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Abstract
Preexposure prophylaxis (PrEP) is increasingly implemented in national HIV prevention programmes through routine care. Monitoring will be vital to understand whether programmes succeed in engaging people into using PrEP appropriately, and in reducing the HIV epidemic. Yet, it is currently unclear which indicators are most suited to monitor PrEP programmes' performance. We therefore aimed to identify and map indicators that are currently used or suggested for monitoring PrEP programmes. We conducted a scoping review based on the framework by Arksey and O'Malley. We combined a systematic search in the peer-reviewed literature with hand-searching grey literature documents describing indicators and strategies that are used or suggested for PrEP monitoring. Only literature published after 2012 was included. No geographical restrictions were set. We charted data on indicator definitions, data sources used, reported experiences with monitoring and any relevant contextual factors. Ultimately, 35 peer-reviewed and 14 grey literature records were included. We identified indicators related to preuptake stages of PrEP, uptake and coverage, and programme impact. The indicators most commonly suggested for national-level monitoring were the number of new and current PrEP users, the number of HIV seroconversions among PrEP users and some variably defined indicators related to continuation and discontinuation of PrEP. Despite its perceived high relevance, studies reported several challenges to routinely monitor the population in need of PrEP and track prevention-effective PrEP use. In conclusion, a variety of indicators is currently used or suggested for monitoring PrEP programmes. Implementing proxy measures that track different aspects of PrEP use over time, and making synergies with research more explicit, could be used as strategies to obtain more granular insights into trends revealed by routine monitoring.
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Self-reported and pill count measures of adherence to oral HIV PrEP among female sex workers living in South-Western Uganda. PLoS One 2022; 17:e0277226. [DOI: 10.1371/journal.pone.0277226] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2022] [Accepted: 10/23/2022] [Indexed: 11/12/2022] Open
Abstract
Background
Female sex workers (FSWs) in Uganda are at high risk of HIV infection. Scaling up oral pre-exposure prophylaxis (PrEP) will reduce HIV incidence if high levels of adherence are maintained. This study evaluates PrEP adherence using clinic-based pill counts and self-reported measures, and factors associated with protective levels of adherence.
Methods
Participants were sex workers who had been taking PrEP for at least 5 months and were attending routine follow-up visits for PrEP care in fishing communities and along the Trans-African Highway. Participants who had a pill count showing at least 85% use since their last clinic visit and those who reported taking their PrEP every day in the last 5 months were categorised as having ‘protective adherence’. Spearman’s correlation and weighted kappa assessed the relationship between pill count and self-reported measures. Bivariate and multivariate logistic regression was used to determine factors associated with protective adherence as measured by pill count.
Results
We recruited 524 FSWs, with a median age of 29 years (IQR 23–35). Participants were recruited from fishing communities and Trans-African Highway towns (n = 297, 56.7%, and n = 227, 43.0%). Nearly three quarters (n = 372, 71.0%) of women were estimated to have protective adherence based on pill count (i.e., a pill count of >85%) and 50.4% by self-report in last 3 months. There was a strong positive association between self-reported measures and pill count measures (rest = 0.6453, 95% CI = 0.5924–0.6927) and a moderate agreement between self-reported measures and pill count measures, κ = 0.544 (95%CI = 0.4869–0.6011, p < 0.001).
Factors associated with protective adherence included being aged 35 years or older (aOR = 2.40, 95% CI = 1.17–4.86), living in a fishing community (aOR = 1.45, 95% CI = 0.62–3.38), and having an STI in last 3 months (aOR = 1.64, 95% CI = 1.07–2.49).
Conclusion
Our findings indicate that PrEP-experienced FSWs attending clinical follow-up visits reported high protective levels of oral pre-exposure prophylaxis, as measured by both pill count and self-reported measures, and a moderate agreement between pill count and self-reported measures.
