Latent class analysis of barriers to HIV testing services and associations with sexual behaviour and HIV status among adolescents and young adults in Nigeria

INTRODUCTION

Adolescents and young adults (AYA) face multiple barriers to accessing healthcare services, which can interact, creating complex needs that often impact health behaviours, leading to increased vulnerability to HIV. We aimed to identify distinct AYA subgroups based on patterns of barriers to HIV testing services and assess the association between these barrier patterns and sexual behaviour, socio-demographics, and HIV status.

METHODS

Data were from Nigeria's AIDS Indicator and Impact Survey (NAIIS, 2018) and included 18,612 sexually active AYA aged 15-24 years who had never been tested for HIV and reported barriers to accessing HIV testing services. A Latent class analysis (LCA) model was built from 12 self-reported barrier types to identify distinct subgroups of AYA based on barrier patterns. Latent class regressions (LCR) were conducted to compare the socio-demographics, sexual behaviour, and HIV status across identified AYA subgroups. Sex behaviour characteristics include intergenerational sex, transactional sex, multiple sex partners, condom use, and knowledge of partner's HIV status.

RESULTS

Our LCA model identified four distinct AYA subgroups termed 'low-risk perception' (n = 7,361; 39.5%), 'consent and proximity' (n = 5,163; 27.74%), 'testing site' (n = 4,996; 26.84%), and 'cost and logistics' (n = 1,092; 5.87%). Compared to adolescents and young adults (AYA) in the low-risk perception class, those in the consent and proximity class were more likely to report engaging in intergenerational sex (aOR 1.17, 95% CI 1.02-1.35), transactional sex (aOR 1.50, 95% CI 1.23-1.84), and have multiple sex partners (aOR 1.75, 95% CI 1.39-2.20), while being less likely to report condom use (aOR 0.79, 95% CI 0.63-0.99). AYA in the testing site class were more likely to report intergenerational sex (aOR 1.21, 95% CI 1.04-1.39) and transactional sex (aOR 1.53, 95% CI 1.26-1.85). AYA in the cost and logistics class were more likely to engage in transactional sex (aOR 2.12, 95% CI 1.58-2.84) and less likely to report condom use (aOR 0.58, 95% CI 0.34-0.98). There was no significant relationship between barrier subgroup membership and HIV status. However, being female, aged 15-24 years, married or cohabiting, residing in the Southsouth zone, and of Christian religion increased the likelihood of being HIV infected.

CONCLUSIONS

Patterns of barriers to HIV testing are linked with differences in sexual behaviour and sociodemographic profiles among AYA, with the latter driving differences in HIV status. Findings can improve combination healthcare packages aimed at simultaneously addressing multiple barriers and determinants of vulnerability to HIV among AYA.

Understanding why and how youth-friendly health services improve viral load suppression among adolescents and young people living with HIV in Nigeria: realist evaluation with qualitative comparative analysis

INTRODUCTION

Youth-friendly health service (YFHS) approaches are essential to better outcomes for young people. We evaluated attainment of viral load suppression among young people living with HIV (YPLHIV) enrolled in an HIV treatment programme implementing YFHS models in Nigeria.

METHODS

A realist evaluation using qualitative and quantitative programme data from 10 implementing health facilities. We used qualitative information to explore how and why viral load suppression was attained across different settings and quantitative data to describe patterns and associations between youth-friendly structures and processes of care, care retention and viral load suppression. To consolidate the theories, we used qualitative comparative analysis to identify the necessary and sufficient conditions for attaining viral load suppression, using 30 YPLHIV as cases.

RESULTS

Between baseline (2018) and study-end (May 2022), viral load suppression coverage increased in 8 of the 10 study facilities. The number of facilities with viral load suppression coverage ≥90% rose from two to seven, while one facility remained unchanged, and another had a decline in coverage. Among the 30 selected YPLHIV cases, 18 had viral load suppression during the first test and 24 at the second test. However, viral load suppression attainment varied in different contexts. We identified the different YFHS interventions and key mechanisms that influenced viral load suppression in different contexts.

CONCLUSION

YFHS interventions can improve young people's engagement with HIV services, but their effectiveness depends on specific mechanisms and contextual factors influencing their response to interventions. By exploring how and why viral load suppression was attained in different contexts, the findings will improve the design and implementation of strategies to improve outcomes in young people, which will be relevant for achievement of global goals to eliminate HIV by 2030.

Understanding sexual transmission dynamics and transmission contexts of monkeypox virus: a mixed-methods study of the early outbreak in Belgium (May-June 2022)

OBJECTIVE

The available epidemiological and clinical evidence from the currently ongoing monkeypox (MPX) outbreak in non-endemic areas suggests an important factor of sexual transmission. However, limited information on the behaviour and experiences of individuals with an MPX infection has to date been provided. We aimed to describe the initial phase of the MPX outbreak in Belgium, and to provide a more in-depth description of sexual behaviour and transmission contexts.

METHODS

We used routine national surveillance data of 139 confirmed MPX cases with date of symptom onset until 19 June 2022, complemented with 12 semistructured interviews conducted with a subsample of these cases.

RESULTS

Sexualised environments, including large festivals and cruising venues for gay men, were the suspected exposure setting for the majority of the cases in the early outbreak phase. In-depth narratives of sexual behaviour support the hypothesis of MPX transmission through close physical contact during sex. Despite awareness of the ongoing MPX outbreak, low self-perceived risk of MPX acquisition and confusing initial signs and symptoms for other STIs or skin conditions delayed early detection of an MPX infection. In addition, we describe relevant contextual factors beyond individual behaviour, related to sexual networks, interpersonal interactions and health systems. Some of these factors may complicate early MPX detection and control efforts.

CONCLUSION

Our results highlight the role of sexual contact and networks in the transmission of MPX during the early phase of the outbreak in Belgium. Risk communication messages should consistently and transparently state the predominant sexual transmission potential of MPX virus, and prevention and control measures must be adapted to reflect multilevel factors contributing to MPX transmission risk.

Trajectories of PrEP use among men who have sex with men: a pooled analysis of two prospective, observational cohort studies

INTRODUCTION

Daily and event-driven oral pre-exposure prophylaxis (PrEP) reduce the risk of HIV acquisition. PrEP use can vary over time, yet little is known about the trajectories of PrEP use irrespective of the chosen PrEP regimens among men who have sex with men (MSM).

METHODS

Using data from a mobile, web-based diary application collected daily from 17 August 2015 until 6 May 2018, we analysed PrEP use and sexual behaviour in two large cohorts, AMPrEP (Amsterdam, the Netherlands) and Be-PrEP-ared (Antwerp, Belgium). In both cohorts, participants could choose between daily and event-driven oral PrEP every 3 months. We used group-based trajectory modelling to identify trajectories of PrEP use over time and their determinants. In addition, we estimated the incidence rate of chlamydia, gonorrhoea and syphilis within these trajectories.

RESULTS

We included 516 MSM (n = 322 AMPrEP; n = 194 Be-PrEP-ared), of whom 24% chose event-driven PrEP at PrEP initiation. Participants contributed 225,015 days of follow-up (median = 508 days [IQR = 429-511]). Four distinct PrEP use trajectories were identified: ≤2 tablets per week ("low frequency," 12% of the total population), 4 tablets per week ("variable," 17%), "almost daily" (31%) and "always daily" (41%). Compared to participants with "low frequency" PrEP use, participants with "variable" (odds ratio [OR] = 2.18, 95% confidence interval [CI] = 1.04-4.60) and "almost daily" PrEP use were more often AMPrEP participants (OR = 2.64, 95% CI = 1.27-5.49). "Almost daily" PrEP users were more often employed (OR = 6.76, 95% CI = 2.10-21.75) and were younger compared to participants with "low frequency" PrEP use. In addition, the number of days on which anal sex occurred was lower among participants with "low frequency" PrEP use compared to the other groups (all p<0.001). Compared to "low frequency" PrEP users, the incidence rates of chlamydia and gonorrhoea were higher for participants with "almost daily" and "always daily" PrEP use.

CONCLUSIONS

We uncovered four distinct PrEP use trajectories, pointing to different patterns of PrEP use in practice beyond the two-regimen dichotomy. These trajectories were related to sexual behaviour and rates of sexually transmitted infection. Tailoring PrEP care according to different PrEP use patterns could be an important strategy to improve efficient PrEP delivery.

