Perceptions of Pre-exposure Prophylaxis (PrEP) for HIV prevention among men living with HIV in the context of reproductive goals in South Africa: a qualitative study

BACKGROUND

Pre-exposure Prophylaxis (PrEP) and Treatment as Prevention (TasP) are effective strategies to prevent HIV transmission within serodifferent couples. However, limited usage of PrEP, knowledge and interest has been amongst the barriers for men, alongside testing and treatment adherence. We explored the perceptions of PreP for HIV prevention with Men living with HIV (MWH) who have reproductive goals, to understand awareness and experiences related to PrEP use in the context of HIV prevention with their partners.

METHODS

We undertook a qualitative study with 25 MWH aged 18 to 65 between April and September 2021 in South Africa. Potential participants were screened for eligibility and scheduled to participate in telephonic interviews. Interviews were audio recorded, transcribed, translated and thematically analysed.

RESULTS

Themes were organized into opportunities and barriers that men with HIV articulate as important for using PrEP to meet individual, couple, and community reproductive goals. At the individual level, some men were willing to discuss PrEP with their partners to protect their partners and babies from acquiring HIV. Lack of knowledge about PrEP among men was a potential barrier to promoting PrEP among their female partners. At the couple level, PrEP use was seen as a way to strengthen relationships between partners, signifying care, trust, and protection and was seen as a tool to help serodifferent couples meet their reproductive goals safely. At the community level, PrEP was viewed as a tool to promote HIV testing and prevention efforts, especially among men, but participants emphasized the need for more education and awareness.

CONCLUSION

Despite PrEP implementation in South Africa, awareness of PrEP among men with HIV in rural areas remains low. Engaging MWH to support their partners in accessing PrEP could be an innovative strategy to promote HIV prevention. Additionally, providing men with comprehensive reproductive health information can empower them to make more informed decisions, adopt safer sexual practices, and challenge societal norms and stigmas around HIV.

Adherence to daily, oral TDF/FTC PrEP during periconception among HIV-exposed South African women

Background

Daily, oral tenofovir disoproxil fumarate/emtricitabine (TDF/FTC) as pre-exposure prophylaxis (PrEP) reduces HIV acquisition for African women. Adherence is key to efficacy and patterns of adherence can be highly variable in real-world settings. Using group-based trajectory modeling (GBTM), we sought to identify distinct patterns of periconception PrEP adherence and evaluate potential baseline predictors of such adherence trajectories.

Methods

We conducted a single-arm longitudinal study for women aged 18-35 years living in Durban, South Africa with personal or partner plans for pregnancy with a partner with HIV or of unknown serostatus. Participants were offered safer conception counseling, including daily oral PrEP; women who initiated PrEP were given a bottle with an electronic pillcap that recorded when device opens. Weekly adherence to daily PrEP was modeled using GBTM with a censored normal outcome distribution as a function of weeks since PrEP initiation. The number and functional form of the adherence trajectory groups were primarily selected based on Bayesian information criteria (BIC) and confirmed by mean estimated probabilities of group membership. A multivariable version of the selected model assessed baseline predictors of membership in adherence trajectory groups.

Results

Overall mean (95% CI) adherence to PrEP was 63% (60%, 67%). We identified four groups of women with distinct patterns of adherence: (1) high (i.e., ≥6 doses per week) steady adherence throughout follow-up (22% of PrEP initiators); (2) moderate (i.e., 4-5 doses per week), but steady adherence (31%); (3) initially high, but consistently declining adherence (21%); and (4) initially moderate adherence, followed by a rapid decline and subsequent rebound (26%). In multivariable-adjusted analyses, older age was associated with membership in the high, steady adherence group as compared to the group identified with an adherence trajectory of initially high, then decline, and finally a rebound.

Conclusions

GBTM is useful for exploring potential heterogeneity in longitudinal patterns of medication adherence. Although a large proportion of women in this study achieved high levels of adherence by electronic pillcap initially, far fewer women maintained these levels consistently. Knowledge of different adherence trajectories could be used to develop targeted strategies for optimizing HIV prevention during periconception.

