HIV Prevention Research Articles

"You're in an Image of a Man but Not a Man": A Qualitative Analysis of Intersectional Stigma Among Men with HIV Experiencing Subfertility in Rural Southwestern Uganda.

Many men with HIV (MWH) want to have children and may encounter HIV- and infertility-related stigma experiences. Integration of reproductive health and HIV care for men is rare. When available, safer conception care focuses on HIV prevention but lacks fertility support. We conducted qualitative in-depth interviews in Uganda with 30 MWH who desired more children and self-reported no partner pregnancy after 12 or more months of conception attempts. We separately interviewed 10 female partners. Interviews explored stigma experiences and factors impacting engagement in HIV and reproductive care. We used vignettes to elicit responses to stories of couples experiencing challenges of HIV and subfertility. The study team discussed, coded, and analyzed data from individual participant interview transcripts, inductively identifying emergent themes. The following overarching themes emerged: (1) Reproductive goals often take priority over HIV prevention among HIV-affected couples in this context, influenced by multi-level subfertility stigma in society. (2) MWH may pursue behaviors that increase risk of HIV transmission to meet their reproductive goals. (3) Men and women are eager to maintain their primary partnerships, prevent HIV transmission, and meet their reproductive goals with guidance from healthcare providers. Further research is needed on the causes of subfertility and infertility among HIV-affected couples in East Africa to better support their conception goals. Additionally, studies on the intersection of HIV and infertility stigma in high-fertility, high-HIV prevalence areas are essential for designing interventions that meet couples' social, emotional, and medical needs.

HIV Prevention in Syringe Service Programs Since the Start of COVID-19: Where Do We Go From Here?

This narrative review addresses post-2020, specific, complex challenges for use of and adherence to pre-exposure prophylaxis (PrEP) for HIV prevention among out-of-treatment people who use drugs (PWUD) at syringe services programs (SSPs). The COVID-19 pandemic and its associated changes to the provision of healthcare have significantly impacted HIV prevention, especially for PWUD. Through a synthesis of literature and clinical experience, we (1) characterize the operational changes imposed by the pandemic on SSPs that shaped the current HIV prevention landscape; (2) describe three levels of current challenges for PWUD, including consumer attitudes, non-medical and medical provider attitudes, and structural and scalability barriers; (3) characterize current models for PrEP in SSPs; and (4) offer practical recommendations for HIV prevention in harm reduction programs. PrEP is a highly effective prevention tool if taken as prescribed. It has been enthusiastically promoted by members of the research, public health and provider communities. Despite its efficacy, PWUD struggle to engage with the PrEP care continuum. We highlight opportunities to advance HIV prevention for PWUD by enhancing tailored, whole-person approaches that may set aside PrEP in favor of other risk reduction routes. For most PWUD who receive services at SSPs, PrEP is a single tool and not realistic until other social and structural determinants of health are addressed.

Acceptability of a dapivirine levonorgestrel vaginal ring in two Phase 1 trials (MTN-030/IPM 041 and MTN-044/IPM 053/CCN019): Implications for multipurpose prevention technology development.

End-user feedback early in product development is important for optimizing multipurpose prevention technologies for HIV and pregnancy prevention. We evaluated the acceptability of the 90-day dapivirine levonorgestrel ring (DPV-LNG ring) used for 14 days compared to a dapivirine-only ring (DVR-200mg) in MTN-030/IPM 041 (n = 23), and when used for 90 days cyclically or continuously in MTN-044/IPM 053/CCN019 (n = 25). We enrolled healthy, non-pregnant, HIV-negative women aged 18-45 in Pittsburgh, PA and Birmingham, AL (MTN-030 only). Self-reports of vaginal bleeding and adherence (ring removals, expulsions) were collected via daily short message service. Acceptability data were recorded in face-to-face interviews at study exit. We assessed differences in acceptability by product characteristics and adherence; and associations between baseline characteristics/demographics, number of bleeding days, adherence, and overall acceptability. Most (21/23) women in the 14-day MTN-030 study and about half (13/25) in the 90-day MTN-044 study liked their assigned rings. In MTN-030 there were no significant associations between any variables and overall acceptability of either ring. In MTN-044, women who disliked the DPV-LNG ring had a significantly higher incidence of unanticipated vaginal bleeding, and reporting that vaginal bleeding changes were unacceptable than those who liked it. Although we found no overall association between adherence and acceptability, significantly more women who disliked (versus liked) the DPV-LNG ring reported expulsions during toileting. The DPV-LNG ring could meet the needs of women seeking simultaneous protection from HIV and unintended pregnancy. Addressing issues related to vaginal bleeding and expulsions early in product development will likely enhance acceptability of the DPV-LNG ring. Trial registration: Clinical Trial Registration: MTN-030/IPM 041: ClinicalTrials.gov NCT02855346; MTN-044/IPM 053/CCN019: ClinicalTrials.gov NCT03467347.

