Design and Implementation of a Multilevel Intervention to Reduce Hepatitis C Transmission Among Men Who Have Sex With Men in Amsterdam: Co-Creation and Usability Study

Doxycycline prophylaxis for sexually transmitted infection prevention in Vietnam: Awareness, attitudes, and willingness to use among men who have sex with men using HIV-PrEP

Objectives

Doxycycline prophylaxis shows promise for sexually transmitted infection (STI) prevention, but data primarily come from high-income countries. This study assessed awareness, willingness and factors associated with willingness to use doxycycline for STI prevention among men who have sex with men (MSM) using HIV-PrEP in Vietnam.

Methods

Between January 25 and February 4, 2024, a cross-sectional study recruited males aged ≥18 years who reported sex with men in the past 12 months from 11 PrEP clinics in Hanoi and Ho Chi Minh City. Self -administered surveys were conducted, and multivariable logistic regression was applied to identify factors associated with willingness to use doxyPEP/PrEP.

Results

Among 350 participants (45.7% Hanoi, 54.3% Ho Chi Minh City), the median age was 25 (interquartile range [IQR]: 21-30), and 10.6% self-reported an STI diagnosis in the past 12 months. In the previous 6 months, the median number of sex partners was 2 (IQR: 1-4), 53.1% reported condomless anal sex. Awareness of doxycycline was low (20.2%; 65/322), however, 75.4% (264/350) expressed willingness to use it, with 63.6% (168/264) preferring doxyPrEP. Participants who disclosed HIV-PrEP use to all sex partners (adjusted odds ratio [aOR]: 4.17; 95% confidence interval [95%CI] 1.84, 9.46), and those with higher perceived STI risk (aOR: 1.12; 95% CI 1.03, 1.22) were more likely to report willingness to use doxycycline prophylaxis. Concerns about daily medication (aOR: 0.43; 95% CI 0.24, 0.81) and fear of judgement from peers (aOR: 0.41; 95% CI: 0.21, 0.81) were associated with lower willingness.

Conclusions

Knowledge of doxyPEP/PrEP among MSM on HIV-PrEP in Vietnam was low. However, most expressed willingness to use doxycycline prophylaxis, with two-thirds preferring doxyPrEP. Findings highlight the need to disseminate information on doxyPEP/PrEP for STI prevention strategy, evaluating the usage and comparative effectiveness of doxyPEP and doxyPrEP to guide implementation efforts in Vietnam.

1 What is already known on this topic

Men who have sex with men (MSM) experience a disproportionate burden of HIV and bacterial sexually transmitted infections (STIs) worldwide, including in Vietnam. Despite the successful expansion of HIV Pre-Exposure Prophylaxis (PrEP) programs in Vietnam, bacterial STI rates remain persistently high among PrEP users, highlighting gaps in prevention efforts. Evidence from high-income countries (HICs) suggests that doxycycline prophylaxis can significantly reduce the incidence of bacterial STIs such as syphilis and chlamydia. However, little is known about the awareness, acceptability, and feasibility of doxycycline prophylaxis in Vietnam and other low-and middle-income countries (LMICs).

2 What this study adds

This study is the first to assess awareness, attitudes, and willingness to use doxycycline prophylaxis for STI prevention among MSM in Vietnam, a LMIC setting. Despite low prior awareness, the study found high willingness (75.4%) to use doxycycline, with most participants preferring daily doxyPrEP over doxyPEP. It also identified critical facilitators, such as perceived high STI risk and disclosure of HIV-PrEP use to sex partners, as well as barriers, including stigma, cost, and concerns about daily medication. These findings provide insights into the feasibility of introducing doxycycline prophylaxis in Vietnam, distinguishing it from contexts in HICs where different preferences and barriers may exist.

3 How this study might affect research practice or policy

This study provides a foundation for further research on doxycycline prophylaxis in LMICs, emphasizing the need to evaluate its real-world effectiveness and implementation in settings with high AMR prevalence. Policymakers can use these findings to develop tailored guidelines and subsidies for doxycycline prophylaxis in Vietnam, ensuring affordability and accessibility.

Exploring group differences in the response to a sexual risk reduction intervention to prevent hepatitis C virus reinfection in HIV-infected MSM: a mixed-methods study

To prevent hepatitis C virus (HCV) reinfection, within the Swiss HCVree Trial, a preventive risk reduction intervention was implemented alongside curative treatment. Formative qualitative research identified three response patterns to the intervention. This mixed-methods study's aim was to cross-validate group differences in (a) the content of sexual risk reduction goals set during intervention and (b) the extent of their behavioural change in condomless anal intercourse with non-steady partners (nsCAI), sexualised and intravenous drug use at start and six-month post-intervention. Qualitative thematic analysis was used to summarise goal setting domains. Quantitative descriptive analysis was used to evaluate group differences based on assumptions of the group descriptions. Results largely confirmed assumptions on inter-group response differences in goal setting and behaviour: as expected group 1 Avoid risks showed the lowest HCV risk profile with changes in nsCAI. Group 2 Minimize-risks and Group 3 Accept-risks showed unchanged nsCAI. Group 3 had the highest HCV risk profile. Differences in their goal preferences (1: condom use; 2 reduction blood exposure; 3 safer dating) highlight diversity in attitudes to behavioural change. Our results improve understanding of variability in intervention responses such as changes in attitudes and behaviour. This provides evidence for intervention tailoring and outcome measurement.