Developing evidence-informed indicators to monitor HIV pre-exposure prophylaxis programmes across EU/EEA countries: a multi-stakeholder consensus

Several countries in the European Union (EU) and European Economic Area (EEA) established and/or scaled up HIV pre-exposure prophylaxis (PrEP) programmes between 2016 and 2023. Data on PrEP programmes' performance and effectiveness in reaching those most in need will be needed to assess regional progress in the roll-out of PrEP. However, there is a lack of commonly defined indicators for routine monitoring to allow for minimum comparability. We propose a harmonised PrEP monitoring approach for the EU/EEA, based on a systematic and evidence-informed consensus-building process involving a broad and multidisciplinary expert panel. We present a set of indicators, structured along relevant steps of an adapted PrEP care continuum, and offer a prioritisation based on the degree of consensus among the expert panel. We distinguish between 'core' indicators deemed essential for any PrEP programme in the EU/EEA, vs 'supplementary' and 'optional' indicators that provide meaningful data, yet where experts evaluated their feasibility for data collection and reporting as very context-dependent. By combining a standardised approach with strategic opportunities for adaptation and complementary research, this monitoring framework will contribute to assess the impact of PrEP on the HIV epidemic in Europe.

Local initiative supports case isolation and contact tracing during a SARS-CoV-2 surge in summer 2020: a community case study in Antwerp, Belgium

In Antwerp, Belgium's second largest city, a COVID-19 surge in July 2020 predominantly affected neighborhoods with high ethnic diversity. Local volunteers reacted and set up an initiative to support contact tracing and self-isolation. We describe the origin, implementation, and transfer of this local initiative, based on semi-structured interviews of five key informants and document review. The initiative started in July 2020, when family physicians signaled a surge of SARS-CoV-2 infections among people of Moroccan descent. Family physicians feared that the mainstream contact tracing organized by the Flemish government through centralized call centers would not be efficient in halting this outbreak. They anticipated language barriers, mistrust, inability to investigate case clusters, and practical problems with self-isolation. It took 11 days to start up the initiative, with logistical support from the province and city of Antwerp. Family physicians referred SARS-CoV-2-infected index cases with complex needs (including language and social situation) to the initiative. Volunteer COVID coaches contacted cases, got a contextualized understanding of their living conditions, assisted with backward and forward contact tracing, offered support during self-isolation, and checked if infected contacts also needed support. Interviewed coaches were positive about the quality of the interaction: they described extensive open conversations with cases. The coaches reported back to referring family physicians and coordinators of the local initiative, who took additional action if necessary. Although interactions with affected communities were perceived as good, respondents considered that the number of referrals by family physicians was too low to have a meaningful impact on the outbreak. In September 2020, the Flemish government assigned the tasks of local contact tracing and case support to the local health system level (primary care zones). While doing so, they adopted elements of this local initiative, such as COVID coaches, tracing system, and extended questionnaires to talk with cases and contacts. This community case study illustrates how urgency can motivate people to action yet support from people with access to resources and coordination capacity is vital for effective organization and transition to long-term sustainability. From their conception, health policies should consider adaptability of new interventions to local contexts.

Putting 2-1-1 into Practice: PrEP Users’ Knowledge of Effectively Starting and Stopping Oral PrEP Use

Starting and stopping oral HIV pre-exposure prophylaxis (PrEP) in a way that compromises its effectiveness should be avoided. Between September 2020 and June 2021, we assessed self-perceived and actual knowledge of effectively starting and stopping oral PrEP through an online survey among 206 PrEP users assigned male at birth in Belgium. We examined associations between incorrect start-and-stop knowledge and socio-demographics, sexual behaviour and PrEP use, using bi- and multi-variable logistic regression. The majority of men (84.9%) perceived their start-and-stop knowledge as 'very good', but only 62.1% of all men correctly indicated how to effectively start and stop with PrEP. Using PrEP daily [adjusted OR 2.12, 95% CI (1.06-4.28), p = 0.034] was significantly associated with incorrect start-and-stop knowledge. To enable PrEP users to effectively use PrEP, they need to be better informed about how to start and stop use, irrespective of the dosing regimen.

The role of airborne transmission in a large single source outbreak of SARS-CoV-2 in a Belgian nursing home in 2020

Objectives

To better understand the conditions which have led to one of the largest COVID-19 outbreaks in Belgian nursing homes in 2020.

Setting

A nursing home in Flanders, Belgium, which experienced a massive outbreak of COVID-19 after a cultural event. An external volunteer who dressed as a legendary figure visited consecutively the 4 living units on December, 4th and tested positive for SARS-CoV-2 the next day. Within days, residents started to display symptoms and the outbreak spread rapidly within the nursing home.

Methods

We interviewed key informants and collected standardized data from all residents retrospectively. A batch of 115 positive samples with a Ct value of < 37 by qRT-PCR were analyzed using whole-genome sequencing. Six months after the outbreak, ventilation assessment of gathering rooms in the nursing home was done using a tracer gas test with calibrated CO₂ sensors.

Results

Timeline of diagnoses and symptom onsets clearly pointed to the cultural event as the start of the outbreak, with the volunteer as index case. The genotyping of positive samples depicted the presence of one large cluster, suggesting a single source outbreak.

By the end of December, a total of 127 residents and 40 staff were diagnosed with SARS-CoV-2 since the beginning of the outbreak. The attack rate among residents was 77 % and significantly associated with presence at the event but not with close contact or mask wearing. The ventilation assessment showed a high background average CO₂ level in four main rooms varying from 657 ppm to 846 ppm.

Conclusions

Our investigation shows a rapid and widespread single source outbreak of SARS-CoV-2 in a nursing home, in which airborne transmission was the most plausible explanation for the massive intra-facility spread. Our results underscore the importance of ventilation and air quality for the prevention of future outbreaks in closed facilities.

Awareness of, Willingness to Take PrEP and Its Actual Use Among Belgian MSM at High Risk of HIV Infection: Secondary Analysis of the Belgian European MSM Internet Survey

We examined PrEP awareness, willingness to take it and early PrEP use among men who have sex with men (MSM) at increased risk of HIV acquisition in Belgium. This analysis of the Belgian EMIS online data of 2017-2018 adopts a cascade approach, with the following steps quantified as conditional probabilities: being eligible for, aware of, willing to take PrEP, and PrEP use. One out of three MSM was eligible to use PrEP according to the operationalized Belgian reimbursement criteria. PrEP awareness was lower among socioeconomically vulnerable MSM, MSM living outside large cities, MSM who were less open about their sexuality and those who did not identify as gay or homosexual. A lack of PrEP knowledge, a higher self-efficacy regarding safe sex, having a steady partner and reporting more symptoms of depression were related to unwillingness to use PrEP. Among those willing to take PrEP, less than one third were actually using PrEP. Not using PrEP was associated with living in small cities and experiencing financial problems.

HIV among migrants in precarious circumstances in the EU and European Economic Area

HIV epidemics in the EU and European Economic Area are increasingly diverse in transmission modes and groups affected. Substantial gaps in data exist on HIV burden and access to the HIV continuum of care among migrants living in this region, particularly individuals in precarious circumstances such as migrants with irregular status. Migrants have a higher HIV burden compared with the general population, and high rates of post-migration HIV acquisition. Migrants also face challenges in access to health and HIV services, with irregular migrants, foreign-born key populations such as men who have sex with men, sex workers, and people who inject drugs, and migrants from sub-Saharan Africa being most affected. Intersecting factors negatively affect their access to services along the full continuum of care, including prevention and psychosocial services. Ensuring equitable access to general health and HIV services, regardless of immigration status, and implementing interventions to reduce stigma and discrimination are crucial to ending AIDS by 2030.

How Do Family Physicians Perceive Their Role in Providing Pre-exposure Prophylaxis for HIV Prevention?-An Online Qualitative Study in Flanders, Belgium

Introduction:

In Belgium, the provision of pre-exposure prophylaxis (PrEP) for HIV prevention is centralized in specialized HIV clinics. Engaging family physicians in PrEP care could help scale-up its delivery and reach underserved populations. The objective of this study was to gain insight into family physicians' self-perceived roles in providing PrEP.