Determinants of continuation on HIV pre-exposure propylaxis among female sex workers at a referral hospital in Uganda: a mixed methods study using COM-B model

BackgroundFemale sex workers (FSWs) have the highest HIV prevalence in Uganda. Pre-exposure prophylaxis (PrEP) has been recommended as a key component of the HIV combination prevention strategy. Although patient initiation of PrEP has improved, continuation rates remain low. This study evaluated PrEP continuation among FSWs and explored potential determinants of PrEP adherence within a public referral hospital in urban Uganda.MethodsWe conducted an explanatory sequential mixed method study at Kiruddu National referral hospital in Uganda. Secondary data on socio demographic characteristics and follow up outcomes of at least one year was collected for all FSWs who were initiated PrEP between May 2020 and April 2021 and data analyzed on July 15,2023. We used Kaplan–Meier survival analysis to evaluate continuation on PrEP from time of initiation and follow-up period. The capability, opportunity, and motivation to change behaviour model was used to explore perspectives and practices of FSWs (n = 24) and health care providers (n = 8) on continuation on PrEP among FSWs, using semi structured interviews. The qualitative data was deductively coded and analyzed thematically, categorizing the themes related to PrEP continuation as facilitators and barriers.ResultsOf the 292 FSWs initiated on PrEP, median age was 26 years (interquartile range, 21–29), 101 (34.6) % were active on PrEP, 137 (46.9%) were lost to follow-up, 45 (15.4%) were no longer eligible to continue PrEP, eight (2.7%) were transferred out and one (0.3%) had died. Median survival time on PrEP was 15 months (Interquartile range IQR, 3–21). The continuation rates on PrEP at six (6) and 12 months were 61.1% and 53.1%, respectively. Facilitators of PrEP continuation included awareness of risk associated with sex work, integration of PrEP with other HIV prevention services, presence of PrEP Peer support and use of Drop-in centers. The barriers included low community awareness about PrEP, high mobility of sex workers, substance abuse, and the unfavorable daytime clinic schedules. However, the quantitative findings from the multivariable Cox Proportional Hazards Model did not align with the reported findings for the qualitative evaluation.ConclusionContinuation on PrEP remains low among FSWs. Interventions for PrEP continuation should address barriers such as low community awareness of PrEP, substance abuse and restrictive health facility policies for scale of the PrEP program among FSWs in Uganda. Integration of PrEP with other services and scale up of community PrEP delivery structures may improve its continuation.

Predictors of HIV testing adherence among men who have sex with men: a cross-sectional study

Men who have sex with men are a target group for HIV prevention and control. HIV testing is part of a broader combination prevention strategy. This study aimed to analyze the predictors for adherence to HIV infection testing among Brazilian men who have sex with men. A cross-sectional study was conducted with 1438 participants, online selected for convenience in all regions of Brazil. Binary logistic regression analysis was used to identify independent predictors of HIV testing in the study population. Adherence to the HIV test was high (80.1%). Had condomless anal intercourse in the last 12 months (Adjusted Odds Ratio [AOR]: 1,659; 95% Confidence Interval [CI]:1,12 − 2,43; p = 0,010), knew one place to seek HIV testing (AOR 6,158 [IC95%: 4,27 − 8,86]; p < 0,001), Received counselling on HIV testing by a health professional (AOR 3,389 [IC95%: 2,28 − 5,02]; p < 0,001), Have been diagnosed with STI (AOR 2,266 [IC95%: 1,41 − 3,62]; p < 0,001) and Knew someone living with HIV (AOR 1,86 [IC95%: 1,29 − 2,67]; p < 0,001) were independently associated with higher chances of HIV testing.

