Inequities in PrEP use according to Medicare status in a publicly funded sexual health clinic; a retrospective analysis.

New HIV diagnoses continue to disproportionately affect overseas-born men who have sex with men (MSM). A retrospective study of all pre-exposure prophylaxis (PrEP)-eligible MSM attending Sydney Sexual Health Centre for the first time in 2021 analysed self-reported PrEP-use, PrEP prescribed at the initial consult, and PrEP taken during 2021 using binomial logistic regression models. A total of 1367 clients were included in the analysis, 716 (52.4%) were born overseas and 414 (57.8%) were Medicare-ineligible. Medicare-ineligible clients were less likely to be on PrEP at initial visit (OR 0.45, 95% CI 0.26-0.77). This study suggests inequities in PrEP access and/or awareness in Medicare-ineligible MSM in Australia.

Eita! Reaching Communities and Young People to Drive Demand for Oral Pre-Exposure Prophylaxis in South Africa.

PURPOSE: This paper describes a holistic but flexible demand creation strategy for pre-exposure prophylaxis (PrEP) in national public health-care settings in low-income to middle-income countries. METHODS: We describe the development and implementation of a model to drive demand for oral PrEP uptake and use as part of comprehensive sexual and reproductive health services in South Africa: The Eita! MODEL: The project adapted two existing response hierarchy models (marketing models used to describe the stages individuals move through from being unaware to using a product), to formulate the Eita! MODEL: Using the RE-AIM framework, we report on the reach, effectiveness, adoption, implementation, and maintenance of the Eita! RESULTS: More than 34 million connections were made from December 2018 to 2021 through a variety of channels: social media and websites, at events and mobile clinic outreach, and radio and community dialogs. There were 42,447 adolescent girls and young women reached in-person during this time, 16,823 adolescent girls and young women presented for sexual and reproductive health services, and of those 14,637 (87%) initiated on PrEP. The model was implemented in eight health-care facilities and four mobile clinics in three provinces in South Africa. A total of 26 trainings were delivered to project staff implementing the strategy. Various demand creation resources, such as materials and online platforms, have since been adopted by the National Department of Health as national tools. DISCUSSION: The Eita! model was successfully implemented to support the uptake of HIV prevention services and rollout of biomedical prevention products, and can be adapted by other low-income to middle-income countries.

Characterizing Twitter Content About HIV Pre-exposure Prophylaxis (PrEP) for Women: Qualitative Content Analysis.

BACKGROUND: HIV remains a persistent health problem in the United States, especially among women. Approved in 2012, HIV pre-exposure prophylaxis (PrEP) is a daily pill or bimonthly injection that can be taken by individuals at increased risk of contracting HIV to reduce their risk of new infection. Women who are at risk of HIV face numerous barriers to HIV services and information, underscoring the critical need for strategies to increase awareness of evidence-based HIV prevention methods, such as HIV PrEP, among women. OBJECTIVE: We aimed to identify historical trends in the use of Twitter hashtags specific to women and HIV PrEP and explore content about women and PrEP shared through Twitter. METHODS: This was a qualitative descriptive study using a purposive sample of tweets containing hashtags related to women and HIV PrEP from 2009 to 2022. Tweets were collected via Twitter's API. Each Twitter user profile, tweet, and related links were coded using content analysis, guided by the framework of the Health Belief Model (HBM) to generate results. We used a factor analysis to identify salient clusters of tweets. RESULTS: A total of 1256 tweets from 396 unique users were relevant to our study focus of content about PrEP specifically for women (1256/2908, 43.2% of eligible tweets). We found that this sample of tweets was posted mostly by organizations. The 2 largest groups of individual users were activists and advocates (61/396, 15.4%) and personal users (54/396, 13.6%). Among individual users, most were female (100/166, 60%) and American (256/396, 64.6%). The earliest relevant tweet in our sample was posted in mid-2014 and the number of tweets significantly decreased after 2018. We found that 61% (496/820) of relevant tweets contained links to informational websites intended to provide guidance and resources or promote access to PrEP. Most tweets specifically targeted people of color, including through the use of imagery and symbolism. In addition to inclusive imagery, our factor analysis indicated that more than a third of tweets were intended to share information and promote PrEP to people of color. Less than half of tweets contained any HBM concepts, and only a few contained cues to action. Lastly, while our sample included only tweets relevant to women, we found that the tweets directed to lesbian, gay, bisexual, transgender, queer (LGBTQ) audiences received the highest levels of audience engagement. CONCLUSIONS: These findings point to several areas for improvement in future social media campaigns directed at women about PrEP. First, future posts would benefit from including more theoretical constructs, such as self-efficacy and cues to action. Second, organizations posting on Twitter should continue to broaden their audience and followers to reach more people. Lastly, tweets should leverage the momentum and strategies used by the LGBTQ community to reach broader audiences and destigmatize PrEP use across all communities.

