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Mohareb AM, Kouamé MG, Nouaman M, Kim AY, Larmarange J, Neilan AM, Lacombe K, Freedberg KA, Boyd A, Coffie P, Hyle EP. What does the scale-up of long-acting HIV pre-exposure prophylaxis mean for the global hepatitis B epidemic? J Int AIDS Soc 2024; 27:e26218. [PMID: 38444112 PMCID: PMC10935702 DOI: 10.1002/jia2.26218] [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: 07/12/2023] [Accepted: 01/29/2024] [Indexed: 03/07/2024] Open
Abstract
INTRODUCTION The HIV and hepatitis B virus (HBV) epidemics are interconnected with shared routes of transmission and specific antiviral drugs that are effective against both viruses. Nearly, 300 million people around the world live with chronic HBV, many of whom are from priority populations who could benefit from HIV prevention services. Oral pre-exposure prophylaxis (PrEP) for HIV has implications in the prevention and treatment of HBV infection, but many people at increased risk of HIV acquisition may instead prefer long-acting formulations of PrEP, which are currently not active against HBV. DISCUSSION People at increased risk for HIV acquisition may also be at risk for or already be living with HBV infection. Oral PrEP with tenofovir is effective in preventing both HIV and HBV, and tenofovir is also the recommended treatment for chronic HBV infection. Although implementation of oral PrEP has been challenging in sub-Saharan Africa, investments in its scale-up could secondarily reduce the clinical impact of HBV. Long-acting PrEP, including injectable medicines and implantable rings, may overcome some of the implementation challenges associated with oral PrEP, such as daily pill burden, adherence challenges and stigma; however, current formulations of long-acting PrEP do not have activity against HBV replication. Ideally, PrEP programmes would offer both oral and long-acting formulations with HBV screening to optimize HIV prevention services and HBV prevention and care, when appropriate. People who are not immune to HBV would benefit from being vaccinated against HBV before initiating long-acting PrEP. People who remain non-immune to HBV despite vaccination may benefit from being offered oral, tenofovir-based PrEP given its potential for HBV PrEP. People using PrEP and living with HBV who are not linked to dedicated HBV care would also benefit from laboratory monitoring at PrEP sites to ensure safety when using and after stopping tenofovir. PrEP programmes are ideal venues to offer HBV screening, HBV vaccination for people who are non-immune and treatment with tenofovir-based PrEP for people with indications for HBV therapy. CONCLUSIONS Long-acting PrEP holds promise for reducing HIV incidence, but its implications for the HBV epidemic, particularly in sub-Saharan Africa, should not be overlooked.
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Affiliation(s)
- Amir M. Mohareb
- Medical Practice Evaluation CenterMassachusetts General HospitalBostonMassachusettsUSA
- Division of Infectious DiseasesMassachusetts General HospitalBostonMassachusettsUSA
- Harvard University Center for AIDS ResearchBostonMassachusettsUSA
| | - Menan Gérard Kouamé
- Département de Santé PubliqueUFR d'Odonto‐stomatologieUniversité Félix Houphouët BoignyAbidjanCôte d'Ivoire
| | - Marcellin Nouaman
- Département de Santé PubliqueUFR d'Odonto‐stomatologieUniversité Félix Houphouët BoignyAbidjanCôte d'Ivoire
| | - Arthur Y. Kim
- Division of Infectious DiseasesMassachusetts General HospitalBostonMassachusettsUSA
- Harvard University Center for AIDS ResearchBostonMassachusettsUSA
| | - Joseph Larmarange
- Centre Population et DéveloppementUniversité Paris Cité, IRD, InsermParisFrance
| | - Anne M. Neilan
- Medical Practice Evaluation CenterMassachusetts General HospitalBostonMassachusettsUSA
- Division of Infectious DiseasesMassachusetts General HospitalBostonMassachusettsUSA
- Harvard University Center for AIDS ResearchBostonMassachusettsUSA
- Division of General Academic PediatricsDepartment of PediatricsMassachusetts General HospitalBostonMassachusettsUSA
| | - Karine Lacombe
- Sorbonne Université, IPLESPParisFrance
- Department of Infectious DiseasesSt. Antoine Hospital, AP‐HPParisFrance
| | - Kenneth A. Freedberg
- Medical Practice Evaluation CenterMassachusetts General HospitalBostonMassachusettsUSA
- Division of Infectious DiseasesMassachusetts General HospitalBostonMassachusettsUSA
- Harvard University Center for AIDS ResearchBostonMassachusettsUSA
- Department of General Internal MedicineMassachusetts General HospitalBostonMassachusettsUSA
| | - Anders Boyd
- Stichting HIV MonitoringAmsterdamthe Netherlands
- Department of Infectious DiseasesPublic Health Service of AmsterdamAmsterdamthe Netherlands
- Amsterdam UMC, Infectious DiseasesAmsterdamthe Netherlands
- Amsterdam Institute for Infection and Immunity, Infectious DiseasesAmsterdamthe Netherlands
| | - Patrick Coffie
- Département de Santé PubliqueUFR d'Odonto‐stomatologieUniversité Félix Houphouët BoignyAbidjanCôte d'Ivoire
- Département de Dermatologie et InfectiologieUniversité Félix Houphouët‐BoignyAbidjanCôte d'Ivoire
| | - Emily P. Hyle
- Medical Practice Evaluation CenterMassachusetts General HospitalBostonMassachusettsUSA
- Division of Infectious DiseasesMassachusetts General HospitalBostonMassachusettsUSA
- Harvard University Center for AIDS ResearchBostonMassachusettsUSA
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Aidoo-Frimpong G, Abu-Ba’are GR, Apreku A, Amoh-Otu RP, Zigah E, Amu-Adu P, Amuah S, Nyblade L, Torpey K, Nelson LE. "We have our reasons": Exploring the acceptability of pre-exposure prophylaxis among gay, bisexual, and other men who have sex with men in Ghana. MEDRXIV : THE PREPRINT SERVER FOR HEALTH SCIENCES 2023:2023.12.05.23299515. [PMID: 38105990 PMCID: PMC10723517 DOI: 10.1101/2023.12.05.23299515] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/19/2023]
Abstract
Ghanaian men who have sex with men (MSM) face significant HIV disparities. Pre-exposure prophylaxis (PrEP) is a highly effective tool for HIV prevention. Previous studies on the perspectives of PrEP use among Ghanaian MSM identified high interest in PrEP among this population. However, the knowledge from the previous research, which was the best available evidence at the time, was primarily hypothetical because those data were collected before any real-world implementation of PrEP in Ghana. The purpose of the analysis is to identify and understand the factors currently influencing PrEP acceptance. We conducted a secondary analysis of focus group (n=8) data with Ghanaian MSM. Audio transcripts were subjected to descriptive thematic analysis. There was an almost universal awareness of PrEP, but inaccuracies about PrEP were common. PrEP acceptability was influenced by a mix of individual and intrapersonal factors. To bridge the gap between awareness, knowledge, and acceptability, HIV prevention programs should address access barriers and incorporate community-derived strategies.
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Affiliation(s)
- Gloria Aidoo-Frimpong
- Center for Interdisciplinary Research on AIDS, School of Public Health, Yale University, New Haven, CT
| | - Gamji Rabiu Abu-Ba’are
- Center for Interdisciplinary Research on AIDS, School of Public Health, Yale University, New Haven, CT
- Behavioral, Sexual, and Global Health Lab, School of Nursing, University of Rochester, Rochester, New York, USA
| | - Amos Apreku
- Department of Population, Family & Reproductive Health, School of Public Health, University of Ghana, Legon-Accra, Ghana
| | | | - Edem Zigah
- Priorities on Rights and Sexual Health, Accra, Ghana
| | | | - Samuel Amuah
- Youth Alliance for Health and Human Rights, Kumasi, Ghana
| | | | - Kwasi Torpey
- Department of Population, Family & Reproductive Health, School of Public Health, University of Ghana, Legon-Accra, Ghana
| | - LaRon E. Nelson
- Center for Interdisciplinary Research on AIDS, School of Public Health, Yale University, New Haven, CT
- School of Nursing, Yale University, New Haven CT, USA
- Social and Behavioral Sciences Division, School of Public Health, Yale University, New Haven CT, USA
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Goymann H, Mavuso M, McMahon SA, Hettema A, Hughey AB, Matse S, Dlamini P, Kahn K, Bärnighausen T, Jahn A, Bärnighausen K. 'We Should Not Be Quiet but We Should Talk': Qualitative Accounts of Community-Based Communication of HIV Pre-Exposure Prophylaxis. QUALITATIVE HEALTH RESEARCH 2023; 33:842-856. [PMID: 37403738 PMCID: PMC10426252 DOI: 10.1177/10497323231181207] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 07/06/2023]
Abstract
Community leaders play an important role in the acceptance of public health services, but little is known about their willingness to facilitate HIV pre-exposure prophylaxis (PrEP) roll-out in Eswatini. We conducted in-depth interviews (n = 25) with purposefully selected male and female community leaders in Eswatini. We analysed our data inductively using a thematic analysis approach. Community leaders feel they are important communicators of culturally appropriate PrEP messaging. Our participants described a complex social space within their communities influenced by religion, tradition, values, and HIV stigma. Community leaders use their position to provide leverage for unique, effective, and easily accessible messages and platforms to reach the community in a manner that ensures trust, relatability, familiarity, and shared faith. Community leaders feel that they are trusted and see trust manifesting in the conversations they are able to engage in, and have a reach that extends beyond formal health services. Existing PrEP programming should embed community leader participation in PrEP programming and engage the trust, knowledge, and potential of community leaders to support PrEP uptake and acceptance.
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Affiliation(s)
- Hannah Goymann
- Institute of Global Health, Heidelberg University, Heidelberg, Germany
| | | | | | | | | | | | | | - Kathleen Kahn
- MRC/Wits Rural Public Health and Health Transitions Research Unit, School of Public Health, University of the Witwatersrand, Johannesburg, South Africa
| | - Till Bärnighausen
- Institute of Global Health, Heidelberg University, Heidelberg, Germany
- Department of Global Health and Population, Harvard T.H. Chan School of Public Health, Boston, MA, USA
- Africa Health Research Institute, Kwazulu-Natal, South Africa
| | - Albrecht Jahn
- Institute of Global Health, Heidelberg University, Heidelberg, Germany
| | - Kate Bärnighausen
- Institute of Global Health, Heidelberg University, Heidelberg, Germany
- School of Public Health, University of the Witwatersrand, Johannesburg, South Africa
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Hicks S, Abuna F, Odhiambo B, Dettinger JC, Sila J, Oketch G, Sifuna E, Ngumbau N, Gómez L, John-Stewart GC, Kinuthia J, Wagner AD. Integrating PrEP in maternal and child health clinics in Kenya: analysis of a service availability and readiness assessment (SARA) survey. FRONTIERS IN REPRODUCTIVE HEALTH 2023; 5:1206150. [PMID: 37484872 PMCID: PMC10359145 DOI: 10.3389/frph.2023.1206150] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2023] [Accepted: 06/12/2023] [Indexed: 07/25/2023] Open
Abstract
Background Risk of HIV acquisition is high during pregnancy and postpartum, and pre-exposure prophylaxis (PrEP) is recommended for peripartum populations. Integrating PrEP into maternal and child health (MCH) clinics is feasible and acceptable. Understanding clinics' service availability and readiness is essential for effective scale up. Methods The PrEP in Pregnancy, Accelerating Reach and Efficiency study (PrEPARE; NCT04712994) engaged PrEP-experienced facilities previously linked to a programmatic or research study in Western Kenya to document available services and commodities via a modified service availability and readiness assessment (SARA) survey with 20 PrEP tracer items covering: staffing/guidelines, services/equipment, and medicines/commodities. Facilities' prior study engagement occurred between 2017 and 2019; SARA survey data was collected between April 2020 and June 2021. Descriptive statistics were stratified by prior study engagement. ANOVA tests assessed associations between facility characteristics and gaps. Fisher's tests assessed differences in commodity availability and stockouts. Results Of the 55 facilities surveyed, 60% had received PrEP training in the last two years, 95% offered PrEP integrated into MCH, and 64% and 78% had both auditory and visual privacy in PrEP and HIV testing service (HTS) delivery spaces, respectively. Supervision frequency was heterogeneous, but 82% had received a supervision visit within 3 months. Availability of commodities was variable and the most commonly unavailable commodities were PrEP in MCH (71% available) and risk assessment screening tool (RAST) and PrEP cards (60% and 75% available, respectively). The number of service and commodity gaps per facility ranged from zero to eight (median: 3; IQR: 2, 5). The most frequent gaps were: PrEP training and risk assessment cards (40% each), lack of privacy in PrEP (36%) and HIV testing services (31%) spaces, PrEP pills in MCH (29%), and PrEP cards (25%). There were no differences in mean number of gaps by county, previous study engagement, or public vs. private status. Level 4 facilities had fewer gaps (mean 2.2) than level 2, 3, and 5 facilities (mean 5.7, 4.5, and 5.3 respectively; p < 0.001). Conclusions PrEP service availability and readiness was generally high across MCH facilities. However, there is a need for increased frequency of provider training and supportive supervision focused on fidelity. To address key commodity stockouts such as PrEP pills, implementation of electronic logistics management information systems may be needed. Targeting these gaps is essential to effectively scale up integrated PrEP delivery, especially among facilities with limited infrastructure.
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Affiliation(s)
- Sarah Hicks
- Department of Epidemiology, University of Washington, Seattle, WA, United States
| | - Felix Abuna
- Research and Programs, Kenyatta National Hospital, Nairobi, Kenya
| | - Ben Odhiambo
- Research and Programs, Kenyatta National Hospital, Nairobi, Kenya
| | - Julia C. Dettinger
- Department of Global Health, University of Washington, Seattle, WA, United States
| | - Joseph Sila
- Research and Programs, Kenyatta National Hospital, Nairobi, Kenya
| | - George Oketch
- Research and Programs, Kenyatta National Hospital, Nairobi, Kenya
| | - Enock Sifuna
- Research and Programs, Kenyatta National Hospital, Nairobi, Kenya
| | - Nancy Ngumbau
- Research and Programs, Kenyatta National Hospital, Nairobi, Kenya
| | - Laurén Gómez
- Department of Global Health, University of Washington, Seattle, WA, United States
| | - Grace C. John-Stewart
- Department of Epidemiology, University of Washington, Seattle, WA, United States
- Department of Global Health, University of Washington, Seattle, WA, United States
- Departments of Medicine, University of Washington, Seattle, WA, United States
- Departments of Pediatrics, University of Washington, Seattle WA, United States
| | - John Kinuthia
- Research and Programs, Kenyatta National Hospital, Nairobi, Kenya
| | - Anjuli D. Wagner
- Department of Global Health, University of Washington, Seattle, WA, United States
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Chebet JJ, McMahon SA, Tarumbiswa T, Hlalele H, Maponga C, Mandara E, Ernst K, Alaofe H, Baernighausen T, Ehiri JE, Geldsetzer P, Nichter M. Motivations for pre-exposure prophylaxis uptake and decline in an HIV-hyperendemic setting: findings from a qualitative implementation study in Lesotho. AIDS Res Ther 2023; 20:43. [PMID: 37415180 PMCID: PMC10324220 DOI: 10.1186/s12981-023-00535-x] [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: 02/15/2023] [Accepted: 06/05/2023] [Indexed: 07/08/2023] Open
Abstract
BACKGROUND Pre-Exposure Prophylaxis (PrEP) has demonstrated clinical efficacy in preventing HIV infection, yet its uptake remains low. This study, conducted in five PrEP implementing districts in Lesotho, examined factors motivating persons at risk of HIV infection to adopt or reject PrEP when offered freely. METHODS In-depth interviews were undertaken with stakeholders directly engaged with PrEP policy (n = 5), program implementation (n = 4), and use (current PrEP users = 55, former PrEP users = 36, and PrEP decliners (n = 6)). Focus group discussions (n = 11, 105 total participants) were conducted with health staff directly providing HIV and PrEP services. RESULTS Demand for PrEP was reported highest among those at greatest risk for HIV acquisition: those in serodiscordant relationships and/or engaged in sex work. Culturally sensitive PrEP counseling was described as an opportunity to transfer knowledge, build trust, and address user concerns. Conversely, top-down counseling resulted in PrEP distrust and confusion about HIV status. Key motivations for PrEP uptake revolved around sustaining core social relationships, desire for safer conception, and caring for ailing relatives. The decline of PrEP initiation was driven by a combination of individual-level factors (risk perception, perceived side effects, disbelief of the drug's efficacy and PrEP's daily pill regimen), societal factors (lack of social support and HIV-related stigma), and structural factors related to PrEP access. CONCLUSIONS Our findings suggest strategies for effective national PrEP rollout and implementation include: (1) demand creation campaigns which highlight positive aspects of PrEP, while simultaneously addressing apprehensions for uptake; (2) strengthening health provider counseling capacity; and (3) addressing societal and structural HIV-related stigma.