Recent Advances in Our Understanding of Human Inflammatory Dendritic Cells in Human Immunodeficiency Virus Infection

Anogenital inflammation is a critical risk factor for HIV acquisition. The primary preventative HIV intervention, pre-exposure prophylaxis (PrEP), is ineffective in blocking transmission in anogenital inflammation. Pre-existing sexually transmitted diseases (STIs) and anogenital microbiota dysbiosis are the leading causes of inflammation, where inflammation is extensive and often asymptomatic and undiagnosed. Dendritic cells (DCs), as potent antigen-presenting cells, are among the first to capture HIV upon its entry into the mucosa, and they subsequently transport the virus to CD4 T cells, the primary HIV target cells. This increased HIV susceptibility in inflamed tissue likely stems from a disrupted epithelial barrier integrity, phenotypic changes in resident DCs and an influx of inflammatory HIV target cells, including DCs and CD4 T cells. Gaining insight into how HIV interacts with specific inflammatory DC subsets could inform the development of new therapeutic strategies to block HIV transmission. However, little is known about the early stages of HIV capture and transmission in inflammatory environments. Here, we review the currently characterised inflammatory-tissue DCs and their interactions with HIV.

An Open Letter on Advancing HIV prevention: Augmenting an ecosystem-based approach to understand prevention decision-making

In the last two decades, HIV programs have been able to avert millions of AIDS-related deaths and reduce HIV incidence. However, the 1.3 million new HIV infections in 2022 remain significantly above the UNAIDS target of fewer than 370,000 new infections by 2025. HIV programs worldwide also did not achieve the UN’s 90-90-90 target for testing and treatment set for 2020. Within this broader picture, HIV continues to disproportionately affect key and at-risk populations, including gay men and other men who have sex with men, female sex workers, and adolescent girls and young women. As HIV incidence declines and biomedical advances continue, it will become critical for public-health practitioners to reach key and at-risk populations with prevention services and limit primary transmission. In this Open Letter, we focus on factors that influence uptake of HIV prevention products and thereby demand for HIV prevention products and services. These factors exist at three levels of the decision-making ecosystem – the individual level, interaction level and systemic level. We argue that approaching HIV prevention solely through the lens of these levels creates a static view of prevention decision-making. There is a need instead for a dynamic viewpoint that can mirror the changing contexts in which users find themselves and make prevention decisions. We demonstrate that the current ecosystem viewpoint is useful to understand the gaps that exist in program implementation, but does not provide adequate insights into the underlying behaviors that contribute to these gaps. To address this, we suggest an approach to include dynamic aspects of decision-making with factors that influence the individual’s assessment of risk, their evaluation of the opportunities to use HIV prevention, and their effective use of prevention products.

Sexual Networks and Behavioral Characteristics of HIV-Positive Male Military Members, Female Sex Workers, and Male Civilians.

Military members and female sex workers (FSWs) may be more likely to acquire or transmit HIV. Mapping HIV transmission across these high-risk populations and identifying behaviors associated with sexual network clustering are needed for effective HIV prevention approaches. A cross-sectional study recruited participants newly diagnosed with HIV among militaries, civilians, and FSWs in Zambia, Senegal, and Democratic Republic of the Congo (DRC). Participants were interviewed on behaviors and provided blood samples for HIV-1 partial pol sequencing. Genetic-distance based network analyses inferred putative relationships between HIV-1 partial pol sequences. Bivariate logistic regression models identified variables associated with clustering in a sexual network. 908 participants were included (n = 313 FSWs, n = 297 military, n = 298 civilians). 311 blood samples were sequenced and had survey data, of which 93 (29.9%) were genetically linked, forming 36 transmission clusters. All but one cluster were comprised of participants from the same country, including one large cluster (n = 12; 9 FSWs and 3 civilians) from DRC. A large mixed-country cluster (n = 9) including 7 men (4 civilians, 3 military) and 2 FSWs was observed. The odds of clustering in a sexual network were elevated for DRC participants, FSWs, and those cohabitating with a sexual partner. Findings underscore the importance of identifying linkages in high-risk populations to develop tailored HIV prevention strategies. Linkages across risk groups and countries illustrate the potential role of mobile populations in HIV transmission and acquisition. Larger studies including HIV recency testing may better elucidate biological and behavioral interactions between military, civilians, and FSWs.

Awareness of Sexual Partner's HIV Status Among Men Who Have Sex With Men in China: Cross-Sec. tional Survey Study.

