Lessons learnt from daily oral PrEP delivery to inform national planning for PrEP ring introduction for women in low-income and middle-income countries: a qualitative inquiry of international stakeholders.

INTRODUCTION: Some African countries plan to introduce and scale-up new long-acting pre-exposure prophylaxis methods (LA-PrEP), like the monthly dapivirine vaginal ring (PrEP ring) and injectable cabotegravir. National costed implementation plans, roadmaps for successful product implementation, are often overlooked. International stakeholders engaged in oral PrEP planning, introduction and scale-up are an information resource of lessons learned to advise LA-PrEP planning. We consulted such international stakeholders and synthesised oral PrEP lessons to inform the development of a costed rollout plan template for LA-PrEP. METHODS: From selected global health organisations (five international nongovernmental, four donor, four university/research and two multilateral), we interviewed 27 representatives based in America, Europe, Asia and Africa about strategic content and approaches for LA-PrEP policy, programming and implementation. We conducted a thematic analysis of the interview data for implementation considerations. RESULTS: From the consultations, we identified six implementation themes for LA-PrEP introduction and scale-up: (1) ethically increasing choice and avoiding coercion; (2) de-stigmatising PrEP by focusing on preference rather than risk-based eligibility; (3) integrating LA-PrEP into services that are more woman-oriented, couple-oriented and family-oriented, and providing private spaces for LA-PrEP delivery; (4) de-medicalising delivery of relatively safe products (eg, PrEP ring); (5) constructing multilevel, nuanced communication strategies to address measured and perceived product efficacy and effectiveness; and (6) devising product-agnostic, modular approaches to service delivery. Despite the widespread emphasis on integration, few stakeholders offered empirical examples of successful integration approaches and frameworks. CONCLUSIONS: Lessons learnt from stakeholder participants suggest standardised and modular processes can improve efficiencies in LA-PrEP planning and implementation. Tiered communication strategies addressing product efficacy and effectiveness will improve clients' and providers' efficacy in making informed decisions. Integration is important for LA-PrEP delivery, but data on empirical integration approaches and frameworks is minimal: further research in this discipline is needed.

Examining Patient Preferences for Express, Telemedicine, and Standard Visits in a Sexual Health Clinic in New York City.

ABSTRACT: This study, completed at an sexually transmitted infection (STI) clinic in 2019 to 2020, evaluated patient preferences for telemedicine, express, and standard visits. Active PrEP users preferred telemedicine and express visits, patients with prior STIs preferred express visits, and cisgender women preferred standard visits. Configuring STI clinic visit types requires shared decision making and individualization.

The Index of Engagement in PrEP Care: Evaluation of Psychometric Properties and Predictive Potential.

BACKGROUND: The Index of Engagement in HIV Care is a psychometrically valid 10-item self-report measure with predictive power to classify individuals to higher and lower odds of disengaging from HIV care. Given high rates of disengagement from preexposure prophylaxis (PrEP) care, we adapted the HIV Index to PrEP. METHODS: We evaluated the psychometric properties of the PrEP-Index in a cross-sectional validation among PrEP-eligible persons seen in an HIV Prevention Program and conducted exploratory analysis to assess its potential utility as a prognostic tool. The PrEP Index contains 10 items with answers ranging from (1) not at all to (5) extremely. Possible PrEP-Index scores ranged from 10 to 50, with higher sum scores representing higher levels of engagement. RESULTS: Study participants were cisgender men who have sex with men, and racially and ethnically diverse (non-Hispanic White = 39.2%). Factor analyses supported the 1-factor structure. Among 347 respondents, 118 individuals (34.0%) were available for predictive validity analysis. The PrEP Index score was positively associated with visit constancy at 6 months ( = 0.2261; 95% confidence interval: 0.0363 to 0.4051). Finally, a patient scoring 45 on the PrEP-Index will be classified as not returning within 6 months (sensitivity = 0.73, specificity = 0.65). CONCLUSIONS: The PrEP-Index is a psychometrically valid and reliable scale that demonstrates potential utility in identifying individuals at elevated risk of falling out of PrEP care by 6 months, the time point by which the majority of PrEP discontinuations occur. The PrEP-Index could be a useful clinical prognostic tool to allow for efficient resource targeting by clinics to improve engagement in PrEP care.

Predictors of missed HIV screening opportunities among newly diagnosed individuals at an urban medical center in New York City, 2018-2022.

OBJECTIVE: To identify demographic and clinical factors predictive of having a missed opportunity (MO) for HIV screening. DESIGN: Retrospective cohort study. METHODS: Electronic medical records were queried for individuals newly diagnosed with HIV in different sites within a large urban academic medical center in New York City between 2018 and 2022. The primary outcome was having one or more MO for HIV screening within the institution, defined as any encounter at which screening was not performed in the 365 days preceding the HIV diagnosis. RESULTS: Over one third of new diagnoses had at least one MO in the preceding year. Older individuals, cisgender women and those assigned female sex at birth, and heterosexual individuals were more likely to have at least one MO. An initial CD4 < 200 cells/ul was more likely among men who have sex with women specifically. Most MOs occurred in the emergency department and outpatient settings, with minimal HIV prevention discussions documented during each MO. CONCLUSIONS: These findings suggest that populations perceived to be at lower risk for HIV are more likely to have MOs and possibly late diagnoses, and that universal HIV screening must be implemented into the workflows of emergency department and outpatient settings to facilitate early diagnosis and reduce the incidence of HIV.