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Heffron R, Muwonge TR, Thomas KK, Nambi F, Nakabugo L, Kibuuka J, Thomas D, Feutz E, Meisner A, Ware NC, Wyatt MA, Simoni JM, Katz IT, Kadama H, Baeten JM, Mujugira A. PrEP uptake and HIV viral suppression when PrEP is integrated into Ugandan ART clinics for HIV-negative members of HIV-serodifferent couples: A stepped wedge cluster randomized trial. EClinicalMedicine 2022; 52:101611. [PMID: 35990584 PMCID: PMC9386395 DOI: 10.1016/j.eclinm.2022.101611] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/27/2022] [Revised: 07/15/2022] [Accepted: 07/22/2022] [Indexed: 11/11/2022] Open
Abstract
Background Global scale-up of HIV pre-exposure prophylaxis (PrEP) includes services to HIV-negative people in partnerships with people living with HIV (serodifferent couples). Data are needed on HIV outcomes, including uptake and adherence to PrEP and antiretroviral treatment (ART), to describe the impact of integrating PrEP into an existing HIV program. Methods Using a stepped-wedge cluster randomized trial design, we launched PrEP delivery for HIV-negative members of serodifferent couples in Uganda by integrating PrEP into existing ART programs for people living with HIV. The program provided PrEP training for ART providers, ongoing technical assistance, and a provisional supply chain mechanism for PrEP medication. Primary data on PrEP initiation, PrEP refills, ART initiation, and HIV viremia at 6 months (measured at 42-270 days) were collected through data abstraction of medical records from HIV-serodifferent couples sequentially enrolling at the ART clinics. Modified Poisson regression models, controlling for time and cluster, compared viral suppression (<1000 copies/ml) before and after launch of the PrEP program. This trial was registered at ClinicalTrials.gov, NCT03586128. Findings From June 1, 2018-December 15, 2020, 1,381 HIV-serodifferent couples were enrolled across 12 ART clinics in Kampala and Wakiso, Uganda, including 730 enrolled before and 651 after the launch of PrEP delivery. During the baseline period, 99.4% of partners living with HIV initiated ART and 85.0% were virally suppressed at 6 months. Among HIV-negative partners enrolled after PrEP launched, 81.0% (527/651) initiated PrEP within 90 days of enrolling; among these 527, 11.2% sought a refill 6 months later. In our powered intent-to-treat analysis, 82.1% and 76.7% of partners living with HIV were virally suppressed, respectively, which was not a statistically significant difference (RR=0.94, 95% CI: 0.82-1.07) and was stable across sensitivity analyses. Interpretation Integration of PrEP into ART clinics reached a high proportion of people in HIV-serodifferent relationships and did not improve the already high frequency of HIV viral suppression among partners living with HIV. Funding National Institute of Mental Health (R01MH110296).
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Affiliation(s)
- Renee Heffron
- University of Washington, 325 Ninth Avenue, Box 359927 Seattle, Washington, USA
- University of Alabama Birmingham, Birmingham, Alabama, USA
| | | | - Katherine K. Thomas
- University of Washington, 325 Ninth Avenue, Box 359927 Seattle, Washington, USA
| | - Florence Nambi
- Infectious Diseases Institute, Makerere University, Kampala, Uganda
| | | | - Joseph Kibuuka
- Infectious Diseases Institute, Makerere University, Kampala, Uganda
| | - Dorothy Thomas
- University of Washington, 325 Ninth Avenue, Box 359927 Seattle, Washington, USA
| | - Erika Feutz
- University of Washington, 325 Ninth Avenue, Box 359927 Seattle, Washington, USA
| | - Allison Meisner
- University of Washington, 325 Ninth Avenue, Box 359927 Seattle, Washington, USA
- Fred Hutch, Vaccine and Infectious Disease Division, 1100 Fairview Ave N, Seattle, Washington, USA
