HIV Pre-exposure Prophylaxis Use Research Articles

Demographic, socioeconomic, and health structure factors associated with the use of HIV pre-exposure prophylaxis in Brazil: A nationwide ecological study.

Aims: To assess the cumulative rate of HIV Pre-Exposure Prophylaxis (PrEP) users in Brazil since its 2018 implementation and to analyze the association between PrEP usage and state-level structural factors. Methods: A nationwide ecological study from 2018 to 2022 was conducted, examining the 5-year cumulative rate of PrEP users in relation to demographic, socioeconomic, and healthcare infrastructure variables. Multiple linear regression analysis identified significant predictors of PrEP utilization. Results: Between 2018 and 2022, 124,796 individuals used PrEP, with a cumulative rate of 61.5 per 100,000 population. The highest usage was in Minas Gerais, São Paulo, and Santa Catarina, while the lowest was in Distrito Federal, Maranhão, and Alagoas. Regression analysis showed that higher PrEP usage was associated with lower population density, a younger median age, a lower male to female ratio, and reduced social vulnerability. Additionally, PrEP usage was positively associated with the density of medical doctors and the number of dispensing units. Conclusions: The study reveals significant regional disparities in PrEP usage across Brazil, influenced by socioeconomic and healthcare factors. It highlights the need for targeted public health strategies to enhance PrEP access and uptake, especially in socially vulnerable regions.

Impact of simplified HCV diagnostic strategies on the HCV epidemic among men who have sex with men in the era of HIV oral pre-exposure prophylaxis in Taiwan: a modelling study.

Simplified hepatitis C virus (HCV) diagnostic strategies have the potential to improve HCV diagnoses and treatment. We aimed to investigate the impact of simplified HCV diagnostic strategies on HCV incidence and its effect on HCV diagnosis and treatment among men who have sex with men (MSM) regardless of HIV status and use of HIV pre-exposure prophylaxis (PrEP) in Taiwan. A compartmental deterministic model was developed to describe the natural history of HCV disease progression, the HCV care cascade and the HIV status and PrEP using among MSM. The model was calibrated to available data for HCV and HIV epidemiology and population demographics in Taiwan. We simulated the epidemic from 2004 and projected the impact of simplified testing strategies on the HCV epidemic among MSM over 2022-2030. Under the current testing approach in Taiwan, total HCV incidence would increase to 12.6 per 1000 person-years among MSM by 2030. Single-visit point-of-care RNA testing had the largest impact on reducing the number of new HCV infections over 2022-2030, with a 31.1% reduction (interquartile range: 24.9%-32.8%). By 2030, single-visit point-of-care HCV testing improved HCV diagnosis to 90.9%, HCV treatment to 87.7% and HCV cure to 81.5% among MSM living with HCV. Compared to status quo, prioritized simplified HCV testing for PrEP users and MSM living with diagnosed HIV had considerable impact on the broader HCV epidemic among MSM. A sensitivity analysis suggests that reinfection risk would have a large impact on the effectiveness of each point-of-care testing scenario. Simplified HCV diagnostic strategies could control the ongoing HCV epidemic and improve HCV testing and treatment among Taiwanese MSM. Single-visit point-of-care RNA testing would result in large reductions in HCV incidence and prevalence among MSM. Efficient risk-reduction strategies will need to be implemented alongside point-of-care testing to achieve HCV elimination among MSM in Taiwan.

Factors associated with HIV pre-exposure prophylaxis use among Asian men who have sex with men in Sydney and Melbourne, Australia: a cross-sectional study

