Pre-exposure Prophylaxis Implementation Research Articles

Costs and outcomes of routine HIV oral pre-exposure prophylaxis implementation across different service delivery models and key populations in South Africa: a retrospective cohort study.

Despite several service delivery models that aim to improve uptake and persistence of pre-exposure prophylaxis (PrEP) in sub-Saharan Africa, the full costs of daily oral PrEP provision in routine care settings remain largely unknown. We aimed to evaluate outcomes and costs of daily oral PrEP delivery among key and priority populations at in-facility and community outreach programmes in South Africa. This retrospective cohort study was done at seven urban sites across South Africa with in-facility or community outreach PrEP service delivery models. We did top-down and bottom-up microcosting, from the provider perspective, of routine oral PrEP provision in programmes focusing on men who have sex with men (MSM), female sex workers, and adolescent girls and young women (aged 15-24 years) who initiated oral PrEP between March 12, 2018, and Aug 13, 2019. The primary outcome was PrEP in-hand at 6 months, defined as having sufficient PrEP drug dispensed at the last visit to have the drug available 6 months after PrEP initiation. A subset of enrolled participants with sufficient potential follow-up were included in a 12-month outcome analysis. We report the cost per client initiated on PrEP in 2021 US dollars. We enrolled 1281 people aged at least 15 years who initiated oral PrEP in either in-facility or community outreach programmes between March 12, 2018, and Aug 13, 2019. The proportion of participants with PrEP in-hand at 6 months varied from 41·8% (95% CI 31·9-52·2; 41 of 98 participants) at one MSM-focused clinic to 0% (0-6·7; 0 of 53 participants) in an MSM-focused outreach programme. Among 633 clients receiving oral PrEP with the potential for 12 months follow-up, 86 (13·6%) had PrEP in-hand at 12 months. The mean average 6-month costs per client initiating oral PrEP ranged from US$29 (95% CI 26-31) to $590 (488-692), with higher costs generally observed for in-facility programmes ($152, 140-164) than for outreach programmes ($84, 79-88). The mean average monthly cost per client with PrEP in-hand at 6 months ranged from $18 (15-21) to $160 (126-194). Costs and outcomes of daily oral PrEP provision across several populations and service delivery models in real-world settings show substantial variability. Policy makers should consider this variability when planning further scale-up of oral PrEP programmes in South Africa and the sub-Saharan Africa region to maximise opportunities to improve efficiency based on local context. The US President's Emergency Plan for AIDS Relief, the US Agency for International Development, and the National Institutes of Health.

P-1387. Barriers to PrEP Implementation in Publicly Funded Family Planning Clinics in Atlanta, Georgia

Abstract Background Although Georgia has the highest HIV incidence in the US, uptake of pre-exposure prophylaxis (PrEP) for HIV is inadequate, especially among cisgender (cis) women. The Title X Family Planning Program (FP) provides federal funding for sexual health services to low income or uninsured individuals. We sought to understand clinic interest in and capacity for women-centered PrEP care implementation in Title X FP clinics in metro Atlanta. Methods From Jan 2022-Nov 2023, we held focus groups with 47 participants representing 22 FP clinics across four metro Atlanta Ending the HIV Epidemic priority counties (71% of all Title X FP clinics in the area). We used a structured interview guide to assess PrEP implementation strategies across each step of PrEP care; participants included advanced practice providers, medical assistants, nurses, and FP program leaders. Following standard rapid qualitative analytic methods, two trained researchers created a matrix of responses by question, assessed salience of responses by deductive themes, and used memos to summarize themes for narrative description. Results Clinics had few-to-no cis women on PrEP. Conversations regarding PrEP eligibility were often patient-initiated, rather than provider-initiated. Many providers expressed unfamiliarity with sexual history taking and assessing HIV risk, especially with cis women. Providers also cited patient barriers to PrEP uptake and persistence, including insurance navigation and follow-up visit costs. All providers expressed a need for time-efficient screening and counseling procedures and trainings covering sexual history taking, destigmatizing PrEP, and medication access. Population-tailored information, such as non-English, youth-focused, and low literacy responsive materials were highly desired (Table 1). Conclusion Family planning clinics in Atlanta require comprehensive training across the steps of PrEP care, given limited provider initiation of and comfort with risk assessment and counseling, and perceived barriers to uptake and retention. Multi-pronged implementation strategies are necessary to prevent new HIV infections, particularly among cis women, and to progress toward ending the HIV epidemic. Disclosures All Authors: No reported disclosures

