A Systematic Review of Oral Pre-exposure Prophylaxis HIV Adherence Interventions

A second decade of PrEP.

Oral preexposure prophylaxis (PrEP) with antiretrovirals (ARVs) is at the forefront of biomedical HIV prevention research, and ARVs are also being tested for rectal administration to target people practicing unprotected receptive anal intercourse (URAI) and at risk of HIV infection. This study assessed the acceptability of daily oral PrEP and rectal PrEP during URAI among men who have sex with men (MSM) and transgender women (TGW) in Peru. During the 2008 HIV sentinel surveillance survey conducted in 3 Peruvian cities (Lima, Iquitos, and Pucallpa), MSM and TGW reported being "versatile," "most of the time receptive," and "exclusively receptive" during anal sex behavior where surveyed on their acceptability of oral and rectal PrEP. Among 532 individuals, high acceptance of either oral (96.2%) or rectal (91.7%) PrEP products was reported. If both products were efficacious/available, 28.6% would prefer a pill, 57.3% a rectal lubricant, and 14.1% either. A trend toward higher acceptance was observed as receptive anal sex behavior exclusivity rose (P = .013). Being receptive most of the time (adjusted odds ratio [aOR]: 9.1, P = .01) and exclusively receptive (aOR: 7.5, P = .01), compared to being versatile, were independently associated with oral PrEP acceptability. A similar association was found with the acceptability of rectal formulations (aOR: 2.3, P = .07; and aOR: 2.5, P = .02; respectively). Oral and rectal PrEP were highly acceptable among Peruvian MSM and TGW, particularly among those at the highest HIV infection risk. These data can guide the implementation of PrEP programs in Peru and similar settings and populations.

SummaryBackgroundCommunity-based oral pre-exposure prophylaxis (PrEP) provision has the potential to expand PrEP coverage. HIV self-testing can facilitate PrEP community-based delivery but might have lower sensitivity than facility-based HIV testing, potentially leading to inappropriate PrEP use among people with HIV and subsequent development of drug resistance. We aimed to evaluate the impact of HIV self-testing use for PrEP scale-up.MethodsWe parameterised an agent-based network model, EMOD-HIV, to simulate generic tenofovir disoproxil fumarate and emtricitabine PrEP scale-up in western Kenya using four testing scenarios: provider-administered nucleic acid testing, provider-administered rapid diagnostic tests detecting antibodies, blood-based HIV self-testing, or oral fluid HIV self-testing. Scenarios were compared with a no PrEP counterfactual. Individuals aged 18–49 years with one or more heterosexual partners who screened HIV-negative were eligible for PrEP. We assessed the cost and health impact of rapid PrEP scale-up with high coverage over 20 years, and the budget impact over 5 years, using various HIV testing modalities.FindingsPrEP coverage of 29% was projected to avert approximately 54% of HIV infections and 17% of HIV-related deaths among adults aged 18–49 years over 20 years; health impacts were similar across HIV testing modalities used to deliver PrEP. The percentage of HIV infections with PrEP-associated nucleoside reverse transcriptase inhibitor (NRTI) drug resistance was 0·6% (95% uncertainty intervals 0·4–0·9) in the blood HIV self-testing scenario and 0·8% (0·6–1·0) in the oral HIV self-testing scenario, compared with 0·3% (0·2–0·3) in the antibody rapid diagnostic testing scenario and 0·2% (0·1–0·2) in the nucleic acid testing scenario. Accounting for background NRTI resistance, we found similarly low proportions of drug resistance across scenarios. The budget impact of implementing PrEP using HIV self-testing and provider-administered rapid diagnostic tests were similar, while nucleic acid testing was approximately 50% more costly.InterpretationScaling up PrEP using HIV self-testing has similar health impacts, costs, and low risk of drug resistance as provider-administered rapid diagnostic tests. Policy makers should consider leveraging HIV self-testing to expand PrEP access among those at HIV risk.FundingThe Bill and Melinda Gates Foundation.

