Future Pre-exposure Prophylaxis Research Articles

‘Why are PrEP gays always like this … ’: psychosocial influences on U.K.-based men who have sex with men’s perceptions and use of HIV pre-exposure prophylaxis

ABSTRACT Background Pre-Exposure Prophylaxis (PrEP) is a prescription-based drug used to prevent the spread of Human Immunodeficiency Virus (HIV). In the four nations of the United Kingdom, those with increased need for HIV prevention (e.g. some groups of men who have sex with men) are eligible for PrEP for free, provided by the National Health Service. However, the uptake of PrEP has faced several challenges and many still report barriers to accessing PrEP. This current study aimed to augment current understandings of key psychosocial factors that encourage and inhibit PrEP usage. Method Twenty-two individuals participated in a qualitative interview study and thematic analysis was used to analyse the data. Results The findings are presented under three themes: (1) Reckoning with the Legacies of HIV; (2) PrEP versus Condoms: tensions of sexual liberation!; and (3) The Transposition of PrEP Stigma. Conclusion This study highlights current psychosocial barriers to PrEP uptake and use, as well as the benefits (e.g. reduced HIV anxiety) that PrEP usage can elicit. Three superordinate themes describe how PrEP use is influenced by perceptions of HIV and individuals’ condom use preferences. These coalesce into an identity of a ‘PrEP User’, shaping how stigmas associated with PrEP are then both attributed and mitigated. These data hold merit for informing future PrEP uptake campaigns.

Disclosure of oral pre-exposure prophylaxis use for HIV prevention among women enrolled in a contraceptive study: qualitative findings from Durban, South Africa.

Disclosure of oral pre-exposure prophylaxis (PrEP) use for HIV prevention may improve adherence to PrEP; however, disclosure can be challenging and may result in stigma. Here, we describe disclosure of PrEP use among young women enrolled in a contraceptive study. In this qualitative study, we conducted semi-structured, in-depth, face-to-face interviews with 13 women aged 18-25 years who initiated oral PrEP for HIV prevention during the Evidence for Contraceptive Options and HIV Outcomes (ECHO) Trial. Interviews were conducted in 2021 with women from Durban, South Africa. In this analysis, we explore women's experiences of PrEP disclosure including whether they disclosed PrEP use, who they disclosed to and the reaction to disclosure, and the impact of disclosure on PrEP use. Interviews were conducted in English, audio-recorded and transcribed. Data were analysed thematically. All women disclosed oral PrEP use to at least one individual, with some women disclosing to multiple individuals including family, friends, partners and community members. Few women did not disclose oral PrEP use to their partner due to anticipating a negative reaction from the partner, feeling that the partner would assume the woman has HIV and is taking antiretroviral therapy and fear that the partner would associate PrEP use with the woman having other partners. Reactions to oral PrEP disclosure were generally supportive or neutral, however, few women reported negative reactions that included distrust in the efficacy of PrEP to prevent HIV, discouraging the woman from using oral PrEP because of the assumption that PrEP is HIV treatment, and concern about the woman having oral PrEP side effects. Negative reactions to disclosure generally did not impact on oral PrEP use. Supportive disclosures sometimes resulted in reminders for oral PrEP dosing. Our findings indicate that women are willing to disclose their PrEP use to at least one other person when supported. These study findings may contribute to future PrEP counselling guidelines and strategies.

Increasing event-driven HIV pre-exposure prophylaxis use among gay, bisexual and other men who have sex with men in Australia: results from behavioural surveillance 2019-2023.