A Scoping Review of Oral Pre-exposure Prophylaxis for Cisgender and Transgender Adolescent Girls and Young Women: What Works and Where Do We Go from Here?

Adolescent girls and young women (AGYW) are disproportionately affected by HIV, and oral pre-exposure prophylaxis (PrEP) can reduce HIV acquisition. The purpose of this scoping review was to synthesize results from interventions along the PrEP continuum for AGYW to inform research and programs. We searched electronic databases for studies published between January 2012-July 2021 and conducted secondary reference searching. Studies were included if they assessed interventions to increase PrEP interest, uptake, or continuation among AGYW. Results were synthesized narratively. Of 2168 citations identified, 50 studies were eligible for inclusion, and 20 contained AGYW-specific data. Among cisgender and transgender AGYW, studies overall demonstrated a positive impact on PrEP interest and uptake but generally attained suboptimal continuation rates. Results demonstrate feasibility of deploying PrEP across diverse settings-particularly when interventions are layered, tailored to AGYW, and include differentiated delivery-but also highlight knowledge gaps and the need for more holistic metrics of success.

RESUMEN: Las adolescentes y las mujeres jóvenes se ven afectadas de forma desproporcionada por el VIH, y la Profilaxis Pre-Exposición oral (PrEP) puede reducir la adquisición del VIH. El propósito de esta revisión de alcance fue sintetizar los resultados de las intervenciones a lo largo del continuo de la PrEP para las adolescentes y las mujeres jóvenes con el fin de informar la investigación y los programas. Se realizaron búsquedas en bases de datos electrónicas de estudios publicados entre enero 2012 a julio 2021 y se llevó a cabo una búsqueda secundaria de referencias. Los estudios se incluyeron si evaluaban intervenciones para aumentar el interés, la iniciación, o la continuación de la PrEP entre las adolescentes y las mujeres jóvenes. Los resultados se sintetizaron narrativamente. De las 2168 citas identificadas, 50 estudios fueron elegibles para inclusión y 20 contenían datos específicos de las adolescentes y las mujeres jóvenes. Entre las adolescentes y las mujeres jóvenes cisgénero y transgénero, los estudios demostraron un impacto positivo en el interés y la iniciación de la PrEP, pero en general alcanzaron tasas de continuación subóptimas. Los resultados demuestran la viabilidad del despliegue de la PrEP en diversos entornos­en particular cuando las intervenciones son estratificadas, se adaptan a las adolescentes y las mujeres jóvenes, e incluyen una prestación diferenciada­pero también destacan las lagunas de conocimiento y la necesidad de una métrica más holística del éxito.

A randomized trial of safety, acceptability and adherence of three rectal microbicide placebo formulations among young sexual and gender minorities who engage in receptive anal intercourse (MTN-035).