Men who have sex with men (MSM) constitute a significant proportion of individuals living with human immunodeficiency virus. Over the past few years, China has implemented various strategies aimed at increasing the rate of HIV testing and reducing HIV transmission among MSM. Among these, the disclosure of HIV serostatus is an effective prevention strategy. This study aimed to assess HIV serostatus disclosure and identify factors associated with awareness of sexual partners' HIV status among MSM to provide a scientific basis for promoting HIV testing and reducing HIV transmission. A cross-sectional study based on a large-scale web-based survey was conducted among MSM in Zhejiang province, China, between July and December 2023. MSM who were HIV-negative or had an unknown HIV status were recruited from the Sunshine Test, a web-based platform that uses location-based services to provide HIV prevention services. Participants were required to complete a questionnaire on demographic characteristics, sexual behavior, rush popper use, awareness of sexual partners' HIV status, and knowledge of pre-exposure prophylaxis (PrEP) and postexposure prophylaxis (PEP). A multinomial regression model was used to identify the factors associated with awareness of sexual partners' HIV status. A total of 7629 MSM participated in the study, with 45.2% (n=3451) being aware, 35.4% (n=2701) being partially aware, and 19.4% (n=1477) being unaware of their sexual partner's HIV status. The multinomial logistic regression analysis revealed the following results. Compared to those who were unaware of their sexual partner's HIV status, participants who were students (adjusted odds ratio [aOR] 1.43, 95% CI 1.09-1.86), had a monthly income of more than US $1400 (aOR 1.36, 95% CI 1.03-1.80), had insertive anal sex (aOR 1.35, 95% CI 1.12-1.63), had only male sexual partners (aOR 1.53, 95% CI 1.28-1.82), had 1 sexual partner in the past 3 months (aOR 2.36, 95% CI 2.01-2.77), had used condoms for the past 3 months (aOR 1.72, 95% CI 1.33-2.22), had frequently used rush poppers in the past 3 months (aOR 2.27, 95% CI 1.81-2.86), were aware of HIV PrEP (aOR 2.04, 95% CI 1.68-2.48), were aware of HIV PEP (aOR 1.69, 95% CI 1.39-2.06), used mail reagent self-testing (aOR 1.19, 95% CI 1.04-1.36), and had previously undergone HIV testing (aOR 1.40, 95% CI 1.16-1.69) were associated with increased odds of being aware of their sexual partner's HIV status. Overall, 45.2% of MSM who were HIV-negative or had an unknown status were aware of their sexual partners' HIV status in China. We suggest strengthening targeted interventions through web-based platforms and gay apps to promote the disclosure of HIV serostatus and reduce HIV transmission among MSM.

Review of Impact of Risk Reduction Sessions on Sexual Behaviors in HIV Prevention Trials: Insights from Africa.

Over the past two decades, numerous HIV prevention trials have targeted thousands of young African women, aiming not only to reduce transmissions through biomedical interventions but also to promote safe sexual practices through intensive risk reduction sessions. The primary objective of this study was to review the impact of risk reduction sessions in HIV prevention trials conducted in Africa. We assessed changes in sexual behaviors among women enrolled in various biomedical intervention trials across the African region using both visual and quantitative evaluations. Meta-analysis techniques were used to estimate overall odds ratios. In a sub-group analysis, we also used semiparametric regression models to capture important features of the associations between sexual behaviors across the study visits with minimal statistical assumptions. Key time points were identified using the "zero-crossing" technique. Overall summary odds ratio (OR) for condom use in last sex was estimated as 2.21 (95% CI 2.06, 2.36). In our sub-group analysis, women who reported multiple sexual partners declined (adjusted odds ratios (aORs) range: 0.61-0.67) while condom use in last sex improved over time (aORs ranged from 2.22-to-2.60); 347(57%) women HIV seroconverted within the first 6-months which was the most crucial time point with substantial reductions in risky behaviors. This review highlights that the gradual cumulative effect of risk reduction sessions, rather than an immediate substantial impact, may have significant implications in clinical research settings. Effective and sustainable risk reduction programs should include biological components such as pre-exposure prophylaxis (PrEP) to reduce HIV transmission.

Updated Review for Guidelines for Cervical Cancer Screening in Immunosuppressed Women Without HIV Infection.

