir disoproxil fumarate and emtricitabine for pre-exposure prophylaxis (PrEP) in adults at high risk of HIV. We report the results of the first year of PrEP implementation in France.

METHODS

Data were collected by physicians using a secured web subject-monitoring interface, with two forms: an initiation form, with patients' baseline characteristics, and an HIV seroconversion form. Univariate and adjusted multivariate analysis using a logistic regression model were performed to identify baseline factors associated with on-demand PrEP regimen prescription.

RESULTS

From 4 January 2016 to 28 February 2017, 3405 subjects were enrolled, with 2774 initiation forms completed; 98.1% were male and 96.9% were MSM. An on-demand regimen was prescribed to 57% of subjects. Older age (OR for participants older than 50 years = 1.76, 95% CI 1.35-2.3, P < 0.001) and site of prescription (OR of former IPERGAY sites = 2.28, 95% CI 1.84-2.83, P < 0.001) were associated with on-demand prescription. Those reporting sexually transmitted infection (STI) and condomless anal sex with at least two different partners were less likely to receive on-demand PrEP (OR = 0.68, 95% CI 0.57-0.82 and 0.75, 95% CI 0.57-0.98, respectively; P < 0.05 for all). Four breakthrough HIV infections were reported during the study, in the context of PrEP interruption or acute infection at the time of PrEP initiation.

CONCLUSIONS

In a real-life setting in France, PrEP was used, either daily or on-demand, mostly by MSM, with breakthrough infections being rare.

Defining gaps in pre-exposure prophylaxis delivery for pregnant and post-partum women in high-burden settings using an implementation science framework

Pregnancy is a high-risk period for HIV acquisition in African women, and pregnant women who become acutely infected with HIV account for up to a third of vertical HIV transmission cases in African settings. To protect women and eliminate vertical transmission, WHO recommends offering oral pre-exposure prophylaxis (PrEP) based on tenofovir to HIV-negative pregnant and post-partum women with a substantial risk of HIV acquisition. PrEP implementation for pregnant and post-partum women lags behind implementation for other high-risk populations. Unique considerations for PrEP implementation arise during pregnancy and post partum, including the integration of provider training with clinical delivery and monitoring of PrEP exposure and outcomes within existing maternal health systems, yet scarce implementation data are available to generate evidence in this context.

Changing the Use of HIV Pre-exposure Prophylaxis Among Men Who Have Sex With Men During the COVID-19 Pandemic in Melbourne, Australia

We surveyed 204 men who have sex with men (MSM) who were pre-exposure prophylaxis (PrEP) users. One in 4 daily PrEP users stopped taking PrEP during the COVID-19 pandemic, and 5% switched to on-demand PrEP. Most men reduced PrEP use because they stopped having casual sex and reduced the number of casual partners during the COVID-19 pandemic.

Factors associated with the informal use of HIV pre-exposure prophylaxis in Germany: a cross-sectional study

INTRODUCTION

Until September 2019, pre-exposure prophylaxis (PrEP) with tenofovir disoproxil/emtricitabine for HIV prevention was not covered by health insurance plans in Germany, and was only available through private prescriptions with self-pay or through informal non-prescription sources. The objective of this study was to investigate the proportion of informal PrEP use among PrEP users and to identify factors of public health relevance that might be associated with informal PrEP use.

METHODS

We conducted a cross-sectional study recruiting PrEP users independent of their PrEP source. Clients from anonymous community testing checkpoints, users of three dating apps for men who have sex with men residing in Germany and users of a PrEP community website, were recruited to complete a short anonymous online survey. Participants were recruited between 24 July and 3 September 2018. The results were analysed using univariable and multivariable logistic regressions.

RESULTS

We recruited 2005 participants currently using PrEP. The median age was 38 years, and 80.3% of the participants identified themselves as male (missing: 19.1%). Overall, 71.6% obtained PrEP through medical services with a private prescription or a clinical trial, and 17.4% obtained PrEP through informal sources (missing: 11.0%). The most common informal sources were ordering online from another country (8.8%), travel abroad (3.6%), and friends (2.5%). Factors associated with informal PrEP use were on demand/intermittent dosing (adjusted OR: 3.5, 95% CI 2.5 to 5.0) and not receiving medical tests during PrEP use (adjusted OR: 3.2, 95% CI 2.0 to 5.2). In addition, informal PrEP users who did not take PrEP daily had a strongly increased risk of starting PrEP without prior medical tests (adjusted stratum-specific OR = 31.7, 95% CI 4.6 to 219.5).

CONCLUSIONS

Informal PrEP use was associated with a higher risk of not getting tested before and during PrEP use, which could lead to HIV infections resistant to tenofovir and emtricitabine if people with undiagnosed HIV use PrEP. Health insurance plans that cover PrEP and the accompanying routine tests could ensure adequate medical supervision of PrEP users and reduce barriers to PrEP use. Our findings strongly support the implementation of PrEP programmes in countries with similar patterns of informal PrEP use.