Asian-born MSM are a priority population as Australia aims to end HIV transmission, but they reported additional barriers to access PrEP and other HIV prevention methods. This study investigates factors associated with PrEP use among Asian MSM in Sydney and Melbourne, Australia, to inform strategies to improve PrEP uptake in this population. This was a sub-analysis of a community-based cross-sectional survey conducted from March to June 2021. We recruited participants online in Sydney and Melbourne, Australia. Univariable and multivariable logistic regression analyses were performed to identify the factors associated with PrEP use in the last six months and lifetime. Latent class analyses were used to identify subgroups of Asian MSM sharing similar characteristics related to their risk practices for HIV. Overall, 870 Asian MSM were included: 288 Oceanian-born Asian MSM and 582 Asian-born MSM. Three latent classes were identified: 1) Asian-born MSM who recently arrived in Australia with limited English, were less likely to use PrEP and at higher risk of HIV infection (e.g., had condomless anal sex with a casual sex partner in the last six months) (4.6%); 2) Asian MSM who were at lower risk of HIV infection and less likely to use PrEP (69.3%) and; 3) Asian MSM who were at substantial risk of HIV infection and more likely to use PrEP (26.1%). Compared to Oceanian-born Asian MSM, those who were born in Southeast Asia (adjusted odds ratio (aOR)=0.5, 95% confidence interval (CI) 0.3-0.7) and South Asia (aOR=0.4, 95% CI 0.2-0.8) were less likely to ever use PrEP. Compared to Oceanian-born Asian MSM, those who were born in Southeast Asia (aOR=0.4, 95% CI 0.3-0.7), Northeast Asia (aOR=0.5, 95% CI 0.3-0.8) and South Asia (aOR=0.4, 95% CI 0.2-0.7) were less likely to use PrEP in the last six months. To end HIV transmission in Australia, it will be necessary to develop strategies to improve PrEP access for the significant minority of Asian-born MSM who are at substantial risk of HIV infection. EPFC and JJO are supported by an Australian National Health and Medical Research Council (NHMRC) Emerging Leadership Investigator Grant (EPFC: GNT1172873 and JJO: GNT1193955). CKF is supported by an Australian National Health and Medical Research Council (NHMRC) Leadership Investigator Grant (GNT1172900).

HIV Pre-exposure Prophylaxis Use among Men Experiencing Incarceration in the United States: A Prospective Cohort Study

Background: Pre-exposure prophylaxis (PrEP) is an effective approach to preventing HIV acquisition and is recommended for populations overrepresented in carceral systems given the overlap with populations disproportionately impacted by HIV. However, few studies have focused on PrEP initiation outcomes in a carceral setting to maximize public health impact. Setting: This study was conducted in a unified jail/prison system within the state of Rhode Island located in the United States. Methods: A prospective observational cohort of men initiating PrEP within a jail setting were enrolled in this trial. Men were referred by providers, staff, or after self-presenting for HIV preventive care, these individuals were offered enrollment in the study which involved evaluation for clinical PrEP eligibility, PrEP initiation while incarcerated, continuation upon community re-entry and linkage to a community PrEP provider post-release. Results: A total of (N=100) men in the jail facility (e.g. “intake”) were enrolled in the cohort. Of the 100 men enrolled, 83% were determined to be PrEP eligible through standard clinical evaluation, 37% were prescribed PrEP, and 26% initiated PrEP while incarcerated. In total, 5% of enrolled individuals were linked successfully to PrEP care in the community. Conclusion: Our findings suggest preliminary feasibility and acceptability of initiating PrEP within a jail setting. There were significant challenges across the PrEP care continuum that can be used to inform future studies and practice.

Barriers to HIV Pre-Exposure Prophylaxis Use Among Women in the US: A Systematic Literature Review

Introduction: The high acquisition rate of HIV infection among women in the United States is concerning. Despite the FDA approving the first pre-exposure prophylaxis (PrEP) drug in 2012, PrEP utilization remains significantly lower among women. This literature review aims to analyze the current body of research concerning HIV PrEP usage among women in the US. Methods: A search of three medical databases was conducted. After the screening, 19 studies were selected for analysis. A risk of bias assessment was performed. Results: A final set of records meeting the inclusion criteria (n=19) was included in the review for data collection and analysis. The study methodology for these research articles included interview-based designs (semi-structured and brief formats) in 1-on-1 meetings, focus groups, surveys, and retrospective data analysis. Participants' HIV risk characteristics were reported by way of sexual behavior, drug use, combined sexual behavior and drug use, and living in a high HIV rate neighborhood. Nineteen themes were identified and organized into three categories: (1) Common medication administration barriers, (2) PrEP-specific barriers, and (3) Situational barriers. The three most common themes reported by participants included a concern about side effects, low perceived risks of HIV, and lack of PrEP information. The CASP Qualitative Checklist and risk assessment summary showed acceptable validity among studies. Discussion: This review identifies significant barriers hindering women's PrEP utilization, which would benefit from more prevalent stakeholder communication and education directed to at-risk populations. Inconsistently reported descriptive data on participants and the low patient populations make it difficult to generalize outcomes.