HIV pre-exposure prophylaxis (PrEP) has been publicly available since 2018 in Australia as a daily regimen. In 2019, clinical guidelines were updated to support guidance on event-driven PrEP (ED-PrEP) use. We assessed trends in the PrEP dosing regimen by comparing daily PrEP use to ED-PrEP among cisgender gay, bisexual and other men who have sex with men (GBMSM). Data from repeated, cross-sectional, national behavioural surveillance surveys were analysed from 2019 to 2023 among participants not living with HIV. Logistic regression models were conducted to assess trends and compared ED-PrEP users to non-PrEP users and daily PrEP. Among 38,880 participants, overall PrEP use with any regimen increased from 27.6% in 2019 to 42.7% in 2023 (OR = 1.16, 95% CI = 1.15-1.18, p < 0.001). Among 12,922 participants who reported PrEP use in the last 6months, the proportion reporting ED-PrEP use increased from 7.6% in 2019 to 27.8% in 2023 (OR = 1.41, 95% CI = 1.37-1.46, p < 0.001) with those who reported daily PrEP decreasing from 92.4% to 63.3% (OR = 0.64, 95% CI = 0.62-0.66, p < 0.001). In a cross-sectional sub-sample in 2022-2023 (n = 8840), compared to ED-PrEP users, non-PrEP users were less likely to have received three or more HIV tests in the last 12 months (aRRR = 0.26, 95% CI = 0.22-0.31, p < 0.001), have 2-10 male sexual partners in the last 6months (aRRR = 0.24, 95% CI = 0.14-0.41, p < 0.001) or 11 or more (aRRR = 0.26, 95% CI = 0.15-0.45, p < 0.001) compared to none, or to report condomless anal intercourse with casual partners (aRRR = 0.38, 95% CI = 0.32-0.46, p < 0.001). Compared to ED-PrEP users, daily PrEP users were more likely to have received three of more HIV tests in the last year (aRRR = 3.73, 95% CI = 3.15-4.40, p < 0.001) and less likely to be born overseas and lived in Australia for less than 5 years compared to being born in Australia (aRRR = 0.64, 95% CI = 0.49-0.83, p = 0.001). While daily PrEP remains the most common PrEP dosing regimen among GBMSM in Australia, there has been a steep increase in the proportion of PrEP users who are taking ED-PrEP. Monitoring of PrEP use should continue to adapt to new dosing methods and future PrEP options. As ED-PrEP use increases, further work is needed to ensure those taking ED-PrEP are taking it effectively to prevent HIV.

Hoping to Adhere? Examining the Relationship Between Hope and Pre-exposure Prophylaxis Willingness, Adherence, and Persistence Among Young Women in South Africa and Zimbabwe (HPTN 082).

Hope is a powerful psychological construct which is linked to positive health. Greater hope is associated with improved antiretroviral therapy adherence; however, less is known about the impact of hope on oral pre-exposure prophylaxis (PrEP) outcomes. HIV Prevention Trials Network 082, was an open-label PrEP study among young women (ages 16-25) in South Africa and Zimbabwe. Hope was measured at baseline and follow-up using a subset of the Hope for the Future Scale (score range 6-24) and PrEP willingness was measured using a subscale of the HIV Prevention Readiness Measure (score range 6-30). Intracellular tenofovir-diphosphate (TFV-DP) concentrations were obtained from dried blood spot samples at weeks 13, 26, and 52; high PrEP adherence was defined as TFV-DP concentrations ≥ 700 fmol/punch. Persistence was defined as TFV-DP > 16 fmol/punch at weeks 26 and 52. Linear regression and generalized estimating equations were used to assess the relationship between hope and PrEP willingness, adherence, and persistence. The median age of participants (n = 432) was 21years (interquartile range [IQR]: 19-22). The mean hope score at baseline was 21.0 (SD = 3.4). Although hope was positively associated with PrEP willingness (β = 0.22, 95% CI 0.15, 0.37), it was not associated with high PrEP adherence (aRR = 1.00, 95% CI 0.96, 1.05), or persistence at follow-up (aRR = 1.02, 95% CI 0.99, 1.05). While cultivating hope may be an important strategy in building willingness to take oral PrEP, it may not be enough to sustain PrEP adherence or persistence.