P-516. Implementation and Uptake of Long-acting Injectable PrEP at Atlanta VA Healthcare System

Abstract Background Long-acting injectable (LAI) pre-exposure prophylaxis (PrEP) is highly effective at preventing HIV and has the potential to expand PrEP access. Atlanta VA Healthcare System (AVAHCS) has one of the largest PrEP programs within the Veteran’s Health Administration (VHA). In mid-2023, we started a LAI PrEP program and quickly became the largest provider of LAI PrEP within VHA. We aim to share our experience building this program as well as describe uptake amongst patients Methods In May of 2023, a dedicated advanced practice provider (APP) was hired to manage the LAI program, working closely with an Infectious Disease (ID) clinical pharmacist and ID nurse to refer patients for LAI PrEP based on VA criteria (Figure 1, Figure 2). Active LAI PrEP patients are added to a database tracker and reviewed at weekly interdisciplinary team rounds Results From May 2023 to April 2024, 77 patients were referred for LAI PrEP. There are 62 active LAI PrEP patients, with a mean age of 41 years (23-83 years). Most were men (n=49, 79%) and self-identified as black race (n=51, 82%). The most common indication for LAI PrEP use (n=46, 74%) was being at high risk of HIV acquisition, or having special patient factors that affect adherence to oral PrEP (Table 1). Of the 15 patients who were referred for LAI PrEP but discontinued use , reasons cited included: adverse reactions (n=4, 40%), inability to adhere to clinic scheduling (n=3, 30%), no longer desiring PrEP (n=2, 20%), and relocation to another state (n=1, 10%); 5 never initiated LAI PrEP. There were 7 patients (46%) who resumed oral PrEP after LAI discontinuation. Conclusion We have rapidly expanded access to LAI PrEP at the AVAHCS using a model that may be replicated at other VA facilities. Assessment of risk and patient preference often guides the decision about starting LAI PrEP in our cohort and should be an important consideration when creating guidance about eligibility for LAI PrEP. Disclosures All Authors: No reported disclosures

P-503. Health Care Providers' Experiences with and Perceived Barriers to Implementation of Long-Acting Injectable Preexposure Prophylaxis

Abstract Background Many patients eligible for preexposure prophylaxis (PrEP) for HIV are not yet prescribed it. Long-acting injectable cabotegravir (CAB-LA) may be a tool to increase PrEP coverage, though its uptake has been limited. Methods We conducted an online national survey to evaluate providers’ experiences with prescribing and perceived barriers to implementing CAB-LA. The anonymous survey was administered from 07/2023 to 11/2023 to a convenience sample of providers affiliated with the AIDS Education and Training Centers. We used Fisher’s exact tests to assess for factors associated with availability and use of CAB-LA. Results There were 89 total respondents from diverse professions (40% physicians, 60% non-physicians) from multiple regions (61% in the Northeast). Nearly half (46%) reported that at least 10% of their panel was uninsured and most (85%) reported that at least 40% of their panel had public insurance. Among providers, 57% reported their primary clinic site offered CAB-LA. Only 29% had patients on CAB-LA, and 10% had patients who tried CAB-LA and switched to oral PrEP. The most common perceived systems-level barriers to use of CAB-LA were concerns about insurance coverage (84%) and logistic constraints (78%). The most common perceived patient-related barriers were lack of patient requests (71%), concern for missed injections (68%), and cost (64%). The most common perceived reasons for patients to switch off of CAB-LA were burden of appointments (78%), injection site pain (67%) or other side effects (44%), and cost (33%). A majority (67%) reported that lack of training was at least a minor barrier to the prescribing of CAB-LA by providers at their practice site. Rates of CAB-LA availability and providers having prescribed CAB-LA did not vary by provider credentials, region, panel insurance mix, or rates of uninsured patients in providers’ panels (p-values all >0.05). Conclusion This study highlights the modest rate of availability and the low rate of prescribing of CAB-LA. This suggests the need for improved strategies to implement CAB-LA, specifically surrounding cost, clinic logistics, patient awareness, and provider education. The rate of providers who have had patients switch off of CAB-LA suggests that patients may benefit from support to ease the burden of appointments and cost. Disclosures Douglas Krakower, MD, FluidForm Bio: Stocks/Bonds (Private Company)|Gilead: Grant/Research Support|Matchbox Health: Stocks/Bonds (Private Company)|Medscape: Funding to develop educational content|Merck: Grant/Research Support