Uptake and persistent use of HIV pre-exposure prophylaxis (PrEP) among key populations: Results from Ukraine’s scaled national PrEP program

Background: Ukraine has implemented ambitious HIV-prevention programs since 1999 and began offering pre-exposure prophylaxis (PrEP) in 2017. Little is known about PrEP uptake and persistence in this setting. Setting: We analyzed data from 40 facilities providing PrEP in 11 oblasts (regions) of Ukraine between October 2020-February 2022. Methods: We estimated the time between PrEP visits and conducted Kaplan-Meier analyses to estimate retention on PrEP stratified by sex, age, and key populations (KPs): men who have sex with men (MSM), people who inject drugs (PWID), sex workers (SW), discordant couples and others vulnerable to HIV acquisition (DC/Other). We used Cox regression to estimate risk of PrEP discontinuation by KP group and sex, adjusting for age. Results: Overall, 2,033 clients initiated PrEP across regions; the majority (51%) were DC/Other, 22% were MSM, 22% were PWID, and 5% were SW. The overall three-month persistence was 52.3% (95% confidence interval [CI]: 49.9-54.8%) and was lowest among MSM (46.7%; 95% CI: 41.9-52.2%) and SW (25.9%; 95% CI: 18.2-36.9%) (p<0.05 for differences by KP group). After adjusting for age, PrEP discontinuation was not statistically significantly different across groups, although female PWID tended to have the lowest discontinuation risk (adjusted hazard ratio [aHR] 0.59; 95% CI: 0.31-1.11 while male SW tended to have the highest risk (aHR 1.87, 95% CI: 0.57-6.11) compared with females in the DC/Other group). Conclusion: Three-month PrEP persistence was low across KP groups, especially in SW. Further research examining the barriers and enablers of persistence by KPs is needed.

Assessing Patient Acceptance of an Automated Algorithm to Identify Ciswomen for HIV Pre-Exposure Prophylaxis.

The use of HIV pre-exposure prophylaxis (PrEP) in cisgender women (ciswomen) lags far behind their need. Data elements from the electronic medical record (EMR), including diagnosis of a sexually transmitted infection (STI), can be incorporated into automated algorithms for identifying clients who are most vulnerable to HIV and would benefit from PrEP. However, it is unknown how women feel about the use of such technology. In this study, we assessed women's attitudes and opinions about an automated EMR-based HIV risk algorithm and determined if their perspectives varied by level of HIV risk. Respondents were identified using best practice alerts or referral to a clinic for STI symptoms from January to December 2021 in Chicago, IL. Participants were asked about HIV risk factors, their self-perceived HIV risk, and their thoughts regarding an algorithm to identify ciswomen who could benefit from PrEP. Most of the 112 women who completed the survey (85%) thought they were at low risk for HIV, despite high rates of STI diagnoses. The majority were comfortable with the use of this algorithm, but their comfort level dropped when asked about the algorithm identifying them specifically. Ciswomen had mixed feelings about the use of an automated HIV risk algorithm, citing it as a potentially helpful and empowering tool for women, yet raising concerns about invasion of privacy and potential racial bias. Clinics must balance the benefits of using an EMR-based algorithm for ciswomen with their concerns about privacy and bias to improve PrEP uptake among particularly vulnerable women.

1560. Factors Driving Decisions in the use of HIV Pre-Exposure Prophylaxis: Data from a Real-World Study in the United States