The purpose of this review was to examine new evidence since our 2019 guidelines for cervical cancer (CC) screening in non-HIV immunocompromised persons and to provide updated recommendations based on literature review and expert opinion. In addition, human papillomavirus (HPV) vaccine efficacy in these populations was reviewed. A literature search was performed similar to our previous publication but was conducted through March 2023. Risk of CC, squamous intraepithelial lesions, and HPV infection in those living with solid organ transplant (SOT), end-stage renal disease (ESRD), hematopoietic stem cell transplant (HSCT), and autoimmune diseases (AID), specifically systemic lupus erythematosus (SLE), rheumatoid arthritis (RA), and inflammatory bowel disease (IBD) with addition of multiple sclerosis (MS) were researched. This update also summarizes data available on newer disease-modifying therapies (DMTs) including monoclonal antibodies (MABs). We then made recommendations for HPV vaccine administration, and screening using either general population guidelines or increased surveillance, the latter based on following current recommendations for women living with HIV. Additionally, the literature search included antibody response to HPV vaccines and recommendations for their administration for these same conditions. Based on the reviewed risks, evidence continued to support those persons living with SOT, ESRD, HSCT, and SLE, whether on immunosuppressant therapy or not, had an increased risk of HPV, squamous intraepithelial lesions, and CC whereas there was weak evidence that those persons with IBD, RA, and MS not on immunosuppressants were at risk. Data on persons using DMT/MAB were conflicting. Data showed that patients on certain immunosuppressants had lower antibody titers following HPV vaccination. There were no studies on HPV vaccine efficacy. Following US Center for Disease Control and Prevention HIV Cervical cancer screening (CCS) guidelines is recommended for the following: SOT, ESRD, HSCT, and SLE whether on immunosuppressants or not, and IBD, RA, and MS on immunosuppressants. Shared decision-making about increased surveillance for IBD and RA not on immunosuppressants and persons on any DMT or MAB is reasonable based on conflicting data. Human papillomavirus vaccination should not change the recommendations for increased CC surveillance. A 3-dose series of the HPV vaccine is recommended for all age-eligible patients starting at 9 years of age, with catch-up to 26 years of age. Vaccination from age 27 up to age 45 years per Advisory Committee on Immunization Practices guidelines should be considered in shared decision-making. When possible, HPV vaccine series should be initiated and completed before SOT or initiation of DMT/MAB. For HSCT, the vaccine series should be readministered along with other childhood vaccines.

Impact of COVID-19 Public Health Measures on Antiretroviral Therapy Use Among Ugandans Living with HIV in Sero-Different Couples.

Antiretroviral therapy (ART) use and HIV suppression among people living with HIV (PLHIV) are critical for HIV control and prevention. Extreme restrictions on movement early during the COVID-19 pandemic in Uganda may have impeded the ability to initiate and sustain access to and use of ART. From our stepped-wedge cluster-randomized trial of an integrated PrEP and ART intervention for HIV-serodifferent couples at 12 ART clinics in Uganda, we identified participants who enrolled and had a 6-month post-ART initiation viral load measured before the beginning of the first COVID-19 lockdown (Period 1), participants whose enrollment and 6-month viral load measurement straddled pre-COVID and COVID lockdown times (Period 2), and participants whose enrollment and 6-month viral load were quantified entirely during COVID-19 (Period 3). ART and viral load data were abstracted from standard-of-care HIV clinic records. We used adjusted generalized estimating equation models to compare viral suppression between the different periods. We enrolled 1,381 PLHIV, including 896 (64.9%) in Period 1, 260 (18.8%) in Period 2, and 225 (16.3%) in Period 3. Almost all (1371, 99.3%) initiated ART within 90days of enrollment and 59.2% had baseline CD4 > 350 cells/mm3. Among those enrolled, 88.8% of participants in Period 1 were virally suppressed (< 1000 copies/mL) within six months of ART initiation, 80.5% in Period 2, and 88.2% in Period 3. All pairwise comparisons demonstrated statistically similar levels of viral suppression. Despite COVID-19 lockdown measures, PLHIV in serodifferent partnerships successfully initiated ART and attained and maintained viral suppression.

Understanding Awareness, Utilization, and the Awareness-Utilization Gap of HIV PrEP and nPEP Among Young MSM in China.