Efforts to develop a range of HIV prevention products that can serve as behaviorally congruent viable alternatives to consistent condom use and oral pre-exposure prophylaxis (PrEP) remain crucial. MTN-035 was a randomized crossover trial seeking to evaluate the safety, acceptability, and adherence to three placebo modalities (insert, suppository, enema) prior to receptive anal intercourse (RAI). If participants had no RAI in a week, they were asked to use their assigned product without sex. We hypothesized that the modalities would be acceptable and safe for use prior to RAI, and that participants would report high adherence given their behavioral congruence with cleansing practices (e.g., douches and/or enemas) and their existing use to deliver medications (e.g., suppositories; fast-dissolving inserts) via the rectum. Participants (N = 217) were sexual and gender minorities enrolled in five different countries (Malawi, Peru, South Africa, Thailand, and the United States of America). Mean age was 24.9 years (range 18-35 years). 204 adverse events were reported by 98 participants (45.2%); 37 (18.1%) were deemed related to the study products. The proportion of participants reporting "high acceptability" was 72% (95%CI: 65% - 78%) for inserts, 66% (95%CI: 59% - 73%) for suppositories, and 73% (95%CI: 66% - 79%) for enemas. The proportion of participants reporting fully adherent per protocol (i.e., at least one use per week) was 75% (95%CI: 69% - 81%) for inserts, 74% (95%CI: 68% - 80%) for suppositories, and 83% (95%CI: 77% - 88%) for enemas. Participants fully adherent per RAI-act was similar among the three products: insert (n = 99; 58.9%), suppository (n = 101; 58.0%) and enema (n = 107; 58.8%). The efficacy and effectiveness of emerging HIV prevention drug depends on safe and acceptable delivery modalities that are easy to use consistently. Our findings demonstrate the safety and acceptability of, and adherence to, enemas, inserts, and suppositories as potential modalities through which to deliver a rectal microbicide.

Hepatitis C testing among three distinct groups of gay, bisexual and other men who have sex with men: a cross-sectional study in the Celtic nations.

OBJECTIVE: The hepatitis C virus (HCV) epidemic among gay, bisexual and other men who have sex with men (GBMSM) is associated with sexual and drug-related behaviours. To stem the tide of HCV infection in GBMSM, regular testing leading to early diagnosis and treatment as prevention is vital. This study aimed to evaluate the success of current HCV testing guidelines from the perspective of GBMSM in four Celtic nations. METHODS: Subpopulation analysis of data from the 2020 cross-sectional online SMMASH3 (social media, men who have sex with men, sexual and holistic health) survey was undertaken to examine HCV testing experiences and sexual behaviours among sexually active GBMSM (n=1886) stratified across three groups: HIV-diagnosed GBMSM (n=124); HIV-negative GBMSM using pre-exposure prophylaxis (PrEP) (n=365); and HIV-negative/untested GBMSM not using PrEP (n=1397). RESULTS: Sexual behaviours associated with HCV acquisition were reported by the majority of HIV-diagnosed (76.6%, n=95) and PrEP-using (93.2%, n=340) GBMSM. Reassuringly, recent testing for HCV in these groups was common, with 79.8% (n=99) and 80.5% (n=294) self-reporting HCV screening within the preceding year, respectively, mostly within sexual health settings. While 54.5% (n=762) of HIV-negative/untested GBMSM not using PrEP reported sexual behaviours associated with HCV, 52.0% had not been screened for HCV in the last year, despite almost half (48.0%, n=190) of unscreened men being in contact with sexual health services in the same period. CONCLUSIONS: Sexual behaviours associated with HCV acquisition among HIV-diagnosed and PrEP-using GBMSM are common but complemented by regular HCV testing within sexual health services. Current testing guidelines for these groups appear to be effective and generally well observed. However, behaviour-based HCV testing for HIV-negative/untested GBMSM not using PrEP appears less effective and may undermine efforts to achieve HCV elimination. Accordingly, we need to increase HCV testing for these men in clinical settings and explore ways to screen those who are not in touch with sexual health services.

Ending the HIV epidemic PrEP equity recommendations from a rapid ethnographic assessment of multilevel PrEP use determinants among young Black gay and bisexual men in Atlanta, GA.