Methods

We conducted 16 online group discussions with a total of 105 Flemish family physicians, between November 2020 and February 2021. A brief online questionnaire assessed their socio-demographics and experience with sexual health. We analyzed verbatim transcribed data using a grounded theory approach.

Results

Despite limited awareness and experience, participants reported a high willingness to be more actively involved in PrEP care. Four potential roles for the family physician in PrEP care were identified: acting as low-threshold entry point for advice; opportunistic case finding of PrEP candidates; initiating appropriate care for PrEP-eligible clients; and ensuring high-quality follow-up care for PrEP users. Participants framed each of these roles within their current activities and responsibilities as primary care providers. Yet, participants differed in their views on the concrete operationalization of these roles, and in the extent of their involvement in PrEP. Particular challenges were a lack of experience with antiretrovirals, perceived limited exposure to clients at high HIV risk, and a lack of expertise and resources to conduct time-intensive risk assessments and counseling related to PrEP.

Conclusion

Belgian family physicians demonstrated a keen willingness to be involved in PrEP care, but had differing views on the practical implementation into their practices. Providing tailored training on sexual health and PrEP, and investing in collaboration between primary and secondary care, could optimize the integration of PrEP in the primary care practice.

Why Do HIV Pre-Exposure Prophylaxis Users Discontinue Pre-Exposure Prophylaxis Care? A Mixed Methods Survey in a Pre-Exposure Prophylaxis Clinic in Belgium

It remains unclear why patients discontinue HIV pre-exposure prophylaxis (PrEP) care and to what extent they remain at risk for HIV when they do. We reviewed routinely collected medical records and patient questionnaires and performed an e-mail/telephone survey to assess reasons for discontinuing PrEP care, ongoing risks for HIV infection, and associated factors. Patients with more than two registered PrEP visits from a PrEP clinic in Antwerp, Belgium between June 2017 and February 2020 were included in this study. Patients who did not return for a visit after October 30, 2019 and who were not transferred out were considered as having discontinued PrEP care. A total of 143/1073 patients were considered as having discontinued PrEP care. Patients who discontinued PrEP care were more likely to be younger than those who remained in care (35 vs. 38 years old, p < 0.01). The most common reasons for discontinuation were having stopped using PrEP (62/101, 61.4%) and "COVID-19" (n = 35, 34.7%). The most common reasons for stopping PrEP use was a decreased sexual activity due to coronavirus disease 2019 (COVID-19; 21/62, 33.9%) or not COVID-19 related (10/62, 16.1%), a monogamous relationship (20/62, 32.3%) and consistent condom use (7/62, 11.3%). Among respondents who reported about current HIV risk the majority reported being at low risk either by still taking PrEP (32/91, 35.2%), consistently using condoms, or limiting number of sex acts or partners (58/91, 52.7%). No HIV seroconversion was reported.

Facilitators and barriers to status disclosure and partner testing of women living with HIV in Indonesia: a mixed methods study

This mixed-methods study investigated HIV status disclosure and partner testing of women living with HIV (WLWH) in a concentrated epidemic setting in Bandung, Indonesia. The qualitative exploratory strand used theoretical sampling to carry out semi-structured interviews with 47 HIV-infected women with varying anti-retroviral therapy status. The quantitative strand included 122 female patients receiving HIV care at a referral clinic. HIV diagnosis made women reassess their sexual partnerships. Some lost their partner due to death or divorce. Women with a longstanding HIV infection often formed new partnerships. They disclosed their status to new partners without assistance from health providers; the type and stability of the partnership influenced decision to disclose. Fear of rejection prevented initial disclosure prior to bringing the new partners to a health provider. Disclosure did not always result in partner testing because of low risk-awareness or denial of the partner. Despite a similar proportion of status disclosure to partner (92.8%), only 53.7% of new partners of WLWH were tested in contrast to 89.7% of partners tested among WLWH who stayed with the same partner. In antenatal care, where same-day testing was often done for pregnant couples, more partners were tested. Overall, consistent condom use was low and HIV status forced WLWH who continued sex work to work at settings where condom use was not enforced. WLWH face barriers to HIV status disclosure and partner testing and would benefit from partnership counselling. Guidelines for partner notification and testing should include specific strategies for women with longstanding HIV infection.

Recurrent Sexually Transmitted Infections Among a Cohort of Men Who Have Sex With Men Using Preexposure Prophylaxis in Belgium Are Highly Associated With Sexualized Drug Use

BACKGROUND

Men who have sex with men (MSM) experiencing recurrent sexually transmitted infections (STIs) may play a crucial role in the STI epidemic. However, there is limited understanding of what kind of behavior leads to recurrent STIs.

METHODS

A total of 179 MSM using preexposure prophylaxis were followed up for 18 months and were screened quarterly for chlamydia, gonorrhea, and syphilis from 2015 to 2018 in Belgium. Participants were stratified into 3 different groups (no STI, one STI episode, recurrent STI episodes during the study). Sociodemographic and sexual behavioral characteristics were compared between the 3 groups, and significant associations with recurrent STI were explored using multivariate logistic regression models.

RESULTS

A total of 62.0% (n = 111/179) of participants experienced at least one STI during the study, and more than 1 in 3 became reinfected with an STI at another visit (n = 66/179 [36.9%]). Participants experiencing recurrent STIs reported the highest frequency of sexualized drug use (86.4%) compared with participants experiencing one (60.0%) or no STI (47.1%). Therefore, sexualized drug use was highly associated with recurrent STIs (adjusted odds ratio [aOR]. 4.35). Other factors associated with recurrent STIs were being younger than 40 years (aOR, 3.29), had a high number (>4) of nonsteady partners with whom receptive (aOR, 1.17) or insertive (aOR, 1.12) condomless anal intercourse occurred in the last 3 months.

CONCLUSIONS

Sexualized drug use was the greatest risk factor for having recurrent STIs. Tailoring prevention and care, including specialized services tackling problematic drug use in a sexual context, may help to curb the STI epidemic among MSM.

Choosing event-driven and daily HIV pre-exposure prophylaxis - data from two European PrEP demonstration projects among men who have sex with men

INTRODUCTION

Daily and event-driven PrEP are both efficacious in reducing the risk for HIV infection. However, the practice of event-driven PrEP (edPrEP) is less well studied, in particular when provided as an alternative to daily PrEP. We studied regimen preferences and switches, and sexually transmitted infection (STI) incidence.

METHODS

We analysed pooled data from two prospective cohort studies among MSM: Be-PrEP-ared, Belgium and AMPrEP, the Netherlands. In both projects, participants could choose between daily and edPrEP at three-monthly study visits, when they were also screened for sexually transmitted infections including hepatitis C (HCV). We assessed the proportion choosing each regimen, and the determinants of choosing edPrEP at baseline. Additionally, we compared the incidence rates (IRs) of HCV, syphilis and chlamydia or gonorrhoea between regimens using Poisson regression. The study period was from 3 August 2015 until 24 September 2018.

RESULTS AND DISCUSSION

We included 571 MSM, of whom 148 (25.9%) chose edPrEP at baseline. 31.7% of participants switched regimen at least once. After 28 months, 23.5% used edPrEP. Older participants (adjusted odds ratio (aOR) = 1.38 per 10 years, 95% confidence interval (CI) = 1.15 to 1.64) and those unemployed (aOR = 1.68, 95% CI = 1.03 to 1.75) were more likely to initially choose edPrEP. IR of HCV and syphilis did not differ between regimens, but the IR of chlamydia/gonorrhoea was higher among daily users (adjusted incidence rate ratio = 1.61, 95% CI = 1.35 to 1.94).

CONCLUSIONS

A quarter of participants chose edPrEP at baseline and at 28 months this proportion was similar. Although the IR of HCV and syphilis were similar in the two regimens, the lower incidence of chlamydia and gonorrhoea among edPrEP users may suggest that less frequent STI testing of this group could be considered.