The PrEP You Want: A Web-Based Survey of Online Cross-Border Shopping for HIV Prophylaxis Medications

Background

In response to the high cost of HIV pre-exposure prophylaxis (PrEP) medications in Canada, community organizations have created internet-based guides detailing how to legally order generic medications online and travel to collect them in the United States. However, little is known about the patients following these guides.

Objective

Our primary objective was to measure the proportion of Ontario gay, bisexual, and other men who have sex with men (GBMSM) accessing these online guides who intended to use the border-crossing approach. Our secondary objectives were to explore their demographic characteristics, their completion of the steps in the border-crossing approach, and the barriers they perceived.

Methods

Between July 20, 2017, and May 18, 2018, we administered two online surveys of GBMSM accessing an online border-crossing guide posted by a gay men’s health organization in Ontario. Participants completed an open baseline survey posted on the border-crossing guide’s Web page and a follow-up survey 3 months later. The data were analyzed using descriptive statistics. We used multivariable logistic regression to identify characteristics associated with the intention to use the border-crossing approach.

Results

Most of the 141 participants were young (median age 23, interquartile range 22-25 years) and black (79.4%; 112/141) GBMSM who had completed a college or an undergraduate degree (62.4%; 88/141). In addition, 19.9% (28/141) of them reported a total family income less than Can $30,000 and another 53.9% (76/141) reported income between Can $30,000 and Can $60,000. 54.6% (76/141) paid for medications entirely out of pocket. Most participants indicated that they were likely to complete a border-crossing approach: 80.1% (113/141) at baseline and 79.1% (87/110) at follow-up. The characteristics associated with the intention to use the approach included being black (adjusted odds ratio [aOR] 5.73, 95% CI 2.06-16.61), paying for medications out of pocket (aOR 5.18, 95% CI 1.82-17.04), and having a provider who was thought to be willing to prescribe PrEP (aOR 4.42, 95% CI 1.63-12.41). Comparing baseline and follow-up for the 110 participants who completed both surveys, 65.4% (72/110) and 80.0% (88/110) had discussed PrEP with a health care provider, 18.1% (20/110) and 25.4% (28/110) had obtained a PrEP prescription, and 8.2% (9/110) and 5.5% (6/110) had ordered medications to that mailbox, whereas only 1.0% (1/110) and 0.0% (0/110) had crossed the border to collect them at baseline and follow-up, respectively. Reported barriers included perceived concerns about the approach’s legality (56.0%; 79/141), the security of personal health information (39.0%; 55/141), and the safety of online vendors (38.3%; 54/141).

Conclusions

Despite high interest in pursuing an online border-crossing approach to get PrEP medications, such an approach may not be a viable option for PrEP scale-up among interested GBMSM because of logistical challenges and perceptions of safety and legitimacy.

Interest in Switching to On-Demand HIV Pre-Exposure Prophylaxis (PrEP) Among Australian Users of Daily PrEP: An Online Survey

We surveyed 970 PrEPX study participants to evaluate interest in switching from daily to on-demand PrEP in a study setting. Interested respondents (n = 469, 48%) more commonly reported PrEP cessation (adjusted odds ratio [aOR], 3.0; P < .001), difficulty with adherence (aOR, 1.6; P = .029), infrequent sex (aOR, 3.7; P < .001), and toxicity concerns (aOR, 2.7; P < .001).

Quantification of tenofovir disoproxil fumarate and emtricitabine in generic pre-exposure prophylaxis tablets obtained from the internet

In this study, we addressed the recent concerns over the authenticity of generic pre-exposure prophylaxis (PrEP) purchased online by sampling 14 generic PrEPs from different manufacturers and suppliers and measuring tenofovir disoproxil fumarate (TDF) and emtricitabine (FTC) content using high-performance liquid chromatography. We confirmed that all the PrEP tablets contained 94.3% to 104.9% of the 300 mg of TDF claimed on the label and 97.3% to 104.4% of the 200 mg FTC claimed on the label.

Sexual safety and HIV prevention in travel medicine: Practical considerations and new approaches

Travellers who engage in sexual contact with a new sexual partner abroad may be at high risk of HIV and other sexually transmitted infections (STIs), but these risks can be reduced through appropriate planning during the pre-travel clinic visit. Here we discuss strategies available to the clinician to maximise travellers' sexual safety during travel. Strategies may include immunizations, condoms, HIV pre-exposure prophylaxis (PrEP), HIV post-exposure prophylaxis (PEP), self-initiated treatment of symptomatic bacterial STIs, post-exposure prophylaxis for bacterial STIs and hormonal contraception. We discuss the role of these different strategies for travellers, and provide resources to assist clinicians in making clinical decisions and in educating travellers about sexual safety.

