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Poteat T, Bothma R, Maposa I, Hendrickson C, Meyer-Rath G, Hill N, Pettifor A, Imrie J. Transgender-Specific Differentiated HIV Service Delivery Models in the South African Public Primary Health Care System (Jabula Uzibone): Protocol for an Implementation Study. JMIR Res Protoc 2024; 13:e64373. [PMID: 39269745 DOI: 10.2196/64373] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2024] [Revised: 07/24/2024] [Accepted: 07/25/2024] [Indexed: 09/15/2024] Open
Abstract
BACKGROUND Almost 60% of transgender people in South Africa are living with HIV. Ending the HIV epidemic will require that transgender people successfully access HIV prevention and treatment. However, transgender people often avoid health services due to facility-based stigma and lack of availability of gender-affirming care. Transgender-specific differentiated service delivery (TG-DSD) may improve engagement and facilitate progress toward HIV elimination. Wits RHI, a renowned South African research institute, established 4 TG-DSD demonstration sites in 2019, with funding from the US Agency for International Development. These sites offer unique opportunities to evaluate the implementation of TG-DSD and test their effectiveness. OBJECTIVE The Jabula Uzibone study seeks to assess the implementation, effectiveness, and cost of TG-DSD for viral suppression and prevention-effective adherence. METHODS The Jabula Uzibone study collects baseline and 12-month observation checklists at 8 sites and 6 (12.5%) key informant interviews per site at 4 TG-DSD and 4 standard sites (n=48). We seek to enroll ≥600 transgender clients, 50% at TG-DSD and 50% at standard sites: 67% clients with HIV and 33% clients without HIV per site type. Participants complete interviewer-administered surveys quarterly, and blood is drawn at baseline and 12 months for HIV RNA levels among participants with HIV and tenofovir levels among participants on pre-exposure prophylaxis. A subset of 30 participants per site type will complete in-depth interviews at baseline and 12 months: 15 participants will be living with HIV and 15 participants will be HIV negative. Qualitative analyses will explore aspects of implementation; regression models will compare viral suppression and prevention-effective adherence by site type. Structural equation modeling will test for mediation by stigma and gender affirmation. Microcosting approaches will estimate the cost per service user served and per service user successfully treated at TG-DSD sites relative to standard sites, as well as the budget needed for a broader implementation of TG-DSD. RESULTS Funded by the US National Institutes of Mental Health in April 2022, the study was approved by the Human Research Ethics Committee at University of Witwatersrand in June 2022 and the Duke University Health System Institutional Review Board in June 2023. Enrollment began in January 2024. As of July 31, 2024, a total of 593 transgender participants have been enrolled: 348 are living with HIV and 245 are HIV negative. We anticipate baseline enrollment will be complete by August 31, 2024, and the final study visit will take place no later than August 2025. CONCLUSIONS Jabula Uzibone will provide data to inform HIV policies and practices in South Africa and generate the first evidence for implementation of TG-DSD in sub-Saharan Africa. Study findings may inform the use of TG-DSD strategies to increase care engagement and advance global progress toward HIV elimination goals. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID) DERR1-10.2196/64373.