Applying CFIR to assess multi-level barriers to PrEP delivery in rural South Africa: Processes, gaps and opportunities for service delivery of current and future PrEP modalities

Despite established efficacy for oral pre-exposure prophylaxis (PrEP) in reducing HIV incidence, multi-level barriers within the health system, clinics, and the processes that shape practice have hindered service delivery and subsequent population-level effects. We applied the Consolidated Framework for Implementation Research (CFIR) to assess the context of PrEP delivery for adolescent girls and young women (AGYW) in rural South Africa and identify the factors supporting and impeding PrEP implementation to develop strategies to improve PrEP delivery. Between 2021 and 2022, we conducted in-depth interviews with five young women with PrEP use experience and 11 healthcare providers as well as four key informant stakeholder interviews. Tailored interviews organized around the CFIR domains provided multiple perspectives on the inter-connected processes, gaps, and opportunities between health systems, clinics, communities, and PrEP services. Shifts in PrEP policies, funding pressures, and inconsistent communications from the National Department of Health spurred fragmented planning, engagement, execution, and monitoring of PrEP delivery processes within clinics already struggling to address multiple population health needs. Resulting challenges included: conflicting priorities within clinics and across NGO partners, unclear goals and targets, staffing and space constraints, and insufficient community engagement. Individual clinics’ implementation climate and readiness to deliver PrEP varied in terms of operational plans and delivery models. Interviewees reported complexity of initiation procedures and support for PrEP maintenance, with opportunities to improve systems communications and processes to facilitate integrated services and more user-friendly experiences. Applying CFIR identified opportunities to strengthen PrEP delivery across levels within this complex service delivery setting.

Knowledge and Attitudes About HIV Pre-Exposure Prophylaxis Among Sexually Active Black and Latina Cisgender Women: Findings from the 2017 and 2018 New York City Sexual Health Survey.

Pre-exposure prophylaxis (PrEP) is a highly effective tool to prevent HIV, yet it is underutilized among women. The current study aims to evaluate the awareness, attitudes, and perceptions of PrEP among a large survey sample of Black and Latina women in New York City (NYC). Interviewer-administered surveys were conducted in high HIV incidence neighborhoods in NYC among Black, Latina, and Afro-Latina women who reported recent sex with a man in 2017 (n = 398) and 2018 (n = 405). About 40% of participants were aware of PrEP, whereas 30.4% indicated interest in using it. The top reason for not utilizing it was low HIV risk perception. However, most participants supported the idea that using PrEP meant asserting control over their health (94.1%). Primary care providers and obstetricians/gynecologists were participants' preferred sources for PrEP (91.6%). Across survey cycles, compared to non-Black Latina participants, Black participants had significantly higher PrEP awareness (44.4% vs. 29.1%). PrEP awareness was also significantly higher among survey participants in 2018 (45.2%) than in 2017 (34.3%). Less than half of the participants were aware of PrEP, but those who were aware expressed largely positive attitudes toward the medication. Our findings may inform future PrEP implementation strategies to optimize awareness and access to PrEP among women disproportionately affected by HIV, like focusing on personal empowerment instead of risk-based messaging and training women's sexual health care providers in PrEP provision.

Point-of-care urine tenofovir test predicts future HIV preexposure prophylaxis discontinuation among young users.