Abstract Background Although pre-exposure prophylaxis (PrEP) is recommended for people at risk of acquiring HIV, usage remains low. Our study used real-world data to characterise the factors driving decision-making in PrEP use, among current PrEP users (PU) and at-risk non-users (NU). Methods Data were drawn from the Adelphi PrEP Disease Specific Programme (DSP)™, a real-world, cross-sectional survey of PU, NU, and physicians in the United States between December 2021 and June 2022. PU, NU, and physicians completed distinct questionnaires. Physicians (n=61) reported demographic data and PrEP usage for next 8 PU and 2 NU. These individuals were invited to complete a questionnaire reporting reasons for/against PrEP use (PU n=196; NU n=38). Results Mean age [SD] of PU (n=480) and NU (n=121) was 35.3 [10.8] and 32.5 [10.8] years, respectively. Majority were male (PU 87%; NU 79%) and men who have sex with men (MSM) (PU 75%, NU 62%). Overall, 90% PU were taking PrEP daily and reported fear of contracting HIV (79%) and at-risk behaviours as major drivers for PrEP usage (Figure 1). Physicians reported that of the NU who chose not to start PrEP, 49% stated this was due to not wanting long-term medication (Figure 2). PrEP stigma was a concern for both PU (50%) and NU (65%). Conclusion This study provides data on unmet needs and potential drivers for PrEP uptake from the healthcare provider, PU and NU perspectives. Understanding factors that influence the decision to use PrEP may highlight the attributes needed in new products to increase uptake. Disclosures Yohance Whiteside, PhD, MSPH, Merck & Co., Inc: Employee|Merck & Co., Inc: Stocks/Bonds Bekana K. Tadese, PhD, MPH, Merck and Co Inc: Employee

1533. The First Ten Years of HIV Preexposure Prophylaxis Use and Missed Opportunities at an Urban Academic Children’s Hospital

Abstract Background HIV preexposure prophylaxis (PrEP) is underprescribed in adolescents, with ∼16% of PrEP-eligible youth receiving prescriptions in 2019. We analyzed trends in PrEP prescribing and quality of care in adolescents at the largest academic pediatric hospital in New England to inform strategies to improve HIV prevention in this group. Methods We reviewed charts of all patients prescribed PrEP at Boston Children’s Hospital between July 2012-December 2021 and extracted demographics, lab results and details of PrEP discussions. We extracted data on all patients with new HIV diagnoses to identify missed opportunities for PrEP. Results From 2015-2021, 54 patients were prescribed PrEP; none were during 2012-2014. Prescriptions increased annually except for 2020, coinciding with the COVID-19 pandemic. Most PrEP patients (87%) were >18 years old and prescribing for those < 18 years old remained rare despite regulatory approval for this age-range in 2018 (Fig. 1). Of the 54 PrEP patients,16% never initiated, 28% discontinued within 6 months, 31% had multiple short (median 3.5 months) periods of use, and 13% started once and continued for >6 months (median 12 months, range 7-36 months). (Fig. 2) The most common reason for discontinuing PrEP was loss to follow up (Fig. 3). Patients initiated PrEP discussions in 78% of cases, and half of PrEP prescriptions were same day starts. Most patients accessed PrEP through adolescent (81%) or gender speciality (11%) clinics with only 4% through General Pediatrics. Nearly all patients (98%) had baseline HIV and Hepatitis B testing; of 41 patients using PrEP for >3 months, all had follow up HIV tests within 4 months. Of 22 patients newly diagnosed with HIV, none had taken PrEP. The majority of HIV diagnoses were made during routine screening (68%); three were diagnosed at pre-PrEP screening. Most diagnoses (68%) were made by generalists.Figure 1:Number of Patients Prescribed PrEP per YearFigure 2:Duration of PrEP UseFigure 3:Reasons for PrEP Discontinuation Conclusion Only 54 patients were prescribed PrEP during the past decade at a large pediatric hospital despite 22 new HIV diagnoses in this period. Non-initiations or discontinuations were common, suggesting a need for strategies to improve PrEP provision and persistence. With youth initiating most PrEP discussions, strategies to engage providers in PrEP are needed, in particular among generalists where most new HIV diagnoses occurred. Disclosures Douglas Krakower, MD, Gilead: Grant/Research Support|Merck: Grant/Research Support|U. North Texas Health Sciences Center: Funding for mentoring|UAB: Advisor/Consultant|UpToDate, Inc.: Royalties|Virology Education: Honoraria

The Use of HIV Pre-exposure Prophylaxis Among Men Accessing Routine Sexual and Reproductive Health Services in South Africa