We sought to determine preferences for oral versus long-acting injectable (LAI) PrEP among gay and bisexual men (GBM). We surveyed a national U.S. sample of 1071 GBM about forms of PrEP. LAI PrEP was found to be acceptable among 43.2% of men when injected monthly compared with 53.6% of men when injected every 3months. When asked to choose between forms of PrEP, 46.0% preferred LAI, 14.3% oral, 21.7% whichever was most effective, 10.1% had no preference, and 7.8% would not take PrEP. There were no differences in PrEP preferences by race/ethnicity, income, region of residence, or relationship status. Those unwilling to take PrEP were significantly older than those who preferred LAI PrEP and those who would take either. Those who preferred the most effective form were younger, had less education, and reported more recent club drug use. Those who reported condomless anal sex and those who thought they were good PrEP candidates were more willing to take PrEP. Long-term health and side effects were of the greatest concern for both LAI and oral PrEP. The availability of LAI PrEP has the potential to increase uptake among GBM. The results of ongoing clinical trials of LAI PrEP will need to demonstrate similar or greater efficacy as daily Truvada for uptake to be maximized.

A Systematic Review of Oral Pre-exposure Prophylaxis HIV Adherence Interventions

Understanding women’s decision-making when offered different HIV pre-exposure prophylaxis (PrEP) options is critical for improving uptake. This qualitative study explored factors influencing PrEP choices among Swazi women in 2022–2023. In-depth interviews were conducted with 17 women who accepted or declined oral PrEP or the Dapivirine vaginal ring; and 6 healthcare workers who prescribed PrEP. One focus group discussion (FGD) with eight women eligible for PrEP and three FGDs with six to eight male community members explored attitudes to PrEP. Data were collected in Siswati, transcribed into English, and analyzed thematically. Women’s decisions around PrEP use and product preferences were shaped by social norms around sexual relationships, practicalities of use and perceptions of effectiveness. Many preferred “invisible” methods, such as the ring, to avoid stigma or partner violence, while oral PrEP was favored by some women practicing anal sex. Ease of adherence, side-effects and ring insertion practicalities also influenced choices. Some participants questioned PrEP effectiveness or feared it might spread HIV, while some healthcare workers noted that future injectable options could reduce blame in cases of seroconversion. The findings highlight the need to offer women a range of PrEP options, supported by accurate information, to expand coverage in high-incidence settings.

Long-acting injectable (LAI) pre-exposure prophylaxis (PrEP) has potential to increase PrEP uptake and adherence. However, most studies investigating opinions about LAI PrEP were done prior to its approval. We administered a cross-sectional electronic survey to clients at an urban PrEP clinic in the U.S. South. Eligible participants were 18 + and had previously taken or been prescribed oral or LAI PrEP. They were asked their opinions on PrEP, barriers to access, perceived HIV risk, and PrEP stigma. Between January and April 2024, 123 people participated. Twenty-two (17.9%) used LAI PrEP, 80 (65.0%) oral PrEP, and 21 (17.1%) were not currently using PrEP. Most participants identified as men (87.8%), and mean age was 38.6 (range 19-78). Participants were 52.8% White, 27.6% Black, and 14.6% Latinx. 56.1% preferred injection versus daily oral pill. Common concerns about PrEP included side effects (n = 48), cost of medication (n = 21), and cost of clinic visits/tests (n = 21). Of those taking oral PrEP, 56.3% reported remaining on oral because LAI was not offered to them and/or they were not aware of it. Perceived HIV risk scores were on average higher for those not currently taking PrEP (not on = 26.8, SD = 6.54; LAI = 22.3, SD = 6.45; oral = 24.2, SD = 6.13). Overall, participants had low to moderate PrEP stigma scores. Despite majority preference for LAI PrEP, patients are frequently unaware of or not offered LAI. Common concerns about PrEP include side effects and costs. These data demonstrate the importance of improving LAI PrEP awareness and accessibility of choice.

ObjectivesUK Black African/Black Caribbean women remain disproportionately affected by HIV. Although oral pre-exposure prophylaxis (PrEP) could offer them an effective HIV prevention method, uptake remains limited. This study examined barriers...