Young men who have sex with men and transgender women (YMSM/TGW) have disproportionately high HIV incidence and lower preexposure prophylaxis (PrEP) adherence. Point-of-care (POC) urine tenofovir (TFV) rapid assay (UTRA) testing permits real-time monitoring for nonadherence within clinical settings. We performed UTRA testing among PrEP users to examine the relationship between low PrEP adherence and future PrEP discontinuation, and the accuracy of POC testing compared to gold-standard liquid chromatography tandem mass spectrometry (LC/MS/MS). YMSM/TGW participants ( n = 100) were recruited during a daily PrEP visit. Logistic regression models analyzed the relationship between the primary predictor of urine POC assay results (cutoff 1,500 ng/ml) and the primary outcome of PrEP discontinuation, defined as no PrEP follow-up or prescription within 120 days. Overall, 19% of participants had low urine TFV and 21% discontinued PrEP, while 11% of participants self-reported low PrEP adherence (<4 pills per week), which was only 43% sensitive/84% specific in predicting low TFV levels and was not associated with PrEP discontinuation. Low urine TFV level predicted PrEP discontinuation [adjusted odds ratio (AOR) 6.1; 95% confidence interval (CI): 1.4-11; P = 0.005] and was 71% sensitive/90% specific for discontinuation after 120 days. Compared to LC/MS/MS, UTRA testing had a 98% positive and 100% negative predictive value. In a sample of YMSM/TGW on daily PrEP, POC UTRA testing predicted PrEP discontinuation more accurately than self-reported adherence, with high predictive values compared to LC/MS/MS. UTRA testing may be a clinical tool for directing preventive interventions towards those likelier to discontinue PrEP despite ongoing HIV vulnerability.

Interventions to Improve Adherence to Oral Pre-exposure Prophylaxis: A Systematic Review and Network Meta-analysis.

For people at risk of HIV infection, pre-exposure prophylaxis (PrEP) can reduce the risk of infection in anticipation of exposure to HIV. The effectiveness of PrEP relies upon a user's adherence to their PrEP regimen. We sought to assess the effect of PrEP adherence interventions compared to usual care or another intervention for people at risk of HIV. We searched electronic databases from 2010 onwards for randomized controlled trials (RCTs) involving persons at risk of HIV randomized to an adherence promoting intervention vs usual care or another intervention. We used network meta-analyses to compare PrEP adherence for all participant populations. Certainty of evidence was assessed using Confidence in Network Meta-Analysis (CINeMA). 21 trials (N = 4917) were included in qualitative analysis (19 in network meta-analyses (N = 4101)). HIV self-testing interventions with adherence feedback elements improved adherence compared to usual care (risk ratio (RR): 1.83, 95%CI 1.19, 2.82). In contrast, HIV self-testing alone was inferior to HIV self-testing with adherence feedback (RR: 0.58, 95%CI 0.37-0.92). Reminders alone also were inferior to HIV self-testing with adherence feedback on adherence (RR: 0.53, 95%CI 0.34-0.84) and had similar effects on adherence as usual care (RR: 0.98, 95%CI: 0.86-1.11). Interventions with only one component were inferior for adherence than those with two components (RR: 0.74, 95%CI 0.62-0.88) and those with three components (RR: 0.78, 95%CI 0.65-0.93). The certainty of evidence was moderate for HIV self-testing plus adherence feedback and interventions with two or three components. When designing future PrEP adherence interventions, we recommend strategies with more than one but no more than three components.

Breakthrough Acute HIV Infections among Pre-Exposure Prophylaxis Users with High Adherence: A Narrative Review.

Pre-exposure prophylaxis (PrEP) is a pivotal intervention among HIV prevention strategies. We aimed to narratively revise the topic of HIV acute infection in the setting of PrEP exposure with a focus on diagnostic options, clinical features, and future PrEP perspectives, with a particular focus on users with high adherence to PrEP. We searched the main databases (PubMed, Embase, and Scopus) with the keywords "PrEP" or "Pre-Exposure Prophylaxis" and "HIV" or "PLWH" and "breakthrough" or "acute infection" or "primary infection". We included all randomized clinical trials and non-experimental studies (both case reports and observational studies) ever published. In the present narrative review, we revise the diagnostic challenges related to HIV diagnosis in the setting of PrEP and the clinical characteristics and symptoms of breakthrough infections. We discuss the management of acute HIV infection during PrEP and the new challenges that arise from the use of long-acting drugs for PrEP. Our review underlines that although extremely rare, HIV seroconversions are still possible during PrEP, even in a context of high adherence. Efforts to promptly identify these events must be included in the PrEP follow-up in order to minimize the chance of overlooked HIV breakthrough infections and thus exposure to suboptimal concentrations of antiretrovirals.