HIV/AIDS remains a significant public health challenge in China, particularly among men who have sex with men (MSM). Pre-Exposure Prophylaxis (PrEP) and non-occupational post-exposure Prophylaxis (nPEP) are effective interventions to reduce HIV transmission in high-risk populations. This study assessed awareness and utilization levels of PrEP and nPEP among young MSM (YMSM) aged 18-29 in China and examined associated factors. A cross-sectional survey of 2,493 YMSM was conducted across six Chinese provinces in September 2022. Participants, recruited via facility-based sampling, completed self-administered online questionnaires distributed by MSM-oriented community-based organizations. Of all the participants, 2,278 (91.4%) were aware of PrEP, and 220 (8.8%) had ever used PrEP; 2,321 (93.1%) were aware of nPEP, and 209 (8.4%) had ever used nPEP. Education level and having recent male sexual partners were positively associated with awareness of PrEP and nPEP, while self-stigma was negatively associated with awareness for both. Among those who had head of PrEP or nPEP, age, having more than 2 male sex partners, and having a history of sexually transmitted diseases (STD) infection were positively associated with the utilization of PrEP and nPEP; inconsistent condom use was associated with less PrEP utilization; monthly income was positively associated with nPEP utilization. Despite high awareness levels, the low utilization of PrEP and nPEP highlights missed opportunities for HIV prevention. Strengthening education on their importance, promoting condom use alongside PrEP/nPEP, reducing stigma, and addressing financial barriers are critical steps toward improving HIV prevention strategies and empowering YMSM to engage with these life-saving interventions.

Long-Acting Injectable Prep for People Who Inject Drugs at a Syringe Services Program: A Qualitative Acceptability and Feasibility Study.

Although people who inject drugs (PWID) are at high risk of acquiring HIV, knowledge and uptake of pre-exposure prophylaxis (PrEP) for HIV prevention among this population remain low due to numerous psychosocial and structural barriers. Multiple implementation strategies have been proposed to address this gap, notably providing long-acting injectable (LAI) formulations of PrEP and offering PrEP at syringe services programs (SSPs). This qualitative study explores the acceptability and feasibility of offering LAI-PrEP for PWID at risk for HIV at Florida's first legal SSP. In-depth semi-structured interviews were conducted with PWID (n = 25) and healthcare providers (n = 5), and transcripts were analyzed using iterative thematic analysis. The provision of LAI-PrEP at the SSP was overwhelmingly acceptable to both PWID and providers, and specific advantages and disadvantages of LAI-PrEP compared to oral PrEP among this population were elucidated. Likewise, PWID and providers identified facilitators and barriers to offering LAI-PrEP at the SSP and proposed recommendations for implementation. Overall, this study adds to the growing evidence that provision of LAI-PrEP at SSPs is acceptable and feasible and holds promise in expanding access to and uptake of HIV prevention services among PWID.

Access to HIV prevention, testing and care among people with a migration background in Euregio Meuse-Rhine: a needs and assets assessment

ABSTRACT This study addresses disparities among people with a migration background (PMB) and those in less-urban regions, across the HIV prevention and care continuum (HIVPCC). We conducted a needs assessment and assets assessment to identify gaps between existing initiatives and persisting barriers. The research was conducted in the Euregio Meuse-Rhine (EMR), encompassing bordering regions in Belgium, Germany, and the Netherlands, and involved in-depth interviews with fifteen first-generation PMB, including nine with HIV. Six factors influencing PMB access to the HIVPCC were identified: past experiences with sexually transmitted infections (STIs) or HIV; HIV stigma and social dynamics; confidence and communication with healthcare providers and social workers; healthcare system navigation; precarity; and knowledge and beliefs about HIV/STIs. Existing assets mostly target individual or interpersonal levels, are often inaccessible due to language barriers, inadequately match PMB’s living conditions and culture, and are irregular and hyperlocal. Recommendations include enhancing cultural sensitivity, adopting participatory approaches, tailoring outreach activities to legal situations and cultural context, and fostering cooperation between healthcare and social work institutions. This study underscores the importance of considering societal and institutional dynamics in bridging gaps in the HIVPCC for PMB, advocating for targeted interventions that promote inclusivity and equity.

Experiences with Oral Pre-Exposure Prophylaxis (PrEP) Service Delivery and Use Among Adolescent Girls and Young Women (AGYW) in Routine Primary Care Settings, South Africa.

