Ambiguity, ambivalence, and apprehensions of taking HIV-1 pre-exposure prophylaxis among male couples in San Francisco: a mixed methods study

[Discrepancy between behavioral-indicated and perceived candidacy for HIV pre-exposure prophylaxis among men who have sex with men in Chengdu, China]

OBJECTIVE

To explore the discrepancy between behavioral-indicated candidacy and perceived candidacy (behavioral-perceived gap) and its associated factors of human immunodeficiency virus (HIV) pre-exposure prophylaxis (PrEP) among men who have sex with men (MSM), so as to identify the focus population of PrEP interventions and to design and implement targeted interventions.

METHODS

We recruited a sample of 622 HIV-negative MSM who were regular clients of a community-based organization located in Chengdu, China, from November to December 2021. A cross-sectional questionnaire was used to collect the participants' information on social demographics, PrEP-related knowledge and cognitions, and risk behaviors. In this study, behaviorally eligible for PrEP was defined as performing at least one type of high-risk behavior in the past six months, including inconsistent condom use, sex with an HIV-positive partner, confirmed sexual transmitted infections (STI) diagnosis, substance use, and post-exposure prophylaxis (PEP) experience. Logistic regression models were fitted, and multivariate analyses were adjusted for social demographics.

RESULTS

Among the 622 eligible participants, 52.6% (327/622) were classified as behaviorally eligible for PrEP. Only 37.9% (124/327) of the participants perceived themselves as appropriate candidates for PrEP and 62.1% (203/207) had discrepancy between behavioral-indicated and perceived candidacy. 85.9% (281/327) had heard of PrEP, and 14.2% (40/281) accessed PrEP information through health care providers. Of the 327 participants eligible for behavior-indicated PrEP use, about half (47.1%) knew how to obtain PrEP medication and 33.0% had a professional PrEP counseling experience. The majority (93.3%) had no or few friends using PrEP. 54.1% scored eight or above in PrEP knowledge level. 66.7% reported having two or more sexual partners in the past six months. After adjusting for age and recruitment channel, we found six factors that were associated with perceived candidacy for PrEP, including PEP use [adjusted odds ratio (ORA)=2.20; 95% confidence interval (CI): 1.33-3.63], PrEP availability (ORA=1.69; 95%CI: 1.06-2.68), a greater number of PrEP-using friends (ORA=4.92; 95%CI: 1.77-13.65), PrEP know-ledge (ORA=2.21; 95%CI: 1.38-3.56), multiple sexual partnership (ORA=1.77; 95%CI: 1.07-2.94), and perceiving a higher risk of HIV infection (ORA=4.02; 95%CI: 1.73-9.32). Substance use during sex and PrEP information channel were not statistically associated with this beha-vioral-perceived gap.

CONCLUSION

We observed a high discrepancy between behavioral-indicated and perceived candidacy for PrEP among Chengdu MSM in China. Future PrEP implementation efforts should be made in skills training in assessing HIV infection risk, increasing PrEP knowledge, providing professional PrEP counselling, and fostering PrEP support environment.

Explicit Relationship Agreements and HIV Pre-exposure Prophylaxis Use by Gay and Bisexual Men in Relationships

Relationship agreements are important for HIV prevention among gay and bisexual men (GBM) in relationships, with research earlier in the HIV epidemic often finding that agreements specified monogamy or condom use with casual partners. There is evidence that HIV pre-exposure prophylaxis (PrEP) has shifted sexual practices among some men in relationships, such as allowing condomless sex with casual partners, but there has been little attention paid to relationship agreements among GBM who use PrEP. In this paper, we analyzed national, Australian, cross-sectional data from an online survey completed by non-HIV-positive GBM in 2021 (N = 1,185). Using logistic regression, we identified demographic characteristics, sexual practices and the types of relationship agreement that were associated with PrEP use among GBM in relationships. Using Pearson's chi-squared tests, we explored whether PrEP users in relationships reported similar sexual practices to PrEP users not in relationships. PrEP use among GBM in relationships was independently associated with older age, identifying as gay, being in a non-monogamous relationship, having a spoken (explicit) relationship agreement, having a primary HIV-negative partner taking PrEP or a primary partner living with HIV, reporting recent condomless casual sex, reporting an STI diagnosis in the past year, and knowing at least one other PrEP user. We found that PrEP users in relationships had similar sexual practices to PrEP users not in relationships. GBM in relationships who have casual sex and who meet PrEP suitability criteria may be good candidates for PrEP. Our findings suggest that explicit relationship agreements remain important for HIV prevention, and they support PrEP use among GBM in relationships.

Paying for PrEP: A qualitative study of cost factors that impact pre-exposure prophylaxis uptake in the US

BACKGROUND

Concerns about the actual and perceived costs of pre-exposure prophylaxis (PrEP) continue to be a major barrier to uptake among gay, bisexual and men who have sex with men (GBMSM) in the United States.

METHODS

We conducted semi-structured interviews with 25 GBMSM who presented for routine health care at a STD clinic in the northeastern United States. The cohort included GBMSM who were or were not currently taking PrEP and represented varied health care coverage and financial resources. We used a structured coding scheme to analyze transcripts and identify themes relevant to cost factors.

RESULTS

Participants shared their perspectives about PrEP and their experiences with accessing and paying for PrEP. Our findings suggest that health care coverage or financial assistance were essential to PrEP access but were not easily accessible to all people and did not always cover all costs. Therefore, paying for PrEP had to be balanced with other life expenses. Participants had multiple sources for information about PrEP cost and assistance from clinic and pharmacy staff helped reduce burden and resolve difficulties.

CONCLUSION

Addressing gaps in health care coverage, providing financial support, and improving the enrollment process in a financial assistance program may improve PrEP uptake.

Dyadic Influences on Pre-exposure Prophylaxis (PrEP) Use and Attitudes Among Male Couples

Pre-exposure prophylaxis (PrEP) affords an opportunity to significantly reduce the risk of HIV infection among male couples. We used cross-sectional dyadic data from 382 concordant-negative male couples to examine demographic and relationship characteristics associated with current PrEP use, willingness to use PrEP in the future, and perceived ability to adhere to PrEP using Actor-Partner Independence Models. Few partnered men reported currently using PrEP (16.4%) and 57.7% of non-users reported being unlikely to use PrEP in the future. Actor and partner perceptions of PrEP stigma significantly reduced PrEP use and perceptions of willingness to use PrEP or the ability to adhere to PrEP, while perceiving a higher prevalence of HIV among men was associated with significant increases in PrEP use, willingness and perceived ability to adhere. Perceptions that more friends would support PrEP use were also significantly associated with increases in willingness and perceived ability to adhere to PrEP. Dyadic interventions are needed to provide couples the skills to communicate about HIV risk and prevention, and address myths around the protective effect of relationships against HIV acquisition.

Pre-exposure Prophylaxis (PrEP) Information on Instagram: Content Analysis

Background

There is still an HIV epidemic in the United States, which is a substantial issue for populations bearing a disproportionate burden of HIV infections. Daily oral pre-exposure prophylaxis (PrEP) has proven to be safe and effective in reducing HIV acquisition risk. However, studies document that PrEP awareness/usage is low. There is also limited understanding of social media platforms, such as Instagram, as PrEP information sources.

Objective

Given the paucity of research on PrEP-related Instagram posts and popularity of this social media platform, the purpose of this research is to describe the source characteristics, image types, and textual contents of PrEP-related posts on Instagram.

Methods

Using Crowdtangle Search, a public insights tool owned/operated by Facebook, we retrieved publicly accessible and English-language-only Instagram posts for the 12-month period preceding April 22, 2020, using the following terms: Truvada or “pre-exposure prophylaxis” or #truvada or #truvadaprep or #truvadawhore or #truvadaforprep. We employed a qualitative coding methodology to manually extract information from posts. Using a pretested codebook, we performed content analysis on 250 posts, examining message and source characteristics (ie, organization type [eg, government, news] and individual type [eg, physician]), including information about PrEP (eg, how it works, cost), and indicated users. Frequencies and percentages were calculated for all categorical variables. A Chi-square test was conducted to determine differences between source types on a variety of message characteristics.

Results

Three-quarters of the posts (193/250, 77.2%) were posted by organizations. Of the 250 posts reviewed, approximately two-thirds (174/250, 69.6%) included a photograph, more than half (142/250, 56.8%) included an infographic, and approximately one-tenth (30/250, 12%) included a video. More than half defined PrEP (137/250, 54.8%), but fewer posts promoted PrEP use, explained how PrEP works, and included information on the effectiveness of PrEP or who can use it. The most commonly hashtagged populations among posts were men who have sex with men (MSM), but not necessarily bisexual men. Few posts contained race-/ethnicity-related hashtags (11/250, 4.4%). Fewer posts contained transgender-associated tags (eg, #transgirl; 5/250, 2%). No posts contained tags related to heterosexuals or injection drug users. We found statistical differences between source types (ie, individual versus organization). Specifically, posts from organizations more frequently contained information about who can use PrEP, whereas posts from individuals more frequently contained information describing adverse effects.