Awareness, willingness to use pre-exposure prophylaxis, and use of post-exposure prophylaxis for HIV prevention among men who have sex with men in Mexico.

Little is known about awareness and willingness to use or purchase HIV pre-exposure prophylaxis (PrEP) among men who have sex with men (MSM) in Mexico. MSM in Mexico were recruited via advertisements on online social venues to participate in Encuesta de Sexo Entre Hombres, an online behavioral survey. Awareness of PrEP, willingness to take PrEP if available for free, willingness to purchase PrEP, awareness of post-exposure prophylaxis (PEP), and ever PEP use were assessed in descriptive and multivariate analyses. Overall, 54.8% (4588/8376) of participants were aware of PrEP. Of those aware, 77.6% were willing to use PrEP if free and 52.6% were willing to purchase PrEP, generally at a maximum monthly cost of $500MXP. Both awareness of and willingness to use PrEP if free or for purchase were significantly greater among MSM who were younger, and varied by demographic, recent healthcare use, and behavioral risk factors. Only 8.2% had ever used PEP, which was highly associated with healthcare utilization. About half of Mexican MSM were aware of PrEP. The majority of those aware were willing to use PrEP if available for free and many were willing to purchase PrEP at low cost. Leveraging demographic, recent healthcare use, and behavioral risk characteristics associated with awareness and willingness to use PrEP could be useful in designing future PrEP programs for MSM in Mexico. Expanding healthcare settings in which PEP is available may also support identifying candidates for PrEP and scaling up PrEP implementation.

Qualitative focus group discussions exploring PrEP method and service delivery preferences among female sex workers and their managers in four Zambian provinces

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...

Likelihood-based inferences for active-arm trial with counterfactual incidence based on recency assay

Abstract Objectives The approach of using HIV recency assay to estimate the counterfactual incidence rate is being used as the primary efficacy method in a few ongoing large-scale HIV pre-exposure prophylaxis (PrEP) trials, and the current available approach for the inference is based on the Wald method that leverages the asymptotic distribution of the estimators. One issue with the Wald test is that it does not work well when the number of HIV infections are small in the active arm, and it fails to work when there are zero HIV infections. As future long-acting PrEP products are becoming more efficacious, it is very likely that a small or zero number of infections will be observed in HIV prevention trials, especially for subgroup analyses or interim analyses, hence there is a pressing need to develop inference methods that work under such scenarios. Methods It is well known that when the sample size is small to moderate, likelihood ratio tests are more reliable than Wald tests in terms of actual error probabilities coming close to matching nominal levels. In this manuscript we derive the likelihood ratio test and the likelihood-based confidence intervals for HIV prevention trials based on recency assays. Results Compared with the Wald test, the proposed method works when there are zero infections. Additionally, unlike the Wald test, the p-value from the likelihood ratio test is an increasing function with respect to the number of infections, which is a desirable property as otherwise it will cause confusions. Conclusions For HIV PrEP trials based on recency assay, the likelihood-based p-value and confidence interval can be preferable to the Wald based inference methods when the number of HIV infections is expected to be small.

Creating allies: qualitative exploration of young women’s preferences for PrEP methods and parents’ role in PrEP uptake and user support in urban and rural Zambia