Internet-guided HCV-RNA testing: A promising tool to achieve hepatitis C micro-elimination among men who have sex with men

In the Netherlands, hepatitis C virus (HCV) transmission occurs primarily in men who have sex with men (MSM). By early diagnosis and immediate treatment of acute HCV infections, HCV micro-elimination in MSM is within reach. In cooperation with the community affected, we developed an online HCV-RNA home-based self-sampling test service. This service combined online HCV self-risk assessment with the possibility to test anonymously for HCV-RNA. The service was available in the Netherlands from February 2018 till December 2020 and was promoted online on various dating sites and offline by community volunteers. Using website user data, test results and an online post-test user survey, we evaluated the service and user experiences. The website page with information about testing was visited by 3401 unique users, of whom 2250 used the HCV-risk assessment tool, 152 individuals purchased 194 HCV-RNA tests, and 104 tests were used, of which 101 gave a conclusive result. The target population of MSM at risk was successfully reached with 44.1% of users receiving the advice to test. The test service had a satisfactory uptake (6.8%, 152/2250), a very high HCV-RNA positivity rate (10.9%, 11/101) and was considered acceptable and easy to use by most MSM. We demonstrate that an HCV-RNA home-based self-sampling test service is successful in diagnosing HCV infections among MSM. This service could be a valuable addition to existing sexual healthcare services as it may reach men who are otherwise not tested.

Usability, acceptability, and self-reported impact of an innovative hepatitis C risk reduction intervention for men have sex with men: A mixed methods study

Hepatitis C virus (HCV) elimination among men who have sex with men (MSM) is unlikely to be feasible without effective behavioural interventions. We developed a multilevel intervention to reduce HCV transmission among MSM in Amsterdam. The intervention includes a toolbox to facilitate risk reduction among MSM and support health care professionals in risk reduction counselling. To assess the use of the toolbox and its impact on behavior, we conducted a mixed-methods study. We collected data through online questionnaires (n = 49), and in-depth interviews with MSM at risk of HCV (n = 15) and health care professionals (n = 7). We found that the toolbox has been well received by MSM, increased awareness of HCV risks and has facilitated preventive behaviours and risk-reduction communication with peers. Professionals reported the toolbox to be a useful aid for discussions about HCV risk and risk reduction strategies with their clients.

Response to a sexual risk reduction intervention provided in combination with hepatitis C treatment by HIV/HCV co-infected men who have sex with men: a reflexive thematic analysis

BACKGROUND

Hepatitis C virus reinfections in HIV-positive men-who-have-sex-with-men (MSM) challenge the effectiveness of antiviral treatment. To fight this problem, an adapted sexual risk reduction intervention was implemented within a hepatitis C treatment trial. Following this, the current study had two aims and describes 1) how the program was received by participants; and 2) their responses to the program regarding sexual risk taking. Based on the participants' input, we hoped to judge the intervention's potential for scale-up.

METHODS

Seventeen participants who received the sexual risk reduction intervention in addition to hepatitis C treatment were recruited for semi-structured interviews six to 12 months post-intervention. We evaluated the responses via reflexive thematic analysis and applied the concept of sense-making.

RESULTS

Giving hepatitis C a place and living without it again illustrates how participants received the program and how their experiences were altered by the impact of sense-making. Based on their responses, we allocated participants to three groups: 1. Avoid risks: get rid of hepatitis C for life. For these men, hepatitis C remained a life-threatening disease: they actively modified their risk behavior and felt supported by the intervention in maintaining their behavioral changes. 2. Minimize risks: live as long as possible without hepatitis C. In contrast to group 1, these men saw hepatitis C as a manageable disease. The intervention facilitated reflection on risks and how to develop behavioral changes that suited them individually. 3. Accept risks; live with the risk of hepatitis C. These men perceived behavioral changes as much more difficult than "easy" medical treatment. They expected to either undergo repeated rounds of treatment or stay HCV re-infected.

CONCLUSION

These results illustrate the diversity of men's responses and their decisions regarding sexual risk behavior after participating in a combination of antiviral treatment and a sexual risk reduction intervention. Two major aspects were identified: 1) Teachable moments, particularly at the time of diagnosis/treatment, could offer an opportunity to develop openness for behavioral change; 2) adapting sexual risk reduction interventions to sense-making patterns could help to improve its effectiveness. Support for reducing infection risk and raising awareness of preventative measures are additional benefits.

TRIAL REGISTRATION

Clinical Trial Number: NCT02785666 , 30.05.2016.