P-520. Barriers and facilitators towards HIV Pre-Exposure Prophylaxis (PrEP) prescription among healthcare providers in North Louisiana

Abstract Background The HIV/AIDS epidemic remains a major global health challenge. To end the HIV epidemic, it is crucial to ensure that everyone has fair and equal access to HIV treatment and prevention, including PrEP. Identifying and addressing barriers to PrEP prescription to ensure equitable access to prevent new infections is essential to end the HIV epidemic. Therefore, this study aims to identify incentives and barriers towards HIV PrEP prescription among healthcare providers in North Louisiana.Figure 1.How would you rate your knowledge of PrEP?The majority of participants (48%) rated their knowledge about PrEP as fair, good in 20%, and it was reported as poor in 16% of participants. Methods This is an ongoing observational cross-sectional survey study that aims to identify knowledge, attitudes, and intentions toward HIV PrEP among healthcare providers. Participants are faculty, residents, and fellows from the departments of Medicine, Pediatrics, Family Medicine and Obstetrics and Gynecology at an academic center in North Louisiana. A multi-modal recruitment strategy is being used to maximize the number of participants. We have conducted a preliminary descriptive analysis of the responses obtained from the study participants.Figure 2.Have you ever prescribed PrEP to a patient?Among healthcare providers surveyed, the majority (68%) reported that they had never prescribed PrEP to a patient. Results A total of 50 healthcare providers have taken the survey so far. Based on our initial findings, most study participants rated their knowledge of PrEP as either fair (48%) or poor (16%) (Fig.1). Concerning awareness of potential side effects, 44% reported poor knowledge. Most respondents (68%) had never prescribed PrEP (Fig.2). Barriers to PrEP prescription included: lack of PrEP provider training, lack of clinical guidelines for prescription and monitoring, challenges related to clinical and laboratory monitoring requirements, time constraints for patient education, and lack of insurance coverage (Fig.3). Facilitators to PrEP prescription included: access to resources such as PrEP prescription guidelines, implementation of Electronic Medical Records (EMR) order sets, clinical pharmacist support, and having peers who are knowledgeable and supportive of PrEP provision within their practice (Fig.4).Figure 3.Potential barriers to prescribing PrEP.Lack of provider training on PrEP was considered a very likely barrier to prescribing PrEP by 45% of respondents, while more than 50% of participants considered staffing and time constraints likely to be a barrier. Conclusion In order to make a significant contribution to HIV prevention, it is crucial to identify gaps in knowledge, attitudes, and practices among healthcare providers. This study’s ultimate goal is to improve PrEP implementation and dissemination, ultimately reducing new HIV infections among at-risk populations in Louisiana.Figure 4.Facilitators of PrEP prescription.More than 60% of participants considered that having Electronic medical records (EMR) order sets was an extremely likely facilitator, followed by clinical pharmacy support and having knowledgeable and supportive peers of PrEP use. Disclosures All Authors: No reported disclosures

Understanding the PrEP Care Continuum for Adults: Health Care Providers' Perspectives on Barriers, Facilitators, and Missed Opportunities.

Pre-exposure prophylaxis (PrEP) is an effective strategy in reducing HIV transmission, yet its uptake remains suboptimal. Health care providers play a vital role in facilitating PrEP access and care. This qualitative study explores health care providers' perspectives on the oral PrEP care continuum for adults, emphasizing barriers, facilitators, and missed opportunities in PrEP implementation. Drawing on interviews with 18 primary care providers in New York State, our research investigates multi-level factors influencing PrEP awareness, initiation, and management. Findings reveal significant barriers at the patient level, such as low awareness, stigma, and misconceptions about HIV risk. Provider-level challenges include knowledge gaps, discomfort in discussing sexual health, and logistical constraints. Structural factors such as insufficient infrastructure and high costs impede consistent PrEP management. Facilitators identified include proactive provider-patient communication, educational resources, and workflow integration strategies. Subgroup analyses highlight variations in attitudes based on provider demographics and experience. Younger and female providers are more proactive in discussing PrEP, while older and male providers often perceive it as less relevant. Nurses emphasize patient education and trust-building, contrasting with physicians' focus on logistical challenges. Providers experienced in prescribing PrEP view it as a valuable prevention tool, while nonprescribers report hesitancy and limited familiarity. Discrepancies in patient-perceived versus actual HIV risk, as well as provider assumptions about patient candidacy for PrEP, underscore the need for routine, stigma-free discussions about HIV prevention. This study emphasizes the importance of targeted provider training, system-level support, and inclusive policies to enhance PrEP uptake. Addressing these barriers and leveraging facilitators can advance public health efforts, fostering equitable and effective HIV prevention strategies.