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Affiliation(s)
- Joy J. Chebet
- Department of Health Promotion Sciences, Mel and Enid Zuckerman College of Public Health, University of Arizona, Tucson, AZ USA
| | - Shannon A. McMahon
- Heidelberg Institute of Global Health (HIGH), Heidelberg University, Heidelberg, Germany
- Social and Behavioral Interventions, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD USA
| | | | | | | | | | - Kacey Ernst
- Department of Epidemiology and Biostatistics, Mel and Enid Zuckerman College of Public Health, University of Arizona, Tucson, AZ USA
| | - Halimatou Alaofe
- Department of Health Promotion Sciences, Mel and Enid Zuckerman College of Public Health, University of Arizona, Tucson, AZ USA
| | - Till Baernighausen
- Heidelberg Institute of Global Health (HIGH), Heidelberg University, Heidelberg, Germany
- Department of Global Health and Population, Harvard T.H. Chan School of Public Health, Boston, MA USA
- Africa Health Research Institute (AHRI), Durban, South Africa
| | - John E. Ehiri
- Department of Health Promotion Sciences, Mel and Enid Zuckerman College of Public Health, University of Arizona, Tucson, AZ USA
| | - Pascal Geldsetzer
- Division of Primary Care and Population Health, Department of Medicine, Stanford University, Stanford, CA USA
- Chan Zuckerberg Biohub, San Francisco, CA USA
| | - Mark Nichter
- Department of Health Promotion Sciences, Mel and Enid Zuckerman College of Public Health, University of Arizona, Tucson, AZ USA
- School of Anthropology, University of Arizona, Tucson, AZ USA
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Dietrich JJ, Ahmed N, Tshabalala G, Wu M, Mulaudzi M, Hornschuh S, Atujuna M, Muhumuza R, Ssemata AS, Stranix-Chibanda L, Nematadzira T, Bekker LG, Martinson N, Seeley J, Fox J. A qualitative study to explore daily versus on-demand oral pre-exposure prophylaxis (PrEP) in young people from South Africa, Uganda and Zimbabwe. PLoS One 2023; 18:e0287627. [PMID: 37384792 PMCID: PMC10310032 DOI: 10.1371/journal.pone.0287627] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2021] [Accepted: 06/12/2023] [Indexed: 07/01/2023] Open
Abstract
BACKGROUND Adolescents in sub-Saharan Africa (SSA) remain vulnerable to HIV infection. While pre-exposure prophylaxis (PrEP) is highly effective in preventing HIV transmission as a daily or on-demand regimen, tailored approaches are necessary. The Combined HIV Adolescent PrEP and Prevention Study (CHAPS) is a mixed-methods research program investigating the acceptability and feasibility of implementing daily and on-demand PrEP among young people in SSA. It also aims to determine an on-demand dosing schedule for insertive sex. For this paper, we explored preferences for daily versus on-demand PrEP amongst adolescents as part of CHAPS. METHODS Purposive sampling was used to recruit participants from Soweto and Cape Town (South Africa), Wakiso district (Uganda) and Chitungwiza (Zimbabwe). At the time of the study in 2018/2019, Uganda had not rolled out PrEP to the general population; in Zimbabwe, PrEP for young people was only available at selected sites with one located within the study recruitment area. In South Africa, PrEP was made available to selected high-risk groups. We conducted 60 in-depth interviews and 24 group discussions amongst young people aged 13-24 without HIV in South Africa, Uganda, and Zimbabwe. All in-depth interviews and group discussions were audio-recorded, transcribed verbatim and translated to English. Data were analysed using framework analysis. The main themes were centered around preferences for daily and on-demand PrEP. RESULTS Reasons for on-demand preferences included stigma, pill fatigue, adherence and side effects. Reasons for daily PrEP preferences included factors related to sexual risk behaviour, continuous protection against incidents of unintentional exposure, and the increased efficacy of a daily dose. Participants at all sites preferring daily PrEP identified the same reasons, with more males than females citing inadvertent blood contact or perceived increased efficacy. Similarly, participants at all sites preferring on-demand PrEP gave the same reasons for their preferences for on-demand PrEP; the exception was South Africans who did not mention the hope of having fewer side effects by not taking daily PrEP. Additionally, more males than females cited intermittent sex as a reason for opting for on-demand PrEP. CONCLUSIONS Our study is the first known to explore and describe youth preferences for daily versus on-demand PrEP. While the choice is clear-cut, the reasons cited in the different options provide invaluable insights into their decisions, and the actual and perceived facilitators and barriers to access to PrEP. Further education is needed amongst young people, not only about PrEP but also in other areas of comprehensive sexuality education. Exploring all options of HIV prevention is crucial to provide a tailored, one-size-does-not-fit-all approach to adolescent care in SSA to reduce and, the continued and increasing risk of this preventable infection.
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Affiliation(s)
- Janan Janine Dietrich
- Perinatal HIV Research Unit, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
- Health Systems Research Unit, South African Medical Research Council, Bellville, South Africa
- African Social Sciences Unit of Research and Evaluation (ASSURE), Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Nadia Ahmed
- Mortimer Market Centre, Central North West London NHS Trust, London, United Kingdom
- Desmond Tutu HIV Centre, University of Cape Town, Cape Town, South Africa
| | - Gugulethu Tshabalala
- Perinatal HIV Research Unit, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Minju Wu
- Harvard College, Cambridge, MA, United States of America
| | - Mamakiri Mulaudzi
- Perinatal HIV Research Unit, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Stefanie Hornschuh
- Perinatal HIV Research Unit, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Millicent Atujuna
- Desmond Tutu HIV Centre, University of Cape Town, Cape Town, South Africa
| | - Richard Muhumuza
- Medical Research Council/Uganda Virus Research Institute and London School of Hygiene & Tropical Medicine Uganda Research Unit, Entebbe, Uganda
| | - Andrew Sentoogo Ssemata
- Medical Research Council/Uganda Virus Research Institute and London School of Hygiene & Tropical Medicine Uganda Research Unit, Entebbe, Uganda
- Department of Global Health and Development, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Lynda Stranix-Chibanda
- University of Zimbabwe Clinical Trials Research Centre, Faculty of Medicine and Health Sciences, Harare, Zimbabwe
| | - Teacler Nematadzira
- University of Zimbabwe Clinical Trials Research Centre, Faculty of Medicine and Health Sciences, Harare, Zimbabwe
| | - Linda-Gail Bekker
- Desmond Tutu HIV Centre, University of Cape Town, Cape Town, South Africa
| | - Neil Martinson
- Perinatal HIV Research Unit, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Janet Seeley
- Medical Research Council/Uganda Virus Research Institute and London School of Hygiene & Tropical Medicine Uganda Research Unit, Entebbe, Uganda
- Department of Global Health and Development, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Julie Fox
- King’s College London, London, United Kingdom
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Reyniers T, Babo SAY, Ouedraogo M, Kanta I, Ekon Agbégnigan L, Rojas D, Eubanks A, Anoma C, Dah TTE, Mensah E, Dembélé Keita B, Spire B, Vuylsteke B, Laurent C. Strategies to improve PrEP uptake among West African men who have sex with men: a multi-country qualitative study. Front Public Health 2023; 11:1165327. [PMID: 37181706 PMCID: PMC10167043 DOI: 10.3389/fpubh.2023.1165327] [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: 02/13/2023] [Accepted: 03/27/2023] [Indexed: 05/16/2023] Open
Abstract
Introduction West African men who have sex with men (MSM) remain at substantial risk of contracting HIV. Pre-exposure prophylaxis (PrEP) can be an effective game-changer in reducing the number of HIV infections in MSM communities. To optimize the roll-out of PrEP, we need to better understand how we can increase its uptake. The objective of this study was to explore the perceptions of West African MSM toward PrEP and their proposed strategies to overcome barriers to PrEP uptake within their communities. Methods Between April 2019 and November 2021, we conducted 12 focus group discussions with 97 MSM not taking PrEP, and 64 semi-structured interviews with MSM taking PrEP, in Burkina Faso, Côte d'Ivoire, Mali, and Togo. Data collection and analysis were guided and conducted by local research teams, enabling a community-based participatory approach. A coordinating researcher collaborated with these local teams to analyze the data guided by a grounded theory approach. Results The results show that participants were generally positive toward PrEP and that MSM communities have become more aware of PrEP for the study. We identified three main strategies for increasing PrEP uptake. First, participants proposed to raise awareness and improve knowledge of HIV as they considered the self-perceived risk of MSM in their communities to be low. Second, because of existing misconceptions and false information, participants proposed to improve the dissemination of PrEP to allow for informed choices, e.g., via peers or PrEP users themselves. Third, as oral PrEP also entails a risk of being associated with HIV or homosexuality, strategies to avoid stigmatization (e.g., hiding pills) were deemed important. Discussion These findings indicate that the roll-out of oral PrEP and other future PrEP modalities should be accompanied by raising awareness and improving knowledge on HIV, and wide dissemination of information that focuses on the health-promoting aspect of these tools. Tailored delivery and long-acting PrEP modalities will be important to avoid potential stigmatization. Sustained efforts to prevent discrimination and stigmatization based on HIV status or sexual orientation continue to be highly important strategies to address the HIV epidemic in West Africa.
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Affiliation(s)
- Thijs Reyniers
- Department of Public Health, Institute of Tropical Medicine, Antwerp, Belgium
| | | | | | | | | | - Daniela Rojas
- Aix Marseille Univ, INSERM, IRD, SESSTIM Sciences Economiques & Sociales de la Santé & Traitement de l'Information Médicale, Marseille, France
- Coalition Plus, Community-based Research Laboratory, Pantin, France
| | - August Eubanks
- Aix Marseille Univ, INSERM, IRD, SESSTIM Sciences Economiques & Sociales de la Santé & Traitement de l'Information Médicale, Marseille, France
| | | | - Ter Tiero Elias Dah
- Association African Solidarité, Ouagadougou, Burkina Faso
- UFR Sciences de la Santé, Université de Ouahigouya, Ouahigouya, Burkina Faso
| | | | | | - Bruno Spire
- Aix Marseille Univ, INSERM, IRD, SESSTIM Sciences Economiques & Sociales de la Santé & Traitement de l'Information Médicale, Marseille, France
| | - Bea Vuylsteke
- Department of Public Health, Institute of Tropical Medicine, Antwerp, Belgium
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Katz IT, Ngure K, Kamolloh K, Ogello V, Okombo M, Thuo NB, Owino E, Garrison LE, Lee YS, Nardell MF, Anyacheblu C, Bukusi E, Mugo N, Baeten JM, Haberer JE. Multi-level Factors Driving Pre-exposure Prophylaxis Non-initiation Among Young Women at High Risk for HIV in Kenya. AIDS Behav 2023; 27:106-118. [PMID: 35930203 DOI: 10.1007/s10461-022-03748-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/06/2022] [Indexed: 01/29/2023]
Abstract
Few studies have focused on understanding pre-exposure prophylaxis (PrEP) non-initiation among young, high-risk women in sub-Saharan Africa. This study aimed to qualitatively explore why young women in Kenya at high-risk for HIV chose not to enroll in a PrEP adherence trial. We performed 40 semi-structured interviews with young high-risk women assessing concerns about PrEP and/or study participation. We also assessed community-level factors influencing decision-making around PrEP through 10 focus groups involving peers, young men, caregivers, and community leaders. Our qualitative data reflect the complexity of navigating barriers preventing PrEP initiation in settings where taking PrEP may be perceived as immoral behavior. Framed within the context of risk perception, the decision to start PrEP may run counter to the potential risk of losing support from one's community. Our findings suggest that approaches addressing social norms, while de-medicalizing HIV prevention services, are needed to further increase PrEP uptake among young Kenyan women.
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Affiliation(s)
- Ingrid T Katz
- Department of Medicine, Brigham and Women's Hospital, Boston, MA, USA. .,Harvard Medical School, Boston, MA, USA. .,Massachusetts General Hospital Center for Global Health, Boston, MA, USA. .,Harvard Global Health Institute, Cambridge, MA, USA. .,Division of Women's Health, Brigham and Women's Hospital, 1620 Tremont St. - 3rd Floor, Boston, MA, 02120, USA.
| | - Kenneth Ngure
- Department of Community Health, Jomo Kenyatta University of Agriculture and Technology, Nairobi, Kenya
| | | | | | - Moses Okombo
- Kenya Medical Research Institute, Nairobi, Kenya
| | | | - Esther Owino
- Kenya Medical Research Institute, Nairobi, Kenya
| | - Lindsey E Garrison
- Massachusetts General Hospital Center for Global Health, Boston, MA, USA
| | - Yeonsoo S Lee
- Department of Medicine, Brigham and Women's Hospital, Boston, MA, USA.,Mayo Clinic Alix School of Medicine, Scottsdale, AZ, USA
| | - Maria F Nardell
- Department of Medicine, Brigham and Women's Hospital, Boston, MA, USA.,Harvard Medical School, Boston, MA, USA
| | - Chiemelie Anyacheblu
- Harvard T.H Chan School of Public Health, Boston, MA, USA.,SUNY Downstate Medical Center, Brooklyn, NY, USA
| | - Elizabeth Bukusi
- Kenya Medical Research Institute, Nairobi, Kenya.,Department of Obstetrics and Gynecology, University of Washington, Seattle, WA, USA
| | - Nelly Mugo
- Kenya Medical Research Institute, Nairobi, Kenya.,Department of Global Health, Medicine, and Epidemiology, University of Washington, Seattle, WA, USA
| | - Jared M Baeten
- Department of Global Health, Medicine, and Epidemiology, University of Washington, Seattle, WA, USA.,Gilead Sciences, Foster City, CA, USA
| | - Jessica E Haberer
- Harvard Medical School, Boston, MA, USA.,Massachusetts General Hospital Center for Global Health, Boston, MA, USA
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9
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Kayesu I, Mayanja Y, Nakirijja C, Machira YW, Price M, Seeley J, Siu G. Uptake of and adherence to oral pre-exposure prophylaxis among adolescent girls and young women at high risk of HIV-infection in Kampala, Uganda: A qualitative study of experiences, facilitators and barriers. BMC Womens Health 2022; 22:440. [PMCID: PMC9648457 DOI: 10.1186/s12905-022-02018-z] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2021] [Accepted: 10/20/2022] [Indexed: 11/12/2022] Open
Abstract
Background There is limited information on factors that influence oral pre-exposure prophylaxis (PrEP) uptake and adherence among adolescent girls and young women (AGYW). We conducted a qualitative methods study to explore experiences, facilitators and barriers of PrEP uptake and adherence to PrEP among AGYW at risk of Human Immunodeficiency Virus (HIV) infection in Kampala, Uganda. Methods This study was nested in a prospective cohort study that offered daily oral PrEP to AGYW. Between April 2019 and October 2020 we conducted in-depth interviews with 26 AGYW aged 14–24 years who had been offered or had been using PrEP for at least 6 months, including PrEP adherers (8), non-adherers (8) and those who had declined PrEP (10). After 12 months, follow-up interviews were conducted with 12 AGYW who had adhered to PrEP and those who had dropped it. Thematic analysis was conducted and data were further examined and categorized into the 5 constructs of the Socio-Ecological Model (SEM). Results PrEP uptake and adherence were facilitated by factors including: perceptions that one’s own or partner’s sexual behaviour was high risk, a negative attitude towards condoms, social support and wanting to maintain a negative HIV status after receiving a negative HIV test result. Good adherence to PrEP was enabled by effective counselling, support tools such as alarms and phone reminders and incentives like free treatment for STIs and other illnesses during study visits. Barriers to uptake included: anxiety about the pill burden, perceptions of being too young for PrEP and fear of being labelled `prostitute’ or `HIV positive’. Poor adherence was attributed to doubt over the efficacy of PrEP as a result of beliefs that because HIV was incurable, no medicine could prevent it. Alcohol use, side effects experienced, and mobility all had a negative impact on adherence. The majority of PrEP users reported feeling safe as a result of using PrEP which had both good and negative implications on their sexual behaviour, specifically the number of sexual partners and condom use. Conclusion Addressing community misconceptions to maximize uptake of PrEP among AGYW is important. Targeted education messages, and counselling to address misconceptions in ways that capture the attention of AGYW in communities are required.
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Affiliation(s)
- Ivy Kayesu
- grid.415861.f0000 0004 1790 6116Medical Research Council, Uganda Virus Research Institute and London School of Hygiene and Tropical Medicine Uganda Research Unit, P.O. Box 49, Entebbe, Uganda
| | - Yunia Mayanja
- grid.415861.f0000 0004 1790 6116Medical Research Council, Uganda Virus Research Institute and London School of Hygiene and Tropical Medicine Uganda Research Unit, P.O. Box 49, Entebbe, Uganda
| | - Catherine Nakirijja
- grid.415861.f0000 0004 1790 6116Medical Research Council, Uganda Virus Research Institute and London School of Hygiene and Tropical Medicine Uganda Research Unit, P.O. Box 49, Entebbe, Uganda
| | - Yvonne Wangũi Machira
- grid.420368.b0000 0000 9939 9066International AIDS Vaccine Initiative (IAVI), 125 Broad Street, 9th Floor, 10004 New York, NY USA
| | - Matt Price
- grid.420368.b0000 0000 9939 9066International AIDS Vaccine Initiative (IAVI), 125 Broad Street, 9th Floor, 10004 New York, NY USA ,grid.266102.10000 0001 2297 6811Department of Epidemiology and Biostatistics, University of California, San Francisco (UCSF), 550 16th St, 94158 San Francisco, CA USA
| | - Janet Seeley
- grid.415861.f0000 0004 1790 6116Medical Research Council, Uganda Virus Research Institute and London School of Hygiene and Tropical Medicine Uganda Research Unit, P.O. Box 49, Entebbe, Uganda ,grid.8991.90000 0004 0425 469XGlobal Health and Development Department, London School of Hygiene and Tropical Medicine, 15-17 Tavistock Place, WC1H 9SH London, UK
| | - Godfrey Siu
- grid.415861.f0000 0004 1790 6116Medical Research Council, Uganda Virus Research Institute and London School of Hygiene and Tropical Medicine Uganda Research Unit, P.O. Box 49, Entebbe, Uganda ,grid.11194.3c0000 0004 0620 0548Child Health and Development Centre, Makerere University, Mulago Hill Road, Kampala, Uganda
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10
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Ndenkeh JJN, Bowring AL, Njindam IM, Folem RD, Fako GCH, Ngueguim FG, Gayou OL, Lepawa K, Minka CM, Batoum CM, Georges S, Temgoua E, Nzima V, Kob DA, Akiy ZZ, Philbrick W, Levitt D, Curry D, Baral S. HIV Pre-exposure Prophylaxis Uptake and Continuation Among Key Populations in Cameroon: Lessons Learned From the CHAMP Program. J Acquir Immune Defic Syndr 2022; 91:39-46. [PMID: 35536113 PMCID: PMC9377496 DOI: 10.1097/qai.0000000000003012] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2021] [Accepted: 04/25/2022] [Indexed: 11/26/2022]
Abstract
INTRODUCTION Pre-exposure prophylaxis (PrEP) is proven to be a highly effective HIV prevention method for key populations. However, its scale-up in resource-limited settings remains suboptimal. This paper seeks to describe PrEP initiation and continuation among key populations in Cameroon. METHODOLOGY From June 2019 through October 2020, we collected routine program data on PrEP uptake and continuation among female sex workers (FSWs) and men who have sex with men (MSM) in the Continuum of prevention, care and treatment of HIV/AIDS with Most-at-risk Populations (CHAMP) program in Cameroon. PrEP was offered to clients who tested negative for HIV and were assessed to potentially benefit from PrEP. Using survival analysis, we identified factors associated with PrEP discontinuation over time with significance set at 5%. RESULTS Overall, 27,750 clients were sensitized for PrEP of whom 3,138 persons were eligible to start PrEP and 1,409 (45%; FSW: 691 and MSM: 718) initiated PrEP. The PrEP continuation rate was 37% at 3 months, 28% at 6 months and 19% at 12 months. PrEP discontinuation was significantly higher among FSW than MSM [adjusted hazard ratio (aHR) 1.5 (95% CI: 1.2 to 1.9)] in Yaounde [aHR 1.5 (95% CI: 1.2 to 1.9)] and Bafoussam/Bertoua [aHR 3.1 (2.2-4.5)] relative to Douala. Discontinuation was lower among those with moderate [aHR 0.3 (0.3-0.4)] or good adherence [aHR 0.4 (0.3-0.6)] compared with poor adherence (all P < 0.001). CONCLUSION Differentiated approaches to deliver PrEP, create demand, and provide more intensive support for adherence and continuation may support scale-up of PrEP in Cameroon for equitable and prolonged impact on HIV prevention.