PurposeThis study describes a cohort of men seeking oral pre-exposure prophylaxis (PrEP) services and explores their patterns of PrEP use within an implementation project seeking to integrate PrEP provision within sexual and reproductive health services in public health clinics in South Africa. MethodsRoutine program and survey data from 364 males initiated on oral PrEP between July 2020 and May 2022 were analyzed. PrEP use was examined, including time to first discontinuation and restart patterns. Factors associated with early PrEP discontinuation and PrEP restart were analyzed. ResultsDespite primarily focusing on access for adolescent girls and young women, PrEP services reached males with HIV prevention needs. PrEP use for ≤1 month (early discontinuation) was high at 58%; however, 18% restarted on PrEP, with 4% restarting repeatedly. Having depression symptoms was associated with early PrEP discontinuation (adjusted odds ratio [AOR]: 1.71, 95% CI [confidence interval]: 1.06–2.78). Those ≥25 years were less likely to discontinue early, as were those with a partner treated for a sexually transmitted infection in the preceding three months (AOR: 0.33, 95% CI: 0.13–0.84) and those who had been circumcised (AOR: 0.59, 95% CI: 0.36–0.96). Those 18–20 years old were less likely to restart PrEP than those ≥25 years (AOR: 0.43, 95% CI: 0.19–0.97), as were those whose partner's HIV status was unknown (AOR: 0.33, 95% CI: 0.12–0.88). DiscussionThis study identified interest and uptake of oral PrEP among an underrepresented population of predominantly heterosexual males seeking sexual and reproductive health services. It found high rates of early PrEP discontinuation, with a subset returning to restart PrEP. Further research is needed to determine whether these periods of PrEP use are associated with periods of HIV risk.

Patterns of HIV Pre-exposure Prophylaxis use Among Adolescent Girls and Young Women Accessing Routine Sexual and Reproductive Health services in South Africa

PurposeThis study describes the patterns of pre-exposure prophylaxis (PrEP) use among adolescent girls and young women (AGYW) initiated on daily oral PrEP for the prevention of HIV, within routine sexual and reproductive health services in South Africa. MethodsWe analysed clinical and survey data from a nested cohort of 967 AGYW initiated on oral PrEP between January 2019 and December 2021 in four geographical clusters in South Africa. We describe the periods of PrEP use, and the proportion who discontinued and subsequently restarted PrEP. Logistic regression analyses were conducted to determine factors associated with early PrEP discontinuation, PrEP use for ≥4 months and PrEP restart. ResultsPrEP use for ≤1 month was high (68.6%), although 27% returned and restarted PrEP; and 9% restarted more than once. Initiating PrEP at a mobile clinic (AOR 2.10, 95% CI 1.51 – 2.93) and having a partner known to be HIV negative or whose HIV status was unknown (AOR 7.11, 95% CI 1.45 – 34.23; AOR 6.90, 95% CI 1.44 – 33.09) were associated with PrEP use for ≤1 month. AGYW receiving injectable contraceptives were more likely to restart PrEP (AOR 1.61, 95% CI 1.10 – 2.35). Compared to those aged 15–17 years, participants 18 – 20 and 21 – 24 years were less likely to restart PrEP (AOR 0.51, 95% CI 0.35 – 0.74; AOR 0.60, 95%, CI 0.41 – 0.87), as were those initiating PrEP at a mobile clinic compared to a fixed facility (AOR 0.66, 95% CI 0.47 – 0.92). DiscussionAlthough early PrEP discontinuation was high, it appears that PrEP use is frequently cyclical in nature. Further research is needed to determine if these cycles of PrEP correlate to periods of perceived or actual vulnerability to HIV, which may also be cyclical. PrEP delivery presents a unique opportunity to address multiple unmet health needs of young people.

Attitudes and Intentions toward Use of HIV Pre-Exposure Prophylaxis (PrEP) among Adults Receiving Treatment for Opioid Use