Corrigendum: Oral pre-exposure prophylaxis implementation in South Africa: a case study of USAID-supported programs

Corrigendum: Oral pre-exposure prophylaxis implementation in South Africa: a case study of USAID-supported programs

Corrigendum: Oral pre-exposure prophylaxis implementation in South Africa: a case study of USAID-supported programs

Corrigendum: Oral pre-exposure prophylaxis implementation in South Africa: a case study of USAID-supported programs

Real-World Rollout of Injectable Antiretrovirals for HIV Prevention and Treatment: Correlates of Early Adoption

Abstract Background Data is limited on implementation of long-acting injectable (LAI) HIV treatment (ART) and pre-exposure prophylaxis (PrEP). We characterized “early adopters” of LAI ART and PrEP in terms of social determinants of health, using a health equity lens. Methods A retrospective cohort included patients prescribed ART or PrEP through a large urban health system (January 2021-September 2023) in the Northeastern US. We used EHR data for PrEP and ART to examine group differences between those on LAI or oral medications for each, using ANOVA, chi-square tests or Fisher’s exact tests. Bivariate logistic regression modeled associations between LAI ART or LAI PrEP and social determinants of health. Results In the PrEP group, 238 patients were prescribed LAI (n=63) or oral (n=193) PrEP. Most PrEP patients were men (80.7%), non-Hispanic (79.5%), white (60.7%) and had public insurance (83.1%). Compared to patients on oral PrEP, those on LAI less often experienced food insecurity, financial strain, depression, anxiety or substance use disorders. In bivariate models, LAI PrEP inversely correlated with female sex, current smoking, depression, anxiety, and substance use disorders. In the treatment group, 1194 patients were prescribed LAI (n=76) or oral (n=1118) ART, with median age 57.0; 63.6% were from minoritized groups. Only age was significantly associated with LAI ART (OR=0.97,95% CI=0.961-0.993, p=0.005). Conclusion In this large retrospective cohort of patients on LAI PrEP and ART, patients receiving LAI less often experienced social barriers. Public health interventions are needed to overcome health inequities tied to access of LAI for HIV prevention and treatment.

Addressing Barriers to Implementing and Scaling PrEP in Carceral Settings: Applying Insights From Implementation Science.

Within the United States, individuals experiencing incarceration are at higher risk for HIV acquisition than the general population, yet may face additional difficulty engaging in HIV prevention clinical services. HIV preexposure prophylaxis (PrEP) is an effective approach to preventing HIV transmission, and the Centers for Disease Control recommends that PrEP be offered in carceral settings, particularly during the vulnerable community reentry period. However, there have been few efforts to scale PrEP in this setting. Based on our experience implementing PrEP in Rhode Island's state carceral system, we have identified potential approaches to overcoming barriers to PrEP use in this unique practice environment by using the implementation research logic model. We then evaluated specific implementation determinants and barriers as well as strategies used to overcome those barriers to effectively scale PrEP in this setting. We developed a "toolkit," or 14-step guide, for others in the field to use for implementing PrEP in carceral settings, including the development and use of clinical protocols and community linkage strategies. Our experiences with barriers in the carceral setting, identifying and leveraging implementation strategies, allowed us to develop a "toolkit" to guide other PrEP implementation projects in carceral settings. We encourage others to scale-out our work to other carceral settings to better reach and engage a group of individuals both at elevated risk for HIV and currently underserved by HIV prevention strategies, including PrEP.

Characterizing populations prioritized for PrEP in 19 African countries: a review of national guidance.