BACKGROUND: Efforts to mitigate HIV transmission among gay and bisexual men have not been sufficient to level persistent racial inequities which now extend to the use of daily oral pre-exposure prophylaxis (PrEP) for HIV prevention. Community-involved ethnographic research is crucial to galvanizing collaboration between patients, researchers, and policymakers to identify the social determinants of emerging PrEP inequities. In partnership with community key informants, we conducted a Rapid Ethnographic Assessment (REA) of multilevel PrEP use determinants among young Black gay and bisexual (YBGBM) men in the metropolitan Atlanta area to inform the development and coordination of local HIV programs. METHODS: In the assessment, we drew upon the perspectives of local clinicians, community-based organization leaders, health educators, and PrEP clients to identify barriers and facilitators to PrEP use among YBGBM through interviews (N = 23). Data were collected from September 2020 -to January 2021 and were analyzed through a staged deductive-inductive thematic analysis. The themes were later summarized and presented to community stakeholder participants to facilitate member-checking. RESULTS: Our analyses revealed structural, cultural, relationship, and developmental factors which shaped PrEP use. The most prominent being "ease of access to PrEP" (structural level), "provider support" (interpersonal), and "life-stage traits" (individual). Our results also contribute novel information concerning the axes of intersectional stigma (spatial, racial, sexual identity, and HIV) among YBGBM in Atlanta and its divergent effects on PrEP use. CONCLUSION: Increased PrEP use among YBGBM, particularly among those living in the south, is essential to ending the domestic HIV epidemic. Altogether, our results emphasize the need for PrEP program modifications, which increase flexibility in methods and modes of access and are culturally adapted to the needs of YBGBM. There is also a need for resources that holistically focus on mental health, trauma, and racism as critical components of support.

Understanding Barriers and Facilitators of Pre-exposure Prophylaxis (PrEP) Among Transgender and Gender Diverse Adults in an Integrated Health Care System.

Transgender and gender diverse individuals face health disparities such as higher HIV prevalence, but limited studies have found low PrEP uptake among these populations. To understand both patient and provider perspectives regarding PrEP care for transgender and gender diverse individuals, we conducted a mixed-methods study at Kaiser Permanente Southern California from September 2020 to October 2021. Transgender and gender diverse adults (N = 396) participated in a web-based survey, and qualitative interviews were subsequently conducted with a subset of survey respondents (N = 32) and healthcare providers (N = 8). Among survey respondents, > 75% were familiar with PrEP, and > 40% reported at least one HIV risk factor, but < 5% had taken PrEP. Interview themes included increasing providers' inclusivity in primary care for transgender and gender diverse patients, and reducing logistical barriers and costs associated with PrEP-related visits. To improve PrEP uptake among transgender and gender diverse individuals, barriers across patient, provider, and health system levels must be addressed.

Examining HIV Diagnosis and Linkage to PrEP Prescription Among Members at An Integrated Health System in the Southeast United States.

Pre-Exposure Prophylaxis (PrEP) is a priority method for preventing HIV infection. This study's aims were threefold: (1) identify characteristics of members of a large health maintenance organization, Kaiser Permanente Georgia (KPGA), associated with HIV infection, (2) identify which member characteristics associated with HIV were also associated with PrEP prescription, and (3) identify which HIV-associated characteristics were associated with under- or over-prescribing of PrEP. Analysis of variables from the electronic medical record revealed that age, race, gender, mental health diagnosis, STI diagnosis, and sexual orientation were independently associated with HIV diagnosis. The same characteristics were independently associated with PrEP prescription except for race. Persons identifying as Black or unknown race, women, and/or heterosexual; and who had an STI diagnosis and/or illicit drug use had lower odds of being prescribed PrEP than of having an HIV diagnosis. The implications of these findings for improving physician identification of candidates for PrEP prescription are discussed.

Identifying Strategies for Improving Pre-exposure Prophylaxis Adherence: Perspectives from a Sample of Highly Adherent Young Men Who have Sex with Men.

Most research on pre-exposure prophylaxis (PrEP) adherence and persistence uses a deficit-based approach to identify negative influences on PrEP adherence; however, an alternative set of approaches (such as resilience, asset-based, and positive variation) may identify equally important positive influences on PrEP adherence. Thus, the current study presents qualitative perspectives of PrEP adherence strategies from a sample of adherent YMSM. PrEP-using YMSM living in the Chicago area from a larger cohort study were recruited into a 90-day diary study that measured sexual health behaviors including PrEP use. A subset (n = 28) were then recruited for in-depth interviews between April and September 2020 covering topics of PrEP use and adherence. Thematic analysis was used to interpret patterns within the data. The analytic sample (n = 19) consistently reported high levels of adherence. Adherence strategies were organized into three broader categories: psychological (e.g. mindfulness, pill auditing), technical/instrumental (e.g. automated reminders, pill organizers), and social strategies (e.g. checking in with friends, or getting suggestions from friends). The majority of participants described using multiple strategies and changing strategies to respond to barriers to adherence. Other themes that were related to adherence included having a daily medication history and a generally positive outlook toward the PrEP regimen. Those who had medication histories were able to draw from experience to develop strategies for PrEP adherence. Findings suggest the need for pre-emptive counseling for PrEP-initiators on the use of multiple strategies, how to prepare for PrEP adherence, to adapt to challenges, and to adopt a range of potential strategies for adherence.