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Affiliation(s)
- Jackson Jr Nforbewing Ndenkeh
- Care International in Cameroon, Yaoundé, Cameroon
- CIH Center for International Health, University Hospital, Ludwig Maximilian University of Munich, Munich, Germany
| | - Anna L. Bowring
- Burnet Institute, Melbourne, Australia
- John Hopkins School of Public Health, Baltimore, USA
| | | | | | | | | | | | - Kelly Lepawa
- Care and Health Program (CHP), Yaoundé, Cameroon
| | | | | | | | - Edith Temgoua
- National AIDS Control Committee (NACC), Yaoundé, Cameroon
| | - Valery Nzima
- United States Agency for International Development (USAID), Yaoundé, Cameroon; and
| | - David Anouar Kob
- United States Agency for International Development (USAID), Yaoundé, Cameroon; and
| | - Zacheus Zeh Akiy
- United States Agency for International Development (USAID), Yaoundé, Cameroon; and
| | | | | | | | - Stefan Baral
- John Hopkins School of Public Health, Baltimore, USA
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11
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Beckham SW, Mantsios A, Galai N, Likindikoki S, Mbwambo J, Davis W, Kerrigan D. Acceptability of multiple modalities of pre-exposure prophylaxis (PrEP) among female sex workers in Tanzania: a mixed-methods study. BMJ Open 2022; 12:e058611. [PMID: 35977762 PMCID: PMC9389123 DOI: 10.1136/bmjopen-2021-058611] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/07/2023] Open
Abstract
OBJECTIVES Modalities of pre-exposure prophylaxis (PrEP) for HIV prevention offer options to women at high risk including female sex workers (FSW). This study aimed to explore FSW's acceptability and preferences for oral pills, long-acting (LA) injectable and vaginal ring PrEP. DESIGN Sequential, explanatory, mixed methods. SETTING Iringa, Tanzania. PARTICIPANTS FSW aged above 18 were recruited from sex work venues using time-location sampling (n=496); HIV-uninfected (n=293) were included in this analysis. Subsequently, survey participants were recruited for in-depth interviews (n=10) and two focus group discussions (n=20). PRIMARY OUTCOME MEASURES (1) Acceptability of PrEP (Do you personally think it would be worth it to you to take ART if it could prevent HIV?: yes/no) and (2) preference for LA injectable versus oral pills (If you personally were going to take ART to prevent HIV infection, would you prefer to take it in the form of a daily pill or an injection once every 3 months? Injection/pill). RESULTS Participants were (92%) unaware of PrEP but 58% thought it would be worth it to personally take PrEP. Acceptability of PrEP was significantly associated with higher social cohesion (aOR 2.12; 95% CI 1.29 to 3.50) and STI symptoms in the past 6 months (aOR 2.52; 95% CI 1.38 to 4.62). Most (88%) preferred LA vs oral PrEP. Qualitative findings revealed generally positive reactions to all types of PrEP, and they were viewed as a welcome backup to condoms. Participants had concerns about pills (burden of daily use, stigma from clients), and the vaginal ring (fear of client noticing and becoming suspicious, fear of infertility) and overall preferred LA-PrEP (less frequent use, easy to hide, belief in higher efficacy). CONCLUSIONS Offering multiple formulations of PrEP within the context of community-driven HIV prevention interventions among FSW may facilitate increased uptake and adherence. LA injectable PrEP may be a particularly preferred formulation among FSW. TRIAL REGISTRATION NUMBER NCT02281578.
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Affiliation(s)
- S Wilson Beckham
- Health, Behavior and Society, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
| | | | - Noya Galai
- Department of Epidemiology, Johns Hopkins University Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Samuel Likindikoki
- Psychiatry and Mental Health, Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania, United Republic of
| | - Jessie Mbwambo
- Psychiatry and Mental Health, Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania, United Republic of
| | - Wendy Davis
- Department of Prevention and Community Health, George Washington University Milken Institute School of Public Health, Washington, DC, USA
| | - Deanna Kerrigan
- Department of Prevention and Community Health, George Washington University Milken Institute School of Public Health, Washington, DC, USA
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12
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Skovdal M, Clausen CL, Magoge-Mandizvidza P, Dzamatira F, Maswera R, Nyamwanza RP, Nyamukapa C, Thomas R, Gregson S. How gender norms and 'good girl' notions prevent adolescent girls and young women from engaging with PrEP: qualitative insights from Zimbabwe. BMC Womens Health 2022; 22:344. [PMID: 35974360 PMCID: PMC9379870 DOI: 10.1186/s12905-022-01928-2] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2021] [Accepted: 08/11/2022] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Pre-exposure prophylaxis, or PrEP, has been hailed for its promise to provide women with user-control. However, gender-specific challenges undermining PrEP use are beginning to emerge. We explore the role of gender norms in shaping adolescent girls and young women's (AGYW) engagement with PrEP. METHODS We draw on qualitative data from 12 individual interviews and three focus group discussions with AGYW from eastern Zimbabwe. Interviews were transcribed and thematically coded in NVivo 12. Emerging themes were further investigated using Connell's notion of 'emphasised femininity'. RESULTS Participants alluded to the patriarchal society they are part of, with 'good girl' notions subjecting them to direct and indirect social control. These controls manifest themselves through the anticipation of intersecting sexuality- and PrEP-related stigmas, discouraging AGYW from engaging with PrEP. AGYW recounted the need for permission to engage with PrEP, forcing them to consider engaging with PrEP in secrecy. In addition, limited privacy at home, and fear of disclosure of their health clinic visits, further heightened their fear of engaging with PrEP. PrEP is not simply a user-controlled HIV prevention method, but deeply entrenched within public gender orders. CONCLUSION AGYW face significant limitations in their autonomy to initiate and engage with PrEP. Those considering PrEP face the dilemma of Scylla and Charybdis: The social risks of stigmatisation or risks of HIV acquisition. Efforts to make PrEP available must form part of a combination of social and structural interventions that challenge harmful gender norms.
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Affiliation(s)
- Morten Skovdal
- Department of Public Health, University of Copenhagen, Øster Farimagsgade 5, 1014, Copenhagen, Denmark.
| | - Camilla Lysemose Clausen
- Department of Public Health, University of Copenhagen, Øster Farimagsgade 5, 1014, Copenhagen, Denmark
| | - Phyllis Magoge-Mandizvidza
- Manicaland Centre for Public Health Research, Biomedical Research and Training Institute, Harare, Zimbabwe
| | - Freedom Dzamatira
- Manicaland Centre for Public Health Research, Biomedical Research and Training Institute, Harare, Zimbabwe
| | - Rufurwokuda Maswera
- Manicaland Centre for Public Health Research, Biomedical Research and Training Institute, Harare, Zimbabwe
| | | | - Constance Nyamukapa
- Manicaland Centre for Public Health Research, Biomedical Research and Training Institute, Harare, Zimbabwe
- Department of Infectious Disease Epidemiology, Imperial College London, London, UK
| | - Ranjeeta Thomas
- Department of Health Policy, London School of Economics and Political Science, London, UK
| | - Simon Gregson
- Manicaland Centre for Public Health Research, Biomedical Research and Training Institute, Harare, Zimbabwe
- Department of Infectious Disease Epidemiology, Imperial College London, London, UK
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13
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Ssempijja V, Nakigozi G, Ssekubugu R, Kagaayi J, Kigozi G, Nalugoda F, Nantume B, Batte J, Kigozi G, Yeh PT, Nakawooya H, Serwadda D, Quinn TC, Gray RH, Wawer MJ, Grabowski KM, Chang LW, van't Hoog A, Cobelens F, Reynolds SJ. High Rates of Pre-exposure Prophylaxis Eligibility and Associated HIV Incidence in a Population With a Generalized HIV Epidemic in Rakai, Uganda. J Acquir Immune Defic Syndr 2022; 90:291-299. [PMID: 35259129 PMCID: PMC9177156 DOI: 10.1097/qai.0000000000002946] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2021] [Accepted: 11/04/2021] [Indexed: 11/27/2022]
Abstract
BACKGROUND The utility of using pre-exposure prophylaxis (PrEP) eligibility assessments to identify eligibility in general populations has not been well studied in sub-Saharan Africa. We used the Rakai Community Cohort Study to conduct a cross-sectional analysis to estimate PrEP eligibility and a cohort analysis to estimate HIV incidence associated with PrEP eligibility. METHODS Based on Uganda's national PrEP eligibility tool, we defined eligibility as reporting at least one of the following HIV risks in the past 12 months: sexual intercourse with more than one partner of unknown HIV status; nonmarital sex act without a condom; sex engagement in exchange for money, goods, or services; or experiencing genital ulcers. We used log-binomial and modified Poisson models to estimate prevalence ratios for PrEP eligibility and HIV incidence, respectively. FINDINGS We identified 12,764 participants among whom to estimate PrEP eligibility prevalence and 11,363 participants with 17,381 follow-up visits and 30,721 person-years (pys) of observation to estimate HIV incidence. Overall, 29% met at least one of the eligibility criteria. HIV incidence was significantly higher in PrEP-eligible versus non-PrEP-eligible participants (0.91/100 pys versus 0.41/100 pys; P < 0.001) and independently higher in PrEP-eligible versus non-PrEP-eligible female participants (1.18/100 pys versus 0.50/100 pys; P < 0.001). Among uncircumcised male participants, HIV incidence was significantly higher in PrEP-eligible versus non-PrEP-eligible participants (1.07/100 pys versus 0.27/100 pys; P = 0.001), but there was no significant difference for circumcised male participants. INTERPRETATION Implementing PrEP as a standard HIV prevention tool in generalized HIV epidemics beyond currently recognized high-risk key populations could further reduce HIV acquisition and aid epidemic control efforts.
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Affiliation(s)
- Victor Ssempijja
- Clinical Monitoring Research Program Directorate, Frederick National Laboratory for Cancer Research, Frederick, MD
- Rakai Health Sciences Program, Entebbe, Uganda;
| | | | | | | | | | | | | | - James Batte
- Rakai Health Sciences Program, Entebbe, Uganda;
| | | | - Ping Teresa Yeh
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD
| | | | - David Serwadda
- Rakai Health Sciences Program, Entebbe, Uganda;
- Makerere University School of Public Health, Kampala, Uganda;
| | - Thomas C. Quinn
- Division of Infectious Diseases, Department of Medicine, Johns Hopkins School of Medicine, Baltimore, MD
- Division of Intramural Research, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, MD
| | - Ronald H. Gray
- Rakai Health Sciences Program, Entebbe, Uganda;
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD
| | - Maria J. Wawer
- Rakai Health Sciences Program, Entebbe, Uganda;
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD
| | - Kate M. Grabowski
- Rakai Health Sciences Program, Entebbe, Uganda;
- Department of Pathology, Johns Hopkins School of Medicine, Baltimore, MD; and
| | - Larry W. Chang
- Rakai Health Sciences Program, Entebbe, Uganda;
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD
- Division of Infectious Diseases, Department of Medicine, Johns Hopkins School of Medicine, Baltimore, MD
| | - Anja van't Hoog
- Amsterdam Institute for Global Health and Development, Amsterdam University Medical Centers, Amsterdam, the Netherlands.
| | - Frank Cobelens
- Amsterdam Institute for Global Health and Development, Amsterdam University Medical Centers, Amsterdam, the Netherlands.
| | - Steven J. Reynolds
- Rakai Health Sciences Program, Entebbe, Uganda;
- Division of Infectious Diseases, Department of Medicine, Johns Hopkins School of Medicine, Baltimore, MD
- Division of Intramural Research, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, MD
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14
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Webb EL, Dietrich JJ, Ssemata AS, Nematadzira TG, Hornschuh S, Kakande A, Tshabalala G, Muhumuza R, Mutonyi G, Atujuna M, Bere T, Bekker LG, Abas MA, Weiss HA, Seeley J, Stranix-Chibanda L, Fox J. Symptoms of post-traumatic stress and associations with sexual behaviour and PrEP preferences among young people in South Africa, Uganda and Zimbabwe. BMC Infect Dis 2022; 22:466. [PMID: 35578175 PMCID: PMC9109411 DOI: 10.1186/s12879-022-07430-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2021] [Accepted: 04/28/2022] [Indexed: 12/02/2022] Open
Abstract
BACKGROUND It is not known whether post-traumatic stress disorder (PTSD) increases HIV-risk behaviours among young people in sub-Saharan Africa. We assessed associations of PTSD symptoms with sexual behaviour, HIV risk perception, and attitudes towards PrEP among young people taking part in the CHAPS community survey. We hypothesised that PTSD symptoms would increase sexual behaviours associated with HIV risk, hinder PrEP uptake and influence preference for daily versus on-demand PrEP. METHODS Young people without HIV, aged 13-24 years, were purposively recruited in Johannesburg and Cape Town in South Africa, Wakiso in Uganda, and Chitungwiza in Zimbabwe, and surveyed on socio-demographic characteristics, PrEP knowledge and attitudes, sexual behaviour, HIV perception and salience, and mental health. PTSD symptoms were measured using the Primary Care PTSD Screen for the Diagnostic and Statistical Manual of Mental Disorders 5 (PC-PTSD-5). Logistic and ordinal logistic regression was used to assess associations between PC-PTSD-5 score and socio-demographic characteristics, sexual behaviour, HIV risk perception, PrEP attitudes, and substance use, adjusting for age, sex, setting, depression and anxiety. RESULTS Of 1330 young people (51% male, median age 19 years), 522 (39%) reported at least one PTSD symptom. There was strong evidence that having a higher PC-PTSD-5 score was associated with reported forced sex (OR 3.18, 95%CI: 2.05-4.93), self-perception as a person who takes risks (OR 1.12, 95%CI: 1.04-1.20), and increased frequency of thinking about risk of HIV acquisition (OR 1.16, 95%CI: 1.08-1.25). PTSD symptoms were not associated with willingness to take PrEP, preference for on-demand versus daily PrEP, or actual HIV risk behaviour such as condomless sex. CONCLUSIONS Symptoms consistent with probable PTSD were common among young people in South Africa, Uganda and Zimbabwe but did not impact PrEP attitudes or PrEP preferences. Evaluation for PTSD might form part of a general assessment in sexual and reproductive health services in these countries. More work is needed to understand the impact of PTSD on HIV-risk behaviour, forced sex and response to preventive strategies including PrEP.
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Affiliation(s)
- Emily L Webb
- MRC International Statistics and Epidemiology Group, London School of Hygiene and Tropical Medicine, WC1E 7HT, London, UK.
| | - Janan J Dietrich
- Perinatal HIV Research Unit (PHRU), Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
- Health Systems Research Unit, South African Medical Research Council, Bellville, South Africa
- African Social Sciences Unit of Research and Evaluation (ASSURE), School of Clinical Medicine, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | | | | | - Stefanie Hornschuh
- Perinatal HIV Research Unit (PHRU), Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Ayoub Kakande
- MRC/UVRI and LSHTM Uganda Research Unit, Entebbe, Uganda
| | - Gugulethu Tshabalala
- Perinatal HIV Research Unit (PHRU), Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | | | | | - Millicent Atujuna
- Desmond Tutu HIV Centre, University of Cape Town, Cape Town, South Africa
| | - Tarisai Bere
- Clinical Trials Research Centre, University of Zimbabwe, Harare, Zimbabwe
| | - Linda-Gail Bekker
- Desmond Tutu HIV Centre, University of Cape Town, Cape Town, South Africa
| | - Melanie A Abas
- Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, UK
| | - Helen A Weiss
- MRC International Statistics and Epidemiology Group, London School of Hygiene and Tropical Medicine, WC1E 7HT, London, UK
| | - Janet Seeley
- MRC/UVRI and LSHTM Uganda Research Unit, Entebbe, Uganda
- Department of Global Health and Development, London School of Hygiene and Tropical Medicine, London, UK
| | - Lynda Stranix-Chibanda
- Clinical Trials Research Centre, University of Zimbabwe, Harare, Zimbabwe
- Child and Adolescent Health Unit, Faculty of Medicine and Health Sciences, University of Zimbabwe, Harare, Zimbabwe
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15
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Ssemata AS, Muhumuza R, Stranix-Chibanda L, Nematadzira T, Ahmed N, Hornschuh S, Dietrich JJ, Tshabalala G, Atujuna M, Ndekezi D, Nalubega P, Awino E, Weiss HA, Fox J, Seeley J. The potential effect of pre-exposure prophylaxis (PrEP) roll-out on sexual-risk behaviour among adolescents and young people in East and southern Africa. AFRICAN JOURNAL OF AIDS RESEARCH : AJAR 2022; 21:1-7. [PMID: 35361057 DOI: 10.2989/16085906.2022.2032218] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
Pre-exposure prophylaxis (PrEP) is an HIV-prevention strategy recommended for those at high-risk of infection, including adolescents and young people (AYP). We explored how PrEP roll-out could influence sexual risk behaviour among AYP in East and southern Africa. Twenty-four group discussions and 60 in-depth interviews were conducted with AYP between 13 and 24 years old, recruited from community settings in Uganda, Zimbabwe and South Africa, from September 2018 to January 2019. Participants perceived that PrEP availability could change sexual behaviour among AYP, influencing: (1) condom use (increased preference for condomless sex, reduced need and decrease in use of condoms, relief from condom use discomfort, consistent condom use to curb sexually transmitted infections and pregnancies); (2) sexual activities (increase in sexual partners and sexual encounters, early sexual debut, sexual experimentation and peace of mind during risky sex, sexual violence and perversion); (3) HIV risk perception (neglect of other HIV prevention strategies, unknown sexual partner HIV status, adoption of PrEP). PrEP initiation may be associated with increased interest in sexual activities and risky sexual behaviour among AYP. PrEP should be included as part of a combination package of HIV prevention strategies for AYP with methods to prevent other sexually transmitted infections and unwanted pregnancies.