Pre-exposure prophylaxis (PrEP) prevents HIV infection among female sex workers (FSW). WHO recommends the use of Tenofovir disoproxil fumarate for use in oral PrEP regimens (TDF). Emtricitabine (FTC) 200 mg/Tenofovir Disoproxil Fumarate (TDF) 300 mg (Truvada) daily is the approved PrEP regimen in Tanzania. Evidence is limited on oral PrEP uptake and its associated factors in countries with a high burden of HIV, such as Tanzania. This study aimed to examine the uptake of oral PrEP and its associated factors among FSW in the Tanga region of Tanzania. This community-based cross-sectional study was conducted among 428 FSW. Data were collected through face-to-face interviews and analysed using STATA version 17 and RDSAT. Logistic regression was used to examine the associations of independent factors and PrEP uptake among study participants. About 55% of the recruited FSW used oral PrEP. FSW with three or more children were 2.41 times more likely to take oral PrEP (AOR 2.41, 95% CI: 1.08–4.25, p < 0.05). Moreover, those with a positive attitude were more likely to use oral PrEP (AOR 2.8, 95% CI: 1.88–4.17, p < 0.05). Poor belief was a barrier to PrEP use, and side effects of the drugs were a reason for the discontinuation of PrEP services. Most of the participants preferred PrEP services to be provided in the community. Oral PrEP uptake was 55%. Efforts to scale up PrEP for FSW should address misconceptions regarding PrEP, PrEP sensitization, and improving access through community-based intervention.

Cisgender women, particularly pregnant and postpartum women in Eastern and Southern Africa, face an unacceptably high risk of HIV acquisition. Oral pre-exposure prophylaxis (PrEP) is an effective HIV prevention intervention that can reduce HIV acquisition and vertical transmission. In this qualitative study, we interviewed 21 postpartum women from Cape Town, South Africa who initiated PrEP during pregnancy and who self-reported low PrEP adherence or missed > 1 PrEP follow-up collection. We identified multiple overlapping barriers to PrEP continuation and/or adherence. Individual factors included forgetting to take PrEP daily, being away from home when PrEP should be taken, anticipated stigma and limited disclosure of PrEP use. Women also reported pill-related factors such as side effects and having to take PrEP in addition to other tablets during pregnancy and the postpartum period. Facility-related barriers included logistics around PrEP collection especially when not in antenatal care, as well as transport and financial barriers.

BackgroundDaily oral (DO) HIV pre-exposure prophylaxis (PrEP) effectively prevents HIV acquisition, but few men who have sex with men (MSM) currently use it. Newer options, such as on-demand (OD) oral and long-acting injectable (LA) PrEP may improve uptake, but little is understood about relative preferences among these options in practical start scenarios. Preferences for starting various PrEP options were examined among a US nationwide online convenience sample of MSM age 15+ collected September 2021 to February 2022.MethodsParticipants reporting no prior HIV diagnosis were given brief descripitions of each PrEP option and were asked “If [PrEP option] were available from your local doctor and you could access it for free, would you go to your doctor in the next month to start [PrEP option]?” Those who said yes to multiple options were asked to rank them in order of preference. MSM currently taking DO PrEP were asked whether they would switch to OD or LA. Willingness to start LA was examined by age, race/ethnicity, insurance, and prior awareness of LA.ResultsOf 5585 MSM not currently using DO PrEP, 50% (n=2805) would start at least one option with greatest preference for OD (Figure 1). Among this group, 73% (n=2060) were willing to start more than one option, with LA the most preferred option. Among the 27% (n=745) who would start only one, OD was the most preferred. Overall, 58% of DO PrEP users (n=1342/2332) would switch to either OD or LA, with LA being most preferred (Figure 2). Hispanic MSM who were not DO PrEP users were more likely to start LA compared to white MSM, and those with other/multiple health insurance were less likely to start LA compared to those on private health insurance (Table 1). Regardless of current DO PrEP use, MSM aware of LA were more likely to start it.ConclusionThere is substantial interest in new PrEP options. Current DO PrEP users appear to be more aware of and interested in LA than PrEP naïve. Although OD PrEP may be favored by those who are PrEP-naïve, most selected multiple options and preferred LA PrEP. Increasing awareness of LA PrEP may bolster interest in its use. These findings highlight the potential role that newer PrEP options will play in community uptake of PrEP and can also inform patient-provider decisions about which PrEP options to consider.DisclosuresTravis Sanchez, DVM, MPH, ViiV Healthcare: Grant/Research Support S. Wilson Beckham, PhD, MPH, MA, Viiv Healthcare: Advisor/Consultant Keith Rawlings, MD, ViiV Healthcare: Employee Alex R. Rinehart, PhD, ViiV Healthcare: Stocks/Bonds Supriya Sarkar, PhD, MPH, ViiV Healthcare: Salary|ViiV Healthcare: Stocks/Bonds Vani Vannappagari, MBBS, MPH, PhD, ViiV Healthcare: I am full time employee of ViiV Healthcare and receive GlaxoSmithKline stock as part of my compensation package|ViiV Healthcare: Stocks/Bonds.