While African countries have expanded access to HIV pre-exposure prophylaxis (PrEP) since 2015, regional targets for PrEP uptake remain unmet. Understanding which populations are prioritized for PrEP at the policy level is an important step in determining the scope of PrEP distribution across Africa and identifying gaps in programme implementation. We reviewed national guidance to characterize populations prioritized for PrEP in Africa. Between January and June 2023, we searched for current National HIV Treatment and Prevention Guidelines, National HIV Strategic Plans, and the United States President's Emergency Plan for AIDS Relief (PEPFAR) Country Operational Plans (COPs) for all African countries implementing PrEP programmes supported by PEPFAR in 2022. From each document, we summarize the populations prioritized for PrEP within a country and describe PrEP eligibility. In 2022, 19 African countries implemented PrEP programmes supported by PEPFAR. Eighteen of these countries contributed National Guidelines (2016-2022), 18 contributed National Strategic Plans (2017-2023) and 19 contributed COPs (2022) to this review. Twenty-nine population groups were prioritized for PrEP in these documents. All countries prioritized HIV-serodifferent couples, female sex workers (FSWs), adolescent girls and young women (AGYW), pregnant and breastfeeding women (PBFW) and people who inject drugs (PWID), and most prioritized men who have sex with men (MSM; n = 18), transgender people (n = 18) and people in prisons (n = 17). The remaining 21 populations were prioritized in fewer than two-thirds of countries. FSWs, MSM, PWID, transgender people and people in prisons were typically prioritized for PrEP with no eligibility restrictions. In contrast, most countries had at least one document indicating that HIV-serodifferent couples, AGYW and PBFW were only eligible for PrEP if classified as high risk. Few documents specified how risk was determined, and no document included validated HIV risk assessment tools to guide implementation. We observed similarities in priority populations across countries with different HIV epidemics and inconsistencies in who was prioritized for PrEP within a country's own set of policy documents. Understanding how PrEP prioritization policies impact HIV incidence in different epidemiologic settings is critical for strengthening PrEP implementation across the continent.

HIV Pre-Exposure Prophylaxis Cascade Stages Among Men Who Have Sex With Men With Sexually Transmitted Infections in China: Multicenter Cross-Sectional Survey Study

Abstract Background There is limited literature available regarding the knowledge and use of HIV pre-exposure prophylaxis (PrEP) among men who have sex with men (MSM) with sexually transmitted infections (STIs). Objective This study’s objective was to explore the HIV PrEP cascade stages (knowledge, willingness to use, and use) among MSM with STIs in China, in order to promote the implementation of PrEP in this population. Methods A cross-sectional study was conducted using a respondent-driven sampling method in 19 cities in China, from January to August 2022. The study collected data on demographics, behaviors, and PrEP cascade stages from participants who were not infected with HIV and who self-reported being recently infected with STIs. After using chi-square tests or Fisher exact tests to analyze differences in the knowledge of PrEP, willingness to use PrEP, and PrEP use across different variables, multivariate logistic regression was used to analyze the influences of the different variables on PrEP cascade stages. Results By August 2022, following screening and exclusion, a total of 1329 MSM were included in the study. Among them, 85.55% (n=1137) had heard of PrEP, 81.57% (n=1084) expressed their willingness to use PrEP if engaging in high-risk HIV behaviors, 70.58% (n=938) had consulted a health care professional about PrEP, 62.98% (n=837) reported having used PrEP, and 46.35% (n=616) possessed a basic understanding of PrEP. The results of multivariate logistic regression analyses showed that the same factors significantly influenced both knowledge of PrEP and willingness to take PrEP, including age, education, marital status, income, condom usage, participation in group sex, HIV status of the most recent male sexual partner, and postexposure prophylaxis (PEP) usage. The factors significantly related to the PrEP use included income, engagement in commercial sex, participation in group sex, HIV status of the most recent male sexual partner, new drug usage, and PEP usage. Conclusions MSM with STIs were engaged with the PrEP cascade stages at a relatively high rate, but they lacked an understanding of PrEP and underestimated HIV risk. The prevalence of having a basic understanding of PrEP was lower than PrEP usage, and this suboptimal awareness could impede PrEP efficacy and lead to risk compensation.

Analysis of Pre-Exposure Prophylaxis (PrEP) Program in Preventing HIV/AIDS Based on the Health Policy Triangle