Background: Although pre-exposure prophylaxis (PrEP) prevents HIV, little is known about PrEP awareness and factors associated with intention to take PrEP among people with opioid use disorder (OUD). Methods: HIV-negative adults recruited from an outpatient treatment program in Cincinnati, Ohio completed self-administered surveys. Items derived from literature and health behavioral theory included demographics, sexual and drug use behaviors, HIV prevention practices, PrEP knowledge, and attitudes toward PrEP. Primary outcomes were 1) intention to ask a clinician about PrEP and 2) intention to accept PrEP if recommended by a clinician. Outcomes were dichotomized into higher vs. lower intention for analyses in logistic regression models. Results: Among 198 participants, 60.3% reported past injection drug use. Among 58 participants (29.3%) meeting criteria for PrEP, 24% were aware of PrEP, 15.5% had discussed it with a clinician, and 5% had taken it. Factors associated with intention to ask a clinician about PrEP included being somewhat confident about consistent condom use (p < 0.01), motivation to comply with normative beliefs (p < 0.01), and reporting that PrEP fits very well (p < 0.01) and is easy to fit (p < 0.01) into current prevention practices. Factors associated with intention to accept PrEP if recommended by a clinician included motivation to comply with normative beliefs (p < 0.01) and PrEP being easy to fit into current prevention practices (p < 0.01). Conclusion: Among participants meeting indications for PrEP, only 24% were aware of it and few had taken it. Interventions that normalize PrEP and target incorporating PrEP into current prevention practices may improve uptake among individuals with OUD.

Factors Associated with HIV Pre-Exposure Prophylaxis Use Among Transmasculine People Who Have Sex with Cisgender Men, at a Federally Qualified Health Center in Chicago, Illinois

Factors Associated with HIV Pre-Exposure Prophylaxis Use Among Transmasculine People Who Have Sex with Cisgender Men, at a Federally Qualified Health Center in Chicago, Illinois

Oral HIV pre-exposure prophylaxis use among pregnant and postpartum women: results from real-world implementation in Lesotho.

Lesotho has reached epidemic control, PrEP is an important component in maintaining that and in reaching the goal of eliminating mother-to-child transmission. We conducted a retrospective review of existing, routine PrEP health records in 26 health facilities in Lesotho. PrEP visit data were collected for pregnant and postpartum women screened for PrEP and/or enrolled in PrEP programs from 1 January 2019 through 30 June 2021 with follow-up data collected up to the date of data abstraction per site between October 2021 and May 2022. Poisson regression with robust variance was used to evaluate the association between patient characteristics and continuation of PrEP. Indications for starting PrEP were significantly associated with continuation in PrEP use. Women starting PrEP due to having a partner known to be living with HIV were the most likely to return for follow-up. In all age groups, the most common reason for starting PrEP was being in a serodiscordant relationship, though the proportion varies by age. As Lesotho is now in the process of optimizing PrEP use among pregnant and postpartum women, it is critical to revise data sources to capture information that will link PrEP records and ANC/PNC records and document pregnancy/postpartum status in order to better understand PrEP use and gaps in this population.

HIV Pre-Exposure Prophylaxis Use on a Global Scale Among Men Who Have Sex with Men: A Systematic Review and Meta-Analysis.

Knowledge of the proportion of Pre-Exposure Prophylaxis (PrEP) use among men who have sex with men (MSM) and the specific gaps in PrEP use can stimulate enhanced focus on HIV prevention policies and programs. To summarize the proportion of PrEP use and explore the temporal trend in the proportion of PrEP use and factors associated with PrEP use among MSM on a global scale, we searched PubMed, Embase, Web of Science Core Collection, and APA PsycINFO for studies reporting on the use of HIV PrEP among MSM before April 2022. Freeman-Tukey double arc-sine transformation and random-effects models were used to pool estimates. A total of 147 articles involving 395,218 MSM were included. The pooled proportions of PrEP use among MSM and PrEP-eligible MSM were 11.23% [95% confidence interval (CI): 9.71-12.84] and 16.04% (95% CI: 11.99-23.36), respectively. The proportion of PrEP use varied among countries with different support policies. β regressions with the logit link showed that the proportion of PrEP use has increased in recent years. Interrupted time series analyses further supported that the approval of PrEP use would decrease the number of new HIV diagnoses among MSM. The main factors associated with PrEP use include health insurance, having a regular medical provider, prior HIV testing, past use of PrEP or Post-Exposure Prophylaxis, social networks, and stigma. Although the proportion of PrEP use among MSM has remained low, it has increased in recent years. More studies are needed to explore the factors associated with PrEP use, especially for PrEP-eligible MSM in low- and middle-income countries.

Corrigendum to: Efficacy and acceptability of 'nudges' aimed at promoting pre-exposure prophylaxis (PrEP) use: a survey of overseas born men who have sex with men.