The social meanings of PrEP use - A mixed-method study of PrEP use disclosure in Antwerp and Amsterdam

Pre-Exposure Prophylaxis (PrEP) is a novel HIV prevention tool. PrEP stigma is a frequently reported barrier, while social disclosure of PrEP use may be an important facilitator. We explored how PrEP users managed PrEP use disclosure using a symbolic interactionist approach. We interviewed 32 participants from two PrEP demonstration projects (Be-PrEP-ared, Antwerp; AMPrEP, Amsterdam). We validated qualitative findings through Be-PrEP-ared questionnaire data. A minority of participants had received negative reactions on PrEP. The way PrEP use was disclosed was highly dependent on the social situation. In a sexual context among MSM, PrEP use was associated with condomless sex. Friends endorsed PrEP use as a healthy choice, but also related it to carelessness and promiscuity. It was seldom disclosed to colleagues and family, which is mostly related to social norms dictating when it is acceptable to talk about sex. The study findings reveal that PrEP stigma experiences were not frequent in this population, and that PrEP users actively manage disclosure of their PrEP user status. Frequent disclosure and increased use may have helped PrEP becoming normalised in these MSM communities. To increase uptake, peer communication, community activism and framing PrEP as health promotion rather than a risk-reduction intervention may be crucial.

Multilevel modelling and multiple group analysis of disparities in continuity of care and viral suppression among adolescents and youths living with HIV in Nigeria

INTRODUCTION

Substantial disparities in care outcomes exist between different subgroups of adolescents and youths living with HIV (AYLHIV). Understanding variation in individual and health facility characteristics could be key to identifying targets for interventions to reduce these disparities. We modelled variation in AYLHIV retention in care and viral suppression, and quantified the extent to which individual and facility characteristics account for observed variations.

METHODS

We included 1170 young adolescents (10-14 years), 3206 older adolescents (15-19 years) and 9151 young adults (20-24 years) who were initiated on antiretroviral therapy (ART) between January 2015 and December 2017 across 124 healthcare facilities in Nigeria. For each age group, we used multilevel modelling to partition observed variation of main outcomes (retention in care and viral suppression at 12 months after ART initiation) by individual (level one) and health facility (level two) characteristics. We used multiple group analysis to compare the effects of individual and facility characteristics across age groups.

RESULTS

Facility characteristics explained most of the observed variance in retention in care in all the age groups, with smaller contributions from individual-level characteristics (14%-22.22% vs 0%-3.84%). For viral suppression, facility characteristics accounted for a higher proportion of variance in young adolescents (15.79%), but not in older adolescents (0%) and young adults (3.45%). Males were more likely to not be retained in care (adjusted OR (aOR)=1.28; p<0.001 young adults) and less likely to achieve viral suppression (aOR=0.69; p<0.05 older adolescent). Increasing facility-level viral load testing reduced the likelihood of non-retention in care, while baseline regimen TDF/3TC/EFV or NVP increased the likelihood of viral suppression.

CONCLUSIONS

Differences in characteristics of healthcare facilities accounted for observed disparities in retention in care and, to a lesser extent, disparities in viral suppression. An optimal combination of individual and health services approaches is, therefore, necessary to reduce disparities in the health and well-being of AYLHIV.

The Impact of PrEP on the Sex Lives of MSM at High Risk for HIV Infection: Results of a Belgian Cohort

There is a need for an in-depth understanding of the impact of PrEP on users' sexual health and behaviour, beyond the focus on 'risk'. This mixed-method study was part of a Belgian PrEP demonstration project following 200 men who have sex with men (MSM) for at least 18 months. Taking a grounded-theory approach, 22 participants were interviewed and their transcripts analysed. The preliminary analysis guided the analysis of the questionnaire data. Overall, PrEP improved sexual health. Participants felt better protected against HIV, which enabled them to change their sexual behaviour. The reduction in condom use was moderated by interviewees' attitudes towards the risk for other STIs. Other changes included having more anal sex and experimentation with new sexual behaviours. While PrEP empowers MSM in taking care of their sexual health, comprehensive sexual health counselling is crucial to provide care for users who feel less in control over their sexual health.

Reducing contacts to stop SARS-CoV-2 transmission during the second pandemic wave in Brussels, Belgium, August to November 2020

To evaluate the effect of physical distancing and school reopening in Brussels between August and November 2020, we monitored changes in the number of reported contacts per SARS-CoV-2 case and associated SARS-CoV-2 transmission. The second COVID-19 pandemic wave in Brussels was the result of increased social contact across all ages following school reopening. Physical distancing measures including closure of bars and restaurants, and limiting close contacts, while primary and secondary schools remained open, reduced social mixing and controlled SARS-CoV-2 transmission.

Reducing contacts to stop SARS-CoV-2 transmission during the second pandemic wave in Brussels, Belgium, August to November 2020

To evaluate the effect of physical distancing and school reopening in Brussels between August and November 2020, we monitored changes in the number of reported contacts per SARS-CoV-2 case and associated SARS-CoV-2 transmission. The second COVID-19 pandemic wave in Brussels was the result of increased social contact across all ages following school reopening. Physical distancing measures including closure of bars and restaurants, and limiting close contacts, while primary and secondary schools remained open, reduced social mixing and controlled SARS-CoV-2 transmission.

Reduced sexual contacts with non-steady partners and less PrEP use among MSM in Belgium during the first weeks of the COVID-19 lockdown: results of an online survey

Objectives

To examine changes in the occurrence of physical sex with non-steady partners among men who have sex with men (MSM) in Belgium during the first weeks of the COVID-19 lockdown and associations with sociodemographic factors, sexual practices, drug, alcohol and pre-exposure prophylaxis (PrEP) use. A secondary objective was to explore changes in PrEP use and the need for PrEP follow-up.

Methods

A cross-sectional online survey. The questionnaire was available in Dutch, French and English, between April 10 and 27 (2020), and disseminated via sexual health and lesbian, gay, bisexual, trans, queer or intersex organisations throughout Belgium. Eligibility criteria included being 18 years or older, not being exclusively heterosexual and living or being born in Belgium.

Results

The sample included 694 MSM. Physical sex with non-steady partners decreased from 59.1% to 8.9% during the first weeks of the lockdown. Those who had sex with non-steady partners were significantly more likely to be HIV positive, to use PrEP or to have engaged in sexual practices such as group sex, chemsex and sex work before the lockdown, compared with their counterparts. Among those who used PrEP before the lockdown, 47.0% stopped using PrEP, 19.7% used event-driven PrEP and 33.3% used daily PrEP during the lockdown. Almost two-thirds of PrEP users had a PrEP care appointment in the weeks before the lockdown and a minority received follow-up elsewhere or online. Some PrEP users had concerns regarding their follow-up.

Conclusions

MSM in our survey substantially reduced sexual contact with non-steady partners during the first weeks of the COVID-19 lockdown, suggesting that the risk for HIV and STI transmission in this period was low. We recommend ensuring access to sexual health services, such as HIV testing and follow-up for PrEP for the small group having multiple sex partners and engaging in sexual practices such as chemsex, or group sex, even in times of a pandemic threat.

"No good man will ever want me". How structural social inequality increases women's vulnerability to HIV transmission: a qualitative study from Bandung, Indonesia

Understanding the pathways that expose women to HIV transmission are vital in improving HIV prevention, especially among a "hidden" group of women without pre-established known risk for HIV. We investigated the pathways which place certain women at greater risk for HIV in a qualitative exploratory study with theoretical sampling using an emergent theory study design in an urban setting in Indonesia. We conducted semi-structured interviews with 47 HIV-infected women, one focus group discussion with five young women who occassionally engage in sex work, participant observation at six sex work venues and two midwife clinics, and 11 informal interviews with midwives, nurses, and obstetricians. Our research found that many women not characterized as belonging to a "high-risk group" or "key population" were nevertheless at increased risk for HIV. A history of sexual abuse, premarital sex, divorce, or involvement in sex work, often precipitated by poverty coupled with discriminatory public health policies further heightened women's exposure to HIV. While reaching at-risk populations is a key strategy in HIV prevention, a novel and more tailored approach is needed to reach more hidden categories of women with less apparent risk behavior yet considerable risk for HIV infection.

The current landscape of pre-exposure prophylaxis service delivery models for HIV prevention: a scoping review

Background

Strengthening HIV prevention is imperative given the continued high HIV incidence worldwide. The introduction of oral PrEP as a new biomedical HIV prevention tool can be a potential game changer because of its high clinical efficacy and the feasibility of its provision to different key populations. Documenting the existing experience with PrEP service delivery in a variety of real-world settings will inform how its uptake and usage can be maximised.