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Affiliation(s)
- Andrew Sentoogo Ssemata
- Medical Research Council/Uganda Virus Research Institute and London School of Hygiene & Tropical Medicine, Uganda Research Unit, Entebbe, Uganda
| | - Richard Muhumuza
- Medical Research Council/Uganda Virus Research Institute and London School of Hygiene & Tropical Medicine, Uganda Research Unit, Entebbe, Uganda
| | | | | | - Nadia Ahmed
- Desmond Tutu HIV Centre, Faculty of Health Sciences, University of Cape Town, South Africa
- Mortimer Market Centre, Central North West London NHS Trust, London, United Kingdom
| | - Stefanie Hornschuh
- Perinatal HIV Research Unit (PHRU), School of Clinical Medicine, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Janan Janine Dietrich
- Perinatal HIV Research Unit (PHRU), School of Clinical Medicine, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Gugulethu Tshabalala
- Perinatal HIV Research Unit (PHRU), School of Clinical Medicine, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Millicent Atujuna
- Desmond Tutu HIV Centre, Faculty of Health Sciences, University of Cape Town, South Africa
| | - Denis Ndekezi
- Medical Research Council/Uganda Virus Research Institute and London School of Hygiene & Tropical Medicine, Uganda Research Unit, Entebbe, Uganda
| | - Phiona Nalubega
- Medical Research Council/Uganda Virus Research Institute and London School of Hygiene & Tropical Medicine, Uganda Research Unit, Entebbe, Uganda
| | - Esther Awino
- Medical Research Council/Uganda Virus Research Institute and London School of Hygiene & Tropical Medicine, Uganda Research Unit, Entebbe, Uganda
| | - Helen A Weiss
- MRC International Statistics and Epidemiology Group, Department of Infectious Disease Epidemiology, London School of Hygiene & Tropical Medicine, London, United Kingdom
| | - Julie Fox
- King's College London, United Kingdom
| | - Janet Seeley
- Medical Research Council/Uganda Virus Research Institute and London School of Hygiene & Tropical Medicine, Uganda Research Unit, Entebbe, Uganda
- Department of Global Health and Development, London School of Hygiene and Tropical Medicine, London, United Kingdom
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Chimbindi N, Mthiyane N, Zuma T, Baisley K, Pillay D, McGrath N, Harling G, Sherr L, Birdthistle I, Floyd S, Dreyer J, Nakasone S, Seeley J, Shahmanesh M. Antiretroviral therapy based HIV prevention targeting young women who sell sex: a mixed method approach to understand the implementation of PrEP in a rural area of KwaZulu-Natal, South Africa. AIDS Care 2022; 34:232-240. [PMID: 33769156 PMCID: PMC8464632 DOI: 10.1080/09540121.2021.1902933] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
Pre-Exposure Prophylaxis (PrEP) is a potential game-changer for HIV. We used PrEP introduction for Young Women Who Sell Sex (YWSS) in a rural South Africa district to understand community norms and PrEP coverage in YWSS. Between 2017 and 2018, we measured awareness and uptake of PrEP in a representative cohort of 2184 Adolescent Girls and Young Women (AGYW) aged 13-22. We conducted group discussions with young people and community members (19); key informant interviews (9), in-depth interviews with 15-24 year-olds (58) and providers (33). Interviews were analysed using thematic analysis. PrEP awareness increased from 2% to 9%. Among 965 AGYW sexually-active by 2018, 13.4% (95%CI: 11.4%-15.7%) reported transactional sex and 10.6% (95%CI: 8.85-12.7%) sex for money. Of the 194 YWSS, 21 were aware of PrEP, but none had used it. Youth were enthusiastic about PrEP as tool for HIV prevention; whilst older community members were cautious about a technology they had limited experience with but could benefit select groups. Teachers and healthcare providers were concerned that PrEP would lower personal responsibility for sexual health. In conclusion, the narrow and limited introduction of PrEP to YWSS reduced the accessibility and reach. Introducing PrEP as part of sexual healthcare may improve demand and access for YWSS.
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Affiliation(s)
- Natsayi Chimbindi
- Africa Health Research Institute (AHRI), KwaZulu-Natal, South Africa,,University College London, United Kingdom
| | | | - Thembelihle Zuma
- Africa Health Research Institute (AHRI), KwaZulu-Natal, South Africa
| | - Kathy Baisley
- Africa Health Research Institute (AHRI), KwaZulu-Natal, South Africa,,London School of Hygiene & Tropical Medicine, United Kingdom
| | - Deenan Pillay
- Africa Health Research Institute (AHRI), KwaZulu-Natal, South Africa,,University College London, United Kingdom
| | - Nuala McGrath
- Africa Health Research Institute (AHRI), KwaZulu-Natal, South Africa,,University of Southampton, United Kingdom
| | - Guy Harling
- Africa Health Research Institute (AHRI), KwaZulu-Natal, South Africa,,University College London, United Kingdom,Harvard University, United States of America,University of the Witwatersrand, South Africa
| | | | | | - Sian Floyd
- London School of Hygiene & Tropical Medicine, United Kingdom
| | - Jaco Dreyer
- Africa Health Research Institute (AHRI), KwaZulu-Natal, South Africa
| | | | - Janet Seeley
- Africa Health Research Institute (AHRI), KwaZulu-Natal, South Africa,,London School of Hygiene & Tropical Medicine, United Kingdom
| | - Maryam Shahmanesh
- Africa Health Research Institute (AHRI), KwaZulu-Natal, South Africa,,University College London, United Kingdom,Corresponding author: Maryam Shahmanesh, University College London (UCL) Institute for Global Health, Mortimer Market Centre off Capper Street, London, WC1E 6JB, United Kingdom. Phone number: +44 7776185572
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Larsen A, Abuna F, Owiti G, Kemunto V, Sila J, Wilson KS, Owens T, Pintye J, Richardson BA, Kinuthia J, John-Stewart G, Kohler P. Improving Quality of PrEP Counseling for Adolescent Girls and Young Women in Kenya With Standardized Patient Actors: A Dose-Response Analysis. J Acquir Immune Defic Syndr 2022; 89:34-39. [PMID: 34560769 PMCID: PMC8665073 DOI: 10.1097/qai.0000000000002814] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2021] [Accepted: 08/27/2021] [Indexed: 01/03/2023]
Abstract
BACKGROUND Health care worker (HCW) training using standardized patient actors (SPs) is an evidence-based approach for improving patient-provider interactions. We evaluated whether SP training among HCWs in Western Kenya improved the quality of pre-exposure prophylaxis (PrEP) counseling for adolescent girls and young women (AGYW). METHODS We conducted a 2-day SP training intervention among HCWs providing PrEP counseling for AGYW. Six trained SPs role played one encounter each with HCWs following scripts depicting common PrEP-seeking scenarios. SPs used checklists to report and discuss domains of adherence to national PrEP guidelines, communication, and interpersonal skills using validated scales after each encounter. HCWs presented to each case in a random order. Overall and domain-specific mean score percentages were compared between the first and subsequent case encounters using generalized linear models, clustering by HCWs. RESULTS During 564 training cases among 94 HCWs, the overall mean quality of PrEP counseling score was 83.1 (SD: 10.1); scores improved over the course of the 6 encounters (P < 0.001). Compared with the first case encounter, the mean scores for the fourth were significantly higher (79.1 vs. 85.9, P < 0.001). The mean scores plateaued from the fourth to the sixth case (85.2). Although HCWs demonstrated high baseline communication (95.3) and interpersonal skills (83.7), adherence to PrEP guidelines at baseline was suboptimal (57.6). By the fourth case, scores increased significantly (P < 0.001) for all domains. CONCLUSIONS SP training improved PrEP counseling overall and in domains of interpersonal skills, use of guidelines, and communication with AGYW and could be useful in efforts to improve the quality of PrEP counseling for AGYW.
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Affiliation(s)
- Anna Larsen
- Departments of Global Health
- Epidemiology, University of Washington, Seattle, WA
| | - Felix Abuna
- Department of Research and Programs, Kenyatta National Hospital, Nairobi, Kenya
| | - George Owiti
- Department of Research and Programs, Kenyatta National Hospital, Nairobi, Kenya
| | - Valarie Kemunto
- Department of Research and Programs, Kenyatta National Hospital, Nairobi, Kenya
| | - Joseph Sila
- Department of Research and Programs, Kenyatta National Hospital, Nairobi, Kenya
| | - Kate S Wilson
- Policy Development & Evaluation Unit, Public Health Seattle/King County, Seattle, WA
| | - Tamara Owens
- Clinical Skills & Simulation Centers, Howard University, Washington, DC
| | - Jillian Pintye
- Departments of Global Health
- Departments of Biobehavioral Nursing and Health Informatics
| | | | - John Kinuthia
- Departments of Global Health
- Department of Research and Programs, Kenyatta National Hospital, Nairobi, Kenya
| | - Grace John-Stewart
- Departments of Global Health
- Epidemiology, University of Washington, Seattle, WA
- Medicine
- Pediatrics; and
| | - Pamela Kohler
- Child, Family, and Population Health Nursing, University of Washington, Seattle, WA
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High HIV Detection in a Tertiary Facility in Liberia: Implications and Opportunities. Ann Glob Health 2021; 87:117. [PMID: 34900617 PMCID: PMC8622250 DOI: 10.5334/aogh.3243] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
Background: HIV/AIDS remains one of the world’s most significant public health challenges; sub-Saharan Africa accounts for 71% of the global burden of HIV. Testing for HIV is pivotal to achieving UNAIDS 95-95-95 target towards bringing an end to the epidemic. Objective: The study assessed five-year HIV testing data from the largest tertiary hospital in Monrovia, Liberia and highlights risk groups that would benefit from targeted testing and prevention interventions. Methods: This was a single-center academic hospital-based retrospective analysis of HIV testing data from January 2014 to December 2018 obtained from all testing sites at John F. Kennedy Medical Center in Monrovia, Liberia. Pooled HIV testing data during the study period were analyzed using descriptive statistics and stratified by age, gender and pregnancy status. Annual diagnoses rates were reported as proportion of individuals tested within a specified category (age [<15 years, age 15–24 years and >=25 years], gender, and pregnancy status) that had a positive HIV test. Five-year trends were analyzed. Results: Over the study period, 41,343 non-pregnant individuals were screened for HIV. In addition, the antenatal clinic performed 24,913 tests. Of non-pregnant individuals tested, 4,066 (10%) were diagnosed with HIV ranging from 7% (909/12821) in 2018 to 13% (678/5079) in 2014. Case detection rates for individuals aged 15–24 were 7%, 5%, 4%, 6% and 3% for years 2014, 2015, 2016, 2017 and 2018 respectively. Annually, 2–3% of all pregnant women tested were diagnosed with HIV. While HIV detection rates decreased over time overall, children less than 15 years of age showed an annual increase from 6.7% in 2014 to 12.3% in 2018. Conclusion: A large five-year dataset from the largest tertiary facility in Liberia shows broad HIV detection rates that are much higher than national prevalence estimates. Ramping up HIV testing and prevention interventions including pre-exposure prophylaxis are sorely needed.
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Shava E, Bogart LM, Manyake K, Mdluli C, Maribe K, Monnapula N, Nkomo B, Mosepele M, Moyo S, Mmalane M, Bärnighausen T, Makhema J, Lockman S. Feasibility of oral HIV self-testing in female sex workers in Gaborone, Botswana. PLoS One 2021; 16:e0259508. [PMID: 34748576 PMCID: PMC8575243 DOI: 10.1371/journal.pone.0259508] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2021] [Accepted: 10/20/2021] [Indexed: 11/17/2022] Open
Abstract
BACKGROUND Oral HIV self-testing (HIVST) may be useful for increasing testing in persons at elevated risk of acquiring HIV. METHODS We conducted a pilot study to evaluate the feasibility (defined by uptake) of HIVST among FSW in Gaborone, Botswana. FSW age 18 years and above were recruited through a non-governmental organization serving FSW. FSW with unknown or negative HIV status at screening performed HIVST in the study clinic following brief training. FSW testing HIV-negative were each given two test kits to take home: one kit to perform unassisted HIVST and another to share with others. Feasibility (use) of HIVST (and sharing of test kits with others) was assessed in these women at a study visit four months later. RESULTS Two hundred FSW were screened. Their average age was 34 years (range 18-59), and 115 (58%) were HIV-positive. Eighty-five (42%) tested HIV-negative at entry and were eligible to take part in the HIVST pilot study. All 85 (100%) agreed to take home HIVST kits. Sixty-nine (81%) of these 85 participants had a follow-up visit, 56 (81%) of whom reported performing HIVST at a mean of three and half months after the initial visit. All 56 participants who performed HIVST reported negative HIVST results. Fifty (73%) of the 69 participants who took HIVST kits home shared them with others. Of the 50 women sharing HIVST kits, 25 (50%) shared with their non-client partners, 15 with a family member, 8 with friends, and 3 with a client. One participant did not test herself but shared both her test kits. Most participants 53/56 (95%) found oral HIVST very easy to use whilst 3/56 (5%) felt it was fairly easy. CONCLUSION Oral HIVST is feasible among FSW in Gaborone, Botswana. The majority of FSW used the HIVST kits themselves and also shared extra HIVST kits with other individuals.
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Affiliation(s)
- Emily Shava
- Botswana Harvard AIDS Institute Partnership, Gaborone, Botswana
- Harvard T.H. Chan School of Public Health, Boston, Massachusetts, United States of America
| | - Laura M. Bogart
- RAND Corporation, Santa Monica, California, United States of America
| | - Kutlo Manyake
- Botswana Harvard AIDS Institute Partnership, Gaborone, Botswana
| | | | | | | | | | - Mosepele Mosepele
- Botswana Harvard AIDS Institute Partnership, Gaborone, Botswana
- Harvard T.H. Chan School of Public Health, Boston, Massachusetts, United States of America
- University of Botswana, Gaborone, Botswana
| | - Sikhulile Moyo
- Botswana Harvard AIDS Institute Partnership, Gaborone, Botswana
- Harvard T.H. Chan School of Public Health, Boston, Massachusetts, United States of America
| | - Mompati Mmalane
- Botswana Harvard AIDS Institute Partnership, Gaborone, Botswana
| | - Till Bärnighausen
- Harvard T.H. Chan School of Public Health, Boston, Massachusetts, United States of America
- University of Heidelberg, Heidelberg, Germany
- Wellcome Trust Africa Centre for Health and Population Studies, Mtubatuba, South Africa
| | - Joseph Makhema
- Botswana Harvard AIDS Institute Partnership, Gaborone, Botswana
- Harvard T.H. Chan School of Public Health, Boston, Massachusetts, United States of America
| | - Shahin Lockman
- Botswana Harvard AIDS Institute Partnership, Gaborone, Botswana
- Harvard T.H. Chan School of Public Health, Boston, Massachusetts, United States of America
- Brigham and Women’s Hospital, Boston, Massachusetts, United States of America
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Bärnighausen K, Geldsetzer P, Matse S, Hettema A, Hughey AB, Dlamini P, Mavuso M, Fakudze D, Kahn K, Bärnighausen T, McMahon SA. Qualitative accounts of PrEP discontinuation from the general population in Eswatini. CULTURE, HEALTH & SEXUALITY 2021; 23:1198-1214. [PMID: 32633617 DOI: 10.1080/13691058.2020.1770333] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/12/2019] [Accepted: 05/13/2020] [Indexed: 06/11/2023]
Abstract
People in receipt of pre-exposure prophylaxis (PrEP) for the prevention of HIV in Sub-Saharan Africa often discontinue taking the medication. We conducted 27 semi-structured interviews with men and women who had started PrEP but did not return to the clinic for a refill after a 1, 2 or 3-month period. These 'discontinuation' clients were enrolled in a PrEP demonstration project for the general population in nurse-led, public-sector, primary-care clinics in Eswatini. Reasons for discontinuation included changes to self-perceived HIV risk such as the end of pregnancy and absent partners. Others described PrEP as inaccessible when working away from home and many described difficulties relating to a daily pill regimen and managing side effects. Female clients described being prohibited from using PrEP by their partners and co-wives. From these results, we recommend that client-centred counselling stresses the prevention-effective adherence paradigm, which promotes PrEP use in risk periods that are identifiable and PrEP discontinuation when the risk period has finished. A national scale up of PrEP may mitigate problems accessing PrEP. Extended counselling and support could assist with adherence and the management of side effects. Education and support for partners and families of PrEP clients may also contribute to better PrEP continuation.