Background: Pre-exposure prophylaxis (PrEP) is an action to prevent HIV transmission using antiretroviral (ARV) drugs. During 2022, the PrEP program was implemented in 21 districts/cities as a trial limited to MSM and sex worker populations. This study aims to analyze the PrEP program in preventing HIV/AIDS using a health policy triangle approach that assesses the aspects of actor, context, content, and process. Methods: The study was performed using qualitative methods from electronic document searches. Results: The results of the analysis show that the actors in the PrEP program as HIV/AIDS prevention are the President, Legislative, Ministry of Health, Ministry of Education, Ministry of Internal Affairs, health office, community health centers, hospitals, non-governmental organization (NGOs)/HIV and AIDS care groups, HIV/AIDS key populations, correctional institutions, the Indonesian Ulema Council (MUI), and the Food and Drug Monitoring Agency (BPOM). The context of PrEP implementation in the form of situational factors is high HIV transmission within at-risk populations, structural factors are legal bases, cultural factors are patriarchal culture and MSM and sex workers which are still taboo, as well as international factors in the form of WHO policy. The policy process consists of problem identification, policy analysis, policy formulation, implementation, and program monitoring and evaluation. Conclusion: PrEP content regarding the aim of PrEP, targets, types of drugs used, how to get PrEP services, how to use the drugs, and how to monitor has been explained in the Technical Guidelines for PrEP Services made by WHO and adapted by the Indonesian Ministry of Health.

Staff and Providers' Perceptions of Patients' PrEP Candidacy, Acceptability, and Adherence in Methadone Clinic Settings.

People who use drugs and patients in substance use treatment may be placed at high risk for HIV due to mixing sex and drugs, potential engagement in sex work, and injection drug use. However, pre-exposure prophylaxis (PrEP) adoption among these populations remains low. Methadone clinics, a main point of contact with the healthcare system for this population, are a missed opportunity to offer biomedical HIV prevention. Understanding provider and staff perceptions of patients' PrEP-related candidacy, acceptability, and adherence is a critical first step to informing PrEP implementation in substance use treatment settings. Thirty semistructured interviews were conducted at 2 methadone clinics in Northern New Jersey between January and April 2019. Participants included methadone counselors, medical providers, front desk staff, intake coordinators, and other clinic staff members. Three major themes were identified: (1) provider and staff's perceptions of who would benefit most from PrEP, (2) perceptions of patients' acceptability of PrEP, and (3) perceptions of patients' ability to take a pill every day. Broadly, staff perceived younger patients to be better PrEP candidates than older patients, expressed cautious optimism that PrEP would be acceptable to their patient populations, and were mixed in terms of their perceptions of patients' ability to adhere to PrEP. Notably, staff largely did not mention patients who inject drugs as potential PrEP candidates, suggesting a missed opportunity. To promote PrEP implementation in methadone clinics, staff and providers should receive training around screening for PrEP eligibility in order to maximize the benefits of PrEP for various subpopulations, especially those who inject. Importantly, discussions around sexual behavior and injection drug use must be approached in an open, non-stigmatizing manner. These findings can be used to inform future interventions to integrate PrEP services into substance use treatment settings.

One Step at a Time: Incremental Approaches to HIV Prevention

HIV prevention remains a global priority, with diverse strategies continuously developed to address the needs of high-risk populations. Incremental approaches—emphasizing gradual, step-by-step advancements—are gaining traction as an effective method to tailor interventions, increase accessibility, and foster long-term engagement. These strategies build on existing resources, adjust to unique local contexts, and prioritize community involvement, making them especially impactful in resource-limited or culturally diverse settings. By setting measurable, short-term goals, incremental approaches offer a sustainable pathway for reducing HIV transmission rates. One significant example of incremental HIV prevention is the phased implementation of Pre-Exposure Prophylaxis (PrEP), which has shown remarkable results when introduced progressively to high-risk groups. Alongside PrEP, behavioral interventions such as safe-sex education and harm reduction for injecting drug users are adapted incrementally to shift cultural norms and reduce stigma. Biomedical innovations, like microbicides, are similarly introduced in stages, with user feedback and adherence monitored to enhance real-world effectiveness. By allowing for community-specific refinements, these interventions become more accepted and impactful. Keywords: HIV Prevention, Incremental Strategies, PrEP, Behavioral Interventions, Community Education

Exploring and Predicting HIV Preexposure Prophylaxis Adherence Patterns Among Men Who Have Sex With Men: Randomized Controlled Longitudinal Study of an mHealth Intervention in Western China.