Conclusions

This study is among the first to review Instagram for PrEP-related content, and it answers the National AIDS Strategy’s call for a clearer articulation of the science surrounding HIV risk/prevention through better understanding of the current public information environment. This study offers a snapshot of how PrEP is being discussed (and by whom) on one of the most popular social media platforms and provides a foundation for developing and implementing PrEP promotion interventions on Instagram.

"PrEP"ing for a PrEP demonstration project: understanding PrEP knowledge and attitudes among cisgender women

BACKGROUND

Prior to implementing a pre-exposure prophylaxis (PrEP) demonstration study, we sought to explore cisgender women's experiences with HIV prevention, PrEP knowledge and attitudes, and anticipated barriers and facilitators for PrEP uptake and adherence in Southern California.

METHODS

Three focus groups were held with cisgender women of mixed HIV serostatus in San Diego and Los Angeles between November 2015 and January 2016. Women were recruited through local testing sites, community-based organizations, and social media. Focus groups were audio-recorded and transcripts were analyzed using thematic analysis.

RESULTS

Twenty-two women participated in focus groups, with median age 44 (IQR 30-53) and 6 identifying as non-Hispanic Black, 7 non-Hispanic White, 8 Latina and 1 mixed race. Despite limited prior PrEP knowledge and no PrEP experience, participants expressed interest in taking PrEP. Anticipated benefits were freedom from worry about HIV and control over sexual health; however, these were tempered by concerns including the possibility of increased HIV risk behaviors and potential side effects. Cisgender women reported potential barriers to PrEP uptake and adherence barriers, like competing priorities and poor PrEP access. Conversely, PrEP facilitators included utilizing practical tools such as phone apps and pill boxes as well as receiving encouragement from loved ones and support from other cisgender women on PrEP, women living with HIV and their medical providers.

CONCLUSIONS

Although PrEP awareness was low, participants recognized the importance of PrEP and ways to facilitate adherence. Exploring perspectives of cisgender women is integral to developing effective interventions to support PrEP uptake and adherence for women at elevated risk for HIV.

Association between relationship characteristics and willingness to use PrEP among same-sex male couples: a cross-sectional actor-partner analysis in Guangzhou, China

The association between relationship characteristics and pre-exposure prophylaxis (PrEP) acceptability among same-sex male couples has been limitedly examined. Dyadic survey data of 139 concordant HIV-negative same-sex male couples in Guangzhou, China were collected. The willingness to use PrEP was measured assuming that the participant's partner was HIV-positive. The actor-partner interdependence model was used to examine how one's relationship characteristics affected the PrEP willingness of the subject and his partner. Most participants (79.5%) were willing to use PrEP. The two individuals of the couple were distinguished by sex role in relationship, namely one usually playing the insertive role and the other usually playing the receptive role in anal intercourse. The former was labeled as "top" and the latter labeled as "bottom". The PrEP willingness of the top partner increased when he would think his partner is having sex with other people if the partner requests condom use in relationship (AOR: 5.74, 95% CI: 1.10-29.87), and decreased when his partner would get violent upon condom use requests in relationship (AOR: 0.19, 95% CI: 0.04-0.88). The PrEP willingness of the bottom partner increased when he trusted his partner (AOR: 1.13, 95% CI: 1.02-1.25) and when he or his partner disclosed the relationship to parents (AOR: 10.57, 95% CI: 1.91-58.61). Considering the sex role and relationship characteristics in couple-based interventions are important to optimize PrEP uptake among HIV-discordant same-sex male couples.

Couples-based approach to HIV prevention for transgender women and their partners: study protocol for a randomised controlled trial testing the efficacy of the 'It Takes Two' intervention

INTRODUCTION

HIV transmission and acquisition risk among transgender women is particularly high in the context of primary partnerships. This project extends a previous pilot couples-focused HIV intervention programme, which was shown to be feasible, acceptable and promising in reducing sexual risk behaviour among transgender women and their partners. This randomised controlled trial (RCT) tests the efficacy of this culturally sensitive HIV prevention programme for HIV-serodiscordant and HIV-negative seroconcordant transgender women and their partners.

METHODS AND ANALYSIS

To finalise the protocol for trial, we used qualitative methods to hone eligibility criteria, refine the intervention and control manuals, and name and brand the intervention ('It Takes Two'). The RCT investigates the effects of the It Takes Two intervention on Composite Risk for HIV (CR-HIV) among 100 couples. CR-HIV is a binary indicator of couple HIV risk using validated measures of sexual behaviour, pre-exposure prophylaxis use among HIV-negative participants and viral suppression among participants living with HIV. Using a two-arm RCT, we will examine intervention effects on CR-HIV at 12-month follow-up comparing transgender women and their partners randomised to the intervention versus control (HIV prevention information only).

ETHICS AND DISSEMINATION

This study has been reviewed and approved by the University of California, San Francisco (19-28624) and the University of Michigan (HUM00147690) Institutional Review Boards. Participants provide informed consent before taking part of the study activities. Results will be published in peer-reviewed journals and presented at scientific conferences. We will make our results available to the community of researchers and general public interested in transgender health to avoid unintentional duplication of research, as well as to others in the health and social services community, including LGBT community-based organisations, AIDS service organisations and other transgender-serving organisations. The full de-identified dataset and codebook will be shared at the University of Michigan Digital Repository.

TRIAL REGISTRATION NUMBER

NCT04067661.

The Influence of Relationship Dynamics and Sexual Agreements on Perceived Partner Support and Benefit of PrEP Use Among Same-Sex Male Couples in the U.S

Use of Pre-exposure prophylaxis (PrEP) for HIV prevention by men who have sex with men (MSM) may be impacted by relationship dynamics. We assessed perceived partner support of PrEP use and benefit of PrEP by relationship characteristics among male couples. Baseline data from a randomized control trial of video-based HIV counseling and testing among male couples in the U.S. were used in adjusted multilevel regression models to assess individual and dyadic characteristics. Among 659 participants, 73.3% thought their partner would be supportive of their PrEP use; 26.7% reported their partner would not support PrEP use, which was significantly associated with intimate partner violence (IPV) (p = 0.008). Most (57.7%) did not believe PrEP would be beneficial to them or their partner. Couples with a sexual agreement allowing outside partners were significantly associated with higher perceived support of partners for PrEP (p < 0.001) and benefit of PrEP use (p < 0.001). Perceived partner support of PrEP was high but perceived benefit of PrEP was low, both shaped by relationship dynamics that highlight the need for tailored dyadic interventions. The association between perceived PrEP support and IPV points to the need to integrate relationship contexts in HIV prevention programs.

Community Members' Pre-exposure Prophylaxis Awareness, Attitudes, and Trusted Sources for PrEP Information and Provision, Context Matters Survey, 2015-2016

Men and women of color have had low pre-exposure prophylaxis (PrEP) uptake. How one's preferred source of health information shapes attitudes toward PrEP is unclear. We conducted cross-sectional surveys to assess changes in PrEP awareness, knowledge, and attitudes, trusted sources for PrEP information, and associations between trusted source of information and PrEP knowledge and attitudes. Participants were recruited from six areas served by community health centers in Chicago, IL (two health centers); Jackson, MS; Newark, NJ; Philadelphia, PA; and Washington, D.C. during June-September 2015 (n = 160) and June-September 2016 (n = 200). Participants were Black (74%), heterosexual (81%), and largely unaware of PrEP (72%). Participants who trusted health experts and community organizations for PrEP information had lower percentages of agreeing with statements indicative of negative PrEP attitudes. Interventions that increase PrEP awareness as well as knowledge and favorable attitudes might help increase PrEP use in communities with high HIV prevalence.

Sexual goals and perceptions of goal congruence in individuals' PrEP adoption decisions: A mixed-methods study of gay and bisexual men who are in primary relationships

BACKGROUND

Although health goals are recognized as a central feature of health behavior theories, the relational context through which goals are conceptualized is often overlooked. Interdependence theory represents a valuable framework for understanding goals in the adoption of health behaviors, such as pre-exposure prophylaxis (PrEP), among gay and bisexual men in primary relationships.

PURPOSE

We examined the content and focus of men's sexual health goals, as well as whether goal content, goal focus, or perceptions of goal congruence with a primary partner were related to PrEP adoption among gay and bisexual men in primary relationships.

METHODS

Mixed-methods data were collected from a PrEP demonstration project from 145 HIV-negative gay and bisexual men in primary relationships. Participants reported their sexual health goals and completed measures of perceptions of goal congruence, relationship factors, and sociodemographic factors.

RESULTS

Three main goal content categories were identified: prevention, satisfaction, and intimacy. In expressing these goals, participants framed them with either a self-focus or a relationship-focus. Men in serodiscordant relationships reported more intimacy goals and greater perceptions of goal congruence. There were no differences in goal content or focus by sexual agreement. In the multivariable logistic regression model, perceived goal congruence was associated with PrEP adoption, over and above covariates.

CONCLUSIONS

Intimate relationships play a significant role in the formation of health-related goals. Goal content, focus, and perceived congruence with partners may represent important targets for HIV prevention interventions for gay and bisexual men in primary relationships, especially in the context of PrEP.