RESUMEN: La mayoría de las investigaciones sobre el cumplimiento y la persistencia de la profilaxis pre-exposición (PrEP) utiliza un enfoque basado en el déficit para identificar las influencias negativas en el cumplimiento de la PrEP; sin embargo, un conjunto alternativo de enfoques (como resiliencia, basado en en las capacidades o recursos, y variación positiva) puede identificar influencias positivas igualmente importantes en la adherencia a la PrEP. Por lo tanto, el estudio actual presenta perspectivas cualitativas de las estrategias de adherencia a la PrEP de una muestra de los hombres jóvenes que tienen sexo con hombres (YMSM) adherentes. Los YMSM que usaban PrEP que vivían en la región de Chicago de un estudio de cohorte más grande fueron reclutados en un estudio diario de 90 días que midió los comportamientos de salud sexual, incluido el uso de PrEP. Luego se reclutó un subconjunto (n = 28) para entrevistas en profundidad entre abril y septiembre de 2020 que cubrieron temas de uso y adherencia a la PrEP. El análisis temático se utilizó para interpretar patrones dentro de los datos. La muestra analítica (n = 19) reportó consistentemente altos niveles de adherencia. Las estrategias de adherencia se organizaron en tres categorías más amplias: psicológicas (p. ej., atención plena, auditoría de píldoras), técnicas/instrumentales (p. ej., recordatorios automáticos, organizadores de píldoras) y estrategias sociales (p. ej., ponerse en contacto con amigos o recibir sugerencias de amigos). La mayoría de los participantes describieron el uso de múltiples estrategias y el cambio de estrategias para responder a las barreras a la adherencia. Otros temas relacionados con la adherencia incluyeron tener un historial de medicación diario y una perspectiva generalmente positiva hacia el régimen de PrEP. Aquellos que tenían antecedentes de medicación pudieron aprovechar la experiencia para desarrollar estrategias para la adherencia a la PrEP. Los hallazgos sugieren la necesidad de asesoramiento preventivo para los iniciadores de la PrEP sobre el uso de múltiples estrategias, cómo prepararse para la adherencia a la PrEP, cómo adaptarse a los desafíos y adoptar una variedad de posibles estrategias para la adherencia.

Preclinical Considerations for Long-acting Delivery of Tenofovir Alafenamide from Subdermal Implants for HIV Pre-exposure Prophylaxis.

PURPOSE: Long-acting formulations of the potent antiretroviral prodrug tenofovir alafenamide (TAF) hold potential as biomedical HIV prevention modalities. Here, we present a rigorous comparison of three animal models, C57BL/6 J mice, beagle dogs, and merino sheep for evaluating TAF implant pharmacokinetics (PKs). METHODS: Implants delivering TAF over a wide range of controlled release rates were tested in vitro and in mice and dogs. Our existing PK model, supported by an intravenous (IV) dosing dog study, was adapted to analyze mechanistic aspects underlying implant TAF delivery. RESULTS: TAF in vitro release in the 0.13 to 9.8 mg d-1 range with zero order kinetics were attained. Implants with equivalent fabrication parameters released TAF in mice and sheep at rates that were not statistically different, but were 3 times higher in dogs. When two implants were placed in the same subcutaneous pocket, a two-week creep to Cmax was observed in dogs for systemic drug and metabolite concentrations, but not in mice. Co-modeling IV and TAF implant PK data in dogs led to an apparent TAF bioavailability of 9.6 in the single implant groups (compared to the IV group), but only 1.5 when two implants were placed in the same subcutaneous pocket. CONCLUSIONS: Based on the current results, we recommend using mice and sheep, with macaques as a complementary species, for preclinical TAF implant evaluation with the caveat that our observations may be specific to the implant technology used here. Our report provides fundamental, translatable insights into multispecies TAF delivery via long-acting implants.

Status-Neutral Interventions to Support Health Equity for Black Sexual Minority Men.