BackgroundZambian adolescent girls and young women (AGYW) have high HIV incidence and face barriers to the use of pre-exposure prophylaxis (PrEP). Parental support improves PrEP use and adherence in some settings, but negative parental attitudes toward HIV prevention may inhibit engagement with AGYW. We explored perceptions of future PrEP methods among AGYW and parents and parent-youth engagement on HIV prevention and PrEP use.MethodsWe conducted a qualitative descriptive study among AGYW and parents of AGYW in five provinces in Zambia in September–October 2021. We conducted 10 focus group discussions (FGDs) and four in-depth interviews (IDIs) with AGYW participants (n = 87) and seven FGDs and four IDIs among parents of AGYW (n = 62). All FGDs and IDIs were audio-recorded, transcribed verbatim, and analyzed to identify qualitative themes.ResultsMost AGYW participants preferred the discreet nature and longer duration of injectable PrEP compared to the PrEP ring and oral PrEP. Many AGYWs reported inability to disclose PrEP use to their parents due to lack of parental support based on cultural taboos against premarital sex. Nevertheless, AGYW participants said they would like to talk to their parents about PrEP so their parents could support their use. Many parents also described difficulties discussing PrEP with their daughters because of cultural and religious beliefs about abstinence from sex before marriage. However, parents acknowledged that the threat of HIV is real and said they need PrEP knowledge and guidance on speaking with their children about HIV prevention and PrEP.ConclusionsAlthough many parents are currently not playing a role in daughters’ decisions about PrEP use, both parents and AGYW are willing to engage with each other on HIV prevention issues. To foster parent-child engagement, HIV prevention programs should not only provide information about PrEP but also address social norms that impede discussion of HIV prevention and equip both parents and AGYW with skills and support for such conversations. Community sensitization is also needed as new PrEP products are introduced, to create an enabling environment for parent-child engagement by increasing awareness, countering misconceptions, and reducing stigma.

Influences affecting decision-making regarding use of pre-exposure prophylaxis among black men who have sex with men in the USA: a systematic review and meta-synthesis

AimTo systematically identify, evaluate, and synthesise qualitative research examining positive and negative influences affecting decision-making behaviour among black men who have sex with men (BMSM) in the USA regarding use...

High study participation but diverging adherence levels: qualitatively unpacking PrEP use among adolescent girls and young women over two years in Eastern Cape, South Africa

In Southern and Eastern Africa, initiation of daily oral pre-exposure prophylaxis (PrEP) for HIV prevention has been high among adolescent girls and young women (AGYW) offered PrEP. However, persistence and prevention-effective use of PrEP among this critical group continues to be a challenge. We conducted a qualitative sub-study of AGYW from the Community PrEP Study in Eastern Cape Province, South Africa who had high rates of pick up for monthly PrEP refills over two years, but differing levels of PrEP adherence based on tenofovir-diphosphate (TFV-DP) measurements in dried blood spots (DBS). Contrasting 22 AGYW with low versus high levels of TFV-DP in DBS, we qualitatively explored factors which influenced PrEP persistence vs. non-persistence, unique patterns of PrEP use (e.g., discarding or stockpiling), and participant recommendations for improving AGYW prevention-effective use of PrEP in the future. Results showed that PrEP misconceptions and mistrust among participants’ social networks negatively influenced adherence. In comparison, supportive families and/or partners and personal trust that PrEP works positively influenced adherence. Those with low adherence described being motivated to come to the site for other study benefits (e.g., reimbursement money, snacks, sanitary pads) and discarding PrEP to avoid stigma associated with being seen with pills. Future PrEP implementation strategies should focus on involving families and partners in PrEP support for AGYW and minimizing PrEP stigma at a community level.Trial registration NCT03977181. Retrospectively registered on June 6, 2019.

Intention to Initiate HIV Pre-exposure Prophylaxis Among Cisgender Women in a High HIV Prevalence U.S. City.