Social network intervention to increase pre-exposure prophylaxis (PrEP) awareness, interest, and use among African American men who have sex with men

In the U.S., HIV incidence is highest among Black men who have sex with men (MSM) but PrEP uptake is low, in part due to lack of normative support for using PrEP. This research pilot tested a social network-level intervention designed to increase PrEP use willingness, interest, and peer supports among Black MSM in Milwaukee. Five community social networks (n = 40 participants) of racial minority MSM were assessed at baseline with measures of PrEP knowledge, interest, attitudes, and action taking. Persons most interconnected with others in each network attended an intervention that provided training to increase knowledge about PrEPbenefits, address PrEP concerns, endorse PrEP use as a symbol of pride and health, and deliver these messages to others in their social networks. All network members were re-administered the same measures at 3-month followup. Significant increases over time were found in network members' PrEP knowledge, attitudes, norm perceptions, self-efficacy, and willingness to use PrEP. Participants more often talked with friends about HIV and with their health care providers about PrEP. The percentage of participants who reported using PrEP increased from 3% to 11%. Larger-scale evaluations of this intervention model are needed.

Risk Behavior Not Associated with Self-Perception of PrEP Candidacy: Implications for Designing PrEP Services

In a study of sexually-active HIV-negative men who have sex with men (MSM) in China, we compared behavioral indication for pre-exposure prophylaxis (PrEP) based on risk criteria to self-perception of PrEP candidacy (SPC) and explored factors associated with SPC. Of 708 MSM surveyed, 323 (45.6%) were behaviorally-indicated for PrEP, among whom 42.1% self-perceived as appropriate PrEP candidates. In a multivariable model we found no association between sexual behavior nor HIV risk perception and SPC but found that higher perceived benefits of PrEP, increased frequency of HIV testing, and low condom use self-efficacy were positively-associated with SPC. In a sub-analysis restricted to MSM behaviorally-indicated for PrEP, relationship-factors were also significant. Our findings suggest that PrEP implementers should look beyond risk criteria to consider shared decision-making tools that support individuals to assess whether they are appropriate PrEP candidates based on their existing HIV prevention strategies, sexual health goals, and relationship dynamics.

Impact of Providing Preexposure Prophylaxis for Human Immunodeficiency Virus at Clinics for Sexually Transmitted Infections in Baltimore City: An Agent-based Model

BACKGROUND

Preexposure prophylaxis (PrEP) greatly reduces the risk of human immunodeficiency virus (HIV) acquisition, but its optimal delivery strategy remains uncertain. Clinics for sexually transmitted infections (STIs) can provide an efficient venue for PrEP delivery.

METHODS

To quantify the added value of STI clinic-based PrEP delivery, we used an agent-based simulation of HIV transmission among men who have sex with men (MSM). We simulated the impact of PrEP delivery through STI clinics compared with PrEP delivery in other community-based settings. Our primary outcome was the projected 20-year reduction in HIV incidence among MSM.

RESULTS

Assuming PrEP uptake and adherence of 60% each, evaluating STI clinic attendees and delivering PrEP to eligible MSM reduced HIV incidence by 16% [95% uncertainty range, 14%-18%] over 20 years, an impact that was 1.8 (1.7-2.0) times as great as that achieved by evaluating an equal number of MSM recruited from the community. Comparing strategies where an equal number of MSM received PrEP in each strategy (ie, evaluating more individuals for PrEP in the community-based strategy, because MSM attending STI clinics are more likely to be PrEP eligible), the reduction in HIV incidence under the STI clinic-based strategy was 1.3 (1.3-1.4) times as great as that of community-based delivery.

CONCLUSIONS

Delivering PrEP to MSM who attend STI clinics can improve efficiency and effectiveness. If high levels of adherence can be achieved in this population, STI clinics may be an important venue for PrEP implementation.

Dealing with pre-exposure prophylaxis-associated condom migration: changing the paradigm for men who have sex with men

The behavioural aspects of pre-exposure prophylaxis (PrEP) are challenging, particularly the issue of condom migration. Three vital questions are: (1) at the population-level, will condom migration lead to increases in non-viral sexually transmissible infections?; (2) how can clinic-based counselling best promote the dual use of condoms and PrEP?; and (3) in future PrEP trials, what are the 'best practices' that should be used to avoid type 1 and type 2 errors that arise without accounting for condom use behaviours? This communication piece addresses each question and suggests the risk of a 'PrEP only' focus to widening health disparities.

"I am still negative": Female sex workers' perspectives on uptake and use of daily pre-exposure prophylaxis for HIV prevention in South Africa

Women remain highly vulnerable to HIV infection in sub-Saharan Africa, with female sex workers (FSWs) facing some of the highest rates of HIV. Oral pre-exposure prophylaxis (PrEP) has the potential to reduce new infections among populations at highest risk and end-user perspectives of actual use in ‘real-world’ settings are critical to informing PrEP implementation. This paper presents findings from serial in-depth interviews (IDIs) conducted with FSW participants during the course of the Treatment And Prevention for Sex workers (TAPS) Demonstration Project in South Africa, exploring the lived experiences and perceptions of taking up and using PrEP. This research provides insight into risks and responsibilities facing FSWs perceived as prominent drivers in taking up and using PrEP, how PrEP was adopted to mitigate risk or ameliorate realities, and the characteristics of PrEP most valued, all of which are critical to consider in scale-up. Overall, distrust in the existence and/or efficacy of PrEP affected the motivation of women to come to the clinic and to maintain use. As one of the first reports of PrEP use among FSWs outside of a clinical trial setting, this research shows that it will be important to ensure accurate, relevant, and widespread messaging in communities to generate demand and support for PrEP.

Access to HIV Pre-exposure Prophylaxis in Practice Settings: a Qualitative Study of Sexual and Gender Minority Adults' Perspectives

BACKGROUND

Sexual and gender minority (SGM) populations remain at disproportionate risk of HIV infection. Despite the effectiveness of pre-exposure prophylaxis (PrEP) in preventing HIV, PrEP uptake has been slow.

OBJECTIVE

To identify barriers and facilitators of PrEP access by examining SGM patients' experiences with accessing health care systems and engaging with providers about PrEP in a variety of practice settings.

DESIGN

Semi-structured, individual, qualitative interviews.

PARTICIPANTS

Twenty-seven sexual and gender minority adults residing in Oregon.

APPROACH

Interviews were audio-recorded, transcribed, and analyzed using thematic analysis.

KEY RESULTS

We identified three main themes. Participants described the centrality of patient-provider relationships to positive experiences around PrEP, the necessity of personally advocating to access PrEP, and the experience of system-level barriers to PrEP access. Participants also made several suggestions to improve PrEP access including improving provider engagement with SGM patients, encouraging providers to initiate conversations about PrEP, and increasing awareness of medication financial support.

CONCLUSIONS

In order to reduce HIV disparities, improving PrEP access will require additional efforts by providers and resources across health care settings to reduce barriers. Interventions to improve provider education about PrEP and provider communication skills for discussing sexual health are needed. Additionally, there should be system-level improvements to increase coordination between patients, providers, pharmacies, and payers to facilitate PrEP access and uptake.

Perspectives of US women participating in a candidate PrEP study: adherence, acceptability and future use intentions

INTRODUCTION

Limited data exist on acceptability of candidate pre-exposure prophylaxis (PrEP) regimens among US women. We evaluated PrEP experiences, attitudes and future use intentions among sexually active women who completed the US-based HIV Prevention Trials Network 069/AIDS Clinical Trials Group 5305 study.

METHODS

Women participated in the study between March 2013 and November 2015. We analysed computer-assisted self-interview (CASI) surveys among 130 women and conducted in-depth interviews among a subset of 26 women from three sites. Interviews were conducted in mid/late-2015.

RESULTS

Most women (57%) reported very good/excellent PrEP adherence on CASI, although 21% acknowledged over-reporting adherence at least some of the time. Commitment to preventing HIV infection, a sense of ownership of the study, and keeping pills stored in a visible location facilitated adherence. Adherence barriers included "simply forgetting" and being away from home. Most women interviewed did not intend to use PrEP in the future because of lack of perceived need due to their own (as opposed to their partners') low-risk behaviour and concerns about affordability - but not because of side effects or other characteristics of the regimens.

DISCUSSION

Improving HIV prevention options for US women will require access to affordable PrEP as well as expanding women's understanding of relationship- and community-level factors that increase their risk of acquiring HIV.

"Condoms are … like public transit. It's something you want everyone else to take": Perceptions and use of condoms among HIV negative gay men in Vancouver, Canada in the era of biomedical and seroadaptive prevention

BACKGROUND

The emergence of biomedical and seroadaptive HIV prevention strategies has coincided with a decline in condom use among gay men.

METHODS

We undertook a social ecological analysis of condom use and perceptions using nineteen semi-structured interviews with HIV negative gay men in Vancouver, Canada who used HAART-based prevention strategies.

RESULTS

Contributors to inconsistent condom use were found at various levels of the social ecological model. Ongoing concern regarding HIV transmission and belief in the proven efficacy of condoms motivated contextual use. When condoms were not used, participants utilized seroadaptive and biomedical prevention strategies to mitigate risk.