| | - Norma C. Ware
- Harvard Medical School, 25 Shattuck St., Boston, Massachusetts, USA
- Brigham and Women's Hospital, Harvard Medical School, 75 Francis St, Boston, Massachusetts, USA
| | - Monique A. Wyatt
- Harvard Medical School, 25 Shattuck St., Boston, Massachusetts, USA
- Harvard Global, Cambridge, Massachusetts, USA
| | - Jane M. Simoni
- University of Washington, 325 Ninth Avenue, Box 359927 Seattle, Washington, USA
| | - Ingrid T. Katz
- Brigham and Women's Hospital, Harvard Medical School, 75 Francis St, Boston, Massachusetts, USA
| | | | - Jared M. Baeten
- University of Washington, 325 Ninth Avenue, Box 359927 Seattle, Washington, USA
- Gilead Sciences LLC, Foster City, California, USA
| | - Andrew Mujugira
- Infectious Diseases Institute, Makerere University, Kampala, Uganda
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Muwonge TR, Nsubuga R, Ware NC, Wyatt MA, Pisarski E, Kamusiime B, Kasiita V, Nalukwago GK, Brown C, Nakyanzi A, Bagaya M, Bambia F, Ssebuliba T, Katabira E, Kyambadde P, Baeten JM, Heffron R, Celum C, Mujugira A, Haberer JE. Health Care Worker Perspectives of HIV Pre-exposure Prophylaxis Service Delivery in Central Uganda. Front Public Health 2022; 10:658826. [PMID: 35444979 PMCID: PMC9013815 DOI: 10.3389/fpubh.2022.658826] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2021] [Accepted: 02/14/2022] [Indexed: 01/29/2023] Open
Abstract
Background Scale-up of HIV pre-exposure prophylaxis (PrEP) services in Uganda is ongoing. However, health care workers (HCWs) may not be aware of PrEP nor what offering this service entails. We explored the impact of standardized HCW training on the knowledge and perspectives of PrEP service delivery in Uganda. Methods We recruited HCWs from facilities that offered HIV-related services in Central Uganda. Using the Uganda Ministry of Health curriculum, we trained HCWs on PrEP services. We collected data about PrEP knowledge, preparedness, and willingness to deliver PrEP to multiple key populations before the training, immediately after the training, and >6 months later (exit). We additionally conducted 15 qualitative interviews after the exit survey. Quantitative data were analyzed by Fisher exact test, while qualitative interview data were analyzed inductively. Results We recruited 80 HCWs from 35 facilities in urban (N = 24, 30%), peri-urban (N = 30, 37%), and rural (N = 26, 33%) areas. Most HCWs were nurse counselors (N = 52, 65%) or medical/clinical officers (N = 15, 18%). Surveys indicated that awareness of PrEP increased after the training and remained high. Knowledge of PrEP (i.e., as an effective, short-term antiretroviral medication to use before HIV exposure for people at high risk) generally increased with training, but significant gaps remained, and knowledge decreased with time. Most HCWs recommended PrEP for female sex workers and HIV serodifferent couples, as well as other key populations. We observed increases in the number of HCW who felt their facility was prepared to cater for HIV prevention and provide PrEP, but this view was not universal. HCWs believed in PrEP effectiveness and embraced it as an additional HIV prevention method. Concerns included patient adherence and behavioral risk compensation. HCWs noted challenges in PrEP delivery in terms of inadequate clinic preparedness, infrastructure, staff capacity, and poor attitudes toward key populations by untrained health workers. They felt further training was needed to ensure a smooth scale-up of services without stigmatization. Conclusions Standardized training improved knowledge, willingness, and preparedness to offer PrEP services among most HCWs in Central Uganda. Ongoing training will be needed to optimize PrEP delivery services and expand delivery to levels needed for population-level impact.