PURPOSE OF REVIEW: Status-neutral care, a person-centered approach to healthcare not predicated on HIV serostatus, may improve health equity among Black sexual minority men (BSMM). We reviewed current status-neutral, HIV, and Pre-Exposure Prophylaxis (PrEP) interventions, and coded each for social-ecological focus and use of six approaches: (1) person-centered, (2) anti-stigma, (3) social support, (4) the social determinants of health (SDOH), (5) community engagement, and (6) multi-sectoral partnerships. RECENT FINDINGS: We reviewed 25 studies, of which 3 were status-neutral. Nineteen studies utilized person-centered approaches, with several employing BSMM peers. For SDOH, financial incentives and reducing clinic-level barriers to care improved cascade outcomes. Direct text messaging, anti-stigma, social support, community-engagement, and multi-sectoral partnerships also improved outcomes in some studies. Few status-neutral programs exist and additional research is needed to identify key intervention components and mechanisms of influence. Programs targeting SDOH and multiple social-ecological levels offer promise for providing holistic care to BSMM, while addressing HIV prevention and treatment and health equity.

Sexually Transmitted Infection Testing, Prevalence, and Treatment Among Individuals Receiving HIV Preexposure Prophylaxis Within an Integrated Healthcare Delivery System.

BACKGROUND: Initial and follow-up sexually transmitted infection (STI) and human immunodeficiency virus (HIV) testing are recommended when taking HIV preexposure prophylaxis (PrEP). We assessed STI services before and after PrEP initiation among persons 18 years or older. METHODS: We conducted this retrospective cohort study at a US integrated healthcare delivery system. We measured HIV/STI testing rates, STI prevalence and treatment at 3 time points: (1) at PrEP initiation, (2) at 120 days, and (3) at 210 days. RESULTS: Of 685 PrEP initiators, 67.2% continued PrEP use at 120 days and 49.5% at 210 days. Of PrEP users, HIV and STI testing were greater than 85% and greater than 80%, respectively, at all 3 time points. Prevalence for any chlamydia, rectal chlamydia, and any gonorrhea, rectal gonorrhea, or pharyngeal gonorrhea was always high at the 120 days and 210 days (eg, 6.9%, 10.5%, 6.7%, 5.0%, and 5.2%, respectively, at the 120 days for continuous PrEP users). Over 90% of all individuals who tested positive for chlamydia and gonorrhea received antibiotic pharmacy fills within 7 days at 120 and 210 days. Monthly PrEP-related pharmacy cost was about $2259 to $2659. The proportion of the total medical cost that was PrEP-related pharmacy was about 82% for PrEP continuous users. CONCLUSIONS: Although HIV/STI testing rates were high, they can still be improved during HIV PrEP management. High STI prevalence after PrEP initiation in this study suggests that patients taking PrEP are at risk of acquiring an STI. Interventions to improve STI services during PrEP management are continuously needed.

Sexually Transmitted Infections Among Men and Transgender Women Using HIV Pre-exposure Prophylaxis in a Large Integrated Health System-A Cohort Study.

BACKGROUND: Sexually transmitted infections (STIs) are common in people using pre-exposure prophylaxis (PrEP). We examined risk and factors associated with STIs in a cohort of PrEP users in an integrated health system in the United States. SETTING: The Kaiser Permanente Southern California is a large integrated health system that provides comprehensive medical services to approximately 4.7 million demographically diverse members. METHODS: We identified men and transgender women initiating PrEP between January 1, 2014, and June 1, 2018, and followed through December 31, 2018. Demographic and clinical factors potentially associated with the risk of bacterial STIs during PrEP use were evaluated using Poisson regression models. RESULTS: Among 5042 individuals tested for STIs with 7198 person-years of follow-up, 1709 (33.9%) had at least one new STI. The estimated incidence of STIs was 48.3 per 100 person-years, and the most common STI was rectal chlamydia. Most repeat STIs (61.4%) occurred <180 days apart. In a multivariable analysis, an history of STIs in the prior 6 months through 7 days after the PrEP initiation was the most prominent risk factor of STIs during PrEP use (adjusted risk ratio: 1.78, 95% confidence intervals: 1.65 to 1.93). Other risk factors included younger age (<35 years), being Hispanic, and having a history of alcohol use disorder or drug use disorder. CONCLUSIONS: Quarterly STI testing and targeted intervention to mitigate STI risk are warranted for young and racial minority PrEP users, particularly for those with prior history of STIs and substance use disorders.