CONCLUSIONS

These findings indicate that notions of "safety" and "risk" based on consistent condom use are eroding as other modes of prevention gain visibility. Community-based and public health interventions will need to shift prevention messaging from advocacy for universal condom use toward combination prevention in order to meet gay men's current prevention needs. Interventions should advance gay men's communication and self-advocacy skills in order to optimize these strategies.

Developing a Mobile App (LYNX) to Support Linkage to HIV/Sexually Transmitted Infection Testing and Pre-Exposure Prophylaxis for Young Men Who Have Sex With Men: Protocol for a Randomized Controlled Trial

BACKGROUND

Young men who have sex with men (YMSM) in the United States have among the highest incidence of HIV and sexually transmitted infection (STI) and the lowest uptake of HIV and STI testing and pre-exposure prophylaxis (PrEP). Nearly universal mobile phone ownership among youth provides an opportunity to leverage mobile health apps to increase HIV/STI testing and PrEP uptake among YMSM.

OBJECTIVE

The goals of this project are to develop and refine LYNX, a novel mobile app to support linkage to HIV/STIs testing and PrEP services among YMSM in the United States, and to evaluate the acceptability and feasibility of LYNX in a pilot randomized controlled trial (RCT).

METHODS

This research protocol will be conducted in 3 phases: an iterative development phase with a series of 3 focus groups among 20 YMSM to refine the LYNX app; an open technical pilot among 15 YMSM to optimize usability of the app; and then a 6-month pilot RCT among 60 HIV-uninfected YMSM at risk for HIV acquisition. Developed using the Information, Motivation, and Behavioral skills theoretical model, the LYNX app includes an electronic diary to track sexual behaviors (information), a personalized risk score to promote accurate risk perception (information/motivation), testing reminders (motivation/behavioral skills), and access to home-based HIV/STI testing options and geospatial-based HIV/STI testing care sites (behavioral skills). Feasibility and acceptability will be assessed through app analytics of usage patterns and acceptability scales administered via computer-assisted self-interview at 3 and 6 months. We will also evaluate preliminary efficacy by comparing the proportion of YMSM who test at least once during the 6-month pilot and the proportion who successfully link to a PrEP provider in the intervention versus control groups.

RESULTS

Formative work is currently underway. The LYNX pilot RCT will begin enrollment in October 2018, with study results available in 2019.

CONCLUSIONS

The LYNX app is one of the first mobile apps designed to increase HIV/STI testing and PrEP uptake among YMSM. As low-perceived risk is a barrier to HIV/STI testing and PrEP use among youth, the personalized risk assessment and interactive sexual diary in LYNX could assist YMSM in better understanding their HIV risk and providing motivation to test for HIV/STIs and initiate PrEP. Coupled with community-based recruitment, this novel mobile app has great potential to reach and engage YMSM not currently involved in care and increase rates of HIV/STI testing and PrEP uptake in this vulnerable population.

TRIAL REGISTRATION

ClinicalTrials.gov NCT03177512; https://clinicaltrials.gov/ct2/show/NCT03177512 (Archived by WebCite at http://www.webcitation.org/73c917wAw).

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

PRR1-10.2196/10659.

Optimizing access to PrEP based on MSM preferences: results of a discrete choice experiment

INTRODUCTION

Despite documented effectiveness of pre-exposure prophylaxis (PrEP), PrEP uptake remains low among men who have sex with men (MSM), the population bearing the highest HIV burden in the U.S.

OBJECTIVES

To elicit MSM stakeholder preferences in order to inform program development aimed at improving uptake of PrEP.

METHODS

554 MSM were recruited through social networking applications to complete a stated preference [choice-based conjoint (CBC)] survey. Respondents completed 14 choice tasks presenting experimentally varied combinations of five attributes related to PrEP administration (dosing frequency, dispensing venue, prescription practices, adherence support, and costs). Latent class analysis was used to estimate the relative importance of each attribute and preferences across seven possible PrEP delivery programs.

RESULTS

Preferences clustered into five groups. PrEP affordability was the most influential attribute across groups, followed by dosing strategy. Only one group liked daily and on-demand PrEP equally (n = 74) while the other four groups disliked the on-demand intermittent option. Monthly injectable PrEP is preferred by two (n = 210) out of the five groups, including young MSM. Two groups (n = 267) were willing to take PrEP across all the hypothetical programs. One group (n = 183) almost exclusively considered costs in their decision-making. Participants in the most racially diverse among groups (n = 88) had a very low level of interest in PrEP initiation.

CONCLUSION

Our data suggest that PrEP uptake will be maximized by making daily PrEP affordable to MSM and streamlining PrEP consultation visits for young MSM. Young MSM should be prioritized for injectable PrEP when it becomes available. A successful PrEP program will spend resources on removing structural barriers to PrEP access and educating MSM of color, and will emphasize protection of privacy to maximize uptake among rural/suburban MSM.

An Information-Motivation-Behavioral Skills Model of PrEP Uptake

Despite documented effectiveness of pre-exposure prophylaxis (PrEP), PrEP uptake remains low among at-risk populations. The 2015 CDC report estimates that about 1.2 million people in the US have indications for PrEP. However, only 49,158 or 4% of the targeted population are currently using PrEP. Efforts to optimize uptake of PrEP may be facilitated by the development of a comprehensive theoretical framework which can be used to understand reasons for poor uptake and to develop interventions to maximize PrEP uptake and adherence. This article reviews research on correlates of PrEP uptake and presents findings organized within an Information-Motivation-Behavioral Skills (IMB) model framework. In the context of PrEP uptake, the IMB model asserts that to the extent that at-risk groups are well-informed about PrEP, motivated to act on their knowledge, and have necessary behavioral skills to seek out and initiate PrEP regimen, they will successfully overcome obstacles to initiate and adhere to PrEP. The article proposes an adaptation the IMB model for PrEP uptake, provides empirical support for the adapted IMB model extracted from related research, and discusses its application in PrEP uptake interventions.

Qualitative Consumer Research on Acceptance of Long-Acting Pre-Exposure Prophylaxis Products Among Men Having Sex with Men and Medical Practitioners in the United States

Pre-exposure prophylaxis (PrEP) with oral Truvada^® prevents HIV infection. However, the adherence to pill taking required for efficacy has sparked interest in developing new antiretroviral delivery systems that decrease such demands. Long-acting formulations, such as injections and implants, represent promising options that require less frequent adherence. It is important, however, that development of these new modalities be driven by understanding of the value seen in them by target users to maximize their uptake. To identify the key product features that impact user acceptance, we used a three-phase marketing research approach. In this study, we describe the results of the first-phase, qualitative focus group research performed in Chicago and San Francisco that explored subjective perceptions of oral versus alternative PrEP modalities among men having sex with men (MSM) and medical practitioners caring for MSM. Data revealed that potential value in long-acting PrEP lies more in simplifying the lives of users rather than in making them more confident in their adherence. The results provide an important guidance for designing and promoting these future long-acting products to enhance their contribution to increasing the current limited uptake of PrEP that will better stem the HIV epidemic.

A structural equation model to predict pre-exposure prophylaxis acceptability in men who have sex with men in Leicester, UK

OBJECTIVES

Pre-exposure prophylaxis (PrEP) is an effective HIV prevention tool for high-risk men who have sex with men (MSM). However, acceptability and uptake have been variable. This study explored the factors that predict PrEP acceptability in MSM in Leicester, where HIV prevalence is double the national average.

METHODS

A total of 191 HIV-negative MSM completed a cross-sectional survey. Participants provided demographic information, and completed measures of HIV knowledge, perceived HIV risk, engagement in sexual risk behaviour, acquisition of a sexually transmitted infection (STI) in the last 12 months, frequency of HIV testing and PrEP acceptability.

RESULTS

Kruskal-Wallis tests showed statistically significant effects of sexual orientation, education level and income, respectively, on HIV knowledge. Gay-identified individuals possessed greater HIV knowledge than bisexuals. Respondents with General Certificate of Secondary Education (GCSE)-level education had significantly less HIV knowledge than those educated to postgraduate level. Respondents with income of < £10 000 possessed significantly less HIV knowledge than higher income groups. Structural equation modelling showed that the relationship between HIV knowledge and PrEP acceptability was mediated by perceived HIV risk, engagement in sexual risk behaviour, acquisition of an STI in the past 12 months and frequency of HIV testing.

CONCLUSIONS

The results reveal socio-economic inequalities in HIV knowledge and HIV testing, and suggest that MSM who have high levels of HIV knowledge and perceived HIV risk and who regularly test for HIV are most likely to endorse PrEP as personally beneficial. HIV knowledge and accurate risk appraisal should be promoted in MSM. The HIV testing context constitutes an ideal context for promoting PrEP to high-risk MSM.

University of North Carolina/Emory Center for Innovative Technology (iTech) for Addressing the HIV Epidemic Among Adolescents and Young Adults in the United States: Protocol and Rationale for Center Development

Background

Over a fifth of all new HIV infections in the United States occur among persons aged 13 24 years, with most of these diagnoses occurring among gay and bisexual males (81%). While the epidemic of HIV in the United States has leveled off for many age groups, the annual number of new HIV diagnoses among young men who have sex with men (YMSM; 13-24 years old) remains high. Traditional approaches to continuum improvement for youth have been insufficient, and targeted interventions are urgently needed for young people at risk for or infected with HIV. Interventions delivered through mobile health technology represent a promising approach for improving outcomes in this population. Mobile phones have nearly reached saturation among youth, making mobile technology a particularly promising tool for reaching this population.