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Affiliation(s)
- Timothy R. Muwonge
- Infectious Diseases Institute, Makerere University, Kampala, Uganda,*Correspondence: Timothy R. Muwonge
| | - Rogers Nsubuga
- Infectious Diseases Institute, Makerere University, Kampala, Uganda
| | | | | | | | - Brenda Kamusiime
- Infectious Diseases Institute, Makerere University, Kampala, Uganda
| | - Vicent Kasiita
- Infectious Diseases Institute, Makerere University, Kampala, Uganda
| | | | - Charles Brown
- Infectious Diseases Institute, Makerere University, Kampala, Uganda
| | - Agnes Nakyanzi
- Infectious Diseases Institute, Makerere University, Kampala, Uganda
| | - Monica Bagaya
- Infectious Diseases Institute, Makerere University, Kampala, Uganda
| | - Felix Bambia
- Infectious Diseases Institute, Makerere University, Kampala, Uganda
| | | | - Elly Katabira
- Department of Medicine, College of Health Sciences, Makerere University, Kampala, Uganda
| | - Peter Kyambadde
- Most At-Risk Populations Initiative, Kampala, Uganda,STD/AIDS Control Program, Ministry of Health, Kampala, Uganda
| | - Jared M. Baeten
- Departments of Global Health and Epidemiology, University of Washington, Seattle, WA, United States,Gilead Sciences, Foster City, CA, United States
| | - Renee Heffron
- Departments of Global Health and Epidemiology, University of Washington, Seattle, WA, United States
| | - Connie Celum
- Departments of Global Health and Epidemiology, University of Washington, Seattle, WA, United States
| | - Andrew Mujugira
- Infectious Diseases Institute, Makerere University, Kampala, Uganda
| | - Jessica E. Haberer
- Harvard Medical School, Boston, MA, United States,Center for Global Health, Massachusetts General Hospital, Boston, MA, United States
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5
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Salinas-Rodríguez A, Sosa-Rubí SG, Chivardi C, Rodríguez-Franco R, Gandhi M, Mayer KH, Operario D, Gras-Allain N, Vargas-Guadarrama G, Galárraga O. Preferences for Conditional Economic Incentives to Improve Pre-exposure Prophylaxis Adherence: A Discrete Choice Experiment Among Male Sex Workers in Mexico. AIDS Behav 2022; 26:833-842. [PMID: 34453239 PMCID: PMC8840956 DOI: 10.1007/s10461-021-03443-1] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/14/2021] [Indexed: 12/29/2022]
Abstract
Pre-exposure prophylaxis (PrEP) is highly effective in preventing HIV but requires sustained adherence. Conditional economic incentives (CEIs) can improve medication-taking behaviors, yet preferences for programs that employ CEIs to increase PrEP use among male sex workers (MSWs) have not been investigated. We conducted a discrete choice experiment in Mexico City to elicit stated preferences for a CEI-based PrEP adherence program among MSWs. Respondents expressed their preferences for different program characteristics: incentive amount; incentive format; incentive type; and adherence-verification method. We used a random utility logit model to estimate the relative importance of each attribute and estimated willingness-to-pay. MSWs preferred a higher, fixed incentive, with PrEP adherence measured via hair sampling. MSWs were willing to forego up to 21% of their potential maximum CEI amount to ensure receipt of a fixed payment. MSWs are highly willing to accept a CEI-based intervention for PrEP adherence, if offered along with fixed payments.
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Affiliation(s)
- Aarón Salinas-Rodríguez
- Center for Evaluation Research and Surveys, National Institute of Public Health, Cuernavaca , Morelos, Mexico
| | - Sandra G Sosa-Rubí
- Division of Health Economics, Center for Health Systems Research, National Institute of Public Health (INSP), Cuernavaca, Morelos, Mexico
| | - Carlos Chivardi
- Division of Health Economics, Center for Health Systems Research, National Institute of Public Health (INSP), Cuernavaca, Morelos, Mexico.