Preexposure prophylaxis (PrEP) is an effective strategy to reduce the risk of HIV infection. However, the efficacy of PrEP is highly dependent on adherence. Meanwhile, adherence changes over time, making it difficult to manage effectively. Our study aimed to explore and predict the patterns of change in PrEP adherence among men who have sex with men (MSM) and evaluate the impact of the WeChat-based reminder intervention on adherence, thus providing more information for PrEP implementation strategies. From November 2019 to June 2023, in a randomized controlled longitudinal study of the PrEP demonstration project in Western China (Chongqing, Sichuan, and Xinjiang) based on a mobile health (mHealth) reminder intervention, participants were randomly divided into reminder and no-reminder groups, with those in the reminder group receiving daily reminders based on the WeChat app. Participants were followed up and self-reported their medication adherence every 12 weeks for a total of 5 follow-up visits. We used the growth mixture model (GMM) to explore potential categories and longitudinal trajectories of adherence among MSM, and patterns of change in PrEP adherence were predicted and evaluated based on the decision tree. A total of 446 MSM were included in the analysis. The GMM identified 3 trajectories of adherence: intermediate adherence group (n=34, 7.62%), low adherence ascending group (n=126, 28.25%), and high adherence decline group (n=286, 64.13%). We included 8 variables that were significant in the univariate analysis in the decision tree prediction model. We found 4 factors and 8 prediction rules, and the results showed that HIV knowledge score, education attainment, mHealth intervention, and HIV testing were key nodes in the patterns of change in adherence. After 10-fold cross-validation, the final prediction model had an accuracy of 75%, and the classification accuracy of low and intermediate adherence was 78.12%. The WeChat-based reminder intervention was beneficial for adherence. A short set of questions and prediction rules, which can be applied in future large-scale validation studies, aimed at developing and validating a short adherence assessment tool and implementing it in PrEP practices among MSM.

Oral pre-exposure prophylaxis implementation in South Africa: a case study of USAID-supported programs

Since the introduction of oral pre-exposure prophylaxis (PrEP) in 2016, countries have successfully scaled-up PrEP to populations at risk of HIV acquisition, including key populations, serodiscordant couples and pregnant women. Between 2016 and 2023, there were over 5.6 million oral PrEP initiations globally. Of these, over 1.2 million occurred in South Africa, with nearly 700,000 implemented through USAID/South Africa's PEPFAR program. This case study uses WHO's Building Blocks for Health Systems Strengthening to describe USAID's oral PrEP program in South Africa, reporting experiences and lessons learned in 14 districts across 7 provinces. Key lessons include: (i) Substantial donor financial investment was critical for expanding oral PrEP in South Africa, but sustained leadership and investment from government stakeholders, such as the Department of Health and the National Treasury, have been essential for sustainability. Despite fluctuations in USAID funding, annual PrEP initiations have continued to increase in USAID-supported districts largely due to local leadership. (ii) Health information and supply chain systems required agility to monitor oral PrEP introduction and scale-up. When systems lacked agility, temporary solutions like the development of interim reporting tools were necessary. (iii) Integrating community-based and facility-based service delivery supported client-centered care. Nurses and lay health workers contributed to over 80% of the full-time equivalents supporting PrEP under USAID's human resources for health portfolio. (iv) Integrating sexual and reproductive health services with oral PrEP service delivery provided clients with comprehensive, client-centered care. (v) Other client-centered care included differentiated service delivery options, such as mobile and gazebo modalities, and expanded PrEP choice through implementation science activities for new PrEP products. (vi) USAID-supported PrEP initiations have been highest among females of reproductive age in the general population and men who have sex with men among key populations, priority populations in South Africa. As done in this case study, sharing best practices and lessons learned from USAID/South Africa's oral PrEP program can strengthen the implementation evidence base and inform more efficient PrEP service delivery, particularly as new PrEP products become available.

Transforming HIV prevention: the promise of long-acting preexposure prophylaxis in high HIV burden settings.

Recent research on efficacy and safety of long-acting preexposure prophylaxis (PrEP) holds the promise to transform HIV prevention in high HIV burden settings. We review emerging findings regarding early end-user acceptability of long-acting PrEP modalities, feasibility of integrating long-acting PrEP into health systems, and considerations regarding drug resistance and cost. Long-acting PrEP, particularly injectables, was found to be highly acceptable among individuals across key populations in high HIV burden settings. Concerns around use of long-acting PrEP highlight the importance of choice and ability to switch methods. Existing provider-level barriers to oral PrEP implementation (e.g., overburdened staff, training gaps) may impact long-acting PrEP rollout - however, utilization of PrEP implementation strategies such as task-shifting, timely PrEP training for all providers, differentiated service delivery, and integration with sexual health services, may mitigate barriers. Studies modeling injectable PrEP scale-up demonstrate substantial benefits in HIV mortality reduction, outweighing risks of increased integrase inhibitor resistance, but also highlight the urgency of pricing long-acting PrEP to ensure access and affordability. Long-acting PrEP could be a game changer in HIV prevention in high burden settings. There is an urgent need for rapid scale production and price reductions to ensure access in high HIV burden settings. Implementation strategies are needed to address individual and provider-level barriers.