Methods

We conducted a scoping review using the five-step framework provided by Arksey and O’Malley. We systematically searched the existing peer-reviewed international and grey literature describing the implementation of real-world PrEP service delivery models reporting on four key components: the target population of PrEP services, the setting where PrEP was delivered, PrEP providers’ professionalisation and PrEP delivery channels. We restricted our search to English language articles. No geographical or time restrictions were set.

Results

This review included 33 articles for charting and analysing of the results. The identified service delivery models showed that PrEP services mainly targeted people at high risk of HIV acquisition, with some models targeting specific key populations, mainly men who have sex with men. PrEP was often delivered centralised and in a clinical or hospital setting. Yet also community-based as well as home-based PrEP delivery models were reported. Providers of PrEP were mainly clinically trained health professionals, but in some rare cases community workers and lay providers also delivered PrEP. In general, in-person visits were used to deliver PrEP. More innovative digital options using mHealth and telemedicine approaches to deliver specific parts of PrEP services are currently being applied in a minority of the service delivery models in mainly high-resource settings.

Conclusions

A range of possible combinations was found between all four components of PrEP service delivery models. This reflects differentiation of care according to different contextual settings. More research is needed on how integration of services in these contexts could be expanded and optimised to respond to key populations with unmet HIV prevention needs in different settings.

High uptake of pre-exposure prophylaxis (PrEP) during early roll-out in Belgium: results from surveillance reports

Background Since 1 June 2017, oral pre-exposure prophylaxis (PrEP) could be prescribed and reimbursed in Belgium as prophylactic medication for people who are at increased risk of HIV acquisition. The aim of this study was to determine the uptake of daily and event-driven PrEP in Belgium during the first 9 months of roll-out.

METHODS

Routine aggregated data on the number of reimbursement requests and the number of boxes of Truvada (Gilead Sciences, Cambridge, UK) delivered for PrEP through the Belgian pharmacies were obtained from the National Institute for Health and Disability Insurance. We also collected aggregated data from seven Aids Reference Centres (ARCs) currently providing most of the PrEP care in Belgium.

RESULTS

From 1 June 2017 to 28 February 2018, 1352 requests for reimbursement were approved by the National Institute for Health and Disability Insurance. Almost 98% of those who bought at least one box of 30 tablets of emtricitabine 200mg/tenofovir disoproxil fumarate 300mg (FTC/TDF) in a Belgian pharmacy were male, and most (67%) were between 30 and 50 years of age. According to data obtained from ARCs, the proportion of those choosing event-driven PrEP initially ranged between 29% and 73%.

CONCLUSIONS

The uptake of PrEP in Belgium since the start of the roll-out in June 2017 has been high, and almost entirely limited to men who have sex with men, of whom 43% initially prefer a non-daily regimen. A better understanding is needed as to why other populations, such as sub-Saharan African migrants, are not accessing PrEP, as well as the development of a more sustainable PrEP delivery model.

Drug use, depression and sexual risk behaviour: a syndemic among early pre-exposure prophylaxis (PrEP) adopters in Belgium?

Little is known about how interacting psychosocial problems may influence sexual behaviour among men having sex with men taking Pre-exposure prophylaxis (PrEP). This study assessed (1) the prevalence of depression, recreational drug-use and sexual risk behaviour; (2) changes in these psychosocial conditions over time; and (3) the interaction of drug use and depression with sexual risk behaviour. We analysed data of the Belgian Be-PrEP-ared cohort study (N = 200). We assessed depression using the PHQ-9, recreational drug use and receptive condomless anal intercourse (rCAI) with anonymous partners. Frequencies of psychosocial problems were compared at baseline, 9 and 18 months follow-up (FU). Bivariate associations between depression and drug-use behaviour, and their interaction with rCAI with anonymous sexual partners using was examined using linear regression. Receptive CAI increased from 41% at baseline to 53% at M18 (p = 0.038). At baseline, we found an interaction effect of poly-drug use and depression, potentiating rCAI with anonymous partners. Participants reporting poly-drug use associated with depression were significant more likely to report this type of sexual risk behaviour than those who did not report this association (p = 0.030). The high level of intertwined psychosocial problems call for multi-level interventions for those PrEP users experiencing a syndemic burden.

Physicians' preparedness for pre-exposure prophylaxis: results of an online survey in Belgium

Background Physicians have a crucial role in the implementation and scale up of pre-exposure prophylaxis (PrEP). The objective of this study is to examine Belgian physicians' PrEP knowledge, concerns, acceptance and their willingness to prescribe PrEP.

METHODS

A cross-sectional online survey was conducted between March and June 2016. Dissemination targeted Belgian primary care physicians (PCPs) and HIV specialists. Sociodemographic characteristics, experience with HIV and PrEP, self-assessed PrEP knowledge, concerns about PrEP, and PrEP acceptance were stratified according to professional background. Associations with willingness to prescribe PrEP were examined using univariable and multivariable binary logistic regression analyses.

RESULTS

In total, 333 completed surveys were included in the analysis. Sixty-two physicians (18.6%) scored their knowledge of PrEP to be good, 263 (79.0%) had an accepting attitude towards PrEP and 198 (59.5%) were willing to prescribe PrEP if approved in Belgium. HIV specialists consistently reported having better knowledge of PrEP, less concerns and a more accepting attitude towards PrEP than PCPs. In multivariable logistic regression analysis, higher PrEP knowledge (OR 2.4; 95%CI: 1.0-5.7) and higher PrEP acceptance (OR: 3.8; 95%CI: 2.1-6.8) remained significantly associated with the willingness to prescribe PrEP.

CONCLUSIONS

HIV specialists are better prepared to provide PrEP than PCPs in Belgium. Interventions to improve PrEP knowledge and acceptance among all providers are needed. The role of PCPs could be very important in optimising the rollout of PrEP, but additional training and guidelines will be needed.

Daily and event-driven pre-exposure prophylaxis for men who have sex with men in Belgium: results of a prospective cohort measuring adherence, sexual behaviour and STI incidence

INTRODUCTION

Pre-Exposure Prophylaxis (PrEP) is highly effective in reducing the risk for HIV infection among men who have sex with men (MSM) and may have an important impact in slowing down the HIV epidemic. Concerns remain however about low adherence, increased risk behaviour and reduced condom use when using PrEP. The aim of this study was to assess these factors prospectively among MSM using daily and event-driven PrEP in Belgium.

METHODS

An open-label prospective cohort study was conducted from October 2017 to May 2018 at the Institute of Tropical Medicine, in Antwerp, Belgium. At enrolment, MSM at high risk for HIV chose between daily or event-driven PrEP. They were allowed to switch regimens or stop taking PrEP at each of their tri-monthly visits. Data were collected on an electronic case report form, web-based diary and self-administered questionnaire. Screening for HIV and other Sexually Transmitted Infections (STIs) was also performed.

RESULTS

Two hundred MSM were followed up for a total duration of 318 person-years. At month 18, 75.4% of the participants were on daily and 24.6% were on event-driven PrEP. The mean proportion of covered sex acts by PrEP for the complete follow-up period was 91.5% for all participants, 96.5% for daily and 67.0% for event-driven PrEP use. The number of casual and anonymous sex partners was significantly higher for daily users, as compared with event-driven users, but did not change over time. In contrast, the mean proportion of condomless receptive anal intercourse with casual and anonymous partners increased significantly during follow-up, for both daily and event-driven use (p < 0.0001 for all 4 trends). No new HIV infection was diagnosed during follow-up. The incidence of bacterial STIs was 75.4 per 100 person-years (95% CI 63.8 to 89.1). We did not detect a significant change in N. gonorrhoeae/C. trachomatis incidence over time. The incidence of hepatitis C was 2.9 per 100 person-years.

CONCLUSIONS

PrEP is an effective and well adopted HIV prevention tool for MSM in Belgium. Participants adapted daily and event-driven regimens to their own needs and were able to adapt their PrEP adherence to risk exposure.