In South Africa, oral PrEP was included in national guidelines as part of a combination HIV prevention package for adolescent girls and young women (AGYW) in 2017. Understanding their experiences of accessing and using PrEP is necessary to evaluate and improve PrEP service delivery approaches. This descriptive study explored AGYW's knowledge and understanding of PrEP, their experiences and influences on PrEP access and use in real world settings in South Africa. We conducted 44 in-depth interviews with female PrEP users (15-24 years) enrolled in Project PrEP. Interviews were audio recorded and transcribed for analysis using thematic analysis procedures. Participants reported positive experiences and overall satisfaction with accessing health services (i.e., youth-friendly clinic spaces, friendly and non-judgemental staff, privacy during consultations). Distance from the clinic, long queues, negative provider attitudes, and occasional stock-outs were key health service barriers to accessing PrEP. Individual motivating factors to continued PrEP use included creating daily pilltaking routines and the goal to remain HIV negative, while barriers included pill fatigue, frequent clinic visits, and side-effects. Positive relationships with partners and family facilitated disclosure of PrEP use, while stigma was identified as a community barrier to accessing PrEP services. Our study highlights AGYWs' experiences with PrEP access and use in a real-world setting. Facilitators and barriers identified in this study can be leveraged to strengthen efforts to support young women and ensure effective PrEP use. The findings also contribute to the development of appropriate service delivery.

Impact of Social Determinants of Health on Pre-exposure Prophylaxis Care for HIV Prevention.

HIV continues to disproportionately impact men who have sex with men (MSM) in the United States (US). Pre-exposure prophylaxis (PrEP) is effective, but disparities persist. Limited studies have conducted systematic evaluations of social determinants of health (SDOH) and their effects on PrEP persistence among MSM. We enrolled MSM into a prospective observational cohort to assess progression through the PrEP care continuum. We enrolled patients from three diverse US settings from 2018-2022. We explored the impact of SDOH on PrEP persistence (defined as successfully obtaining PrEP prescriptions and/or clinical documentation of retention in PrEP care) at 6- and 12-months using multilevel, mixed-effects logistic models. A total of N=300 MSM were enrolled. Median age was 28 years; 40% were Black/African American (B/AA), and 11% were Hispanic/Latino (H/L). PrEP persistence was 84.7% and 49.3% at 6- and 12-months, respectively. In the unadjusted analysis, B/AA and H/L individuals were 56% and 54%, respectively, less likely to demonstrate PrEP persistence at 6- and 12-months compared to white/non-H/L individuals. Findings were no longer significant after adjusting for economic stability and educational attainment. Individuals with higher levels of internalized homophobia were less likely to persist on PrEP. Every 1-unit increase on a validated measure of internalized homophobia was independently and negatively associated with PrEP persistence (adjusted odds ratio = 0.95, 95% CI: 0.93-0.98). SDOH are important predictors of racial and ethnic disparities in PrEP persistence among MSM. Addressing these factors could help mitigate racial disparities in PrEP persistence in the US.

Marriage and Steady Relationships with Women in Men Who Have Sex with Men in Sub-Saharan Africa: A Mixed-Method Systematic Review and Meta-analyses.

High HIV prevalence in Sub-Saharan African (SSA) in men who have sex with men (MSM) leads to greater risk for their wives and other steady female partners because of prolonged exposure. To provide insights into the context possibly contributing to the risk of HIV transmission from MSM to women, our mixed-method synthesis about MSM' marriage and steady relationships with cisgender women aimed to: (i) assess the extent of engagement in steady relationships with women and in risky behaviors with these women across SSA's four regions; (ii) explore the underlying dynamics within these relationships by gathering qualitative information. We used quantitative and qualitative data specifically pertaining to related to marriage or other steady relationships with women from a systematic review on men who have sex with both men and women (MSMW) in SSA (PROSPERO-CRD42021237836). Meta-analyses were performed on quantitative data for each region. Pooled proportions were calculated using random-effects models. Qualitative data were analyzed using thematic synthesis. Data were selected from 125 studies. For Southern, East and West Africa, the estimated pooled proportions of married MSM were 4% (95% CI 2-8%; n = 10 studies; 4183 MSM), 8% (6-11%; 19; 7070), and 7% (6-9%; 13; 4705). In Southern Africa, 29% (11-56%; 5; 1667) of MSM had steady female partners. In East Africa, 34% (14-61%; 5; 2003) were currently or previously married to women. Motives to marry women included a desire to have children, and to conform to heteronormative social norms and family pressure. Marriage was seen as a means to discontinue homosexual behaviors or, conversely, a way to secretly continue same-sex behaviors more freely. Procreative intentions and a desire for secrecy often deterred MSM from using HIV prevention methods with their wives. For some MSM, steady relationships with women provided them with mutual support. However, these relationships could also lead to stressful and conflict-ridden situations, potentially resulting in psychosocial and HIV-related risks for the MSM as well as their male and steady female partners. Steady relationships with women are common in MSM in SSA. Sexuality concealment strategies with steady female partners depend on the circumstances that lead MSM to enter into these relationships, and have various implications on sexual behaviors with both male and female partners. Community-based support, HIV research, prevention, and care programs should be adapted to MSM's different life situations to reduce direct HIV transmission risk to steady female partners.