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Affiliation(s)
- Tonia Poteat
- Duke University School of Nursing, Durham, NC, United States
| | - Rutendo Bothma
- Wits RHI, University of the Witwatersrand, Johannesburg, South Africa
| | - Innocent Maposa
- Division of Epidemiology and Biostatistics, Department of Global Health, Faculty of Medicine and Health Sciences, Stellenbosch University, Stellenbosch, South Africa
| | - Cheryl Hendrickson
- Health Economics and Epidemiology Research Office, Faculty of Health Sciences, University of Witwatersrand, Johannesburg, South Africa
- Department of Global Health, Amsterdam Institute for Global Health and Development, Amsterdam UMC, University of Amsterdam, Amsterdam, Netherlands
| | - Gesine Meyer-Rath
- Health Economics and Epidemiology Research Office, Faculty of Health Sciences, University of Witwatersrand, Johannesburg, South Africa
- Department of Global Health, Boston University, Boston, MA, United States
- South African Centre for Epidemiological Modelling and Analysis, Stellenbosch University, Stellenbosch, South Africa
| | - Naomi Hill
- Wits RHI, University of the Witwatersrand, Johannesburg, South Africa
| | - Audrey Pettifor
- Department of Epidemiology, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, NC, United States
| | - John Imrie
- Wits RHI, University of the Witwatersrand, Johannesburg, South Africa
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Matthews LT, Jaggernath M, Kriel Y, Smith PM, Haberer JE, Baeten JM, Hendrix CW, Ware NC, Moodley P, Pillay M, Bennett K, Bassler J, Psaros C, Hurwitz KE, Bangsberg DR, Smit JA. Oral preexposure prophylaxis uptake, adherence, and persistence during periconception periods among women in South Africa. AIDS 2024; 38:1342-1354. [PMID: 38752557 PMCID: PMC11211057 DOI: 10.1097/qad.0000000000003925] [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: 01/18/2024] [Revised: 04/01/2024] [Accepted: 04/08/2024] [Indexed: 05/28/2024]
Abstract
OBJECTIVE We developed the Healthy Families-PrEP intervention to support HIV-prevention during periconception and pregnancy. We evaluated preexposure prophylaxis (PrEP) use with three objective measures. DESIGN This single-arm intervention study enrolled women in KwaZulu-Natal, South Africa, who were HIV-uninfected, not pregnant, in a relationship with a partner with HIV or unknown-serostatus, and with pregnancy plans. PrEP was offered as part of a comprehensive HIV prevention intervention. Participants were followed for 12 months. METHODS We evaluated periconception PrEP uptake and adherence using quarterly plasma tenofovir concentrations. We modeled factors associated with PrEP uptake and high plasma tenofovir (past day dosing). Patterns of use were analyzed using electronic pillcap data. Dried blood spots to measure intracellular tenofovir product (past 2 months dosing) were analyzed for a subset of women. RESULTS Three hundred thirty women with median age 24 (IQR: 22-27) years enrolled. Partner HIV-serostatus was unknown by 96% ( N = 316); 60% (195) initiated PrEP. High plasma tenofovir concentrations were seen in 35, 25, 22, and 20% of samples at 3, 6, 9, and 12 months, respectively. Similar adherence was measured by pillcap and dried blood spots. In adjusted models, lower income, alcohol use, and higher HIV stigma were associated with high plasma tenofovir. Eleven HIV-seroconversions were observed (incidence rate: 4.04/100 person-years [95% confidence interval: 2.24-7.30]). None had detectable plasma tenofovir. CONCLUSION The Healthy Families-PrEP intervention supported women in PrEP use. We observed high interest in periconception PrEP and over one-third adhered to PrEP in the first quarter; one-fifth were adherent over a year. High HIV incidence highlights the importance of strategies to reduce HIV incidence among periconception women. CLINICAL TRIAL NUMBER NCT03194308.
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Affiliation(s)
- Lynn T. Matthews
- Division of Infectious Diseases, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Manjeetha Jaggernath
- Maternal Adolescent and Child Health Research Unit (MRU), Department of Obstetrics and Gynaecology, University of the Witwatersrand, Faculty of Health Sciences, Durban, South Africa
| | - Yolandie Kriel
- Maternal Adolescent and Child Health Research Unit (MRU), Department of Obstetrics and Gynaecology, University of the Witwatersrand, Faculty of Health Sciences, Durban, South Africa