This study explores the potential for behavioural economics techniques called 'nudges' to encourage the use of HIV pre-exposure prophylaxis (PrEP) by overseas-born men who have sex with men (MSM) in Australia. We investigated the preferences of overseas-born MSM for different nudges and the effect of nudges on reported likelihood of seeking information about PrEP. We conducted an online survey of overseas-born MSM, in which they were asked: (1) how likely they and a relevant friend would be to click on PrEP advertisements that used behavioural economics strategies; and (2) what they most and least liked about each ad. We conducted ordered logistic regression of reported likelihood scores against participant age and sexual orientation, use of a model in an advertisement, use of statistics about PrEP, reference to the World Health Organization (WHO), rewards for seeking further information, and use of a call-to-action. Participants (n =324) reported higher likelihoods of clicking on advertisements with images of people, statistics about PrEP, rewards for seeking further information, and calls-to-action. They reported lower likelihoods of clicking on advertisements referencing the WHO. They had negative emotional responses to sexualised humour, gambling metaphors, and the slogan 'Live Fearlessly'. Overseas-born MSM prefer public health messages that feature representative messengers and statistics about PrEP. These preferences are consistent with previous data on descriptive norms (i.e. statistics about the number of peers doing the desired behaviour) and gain-framed information (i.e. focusing on what can be gained from an intervention).

Intersecting Sexual Behavior and Gender Identity Stigmas Among Transgender Women in the United States: Burden and Associations with Sexual Health.

In the United States, a context of multiple marginalization shapes sexual health disparities experienced by transgender women. Using data from 396 transgender women with negative or unknown HIV status, we performed exploratory factor analysis on responses to gender identity and sexual behavior stigma items and regressed sexual health outcomes on extracted factors via modified Poisson regression with robust variance estimation. Overall, 97.2% of participants endorsed ≥ 1 gender identity stigma; 67.2% endorsed ≥ 1 sexual behavior stigma; and 66.9% endorsed ≥ 1 of each. Extracted factors included gender-identity social stigma, reflecting experiences related to family, fearfulness in public, and verbal harassment (α = 0.68); gender-identity institutional stigma/violence, reflecting experiences related to healthcare, police interactions, and interpersonal violence (α = 0.73); and global sexual behavior stigma, reflecting experiences related to family, friends, and healthcare, as well as police interactions, fearfulness in public, verbal harassment,and interpersonal violence (α = 0.83). Gender-identity social stigma was significantly, positively associated with testing for HIV and testing for sexually transmitted infections. Gender-identity institutional stigma/violence and global sexual behavior stigma were both significantly, positively associated with condomless anal sex, sex work, testing for HIV, testing for sexually transmitted infections, and use of HIV pre-exposure prophylaxis. Stigma-mitigation remains critical to improve quality of life and sexual health for transgender women in the United States.

Retention in an mHealth App Aiming to Promote the Use of HIV Pre-Exposure Prophylaxis Among Female Sex Workers in Dar es Salaam, Tanzania: Prospective Cohort Study.

Increasing access to smartphones in sub-Saharan Africa offers an opportunity to leverage mobile health (mHealth) technology to improve access to health care in underserved populations. In the domain of HIV prevention, mHealth interventions can potentially contribute to solving the challenges of suboptimal adherence to pre-exposure prophylaxis (PrEP) and low retention in PrEP services among populations most vulnerable to HIV acquisition. However, there is a gap in the knowledge about the use of such interventions in sub-Saharan Africa. This study aims to evaluate the extent and predictors of retention in an mHealth app (Jichunge) that aims to promote adherence to PrEP and retention in PrEP care among female sex workers in Dar es Salaam, Tanzania. A prospective cohort of female sex workers residing in Dar es Salaam were recruited, using respondent-driven sampling. All participants were provided with the Jichunge app as they started PrEP. A questionnaire was used to collect data on sociodemographics and other structural factors, while app use data for the 60-day period following the first 150 days of being in the intervention arm were extracted from the app's back end. A multivariable log-binomial model was used to determine predictors of 6-month retention in the Jichunge app. A total of 470 female sex workers were recruited. Nearly three-quarters of participants (206/284, 72.5%) who came to the 6-month follow-up interview no longer had the Jichunge app on their phones. The majority of these participants (193/206, 93.7%) no longer had access to the app because of issues related to their phones. Data extracted from the back end of the app showed that the use of the app declined over time, and only 13.4% (63/470) of the participants were retained (continued to use the app) after 6 months of intervention. At 6 months, women aged ≥35 years were >2 times more likely to use the app than women aged 18 to 24 years (adjusted risk ratio [aRR] 2.2, 95% CI 1.2-4.1; P=.01). Furthermore, retention in the app was higher among participants who demonstrated high PrEP awareness at baseline (aRR 1.8, 95% CI 1.1-3; P=.01) and among those who had experienced financial difficulties due to health care spending (aRR 1.9, 95% CI 1.2-3.2; P=.01). Most female sex workers (206/284, 72.5%) who were enrolled in PrEP care in Tanzania no longer used the Jichunge app after 6 months. Retention in the app at 6 months was predicted by older age, high PrEP awareness, and financial difficulties due to health care spending. Strategies for the long-term retention of participants in mHealth apps, such as systems for reinstallations of apps, should be considered during the design phase.