Latino Sexual Minority Men's Pre-Exposure Prophylaxis Modality Preferences: A Latent Class Analysis.

Pre-exposure prophylaxis (PrEP) is an effective HIV prevention tool available in several modalities (e.g., daily oral, injectable, implants, rectal douching). The Ending the HIV Epidemic (EHE) initiative, a national initiative that began in 2019 as a partnership among the Department of Health and Human Services and other federal agencies (e.g., the Centers for Disease Control and Prevention, National Institute of Health), seeks to increase PrEP engagement for groups experiencing HIV inequities, including Latino sexual minority men (LSMM). Given the limited research on PrEP modality preferences among LSMM, this study aimed to explore and characterize these preferences. LSMM (n = 214) not using PrEP and living in South Florida participated in the DÍMELO study, which examined PrEP engagement among LSMM in South Florida. Authors employed latent class analysis (LCA) to identify groups of LSMM based on their PrEP modality preferences and examined predictors of class membership. LCA results led to a three-class solution with participants who were: (1) reluctant to use most PrEP modalities (30.5%), (2) PrEP willing, with constraints (36.0%), and (3) enthusiastically accepting of all PrEP modalities (33.5%). LSMM in the reluctant class (Class 1) showed minimal interest in most PrEP modalities. The constrained class (Class 2) displayed interest in daily oral, on-demand, and quarterly injectable PrEP while the enthusiastic class (Class 3) demonstrated high interest in all modalities except rectal douching. Key predictors of PrEP modality preferences were altruism, community normalization of PrEP, and migration history. Understanding LSMM's PrEP modality preferences can enhance the reach of PrEP to LSMM, a group the EHE initiative prioritizes. The current findings suggest the need to tailor PrEP outreach efforts to promote various PrEP modalities based on LSMM's preferences.

Preferences for and acceptability of long-acting HIV prevention products among pregnant and lactating women accessing health services in Kenya: a mixed method cross-sectional analysis

BackgroundIncreased risk of HIV acquisition during pregnancy and lactation among women is evident, necessitating their inclusion in the evaluation of new HIV prevention interventions. Pregnant and postpartum women specifically face challenges with oral PrEP associated with stigma, and the burden of using other tablets. Long-acting products may address challenges related to oral PrEP, however, there is limited data on product-specific preferences and acceptability among pregnant and lactating women.MethodsWe conducted a mixed-method study to assess the preferences and acceptability of long-acting PrEP modalities either under development or already established among pregnant and lactating women. We conducted quantitative surveys (n = 434) and in-depth interviews (n = 80) in central and western Kenya. We used descriptive statistics and categorical variables to summarize frequencies and proportions. Inductive and deductive content analytic approaches were used for in-depth interviews.ResultsThe median age of respondents was 25 years (IQR 19.3–31.0). Majority were married (263/434, 61%), had completed high school (222/434, 51%), with no condoms use in the prior 3 months (348/434, 80%). The most preferred PrEP formulations were injectable (251/434, 57%) and implantable (175/434, 40%) options. Participants who preferred injectable PrEP had 8.56 times higher odds of considering ease of use as a reason. (aOR = 8.56, 95% CI [3.81–20.48]) and 3.71 odds of choosing perceived discreteness (aOR = 3.71, 95% CI (1.57–9.97)) as their preference reasons. Participants who preferred Implant for HIV prevention had 2.31 odds of considering it due to perceived effectiveness in preventing HIV as a preference reason (aOR = 2.31, 95% CI (1.21—4.66)) and 2.53-fold of considering discreteness as a preference reason (aOR = 2.53, 95% CI (1.46—4.59)). From the in-depth interviews, women reported prospective acceptability due to the perceived convenience of LA products, perceived effectiveness, reduced cost, improved privacy, and reduced stigma. Women had concerns regarding the safety and efficacy of the products during pregnancy and lactation.ConclusionAcceptability of LA products underscores the importance of considering the unique needs of pregnant and breastfeeding women in the development of future prevention interventions. Aligning preferences and needs would enhance the uptake and adherence outcomes of HIV prevention products.