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Affiliation(s)
- Kate Bärnighausen
- School of Public Health, University of the Witwatersrand, Johannesburg, South Africa
| | - Pascal Geldsetzer
- Faculty of Medicine, Heidelberg Institute of Global Health, University of Heidelberg, Heidelberg, Germany
- Stanford University School of Medicine, Stanford, CA, USA
| | - Sindy Matse
- Eswatini Ministry of Health, Mbabane, Eswatini
| | - Anita Hettema
- Clinton Health Access Initiative Eswatini, Mbabane, Eswatini
| | | | - Phiwa Dlamini
- Clinton Health Access Initiative Eswatini, Mbabane, Eswatini
| | - Mxolisi Mavuso
- Clinton Health Access Initiative Eswatini, Mbabane, Eswatini
| | - David Fakudze
- Clinton Health Access Initiative Eswatini, Mbabane, Eswatini
| | - Kathleen Kahn
- School of Public Health, University of the Witwatersrand, Johannesburg, South Africa
| | - Till Bärnighausen
- Faculty of Medicine, Heidelberg Institute of Global Health, University of Heidelberg, Heidelberg, Germany
| | - Shannon A McMahon
- Faculty of Medicine, Heidelberg Institute of Global Health, University of Heidelberg, Heidelberg, Germany
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
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21
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Nalukwago GK, Isunju JB, Muwonge T, Katairo T, Bunani N, Semitala F, Kyambadde P, Matovu F. Adherence to oral HIV pre-exposure prophylaxis among female sex workers in Kampala, Uganda. Afr Health Sci 2021; 21:1048-1058. [PMID: 35222566 PMCID: PMC8843287 DOI: 10.4314/ahs.v21i3.12] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/05/2022] Open
Abstract
INTRODUCTION In Kampala Uganda, female sex workers (FSWs) have high HIV prevalence (33%). Oral PrEP is a novel HIV prevention intervention that offers hope to decrease HIV incidence in key populations especially among FSWs. Studies have shown that with poor adherence, oral PrEP has no efficacy, and therefore adherence to PrEP is critical among FSWs to maximize HIV prevention. However, implementation data on adherence to PrEP among FSWs is limited so this study sought to assess adherence to PrEP. Specifically, we sought to 1) determine the level of adherence to PrEP among FSWs, and 2) determine factors associated with PrEP adherence. METHODS This cross-sectional study was conducted from November to December 2018; 126 FSWs using PrEP were interviewed using a questionnaire. Adherence was categorically defined as high adherence and low adherence. Logistic regression was done. RESULTS Using long-term contraception methods (OR 0.06, 95% CI: 0.04-0.77) and not using condoms with clients (OR 0.07, 95% CI: 0.01-0.42) were negatively associated with high PrEP adherence. CONCLUSION Barriers to PrEP adherence need to be addressed for successful PrEP implementation to improve adherence going forward. Service care providers should reinforce positive behaviors such as use of condoms devotedly during PrEP breaks.
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Affiliation(s)
- Grace Kakoola Nalukwago
- Makerere University College of Health Sciences, Public Health
- Makerere University Infectious Diseases Institute, Research
| | | | | | - Thomas Katairo
- Makerere University College of Health Sciences, School of Medicine, Clinical Epidemiology Unit
| | - Nelson Bunani
- Makerere University College of Health Sciences, Public Health
| | - Fred Semitala
- Makerere University College of Health Sciences, School of Medicine, Clinical Epidemiology Unit
| | | | - Flavia Matovu
- Makerere University School of Public Health, Epidemiology and Biostatistics
- MU-JHU Research Collaboration
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22
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Were D, Musau A, Mugambi M, Plotkin M, Kabue M, Manguro G, Forsythe S, Glabius R, Mutisya E, Dotson M, Curran K, Reed J. An implementation model for scaling up oral pre-exposure prophylaxis in Kenya: Jilinde project. Gates Open Res 2021; 5:113. [PMID: 34988373 PMCID: PMC8669463 DOI: 10.12688/gatesopenres.13342.1] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/13/2021] [Indexed: 12/12/2022] Open
Abstract
Oral pre-exposure prophylaxis (PrEP) is an efficacious way to lower the risk of HIV acquisition among high-risk individuals. Despite the World Health Organization's 2015 recommendation that all persons at substantial risk of HIV infection be provided with access to oral PrEP, the rollout has been slow in many low- and middle-income countries. Initiatives for national rollout are few, and subtle skepticism persists in several countries about the feasibility of national PrEP implementation. We describe the conceptual design of the Jilinde project, which is implementing oral PrEP as a routine service at a public health scale in Kenya. We describe the overlapping domains of supply, demand, and government and community ownership, which combine to produce a learning laboratory environment to explore the scale-up of PrEP. We describe how Jilinde approaches PrEP uptake and continuation by applying supply and demand principles and ensures that government and community ownership informs policy, coordination, and sustainability. We describe the "learning laboratory" approach that informs strategic and continuous learning, which allows for adjustments to the project. Jilinde's conceptual model illustrates how the coalescence of these concepts can promote scale-up of PrEP in real-world conditions and offers critical lessons on an implementation model for scaling up oral PrEP in low- and middle-income countries.
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Affiliation(s)
| | | | - Mary Mugambi
- Division of National AIDS and STI Control Program, Nairobi, 00202, Kenya
| | | | - Mark Kabue
- Jhpiego, USA, Baltimore, Maryland, 21231, USA
| | - Griffins Manguro
- International Center for Reproductive Health, Kenya, Mombasa, 80103, Kenya
| | | | | | | | | | | | - Jason Reed
- Jhpiego, USA, Baltimore, Maryland, 21231, USA
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Lane J, Brezak A, Patel P, Verani AR, Benech I, Katz A. Policy considerations for scaling up access to HIV pre-exposure prophylaxis for adolescent girls and young women: Examples from Kenya, South Africa, and Uganda. Int J Health Plann Manage 2021; 36:1789-1808. [PMID: 34159630 DOI: 10.1002/hpm.3252] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2020] [Revised: 10/09/2020] [Accepted: 05/10/2021] [Indexed: 11/06/2022] Open
Abstract
Adolescent girls and young women (aged 15-24 years; AGYW) continue to carry a disproportionate burden of HIV in sub-Saharan Africa. Pre-exposure prophylaxis (PrEP) helps reduce the risk of acquiring HIV for persons at substantial risk, including AGYW. As countries plan for the rollout of PrEP across sub-Saharan Africa, PrEP policies and programs could address the unique needs of AGYW. The purpose of this analysis was to identify policy considerations to improve AGYW access to PrEP. After reviewing the literature, we identified 13 policy considerations that policymakers and stakeholders could evaluate when developing or reviewing PrEP-related policies. We sorted these considerations into five categories, which together comprise an AGYW Access to PrEP Framework: AGYW-friendly delivery systems, clinical eligibility and adherence support, legal barriers and facilitators, affordability, and community and AGYW outreach. We also reviewed policies in three countries (Kenya, South Africa, and Uganda) to explore how PrEP-related policies addressed these considerations. Some of these policies addressed some of the 13 policy considerations, but none of the policies directly addressed the unique needs of AGYW for accessing PrEP. To improve access to PrEP for AGYW, country policies could include specific components that address these 13 considerations. To reach AGYW effectively, each country could use the 13 considerations we have identified to analyze current policies to identify existing programmatic barriers to AGYW accessing HIV services and address these barriers in PrEP-related policies.
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Affiliation(s)
- Jeff Lane
- University of Washington School of Public Health, Seattle, Washington, USA
| | - Audrey Brezak
- University of Washington School of Public Health, Seattle, Washington, USA
| | - Pragna Patel
- Division of Global HIV and TB, Center for Global Health, Centers for Disease Control and Prevention, Atlanta, Georgia, USA
| | - Andre R Verani
- Division of Global HIV and TB, Center for Global Health, Centers for Disease Control and Prevention, Atlanta, Georgia, USA
| | - Irene Benech
- Division of Global HIV and TB, Center for Global Health, Centers for Disease Control and Prevention, Atlanta, Georgia, USA
| | - Aaron Katz
- University of Washington School of Public Health, Seattle, Washington, USA
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Atkins K, Rucinski K, Mudavanhu M, Holmes L, Mutunga L, Kaufman MR, Bassett J, Van Rie A, Schwartz SR. Sexual Relationship Types, Partner HIV Self-Testing, and Pre-Exposure Prophylaxis Among South African Adolescent Girls and Young Women: A Latent Class Analysis. J Acquir Immune Defic Syndr 2021; 86:413-421. [PMID: 33196552 PMCID: PMC10358829 DOI: 10.1097/qai.0000000000002569] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2020] [Accepted: 09/28/2020] [Indexed: 11/26/2022]
Abstract
BACKGROUND Sexual relationships among adolescent girls and young women (AGYW) are influenced by social, economic, and gender dynamics. Understanding AGYW's different relationship types and their implications for HIV risk is important for development of tailored interventions. We sought to identify relationship typologies among AGYW and their impact on uptake of HIV prevention interventions. METHODS From May 2018 to February 2019, 2200 HIV-negative AGYW (ages 16-24) in Johannesburg, South Africa, participated in an HIV prevention intervention involving distribution of HIV self-test kits to their male partners. AGYW were also offered pre-exposure prophylaxis. At baseline, AGYW completed a questionnaire, and outcomes were assessed for 3 months. We used latent class analysis to identify relationship types and mixture modeling to estimate the impact of relationship type on engagement in prevention interventions. RESULTS We identified 3 relationship types: "stable, empowered relationships with older partners" (class 1, n = 973); "shorter, empowered relationships with peer partners" (class 2, n = 1067); and "shorter relationships with risky partners" (class 3, n = 160). Compared with AGYW in class 1 relationships, AGYW in class 2 and 3 relationships were less likely to complete partner testing alongside HIV results sharing (class 2 adjusted risk ratio: 0.89, 95% confidence interval: 0.85 to 0.95; class 3 adjusted risk ratio: 0.84, 95% confidence interval: 0.73 to 0.94). Pre-exposure prophylaxis uptake was highest in class 3 (11.2%) compared with class 2 (3.8%) and class 1 (1.0%; P < 0.001). CONCLUSIONS Relationship type impacts uptake of HIV prevention interventions among South African youth. Intervention effectiveness could be optimized by using tailored approaches to HIV risk mitigation among AGYW.
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Affiliation(s)
- Kaitlyn Atkins
- Social and Behavioral Interventions Program, Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, United States of America
| | - Katherine Rucinski
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, United States of America
| | | | - Leah Holmes
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, United States of America
| | | | - Michelle R. Kaufman
- Department of Health, Behavior, and Society, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, United States of America
| | | | - Annelies Van Rie
- Department of Epidemiology and Social Medicine, University of Antwerp, Antwerp, Belgium
| | - Sheree R. Schwartz
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, United States of America
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25
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Ware KB, Ajonina MU. Awareness of and willingness to use HIV pre-exposure prophylaxis among community residents. Res Social Adm Pharm 2021; 17:1957-1961. [PMID: 33658158 DOI: 10.1016/j.sapharm.2021.02.012] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2020] [Revised: 02/09/2021] [Accepted: 02/10/2021] [Indexed: 11/17/2022]
Abstract
INTRODUCTION Human Immunodeficiency Virus (HIV) Pre-exposure prophylaxis (PrEP) helps to decrease HIV acquisition and transmission rates. The purpose of this study was to assess awareness of HIV PrEP and willingness to use it, if available, among individuals residing in Buea, Cameroon. METHODS Residents in different communities throughout Buea, Cameroon participated in the study through survey completion with their responses assessed by age, marital status, highest level of education completed, profession, and health area (urban or rural). RESULTS 421 participants completed the survey with the majority being 20-29 years of age, single, having secondary or tertiary education, residing in rural Cameroonian areas. Eighty percent of respondents had not previously heard of HIV PrEP. Ninety-five percent of the study sample expressed willingness to use HIV PrEP, if available. Participants ages 40 years old and above were less aware of HIV PrEP than those 39 years old and younger. Primary education, serving in the role of a nurse, doctor, or scientist, along with hospital affiliations were characteristics closely associated with HIV PrEP awareness. Participants younger than 20 years old were less likely to report willingness to use HIV PrEP whereas married participants found HIV PrEP to be a more favorable option. CONCLUSIONS Awareness of HIV PrEP was minimal with healthcare personnel having more familiarity. Willingness to use HIV PrEP decreased by age but higher among married participants. Further promotion of HIV PrEP and facilitating its accessibility can lead to less transmissions of HIV worldwide.
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Affiliation(s)
- Kenric B Ware
- South University School of Pharmacy, Department of Pharmacy Practice, 10 Science Court, Columbia, SC, 29203, USA.
| | - Marcelus U Ajonina
- Department of Public Health, Faculty of Health Sciences, University of Bamenda, Bambili, Bamenda, Cameroon; School of Health Sciences, Meridian Global University, Southwest Region, Buea, Cameroon.
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Abstract
Adolescent girls and young women (AGYW) ages (15-24 years old) in Southern and Eastern Africa account for nearly 30% of all new HIV infections. We conducted a systematic review of studies examining the effectiveness of behavioral, structural, and combined (behavioral + structural) interventions on HIV incidence and risky sexual behaviors among AGYW. Following PRISMA guidelines, we searched PubMed, CINAHL, Web of Science, and Global Health. Twenty-two studies met inclusion criteria conducted in Eastern and Southern Africa and comprised behavioral, structural, or combined (behavioral and structural) interventions. All findings are based on 22 studies. HIV incidence was significantly reduced by one structural intervention. All three types of interventions improved condom use among AGYW. Evidence suggests that structural interventions can reduce HIV incidence, while behavioral and combined interventions require further investigation.
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Nash S, Dietrich J, Ssemata AS, Herrera C, O'Hagan K, Else L, Chiodi F, Kelly C, Shattock R, Chirenje M, Lebina L, Khoo S, Bekker LG, Weiss HA, Gray C, Stranix-Chibanda L, Kaleebu P, Seeley J, Martinson N, Fox J. Combined HIV Adolescent Prevention Study (CHAPS): comparison of HIV pre-exposure prophylaxis regimens for adolescents in sub-Saharan Africa-study protocol for a mixed-methods study including a randomised controlled trial. Trials 2020; 21:900. [PMID: 33121503 PMCID: PMC7596950 DOI: 10.1186/s13063-020-04760-x] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2020] [Accepted: 09/22/2020] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND HIV remains a major public health issue, especially in Eastern and Southern Africa. Pre-exposure prophylaxis is highly effective when adhered to, but its effectiveness is limited by cost, user acceptability and uptake. The cost of a non-inferiority phase III trial is likely to be prohibitive, and thus, it is essential to select the best possible drug, dose and schedule in advance. The aim of this study, the Combined HIV Adolescent PrEP and Prevention Study (CHAPS), is to investigate the drug, dose and schedule of pre-exposure prophylaxis (PrEP) required for the protection against HIV and the acceptability of PrEP amongst young people in sub-Saharan Africa, and hence to inform the choice of intervention for future phase III PrEP studies and to improve strategies for PrEP implementation. METHODS We propose a mixed-methods study amongst young people aged 13-24 years. The first component consists of qualitative research to identify the barriers and motivators towards the uptake of PrEP amongst young people in South Africa, Uganda and Zimbabwe. The second component is a randomised clinical trial (ClinicalTrials.gov NCT03986970, June 2019) using a novel ex vivo HIV challenge method to investigate the optimal PrEP treatment (FTC-TDF vs FTC-TAF), dose and schedule. We will recruit 144 amongst HIV-negative uncircumcised men aged 13-24 years from voluntary male medical circumcision clinics in two sites (South Africa and Uganda) and randomise them into one of nine arms. One group will receive no PrEP prior to surgery; the other arms will receive either FTC-TDF or FTC-TAF, over 1 or 2 days, and with the final dose given either 6 or 20 h prior to surgery. We will conduct an ex vivo HIV challenge on their resected foreskin tissue. DISCUSSION This study will provide both qualitative and quantitative results to help decide the optimum drug, dose and schedule for a future phase III trial of PrEP. The study will also provide crucial information on successful strategies for providing PrEP to young people in sub-Saharan Africa. TRIAL REGISTRATION ClinicalTrials.gov NCT03986970 . Registered on 14 June 2019.
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Affiliation(s)
- S Nash
- London School of Hygiene and Tropical Medicine, London, UK
| | - J Dietrich
- University of the Witwatersrand Perinatal HIV Research Unit, Johannesburg, South Africa
| | - A S Ssemata
- MRC/UVRI Uganda Research Unit On Aids, Entebbe, Uganda
| | | | - K O'Hagan
- University of Cape Town, Cape Town, South Africa
| | - L Else
- University of Liverpool, Liverpool, UK
| | - F Chiodi
- Karolinska Institutet, Solna, Sweden
| | - C Kelly
- King's College London, London, UK
| | | | - M Chirenje
- University of Zimbabwe, Harare, Zimbabwe
| | - L Lebina
- University of the Witwatersrand Perinatal HIV Research Unit, Johannesburg, South Africa
| | - S Khoo
- University of Liverpool, Liverpool, UK
| | - L-G Bekker
- Desmond Tutu HIV Foundation, Cape Town, South Africa
| | - H A Weiss
- London School of Hygiene and Tropical Medicine, London, UK
| | - C Gray
- University of Cape Town, Cape Town, South Africa
| | | | - P Kaleebu
- MRC/UVRI Uganda Research Unit On Aids, Entebbe, Uganda
| | - J Seeley
- London School of Hygiene, London, UK
| | - N Martinson
- University of the Witwatersrand Perinatal HIV Research Unit, Johannesburg, South Africa
| | - J Fox
- King's College London, London, UK.
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Busza J, Phillips AN, Mushati P, Chiyaka T, Magutshwa S, Musemburi S, Cowan FM. Understanding early uptake of PrEP by female sex workers in Zimbabwe. AIDS Care 2020; 33:729-735. [PMID: 33043688 DOI: 10.1080/09540121.2020.1832192] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
Female sex workers (FSW) are prioritised for increased access to pre-exposure prophylaxis (PrEP), although rates of uptake remain sub-optimal, particularly across Southern Africa. In the first two years of its availability in Zimbabwe, 37.1% of FSW in trial sites initiated PrEP and received at least one re-supply. We conducted a qualitative study on perceptions of PrEP among 19 early users selected from sites with varying rates of PrEP initiation. Narrative interviews examined the pathways taken by FSW from hearing about PrEP, through their decision to start taking it, and early experiences. FSW appreciated PrEP's introduction within familiar and trusted "friendly" services tailored for sex workers and valued positive encouragement from clinic staff and peers over negative influence from family members. They also found PrEP difficult to understand at first, and feared side effects and rare adverse complications described in information leaflets. While FSW identified individual strategies for remembering to take their medication, they also relied on structured peer adherence support, leading some FSW to actively promote the method to other FSW as "PrEP champions". Information on how early users experience a new prevention technology such as PrEP can inform design of interventions that leverage existing support structures and target key barriers.