| | - Roxana Rodríguez-Franco
- Division of Health Economics, Center for Health Systems Research, National Institute of Public Health (INSP), Cuernavaca, Morelos, Mexico
| | - Monica Gandhi
- Department of Medicine, University of California San Francisco, San Francisco, CA, USA
| | - Kenneth H Mayer
- The Fenway Institute, Fenway Health, and Harvard University, Boston, MA, USA
| | - Don Operario
- Department of Behavioral and Social Sciences, Brown University School of Public Health, Providence, RI, USA
| | | | | | - Omar Galárraga
- Department of Health Services, Policy and Practice, Brown University School of Public Health, Providence, RI, USA
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Franks J, Teasdale C, Olsen H, Wang C, Mushimebele N, Mazala RT, Tchissambou T, Bazola FM, Bingham T, Djomand G, Mukinda E, Ewetola R, Abrams E, Reidy W. PrEP for key populations: results from the first PrEP demonstration project in the Democratic Republic of the Congo. AIDS Care 2022; 34:359-362. [PMID: 34495772 PMCID: PMC10627785 DOI: 10.1080/09540121.2021.1969332] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2020] [Accepted: 08/03/2021] [Indexed: 10/20/2022]
Abstract
Oral pre-exposure prophylaxis (PrEP) is recommended for persons at substantial risk for HIV, including female sex workers (FSW), men who have sex with men (MSM), people who inject drugs (PWID), and transgender women (TGW). We report on a PrEP demonstration project at seven clinics in the Democratic Republic of the Congo. Routinely collected data were abstracted to assess PrEP uptake, scheduled visit attendance, and self-reported adherence. Between February and May 2018, 469 eligible clients were offered daily oral PrEP; 75.1% accepted: 78.7% FSW, 20.5% MSM, and 0.9% TGW. Two percent also identified as PWID. Attendance was 64.5% at one-month visits; 82.1% at three-month visits; and among 47.7% of clients who initiated PrEP at least six months before data abstraction, 85.8% at six-month visits. Among 66.3% of clients with at least one adherence assessment, 39% self-reported low adherence. Results demonstrate the acceptability of PrEP delivered in healthcare settings serving FSW, MSM, PWID, and TGW.
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Affiliation(s)
| | - Chloe Teasdale
- ICAP at Columbia University, New York, NY, USA
- Department of Epidemiology, Columbia University Mailman School of Public Health, New York, NY, USA
- Department of Epidemiology & Biostatistics, CUNY Graduate School of Public Health & Health Policy, New York, NY, USA
| | - Halli Olsen
- ICAP at Columbia University, New York, NY, USA
| | | | | | | | | | | | - Trista Bingham
- Division of Global HIV & TB, Center for Global Health, Centers for Disease Control and Prevention, Atlanta, GA, USA
| | - Gaston Djomand
- Division of Global HIV & TB, Center for Global Health, Centers for Disease Control and Prevention, Atlanta, GA, USA
| | - Elie Mukinda
- Democratic Republic of the Congo Centers for Disease Control and Prevention, Kinshasa, Democratic Republic of the Congo
| | - Raimi Ewetola
- Democratic Republic of the Congo Centers for Disease Control and Prevention, Kinshasa, Democratic Republic of the Congo
| | - Elaine Abrams
- ICAP at Columbia University, New York, NY, USA
- Department of Epidemiology, Columbia University Mailman School of Public Health, New York, NY, USA
- Department of Pediatrics, Columbia University Irving Medical Center, New York, NY, USA
| | - William Reidy
- ICAP at Columbia University, New York, NY, USA
- Department of Pediatrics, Columbia University Irving Medical Center, New York, NY, USA
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Were DK, Musau A, Atkins K, Shrestha P, Reed J, Curran K, Mohan D. Health system adaptations and considerations to facilitate optimal oral pre-exposure prophylaxis scale-up in sub-Saharan Africa. Lancet HIV 2021; 8:e511-e520. [PMID: 34265282 DOI: 10.1016/s2352-3018(21)00129-6] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2021] [Revised: 06/06/2021] [Accepted: 06/08/2021] [Indexed: 12/26/2022]
Abstract
Following WHO's 2015 recommendation, countries in sub-Saharan Africa have progressively scaled up oral pre-exposure prophylaxis (PrEP) as part of combination HIV prevention. PrEP has potential to significantly reduce new HIV infections in sub-Saharan Africa if it is widely available, accessible, and effectively used. Initial scale-up efforts have generated progress, drawing lessons from existing HIV interventions, such as antiretroviral therapy and biomedical prevention. However, beset by unprepared health systems, scale-up has been slow, resulting in suboptimal coverage among priority groups at higher risk of HIV acqusition. Using the WHO health system building blocks framework, this Review synthesises literature on essential considerations for PrEP scale-up in sub-Saharan Africa, highlighting the importance of health system adaptability and responsiveness.