Study protocol for an efficacy trial of the “PrEP for Health” intervention to increase HIV PrEP use among people who inject drugs

BackgroundHIV incidence has recently increased among people who inject drugs (PWID) across the United States, with outbreaks occurring in states with long-standing syringe service programs (SSPs) including Massachusetts (MA). Antiretroviral pre-exposure prophylaxis (PrEP) is an evidence-based HIV prevention strategy recommended for PWID, but uptake in this marginalized population is extraordinarily low.MethodsWe describe the design and procedures for a National Institute on Drug Abuse (NIDA)-funded (R01) randomized controlled trial (RCT) testing the efficacy of “PrEP for Health,” a multicomponent behavioral intervention to increase PrEP uptake, adherence, and persistence among HIV-negative PWID attending SSPs in two areas of the U.S. Northeast that are heavily affected by injection-related HIV transmission. Participants are equally randomized to receive the “PrEP for Health” intervention (involving individually tailored HIV and PrEP education, motivational interviewing, problem-solving skills and planning, and ongoing navigation support) or an enhanced standard of care (eSOC) control condition involving a brief educational video on the utility of PrEP for HIV prevention. Co-primary outcomes are PrEP uptake (using medical/pharmacy records) and adherence (using tenofovir quantification in hair samples); a secondary outcome is PrEP persistence (using medical/pharmacy records) over 12 months. Major assessments occur at baseline, 1-, 3-, 6-, and 12-month follow-up visits. Planned analyses will examine intervention efficacy, specific hypothesized conceptual mediators of the intervention effect (e.g., self-perceived HIV risk; PrEP knowledge, interest in use, motivation, and behavioral skills) and epidemiologically linked moderators (e.g., age; gender; condomless vaginal or anal sex).DiscussionFindings from our extensive preliminary research with the study population revealed that a multicomponent, theory-based intervention targeting PrEP knowledge, motivation, self-efficacy, behavioral skills, and structural barriers to PrEP access is urgently needed for PWID who are at risk of HIV acquisition. We also learned that SSPs represent a highly acceptable service setting for delivering such interventions. In this study, we are evaluating the efficacy of the “PrEP for Health” intervention. If efficacious, findings from our implementation evaluation could help guide its dissemination to diverse SSPs and possibly other community-based settings accessed by this population.Trial registrationClinicalTrials.gov number NCT04430257, registered June 12, 2020.

Depression and PrEP uptake, interruption, and adherence among young women in Uganda

ABSTRACT Depression is a common cause of morbidity globally and can impact adherence to medications, posing challenges to medication-based HIV prevention. The objectives of this work are to describe the frequency of depression symptoms in a cohort of 499 young women in Kampala, Uganda and to determine the association of depression symptoms with use of HIV pre-exposure prophylaxis (PrEP). Mild or greater depression, assessed by the patient health questionnaire (PHQ-9), was experienced by 34% of participants at enrollment. Participants with mild depression symptoms tended to uptake PrEP, request PrEP refills, and adhere to PrEP with similar frequency to women with no/minimal signs of depression. These findings highlight opportunities to leverage existing HIV prevention programs to identify women who may benefit from mental health services and may not otherwise be screened. Trial registration: ClinicalTrials.gov identifier: NCT03464266..