Virtual HIV pre-exposure prophylaxis outpatient service in the era of COVID-19

PrEP for women in Europe: a systematic literature review

BACKGROUND

Prevention of HIV transmission is fundamental to ending the HIV epidemic. Pre-exposure prophylaxis (PrEP) with oral tenofovir-emtricitabine (TDF-FTC) is an established HIV-prevention method; however, most PrEP services in Europe have been targeted at men who have sex with men (MSM). A survey in 2021 by Women Against Viruses in Europe (WAVE) showed considerable variation in PrEP access and guidance for women throughout Europe. WAVE therefore commissioned this systematic review to provide insight into PrEP provision and barriers to uptake for women in Europe.

METHODS

PubMed, Embase, and Scopus were searched for studies (January 2013-May 2021) that reported on actual (e.g., efficacy and safety) or hypothetical (e.g., awareness, barriers, PrEP impact models) use of oral PrEP involving women (including cis, transgender, pregnant, migrant, and breastfeeding women). Search terms included HIV, pre-exposure prophylaxis (specifically TDF-FTC), and women. Studies performed outside of the World Health Organization European region were excluded.

RESULTS

The search identified 4716 unique citations, and 45 peer-reviewed articles (44 studies) were included. The majority of these studies (34/44 [77%]) included recipients or potential recipients of PrEP, representing 4699 women (243 transgender women). However, few studies were women focused (4/34 [12%]) or took place outside of Western Europe (3/34 [9%]). Across the three clinical studies that reported women-specific outcomes (60 transgender women, 13 pregnant, and 19 cis women), no breakthrough infections were recorded during the use of PrEP. Lack of awareness of PrEP, low self-estimation of HIV acquisition risk, concerns about stigma, lack of protection against other sexually transmitted infections, and PrEP interaction with hormones (for transgender women) were identified as barriers to use. The remaining studies examined healthcare professionals' perceptions of PrEP (9/44 [20%]), asked for public opinion (2/44 [5%]), or modelled the potential of PrEP for HIV prevention (1/44 [2%]).

CONCLUSIONS

This review revealed a notable lack of literature on PrEP for cis and transgender women in Europe. This is synonymous with a lack of PrEP provision for women in this region. Barriers to PrEP uptake are complex and rooted in institutional and societal stigma, which must be addressed at policy level. HIV prevention with PrEP is not 'one size fits all' and requires a nuanced gender-responsive approach. Further research into the use of PrEP in cis, pregnant, breastfeeding, and transgender women is essential if we are to stop HIV transmission by 2030.

Pre-exposure Prophylaxis Persistence at a Diverse Sexual Health Clinic: Comparison of the pre-COVID-19 era to the COVID-19 era

The COVID-19 pandemic interrupted health care delivery and exacerbated disparities. Many sexual health clinics transitioned to telemedicine, including for pre-exposure prophylaxis (PrEP). We conducted a retrospective cohort study of patients at an urban sexual health clinic to assess the likelihood and predictors of PrEP persistence in the year following PrEP initiation. We compared patients starting PrEP in the four months preceding the first COVID surge to those starting PrEP one year prior. We found lower PrEP persistence in the COVID cohort compared to the pre-COVID cohort (50.8% vs. 68.9%, respectively). In both cohorts, most care was provided through in-person visits and telemedicine was rare. In the pre-COVID cohort, older patients and those identifying as non-Hispanic White were more likely to persist on PrEP. In the COVID cohort, these disparities in PrEP persistence were not observed. Flexible models of care may facilitate equitable care engagement and re-engagement.

Disruptions of sexually transmitted and blood borne infections testing services during the COVID-19 pandemic: accounts of service providers in Ontario, Canada

BACKGROUND

Since the onset of the COVID-19 pandemic in March 2020 in Canada, the availability of sexual health services including sexually transmitted and blood-borne infection (STBBI) testing has been negatively impacted in the province of Ontario due to their designation as "non-essential" health services. As a result, many individuals wanting to access sexual healthcare continued to have unmet sexual health needs throughout the pandemic. In response to this, sexual health service providers have adopted alternative models of testing, such as virtual interventions and self-sampling/testing. Our objective was to investigate service providers' experiences of disruptions to STBBI testing during the COVID-19 pandemic in Ontario, Canada, and their acceptability of alternative testing services.

METHODS

Between October 2020-February 2021, we conducted semi-structured virtual focus groups (3) and in-depth interviews (11) with a diverse group of sexual health service providers (n = 18) including frontline workers, public health workers, sexual health nurses, physicians, and sexual health educators across Ontario. As part of a larger community-based research study, data collection and analysis were led by three Peer Researchers and a Community Advisory Board was consulted throughout the research process. Transcripts were transcribed verbatim and analysed with NVivo software following grounded theory.