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Affiliation(s)
| | | | - Kaitlyn Atkins
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Prakriti Shrestha
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | | | | | - Diwakar Mohan
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
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Jackson-Gibson M, Ezema AU, Orero W, Were I, Ohiomoba RO, Mbullo PO, Hirschhorn LR. Facilitators and barriers to HIV pre-exposure prophylaxis (PrEP) uptake through a community-based intervention strategy among adolescent girls and young women in Seme Sub-County, Kisumu, Kenya. BMC Public Health 2021; 21:1284. [PMID: 34210288 PMCID: PMC8252310 DOI: 10.1186/s12889-021-11335-1] [Citation(s) in RCA: 43] [Impact Index Per Article: 14.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2020] [Accepted: 06/18/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND While the introduction of HIV Pre-Exposure Prophylaxis (PrEP) as an HIV prevention strategy has allowed women to exercise more control over the reduction of HIV transmission rates, adolescent girls and young women in Sub-Saharan Africa continue to experience higher rates of HIV infections and bear the greatest disease burden. Understanding progress in PrEP uptake among adolescent girls and young women would enhance risk reduction in this vulnerable population. The Determined, Resilient, AIDS-Free, Mentored and Safe women (DREAMS) Initiative plays a key role in this risk reduction strategy. METHODS We performed a qualitative study to explore facilitators and barriers to PrEP implementation and assess factors effecting initiation and persistence on PrEP among adolescent girls and young women enrolled in the DREAMS Initiative at Pamoja Community Based Organization in Kisumu, Kenya. We conducted key informant interviews (n = 15) with Pamoja Community Based Organization staff, health care providers and community leaders. Additionally, we conducted focus group discussions with young women receiving PrEP and peer mentors (n = 40). We performed a directed content analysis using the Consolidated Framework for Implementation Research to organize the identified facilitators and barriers. RESULTS We found that the use of the safe space model, decentralization of PrEP support and delivery, peer mentors, effective linkage to local health care facilities, the sensitization of parents and male sexual partners, disclosure of PrEP use by beneficiaries, active stakeholder involvement and community engagement were among some of the facilitators to PrEP uptake. Barriers to PrEP implementation, initiation and persistence included stigma associated with the use of anti-retroviral drugs, drug side effects, frequent relocation of beneficiaries, limited resources for routine screening and medication monitoring, and a limited number of qualified health care workers for PrEP distribution and administration. CONCLUSION Overall, the community roll-out of PrEP within the DREAMS Initiative was successful due to a number of key facilitating factors, which ultimately led to successful PrEP implementation, increased PrEP initiation and enhanced persistence among adolescent girls and young women. The identified barriers should be addressed so that a larger scale-up of PrEP roll-out is possible in the future.
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Affiliation(s)
- Maya Jackson-Gibson
- Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA.
| | | | | | - Irene Were
- Pamoja Community Based Organization, Kisumu, Kenya
| | | | - Patrick Owuor Mbullo
- Pamoja Community Based Organization, Kisumu, Kenya.,Department of Anthropology & Global Health, Northwestern University, Chicago, Illinois, USA
| | - Lisa Ruth Hirschhorn
- Department of Medical Social Sciences, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
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9
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Jones A, Honermann B, Lankiewicz E, Sherwood J, Millett G. Current allocations and target apportionment for HIV testing and treatment services for marginalized populations: characterizing PEPFAR investment and strategy. J Int AIDS Soc 2021; 24 Suppl 3:e25753. [PMID: 34189858 PMCID: PMC8242967 DOI: 10.1002/jia2.25753] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2020] [Revised: 03/31/2021] [Accepted: 04/08/2021] [Indexed: 11/12/2022] Open
Abstract
INTRODUCTION The United States President's Emergency Plan for AIDS Relief (PEPFAR) is a large bilateral funder of the global HIV response whose policy decisions on key populations (KPs) programming determine the shape of the key populations' response in many countries. Understanding the size and relative share of PEPFAR funds going to KPs and the connection between PEPFAR's targets and resulting programming is crucial for successfully serving key populations. METHODS Publicly available PEPFAR budgets for key populations' services were assessed by country and geographical region for all 52 countries with budget data in fiscal year (FY) 2020. For the 23 countries which completed a full planning process in FY 2018 and 2019, PEPFAR targets for HIV testing and treatment initiation for key populations were assessed. Expenditures for KP programming were calculated to determine whether shifts in targets translated into programming. Implementing partners were characterized by the level of specialization using the share of assigned targets made up by KPs. The average target per year and implementing partner was calculated for each KP group and indicator. RESULTS PEPFAR country KP budgets ranged from US$35,000 to $15.2 million, and the proportion of funding to key populations varied by region, with Eastern and Southern African countries having the lowest proportion. Between FY 2018 and 2019, the KP targets for HIV testing and treatment among KPs increased, whereas expenditures on key populations decreased from US$115.4 to $111.0 million. Of the 11 countries with an increase in HIV testing targets, seven had a decrease in KP expenditures. Of the nine countries with an increase in treatment initiation targets, five had a decrease in KP expenditures. The proportion of targets assigned to partners which do not specialize in key populations increased from FY 2018 to 2019. CONCLUSIONS Current key population policies have not resulted in a tight connection between targets and expenditures. This includes assigning a large proportion of key populations programming to partners who do not specialize in key populations, which may weaken the performance management role of the targets. These results signal that a new approach to key populations programming is needed.