Case series on acute HCV in HIV-negative men in regular clinical practice: a call for action

BACKGROUND

The evidence that HIV treatment as prevention (TasP) and HIV pre-exposure prophylaxis (PrEP) reduces the risk of HIV transmission is overwhelming. But as PrEP and TasP can lead to increased sexual mixing between HIV positive and negative men who have sex with men (MSM), sexually transmitted infections such as acute hepatitis C (HCV), which were thought to be limited to HIV-infected MSM, could become more frequent in HIV uninfected MSM as well. The objective of this study was to describe a series of cases of sexually transmitted HCV infections in HIV-uninfected MSM in the Netherlands and Belgium.

METHODS

Through the Dutch Acute HCV in HIV Study (a Dutch-Belgian prospective multicentre study on the treatment of acute HCV infection, NCT02600325) and the Be-PrEP-ared study (a PrEP project in Antwerp, EudraCT2015-000054-37) several acute HCV infections were detected in HIV-negative men.

RESULTS

A newly acquired HCV infection was diagnosed in ten HIV-negative MSM. HCV was diagnosed at a sexually transmitted infection (STI) clinic (n = 2), by their general practitioner (n = 2), by their HIV physician (n = 1) or at a PrEP clinic (n = 5). Ten patients reported unprotected anal intercourse and four had a concomitant STI at the time of HCV diagnosis. Six patients reported using drugs during sex.

CONCLUSIONS

Our observation calls for a larger nationwide epidemiological study on the prevalence, incidence and risk factors of HCV infection in HIV-uninfected MSM. In the changing landscape of TasP and PrEP, reliable and up-to-date epidemiological data on HCV among HIV-uninfected MSM are needed and will help in developing evidence-based testing policies.

Ebola virus disease outbreak in Guinea: what effects on prevention of mother-to-child transmission of HIV services?

Background

An unprecedented epidemic of Ebola virus disease (EVD) affected Guinea in 2014 and 2015. It weakened the already fragile Guinean health system. This study aimed to assess the effects of the outbreak on Prevention of Mother-to-Child Transmission of HIV (PMTCT) services in 2014.

Methods

We conducted a cross-sectional retrospective study. Data was collected from 60 public health centers (30 in the EVD affected areas and 30 in the unaffected areas). The comparison of PMTCT indicators between the period before Ebola (2013) and during Ebola (2014) was done using the t- test for the means and the Chi-square test for the proportions.

Results

This study showed a substantial and significant reduction in the mean number of antenatal care visits (ANC) in the affected localities, 1617 ± 53 in 2013 versus 1065 ± 29 in 2014, p = 0.0004. This would represent 41% drop in health facilities’ performance. On the other hand, in the unaffected localities, the fall was not significant. The same observations were made about the number of HIV tests performed for pregnant women and the number of HIV positive pregnant women initiating ARVs. The study also noted an increase in the proportion of women tested HIV+ but who did not receive ARVs (12% in 2013 versus 44% in 2014) and HIV+ pregnant women who delivered at home (18% in 2014 versus 7% in 2013).

Conclusion

This study showed that PMTCT services, which are one of the key services to improve maternal and child health, were affected in Guinea during this Ebola outbreak in 2014 compared to 2013.

Health and budget impact of combined HIV prevention - first results of the BELHIVPREV model

OBJECTIVES

We developed a pragmatic modelling approach to estimate the impact of treatment as prevention (TasP); outreach testing strategies; and pre-exposure prophylaxis (PrEP) on the epidemiology of HIV and its associated pharmaceutical expenses.

METHODS

Our model estimates the incremental health (in terms of new HIV diagnoses) and budget impact of two prevention scenarios (outreach+TasP and outreach+TasP+PrEP) against a 'no additional prevention' scenario. Model parameters were estimated from reported Belgian epidemiology and literature data. The analysis was performed from a healthcare payer perspective with a 15-year-time horizon. It considers subpopulation differences, HIV infections diagnosed in Belgium having occurred prior to migration, and the effects of an ageing HIV population.

RESULTS

Without additional prevention measures, the annual number of new HIV diagnoses rises to over 1350 new diagnoses in 2030 as compared to baseline, resulting in a budget expenditure of €260.5 million. Implementation of outreach+TasP and outreach+TasP+PrEP results in a decrease in the number of new HIV diagnoses to 865 and 663 per year, respectively. Respective budget impacts decrease by €20.6 million and €33.7 million.

CONCLUSION

Foregoing additional investments in prevention is not an option. An approach combining TasP, outreach and PrEP is most effective in reducing the number of new HIV diagnoses and the HIV treatment budget. Our model is the first pragmatic HIV model in Belgium estimating the consequences of a combined preventive approach on the HIV epidemiology and its economic burden assuming other prevention efforts such as condom use and harm reduction strategies remain the same.

Estimating the number of female sex workers in Côte d'Ivoire: results and lessons learned

OBJECTIVE

To report on the results of three size estimations of the populations of female sex workers (FSW) in five cities in Côte d'Ivoire and on operational lessons learned, which may be relevant for key population programmes in other parts of the world.

METHODS

We applied three methods: mapping and census, capture-recapture and service multiplier. All were applied between 2008 and 2009 in Abidjan, San Pedro, Bouaké, Yamoussoukro and Abengourou.

RESULTS

Abidjan was the city with the highest number of FSW by far, with estimations between 7880 (census) and 13 714 (service multiplier). The estimations in San Pedro, Bouaké and Yamoussoukro were very similar, with figures ranging from 1160 (Yamoussoukro, census) to 1916 (San Pedro, capture-recapture). Important operational lessons were learned, including strategies for mapping, the importance of involving peer sex workers for implementing the capture-recapture and the identification of the right question for the multiplier method.

CONCLUSIONS

Successful application of three methods to estimate the population size of FSW in five cities in Côte d'Ivoire enabled us to make recommendations for size estimations of key population in low-income countries.

HIV Prevention 2020: a framework for delivery and a call for action

Although effective programmes are available and several countries have seen substantial declines in new HIV infections, progress in the reduction of adult HIV incidence has been slower than expected worldwide and many countries have not had large decreases in new infections in adults despite large reductions in paediatric infections. Reasons for slow progress include inadequate commitment, investment, focus, scale, and quality of implementation of prevention and treatment interventions. The UNAIDS-Lancet Commission on Defeating AIDS-Advancing Global Health reported that the provision of large-scale, effective HIV prevention programmes has failed and called on stakeholders to "get serious about HIV prevention". An ambitious worldwide target has been set by UNAIDS to reduce new infections below 500 000 by 2020-a 75% reduction from 2010. Models show that such a reduction requires a combination of primary prevention interventions and preventative effects of treatment. Achievement of the target will require more effective delivery of HIV prevention for sufficient coverage in populations at greatest risk of infection ensuring that interventions that have proved effective are made available, barriers to their uptake are overcome, demand is created, and use is consistent and occurs at the right scale with high coverage. This paper discusses how programmatic targets for prevention in a worldwide plan could be used to re-energise the HIV prevention approach. A management framework is proposed outlining global, regional, national, and subnational actions and is summarised in a call for action on HIV prevention for 2020.

First HIV prevalence estimates of a representative sample of adult sub-Saharan African migrants in a European city. Results of a community-based, cross-sectional study in Antwerp, Belgium

Introduction

While sub-Saharan African migrants are the second largest group affected by HIV in Europe, sound HIV prevalence estimates based on representative samples of these heterogeneous communities are lacking. Such data are needed to inform prevention and public health policy.

Methods

This community-based, cross-sectional study combined oral fluid HIV testing with an electronic behavioral survey. Adopting a two-stage time location sampling HIV prevalence estimates for a representative sample of adult sub-Saharan African migrants in Antwerp, Belgium were obtained. Sample proportions and estimated adjusted population proportions were calculated for all variables. Univariable and multivariable logistic regression analysis explored factors independently associated with HIV infection.