A Multicomponent Intervention to Train and Support Family Medicine Providers to Promote Pre-exposure Prophylaxis (PrEP) for Adolescent Girls and Young Women in the Deep South: Protocol for the PrEP-Pro Study

BACKGROUND

Pre-exposure prophylaxis (PrEP) is a highly effective biomedical prevention intervention and a major strategy for reducing the HIV burden in the United States. However, PrEP provision and uptake remain lower than estimated needs, and in ways that may exacerbate HIV disparities among Black adolescent girls and young women in the southern United States. Data suggest that gaps in provider knowledge of HIV epidemiology and PrEP and skills assessing sexual health practices are important barriers to provision and uptake, with limited evidence-based interventions to address these gaps.

OBJECTIVE

This paper describes the "PrEP-Pro" intervention, a multicomponent intervention to train and support family medicine (FM) trainees to promote PrEP for adolescent girls and young women in Alabama.

METHODS

The PrEP-Pro intervention comprises 3 main components guided by the Capability-Opportunity-Motivation-Behavior (COM-B) model for behavioral change and the Consolidated Framework for Implementation Research (CFIR): (1) provider HIV epidemiology and PrEP education, (2) sexual history taking, and (3) PrEP Champions. In phase 1, we will work with community advisory boards (providers and clients) and then conduct focus groups with FM trainees to adapt content to train FM residents on HIV epidemiology and PrEP and develop implementation strategies, including provider-facing tools and client-facing educational materials. In phase 2, we will pretest and then pilot-test the initially adapted PrEP-Pro intervention with FM trainees. FM trainees will complete baseline, 3-, and 6-month questionnaires post PrEP-Pro intervention. We will also conduct in-depth interviews (IDIs) with FM pilot participants, adolescent girls and young women who accessed care after the PrEP-Pro pilot, and key stakeholders. The primary outcomes are PrEP-Pro acceptability and feasibility, which would be assessed using validated instruments at months 3 (among pretest participants) and 6 (among pilot participants). Secondary outcomes will also be assessed, including PrEP knowledge, sexual history-taking attitudes and practices, PrEP prescriptions among adolescent girls and young women encounters, and sexually transmitted infections (STIs) and HIV testing among adolescent girls and young women encounters in 6 months.

RESULTS

Study results will be disseminated to practices, state health officials, and other key stakeholders to solicit feedback on implementation opportunities and challenges to inform a hybrid effectiveness implementation trial. Our results will also be presented at local and national conferences and submitted to peer-reviewed journals.

CONCLUSIONS

As PrEP grows, there is a pressing need to train FM providers and develop appropriate, contextually relevant tools to support PrEP implementation. The PrEP-Pro intervention is a multicomponent intervention to train FM residents across Alabama on sexual history-taking, PrEP provision for adolescent girls and young women, and supporting practice-based PrEP Champions. The PrEP-Pro intervention is anticipated to increase PrEP prescriptions for adolescent girls and young women and expand comprehensive sexual and reproductive health care for adolescent girls and young women in rural and urban Alabama.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

PRR1-10.2196/44908.

Rapid qualitative analysis approach to stakeholder and client interviews to inform mobile-based HIV testing in the U.S. Deep South

BACKGROUND

The severity of the HIV epidemic in the United States' rural South highlights geographic, socioeconomic, and racial disparities that disproportionately affect poor Black Americans. Approximately 16% of Alabamians living with HIV remain undiagnosed and just 37% of rural Alabamians have ever been tested for HIV.

METHODS

We conducted in-depth interviews with 22 key stakeholders involved in HIV prevention, testing, treatment, or community health initiatives, and 10 adults living in rural communities across Alabama to explore HIV testing challenges and opportunities. We utilized a rapid qualitative analysis approach and engaged community partners for feedback and discussion. This analysis will inform the implementation of a mobile HIV testing service in rural Alabama.