Maintaining access to HIV pre-exposure prophylaxis in a pandemic: A service evaluation of telephone-based pre-exposure prophylaxis provision.

OBJECTIVES: The objective was to perform a survey-based service evaluation of our telephone PrEP clinic (Tele-PrEP), which was instituted during the COVID-19 pandemic, to inform future service delivery. METHODS: We administered parallel, web-based, anonymous surveys to PrEP-users who had a Tele-PrEP appointment between 13.11.2020 and 17.12.2020 and all healthcare professionals (HCPs) conducting Tele-PrEP clinics. We used descriptive statistics to summarise demographic and qualitative data, and thematically categorised free text responses using the Framework for a Systems Approach to Healthcare Delivery. RESULTS: 62/117 (53%) PrEP-users and 8/9 (89%) HCPs completed the surveys. Tele-PrEP was rated 'excellent' or 'good' by 61/62 (98%) PrEP-users. All HCPs felt that Tele-PrEP allowed them to assess patients safely and confidently. 10/62 (16%) PrEP-users and 1 (11%) HCP expressed a preference for face-to-face care. Using the Framework for a Systems Approach to Healthcare Delivery we identified key areas important to respondents who highlighted the rapid changes as a result of COVID-19, which required an increase in dedicated resources. HCPs valued teamwork, support/supervision and convenience in achieving quality care for the patient, who in turn, valued convenient, holistic and individualised management to meet their sexual healthcare needs. CONCLUSION: Tele-PrEP is feasible and acceptable. While most respondents rated the service highly, others identified a need/preference for face-to-face appointments.

Factors associated with willingness to use oral pre-exposure prophylaxis (PrEP) in a fisher-folk community in peri-urban Kampala, Uganda.

BACKGROUND: The World Health Organization (WHO) recommends the use of pre-exposure prophylaxis (PrEP) in key populations at elevated risk for exposure to HIV. If used effectively, PrEP can reduce annual HIV incidence to below 0.05%. However, PrEP is not acceptable among all communities that might benefit from it. There is, therefore, a need to understand perceptions of PrEP and factors associated with willingness to use PrEP among key populations at risk of HIV, such as members of communities with exceptionally high HIV prevalence. OBJECTIVE: To examine the perceptions and factors associated with willingness to use oral PrEP among members of fishing communities in Uganda, a key population at risk of HIV. METHODS: We conducted an explanatory sequential mixed-methods study at Ggaba fishing community from February to June 2019. Survey data were collected from a systematic random sample of 283 community members in which PrEP had not been rolled out yet by the time of we conducted the study. We carried out bivariate tests of association of willingness to use PrEP with demographic characteristics, HIV risk perception, HIV testing history. We estimated prevalence ratios for willingness to use PrEP. We used backward elimination to build a multivariable modified Poisson regression model to describe factors associated with willingness to use PrEP. We purposively selected 16 participants for focus group discussions to contextualize survey findings, analysing data inductively and identifying emergent themes related to perceptions of PrEP. KEY RESULTS: We enrolled 283 participants with a mean age of 31 ± 8 years. Most (80.9%) were male. The majority of participants had tested for HIV in their lifetime, but 64% had not tested in the past 6 months. Self-reported HIV prevalence was 6.4%. Most (80.6, 95%CI 75.5-85.0) were willing in principle to use PrEP. Willingness to use PrEP was associated with perceiving oneself to be at high risk of HIV (aPR 1.99, 95%CI 1.31-3.02, P = 0.001), having tested for HIV in the past 6-months (aPR 1.13, 95%CI 1.03-1.24, P = 0.007), and completion of tertiary education (aPR 1.97, 95%CI 1.39-2.81, P < 0.001). In focus group discussions, participants described pill burden, side-effects and drug safety as potential barriers to PrEP use. CONCLUSIONS AND RECOMMENDATIONS: Oral PrEP was widely acceptable among members of fishing communities in peri-urban Kampala. Programs for scaling-up PrEP for fisherfolk should merge HIV testing services with sensitization about PrEP and also increase means of awareness of PrEP as an HIV preventive strategy .