Our objective was to identify the individual, interpersonal, community, health-system, and structural factors that influence HIV pre-exposure prophylaxis (PrEP) initiation among cisgender women seeking sexual and reproductive health care in a high HIV prevalence community to inform future clinic-based PrEP interventions. We collected anonymous, tablet-based questionnaires from a convenience sample of cisgender women in family planning and sexual health clinics in the District of Columbia. The survey used the lens of the socio-ecological model to measure individual, interpersonal, community, institutional, and structural factors surrounding intention to initiate PrEP. The survey queried demographics, behavioral exposure to HIV, perceived risk of HIV acquisition, a priori awareness of PrEP, intention to initiate PrEP, and factors influencing intention to initiate PrEP. A total of 1437 cisgender women completed the survey. By socio-ecological level, intention to initiate PrEP was associated with positive attitudes toward PrEP (odds ratio [OR], 1.56; 95% confidence interval [CI], 1.13-2.15) and higher self-efficacy (OR, 1.32; 95% CI, 1.02-1.72) on the individual level, perceived future utilization of PrEP among peers and low fear of shame/stigma (OR, 1.65; 95% CI, 1.33-2.04) on the community level, and having discussed PrEP with a provider (OR. 2.39; 95% CI, 1.20-4.75) on the institutional level. Our findings highlight the importance of multilevel, clinic-based interventions for cisgender women, which promote sex-positive and preventive PrEP messaging, peer navigation to destigmatize PrEP, and education and support for women's health medical providers in the provision of PrEP services for cisgender women.

Considerations for PrEP Implementation at Federally Qualified Health Centers in Mississippi: Perspectives From Staff and Patients.

Pre-exposure prophylaxis (PrEP) uptake remains low in the southeastern United States ("the South"), likely owing to overlapping structural barriers, including the lack of nearby PrEP providers. Federally qualified health centers (FQHCs) are potential sites through which to expand PrEP availability in the South, and telemedicine is promising for these services. This study investigated considerations for PrEP implementation at FQHCs and the use of telemedicine through qualitative interviews with 19 FQHC staff and 17 PrEP-eligible patients in Mississippi. Results indicated that existing infrastructure and policies at FQHCs can support PrEP implementation and that additional needed resources include more education for providers and strategies to advertise PrEP services. Findings suggest that using telemedicine for PrEP can address some regional implementation barriers (e.g., transportation problems and confidentiality concerns) but may present new ones (e.g., concerns about patients performing home HIV/STI testing procedures). Results can inform future PrEP implementation efforts in the South.

Sociocultural and structural influences on HIV Pre-Exposure Prophylaxis (PrEP) Engagement and Uptake among African American Young adults

BackgroundPre-exposure prophylaxis (PrEP) demonstrates effectiveness in decreasing new cases of HIV. However, few African Americans use PrEP, despite being disproportionately impacted by HIV. Understanding the influence of sociocultural and structural factors on PrEP use among multiple priority groups of African Americans, including but not limited to men who have sex with men, may improve PrEP engagement and uptake. The social ecological model (SEM) as a framework guided the understanding of how these factors operate on multiple levels to influence PrEP use among this population.MethodsThis study derived data from the Afya PrEP study consisting of eleven focus groups (N = 63) with 18-29-year-old African American sexual and gender minority and heterosexual individuals at heightened behavioral vulnerability to HIV. We employed constructivist grounded theory processes to inductively analyze the data. A pooled kappa score of 0.90 indicated excellent inter-rater agreement.ResultsFactors impacting PrEP engagement among African American young adults included: (1) Community/social network influences; (2) medical mistrust; (3) stigma; (4) PrEP availability and accessibility, which had two sub-categories: (a) cost and (b) where to obtain PrEP; and (5) PrEP engagement strategies, which had two sub-categories: (a) current AIDS service organizations’ PrEP engagement practices and (b) recommended future PrEP engagement strategies. Categories one through three represent sociocultural factors, and categories four and five represent structural factors that influence perceptions and attitudes of African American young adults regarding PrEP.ConclusionOur study highlights sociocultural and structural factors that act as barriers and facilitators to PrEP engagement. The SEM guided the understanding of how these factors operated on multiple levels. One of the sociocultural factors, community/social network influences operated at the interpersonal level of the SEM; the other two, stigma and medical mistrust, operated at the community level. The structural factors (PrEP availability, accessibility, and engagement strategies) operated at the institutional/organizational level. Thus, multi-level interventions are warranted to improve PrEP engagement among various African American young adult priority groups.