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Affiliation(s)
- Joanna Busza
- Centre for Evaluation, London School of Hygiene & Tropical Medicine, London, UK
| | | | - Phillis Mushati
- Centre for Sexual Health and HIV AIDS Research, Harare, Zimbabwe
| | - Tarisai Chiyaka
- Centre for Sexual Health and HIV AIDS Research, Harare, Zimbabwe
| | | | | | - Frances M Cowan
- Centre for Sexual Health and HIV AIDS Research, Harare, Zimbabwe.,Liverpool School of Tropical Medicine, Liverpool, UK
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Nakasone SE, Chimbindi N, Mthiyane N, Nkosi B, Zuma T, Baisley K, Dreyer J, Pillay D, Floyd S, Birdthistle I, Seeley J, Shahmanesh M. "They have this not care - don't care attitude:" A Mixed Methods Study Evaluating Community Readiness for Oral PrEP in Adolescent Girls and Young Women in a Rural Area of South Africa. AIDS Res Ther 2020; 17:55. [PMID: 32894138 PMCID: PMC7487548 DOI: 10.1186/s12981-020-00310-2] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2020] [Accepted: 08/29/2020] [Indexed: 01/27/2023] Open
Abstract
INTRODUCTION Adolescent girls and young women (AGYW) remain disproportionately affected by HIV. In a rural area of South Africa with an annual incidence (2011-2015) of 5 and 7% per annum for 15-19 and 20-24-year olds respectively, oral pre-exposure prophylaxis (PrEP) could provide AGYW with a form of HIV prevention they can more easily control. Using quantitative and qualitative methods, we describe findings from a study conducted in 2017 that assessed knowledge of and attitudes toward PrEP to better understand community readiness for an AGYW PrEP rollout. METHODS We used descriptive analysis of a quantitative demographic survey (n = 8,414 ages 15-86) to identify population awareness and early PrEP adopters. We also conducted semi-structured, in-depth interviews with a purposive sample of 52 potential PrEP gatekeepers (health care workers, community leaders) to assess their potential influence in an AGYW PrEP rollout and describe the current sexual health landscape. Interviews were recorded, transcribed, and iteratively coded to identify major themes. RESULTS PrEP knowledge in the general population, measured through a demographic survey, was low (n = 125/8,414, 1.49% had heard of the drug). Medicalized delivery pathways created hostility to AGYW PrEP use. Key informants had higher levels of knowledge about PrEP and saw it as a needed intervention. Community norms around adolescent sexuality, which painted sexually active youth as irresponsible and disengaged from their own health, made many ambivalent towards a PrEP rollout to AGYW. Health care workers discussed ways to shame AGYW if they tried to access PrEP as they feared the drug would encourage promiscuity and "risky" behaviour. Others interviewed opposed provision on the basis of health care equity and feared PrEP would divert both drug and human resources from treatment programs. CONCLUSIONS The health system in this poor, high-HIV incidence area had multiple barriers to a PrEP rollout to AGYW. Norms around adolescent sexuality and gatekeeper concerns that PrEP could divert health resources from treatment to prevention could create barriers to PrEP roll-out in this setting. Alternate modes of delivery, particularly those which are youth-led and demedicalize PrEP, must be explored.
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Affiliation(s)
| | - Natsayi Chimbindi
- Africa Health Research Institute, KwaZulu-Natal, South Africa
- Institute of Epidemiology and Health Care Mortimer Market Centre, University College London, London, WC1E 6JB UK
| | | | - Busisiwe Nkosi
- Africa Health Research Institute, KwaZulu-Natal, South Africa
| | | | - Kathy Baisley
- Africa Health Research Institute, KwaZulu-Natal, South Africa
- London School of Hygiene & Tropical Medicine, London, UK
| | - Jaco Dreyer
- Africa Health Research Institute, KwaZulu-Natal, South Africa
| | - Deenan Pillay
- Africa Health Research Institute, KwaZulu-Natal, South Africa
- Institute of Epidemiology and Health Care Mortimer Market Centre, University College London, London, WC1E 6JB UK
| | - Sian Floyd
- London School of Hygiene & Tropical Medicine, London, UK
| | | | - Janet Seeley
- Africa Health Research Institute, KwaZulu-Natal, South Africa
- London School of Hygiene & Tropical Medicine, London, UK
| | - Maryam Shahmanesh
- Africa Health Research Institute, KwaZulu-Natal, South Africa
- Institute of Epidemiology and Health Care Mortimer Market Centre, University College London, London, WC1E 6JB UK
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Yoshioka E, Giovenco D, Kuo C, Underhill K, Hoare J, Operario D. "I'm doing this test so I can benefit from PrEP": exploring HIV testing barriers/facilitators and implementation of pre-exposure prophylaxis among South African adolescents. AFRICAN JOURNAL OF AIDS RESEARCH : AJAR 2020; 19:101-108. [PMID: 32326813 PMCID: PMC8006570 DOI: 10.2989/16085906.2020.1743726] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
In South Africa, adolescents are a key population in the HIV epidemic that can benefit from increased access to oral pre-exposure prophylaxis (PrEP). HIV testing is an integral component of the PrEP care continuum but adolescents in South Africa have generally low HIV testing rates; therefore, adolescents' HIV testing attitudes and behaviours must be understood to develop strategies for effective PrEP implementation. Ten focus groups were conducted with adolescents living with HIV and HIV-uninfected adolescents (n = 55), and in-depth interviews were conducted with service providers (n = 25), adolescents living with HIV (n = 10) and HIV-uninfected adolescents (n = 25). Data were collected in the Western Cape province of South Africa from 2015-2016. Thematic framework analysis was used to understand dynamics by which South African adolescents' attitudes toward HIV testing might influence intended uptake of PrEP and, reciprocally, to explore the implications of adolescents' perceptions about PrEP availability for their willingness to engage in HIV testing. While South African adolescents' current HIV testing attitudes and behaviours present barriers to intended PrEP implementation in this population, increased access to PrEP has the potential to improve their initial HIV testing rates and decrease stigma and fear around HIV testing. However, implementation of PrEP must consider specific HIV testing barriers for adolescent boys and girls, respectively. As PrEP becomes more widely available for adolescents, possible challenges noted by participants may include the potential for adolescents to reduce continued HIV testing behaviours while on PrEP and to share/use unprescribed PrEP medications among peers.
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Affiliation(s)
- Emily Yoshioka
- Department of Behavioral and Social Sciences, Brown University School of Public Health, Providence, Rhode Island, USA
| | - Danielle Giovenco
- Department of Epidemiology, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Caroline Kuo
- Department of Behavioral and Social Sciences, Brown University School of Public Health, Providence, Rhode Island, USA
- Center for Alcohol and Addiction Studies, Brown University School of Public Health, Providence, Rhode Island, USA
- Department of Psychiatry and Mental Health, University of Cape Town, Cape Town, South Africa
| | | | - Jackie Hoare
- Department of Psychiatry and Mental Health, University of Cape Town, Cape Town, South Africa
| | - Don Operario
- Department of Behavioral and Social Sciences, Brown University School of Public Health, Providence, Rhode Island, USA
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Joseph Davey DL, Daniels J, Beard C, Mashele N, Bekker LG, Dovel K, Ncayiyana J, Coates TJ, Myer L. Healthcare provider knowledge and attitudes about pre-exposure prophylaxis (PrEP) in pregnancy in Cape Town, South Africa. AIDS Care 2020; 32:1290-1294. [PMID: 32576023 DOI: 10.1080/09540121.2020.1782328] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
Pre-exposure prophylaxis (PrEP) in pregnancy can reduce HIV incidence and vertical transmission. Healthcare providers (HCPs) play a critical role in delivering PrEP in antenatal care but little is known about HCP knowledge and attitudes about PrEP in pregnancy. We conducted a qualitative study in two healthcare facilities to assess HCPs' PrEP knowledge and perspectives relating to HIV prevention in pregnant women. Between January-March'19, we administered in-depth interviews among antenatal HCPs. We utilized a constant comparison approach to identify major qualitative findings. We enrolled 35 female HCPs (median age=43yrs. Fewer than half of HCPs had heard of PrEP before. Of those who had heard of PrEP, most felt that it was safe to take during pregnancy. Most HCPs described inaccurate PrEP knowledge regarding effectiveness, and most who knew about PrEP lacked clinical detail. HCPs highlighted important potential barriers to maternal PrEP use including: fear that PrEP may be unsafe, or belief that women must talk to partners/parents before initiating PrEP. Facilitators include good knowledge about serodiscordancy and vulnerability to seroconversion in pregnancy and desire to help women gain control overHIV prevention. We recommend integrating PrEP training into HIV testing and PMTCT nurse training to improve counseling and maternal PrEP delivery.
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Affiliation(s)
- Dvora L Joseph Davey
- Department of Epidemiology, Fielding School of Public Health, University of California, Los Angeles, CA, USA.,Division of Epidemiology and Biostatistics, School of Public Health and Family Medicine, University of Cape Town, Cape Town, South Africa
| | - Joseph Daniels
- Department of Psychiatry and Human Behaviors, Charles R. Drew University of Medicine and Science, Los Angeles, CA, USA
| | - Cindy Beard
- Department of Epidemiology, Fielding School of Public Health, University of California, Los Angeles, CA, USA
| | - Nyiko Mashele
- Division of Epidemiology and Biostatistics, School of Public Health and Family Medicine, University of Cape Town, Cape Town, South Africa
| | | | - Kathryn Dovel
- David Geffen School of Medicine, University of California Los Angeles, Los Angeles, CA, USA
| | - Jabulani Ncayiyana
- Division of Epidemiology and Biostatistics, School of Public Health and Family Medicine, 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
- Division of Epidemiology and Biostatistics, School of Public Health and Family Medicine, University of Cape Town, Cape Town, South Africa
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Larsen A, Wilson KS, Kinuthia J, John-Stewart G, Richardson BA, Pintye J, Abuna F, Lagat H, Owens T, Kohler P. Standardised patient encounters to improve quality of counselling for pre-exposure prophylaxis (PrEP) in adolescent girls and young women (AGYW) in Kenya: study protocol of a cluster randomised controlled trial. BMJ Open 2020; 10:e035689. [PMID: 32565464 PMCID: PMC7311012 DOI: 10.1136/bmjopen-2019-035689] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/12/2019] [Revised: 02/03/2020] [Accepted: 05/26/2020] [Indexed: 12/31/2022] Open
Abstract
INTRODUCTION Adolescent girls and young women (AGYW) in sub-Saharan Africa are at high risk of HIV acquisition. Pre-exposure prophylaxis (PrEP) demonstration projects observe that AGYW uptake and adherence to PrEP during risk periods is suboptimal. Judgemental interactions with healthcare workers (HCW) and inadequate counselling can be barriers to PrEP use among AGYW. Improving HCW competency and communication to support PrEP delivery to AGYW requires new strategies. METHODS AND ANALYSIS PrEP Implementation for Young Women and Adolescents Program-standardised patient (PrIYA-SP) is a cluster randomised trial of a standardised patient actor (SP) training intervention designed to improve HCW adherence to PrEP guidelines and communication skills. We purposively selected 24 clinics offering PrEP services under fully programmatic conditions in Kisumu County, Kenya. At baseline, unannounced SP 'mystery shoppers' present to clinics portraying AGYW in common PrEP scenarios for a cross-sectional assessment of PrEP delivery. Twelve facilities will be randomised to receive a 2-day training intervention, consisting of lectures, role-playing with SPs and group debriefing. Unannounced SPs will repeat the assessment in all 24 sites following the intervention. The primary outcome is quality of PrEP counselling, including adherence to national guidelines and communication skills, scored on a checklist by SPs blinded to intervention assignment. An intention-to-treat (ITT) analysis will evaluate whether the intervention resulted in higher scores within intervention compared with control facilities, adjusted for baseline SP scores and accounting for clustering by facility. We hypothesise that the intervention will improve quality of PrEP counselling compared with standard of care. Results from this study will inform guidelines for PrEP delivery to AGYW in low-resource settings and offer a potentially scalable strategy to improve service delivery for this high-risk group. ETHICS AND DISSEMINATION The protocol was approved by institutional review boards at Kenyatta National Hospital and University of Washington. An external advisory committee monitors social harms. Results will be disseminated through peer-reviewed journals and presentations. TRIAL REGISTRATION NUMBER NCT03875950.
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Affiliation(s)
- Anna Larsen
- Department of Global Health, University of Washington, Seattle, Washington, USA
- Department of Epidemiology, University of Washington, Seattle, Washington, USA
| | - Kate S Wilson
- Department of Global Health, University of Washington, Seattle, Washington, USA
| | - John Kinuthia
- Department of Global Health, University of Washington, Seattle, Washington, USA
- Research and Programs, Kenyatta National Hospital/University of Nairobi, Nairobi, Kenya
| | - G John-Stewart
- Department of Epidemiology, University of Washington, Seattle, Washington, USA
- Department of Medicine, University of Washington, Seattle, Washington, USA
- Department of Pediatrics, University of Washington, Seattle, WA, United States
| | - B A Richardson
- Department of Biostatistics, University of Washington, Seattle, WA, United States
| | - Jillian Pintye
- Department of Global Health, University of Washington, Seattle, Washington, USA
| | - Felix Abuna
- Research and Programs, Kenyatta National Hospital/University of Nairobi, Nairobi, Kenya
| | - Harison Lagat
- Research and Programs, Kenyatta National Hospital/University of Nairobi, Nairobi, Kenya
| | - Tamara Owens
- Health Sciences Simulation & Clinical Skills Center, Howard University, Seattle, Washington, DC, USA
| | - Pamela Kohler
- Department of Child, Family, and Population Health Nursing, University of Washington, Seattle, Washington, USA
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Were D, Musau A, Mutegi J, Ongwen P, Manguro G, Kamau M, Marwa T, Gwaro H, Mukui I, Plotkin M, Reed J. Using a HIV prevention cascade for identifying missed opportunities in PrEP delivery in Kenya: results from a programmatic surveillance study. J Int AIDS Soc 2020; 23 Suppl 3:e25537. [PMID: 32602658 PMCID: PMC7325512 DOI: 10.1002/jia2.25537] [Citation(s) in RCA: 32] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2019] [Revised: 03/20/2020] [Accepted: 05/07/2020] [Indexed: 12/20/2022] Open
Abstract
INTRODUCTION HIV prevention cascades have been systematically evaluated in high-income countries, but steps in the pre-exposure prophylaxis (PrEP) service delivery cascade have not been systematically quantified in sub-Saharan Africa. We analysed missed opportunities in the PrEP cascade in a large-scale project serving female sex workers (FSW), men who have sex with men (MSM) and adolescent girls and young women (AGYW) in Kenya. METHODS Programmatic surveillance was conducted using routine programme data from 89 project-supported sites from February 2017 to December 2019, and complemented by qualitative data. Healthcare providers used nationally approved tools to document service statistics. The analyses examined proportions of people moving onto the next step in the PrEP continuum, and identified missed opportunities. Missed opportunities were defined as implementation gaps exemplified by the proportion of individuals who could have potentially accessed each step of the PrEP cascade and did not. We also assessed trends in the cascade indicators at monthly intervals. Qualitative data were collected through 28 focus group discussions with 241 FSW, MSM, AGYW and healthcare providers, and analysed thematically to identify reasons underpinning the missed opportunities. RESULTS During the study period, 299,798 individuals tested HIV negative (211,927 FSW, 47,533 MSM and 40,338 AGYW). Missed opportunities in screening for PrEP eligibility was 58% for FSW, 45% for MSM and 78% for AGYW. Of those screened, 28% FSW, 25% MSM and 65% AGYW were ineligible. Missed opportunities for PrEP initiation were lower among AGYW (8%) compared to FSW (72%) and MSM (75%). Continuation rates were low across all populations at Month-1 (ranging from 29% to 32%) and Month-3 (6% to 8%). Improvements in average annual Month-1 (from 26% to 41%) and Month-3 (from 4% to 15%) continuation rates were observed between 2017 and 2019. While initiation rates were better among younger FSW, MSM and AGYW (<30 years), the reverse was true for continuation. CONCLUSIONS The application of a PrEP cascade framework facilitated this large-scale oral PrEP programme to conduct granular programmatic analysis, detecting "leaks" in the cascade. These informed programme adjustments to mitigate identified gaps resulting in improvement of selected programmatic outcomes. PrEP programmes are encouraged to introduce the cascade analysis framework into new and existing programming to optimize HIV prevention outcomes.
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Affiliation(s)
| | | | | | | | | | | | | | | | - Irene Mukui
- National AIDS and STI Control ProgramNairobiKenya
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Holmes LE, Kaufman MR, Casella A, Mudavanhu M, Mutunga L, Polzer T, Bassett J, Van Rie A, Schwartz S. Qualitative characterizations of relationships among South African adolescent girls and young women and male partners: implications for engagement across HIV self-testing and pre-exposure prophylaxis prevention cascades. J Int AIDS Soc 2020; 23 Suppl 3:e25521. [PMID: 32603025 PMCID: PMC7325584 DOI: 10.1002/jia2.25521] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2019] [Revised: 03/22/2020] [Accepted: 04/23/2020] [Indexed: 12/23/2022] Open
Abstract
INTRODUCTION Adolescent girls and young women (AGYW) in sub-Saharan Africa have emerged as a priority population in need of HIV prevention interventions. Secondary distribution of home-based HIV self-test kits by AGYW to male partners (MP) is a novel prevention strategy that complements pre-exposure prophylaxis (PrEP), a female-controlled prevention intervention. The objective of this analysis was to qualitatively operationalize two HIV prevention cascades through the lens of relationship dynamics for secondary distribution of HIV self-tests to MP and PrEP for AGYW. METHODS From April 2018 to December 2018, 2200 HIV-negative AGYW aged 16-24 years were enrolled into an HIV prevention intervention which involved secondary distribution of self-tests to MP and PrEP for AGYW; of these women, 91 participants or MP were sampled for in-depth interviews based on their degree of completion of the two HIV prevention cascades. A grounded theory approach was used to characterize participants' relationship profiles, which were mapped to participants' engagement with the interventions. RESULTS In cases where AGYW had a MP with multiple partners, AGYW perceived both interventions as inviting distrust into the relationship and insinuating non-monogamy. Many chose not to accept either intervention, while others accepted and attempted to deliver the self-test kit but received a negative reaction from their MP. In the few cases where AGYW held multiple partnerships, both interventions were viewed as mechanisms for protecting one's health, and these AGYW exhibited confidence in accepting and delivering the self-test kits and initiating PrEP. Women who indicated intimate partner violence experiences chose not to accept either intervention because they feared it would elicit a violent reaction from their MP. For AGYW in relationships described as committed and emotionally open, self-test kit delivery was completed with ease, but PrEP was viewed as unnecessary. MP experience with the cascade corroborated AGYW perspectives and demonstrated how men can perceive female-initiated HIV prevention options as beneficial for AGYW and a threat to MP masculinity. CONCLUSIONS Screening to identify AGYW relationship dynamics can support tailoring prevention services to relationship-driven barriers and facilitators. HIV prevention counseling for AGYW should address relationship goals or partner's influence, and engage with MP around female-controlled prevention interventions.