| | - Patricia M. Smith
- Division of Infectious Diseases, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Jessica E. Haberer
- Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - Jared M. Baeten
- Department of Global Health
- Division of Allergy and Infectious Diseases, University of Washington, Seattle, Washington
| | - Craig W. Hendrix
- Department of Medicine (Clinical Pharmacology), Johns Hopkins University, School of Medicine, Baltimore, Maryland
| | - Norma C. Ware
- Department of Global Health & Social Medicine, Harvard Medical School
- Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts
| | - Pravi Moodley
- University of KwaZulu-Natal, School of Laboratory Medicine and Medical Sciences, National Health Laboratory Service
| | - Melendhran Pillay
- Department of Virology, National Health Laboratory Service, Durban, South Africa
| | | | - John Bassler
- Department of Biostatistics, School of Public Health, University of Alabama at Birmingham, Birmingham, Alabama
| | - Christina Psaros
- Department of Psychiatry, Behavioural Medicine Program, Massachusetts General Hospital, Boston, Massachusetts, USA
| | | | | | - Jennifer A. Smit
- Maternal Adolescent and Child Health Research Unit (MRU), Department of Obstetrics and Gynaecology, University of the Witwatersrand, Faculty of Health Sciences, Durban, South Africa
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Wu L, Saina M, Brown C, Chege D, Donnell D, Glidden DV, Ngure K, Mugo NR, Akelo N, Schaafsma T, Anderson PL, Mugwanya KK. Establishing adherence-concentration-efficacy thresholds of TDF-FTC pre-exposure prophylaxis for HIV prevention in African women: a protocol for the Women TDF-FTC Benchmark Study. FRONTIERS IN REPRODUCTIVE HEALTH 2024; 6:1325257. [PMID: 38860025 PMCID: PMC11163076 DOI: 10.3389/frph.2024.1325257] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2023] [Accepted: 05/06/2024] [Indexed: 06/12/2024] Open
Abstract
Background Oral pre-exposure prophylaxis (PrEP) using co-formulated emtricitabine (FTC) and tenofovir disoproxil fumarate (TDF) is a potent HIV prevention method for men and women, with its efficacy highly dependent on adherence. A pivotal HIV efficacy study combined with a directly observed pharmacological study defined the thresholds for HIV protection in men who have sex with men (MSM), which are the keys to PrEP promotion and development of new PrEP agents. For African women at risk for HIV and belonging to a priority group considered due to disproportionately high incident HIV infections, the variable adherence in PrEP clinical trials and the limited pharmacologic data have resulted in a lack of clarity about the PrEP adherence required for HIV protection. We propose a study to quantify the adherence-concentration-efficacy thresholds of TDF/FTC PrEP among African cisgender women to inform decisions about optimal PrEP dosing and adherence for HIV protection. Methods We randomized 45 low-risk HIV-uninfected African women, aged 18-30 years old, to directly observe the TDF/FTC PrEP of two, four, or seven doses per week for 8 weeks. A complementary age-matched pregnant women cohort at high risk of HIV, who will receive seven doses per week, was recruited (N = 15) with the primary aim of establishing benchmark concentrations in dried blood spots and peripheral blood mononuclear cells. Plasma, whole blood (WB), urine, hair, vaginal fluid, and vaginal tissue (non-pregnant women only) were archived for future testing. Drug concentrations were measured using methods validated for each biological matrix. Pharmacokinetic models were fitted to drug concentrations to quantify concentration-adherence thresholds. To define the drug concentrations associated with HIV protection, we applied the newly defined thresholds from the primary pharmacologic trial to the subset of women randomized to TDF/FTC or TDF in the Partners PrEP Study with the drug concentration assessed in plasma and WB samples. Multiple imputation was used to construct a data set with drug concentrations at each visit when an HIV test was performed for the entire cohort, replicating the work for MSM. Discussion The proposed study generated the first African women-specific TDF-PrEP adherence-concentration-efficacy thresholds essential for guiding the accurate interpretation of TDF/FTC PrEP programs and clinical trials of novel HIV prevention products using TDF/FTC as an active control. Clinical Trial Registration ClinicalTrials.gov, identifier (NCT05057858).