RESULTS

Service providers identified the reallocation of public health resources and staff toward COVID-19 management, and closures, reduced hours, and lower in-person capacities at sexual health clinics as the causes for a sharp decline in access to sexual health testing services. Virtual and self-sampling interventions for STBBI testing were adopted to increase service capacity while reducing risks of COVID-19 transmission. Participants suggested that alternative models of testing were more convenient, accessible, safe, comfortable, cost-effective, and less onerous compared to traditional clinic-based models, and that they helped fill the gaps in testing caused by the pandemic.

CONCLUSIONS

Acceptability of virtual and self-sampling interventions for STBBI testing was high among service providers, and their lived experiences of implementing such services demonstrated their feasibility in the context of Ontario. There is a need to approach sexual health services as an essential part of healthcare and to sustain sexual health services that meet the needs of diverse individuals.

Characterizing the Impact of the COVID-19 Pandemic on HIV PrEP care: A Review and Synthesis of the Literature

The global COVID-19 pandemic and associated lockdown measures have caused disruptions to sexual health services and created additional barriers to the continuity of HIV pre-exposure prophylaxis (PrEP) among key populations. This review provides an examination of the influences of the pandemic on engagement in the PrEP care continuum. Using the PRISMA guideline, 46 studies were included in this review and the synthesis. Most of the studies were conducted in high-income settings through quantitative analysis. A majority of studies examining the changes in PrEP use suggested a decline or discontinuation in PrEP uptake during the pandemic. The most common reasons for stopping using PrEP were perceived barriers to PrEP-related care, having reduced sexual behaviors and fewer sexual partners, and reduced perceived risk of HIV infection. Limited studies documenting an increase in PrEP uptake were all in specific PrEP optimizing programs. During the pandemic, there is also an emerging trend of switching to on-demand PrEP from daily oral PrEP. Future studies should understand the mechanism of strategies that facilitated the improvements during the pandemic. PrEP implementation programs should consider alternative PrEP modalities and provide consistent and comprehensive knowledge about correct information.

Provider Perspectives on HIV Pre-Exposure Prophylaxis Service Disruptions and Adaptations During the COVID-19 Pandemic in Baltimore, Maryland: A Qualitative Study

The COVID-19 pandemic continues driving unprecedented disruptions to health care provision, including HIV pre-exposure prophylaxis (PrEP) services. We explored service provider experiences promoting and prescribing PrEP to marginalized populations during the COVID-19 pandemic in Baltimore, Maryland. In February to April 2021, we facilitated four virtual focus group discussions with 20 PrEP providers, representing various professional cadres and practice settings. Employing an iterative, team-based thematic analysis, we identified salient enablers and constraints to PrEP promotion, initiation, and maintenance in the COVID-19 era, along with innovative adaptations to PrEP service delivery. Discussants described attenuated demands for PrEP early in the pandemic, exemplified by high PrEP discontinuation rates. This was attributed to changes in clients' sexual behaviors and shifting priorities, including caregiving responsibilities, during the pandemic. Substantial systems-level disruptions impacting PrEP provision were identified, including outreach service suspension, personnel shortages, and facility restrictions on face-to-face visits. Providers emphasized that these disruptions, though occurring early in the pandemic, had protracted impacts on PrEP accessibility. The transition to telemedicine rendered health care services, including PrEP, more accessible/convenient to some clients and expeditious to providers. However, structural barriers to telehealth engagement (telephone/internet access), coupled with limitations of the virtual care environment (difficulty establishing rapport), impeded efforts to equitably promote and prescribe PrEP. Expanding the PrEP outreach workforce and availing alternatives to telemedicine (e.g., community-based PrEP provision, specimen self-collection) could facilitate PrEP care continuity, especially as COVID-19 transitions from an acute to a protracted health crisis.

Persistent disparities in COVID-19-associated impacts on HIV prevention and care among a global sample of sexual and gender minority individuals

As COVID-19 continues to persist, there is a need to examine its impact among sexual and gender minority individuals, especially those with intersecting vulnerabilities. We conducted a cross-sectional survey with a global sample of sexual and gender minority individuals (n = 21,795) from October 25, 2020 to November 19, 2020, through a social networking app. We characterised the HIV prevention and HIV treatment impacts of COVID-19 and the COVID-19 mitigation response and examined whether subgroups of our study population are disproportionately impacted by COVID-19. Many sexual and gender minority individuals reported interruptions to HIV prevention and HIV care and treatment services. These consequences were significantly greater among people living with HIV, racial/ethnic minorities, immigrants, individuals with a history of sex work, and socio-economically disadvantaged groups. These findings highlight the urgent need to mitigate the negative impacts of COVID-19 among sexual and gender minority individuals.

Evaluation of the impact of human immunodeficiency virus pre-exposure prophylaxis on new human immunodeficiency virus diagnoses during the COVID-19 pandemic

AIMS

The national PrEP programme launched in Ireland in November 2019 with tenofovir/emtricitabine free to those meeting eligibility criteria. We assessed the impact of the first year of the PrEP programme on new HIV diagnoses in the largest sexual health and HIV service in Ireland.