Objective

The University of North Carolina/Emory Center for Innovative Technology (iTech) is a National Institutes of Health cooperative agreement as part of the Adolescent Medicine Trials Network for HIV/AIDS Interventions. iTech aims to impact the HIV epidemic by conducting innovative, interdisciplinary research on technology-based interventions across the HIV prevention and care continuum for adolescents and young adults in the United States, particularly YMSM, by providing the following: (1) evaluation of novel approaches to identifying youth with undiagnosed HIV infections; (2) evaluation of multilevel, combination prevention approaches, particularly relevant to gender- and sexual-minority youth facing co-occurring health risks; (3) evaluation of uptake of and adherence to biomedical prevention modalities; and 4) evaluation of interventions designed to promote or optimize engagement in care and antiretroviral therapy adherence in HIV-positive youth, to optimize viral load suppression.

Methods

iTech brings together multidisciplinary experts in the fields of adolescent HIV treatment and prevention, development and evaluation of technology-based interventions, HIV surveillance and epidemiology, and intervention design and evaluation. This initiative will support 8 efficacy trials and 2 exploratory projects, each led by 2 principal investigators. Taken together, the studies address all of the key steps of the HIV prevention and care continuum for youth in the United States. Each proposal uses technology in a scientifically rigorous and innovative way to access, engage, and impact at-risk or infected youth. Nine iTech subject recruitment venues are spread across 8 US cities. Three cores (management, analytic, and technology) support all iTech activities and form the research network’s infrastructure, facilitating all aspects of study implementation and evaluation.

Results

Formative work has already begun on many of the above-mentioned iTech trials. We expect the first randomized controlled trials to begin in mid-2018. Additional details can be found in the individual intervention protocol papers in this issue.

Conclusions

Through its comprehensive research portfolio, iTech aims to effectively advance HIV prevention and care for youth through technology-based, youth-relevant interventions that maximize adaptability and sustainability.

Registered Report Identifier

RR1-10.2196/10365

HIV-discordant and concordant HIV-positive male couples' recommendations for how an eHealth HIV prevention toolkit for concordant HIV-negative male couples could be improved to meet their specific needs

A number of HIV prevention interventions for male couples are in the pipeline for development as few evidence-based ones exist. Among these projects, none include all three groups of male couples (concordant HIV-negative, HIV-discordant, and concordant HIV-positive) as their target population, and only two are eHealth-based. The present qualitative study sought to assess whether one of the eHealth HIV prevention interventions for concordant HIV-negative male couples - called MCAP - could be adapted to meet the relationship and HIV prevention needs of HIV-discordant and HIV-positive male couples. Data for this study are drawn from in-person, individual-level interviews conducted with a convenience sample of 10 HIV-discordant male couples (n = 20) and 8 HIV-positive male couples (n = 16) from the Miami-Fort Lauderdale metro area in 2016. Thematic analysis was conducted to identify patterns (themes) of partners' thoughts about the toolkit, including how they perceived it could be improved for their own relationship and other couple's relationships. Two themes emerged from analysis of the qualitative data suggesting how the participants wanted the toolkit to be improved to meet their needs. Specifically, participants recommended for the toolkit to include guidance about integrating the use of biomedical HIV prevention strategies into couple's relationships, as well as for how partners can best take care of each other and further protect themselves from HIV and/or other STIs (Prevention Guidance). In addition, participants requested for the concept of sexual agreements to be broadened to include other aspects they deemed to be important in their life (e.g., mental health, exercise and nutrition) (Holistic agreements). Findings from the present study illuminate the ways in which MCAP would need to be adapted for these two groups of male couples in order to meet the needs for all three groups of male couples in the U.S. in a future iteration of this intervention.

Using a "Positive Deviance" Framework to Discover Adaptive Risk Reduction Behaviors Among High-Risk HIV Negative Black Men Who Have Sex with Men

Despite the high incidence of HIV among young Black MSM in the United States and engagement in high risk behaviors, many men in this group avoid infection. This suggests that some men may engage in systematic risk reduction behaviors when not always using condoms or abstaining from substances. Using a "positive deviance" framework, we conducted qualitative interviews with HIV-negative, Black MSM between 25 and 35 who reported unprotected anal sex and drug use in the past six months or current heavy drinking (N = 29) to discover behaviors that could facilitate remaining HIV-uninfected. Findings showed that MSM who remain HIV negative despite continuing to engage in high-risk behaviors may be engaging in adaptive risk reduction behaviors that, through successive decisions and advance planning along the timeline to a sexual event, could lead to increased condom use, avoidance or delay of a risky sexual event, or reduction of HIV positive partners.

A Global Estimate of the Acceptability of Pre-exposure Prophylaxis for HIV Among Men Who have Sex with Men: A Systematic Review and Meta-analysis

Pre-exposure prophylaxis (PrEP) is a new biomedical intervention for HIV prevention. This study systematically reviews the acceptability of PrEP among men who have sex with men (MSM) worldwide. We searched major English databases to identify English-language articles published between July 2007 and July 2016, which reported the acceptability of PrEP and associated population characteristics. Meta-analysis was conducted to estimate a pooled acceptability, and meta-regression and subgroup analysis were used to analyse heterogeneities. The estimated acceptance from included sixty-eight articles was 57.8% (95% confidence internal 52.4-63.1%). MSM who were younger (4/5 studies, range of adjusted odds ratio (aOR) = 1.39-3.47), better educated (aOR = 1.49-7.70), wealthier (aOR = 1.31-13.03) and previously aware of PrEP (aOR = 1.33-3.30) showed significantly higher acceptance. Male sex workers (84.0% [26.3-98.7%] were more likely to accept PrEP than general MSM. Self-perceived low efficacy, concern about side effects, adherence, affordability, and stigma were main barriers. This review identifies a moderate acceptability of PrEP in MSM. Efficacy, perception of HIV risk and experienced stigma determine its acceptance.

The Use of Online Posts to Identify Barriers to and Facilitators of HIV Pre-exposure Prophylaxis (PrEP) Among Men Who Have Sex with Men: A Comparison to a Systematic Review of the Peer-Reviewed Literature

Pre-exposure prophylaxis (PrEP) remains an under-utilized HIV prevention tool among men who have sex with men (MSM). To more comprehensively elucidate barriers and facilitators to PrEP use among US MSM, we conducted a systematic review of peer-reviewed published articles and content analysis of online posts about PrEP. We searched peer-reviewed databases (Medline, Web of Science, Google Scholar) using MESH headings and keywords about PrEP and/or HIV prevention from 2005 to 2015. We included original studies among MSM in the US that reported on barriers, facilitators, or other factors related to PrEP use. We also searched online posts and associated comments (news articles, opinion pieces, blogs and other social media posts) in diverse venues (Facebook, Slate Outward, Huffington Post Gay Voices, Queerty, and My PrEP Experience blog) to identify posts about PrEP. We used content analysis to identify themes and compare potential differences between the peer-reviewed literature and online posts. We identified 25 peer-reviewed articles and 28 online posts meeting inclusion criteria. We identified 48 unique barriers and 46 facilitators to using PrEP. These 94 themes fit into six overarching categories: (1) access (n = 14), (2) attitudes/beliefs (n = 24), (3) attributes of PrEP (n = 13), (4) behaviors (n = 11), (5) sociodemographic characteristics (n = 8), and (6) social network (n = 6). In all categories, analysis of online posts resulted in identification of a greater number of unique themes. Thirty-eight themes were identified in the online posts that were not identified in the peer-reviewed literature. We identified barriers and facilitators to PrEP in online posts that were not identified in a systematic review of the peer-reviewed literature. By incorporating data both from a systematic review of peer-reviewed articles and from online posts, we have identified salient and novel information about barriers to and facilitators of PrEP use. Traditional research approaches may not comprehensively capture current factors important for designing and implementing PrEP related interventions.

Exploring acceptability of oral PrEP prior to implementation among female sex workers in South Africa

INTRODUCTION

Female sex workers (FSWs) are at high-risk for HIV acquisition in South Africa, where the advent of new HIV prevention and treatment interventions represent the potential to significantly impact the epidemic. This paper focuses on aspects of PrEP acceptability as a new intervention within the context of a larger service delivery programme including the simultaneous rollout of early ART. This paper explores PrEP acceptability among the FGD participants as future potential users.

METHODS

FGDs were conducted in two clinic-based sites in Johannesburg and Pretoria. They aimed to explore community-level, multi-dimensional acceptability of PrEP within the context of imminent implementation alongside early ART in the TAPS Demonstration Project. Sex worker peer educators recruited participants from varying sex work locales. Facilitation was in English with adaptation by facilitators into local languages as needed. Transcripts were translated and transcribed into English. Thematic analysis was used to analyse the data.