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Affiliation(s)
- Leah E Holmes
- Department of EpidemiologyJohns Hopkins Bloomberg School of Public HealthBaltimoreMDUSA
| | - Michelle R Kaufman
- Department of Health. Behavior & SocietyJohns Hopkins Bloomberg School of Public HealthBaltimoreMDUSA
| | - Albert Casella
- Department of Health. Behavior & SocietyJohns Hopkins Bloomberg School of Public HealthBaltimoreMDUSA
| | | | | | - Tara Polzer
- Social Surveys AfricaJohannesburgSouth Africa
| | - Jean Bassett
- Witkoppen Health and Welfare ClinicJohannesburgSouth Africa
| | - Annelies Van Rie
- Department of Epidemiology and Social MedicineUniversity of AntwerpAntwerpBelgium
| | - Sheree Schwartz
- Department of EpidemiologyJohns Hopkins Bloomberg School of Public HealthBaltimoreMDUSA
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Kidman R, Nachman S, Kohler HP. Interest in HIV pre-exposure prophylaxis (PrEP) among adolescents and their caregivers in Malawi. AIDS Care 2020; 32:23-31. [PMID: 32178529 PMCID: PMC8073398 DOI: 10.1080/09540121.2020.1742861] [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: 06/20/2019] [Accepted: 03/09/2020] [Indexed: 10/24/2022]
Abstract
Over a third of new HIV infections occur in adolescents aged 10-19 globally. Pre-exposure prophylaxis (PrEP) could be a powerful tool for prevention. Understanding more about the drivers of PrEP interest could inform implementation strategies among this age group. Moreover, family dynamics may play a uniquely critical role for this younger age group, thus it is important to gauge whether caregivers would support their children's use of PrEP. We surveyed 2,089 adolescents (aged 10-16) and their caregivers in Malawi during 2017-2018. Data were collected on PrEP interest, factors that may facilitate PrEP use, and preferences for PrEP modality. We used multivariate logistic regression to estimate the association between the above characteristics and PrEP interest. We find that young adolescents are engaging in behaviors that would put them at substantial risk of acquiring HIV, would likely benefit from PrEP, are largely (82%) interested in using such, would prefer to get an injection over taking a daily pill, and are considerably discouraged by the prospect of side effects. Endorsement by caregivers was even greater (87%). Our findings demonstrate initial support for adolescent PrEP, and suggest parents may be a surprising advocate.
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Affiliation(s)
- Rachel Kidman
- Program in Public Health and Department of Family, Population and Preventive Medicine, Stony Brook University (State University of New York), Stony Brook, USA
| | - Sharon Nachman
- Department of Pediatrics, Stony Brook University (State University of New York), Stony Brook, USA
| | - Hans-Peter Kohler
- Department of Sociology and Population Studies Center, University of Pennsylvania, Philadelphia, USA
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Begnel ER, Escudero J, Mugambi M, Mugwanya K, Kinuthia J, Beima-Sofie K, Dettinger JC, Baeten JM, John-Stewart G, Pintye J. High pre-exposure prophylaxis awareness and willingness to pay for pre-exposure prophylaxis among young adults in Western Kenya: results from a population-based survey. Int J STD AIDS 2020; 31:454-459. [PMID: 32208816 DOI: 10.1177/0956462420912141] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
We conducted a population-level short message service (SMS)-based survey among individuals aged 18–34 years in six HIV high-burden counties in Western Kenya to assess pre-exposure prophylaxis (PrEP) awareness, acceptability of non-facility PrEP delivery, and willingness to pay for PrEP. In January 2019, anonymous data were collected using mSurvey Inc., Nairobi, Kenya, which sends SMS messages via mobile provider networks to a ‘general audience’ pool of subscribers ≥18 years. Subscribers’ demographic information was matched to Kenyan census data by age, gender, and county. Of the 3825 individuals who received the survey, 2617 (68%) opened the survey and 2498/2617 (95%) completed all questions. Overall, 84% had ever heard of PrEP, of whom 59% demonstrated understanding of PrEP; understanding was greater among men than women (64% versus 55%, p < 0.001). Among participants who understood PrEP (n = 1249), 38% reported pharmacies (informal or formal) as the preferred venue to obtain PrEP. Over half (61%) were willing to pay for PrEP and 78% reported that the maximum amount they were willing to pay for a one-month supply was <5 USD. High awareness of PrEP in high HIV prevalence settings in Kenya suggests effective public health messaging. Willingness to pay and preference for pharmacy access suggest that non-facility PrEP delivery may be useful.
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Affiliation(s)
- Emily R Begnel
- Department of Global Health, University of Washington, Seattle, WA, USA
| | - Jaclyn Escudero
- Department of Global Health, University of Washington, Seattle, WA, USA
| | - Melissa Mugambi
- Department of Global Health, University of Washington, Seattle, WA, USA
| | - Kenneth Mugwanya
- Department of Global Health, University of Washington, Seattle, WA, USA
| | - John Kinuthia
- Department of Global Health, University of Washington, Seattle, WA, USA.,Department of Obstetrics/Gynecology, Kenyatta National Hospital, Nairobi, Kenya
| | | | - Julia C Dettinger
- Department of Global Health, University of Washington, Seattle, WA, USA
| | - Jared M Baeten
- Department of Global Health, University of Washington, Seattle, WA, USA.,Department of Epidemiology, University of Washington, Seattle, WA, USA.,Department of Medicine, University of Washington, Seattle, WA, USA
| | - Grace John-Stewart
- Department of Global Health, University of Washington, Seattle, WA, USA.,Department of Epidemiology, University of Washington, Seattle, WA, USA.,Department of Medicine, University of Washington, Seattle, WA, USA.,Department of Pediatrics, University of Washington, Seattle, WA, USA
| | - Jillian Pintye
- Department of Global Health, University of Washington, Seattle, WA, USA
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Gutin SA, Harper GW, Amico KR, Bitsang C, Moshashane N, Harries J, Ramogola-Masire D, Morroni C. 'I'm waiting for that': Interest in the use of PrEP for safer conception in Botswana. Glob Public Health 2020; 15:1200-1211. [PMID: 32175819 DOI: 10.1080/17441692.2020.1741663] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
Safe and effective low-cost safer conception (SC) methods are increasingly available and being integrated into national guidelines in sub-Saharan African contexts. Sero-different couples of childbearing age can benefit from such services and the routine provision of SC counselling. Pre-exposure prophylaxis (PrEP) to prevent HIV acquisition to uninfected partners can reduce the chances of HIV transmission when trying to achieve pregnancy. Botswana has a strong commitment to reducing new HIV infections but PrEP is not yet widely available and little guidance has been offered on counselling sero-different couples. We conducted qualitative in-depth interviews in Gaborone, Botswana with 10 HIV healthcare providers and 10 women living with HIV of childbearing age because they act as a key conduit for reaching sero-different partners with information about PrEP. We examined knowledge and attitudes towards PrEP to assess the viability and develop a deeper understanding of this SC option. Interviews were analysed using an interpretive phenomenological approach. Three themes emerged: (1) awareness of PrEP is limited, (2) providers and women overwhelmingly showed interest in PrEP and (3) women living with HIV and providers have concerns about PrEP use. With the correct support, PrEP could be a useful SC option for sero-different couples in Botswana and other sub-Saharan contexts.
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Affiliation(s)
- Sarah A Gutin
- Department of Health Behavior and Health Education, School of Public Health, University of Michigan, Ann Arbor, MI, USA.,Women's Health Research Unit, School of Public Health and Family Medicine, Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa.,Center for AIDS Prevention Studies, Division of Prevention Science, University of California, San Francisco, San Francisco, CA, USA
| | - Gary W Harper
- Department of Health Behavior and Health Education, School of Public Health, University of Michigan, Ann Arbor, MI, USA
| | - K Rivet Amico
- Department of Health Behavior and Health Education, School of Public Health, University of Michigan, Ann Arbor, MI, USA
| | - Christina Bitsang
- Career and Counseling Services, University of Botswana, Gaborone, Botswana
| | | | - Jane Harries
- Women's Health Research Unit, School of Public Health and Family Medicine, Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa
| | - Doreen Ramogola-Masire
- Department of Obstetrics and Gynecology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA.,Department of Obstetrics and Gynecology, Faculty of Medicine, University of Botswana, Gaborone, Botswana
| | - Chelsea Morroni
- Women's Health Research Unit, School of Public Health and Family Medicine, Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa.,Botswana U-Penn Partnership, Gaborone, Botswana.,Liverpool School of Tropical Medicine, Liverpool, UK
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Abstract
Purpose of Review Clinical trials have found that PrEP is highly effective in reducing risk of HIV acquisition across types of exposure, gender, PrEP regimens, and dosing schemes. Evidence is urgently needed to inform scale-up of PrEP to meet the ambitious WHO/UNAIDS prevention target of 3,000,000 individuals on PrEP by 2020. Recent Findings Successful models of delivering HIV services at scale evolved from years of formal research and programmatic evidence. These efforts produced lessons-learned relevant for scaling-up PrEP delivery, including the importance of streamlining laboratory tests, expanding prescription and management authority, differentiating medication access points, and reducing stigma and barriers of parental consent for PrEP uptake. Further research is especially needed in areas differentiating PrEP from ART delivery, including repeat HIV testing to ensure HIV negative status and defining and measuring prevention-effective adherence. Summary Evidence from 15 years of ART scale-up could immediately inform a public health approach to PrEP delivery.
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Abstract
PURPOSE OF REVIEW Pre-exposure prophylaxis (PrEP) is highly efficacious for preventing HIV. Demonstrations worldwide show growing acceptability with nonoral formulations in the pipeline. Despite these successes, oral PrEP scale-up in sub-Saharan Africa (SSA), the region hardest hit by HIV, remains sub-optimal. This review details emerging practises and addresses challenges in PrEP scale-up and delivery within SSA. RECENT FINDINGS PrEP scale-up varies across SSA. Some countries face implementation challenges, whereas most have not applied for or received regulatory approval. As governments balance treatment and prevention costs, PrEP advocacy is growing. Demand has been slow, because of low-risk perception, HIV treatment conflation or poor information. Challenges in SSA are markedly different than elsewhere, as delivery is targeted to generalized heterosexuals, rather than only key populations. SSA requires public sector engagement and innovative delivery platforms. SUMMARY PrEP scale-up in SSA is sub-optimal, hindered by regulatory processes, implementation challenges, poor community engagement and inadequate funding. Approaches that acknowledge overburdened, under-resourced health sectors, and seek opportunities to integrate, task-shift, decentralize and even de-medicalize, with a tailored approach, while campaigning to educate and stimulate demand are most likely to work. Solutions to oral PrEP scale-up will apply to other formulations, opening new avenues for ARV (microbicides and injectables) and non-ARV-based (future vaccine) biomedical prevention provision.
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Adeagbo OA, Mthiyane N, Herbst C, Mee P, Neuman M, Dreyer J, Chimbindi N, Smit T, Okesola N, Johnson C, Hatzold K, Seeley J, Cowan F, Corbett L, Shahmanesh M. Cluster randomised controlled trial to determine the effect of peer delivery HIV self-testing to support linkage to HIV prevention among young women in rural KwaZulu-Natal, South Africa: a study protocol. BMJ Open 2019; 9:e033435. [PMID: 31874891 PMCID: PMC7008432 DOI: 10.1136/bmjopen-2019-033435] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/09/2023] Open
Abstract
INTRODUCTION A cluster randomised controlled trial (cRCT) to determine whether HIV self-testing (HIVST) delivered by peers either directly or through incentivised peer-networks, could increase the uptake of antiretroviral therapy and pre-exposure prophylaxis (PrEP) among young women (18 to 24 years) is being undertaken in an HIV hyperendemic area in KwaZulu-Natal, South Africa. METHODS AND ANALYSIS A three-arm cRCT started mid-March 2019, in 24 areas in rural KwaZulu-Natal. Twenty-four pairs of peer navigators working with ~12 000 young people aged 18 to 30 years over a period of 6 months were randomised to: (1) incentivised-peer-networks: peer-navigators recruited participants 'seeds' to distribute up to five HIVST packs and HIV prevention information to peers within their social networks. Seeds receive an incentive (20 Rand = US$1.5) for each respondent who contacts a peer-navigator for additional HIVST packs to distribute; (2) peer-navigator-distribution: peer-navigators distribute HIVST packs and information directly to young people; (3) standard of care: peer-navigators distribute referral slips and information. All arms promote sexual health information and provide barcoded clinic referral slips to facilitate linkage to HIV testing, prevention and care services. The primary outcome is the difference in linkage rate between arms, defined as the number of women (18 to 24 years) per peer-navigators month of outreach work (/pnm) who linked to clinic-based PrEP eligibility screening or started antiretroviral, based on HIV-status, within 90 days of receiving the clinic referral slip. ETHICS AND DISSEMINATION This study was approved by the Institutional Review Boards at the WHO, Switzerland (Protocol ID: STAR CRT, South Africa), London School of Hygiene and Tropical Medicine, UK (Reference: 15 990-1), University of KwaZulu-Natal (BFC311/18) and the KwaZulu-Natal Department of Health (Reference: KZ_201901_012), South Africa. The findings of this trial will be disseminated at local, regional and international meetings and through peer-reviewed publications. TRIAL REGISTRATION NUMBER NCT03751826; Pre-results.
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Affiliation(s)
- Oluwafemi Atanda Adeagbo
- Africa Health Research Institute, Mtubatuba, KwaZulu-Natal, South Africa
- Sociology, University of Johannesburg, Auckland Park, Gauteng, South Africa
| | - Nondumiso Mthiyane
- Africa Health Research Institute, Mtubatuba, KwaZulu-Natal, South Africa
| | - Carina Herbst
- Africa Health Research Institute, Mtubatuba, KwaZulu-Natal, South Africa
| | - Paul Mee
- Epidemiology and Public Health, London School of Hygiene and Tropical Medicine, London, UK
| | - Melissa Neuman
- Epidemiology and Public Health, London School of Hygiene and Tropical Medicine, London, UK
| | - Jaco Dreyer
- Africa Health Research Institute, Mtubatuba, KwaZulu-Natal, South Africa
| | - Natsayi Chimbindi
- Africa Health Research Institute, Mtubatuba, KwaZulu-Natal, South Africa
| | - Theresa Smit
- Africa Health Research Institute, Mtubatuba, KwaZulu-Natal, South Africa
| | - Nonhlanhla Okesola
- Africa Health Research Institute, Mtubatuba, KwaZulu-Natal, South Africa
| | - Cheryl Johnson
- Department of HIV/AIDS, World Health Organization, Geneva, Switzerland
| | | | - Janet Seeley
- Africa Health Research Institute, Mtubatuba, KwaZulu-Natal, South Africa
- Public Health and Policy, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Frances Cowan
- International Public Health, Liverpool School of Tropical Medicine, Liverpool, UK
- CeSHHAR Zimbabwe, Harare, Zimbabwe
| | - Liz Corbett
- Infectious and Tropical Diseases, London School of Hygiene and Tropical Medicine, London, UK
| | - Maryam Shahmanesh
- Africa Health Research Institute, Mtubatuba, KwaZulu-Natal, South Africa
- Institute for Global Health, University College London, London, UK
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Stangl AL, Lilleston P, Mathema H, Pliakas T, Krishnaratne S, Sievwright K, Bell‐Mandla N, Vermaak R, Mainga T, Steinhaus M, Donnell D, Schaap A, Bock P, Ayles H, Hayes R, Hoddinott G, Bond V, Hargreaves JR. Development of parallel measures to assess HIV stigma and discrimination among people living with HIV, community members and health workers in the HPTN 071 (PopART) trial in Zambia and South Africa. J Int AIDS Soc 2019; 22:e25421. [PMID: 31840400 PMCID: PMC6912047 DOI: 10.1002/jia2.25421] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2019] [Accepted: 10/23/2019] [Indexed: 12/22/2022] Open
Abstract
INTRODUCTION Integrating standardized measures of HIV stigma and discrimination into research studies of emerging HIV prevention approaches could enhance uptake and retention of these approaches, and care and treatment for people living with HIV (PLHIV), by informing stigma mitigation strategies. We sought to develop a succinct set of measures to capture key domains of stigma for use in research on HIV prevention technologies. METHODS From 2013 to 2015, we collected baseline data on HIV stigma from three populations (PLHIV (N = 4053), community members (N = 5782) and health workers (N = 1560)) in 21 study communities in South Africa and Zambia participating in the HPTN 071 (PopART) cluster-randomized trial. Forty questions were adapted from a harmonized set of measures developed in a consultative, global process. Informed by theory and factor analysis, we developed seven scales, with values ranging from 0 to 3, based on a 4-point agreement Likert, and calculated means to assess different aspects of stigma. Higher means reflected more stigma. We developed two measures capturing percentages of PLHIV who reported experiencing any stigma in communities or healthcare settings in the past 12 months. We validated our measures by examining reliability using Cronbach's alpha and comparing the distribution of responses across characteristics previously associated with HIV stigma. RESULTS Thirty-five questions ultimately contributed to seven scales and two experience measures. All scales demonstrated acceptable to very good internal consistency. Among PLHIV, a scale captured internalized stigma, and experience measures demonstrated that 22.0% of PLHIV experienced stigma in the community and 7.1% in healthcare settings. Three scales for community members assessed fear and judgement, perceived stigma in the community and perceived stigma in healthcare settings. Similarly, health worker scales assessed fear and judgement, perceived stigma in the community and perceived co-worker stigma in healthcare settings. A higher proportion of community members and health workers reported perceived stigma than the proportion of PLHIV who reported experiences of stigma. CONCLUSIONS We developed novel, valid measures that allowed for triangulation of HIV stigma across three populations in a large-scale study. Such comparisons will illuminate how stigma influences and is influenced by programmatic changes to HIV service delivery over time.