Results

Between December 2013 and October 2014, 744 sub-Saharan African migrants were included (37% women). A substantial proportion was socially, legally and economically vulnerable: 21% were probably of undocumented status, 63% had financial problems in the last year and 9% lacked stable housing. Sexual networks were mostly African and crossed national borders, i.e. sexual encounters during travels within Europa and Africa. Concurrency is common, 34% of those in a stable relationship had a partner on the side in the last year. HIV prevalence was 5.9%(95%CI:3.4%-10.1%) among women and 4.2% (95%CI:1.6%-10.6%) among men. Although high lifetime HIV testing was reported at community level (73%), 65.2% (CI95%:32.4%-88.0%) of sub-Saharan African migrants were possibly undiagnosed. Being 45 years or older, unprotected sex when travelling within Europe in the last year, high intentions to use condoms, being unaware of their last sexual partners’ HIV status, recent HIV testing and not having encountered partner violence in the last year were independently associated with HIV infection in multivariable logical regression. In univariable analysis, HIV infection was additionally associated to unemployment.

Conclusions

This is the first HIV prevalence study among adult sub-Saharan African migrants resettling in a European city based on a representative sample. HIV prevalence was high and could potentially increase further due to the high number of people with an undiagnosed HIV infection, social vulnerability, high levels of concurrency and mainly African sexual networks. Given this population’s mobility, an aligned European combination prevention approach addressing these determinants is urgently needed.

Pre-Exposure Prophylaxis (PrEP) as an Additional Tool for HIV Prevention Among Men Who Have Sex With Men in Belgium: The Be-PrEP-ared Study Protocol

Background

Pre-exposure prophylaxis (PrEP) is a promising and effective tool to prevent HIV. With the approval of Truvada as daily PrEP by the European Commission in August 2016, individual European Member states prepare themselves for PrEP implementation following the examples of France and Norway. However, context-specific data to guide optimal implementation is currently lacking.

Objective

With this demonstration project we evaluate whether daily and event-driven PrEP, provided within a comprehensive prevention package, is a feasible and acceptable additional prevention tool for men who have sex with men (MSM) at high risk of acquiring HIV in Belgium. The study’s primary objective is to document the uptake, acceptability, and adherence to both daily and event-driven PrEP, while several secondary objectives have been formulated including impact of PrEP use on sexual behavior.

Methods

The Be-PrEP-ared study is a phase 3, single-site, open-label prospective cohort study with a large social science component embedded in the trial. A total of 200 participants choose between daily or event-driven PrEP use and may switch, discontinue, or restart their regimen at the 3-monthly visits for a duration of 18 months. Data are collected on several platforms: an electronic case report form, a Web-based tool where participants register their sexual behavior and pill use, a more detailed electronic self-administered questionnaire completed during study visits on a tablet computer, and in-depth interviews among a selected sample of participants. To answer the primary objective, the recruitment rate, (un)safe sex behavior during the last 6 months, percentage of reported intention to use PrEP in the future, retention rates in different regimens, and attitudes towards PrEP use will be analyzed. Adherence will be monitored using self-reported adherence, pill count, tenofovir drug levels in blood samples, and the perceived skills to adhere.

Results

All participants are currently enrolled, and the last study visit is planned to take place around Q3 2018.

Conclusions

As PrEP is not yet available in Belgium for use, this study will provide insights into how to optimally implement PrEP within the current health care provision and will shape national and European guidelines with regard to the place of PrEP in HIV prevention strategies.

ClinicalTrial

EU Clinical Trial 2015-000054-37; https://www.clinicaltrialsregister.eu/ctr-search/trial/2015-000054-37/BE (Archived by WebCite at http://www.webcitation.org/6nacjSdmM).

Pre-exposure prophylaxis (PrEP) for men who have sex with men in Europe: review of evidence for a much needed prevention tool

In many Western countries with good coverage of antiretroviral treatment (ART) programmes the annual number of HIV infections is still high and not (yet) declining among men who have sex with men (MSM). This might indicate that antiretroviral treatment roll-out alone will not turn around the course of the epidemic and that new, additional tools are needed. Antiretrovirals used as prevention tools for people not yet infected with HIV, such as pre-exposure prophylaxis (PrEP) could be such important additional tools. PrEP is a new type of biomedical prevention, which involves the use of antiretrovirals before, during and after (periods of) sexual exposure to HIV. In this review, we will focus on PrEP as a new prevention tool for MSM at high risk in Europe, including its evidence for effectiveness, challenges for implementation, ongoing European demonstration studies; as well as how PrEP relates to other existing prevention tools. In light of European Medicines Agency's recent recommendation for approval of PrEP we briefly review the potential implications.

TOGETHER Project to Increase Understanding of the HIV Epidemic Among Sub-Saharan African Migrants: Protocol of Community-Based Participatory Mixed-Method Studies

Background

Sub-Saharan African Migrants (SAM) are the second largest group affected by HIV/AIDS in Belgium and the rest of Western Europe. Increasing evidence shows that, more than previously thought, SAM are acquiring HIV in their host countries. This calls for a renewed focus on primary prevention. Yet, knowledge on the magnitude of the HIV epidemic among SAM (HIV prevalence estimates and proportions of undiagnosed HIV infections) and underlying drivers are scarce and limit the development of such interventions.

Objective

By applying a community-based participatory and mixed-methods approach, the TOGETHER project aims to deepen our understanding of HIV transmission dynamics, as well as inform future primary prevention interventions for this target group.

Methods

The TOGETHER project consists of a cross-sectional study to assess HIV prevalence and risk factors among SAM visiting community settings in Antwerp city, Belgium, and links an anonymous electronic self-reported questionnaire to oral fluid samples. Three formative studies informed this method: (1) a social mapping of community settings using an adaptation of the PLACE method; (2) a multiple case study aiming to identify factors that increase risk and vulnerability for HIV infection by triangulating data from life history interviews, lifelines, and patient files; and (3) an acceptability and feasibility study of oral fluid sampling in community settings using participant observations.

Results

Results have been obtained from 4 interlinked studies and will be described in future research.

Conclusions

Combining empirically tested and innovative epidemiological and social science methods, this project provides the first HIV prevalence estimates for a representative sample of SAM residing in a West European city. By triangulating qualitative and quantitative insights, the project will generate an in-depth understanding of the factors that increase risk and vulnerability for HIV infection among SAM. Based on this knowledge, the project will identify priority subgroups within SAM communities and places for HIV prevention. Adopting a community-based participatory approach throughout the full research process should increase community ownership, investment, and mobilization for HIV prevention.

Women with HIV in Indonesia: are they bridging a concentrated epidemic to the wider community?

Background

Male injecting drug users drove the onset of the HIV epidemic in Indonesia but over time more women have been diagnosed. We examined the relative proportion of female patients in an HIV cohort and characterized their probable transmission route and reproductive profile.

Designs

Prospective cohort study in a referral hospital in West Java.

Methods

Interviews with standardized questionnaires, physical and laboratory examinations were done for 2622 individuals enrolled in HIV care between 2007 and 2012. The proportion of women in this cohort was compared with national estimates. The general characteristics of HIV-infected women and men as well as the sexual and reproductive health of HIV-infected women were described.

Results

The proportion of female patients enrolled in HIV care increased from 22.2 % in 2007 to 38.3 % in 2012, in line with national estimates. Women were younger than men, fewer reported a history of IDU (16.1 vs. 73.8 %, p < 0.001) and more were tested for HIV because of a positive partner (25.5 vs. 4.0 %, p < 0.001). The majority of women were in their reproductive age, had children, and were not using contraceptives at the time of enrolment.

Conclusion

HIV-infected women in Indonesia have specific characteristics that differ them from women in the general population. Further research to elucidate the characteristics of women exposed to HIV, their access to testing and care and sexual and reproductive needs can help reduce transmission to women and children in the context of concentrated HIV epidemic in Indonesia.

Exploring risk behaviors and vulnerability for HIV among men who have sex with men in Abidjan, Cote d'Ivoire: poor knowledge, homophobia and sexual violence

Men who have sex with men (MSM) are at high risk of HIV. Few data are available on MSM and HIV-related risk behaviors in West Africa. We aimed to describe risk behaviors and vulnerability among MSM in Abidjan, Cote d′Ivoire. We conducted a cross-sectional respondent-driven sampling survey with 601 MSM in 2011–2012. Sociodemographic and behavioural data as well as data related to emotional state and stigma were collected. Population estimates with 95% confidence intervals were produced. Survey weighted logistic regression was used to assess factors associated with inconsistent condom use in the prior 12 months. Most MSM were 24 years of age or younger (63.9%) and had attained at least primary education (84.4%). HIV risk behaviors such as low condom and water-based lubricant use, high numbers of male and female sex partners, and sex work were frequently reported as well as verbal, physical and sexual abuse. Inconsistent condom use during anal sex with a male partner in the prior 12 months was reported by 66.0% of the MSM and was positively associated with history of forced sex, alcohol consumption, having a regular partner and a casual partner, having bought sex, and self-perception of low HIV risk. MSM in Abidjan exhibit multiple and frequent HIV-related risk behaviors. To address those behaviours, a combination of individual but also structural interventions will be needed given the context of stigma, homophobia and violence.