Post-trial access to and use of pre-exposure prophylaxis in Durban, South Africa

BackgroundHIV endpoint-driven clinical trials increasingly provide oral pre-exposure prophylaxis (PrEP) as standard of prevention during the trial, however, among participants desiring to continue using PrEP at trial exit, little is known about post-trial PrEP access and continued use.MethodsWe conducted one-time, semi-structured, face-to-face, in-depth interviews with 13 women from Durban, South Africa, from November to December 2021. We interviewed women who initiated oral PrEP as part of the HIV prevention package during the Evidence for Contraceptive Options and HIV Outcomes (ECHO) Trial, elected to continue using PrEP at study exit, and were given a 3-month PrEP supply and referred to facilities for PrEP refills at the final trial visit. The interview guide probed for barriers and enablers to post-trial PrEP access, and current and future PrEP use. Interviews were audio-recorded and transcribed. Thematic analysis was facilitated using NVivo.ResultsOf the 13 women, six accessed oral PrEP post-trial exit, but five later discontinued. The remaining seven women did not access PrEP. Barriers to post-trial PrEP access and continued use included PrEP facilities having long queues, inconvenient operating hours, and being located far from women’s homes. Some women were unable to afford transport costs to collect PrEP. Two women reported visiting their local clinics and requesting PrEP but were informed that PrEP was unavailable at the clinic. Only one woman was still using PrEP at the time of the interview. She reported that the PrEP facility was located close to her home, staff were friendly, and PrEP education and counselling were provided. Most women not on PrEP reported wanting to use it again, particularly if barriers to access could be alleviated and PrEP was easily available at facilities.ConclusionsWe identified several barriers to post-trial PrEP access. Strategies to enhance PrEP access such as a reduction in waiting queues, convenient facility operating hours, and making PrEP more widely available and accessible are needed. It is also worth noting that oral PrEP access has expanded in South Africa from 2018 till now and this could improve access to PrEP for participants exiting trials who desire to continue PrEP.

Experience with Contraceptive Dosage Forms and Interest in Novel PrEP Technologies in Women

New pre-exposure prophylaxis (PrEP) strategies tailored to the needs and expectations of individuals at risk of HIV acquisition are needed. In the CAPRISA 082 prospective cohort study in KwaZulu-Natal, South Africa, sexually active women aged 18 to 30 reported, through interviewer-administered questionnaires, on their prior contraceptive experience and interest in both approved and potential future PrEP dosage forms (oral PrEP, long-acting injectable PrEP, and PrEP implants) between March 2016 and February 2018. Univariable and multivariable Poisson regression models with robust standard errors were used to detect associations between women’s prior and current contraceptive use and interest in PrEP options. Of 425 women enrolled, 381 (89.6%) had used at least one modern female contraceptive method previously, with injectable depot medroxyprogesterone acetate (DMPA) being used by 79.8% (n = 339). Women were more likely to show interest in a future PrEP implant if they were currently using (aRR 2.1, CI 1.43–3.07, p = 0.0001) or had ever used (aRR 1.65, CI 1.14–2.40, p = 0.0087) a contraceptive implant, and were more likely to choose an implant as their first choice method than the implant-naïve (current users aRR 3.2, CI 1.79–5.73, p < 0.0001; “ever” users aRR 2.12, CI 1.16–3.86, p = 0.0142). Women were more interested in injectable PrEP if they had used injectable contraceptives (current users aRR 1.24, CI 1.06–1.46, p = 0.0088; “ever” users aRR 1.72, CI 1.20–2.48, p = 0.0033); and were more interested in oral PrEP if they had ever used oral contraceptives (aRR 1.3, CI 1.06–1.59, p = 0.0114). This apparent relationship between women’s contraceptive experience and their interest in novel forms of PrEP in an equivalent dosage form may play a future role in strengthening HIV prevention efforts in women at high risk of HIV acquisition.