RESULTS

The following themes were identified: (1) Cultural norms, racism, poverty, and rurality impair access to healthcare. (2) Lack of sex education, low knowledge of HIV and perception of risk reinforce stigmas. (3) Messaging about "Undetectable = Untransmissible" (U = U) is not well understood in communities. (4) Community involvement may promote communication and trust between communities and testing advocates. (5) Novel testing strategies are acceptable and may diminish barriers.

CONCLUSIONS

Working with community "gatekeepers" may be a key strategy to understand and promote acceptability of interventions new to rural Alabama and ameliorate stigma within communities. The implementation of new HIV testing strategies requires building and maintaining relationships with advocates, especially faith-based leaders, who engage people across many demographics.

High PrEP uptake and objective longitudinal adherence among HIV-exposed women with personal or partner plans for pregnancy in rural Uganda: A cohort study

BACKGROUND

In Uganda, fertility rates and adult HIV prevalence are high, and many women conceive with partners living with HIV. Pre-exposure prophylaxis (PrEP) reduces HIV acquisition for women and, therefore, infants. We developed the Healthy Families-PrEP intervention to support PrEP use as part of HIV prevention during periconception and pregnancy periods. We conducted a longitudinal cohort study to evaluate oral PrEP use among women participating in the intervention.

METHODS AND FINDINGS

We enrolled HIV-negative women with plans for pregnancy with a partner living, or thought to be living, with HIV (2017 to 2020) to evaluate PrEP use among women participating in the Healthy Families-PrEP intervention. Quarterly study visits through 9 months included HIV and pregnancy testing and HIV prevention counseling. PrEP was provided in electronic pillboxes, providing the primary adherence measure ("high" adherence when pillbox was opened ≥80% of days). Enrollment questionnaires assessed factors associated with PrEP use. Plasma tenofovir (TFV) and intraerythrocytic TFV-diphosphate (TFV-DP) concentrations were determined quarterly for women who acquired HIV and a randomly selected subset of those who did not; concentrations TFV ≥40 ng/mL and TFV-DP ≥600 fmol/punch were categorized as "high." Women who became pregnant were initially exited from the cohort by design; from March 2019, women with incident pregnancy remained in the study with quarterly follow-up until pregnancy outcome. Primary outcomes included (1) PrEP uptake (proportion who initiated PrEP); and (2) PrEP adherence (proportion of days with pillbox openings during the first 3 months following PrEP initiation). We used univariable and multivariable-adjusted linear regression to evaluate baseline predictors selected based on our conceptual framework of mean adherence over 3 months. We also assessed mean monthly adherence over 9 months of follow-up and during pregnancy. We enrolled 131 women with mean age 28.7 years (95% CI: 27.8 to 29.5). Ninety-seven (74%) reported a partner with HIV and 79 (60%) reported condomless sex. Most women (N = 118; 90%) initiated PrEP. Mean electronic adherence during the 3 months following initiation was 87% (95% CI: 83%, 90%). No covariates were associated with 3-month pill-taking behavior. Concentrations of plasma TFV and TFV-DP were high among 66% and 47%, 56% and 41%, and 45% and 45% at months 3, 6, and 9, respectively. We observed 53 pregnancies among 131 women (1-year cumulative incidence 53% [95% CI: 43%, 62%]) and 1 HIV-seroconversion in a non-pregnant woman. Mean pillcap adherence for PrEP users with pregnancy follow-up (N = 17) was 98% (95% CI: 97%, 99%). Study design limitations include lack of a control group.

CONCLUSIONS

Women in Uganda with PrEP indications and planning for pregnancy chose to use PrEP. By electronic pillcap, most were able to sustain high adherence to daily oral PrEP prior to and during pregnancy. Differences in adherence measures highlight challenges with adherence assessment; serial measures of TFV-DP in whole blood suggest 41% to 47% of women took sufficient periconception PrEP to prevent HIV. These data suggest that women planning for and with pregnancy should be prioritized for PrEP implementation, particularly in settings with high fertility rates and generalized HIV epidemics. Future iterations of this work should compare the outcomes to current standard of care.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT03832530 https://clinicaltrials.gov/ct2/show/NCT03832530?term=lynn+matthews&cond=hiv&cntry=UG&draw=2&rank=1.