RESULTS

Four FGDs were conducted in each site for a total of eight FDGs and 69 participants. Demographics were largely similar across the sites. Overall, there was strong acceptability of PrEP among participants and positive anticipation for the imminent delivery of PrEP in the local sex worker clinics. Themes arising from the discussions exploring aspects of PrEP acceptability included: awareness and understanding of PrEP; PrEP motivations including choice, control, and vulnerability, managing PrEP risks and worries; and, de-stigmatizing and empowering PrEP delivery. Participant discussions and recommendations highlighted the importance of developing clear education and messaging to accurately convey the concept of PrEP, and intervention integration into supportive and tailored services.

CONCLUSIONS

Through the course of these FGDs, PrEP became a positive and highly anticipated prevention option among the FSWs participants who endorsed implementation in their communities. Effective integration of PrEP into existing services will include comprehensive health programming where ART is also available, appropriate messaging, and support.

Functional Knowledge of Pre-Exposure Prophylaxis for HIV Prevention Among Participants in a Web-Based Survey of Sexually Active Gay, Bisexual, and Other Men Who Have Sex With Men: Cross-Sectional Study

Background

Awareness of pre-exposure prophylaxis (PrEP) for HIV prevention is increasing, but little is known about the functional knowledge of PrEP and its impact on willingness to use PrEP.

Objective

The objective of this study was to assess the functional knowledge of PrEP among a sample of gay, bisexual, and other men who have sex with men (MSM) participating in a Web-based survey of sexually active MSM.

Methods

Men at least 18 years old, residing in the United States, and reporting sex with a man in the previous 6 months were recruited through social networking websites. PrEP functional knowledge included the following 4 questions (1) efficacy of consistent PrEP use, (2) inconsistent PrEP use and effectiveness, (3) PrEP and condom use, and (4) effectiveness at reducing sexually transmitted infections (STIs). Ordinal logistic regression was used to identify respondent characteristics associated with PrEP functional knowledge. In a subsample of participants responding to HIV prevention questions, we compared willingness to use PrEP by response to PrEP functional knowledge using logistic regression analysis adjusted for age, race and ethnicity, and education level.

Results

Among 573 respondents, PrEP knowledge was high regarding adherence (488/573, 85.2%), condom use (532/573, 92.8%), and STIs (480/573, 83.8%), but only 252/573 (44.0%) identified the correct efficacy. Lower functional PrEP knowledge was associated with minority race/ethnicity (P=.005), lower education (P=.01), and not having an HIV test in the past year (P=.02). Higher PrEP knowledge was associated with willingness to use PrEP (P=.009). Younger age was not associated with higher PrEP functional knowledge or willingness to use PrEP.

Conclusions

PrEP knowledge was generally high in our study, including condom use and consistent use but may be lacking in higher risk MSM. The majority of respondents did not correctly identify PrEP efficacy with consistent use, which could impact motivation to seek out PrEP for HIV prevention. Targeted messaging to increase PrEP knowledge may increase PrEP use.

Facilitators and Barriers to Pre-Exposure Prophylaxis Willingness Among Young Men Who Have Sex with Men Who Use Geosocial Networking Applications in California

While correlates of pre-exposure prophylaxis (PrEP) uptake have been explored among older men who have sex with men (MSM), less is known about the facilitators and barriers that encourage uptake among younger MSM (YMSM). This study explores the association between willingness to take PrEP and demographic characteristics, sexual risk, and substance use, and attitudinal factors among YMSM in California who use geosocial networking applications (GSN apps). Based on survey data from YMSM recruited through GSN apps (n = 687), PrEP willingness was positively associated with Hispanic ethnicity [adjusted odds ratio (aOR): 1.73; confidence interval (CI): 1.01-2.98; p = 0.046], concerns about drug effects (aOR: 0.46; CI: 0.33-0.65; p < 0.001), medical mistrust (aOR: 0.71; CI: 0.53-0.96; p < 0.001), and concerns about adherence (aOR: 0.65; CI: 0.49-0.89; p = 0.005). PrEP willingness was positively associated with medium (aOR: 1.87; CI: 1.14-3.07; p = 0.014) and high concern (aOR: 1.84; CI: 1.13-3.01; p < 0.001) about contracting HIV and perceived benefits of taking PrEP (aOR: 2.59; CI: 1.78-3.78; p < 0.001). In addition to emphasizing the benefits of using PrEP, campaigns that address concerns regarding adherence and side effects may increase interest in and demand for PrEP among YMSM. More opportunities are needed to educate YMSM about PrEP, including addressing their concerns about this new prevention strategy. Providers should speak openly and honestly to YMSM considering PrEP about what to do if side effects occur and how to handle missed doses. Outreach using GSN apps for PrEP education and screening may be an effective way to reach YMSM.

The intention to use HIV-pre-exposure prophylaxis (PrEP) among men who have sex with men in Switzerland: testing an extended explanatory model drawing on the unified theory of acceptance and use of technology (UTAUT)

Aim

The aim of this study was to determine the intention to use pre-exposure prophylaxis (PrEP) when available and to identify predictors of the intention to use PrEP among men who have sex with men (MSM) living in Switzerland. The theoretical model drew on the Unified Theory of Acceptance and Use of Technology and considered additional variables related specifically to PrEP, HIV protection and the resources of MSM.

Subject and methods

For data collection, we used an anonymous, standardized self-administered online questionnaire. In 2015, we gathered a convenience sample of 556 HIV-negative MSM living in Switzerland. We analyzed the data using descriptive and bivariate statistics and used structural equation modeling to test the hypothesized model.

Results

Predictors of respondents’ moderate intention to use PrEP were performance expectancy, effort expectancy, perceived social influence, concerns about using PrEP, attitudes toward condom use, negative experiences of condom use and age. These variables were predicted by HIV protection-related aspects and resources.

Conclusion

The findings provide insights into the complex dynamic underlying the intention to use PrEP.

Awareness and willingness to use HIV pre-exposure prophylaxis among men who have sex with men in low- and middle-income countries: a systematic review and meta-analysis

Introduction: To facilitate provision of pre-exposure prophylaxis (PrEP) in low- and middle-income countries (LMIC), a better understanding of potential demand and user preferences is required. This review assessed awareness and willingness to use oral PrEP among men who have sex with men (MSM) in LMIC.

Methods: Electronic literature search of Cochrane library, Embase, PubMed, PsychINFO, CINHAL, Web of Science, and Google Scholar was conducted between July and September 2016. Reference lists of relevant studies were searched, and three authors contacted for additional data. Non-peer reviewed publications were excluded. Studies were screened for inclusion, and relevant data abstracted, assessed for bias, and synthesized.

Results: In total, 2186 records were identified, of which 23 studies involving 14,040 MSM from LMIC were included. The proportion of MSM who were aware of PrEP was low at 29.7% (95% CI: 16.9–44.3). However, the proportion willing to use PrEP was higher, at 64.4% (95% CI: 53.3–74.8). Proportions of MSM aware of PrEP was <50% in 11 studies and 50–70% in 3 studies, while willingness to use PrEP was <50% in 6 studies, 50–70% in 9 studies, and over 80% in 5 studies. Several factors affected willingness to use PrEP. At the individual domain, poor knowledge of PrEP, doubts about its effectiveness, fear of side effects, low perception of HIV risk, and the need to adhere or take medicines frequently reduced willingness to use PrEP, while PrEP education and motivation to maintain good health were facilitators of potential use. Demographic factors (education, age, and migration) influenced both awareness and willingness to use PrEP, but their effects were not consistent across studies. At the social domain, anticipated stigma from peers, partners, and family members related to sexual orientation, PrEP, or HIV status were barriers to potential use of PrEP, while partner, peer, and family support were facilitators of potential use. At the structural domain, concerns regarding attitudes of healthcare providers, quality assurance, data protection, and cost were determinants of potential use.

Conclusions: This review found that despite low levels of awareness of PrEP, MSM in LMIC are willing to use it if they are supported appropriately to deal with a range of individual, social, and structural barriers.

Awareness and willingness towards pre-exposure prophylaxis against HIV infection among individuals seeking voluntary counselling and testing for HIV in Taiwan: a cross-sectional questionnaire survey

OBJECTIVES

We aimed to investigate the awareness and willingness towards pre-exposure prophylaxis (PrEP) among individuals seeking voluntary counselling and testing (VCT) for HIV in Taiwan, where PrEP is currently not reimbursed by the insurance.

METHODS

Between April and October 2016, a questionnaire interview was conducted among VCT clients to inquire about the attitudes towards PrEP against HIV infection. Multivariate logistic regression analysis was performed to identify the associated factors with willingness to initiate PrEP.

RESULTS

During the 6-month period, 1173 VCT clients (99.8%) completed the interviews, with 67.4% being homosexual or bisexual male. While 67.2% of the clients knew of postexposure prophylaxis, 40.2% heard of PrEP. Overall, 546 clients (46.5%) were willing to initiate PrEP and 89.5% of them would choose event-driven PrEP. In multivariate analysis, male gender (OR 1.796; 95% CI 1.165 to 2.768), full-time job (OR 1.354; 95% CI 1.052 to 1.742), one-night stand (OR 1.374; 95% CI 1.043 to 1.810), having casual sex partners within 3 months (OR 1.329; 95% CI 1.031 to 1.714), condomless anal sex (OR 1.405; 95% CI 1.122 to 1.878) and ever having chemsex or attending a drug party in the past 1 year (OR 2.571; 95% CI 1.541 to 4.287), regular screening for HIV infection (OR 1.321; 95% CI 1.021 to 1.711) and knowledge of PrEP (OR 1.504; 95% CI, 1.159 to 1.953) were associated with willingness to initiate PrEP.