Four-year retention and risk factors for attrition among members of community ART groups in Tete, Mozambique

OBJECTIVE

Community ART groups (CAG), peer support groups involved in community ART distribution and mutual psychosocial support, were piloted to respond to staggering antiretroviral treatment (ART) attrition in Mozambique. To understand the impact of CAG on long-term retention, we estimated mortality and lost-to-follow-up (LTFU) rates and assessed predictors for attrition.

METHODS

Retrospective cohort study. Kaplan-Meier techniques were used to estimate mortality and LTFU in CAG. Individual- and CAG-level predictors of attrition were assessed using a multivariable Cox proportional hazards model, adjusted for site-level clustering.

RESULTS

Mortality and LTFU rates among 5729 CAG members were, respectively, 2.1 and 0.1 per 100 person-years. Retention was 97.7% at 12 months, 96.0% at 24 months, 93.4% at 36 months and 91.8% at 48 months. At individual level, attrition in CAG was significantly associated with immunosuppression when joining a CAG, and being male. At CAG level, attrition was associated with lack of rotational representation at the clinic, lack of a regular CD4 count among fellow members and linkage to a rural or district clinic compared with linkage to a peri-urban clinic.

CONCLUSIONS

Long-term retention in this community-based ART model compares favourably with published data on stable ART patients. Nevertheless, to reduce attrition, further efforts need to be made to enroll patients earlier on ART, promote health-seeking behaviour, especially for men, promote a strong peer dynamic to assure rotational representation at the clinic and regular CD4 follow-up and reinforce referral of sick patients.

International mobility, sexual behaviour and HIV-related characteristics of men who have sex with men residing in Belgium

Background

European men who have sex with men (MSM) continue to be disproportionally affected by the human immunodeficiency virus (HIV). Several factors are contributing to the rates of new HIV infections among MSM. The aim of this study was to investigate the potential role of travel behaviour and sexual mobility in the spread of HIV and sexually transmitted infections (STI) among European MSM.

Methods

Belgian data from the first pan-European MSM internet survey EMIS was used (n=3860) to explore individual and contextual determinants of sexual behaviour among MSM, who resided in Belgium at the time of data collection and who reported having had sexual contact abroad in the last 12 months. Descriptive and bivariate analyses were performed. Odds ratios and 95% confidence intervals were calculated by means of logistic regression.

Results

MSM who practiced unprotected anal intercourse UAI during their last sexual encounter abroad were less likely to be living in a large city (OR:0.62, 95% CI:0.45-0,86, p<0.01) and more likely to be HIV positive (OR:6.20, 95% CI:4.23-9.06, p<0.001) ), to have tested HIV positive in the last 12 months (OR:3.07, 95% CI:1.07-8.80, p<0.05), to have been diagnosed with any STI in the last 12 months (OR:2.55; 95% CI:1.77-3.67, p<0.05), to have used party drugs (OR:2.22, 95% CI:1.59-3.09, p<0.001), poppers (OR:1.52, 95% CI:1.07-2.14, p<0.001) and erection enhancing substances (OR:2.23, 95% CI:1.61-3.09, p<0.001) compared to MSM who did not have UAI with their last sexual partner abroad. Men having had UAI in the last 12 months were more likely to have done so in a neighbouring country of Belgium (OR:1.66, 95% CI:1.21-2.29, p<0.001). Different sexual behavioural patterns related to condom use and drug use were identified according to HIV test status among travelling men.

Conclusions

The results of this study provide evidence for the role of international mobility and sexual behavior while travelling, in the spread of HIV and STI among MSM in Europe. Further, the findings underline the need for development of European cross-border HIV and STI interventions with coherent messages and prevention policies for MSM.

Community-based antiretroviral therapy programs can overcome barriers to retention of patients and decongest health services in sub-Saharan Africa: a systematic review

In sub-Saharan Africa models of care need to adapt to support continued scale up of antiretroviral therapy (ART) and retain millions in care. Task shifting, coupled with community participation has the potential to address the workforce gap, decongest health services, improve ART coverage, and to sustain retention of patients on ART over the long-term. The evidence supporting different models of community participation for ART care, or community-based ART, in sub-Saharan Africa, was reviewed. In Uganda and Kenya community health workers or volunteers delivered ART at home. In Mozambique people living with HIV/AIDS (PLWHA) self-formed community-based ART groups to deliver ART in the community. These examples of community ART programs made treatment more accessible and affordable. However, to achieve success some major challenges need to be overcome: first, community programs need to be driven, owned by and embedded in the communities. Second, an enabling and supportive environment is needed to ensure that task shifting to lay staff and PLWHA is effective and quality services are provided. Finally, a long term vision and commitment from national governments and international donors is required. Exploration of the cost, effectiveness, and sustainability of the different community-based ART models in different contexts will be needed.

What is the place of pre-exposure prophylaxis in HIV prevention?

New tools are needed to bring down ongoing high HIV incidence. This review aims to evaluate the place of one of these new tools (pre-exposure prophylaxis) in a comprehensive prevention strategy. Several trials have demonstrated the safety and the efficacy of pre-exposure prophylaxis in HIV prevention. Two large trials have, however, failed to show such efficacy. This was likely due to poor adherence in these trials. New forms of long-acting pre-exposure prophylaxis currently in trials may deal with these problems of low adherence. Pre-exposure prophylaxis has been demonstrated to be cost-effective within certain settings. The introduction of pre-exposure prophylaxis into prevention programs needs to be carefully thought through. For example, pre-exposure prophylaxis-induced risk compensation, at both an individual and population level, could undermine other aspects of a comprehensive HIV prevention program. In conclusion, pre-exposure prophylaxis could be a useful additional tool for the prevention of HIV in specific high-risk groups. It should be implemented in a way that deals with issues such as ensuring high adherence and ensuring that pre-exposure prophylaxis does not detract from, but complements, other more fundamental elements of HIV prevention programs.

Return to normal life after AIDS as a reason for lost to follow-up in a community-based antiretroviral treatment program

OBJECTIVES

To understand reasons for lost-to-follow-up (LTFU) from a community-based antiretroviral therapy program in Uganda.

STUDY DESIGN

Retrospective cohort of patients LTFU between May 31, 2001, to May 31, 2010, was examined. A representative sample of 579 patients traced to ascertain their outcomes.

METHODS

Mixed methods were used. Using "stopped care" as the hazard and "self-transferred" as the comparator, we examined using Cox proportional multivariable model risk factors for stopping care.

RESULTS

Overall, 2933 of 3954 (74.0%) patients were LTFU. Of 579 of 2933 (19%) patients sampled for tracing, 32 (5.5%) were untraceable, 66(11.4 %) were dead, and 481 (83.0%) found alive. Of those found alive, 232 (40.0%) stopped care, 249 (43.0%) self-transferred, whereas 61 (12.7%) returned to care at Reach Out Mbuya HIV/AIDS Initiative. In adjusted hazards ratios, born-again religion, originating from outside Kampala, resident in Kampala for <5 years but >1 year, having school-age children who were out of school, non-HIV disclosure, CD4 counts >250 cells per cubic millimeter and pre-antiretroviral therapy were associated with increased risk of stopping care. Qualitative interviews revealed return to a normal life as a key reason for LTFU. Of 61 patients who returned to care, their median CD4 count at LTFU was higher than on return into care (401/mm³ vs. 205/mm³, P < 0.0001).

CONCLUSIONS

Many patients become LTFU during the course of years, necessitating the need for effective mechanisms to identify those in need of close monitoring. Efforts should be made to improve referrals and mechanisms to track patients who transfer to different facilities. Additionally, tracing of patients who become LTFU is required to convince them to return.