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Affiliation(s)
- Linxuan Wu
- Department of Global Health, University of Washington, Seattle, WA, United States
- Department of Epidemiology, University of Washington, Seattle, WA, United States
| | - Matilda Saina
- Center for Clinical Research, Kenya Medical Research Institute, Nairobi, Kenya
| | - Clare Brown
- Department of Global Health, University of Washington, Seattle, WA, United States
| | - David Chege
- Clinical Trials Research Laboratory, Kenyatta National Hospital, Nairobi, Kenya
| | - Deborah Donnell
- Department of Global Health, University of Washington, Seattle, WA, United States
- Vaccine and Infectious Disease Division, Fred Hutchinson Cancer Center, Seattle, WA, United States
| | - David V. Glidden
- Department of Epidemiology and Biostatistics, University of California San Francisco, San Francisco, CA, United States
| | - Kenneth Ngure
- Department of Global Health, University of Washington, Seattle, WA, United States
- School of Public Health, Jomo Kenyatta University of Agriculture and Technology, Nairobi, Kenya
| | - Nelly R. Mugo
- Department of Global Health, University of Washington, Seattle, WA, United States
- Center for Clinical Research, Kenya Medical Research Institute, Nairobi, Kenya
| | - Nina Akelo
- Center for Clinical Research, Kenya Medical Research Institute, Nairobi, Kenya
| | - Torin Schaafsma
- Department of Global Health, University of Washington, Seattle, WA, United States
| | - Peter L. Anderson
- Department of Pharmaceutical Science, University of Colorado Denver, Aurora, CO, United States
| | - Kenneth K. Mugwanya
- Department of Global Health, University of Washington, Seattle, WA, United States
- Department of Epidemiology, University of Washington, Seattle, WA, United States
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Musinguzi N, Ngure K, Bukusi EA, Mugo NR, Baeten JM, Anderson PL, Haberer JE. Performance of Multiple Adherence Measures for pre-exposure Prophylaxis (PrEP) Among Young Women in Kenya. AIDS Behav 2023; 27:3961-3969. [PMID: 37351684 DOI: 10.1007/s10461-023-04111-2] [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] [Accepted: 06/03/2023] [Indexed: 06/24/2023]
Abstract
Understanding PrEP adherence is key in the formulation of HIV prevention strategies; however, measurement of adherence can be challenging. We compared multiple adherence measures in a two-year study of young Kenyan women at high risk of HIV acquisition. Among 289 participants, concordance between electronic adherence monitoring (EAM) and tenofovir diphosphate (TFV-DP) in dried blood spots ranged from 57 to 72% depending on selected thresholds. Using area under the receiver operating curve, discrimination of quantifiable TFV-DP was high at 0.85 with EAM and low at 0.49-0.54 for multiple self-reported measures. Correlation between EAM and self-reported measures was low (r < 0.11) although correlation within self-reported measures was moderate (r > 0.69). These findings indicate that both TFV-DP and EAM are useful PrEP adherence tools. Adherence would benefit from better availability of less expensive versions of both measurement tools. Additionally, further research on TFV-DP thresholds is needed to inform interpretation and use in understanding PrEP adherence in this population.
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Affiliation(s)
- Nicholas Musinguzi
- Global Health Collaborative, Mbarara University of Science and Technology, Mbarara, Uganda.
| | - Kenneth Ngure
- Center for Clinical Research (CCR), Kenya Medical Research Institute (KEMRI), Nairobi, Kenya
- Department of Community Health, Jomo Kenyatta University of Agriculture and Technology, Juja, Kenya
| | - Elizabeth A Bukusi
- Department of Obstetrics and Gynecology, University of Washington, Seattle, USA
- Department of Global Health, University of Washington, Seattle, USA
- Center for Microbiology Research (CMR), Kenya Medical Research Institute (KEMRI), Nairobi, Kenya
| | - Nelly R Mugo
- Center for Clinical Research (CCR), Kenya Medical Research Institute (KEMRI), Nairobi, Kenya
- Department of Global Health, University of Washington, Seattle, USA
| | - Jared M Baeten
- Department of Global Health, University of Washington, Seattle, USA
- Department of Epidemiology, University of Washington, Seattle, USA
- Department of Medicine, University of Washington, Seattle, USA
| | - Peter L Anderson
- Colorado Antiviral Pharmacology Laboratory, Department of Pharmaceutical Sciences, Skaggs School of Pharmacy and Pharmaceutical Sciences, University of Colorado-AMC, Aurora, CO, USA
| | - Jessica E Haberer
- Massachusetts General Hospital, Harvard Medical School, Boston, USA
- Department of Medicine, Harvard Medical School, Boston, MA, USA
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Moran A, Mashele N, Mvududu R, Gorbach P, Bekker LG, Coates TJ, Myer L, Joseph Davey D. Maternal PrEP Use in HIV-Uninfected Pregnant Women in South Africa: Role of Stigma in PrEP Initiation, Retention and Adherence. AIDS Behav 2022; 26:205-217. [PMID: 34287756 PMCID: PMC8294266 DOI: 10.1007/s10461-021-03374-x] [Citation(s) in RCA: 24] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/09/2021] [Indexed: 11/29/2022]
Abstract
Pregnant women in sub-Saharan Africa are at high risk of HIV acquisition and require effective methods to prevent HIV. In a cohort of pregnant women offered Pre-exposure prophylaxis (PrEP), we evaluate the relationship between internalized and anticipated stigma and PrEP initiation at first antenatal visit, 3-month continuation and adherence using multivariable logistic regression. High internalized and anticipated PrEP stigma are associated with lower PrEP care initiation at first antenatal visit (aOR internalized stigma = 0.06; 95% CI = 0.03–0.11 and aOR anticipated stigma = 0.55; 95% CI = 0.31–1.00) compared to women with low reported stigma, after controlling for covariates. Women whose partners have not been tested for HIV or whose serostatus remains unknown have 1.6-times odds of PrEP retention at 3-months compared to women whose partners have been tested (aOR = 1.60; 95% CI = 1.02–2.52) after adjusting for covariates. PrEP counseling and maternal PrEP interventions must consider individual- and relational-level interventions to overcome anticipated PrEP stigma and other barriers to PrEP initiation and adherence.