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Affiliation(s)
- Austin Jones
- Public Policy OfficeamfARthe Foundation for AIDS ResearchWashingtonDCUSA
| | - Brian Honermann
- Public Policy OfficeamfARthe Foundation for AIDS ResearchWashingtonDCUSA
| | - Elise Lankiewicz
- Public Policy OfficeamfARthe Foundation for AIDS ResearchWashingtonDCUSA
| | - Jennifer Sherwood
- Public Policy OfficeamfARthe Foundation for AIDS ResearchWashingtonDCUSA
| | - Greg Millett
- Public Policy OfficeamfARthe Foundation for AIDS ResearchWashingtonDCUSA
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Kawuma R, Ssemata AS, Bernays S, Seeley J. Women at high risk of HIV-infection in Kampala, Uganda, and their candidacy for PrEP. SSM Popul Health 2021; 13:100746. [PMID: 33604448 PMCID: PMC7873676 DOI: 10.1016/j.ssmph.2021.100746] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2020] [Revised: 01/25/2021] [Accepted: 01/26/2021] [Indexed: 11/26/2022] Open
Abstract
Pre-exposure prophylaxis (PrEP), antiretroviral medication for prevention of HIV-acquisition, is part of biomedical HIV prevention strategies recommended for people at risk of HIV-infection. A decision to take PrEP depends on an assessment of 'being at risk' either by an individual, or healthcare provider. In this paper, we draw on the concept of 'candidacy' to examine the different ways in which women attending a dedicated clinic in Kampala, Uganda, for women at risk of HIV infection (including sex workers), assessed their suitability for PrEP. We conducted in-depth interviews with 30 HIV negative women up to four different times, to gather information on the motives for taking PrEP, and their life history and daily life. All the women described the relevance of PrEP to mitigate their risk of HIV infection. However, there were challenges to adherence because of alcohol use, irregular working hours and a fear of being seen taking pills that others might assume to be HIV treatment. The ways in which the different women used PrEP and interpreted the place of PrEP in their lives were not solely based on their assessment of protecting themselves during sex work. They also used PrEP to guard against infection from their regular partners, and as a tool to allow them to make more money safely, by having sex without a condom with clients. While eligibility to access PrEP was predicated on the women's being in an 'at risk' population group, an incentive to use PrEP was to protect themselves from HIV acquisition from a long-term partner and preserve the 'trust' in their intimate relationship by having condom-less sex. Applying a candidacy lens we highlight the complexity in how women experience and present as being 'at risk' and query the criteria on which categories of risk and PrEP eligibility are determined.