Pre-exposure prophylaxis implementation gaps among people vulnerable to HIV acquisition: a cross-sectional analysis in two communities in western Kenya, 2021-2023.

Despite theincreasing availability of prevention tools like pre-exposure prophylaxis (PrEP), HIV incidence remains disproportionately high in sub-Saharan Africa. We examined PrEP awareness, uptake and persistence among participants enrolling into an HIV incidence cohort in Kenya. We used cross-sectional enrolment data from the Multinational Observational Cohort of HIV and other Infections (MOCHI) in Homa Bay and Kericho, Kenya. The cohort recruited individuals aged 14-55 years with a recent history of sexually transmitted infection, transactional sex, condomless sex and/or injection drug use. Participants completed questionnaires on PrEP, demographics and sexual behaviours. We used multivariable robust Poisson regression to estimate adjusted prevalence ratios (aPRs) and 95% confidence intervals (CIs) for associations with never hearing of PrEP, never taking PrEP and ever stopping PrEP. Between 12/2021 and 5/2023, 399 participants attempted the PrEP questionnaire, of whom 316 (79.2%) were female and median age was 22 years (interquartile range 19-24); 316 of 390 participants (81.0%) engaged in sex work or transactional sex. Of 396 participants who responded to the question, 120 (30.3%) had never heard of PrEP. Of 275 participants who had heard of PrEP, 206 (74.9%) had never taken it. Of 69 participants who had ever taken PrEP, 50 (72.5%) stopped it at some time prior to enrolment. Participants aged 15-19 years more often reported never taking PrEP compared with those 25-36 years (aPR 1.31, 95% CI: 1.06-1.61). Participants who knew someone who took PrEP less often reported never hearing about PrEP (aPR 0.10, 95% CI: 0.04-0.23) and never taking PrEP (aPR: 0.69, 95% CI: 0.60-0.80). Stopping PrEP was more common among participants with a weekly household income ≤1000 versus >1000 Kenyan shillings (aPR 1.40, 95% CI: 1.02-1.93) and those using alcohol/drugs before sex (aPR 1.53, 95% CI: 1.03-2.26). Stopping PrEP was less common among those engaging in sex work or transactional sex (aPR 0.6, 95% CI: 0.40-0.92). We identified substantial gaps in PrEP awareness, uptake and persistence, which were associated with potential system- and individual-level risk factors. Our analyses also highlight the importance of increasing PrEP engagement among individuals who do not know others taking PrEP.

A mathematical model for the study of HIV/AIDS transmission with PrEP coverage increase and parameter estimation using MCMC with a Bayesian approach

In this article, we present a mathematical model for the study of HIV/AIDS considering the implementation of Pre-Exposure Prophylaxis (PrEP). As a novel element in the construction of the model, we consider the diagnosis of cases for attempting to enter the PrEP program, which allows us to study different forms of PrEP. The diagnosis of new infections helps to reduce transmission in the population because these patients are incorporated into the therapy and can achieve an undetectable viral load in blood which prevents them from infecting others. The model contains a compartment of infected persons with undetectable viral load in blood that is reached by adherence to treatment which is separated from those simply infected with the virus as they do not transmit it. Considering the structure of the model, we propose a method to study the effect of increased PrEP use and HIV incidence in a population. In the case of incidence, we took into account the stochasticity of the behavior. Besides, we find the basic reproduction number and present results that allow us to obtain the impact of the parameters associated with transmission, treatment and diagnosis on the basic reproduction number. We perform computational simulations, using demographic and HIV/AIDS data from Brazil, and utilize the Markov Chain Monte Carlo (MCMC) method with a Bayesian approach to estimate model parameters. We study two coverage increases at 25% and 35% that were selected according to the size of the Brazilian population and the daily use of PrEP. We compare the increases in coverage focused on HIV incidence, which is the number of new HIV cases infected and the number of HIV cases avoided, we conclude that by increasing PrEP coverage the incidence of HIV is reduced and the number of cases avoided increases.