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Affiliation(s)
- Alexander Moran
- Department of Epidemiology, Fielding School of Public Health, University of California Los Angeles, 615 E Charles Young Drive S, Los Angeles, CA, 90095, USA.
| | - Nyiko Mashele
- Department of Biostatistics and Epidemiology, School of Public Health and Family Medicine, University of Cape Town, Cape Town, South Africa
| | - Rufaro Mvududu
- Department of Biostatistics and Epidemiology, School of Public Health and Family Medicine, University of Cape Town, Cape Town, South Africa
| | - Pamina Gorbach
- Department of Epidemiology, Fielding School of Public Health, University of California Los Angeles, 615 E Charles Young Drive S, Los Angeles, CA, 90095, USA
| | - Linda-Gail Bekker
- The Desmond Tutu HIV Centre, University of Cape Town, Cape Town, South Africa
| | - Thomas J Coates
- David Geffen School of Medicine, University of California Los Angeles, Los Angeles, CA, USA
| | - Landon Myer
- Department of Biostatistics and Epidemiology, School of Public Health and Family Medicine, University of Cape Town, Cape Town, South Africa
| | - Dvora Joseph Davey
- Department of Epidemiology, Fielding School of Public Health, University of California Los Angeles, 615 E Charles Young Drive S, Los Angeles, CA, 90095, USA
- Department of Biostatistics and Epidemiology, School of Public Health and Family Medicine, University of Cape Town, Cape Town, South Africa
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Celum C, Hosek S, Tsholwana M, Kassim S, Mukaka S, Dye BJ, Pathak S, Mgodi N, Bekker LG, Donnell DJ, Wilson E, Yuha K, Anderson PL, Agyei Y, Noble H, Rose SM, Baeten JM, Fogel JM, Adeyeye A, Wiesner L, Rooney J, Delany-Moretlwe S. PrEP uptake, persistence, adherence, and effect of retrospective drug level feedback on PrEP adherence among young women in southern Africa: Results from HPTN 082, a randomized controlled trial. PLoS Med 2021; 18:e1003670. [PMID: 34143779 PMCID: PMC8253429 DOI: 10.1371/journal.pmed.1003670] [Citation(s) in RCA: 83] [Impact Index Per Article: 27.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/02/2020] [Revised: 07/02/2021] [Accepted: 05/21/2021] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND Pre-exposure prophylaxis (PrEP) is highly effective and an important prevention tool for African adolescent girls and young women (AGYW), but adherence and persistence are challenging. PrEP adherence support strategies for African AGYW were studied in an implementation study. METHODS AND FINDINGS HIV Prevention Trials Network (HPTN) 082 was conducted in Cape Town, Johannesburg (South Africa) and Harare (Zimbabwe) from October 2016 to October 2018 to evaluate PrEP uptake, persistence, and the effect of drug level feedback on adherence. Sexually active HIV-negative women ages 16-25 were offered PrEP and followed for 12 months; women who accepted PrEP were randomized to standard adherence support (counseling, 2-way SMS, and adherence clubs) or enhanced adherence support with adherence feedback from intracellular tenofovir-diphosphate (TFV-DP) levels in dried blood spots (DBS). PrEP uptake, persistence through 12 months (no PrEP hold or missed visits), and adherence were assessed. The primary outcome was high adherence (TFV-DP ≥700 fmol/punch) at 6 months, compared by study arm. Of 451 women enrolled, median age was 21 years, and 39% had curable sexually transmitted infections (STIs). Most (95%) started PrEP, of whom 55% had uninterrupted PrEP refills through 12 months. Of those with DBS, 84% had detectable TFV-DP levels at month 3, 57% at month 6, and 31% at month 12. At 6 months, 36/179 (21%) of AGYW in the enhanced arm had high adherence and 40/184 (22%) in the standard adherence support arm (adjusted odds ratio [OR] of 0.92; 95% confidence interval [CI] 0.55, 1.34; p = 0.76). Four women acquired HIV (incidence 1.0/100 person-years), with low or undetectable TFV-DP levels at or prior to seroconversion, and none of whom had tenofovir or emtricitabine resistance mutations. The study had limited power to detect a modest effect of drug level feedback on adherence, and there was limited awareness of PrEP at the time the study was conducted. CONCLUSIONS In this study, PrEP initiation was high, over half of study participants persisted with PrEP through month 12, and the majority of young African women had detectable TFV-DP levels through month 6 with one-fifth having high adherence. Drug level feedback in the first 3 months of PrEP use did not increase the proportion with high adherence at month 6. HIV incidence was 1% in this cohort with 39% prevalence of curable STIs and moderate PrEP adherence. Strategies to support PrEP use and less adherence-dependent formulations are needed for this population. TRIAL REGISTRATION ClinicalTrials.gov NCT02732730.
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Affiliation(s)
- Connie Celum
- Departments of Global Health, Medicine, and Epidemiology, University of Washington, Seattle, Washington, United States of America
- * E-mail:
| | - Sybil Hosek
- Department of Psychiatry, Stroger Hospital of Cook County, Chicago, Illinois, United States of America
| | | | - Sheetal Kassim
- Desmond Tutu HIV Centre, University of Cape Town, Cape Town, South Africa
| | - Shorai Mukaka
- University of Zimbabwe, College of Health Sciences Clinical Trials Unit Research Unit, Harare, Zimbabwe
| | - Bonnie J. Dye
- Family Health International 360, Durham, North Carolina, United States of America
| | - Subash Pathak
- Vaccine and Infectious Disease Division, Fred Hutchinson Cancer Research Center, Seattle, Washington, United States of America
| | - Nyaradzo Mgodi
- University of Zimbabwe, College of Health Sciences Clinical Trials Unit Research Unit, Harare, Zimbabwe
| | - Linda-Gail Bekker
- Desmond Tutu HIV Centre, University of Cape Town, Cape Town, South Africa
| | - Deborah J. Donnell
- Vaccine and Infectious Disease Division, Fred Hutchinson Cancer Research Center, Seattle, Washington, United States of America
| | - Ethan Wilson
- Vaccine and Infectious Disease Division, Fred Hutchinson Cancer Research Center, Seattle, Washington, United States of America
| | - Krista Yuha
- Vaccine and Infectious Disease Division, Fred Hutchinson Cancer Research Center, Seattle, Washington, United States of America
| | - Peter L. Anderson
- Department of Pharmaceutical Sciences, University of Colorado, Aurora, Colorado, United States of America
| | - Yaw Agyei
- Department of Pathology, Johns Hopkins University School of Medicine, Baltimore, Maryland, United States of America
| | - Heather Noble
- Vaccine and Infectious Disease Division, Fred Hutchinson Cancer Research Center, Seattle, Washington, United States of America
| | - Scott M. Rose
- Family Health International 360, Durham, North Carolina, United States of America
| | - Jared M. Baeten
- Departments of Global Health, Medicine, and Epidemiology, University of Washington, Seattle, Washington, United States of America
| | - Jessica M. Fogel
- Department of Pathology, Johns Hopkins University School of Medicine, Baltimore, Maryland, United States of America
| | - Adeola Adeyeye
- National Institutes of Allergy and Infectious Diseases, National Institutes of Health, Division of AIDS, Rockville, Maryland, United States of America
| | - Lubbe Wiesner
- Division of Clinical Pharmacology, Department of Medicine, University of Cape Town, Cape Town, South Africa
| | - James Rooney
- Gilead Sciences, Foster City, California, United States of America
