Abstract
Introduction: Pre-exposure prophylaxis (PrEP) is provided free of costs to at-risk populations in Kenya, including men who have sex with men (MSM), but anal intercourse is not an eligibility criterion. We set out to determine PrEP eligibility, uptake and predictors of PrEP uptake among MSM enrolled in an HIV-1 vaccine feasibility cohort in coastal Kenya. Methods: We compared the number of MSM identified as eligible for PrEP from June-December 2017 by Kenyan Ministry of Health (MoH) criteria, which do not include reported anal intercourse, to those identified as eligible by a published MSM cohort-derived HIV-1 risk score (CDHRS). We determined PrEP uptake and assessed factors associated with uptake at first offer among eligible MSM followed up monthly. Results: Out of 167 MSM assessed for PrEP eligibility, 118 (70.7%) were identified by both MoH and CDHRS eligibility criteria; 33 (19.8%) by CDHRS alone, 11 (6.6%) by MoH criteria alone, and 5 (3.0%) by neither criterion. Of the men identified by CDHRS alone, the majority (24 or 72.7%) reported receptive anal intercourse (RAI). Of the 162 MSM eligible for PrEP, 113 (69.7%) accepted PrEP at first offer. Acceptance of PrEP was higher for men reporting RAI (adjusted prevalence ratio [aPR], 1.4; 95% confidence interval [CI], 1.0-1.9), having paid for sex (aPR, 1.3; 95% CI, 1.1-1.6) and group sex (aPR, 1.4; 95% CI, 1.1-1.8), after adjustment for sociodemographic factors. Conclusions: Assessing PrEP eligibility using the CDHRS identified 20% more at-risk MSM for PrEP initiation than when Kenyan MoH criteria were used. Approximately 70% of eligible men accepted PrEP at first offer, suggesting that PrEP is acceptable among at-risk MSM. MSM reporting RAI, group sex, or paying for sex were more likely to accept PrEP. Incorporating RAI into MoH PrEP eligibility criteria would enhance the impact of PrEP programming in Kenya.
Highlights
Pre-exposure prophylaxis (PrEP) is provided free of costs to at-risk populations in Kenya, including men who have sex with men (MSM), but anal intercourse is not an eligibility criterion
In 2017, we developed an empiric risk score to guide PrEP targeting among at-risk MSM who were followed in a vaccine feasibility study in coastal Kenya with an HIV-1 incidence of 7.0 (95% confidence interval [CI], 5.8-8.6) per 100 person-years
Meeting any of the Ministry of Health (MoH) criteria had a sensitivity of 87.6% and specificity of 16.6%, while meeting any of the cohort-derived HIV-1 risk score (CDHRS) criteria had a sensitivity of 97.9% and specificity of 16.9% for detecting visits at which men had acquired HIV-1
Summary
Pre-exposure prophylaxis (PrEP) is provided free of costs to at-risk populations in Kenya, including men who have sex with men (MSM), but anal intercourse is not an eligibility criterion. Methods: We compared the number of MSM identified as eligible for PrEP from June-December 2017 by Kenyan Ministry of Health (MoH) criteria, which do not include reported anal intercourse, to those identified as eligible by a published MSM cohort-derived HIV-1 risk score (CDHRS). We determined PrEP uptake and assessed factors associated with uptake at first offer among eligible MSM followed up monthly. Conclusions: Assessing PrEP eligibility using the CDHRS identified 20% more at-risk MSM for PrEP initiation than when Kenyan MoH criteria were used. “Because the CDHRS tool demonstrated good performance in predicting HIV-1 acquisition among MSM in this cohort, we were interested in comparing its performance to that of the national MoH guidelines for PrEP eligibility, which were developed for use in all populations at risk for HIV-1 acquisition and not for MSM.”. “Because the CDHRS tool demonstrated good performance in predicting HIV-1 acquisition among MSM in this cohort, we were interested in comparing its performance to that of the national MoH guidelines for PrEP eligibility, which were developed for use in all populations at risk for HIV-1 acquisition and not for MSM.” detailed list of the MoH criteria has been included in the fourth paragraph of the methods section under the sub-heading “Preparing MSM for PrEP uptake”
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