Choosing Between Daily and Event-Driven Pre-exposure Prophylaxis: Results of a Belgian PrEP Demonstration Project

BACKGROUND

Daily pre-exposure prophylaxis and event-driven pre-exposure prophylaxis (PrEP) are efficacious in reducing HIV transmission among men who have sex with men (MSM). We analyzed baseline data from a PrEP demonstration project "Be-PrEP-ared" in Antwerp, Belgium, to understand preferences for daily PrEP or event-driven PrEP among MSM at high risk of HIV and factors influencing their initial choice.

METHODS

Cross-sectional data from an open-label prospective cohort study, using mixed methods. Participants who preregistered online were screened for eligibility and tested for sexually transmitted infections (STIs). Eligible participants chose between daily PrEP and event-driven PrEP and reported on behavioral data through an electronic questionnaire. In-depth interviews were conducted with a selected subsample. Bivariate associations were examined between preferred PrEP regimens and sociodemographic factors, sexual behavior, and STIs at screening.

RESULTS

In total, 200 participants were enrolled between October 2015 and December 2016. Self-reported levels of sexual risk-taking before enrollment were high. STI screening revealed that 39.5% had at least 1 bacterial STI. At baseline, 76.5% of participants preferred daily PrEP and 23.5% event-driven PrEP. Feeling able to anticipate HIV risk was the most frequent reason for preferring event-driven PrEP. Regimen choice was associated with sexual risk-taking behavior in the past 3 months. Almost all participants (95.7%) considered it likely that they would change their dosing regimen the following year.

CONCLUSION

Event-driven PrEP was preferred by 23.5% of the participants, which better suits their preventive needs. Event-driven PrEP should be included in PrEP provision as a valuable alternative to daily PrEP for MSM at high risk of HIV.

Daily or on-demand oral tenofovir disoproxil fumarate/emtricitabine for HIV pre-exposure prophylaxis: experience from a hospital-based clinic in France

BACKGROUND

On-demand oral tenofovir disoproxil fumarate and emtricitabine (TDF/FTC) has been approved for pre-exposure prophylaxis (PrEP) in MSM in France following the results of clinical studies, but data are limited on real-world experience.

DESIGN

A single-center, open-label, prospective cohort study that recruited people at high risk of HIV infection in Paris.

METHODS

Participants were enrolled in a single hospital-based outpatient clinic and were proposed to start PrEP with daily or on demand TDF/FTC. At baseline and every 3 months thereafter, patients were tested for HIV and creatinine plasma levels, and data on sexual behavior, other sexually transmitted infections (STIs), and tolerability were collected.

RESULTS

From 10 November 2015 to 30 April 2017, 1069 patients were screened and 1049 (98.1%) started PrEP. Median age was 36 years, 99.4% were MSM with a median number of partners of 10, and 793 (75.6%) opted for on demand PrEP. Over 486 person-years of follow-up, four HIV-infections were diagnosed in poorly or nonadherent patients (incidence 0.82/100 person-years). Rate of condomless sex at last intercourse increased from 53.3% at baseline to 79% at month 12 (P < 10), but increase in bacterial STI rates was modest (14.6% at baseline vs. 19.2% at month 12; P < 10). Most adverse events were gastrointestinal and did not lead to PrEP discontinuation.

CONCLUSIONS

Most PrEP users were high-risk MSM and opted for on-demand PrEP. PrEP use was associated with a low HIV incidence and a high rate of condomless sex with a modest increase in bacterial STIs.

DIY HIV prevention: Formative qualitative research with men who have sex with men who source PrEP outside of clinical trials

Pre-exposure prophylaxis (PrEP) with antiretroviral medication is an effective, evidence-based option for HIV prevention. In England, issues of cost-effectiveness and of responsibility for commissioning prevention services have so far led National Health Service (NHS) England to decide not to commission PrEP. Given the significant lag between the awareness of PrEP efficacy and the opportunity to obtain PrEP through traditional health care routes, many gay and other men who have sex with men (MSM) have turned to ‘DIY PrEP’, purchasing generic formulations of PrEP for themselves on the internet or via other alternative routes. However, there is very little research on DIY PrEP practices and no qualitative study with DIY PrEP users in the UK. A formative qualitative study was conducted in 2017 to inform the development of an intervention (PrEP Club) to support DIY PrEP users and improve the safety and experience of this prevention strategy. Focus groups were held with 20 MSM who are based in London and are obtaining PrEP through means other than clinical trials, to explore their accounts of sourcing and using PrEP and the experiential meanings of these. In this article, we report findings from this first, formative study and present the different practices involved in finding out about PrEP, buying it and ascertaining legitimacy of sellers and products. We reflect on the uncertainties participants described related to actually using PrEP, including deciding on drug dosing and monitoring their health. Finally, we present the results of the discussions participants had about the kind of support they had received, the help they would have liked, and their views on proposed interventions to support DIY PrEP users, such as PrEP Club.