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Blumenthal J, Jain S, He F, Amico KR, Kofron R, Ellorin E, Stockman JK, Psaros C, Ntim GM, Chow K, Anderson PL, Haubrich R, Corado K, Moore DJ, Morris S, Landovitz RJ. Results from a PrEP Demonstration Project for At-Risk Cisgender Women in the United States. Clin Infect Dis 2021; 73:1149-1156. [PMID: 33864370 DOI: 10.1093/cid/ciab328] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2021] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Daily oral tenofovir disoproxil fumarate/emtricitabine (TDF/FTC) is effective for reducing HIV acquisition among cisgender women. We report results from the first United States observational open-label demonstration project of PrEP among at-risk cisgender women. METHODS Adherence Enhancement Guided by Individualized Texting and Drug Levels (AEGiS) was a 48-week single-arm open-label demonstration study of daily oral TDF/FTC in cisgender women ≥18 years old at-risk for HIV. Adherence was supported using two-way text messaging and titrated adherence counseling based on rapid-turnaround tenofovir diphosphate concentrations from dried blood spots. Study visits occurred at baseline, and at weeks 4, 12, and quarterly through week 48. Outcomes included TDF/FTC adherence, retention and persistence. RESULTS From June 2016 to October 2018, 136 cisgender women enrolled [mean age 40 (SD 11); 38% non-Hispanic (NH) Black and 19% Latina]. At 48 weeks, 84 (62%) participants were retained and 62 (46%) remained on PrEP. Over one-third (12/31) of those on study but off PrEP throughout study discontinued TDF/FTC due to side effects, and one adverse event led to study discontinuation. Of 120 participants with drug concentrations measured, 67 (56%) had at least one concentration consistent with ≥6 doses/week (d/w); 22 (18%) had consistent ≥6 d/w across all study visits attended. There were no incident HIV infections and 4 incident bacterial STIs. CONCLUSION Adequate PrEP adherence for protective drug concentrations was not achieved for most study participants. More work needs to be done to fully explicate the reasons for non-adherence and low retention in cisgender women.
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Affiliation(s)
- Jill Blumenthal
- Department of Medicine, University of California San Diego, San Diego, CA, USA
| | - Sonia Jain
- Department of Family Medicine and Public Health, University of California San Diego, San Diego, CA, USA
| | - Feng He
- Department of Family Medicine and Public Health, University of California San Diego, San Diego, CA, USA
| | - K Rivet Amico
- Department of Health Behavior and Health Education, School of Public Health, University of Michigan, Ann Arbor, MI, USA
| | - Ryan Kofron
- Department of Medicine, Ronald Reagan UCLA Medical Center, University of California Los Angeles, Los Angeles, CA, USA
| | - Eric Ellorin
- Department of Medicine, University of California San Diego, San Diego, CA, USA
| | - Jamila K Stockman
- Department of Medicine, University of California San Diego, San Diego, CA, USA
| | - Christina Psaros
- Department of Psychiatry, Massachusetts General Hospital, Boston, MA, USA
| | - Gifty M Ntim
- Department of Medicine, Ronald Reagan UCLA Medical Center, University of California Los Angeles, Los Angeles, CA, USA
| | - Karen Chow
- Department of Medicine, University of California San Diego, San Diego, CA, USA
| | - Peter L Anderson
- Department of Pharmaceutical Sciences, University of Colorado, Denver, CO, USA
| | | | - Katya Corado
- Department of Medicine, Harbor-UCLA Medical Center, Torrance, CA, USA
| | - David J Moore
- Department of Psychiatry, University of California San Diego, San Diego, CA, USA
| | - Sheldon Morris
- Department of Medicine, University of California San Diego, San Diego, CA, USA
| | - Raphael J Landovitz
- Department of Medicine, Ronald Reagan UCLA Medical Center, University of California Los Angeles, Los Angeles, CA, USA