METHODS

A free PrEP service was established in November 2019. We reviewed the number of new diagnoses of HIV between November 2018-2019, before the introduction of the national PrEP programme and compared this with the number of new HIV diagnosis between November 2019-2020.

RESULTS

There were 95 new HIV diagnoses (63.3% MSM) between November 2018 and 2019 and 73 new HIV diagnoses (65.7% MSM) between November 2019 and 2020. There was a statistically significant decline in new HIV diagnoses between the 2 years (P = 0.0003). 546 patients were prescribed PrEP as of December 2020.106 patients (19.4%) changed their PrEP dosing regimen due to lockdown. 178 individuals (32.6%) had a rectal infection diagnosed.

CONCLUSION

There has been a reduction in new HIV diagnoses in our cohort (although this has occurred during a global pandemic). It is too early to say if PrEP reduces late presentations of HIV based on our findings. A significant number of rectal infections were identified in the PrEP clinic suggesting ongoing risk despite pandemic restrictions. Further research into sexual practices during COVID-19 is needed to assess if this had an impact on the lower rates of HIV acquisition.

Accessing needed sexual health services during the COVID-19 pandemic in British Columbia, Canada: a survey of sexual health service clients

Objectives

We assessed COVID-19 pandemic impacts on accessing needed sexual health services, and acceptability of alternative service delivery models, among sexual health service clients in British Columbia (BC), Canada.

Methods

We administered an online survey on 21 July–4 August 2020 to clients using a provincial STI clinic or internet-based testing service, GetCheckedOnline, in the year prior to March 2020. We used logistic regression to identify factors associated with having unmet sexual health needs (ie, not accessing needed services) during March–July 2020 and the likelihood of using various alternative service models, if available.

Results

Of 1198 survey respondents, 706 (59%) reported needing any sexual health service since March 2020; of these 706, 365 (52%) did not access needed services and 458 (66%) had avoided or delayed accessing services. GetCheckedOnline users (univariate OR (uOR)=0.62; 95% CI 0.43 to 0.88) or clients with more urgent needs (eg, treatment for new STI, uOR 0.40 (95% CI 0.21 to 0.7)) had lower odds of unmet sexual health needs. The most common factors reported for avoiding or delaying access were public messaging against seeking non-urgent healthcare (234/662, 35%), concern about getting COVID-19 while at (214/662, 32%) or travelling to (147/662, 22%) a clinic or lab and closure of usual place of accessing services (178/662, 27%). All factors were positively associated with having unmet sexual health needs, with public messaging showing the strongest effect (adjusted OR=4.27 (95% CI 2.88 to 6.42)). Likelihood of using alternative sexual health service models was high overall, with the most appealing options being home self-collection kits (634/706, 90%), receiving test kits or antibiotics at home (592/700, 85%) and express testing (565/706, 80%).

Conclusions

Of BC sexual health service clients needing services during March–July 2020, many had unmet needs. Offering alternative service delivery methods may help to improve access during and beyond the COVID-19 pandemic.

Bringing Iowa TelePrEP to Scale: A Qualitative Evaluation

INTRODUCTION

Regional partnerships between public health organizations and telehealth programs have the potential to expand access to HIV pre-exposure prophylaxis in rural and small urban areas. However, little is known about the best practices for such partnerships. Iowa TelePrEP, a regional public health‒partnered telehealth model created by the Iowa Department of Public Health and the University of Iowa, expanded statewide between 2017 and 2019. This qualitative evaluation assessed the barriers and facilitators to statewide expansion and the lessons learned.

METHODS

Key informants from public health partners across Iowa participated in a focus group and interviews between May 2019 and November 2020. Public health partners included local health departments and disease intervention specialist/partner services programs. Qualitative data were transcribed and thematically coded. Program documents and routinely collected reporting data were reviewed to provide the context for qualitative findings. Data were analyzed in 2020.

RESULTS

TelePrEP expanded in 4 phases through partnerships with 12 public health partners. Public health partners referred 708 clients with pre-exposure prophylaxis indications to telenavigation; of these, 258 were navigated to TelePrEP, and 167 initiated pre-exposure prophylaxis. The facilitators of expansion included early public health partner engagement, model acceptability and inclusion of a navigator, and adaptability to local public health partner settings. The barriers included the need to adapt communication and processes to varying public health partners, difficulty in engaging underserved populations, the COVID-19 pandemic, and perceived gaps in understanding client outcomes.

CONCLUSIONS

Partnerships between regional telehealth programs and local health departments can expand to the state level and increase the capacity to implement pre-exposure prophylaxis in rural and small urban settings. Partnerships should consider how to balance program adaptability to local public health partners with standardization and scalability.