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Affiliation(s)
- Anne L Stangl
- International Center for Research on WomenWashingtonDCUSA
| | | | - Hlengani Mathema
- Desmond Tutu TB CentreDepartment of Paediatrics and Child HealthFaculty of Medicine and Health SciencesStellenbosch UniversityCape TownSouth Africa
- Division of Public Health Surveillance and ResponseNational Institute for Communicable DiseasesNational Health Laboratory ServiceJohannesburgSouth Africa
| | | | | | | | - Nomhle Bell‐Mandla
- Desmond Tutu TB CentreDepartment of Paediatrics and Child HealthFaculty of Medicine and Health SciencesStellenbosch UniversityCape TownSouth Africa
| | - Redwaan Vermaak
- Desmond Tutu TB CentreDepartment of Paediatrics and Child HealthFaculty of Medicine and Health SciencesStellenbosch UniversityCape TownSouth Africa
| | - Tila Mainga
- ZambartSchool of MedicineUniversity of ZambiaLusakaZambia
| | - Mara Steinhaus
- International Center for Research on WomenWashingtonDCUSA
| | | | - Ab Schaap
- London School of Hygiene and Tropical MedicineLondonUnited Kingdom
- ZambartSchool of MedicineUniversity of ZambiaLusakaZambia
| | - Peter Bock
- Desmond Tutu TB CentreDepartment of Paediatrics and Child HealthFaculty of Medicine and Health SciencesStellenbosch UniversityCape TownSouth Africa
| | - Helen Ayles
- London School of Hygiene and Tropical MedicineLondonUnited Kingdom
- ZambartSchool of MedicineUniversity of ZambiaLusakaZambia
| | - Richard Hayes
- London School of Hygiene and Tropical MedicineLondonUnited Kingdom
| | - Graeme Hoddinott
- Desmond Tutu TB CentreDepartment of Paediatrics and Child HealthFaculty of Medicine and Health SciencesStellenbosch UniversityCape TownSouth Africa
| | - Virginia Bond
- London School of Hygiene and Tropical MedicineLondonUnited Kingdom
- ZambartSchool of MedicineUniversity of ZambiaLusakaZambia
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Tugume L, Muwonge TR, Joloba EN, Isunju JB, Kiweewa FM. Perceived risk versus objectively measured risk of HIV acquisition: a cross-sectional study among HIV-negative individuals in Serodiscordant partnerships with clients attending an Urban Clinic in Uganda. BMC Public Health 2019; 19:1591. [PMID: 31783826 PMCID: PMC6884744 DOI: 10.1186/s12889-019-7929-0] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2019] [Accepted: 11/08/2019] [Indexed: 01/13/2023] Open
Abstract
Background Acceptability of Pre-exposure Prophylaxis (PrEP) could be hampered by low self-perceived risk for HIV acquisition. Moreover, discordance between risk perception and actual risk of HIV acquisition is likely to occur. We assessed congruence between the level of self- perceived and that of objectively scored risk of HIV acquisition among HIV-negative individuals in discordant relationships. Methods This was a cross-sectional study among a representative sample of HIV-negative adult males and females whose partners were receiving antiretroviral therapy for at least 3 months from the Infectious Diseases Institute Clinic in Kampala, Uganda. Perceived risk was measured based on self-report using a numerical rating scale whereas objective risk was measured using a validated risk score tool. Congruence between perceived risk and objectively scored risk was evaluated using descriptive statistics and validity measures. Incongruence between the two phenomena was further evaluated using univariate and multivariate regression analyses. Results HIV-negative partners evaluated in this study were mostly male (64%) with a median age of 41 years (IQR 35 to 50). Majority (76.3%) of the partners perceived themselves as low risk for HIV acquisition. Similarly, most (93.8%) were objectively scored as low risk. However, nearly three quarters (72.7%) of partners who were objectively scored as high risk perceived themselves as being at low risk and all were men. The sensitivity and specificity of perceived risk for detecting the objectively measured risk was 27.3 and 76.5% respectively; area under ROC curve = 0.52; 95%CI (0.38, 0.66). The proportion of participants at high risk of HIV acquisition who perceived their risk as low was greater among those whose partners had detectable viral load compared to participants whose partners had undetectable viral load (PR = 0.51; 95%CI 0.29 to 0.90). Conclusion Incongruence between perceived and objectively measured risk of HIV acquisition does occur especially among individuals whose partners had a detectable viral load. PrEP counselling for serodiscordant couples should focus on explaining the consequence of detectable viral load in the HIV-positive partner on HIV transmission risk.
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Affiliation(s)
- Lillian Tugume
- Makerere University College of Health Sciences, School of Public Health, Kampala, Uganda. .,Infectious Diseases Institute, Makerere University, Kampala, Uganda.
| | | | - Edith Nakku Joloba
- Makerere University College of Health Sciences, School of Public Health, Kampala, Uganda
| | - John Bosco Isunju
- Makerere University College of Health Sciences, School of Public Health, Kampala, Uganda
| | - Flavia Matovu Kiweewa
- Makerere University College of Health Sciences, School of Public Health, Kampala, Uganda.,Makerere University- John Hopkins University Research Collaboration, Kampala, Uganda
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Abstract
OBJECTIVES Assessment of safety is an integral part of real-time monitoring in clinical trials. In HIV prevention research, safety of investigational products and trial participation has been expanded to include monitoring for 'social harms', generally defined as negative consequences of trial participation that may manifest in social, psychological, or physical ways. Further research on social harms within HIV prevention research is needed to understand the potential safety risks for women and advance the implementation of prevention methods in real-world contexts. METHODS Secondary analysis of quantitative data from three randomized, double-blind, placebo-controlled trials of microbicide candidates in sub-Saharan Africa was conducted. Additionally, we assessed data from two prospective cohort studies that included participants who became HIV-positive or pregnant during parent trials. RESULTS Social harms reporting was low across the largest and most recent microbicide studies. Social harm incidence per 100 person-years ranged from 1.10 (95% CI 0.78-1.52) to 3.25 (95% CI 2.83-3.74) in the phased trials. Reporting differed by dosing mechanism (e.g. vaginal gel, oral tablet, ring) and study, most likely as a function of measurement differences. Social harms were most frequently associated with male partners, rather than, for example, experiences of stigma in the community. CONCLUSION Measurement and screening for social harms is an important component of conducting ethical research of novel HIV prevention methods. To date, social harm incidence reported in microbicide trials has been relatively low (<4% per 100 person-years), and the majority have been partner-related events. However, any incidence of social harm within the context of HIV prevention is important to capture and understand for the safety of individuals, and for the successful impact of prevention methods in a real-world context.
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Characterizing Sociostructural Associations With New HIV Diagnoses Among Female Sex Workers in Cameroon. J Acquir Immune Defic Syndr 2019; 80:e64-e73. [PMID: 30762674 DOI: 10.1097/qai.0000000000001920] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
BACKGROUND Female sex workers (FSW) are disproportionately affected by HIV in Cameroon, with an estimated 23.6% HIV prevalence. Given the unavailability of HIV incidence data, to better understand associations with acquiring HIV we assessed the prevalence and associations with new HIV diagnoses among FSW in Cameroon. METHODS In 2016, FSW were recruited through respondent-driven sampling from 5 cities for a biobehavioral survey. Participants self-reporting living with HIV or with an indeterminate test status were excluded from analysis. New diagnoses were defined as testing HIV-positive when participants self-reported HIV-negative or unknown status. A multivariable modified Poisson regression model was developed to assess determinants of new HIV diagnosis (referent group: HIV-negative) using key covariates; adjusted prevalence ratios (aPR) are reported if statistically significant (P < 0.05). RESULTS Overall 2255 FSW were recruited. Excluding participants who self-reported living with HIV (n = 297) and indeterminate test results (n = 7), 260/1951 (13.3%) FSW were newly diagnosed with HIV. Variables significantly associated with new HIV diagnosis were: no secondary/higher education [aPR: 1.56, 95% confidence interval (CI): 1.12 to 2.15], 5+ dependents compared with none (aPR: 2.11, 95% CI: 1.01 to 4.40), 5+ years involved in sex work compared with <1 year (aPR: 2.84, 95% CI: 1.26 to 6.42), history of incarceration (aPR: 2.13, 95% CI: 1.13 to 3.99), and low social capital (aPR: 1.53, 95% CI: 1.12 to 2.10). Higher monthly income (>250,000 FCFA vs. <50,000 FCFA) was associated with lower prevalence of new HIV diagnosis (aPR: 0.22, 95% CI: 0.05 to 0.86). CONCLUSIONS There are significant sociostructural factors that seem to potentiate risk of HIV infection and delay diagnosis among FSW in Cameroon. Initiatives to build social capital and integrate services such as pre-exposure prophylaxis and HIV self-testing into HIV programs may reduce new infections and decrease time to diagnosis and treatment.
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Zimba C, Maman S, Rosenberg NE, Mutale W, Mweemba O, Dunda W, Phanga T, Chibwe KF, Matenga T, Freeborn K, Schrubbe L, Vwalika B, Chi BH. The landscape for HIV pre-exposure prophylaxis during pregnancy and breastfeeding in Malawi and Zambia: A qualitative study. PLoS One 2019; 14:e0223487. [PMID: 31584987 PMCID: PMC6777778 DOI: 10.1371/journal.pone.0223487] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2019] [Accepted: 09/23/2019] [Indexed: 01/16/2023] Open
Abstract
High HIV incidence rates have been observed among pregnant and breastfeeding women in sub-Saharan Africa. Oral pre-exposure prophylaxis (PrEP) can effectively reduce HIV acquisition in women during these periods; however, understanding of its acceptability and feasibility in antenatal and postpartum populations remains limited. To address this gap, we conducted in-depth interviews with 90 study participants in Malawi and Zambia: 39 HIV-negative pregnant/breastfeeding women, 14 male partners, 19 healthcare workers, and 18 policymakers. Inductive and deductive approaches were used to identify themes related to PrEP. As a public health intervention, PrEP was not well-known among patients and healthcare workers; however, when it was described to participants, most expressed positive views. Concerns about safety and adherence were raised, highlighting two critical areas for community outreach. The feasibility of introducing PrEP into antenatal services was also a concern, especially if introduced within already strained health systems. Support for PrEP varied among policymakers in Malawi and Zambia, reflecting the ongoing policy discussions in their respective countries. Implementing PrEP during the pregnancy and breastfeeding periods will require addressing barriers at the individual, facility, and policy levels. Multi- level approaches should be considered in the design of new PrEP programs for antenatal and postpartum populations.
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Affiliation(s)
- Chifundo Zimba
- UNC Project-Malawi, Tidziwe Center, Lilongwe, Malawi
- * E-mail:
| | - Suzanne Maman
- Department of Health Behavior, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, United States of America
| | - Nora E. Rosenberg
- Department of Health Behavior, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, United States of America
| | - Wilbroad Mutale
- Department of Health Policy, School of Public Health, University of Zambia, Ridgeway Campus, Lusaka, Zambia
| | - Oliver Mweemba
- Department of Health Promotion and Education, School of Public Health, University of Zambia, Ridgeway Campus, Lusaka, Zambia
| | - Wezzie Dunda
- UNC Project-Malawi, Tidziwe Center, Lilongwe, Malawi
| | | | - Kasapo F. Chibwe
- Department of Health Promotion and Education, School of Public Health, University of Zambia, Ridgeway Campus, Lusaka, Zambia
| | - Tulani Matenga
- Department of Health Promotion and Education, School of Public Health, University of Zambia, Ridgeway Campus, Lusaka, Zambia
| | - Kellie Freeborn
- Department of Obstetrics and Gynecology, School of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, United States of America
| | - Leah Schrubbe
- Department of Obstetrics and Gynecology, School of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, United States of America
| | - Bellington Vwalika
- Department of Obstetrics and Gynecology, School of Medicine, University of Zambia, Ridgeway Campus, Lusaka, Zambia
| | - Benjamin H. Chi
- Department of Obstetrics and Gynecology, School of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, United States of America
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Tolley EE, Li S, Zangeneh SZ, Atujuna M, Musara P, Justman J, Pathak S, Bekker L, Swaminathan S, Stanton J, Farrior J, Sista N. Acceptability of a long-acting injectable HIV prevention product among US and African women: findings from a phase 2 clinical Trial (HPTN 076). J Int AIDS Soc 2019; 22:e25408. [PMID: 31651098 PMCID: PMC6813716 DOI: 10.1002/jia2.25408] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2019] [Accepted: 10/02/2019] [Indexed: 12/20/2022] Open
Abstract
INTRODUCTION High HIV incidence and low adherence to daily oral PrEP among women underscore the need for more acceptable and easier to use HIV prevention products. Global demand for injectable contraception suggests that new, long-acting, injectable formulations could meet this need. We examine acceptability of a long-acting injectable PrEP among HIV-uninfected women in Zimbabwe, South Africa and two United States phase 2 trial sites. METHODS Quantitative surveys were administered at the first, fourth and sixth injection visits. Focus group discussions (FGD) were conducted after the sixth injection visit. We compared the acceptability of injectable product attributes, prevention preferences and future interest in injectable PrEP by site and arm and ran longitudinal ordinal logistic regression models to identify determinants of future interest in injectable PrEP. RESULTS Between April 2015 and February 2017, the trial enrolled 136 (100 African, 36 US) women with a median age of 31 years. Most participants (>75%) rated injectable attributes as very acceptable. While few reported rash or other side effects, 56% to 67% reported injection pain, with nonsignificant differences over time and between arms. During FGDs, participants described initial fear of the injectable and variable experiences with pain. Most US and African participants preferred injectable PrEP to daily oral pills (56% to 96% vs. 4% to 25%). Future interest in using injectable PrEP was associated with acceptability of product attributes and was higher in African than US sites. In FGDs, participants described multiple reasons for trial participation, including a combination of monetary, health-related and altruistic motivations. While associated with future interest in use in univariate models, neither altruistic nor personal motivations remained significant in the multivariate model. CONCLUSIONS This study found that long-acting injectable PrEP is acceptable among African and US women experiencing product use. Acceptability of product attributes better predicted future interest in injectable use than experience of pain. This is reassuring as a single-dose regimen of a different product has advanced to phase 3 trials. Finally, the study suggests that future demand for an injectable PrEP by women may be greater in African than US settings, where the risk of HIV is highest.
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Affiliation(s)
| | - Sue Li
- Vaccine and Infectious Disease DivisionFred HutchSeattleWAUSA
| | | | | | | | | | - Subash Pathak
- Vaccine and Infectious Disease DivisionFred HutchSeattleWAUSA
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Contraception and PrEP in South African Hair Salons: Owner, Stylist, and Client Views. J Acquir Immune Defic Syndr 2019; 79:e78-e81. [PMID: 29985267 PMCID: PMC6143201 DOI: 10.1097/qai.0000000000001794] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
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Pelletier SJ, Gagnon MP, Diabaté S, Kra O, Biékoua YJ, Osso GD, Diané B, N’Dhatz-Ebagnitchié M, Ahouada C, Alary M. Pre-Exposure Prophylaxis (PrEP) in Men Who have Sex with Men in Bouaké, Côte d’Ivoire: A Qualitative Evaluation of Acceptability. Open AIDS J 2019. [DOI: 10.2174/1874613601913010049] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
Background:
HIV remains an important public health issue throughout the world. In Côte d’Ivoire, a high burden of HIV is observed in men who have sex with men (MSM).
Objective:
We assessed the acceptability of Pre-Exposure Prophylaxis (PrEP) among men who have sex with men (MSM) in Bouaké, Côte d’Ivoire.
Methods:
We conducted and analysed four focus groups with 31 HIV-negative MSM and eight in-depth individual interviews with participants recruited from the focus groups.
Results:
Four MSM (13%) were aware of PrEP before participating in the study. All the participants were interested in taking PrEP if available: 19 (61.3%) would prefer the daily regimen and 12 (38.7%) would opt for the on-demand regimen. Many advantages of PrEP were mentioned: protection in case of a condom break, protection in case of high-risk sexual behaviour, self-reliance, decreasing HIV fear and ease of use. Barriers to the use of PrEP included: it does not protect against other Sexually Transmitted Tnfections (STIs), taking a pill regularly is necessary, the size of the pill, possibility of side effects, the cost and accessibility. Six participants (19.3%) admitted that they would use condoms less if they take PrEP.
Conclusion:
Findings indicate that PrEP is acceptable within the MSM community. Implementation should be done rapidly, and PrEP should be part of a global prevention program which includes counselling, STI screening and promotion of safe sex practices. Health authorities should consider PrEP for all high-risk groups to avoid worsening stigmatization by targeting MSM only.
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Skovdal M. Facilitating engagement with PrEP and other HIV prevention technologies through practice-based combination prevention. J Int AIDS Soc 2019; 22 Suppl 4:e25294. [PMID: 31328412 PMCID: PMC6643071 DOI: 10.1002/jia2.25294] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2018] [Accepted: 05/08/2019] [Indexed: 12/18/2022] Open
Abstract
INTRODUCTION Recent years have witnessed a rapid expansion of efficacious biomedical HIV prevention technologies. Promising as they may be, they are largely delivered through standard, clinic-based models, often in isolation from structural and behavioural interventions. This contributes to varied, and often poor, uptake and adherence. There is a critical need to develop analytical tools that can advance our understandings and responses to the combination of interventions that affect engagement with HIV prevention technologies. This commentary makes a call for practice-based combination HIV prevention analysis and action, and presents a tool to facilitate this challenging but crucial endeavour. DISCUSSION Models and frameworks for combination HIV prevention already exist, but the process of identifying precisely what multi-level factors that need to be considered as part of a combination of HIV interventions for particular populations and settings is unclear. Drawing on contemporary social practice theory, this paper develops a "table of questioning" to help interrogate the chain and combination of multi-level factors that shape engagement with HIV prevention technologies. The tool also supports an examination of other shared social practices, which at different levels, and in different ways, affect engagement with HIV prevention technologies. It facilitates an analysis of the range of factors and social practices that need to be synchronized in order to establish engagement with HIV prevention technologies as a possible and desirable thing to do. Such analysis can help uncover local hitherto un-identified issues and provide a platform for novel synergistic approaches for action that are not otherwise obvious. The tool is discussed in relation to PrEP among adolescent girls and young women in sub-Saharan Africa. CONCLUSIONS By treating engagement with HIV prevention technologies as a social practice and site of analysis and public health action, HIV prevention service planners and evaluators can identify and respond to the combination of factors and social practices that interact to form the context that supports or prohibits engagement with HIV prevention technologies for particular populations.
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Affiliation(s)
- Morten Skovdal
- Department of Public HealthUniversity of CopenhagenCopenhagenDenmark
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