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Stranix-Chibanda L, Anderson PL, Kacanek D, Hosek S, Huang S, Nematadzira TG, Taulo F, Korutaro V, Nakabiito C, Masenya M, Lypen K, Brown E, Ibrahim ME, Yager J, Wiesner L, Johnston B, Amico KR, Rooney JF, Chakhtoura N, Spiegel HML, Chi BH. Tenofovir diphosphate concentrations in dried blood spots from pregnant and postpartum adolescent and young women receiving daily observed pre-exposure prophylaxis in sub-Saharan Africa. Clin Infect Dis 2020; 73:e1893-e1900. [PMID: 33341883 PMCID: PMC8492211 DOI: 10.1093/cid/ciaa1872] [Citation(s) in RCA: 28] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2020] [Indexed: 11/12/2022] Open
Abstract
Background Intracellular tenofovir diphosphate (TFV-DP) concentration in dried blood spots (DBSs) is used to monitor cumulative pre-exposure prophylaxis (PrEP) adherence. We evaluated TFV-DP in DBSs following daily oral PrEP (emtricitabine 200 mg/tenofovir diphosphate 300 mg) among pregnant and postpartum adolescent girls and young women (AGYW). Methods Directly observed PrEP was administered for 12 weeks in a pregnancy (14–24 weeks’ gestation, n = 20) and postpartum (6–12 weeks postpartum, n = 20) group of AGYW aged 16–24 years in sub-Saharan Africa. Weekly DBS TFV-DP was measured by validated liquid chromatography–tandem mass spectrometry assay. Week 12 TFV-DP distributions were compared between groups with Wilcoxon test. Population pharmacokinetic models were fit to estimate steady-state concentrations and create benchmarks for adherence categories. Baseline correlates of TFV-DP were evaluated. Results Median age was 20 (IQR, 19–22) years. Of 3360 doses, 3352 (>99%) were directly observed. TFV-DP median (IQR) half-life was 10 (7–12) days in pregnancy and 17 (14–21) days postpartum, with steady state achieved by 5 and 8 weeks, respectively. Observed median (IQR) steady-state TFV-DP was 965 fmol/punch (691–1166) in pregnancy versus 1406 fmol/punch (1053–1859) postpartum (P = .006). Modeled median steady-state TFV-DP was 881 fmol/punch (667–1105) in pregnancy versus 1438 fmol/punch (1178–1919) postpartum. In pooled analysis, baseline creatinine clearance was associated with observed TFV-DP concentrations. Conclusions TFV-DP in African AGYW was approximately one-third lower in pregnancy than postpartum. These Population-specific benchmarks can be used to guide PrEP adherence support in pregnant/postpartum African women. Clinical Trials Registration NCT03386578
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Affiliation(s)
- Lynda Stranix-Chibanda
- University of Zimbabwe, Harare, Zimbabwe.,University of Zimbabwe College of Health Sciences Clinical Trials Research Centre, Harare, Zimbabwe
| | | | | | - Sybil Hosek
- John H. Stroger Jr. Hospital of Cook County, Chicago, IL, USA
| | - Sharon Huang
- Harvard T.H. Chan School of Public Health, Boston, MA, USA
| | - Teacler G Nematadzira
- University of Zimbabwe College of Health Sciences Clinical Trials Research Centre, Harare, Zimbabwe
| | - Frank Taulo
- College of Medicine-Johns Hopkins Research Project, Blantyre, Malawi
| | - Violet Korutaro
- Baylor College of Medicine Children's Foundation-Uganda, Kampala, Uganda
| | | | - Maysebole Masenya
- Wits Reproductive Health and HIV Institute, Johannesburg, South Africa
| | | | | | | | - Jenna Yager
- University of Colorado Anschutz Medical Campus, Aurora, CO, USA
| | - Lubbe Wiesner
- Division of Clinical Pharmacology, Department of Medicine, University of Cape Town, Cape Town, South Africa
| | | | | | | | - Nahida Chakhtoura
- National Institute of Child Health and Human Development, Bethesda, MD, USA
| | - Hans M L Spiegel
- Kelly Government Solutions, Contractor to National Institute of Allergy and Infectious Diseases, National Institutes of Health, Department of Health and Human Services, Rockville, USA
| | - Benjamin H Chi
- University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
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