Renal Outcomes Over the Course of 5 Years of Oral HIV Preexposure Prophylaxis Using Tenofovir Disoproxil/Emtricitabine

SummaryBackgroundIn 2016, the UN General Assembly set a global target of 3 million oral pre-exposure prophylaxis (PrEP) users by 2020. With this target at an end, we aimed to assess global trends in the adoption of WHO PrEP recommendations into national guidelines and numbers of PrEP users, defined as people who received oral PrEP at least once in a given year, and to estimate future trajectories of PrEP use.MethodsIn this global summary and forecasting study, data on adoption of WHO PrEP recommendations and numbers of PrEP users were obtained through the Global AIDS Monitoring system and WHO regional offices. Trends in these indicators for 2016–19 by region and for 2019 by country were described, including by gender and priority populations where data were available. PrEP user numbers were forecasted until 2023 by selecting countries with at least 3 years of PrEP user data as example countries in each region to represent possible future PrEP user trajectories. PrEP user growth rates observed in example countries were applied to countries in corresponding regions under different scenarios, including a COVID-19 disruption scenario with static global PrEP use in 2020.FindingsBy the end of 2019, 120 (67%) of 180 countries with data had adopted the WHO PrEP recommendations into national guidelines (23 in 2019 and 30 in 2018). In 2019, there were about 626 000 PrEP users across 77 countries, including 260 000 (41·6%) in the region of the Americas and 213 000 (34·0%) in the African region; this is a 69% increase from about 370 000 PrEP users across 66 countries in 2018. Without COVID-19 disruptions, 0·9–1·1 million global PrEP users were projected by the end of 2020 and 2·4–5·3 million are projected by the end of 2023. If COVID-19 disruptions resulted in no PrEP user growth in 2020, the projected number of PrEP users in 2023 is 2·1–3·0 million.InterpretationWidespread adoption of WHO PrEP recommendations coincided with a global increase in PrEP use. Although the 2020 global PrEP target will be missed, strong future growth in PrEP use is possible. New PrEP products could expand the PrEP user base, and, with greater expansion of oral PrEP, further adoption of WHO PrEP recommendations, and simplified delivery, PrEP could contribute to ending AIDS by 2030.FundingUnitaid, Bill & Melinda Gates Foundation, and WHO.

ObjectivesTo describe the experiences of oral HIV pre-exposure prophylaxis (PrEP) use, preferences comparing oral PrEP to future long-acting PrEP products (the dapivirine vaginal ring (PrEP ring) and injectable cabotegravir (CAB...

BackgroundEmpowering female sex workers (FSWs) through women controlled HIV prevention option has been in focus globally. FSWs are important target for oral pre exposure prophylaxis (PrEP). A multi-centric qualitative study was conducted to explore the FSWs’ willingness to use oral PrEP in India.MethodsSeventy three interviews and 02 focus group discussions were conducted at 3 high HIV prevalent states in India during 2013–14. Study explored issues around willingness to use oral PrEP. The study was approved by the respective institutional ethics committee of the study sites. Thematic analysis using grounded theory approach was used to analyze the data in N-VIVO version 8.0.ResultsThematic analysis showed events of forced condom-less sex. FSWs believed that oral PrEP could provide independence, financial gains, and privacy and therefore hoped to use it as an alternative to male condom. However, any impact on physical/ aesthetic attributes and reproductive system were not acceptable and could become a barrier. Provider initiated oral PrEP was not preferred. Providers voiced safety monitoring concerns. Adherence emerged as a challenge because of: (1) alcohol use; (2) taking PrEP tablet each day being boring; (3) Stigma because Oral PrEP is ARV based. Alcohol use and dread of repetitive dose brings forth the need for long acting oral PrEP.ConclusionOral PrEP is acceptable among FSWs; it should be rolled out alongside strong messages on STI protection and PrEP as compliment to condoms. PrEP roll out requires educating communities about HIV treatment versus prevention. Long-acting oral PrEP could address both ‘boredom’ and alcoholism and sustain adherence.