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Affiliation(s)
- Rachel Kawuma
- MRC/UVRI and LSHTM Uganda Research Unit, Entebbe, Uganda
| | | | - Sarah Bernays
- School of Public Health, University of Sydney, Sydney, Australia
- Department of Global Health and Development, London School of Hygiene and Tropical Medicine, London, UK
| | - Janet Seeley
- MRC/UVRI and LSHTM Uganda Research Unit, Entebbe, Uganda
- School of Public Health, University of Sydney, Sydney, Australia
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Muwonge TR, Nsubuga R, Brown C, Nakyanzi A, Bagaya M, Bambia F, Katabira E, Kyambadde P, Baeten JM, Heffron R, Celum C, Mujugira A, Haberer JE. Knowledge and barriers of PrEP delivery among diverse groups of potential PrEP users in Central Uganda. PLoS One 2020; 15:e0241399. [PMID: 33112907 PMCID: PMC7592843 DOI: 10.1371/journal.pone.0241399] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2020] [Accepted: 10/13/2020] [Indexed: 01/29/2023] Open
Abstract
BACKGROUND Scale-up of oral pre-exposure prophylaxis (PrEP) for HIV prevention in Uganda began with serodiscordant couples (SDC) and has expanded to other most at-risk populations (MARPs). We explored knowledge, acceptability, barriers and facilitators of PrEP use among potential PrEP users in four MARPs (SDC; men who have sex with men [MSM]; female sex workers [FSW], and fisher folk). METHODS We administered quantitative surveys to potential PrEP users in multiple settings in Central Uganda at baseline and approximately 9 months after healthcare worker (HCW) training on PrEP. RESULTS The survey was completed by 250 potential PrEP users at baseline and 125 after HCW training; 55 completed both surveys. For these 250 participants, mean age was 28.5 years (SD 6.9), 47% were male and 6% were transgender women, with approximately even distribution across MARPs and recruitment locations (urban, peri-urban, and rural). Most (65%) had not heard about PrEP. After HCW training, 24% of those sampled were aware of PrEP, and the proportion of those who accurately described PrEP as "antiretrovirals to be used before HIV exposure" increased from 54% in the baseline survey to 74% in the second survey (p<0.001). The proportion of participants who reported HCW as a source of PrEP information increased after training (59% vs 91%, p<0.001). In both surveys, nearly all participants indicated they were willing to take PrEP if offered. The most common anticipated barriers to PrEP were stigma, transportation, accessibility, busy schedules, and forgetfulness. Closeness to home was a common facilitator for all participant categories. CONCLUSIONS Initial awareness of PrEP was low, but PrEP knowledge and interest increased among diverse MARPs after HCW training. Demand creation and HCW training will be critical for increasing PrEP awareness among key populations, with support to overcome barriers to PrEP use. These findings should encourage the acceleration of PrEP rollout in Uganda.
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Affiliation(s)
- Timothy R. Muwonge
- Infectious Diseases Institute Makerere University, Kampala, Uganda
- * E-mail: ,
| | - Rogers Nsubuga
- Infectious Diseases Institute Makerere University, Kampala, Uganda
| | - Charles Brown
- Infectious Diseases Institute Makerere University, Kampala, Uganda
| | - Agnes Nakyanzi
- Infectious Diseases Institute Makerere University, Kampala, Uganda
| | - Monica Bagaya
- Infectious Diseases Institute Makerere University, Kampala, Uganda
| | - Felix Bambia
- Infectious Diseases Institute Makerere University, Kampala, Uganda
| | - Elly Katabira
- Department of Medicine, College of Health Sciences, Makerere University, Kampala, Uganda
| | - Peter Kyambadde
- Most At-Risk Populations Initiative, Kampala, Uganda
- STD/AIDS Control Program Ministry of Health, Kampala, Uganda
| | - Jared M. Baeten
- Department of Global Health, Medicine, and Epidemiology, University of Washington, Seattle, Washington, United States of America
| | - Renee Heffron
- Department of Global Health, Medicine, and Epidemiology, University of Washington, Seattle, Washington, United States of America
| | - Connie Celum
- Department of Global Health, Medicine, and Epidemiology, University of Washington, Seattle, Washington, United States of America
| | - Andrew Mujugira
- Infectious Diseases Institute Makerere University, Kampala, Uganda
| | - Jessica E. Haberer
- Department of General Internal Medicine, Massachusetts General Hospital Global Health, Boston, Massachusetts, United States of America
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