Opportunities to leverage reproductive goals and ideals among South African men to promote HIV testing, treatment and prevention: A qualitative study

Despite significant gains in HIV testing, treatment and prevention in sub-Saharan Africa, male engagement and retention in HIV care remains a challenge. We conducted in-depth interviews with 25 men with HIV (MWH) living in rural South Africa to explore how men's reproductive goals could inform approaches to engage men and their female partners in HIV care and prevention. Themes were organised into opportunities and barriers for HIV care, treatment and prevention that men articulated as important to their reproductive goals at the individual, couple and community levels. At the individual level, men are motivated to remain healthy so they can raise a healthy child. At the couple level, the importance of maintaining a healthy partner to raise children may promote serostatus-disclosure, testing and encourage men to support partners to access HIV prevention. At the community level, men described the need to be seen as fathers who provide for their families as important motivators to engage in care. Men also articulated barriers including low knowledge about antiretroviral-based HIV prevention, lack of trust within partnerships and community stigma. Addressing reproductive goals of MWH may be an untapped path for promoting male engagement in HIV care and prevention for their partners.

Depression, religiosity, and telomere length in the Study on Stress, Spirituality, and Health (SSSH)

Prospective studies on the association between depression and telomere length have produced mixed results and have been largely limited to European ancestry populations. We examined the associations between depression and telomere length, and the modifying influence of religion and spirituality, in four cohorts, each representing a different race/ethnic population. Relative leukocyte telomere length (RTL) was measured by a quantitative polymerase chain reaction. Our result showed that depression was not associated with RTL (percent difference: 3.0 95% CI: -3.9, 10.5; p = 0.41; p-heterogeneity across studies = 0.67) overall or in cohort-specific analyses. However, in cohort-specific analyses, there was some evidence of effect modification by the extent of religiosity or spirituality, religious congregation membership, and group prayer. Further research is needed to investigate prospective associations between depression and telomere length, and the resources of resilience including dimensions of religion and spirituality that may impact such dynamics in diverse racial/ethnic populations.

R|S Atlas: Identifying existing cohort study data resources to accelerate epidemiological research on the influence of religion and spirituality on human health

OBJECTIVE

Many studies have documented significant associations between religion and spirituality (R/S) and health, but relatively few prospective analyses exist that can support causal inferences. To date, there has been no systematic analysis of R/S survey items collected in US cohort studies. We conducted a systematic content analysis of all surveys ever fielded in 20 diverse US cohort studies funded by the National Institutes of Health (NIH) to identify all R/S-related items collected from each cohort's baseline survey through 2014.

DESIGN

An R|S Ontology was developed from our systematic content analysis to categorise all R/S survey items identified into key conceptual categories. A systematic literature review was completed for each R/S item to identify any cohort publications involving these items through 2018.

RESULTS

Our content analysis identified 319 R/S survey items, reflecting 213 unique R/S constructs and 50 R|S Ontology categories. 193 of the 319 extant R/S survey items had been analysed in at least one published paper. Using these data, we created the R|S Atlas (https://atlas.mgh.harvard.edu/), a publicly available, online relational database that allows investigators to identify R/S survey items that have been collected by US cohorts, and to further refine searches by other key data available in cohorts that may be necessary for a given study (eg, race/ethnicity, availability of DNA or geocoded data).

CONCLUSIONS

R|S Atlas not only allows researchers to identify available sources of R/S data in cohort studies but will also assist in identifying novel research questions that have yet to be explored within the context of US cohort studies.