Harmful Alcohol Use and Associated Socio-Structural Factors among Female Sex Workers Initiating HIV Pre-Exposure Prophylaxis in Dar es Salaam, Tanzania.

Harmful alcohol use is an important risk factor for premature mortality and morbidity and associated with increased HIV risk and lower uptake of and adherence to HIV interventions. This study aimed to assess the extent of harmful alcohol use and associated socio-structural vulnerability factors among female sex workers in Dar es Salaam, Tanzania, a key population in the HIV epidemic. Data from a study of female sex workers initiating pre-exposure prophylaxis (PrEP) recruited through respondent driven sampling were used. We assessed harmful alcohol use with the Alcohol Use Disorders Identification Test (AUDIT) defined as having an AUDIT score ≥ 16. Associations between harmful alcohol use and socio-structural factors were assessed using logistic regression with marginal standardization. Of the 470 women recruited, more than one third (37.3%) had a drinking pattern suggestive of harmful alcohol use. Such use was independently associated with sex work-related mobility (aPR: 1.36, 95% CI: 1.11-1.61), arrest/incarceration (aPR: 1.55, 95% CI: 1.27-1.84) and gender-based violence (aPR: 1.31, 95% CI: 1.06-1.56). The high prevalence of harmful alcohol use and the interconnectedness with socio-structural factors indicate a need for a holistic programmatic approach to health for female sex workers. Programming should not solely direct attention to individual behavior but also include strategies aiming to address socio-structural vulnerabilities.

Effective Dose of Prophylactic Oxytocin Infusion During Cesarean Delivery in 90% Population of Nonlaboring Patients With Preeclampsia Receiving Magnesium Sulfate Therapy and Normotensives: An Up-Down Sequential Allocation Dose-Response Study.

BACKGROUND: Oxytocin administration during cesarean delivery is the first-line therapy for the prevention of uterine atony. Patients with preeclampsia may receive magnesium sulfate, a drug with known tocolytic effects, for seizure prophylaxis. However, no study has evaluated the minimum effective dose of oxytocin during cesarean delivery in women with preeclampsia. METHODS: This study compared the effective dose in 90% population (ED90) of oxytocin infusion for achieving satisfactory uterine tone during cesarean delivery in nonlaboring patients with preeclampsia who were receiving magnesium sulfate treatment with a control group of normotensives who were not receiving magnesium sulfate. This prospective dual-arm dose-finding study was based on a 9:1 biased sequential allocation design. Oxytocin infusion was initiated at 13 IU/h, on clamping of the umbilical cord, in the first patient of each group. Uterine tone was graded as satisfactory or unsatisfactory by the obstetrician at 4 minutes after initiation of oxytocin infusion. The dose of oxytocin infusion for subsequent patients was decided according to the response exhibited by the previous patient in the group; it was increased by 2 IU/h after unsatisfactory response or decreased by 2 IU/h or maintained at the same level after satisfactory response, in a ratio of 1:9. Oxytocin-associated side effects were also evaluated. Dose-response data for the groups were evaluated using a log-logistic function and ED90 estimates were derived from fitted equations using the delta method. RESULTS: The ED90 of oxytocin was significantly greater for the preeclampsia group (n = 27) than for the normotensive group (n = 40) (24.9 IU/h [95% confidence interval {CI}, 22.4-27.5] and 13.9 IU/h [95% CI, 12.4-15.5], respectively); the difference in dose requirement was 10.9 IU/h (95% CI, 7.9-14.0; P < .001). The number of patients with oxytocin-related hypotension, defined as a decrease in systolic blood pressure >20% from baseline or to <90 mm Hg, was significantly greater in the preeclampsia group (92.6% vs 62.5%; P = .030), while other side effects such as ST-T depression, nausea/vomiting, headache, and flushing, were not significantly different. There was no significant difference in the need for additional uterotonic or uterine massage, estimated blood loss, and need for re-exploration for uncontrolled bleeding. CONCLUSIONS: Patients with preeclampsia receiving preoperative magnesium therapy need a greater intraoperative dose of oxytocin to achieve satisfactory contraction of the uterus after fetal delivery, as compared to normotensives.