CONCLUSIONS

Understanding the willingness to initiate PrEP against HIV among the VCT clients in Taiwan, which was associated with male gender, risky sexual behaviours and awareness of PrEP, will help inform the implementation of PrEP programme.

Gay Men's Understanding and Education of New HIV Prevention Technologies in Vancouver, Canada

Effective rollout of HIV treatment-based prevention such as pre-exposure prophylaxis and treatment as prevention has been hampered by poor education, limited acceptability, and stigma among gay men. We undertook a thematic analysis regarding the education sources and acceptability of these New Prevention Technologies (NPTs) using 15 semistructured interviews with gay men in Vancouver, Canada, who were early adopters of NPTs. NPT education was derived from a variety of sources, including the Internet, health care providers, community organizations, sexual partners, and peers; participants also emphasized their own capacities as learners and educators. Acceptable forms of NPT education featured high-quality factual information, personal testimony, and easy access. Stigma was highlighted as a major barrier. For public health, policy makers, and gay communities to optimize the personal and population benefits of NPTs, there is a need for increased community support and dialogue, antistigma efforts, early NPT adopter testimony, and personalized implementation strategies.

Willingness to use pre-exposure prophylaxis for HIV prevention among men who have sex with men in Malaysia: Findings from an online survey

Objective

We examined willingness to use pre-exposure prophylaxis (PrEP) for HIV prevention among men who have sex with men (MSM) in Malaysia.

Methods

An online survey of 990 MSM was conducted between March and April 2016. Eligibility criteria included being biological male, Malaysian citizen, 18 years of age or above, identifying as MSM, and being HIV negative or unknown status. Participants’ demographics, sexual and drug use behaviors, attitudes towards PrEP, and preferences regarding future access to PrEP were collected. Bivariate analysis and logistic regression were performed to determine factors associated with willingness to use PrEP.

Results

Fewer than half of participants (44%) knew about PrEP before completing the survey. Overall, 39% of the sample were willing to take PrEP. Multivariate logistic regression indicated that Malay men (AOR: 1.73, 95% CI:1.12, 2.70), having 2 or more male anal sex partners in the past 6 months (AOR: 1.98, 95% CI: 1.29, 3.05), previous knowledge of PrEP (AOR: 1.40, 95%CI: 1.06, 1.86), lack of confidence in practising safer sex (AOR: 1.36, 95% CI: 1.02, 1.81), and having ever paid for sex with a male partner (AOR: 1.39, 95% CI: 1.01, 1.91) were independently associated with greater willingness to use PrEP, while men who identified as heterosexual were less willing to use PrEP (AOR, 0.36, 95% CI: 0.13, 0.97). Majority of participants preferred to access PrEP at affordable cost below 100 Malaysian Ringgit (USD25) per month from community based organisations followed by private or government hospitals.

Conclusions

Overall, MSM in Malaysia reported a relatively low level of willingness to use PrEP, although willingness was higher among those previously aware of PrEP. There is a need to provide PrEP at affordable cost, increase demand and awareness of PrEP, and to provide access to this preventative medication via diverse, integrated and tailored sexual health services.

A Multi-US City Assessment of Awareness and Uptake of Pre-exposure Prophylaxis (PrEP) for HIV Prevention Among Black Men and Transgender Women Who Have Sex with Men

The HIV epidemic among Black men and transgender women who have sex with men (BMTW) demands an urgent public health response. HIV point prevalence among this population ranges from 25 to 43%-a rate far exceeding any other group. Pre-exposure prophylaxis (PrEP) for HIV prevention is a very promising prevention tool; however, its full potential to slow the epidemic has yet to be realized. For the current study, random time-location sampling at Black Gay Pride Events was used to collect data from N = 1274 BMTW, from five US cities, reporting HIV-negative/unknown status. In-field HIV testing was also provided to participants. Participants were assessed on awareness and use of PrEP, health care factors, HIV testing history, psychosocial variables, and sex behaviors. About one third of participants were aware of PrEP (39%), and a small percentage of participants were users of PrEP (4.6%). In multivariable analyses, being in a relationship, testing for HIV in the past 6 months, and others being aware of one's sexuality were positively associated with PrEP awareness. Higher levels of internalized homophobia and greater numbers of female sex partners were positively associated with PrEP use, while education and condom use were negatively associated. Based on study findings, messaging and uptake of PrEP needs greater expansion and requires novel approaches for scale-up. Improving linkage to HIV testing services is likely critical for engaging BMTW with PrEP. The potential for PrEP to slow the HIV epidemic is high; however, we must strengthen efforts to ensure universal availability and uptake.

Brief Report: The Right People, Right Places, and Right Practices: Disparities in PrEP Access Among African American Men, Women, and MSM in the Deep South

Disproportionate rates of HIV are observed in Black women and men, especially in the Southern United States. We observed limited uptake of preexposure prophylaxis (PrEP) services in our Southern community among these groups, particularly Black men who have sex with men relative to new HIV cases in Birmingham, AL; 18% accessed PrEP services compared with 50% of new HIV cases. Further research is needed to understand PrEP access and uptake in high-risk populations.

Preferences for Long-Acting Pre-exposure Prophylaxis (PrEP), Daily Oral PrEP, or Condoms for HIV Prevention Among U.S. Men Who Have Sex with Men

HIV prevention method preferences were evaluated among 512 U.S. men who have sex with men (MSM; median age: 22 years). Approximately 90 % consistently preferred one option across pairwise comparisons of condoms, daily oral pre-exposure prophylaxis (PrEP), and long-acting PrEP delivered via either an injectable or one of two types of PrEP implants differing in visibility. Condoms were most frequently preferred (33.8 %), followed by non-visible implants (21.5 %), and oral PrEP (17.0 %); HIV risk was reported by more choosing implants. In a follow-up question comparing the four PrEP options only, daily oral pills and non-visible implants were most frequently preferred (35.5 and 34.3 %, respectively), followed by injections (25.2 %) and visible implants (4.3 %). An inductive, open-coding approach determined that convenience, duration of protection, and privacy were the most commonly cited reasons for a PrEP method choice, and associated with self-report of HIV risk. Tailoring PrEP product development to privacy and other concerns important to those at highest HIV risk may improve HIV prevention.

Awareness and Acceptability of Pre-exposure HIV Prophylaxis Among Men Who have Sex with Men in Baltimore

This paper assessed characteristics associated with awareness of and willingness to take pre-exposure prophylaxis (PrEP) among Baltimore men who have sex with men (MSM). We used data from BESURE-MSM3, a venue-based cross-sectional HIV surveillance study conducted among MSM in 2011. Multivariate regression was used to identify characteristics associated with PrEP knowledge and acceptability among 399 participants. Eleven percent had heard of PrEP, 48% would be willing to use PrEP, and none had previously used it. In multivariable analysis, black race and perceived discrimination against those with HIV were significantly associated with decreased awareness, and those who perceived higher HIV discrimination reported higher acceptability of PrEP. Our findings indicate a need for further education about the potential utility of PrEP in addition to other prevention methods among MSM. HIV prevention efforts should address the link between discrimination and potential PrEP use, especially among men of color.

Distinguishing hypothetical willingness from behavioral intentions to initiate HIV pre-exposure prophylaxis (PrEP): Findings from a large cohort of gay and bisexual men in the U.S

RATIONALE

Much of the data on the acceptability of HIV Pre-Exposure Prophylaxis (PrEP) is based on willingness to take PrEP (i.e., hypothetical receptivity) rather than actual intentions (i.e., planned behavioral action) to do so.

OBJECTIVE

We sought to examine differences between hypothetical willingness and behavioral intentions to begin PrEP in a national sample of gay and bisexual men (GBM) across the U.S.

METHODS

We utilized data collected in 2015 to examine differences between those Unwilling (42.6% n = 375), Willing but not intending (41.4%, n = 365), and willing and Intending to take PrEP (15.9%, n = 140) in a multivariable, multinomial logistic regression.

RESULTS

Men with less education had higher odds of Intending to take PrEP. Compared to men unsure about PrEP's efficacy, those who believed PrEP was at least 90% efficacious had higher odds of Intending to take PrEP. Those who saw themselves as appropriate candidates for PrEP had higher odds of Intending to take PrEP while those who saw themselves as inappropriate candidates for PrEP had lower odds of Intending to take PrEP in comparison to men unsure if they were appropriate candidates. Increased motivation for condom non-use because of perceived sexual pressure by partners was associated with higher odds of Intending to take PrEP. The groups did not differ by risk behavior nor recent STI diagnosis.