Local Health Department and Hospital Collaboration Around Community Health Needs Assessment to Improve Health Outcomes

The objectives of this study were to examine the relationships between local health department (LHD) and nonprofit hospital collaboration around community health needs assessment (CHNA), levels of collaboration, and selected community health outcomes. Data were obtained from multiple sources including the National Profile of Local Health Departments. Results showed that high levels of LHD-hospital collaboration around CHNA were associated with lower self-reported poor or fair health, lower years of potential life lost per 100 000 population, and lower premature age-adjusted mortality per 100 000 population. More research is needed to examine the influence of collaboration around CHNA on community health.

Religion, spirituality and diurnal rhythms of salivary cortisol and dehydroepiandrosterone in postmenopausal women

Background

Religion and spirituality (R/S) are important resources for coping with stress and are hypothesized to influence health outcomes via modulation of the hypothalamic-pituitary-adrenal (HPA) axis, though this has not been evaluated extensively. In this study, we examined associations between several measures of religiosity or spirituality (R/S) and three HPA axis biomarkers: cortisol, dehydroepiandrosterone (DHEA), and cortisol:DHEA ratio.

Methods

Sample included 216 female postmenopausal Nurses’ Health Study II participants who provided up to five timed saliva samples: immediately upon awakening, 45 min, 4 h, and 10 h after waking, and prior to going to sleep during a single day in 2013. Multivariable-adjusted linear mixed models with piecewise cubic spline functions and adjustment for potential covariates were used to estimate the cross-sectional associations of eight R/S measures with diurnal rhythms of cortisol, DHEA, and the cortisol/DHEA ratio.

Results

There was little evidence of association between the eight R/S measures analyzed and diurnal rhythms of cortisol, DHEA, and the cortisol/DHEA ratio. Women who reported that R/S was very involved in understanding or dealing with stressful situations had slower night rise in cortisol than those who did not. Greater levels of religious struggles were associated with higher cortisol levels throughout the day. Higher non-theistic daily spiritual experiences scores were associated with slower DHEA night rise, and a higher cortisol/DHEA ratio upon waking and at night. However, these associations were significantly attenuated when we excluded women reporting bedtimes at least 30 min later than usual.

Conclusion

Observed associations were driven by those with late sleep schedules, and given the number of comparisons made, could be due to chance. Future research using larger, more diverse samples of individuals is needed to better understand the relationship between R/S and HPA axis biomarkers.

•

We examined the influence of religion and spirituality on HPA-axis diurnal rhythms of cortisol, DHEA, and their ratio.

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Religious coping, religious struggles, and non-theistic DSES were associated with modest alterations in HPA axis rhythms.

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Observed associations were driven by those with late sleep schedules.

Motivations for Treatment Engagement in a Residential Substance Use Disorder Treatment Program: A Qualitative Study

AIMS

The aim of this study was to explore perspectives on motivations for treatment engagement from substance use disorder (SUD) clients in a long-term residential rehabilitation program.

DESIGN AND METHODS

A convenience sample of 30 clients who were enrolled in a year-long SUD treatment program at a residential rehabilitation facility took part in in-depth interviews. Interview transcripts were analyzed using the directed content analysis approach.

RESULTS

Participant accounts indicated that their treatment engagement was motivated by factors that aligned with the six primary constructs of the Health Belief Model: (i) perceived susceptibility (eg, believing that their substance use required intervention and that they were prone to relapse), (ii) perceived severity (eg, substance use negatively impacted their health and harmed their close relationships), (iii) perceived benefits (eg, opportunities for a better life, reconnecting with family members and close friends, & avoiding legal consequences), (iv) perceived barriers (eg, the length of the treatment program), (v) cues to actions (eg, decisive moments, elements of the treatment program, & faith and spirituality), and (vi) self-efficacy in remaining abstinent (eg, treatment program provided them with skills and experiences to maintain long-term sobriety).

DISCUSSION

Our analysis indicates that participants' treatment engagement was linked to their beliefs regarding the severity of their substance use disorder, their treatment program's ability to help them avoid future relapse, and their own capability to act upon the strategies and resources provided by the treatment program. A theoretical understanding of these aspects can contribute to the future planning of precision interventions.