CONCLUSIONS

Overall, the distinction between willingness and intentions to take PrEP was meaningful and may help explain disparities between PrEP acceptability and uptake. While much of the literature has focused on hypothetical willingness to take PrEP, these results highlight the importance of simultaneously assessing willingness and intentions when examining correspondence with uptake and developing interventions to increase PrEP uptake.

Couples Living with HIV

BACKGROUND

Desires to have children are not lessened by a woman's HIV status. Couples may lack information to conceive safely, and men may be especially uninformed. This study examined reproductive intentions, practices, and attitudes among men in HIV-infected couples, including attitudes regarding the perceived risk of vertical and horizontal transmission, safer conception, and preconception planning.

METHODS

Men ( n = 12) in HIV-infected couples were interviewed regarding reproductive intentions, attitudes, and knowledge and qualitative assessments were coded for dominant themes.

RESULTS

Themes primarily addressed concerns about the health of the baby, men's involvement in pregnancy, safer conception, concerns about HIV transmission and antiretroviral therapy, and HIV infection. Men lacked information on safer conception and newer HIV prevention strategies, such as pre-exposure prophylaxis (PrEP).

DISCUSSION

Gaps in knowledge regarding preconception practices among men in HIV-infected couples were identified. Results highlight men's desire for involvement in preconception planning, and opportunities for providers to facilitate this practice and to increase patient education and the use of PrEP are discussed.

Seasons of Risk: Anticipated Behavior on Vacation and Interest in Episodic Antiretroviral Pre-exposure Prophylaxis (PrEP) Among a Large National Sample of U.S. Men Who have Sex with Men (MSM)

The current analysis evaluates interest in and acceptability of daily PrEP during short episodes of anticipated increased risk (i.e. Epi-PrEP). In 2013, U.S. members of an internet-based MSM sexual networking site were invited to complete a survey about HIV prevention practices in the context of vacationing. 7305 MSM responded to the survey. Of respondents who had vacationed in the past year, 25.6 % reported condomless anal sex (CAS) with new male sex partners while vacationing. Most (92.6 %) respondents agreed that having to use PrEP every day was a barrier to PrEP use and 74.3 % indicated they would take PrEP if they knew it would be helpful for short periods of anticipated increased risk. MSM who reported increased CAS while on vacation in the past year were more likely to indicate that they would take PrEP if it were helpful when used for short periods than respondents who did not (aOR = 2.02, 95 % CI 1.59-2.56, p < 0.001). Studies designed to evaluate uptake, adherence, and protective benefit of short PrEP courses are warranted.

Early Adopters: Correlates of HIV Chemoprophylaxis Use in Recent Online Samples of US Men Who Have Sex with Men

To date, little data on pre-exposure prophylaxis (PrEP) users outside of the clinical trial setting are available. A repeated cross-sectional survey of one of the largest social and sexual networking websites for men who have sex with men (MSM) in the United States was conducted in August 2013 (Wave 1) and January 2014 (Wave 2). Multivariable logistic regression models were used to assess factors associated with having heard of and having taken post-exposure prophylaxis (PEP) and PrEP in Wave 1 (N = 4043) and Wave 2 (N = 2737) separately. In Wave 1, 147 (3.6 %) and 61 (1.5 %) reported using PEP and PrEP, respectively, compared to 119 (4.4 %) and 62 (2.3 %) in Wave 2. Higher-risk sexual behaviors were associated with having taken PEP and PrEP, and previous PEP use was associated with having taken PrEP. Understanding factors that are associated with early use of PrEP may help inform wider utilization of PrEP by at risk MSM.

Framing HIV Pre-Exposure Prophylaxis (PrEP) for the General Public: How Inclusive Messaging May Prevent Prejudice from Diminishing Public Support

Strategic framing of public messages about HIV pre-exposure prophylaxis (PrEP) may influence public support for policies and programs affecting access. This survey study examined how public attitudes toward PrEP differed based on the social group PrEP was described as benefiting ("beneficiary") and the moderating effect of prejudice. Members of the general public (n = 154) recruited online were randomly assigned to three beneficiary conditions: general population, gay men, or Black gay men. All participants received identical PrEP background information before completing measures of PrEP attitudes (specifying beneficiary), racism, and heterosexism. Despite anticipating greater PrEP adherence among gay men and Black gay men and perceiving PrEP as especially beneficial to the latter, participants expressed lower support for policies/programs making PrEP affordable for these groups vs. the general population. This disparity in support was stronger among participants reporting greater prejudice. Inclusive framing of PrEP in public discourse may prevent prejudice from undermining implementation efforts.

A practical online tool to estimate antiretroviral coverage for HIV infected and susceptible populations needed to reduce local HIV epidemics

It remains unclear what proportions of HIV-infected and uninfected people should receive effective antiretroviral therapy (ART) to control local HIV epidemics. We developed a flexible model to evaluate the impact of treatment as prevention (TasP) and pre-exposure prophylaxis (PrEP) on HIV incidence in local communities. We evaluated this tool for determining what TasP and PrEP targets are needed to substantially reduce the HIV epidemic in San Diego, which is predominately comprised of men who have sex with men. By increasing the proportion of HIV-infected individuals on ART from 30% to 50%, 686 new infections would be prevented over five years in San Diego. By providing PrEP to 30% of MSM to the age group that account for 90% of local HIV incident cases (21-52 years), we could prevent 433 infections over five years. When combining these initiatives, a PrEP coverage rate of 40% and TasP coverage rate of 34% would be expected to decrease the number of new infections by over half in one year. This online tool is designed to help local public health planners and policy makers to estimate program outcomes and costs that may lead to better control of their local HIV epidemics.

Who Will Use Pre-Exposure Prophylaxis (PrEP) and Why?: Understanding PrEP Awareness and Acceptability amongst Men Who Have Sex with Men in the UK--A Mixed Methods Study

Background

Recent clinical trials suggest that pre-exposure prophylaxis (PrEP) may reduce HIV transmission by up to 86% for men who have sex with men (MSM), whilst relatively high levels of PrEP acceptability have been reported to date. This study examines PrEP awareness amongst sub-groups of MSM communities and acceptability amongst MSM in a low prevalence region (Scotland, UK), using a mixed methods design.

Methods

Quantitative surveys of n = 690 MSM recruited online via social and sociosexual media were analysed using descriptive statistics and multivariate logistic regression. In addition, n = 10 in-depth qualitative interviews with MSM were analysed thematically.

Results

Under one third (29.7%) of MSM had heard of PrEP, with awareness related to living in large cities, degree level education, commercial gay scene use and reporting an HIV test in the last year. Just under half of participants (47.8%) were likely to use PrEP if it were available but there was no relationship between PrEP acceptability and previous PrEP awareness. Younger men (18–25 years) and those who report higher risk UAI were significantly more likely to say they would use PrEP. Qualitative data described specific PrEP scenarios, illustrating how risk, patterns of sexual practice and social relationships could affect motivation for and nature of PrEP use.

Conclusion

These findings suggest substantial interest PrEP amongst MSM reporting HIV risk behaviours in Scotland. Given the Proud results, there is a strong case to investigate PrEP implementation within the UK. However, it appears that disparities in awareness have already emerged along traditional indicators of inequality. Our research identifies the need for comprehensive support when PrEP is introduced, including a key online component, to ensure equity of awareness across diverse MSM communities (e.g. by geography, education, gay scene use and HIV proximity), as well as to responding to the diverse informational and sexual health needs of all MSM communities.

HIV-negative male couples' attitudes about pre-exposure prophylaxis (PrEP) and using PrEP with a sexual agreement

One efficacious strategy to help prevent HIV is oral pre-exposure prophylaxis (PrEP), a daily regimen of antiretroviral treatment taken by HIV-negative individuals. Two of the recommendations of Centers for Disease Control and Prevention (CDC) guidelines for PrEP pertain to being in a relationship (i.e., male couples). Despite the recognition of how primary partners in male couples' relationships shape HIV risk and CDC's PrEP guidelines, there is a paucity of data that examine HIV-negative male couples' attitudes toward PrEP use and using PrEP with a sexual agreement. A sexual agreement is an explicit agreement made between two individuals about what sex and other related behaviors may occur within and outside of their relationship. In this qualitative study, we examine HIV-negative male couples' attitudes toward PrEP use and whether they thought PrEP could be integrated into a sexual agreement. Data for this study are drawn from couple-level interviews conducted in 2014 with 29 HIV-negative male couples who had a sexual agreement and were from Atlanta or Detroit. Both passive (e.g., flyers) and active (e.g., targeted Facebook advertisements) recruitment methods were used; the sample was stratified by agreement type. Thematic analysis was applied to identify the following themes regarding HIV-negative male couples' attitudes toward PrEP use: (1) PrEP and condom use; (2) concerns about PrEP (e.g., effectiveness, side effects, and promoting sexually risky behavior); and (3) accessibility of PrEP. Some thought PrEP could be a part of couples' agreement because it could help reduce sexual anxiety and sexual risk, and would help keep the couple safe. Others described PrEP use with an agreement as something for "others". Some were also concerned that incorporating PrEP could usurp the need for a sexual agreement in a couples' relationship. These themes highlight the need to improve informational messaging and promotion efforts about PrEP among HIV-negative male couples who may benefit from using it.