Implementation and resource needs for long-acting PrEP in low- and middle-income countries: a scoping review.

INTRODUCTION: Several low- and middle-income countries (LMICs) are preparing to introduce long-acting pre-exposure prophylaxis (LAP). Amid multiple pre-exposure prophylaxis (PrEP) options and constrained funding, decision-makers could benefit from systematic implementation planning and aligned costs. We reviewed national costed implementation plans (CIPs) to describe relevant implementation inputs and activities (domains) for informing the costed rollout of LAP. We assessed how primary costing evidence aligned with those domains. METHODS: We conducted a rapid review of CIPs for oral PrEP and family planning (FP) to develop a consensus of implementation domains, and a scoping review across nine electronic databases for publications on PrEP costing in LMICs between January 2010 and June 2022. We extracted cost data and assessed alignment with the implementation domains and the Global Health Costing Consortium principles. RESULTS: We identified 15 implementation domains from four national PrEP plans and FP-CIP template; only six were in all sources. We included 66 full-text manuscripts, 10 reported LAP, 13 (20%) were primary cost studies-representing seven countries, and none of the 13 included LAP. The 13 primary cost studies included PrEP commodities (n = 12), human resources (n = 11), indirect costs (n = 11), other commodities (n = 10), demand creation (n = 9) and counselling (n = 9). Few studies costed integration into non-HIV services (n = 5), above site costs (n = 3), supply chains and logistics (n = 3) or policy and planning (n = 2), and none included the costs of target setting, health information system adaptations or implementation research. Cost units and outcomes were variable (e.g. average per person-year). DISCUSSION: LAP planning will require updating HIV prevention policies, technical assistance for logistical and clinical support, expanding beyond HIV platforms, setting PrEP achievement targets overall and disaggregated by method, extensive supply chain and logistics planning and support, as well as updating health information systems to monitor multiple PrEP methods with different visit schedules. The 15 implementation domains were variable in reviewed studies. PrEP primary cost and budget data are necessary for new product introduction and should match implementation plans with financing. CONCLUSIONS: As PrEP services expand to include LAP, decision-makers need a framework, tools and a process to support countries in planning the systematic rollout and costing for LAP.

Effect of Participative Web-Based Educational Modules on HIV and Sexually Transmitted Infection Prevention Competency Among Medical Students: Single-Arm Interventional Study.

BACKGROUND: The number of new HIV diagnoses in the United States continues to slowly decline; yet, transgender women and men who have sex with men remain disproportionately affected. Key to improving the quality of prevention services are providers who are comfortable broaching the subjects of sexual health and HIV prevention with people across the spectrum of gender identities and sexual orientations. Preservice training is a critical point to establish HIV prevention and sexual health education practices before providers' practice habits are established. OBJECTIVE: The study aimed to develop participative web-based educational modules and test their impact on HIV prevention knowledge and awareness in future providers. METHODS: Sexual health providers at an academic hospital, research clinicians, community engagement professionals, and New York City community members were consulted to develop 7 web-based educational modules, which were then piloted among medical students. We assessed knowledge of HIV and sexually transmitted infection prevention and comfort assessing the prevention needs of various patients via web-based questionnaires administered before and after our educational intervention. We conducted exploratory factor analysis of the items in the questionnaire. RESULTS: Pre- and postmodule surveys were completed by 125 students and 89 students, respectively, from all 4 years of training. Before the intervention, the majority of students had heard of HIV pre-exposure prophylaxis (122/123, 99.2%) and postexposure prophylaxis (114/123, 92.7%). Before the training, 30.9% (38/123) of the students agreed that they could confidently identify a patient who is a candidate for pre-exposure prophylaxis or postexposure prophylaxis; this increased to 91% (81/89) after the intervention. CONCLUSIONS: Our findings highlight a need for increased HIV and sexually transmitted infection prevention training in medical school curricula to enable future providers to identify and care for diverse at-risk populations. Participative web-based modules offer an effective way to teach these concepts.

Persistently Elevated Risk of Syphilis Among Human Immunodeficiency Virus-Positive Men Receiving Care in a Status-Neutral Setting: A Retrospective Analysis.

BACKGROUND: Over the past decade, the incidence of primary and secondary syphilis has increased dramatically in the United States and Western Europe. Men living with human immunodeficiency virus (HIV) and those at risk of HIV infection experience disproportionately high rates of early syphilis (ES). We compared the odds of ES among HIV-positive and HIV-negative men participating in a status-neutral comprehensive HIV prevention and treatment program (CHP). METHODS: We conducted a retrospective analysis of men aged 18 to 65 years with ≥ 1 CHP visit and ≥2 rapid plasma reagin (RPR) tests performed between January 1, 2018, and December 31, 2021. Early syphilis was defined as newly reactive RPR with a minimum titer of ≥1:4 or a ≥ 4-fold increase in the RPR titer. Multiple logistic regression analyses were performed to determine predictors of ES. RESULTS: A total of 2490 men met the inclusion criteria, of whom 1426 (57.3%) were HIV-positive and 1064 (42.7%) were HIV-negative. Of the 393 men with ES, 284 (72.3%) were HIV-positive and 109 (27.7%) were HIV-negative. Human immunodeficiency virus-positive men had higher adjusted odds of ES (adjusted odds ratio, 2.86; 95% confidence interval, 2.45-3.27) than HIV-negative men did. Chlamydia or gonorrhea infection did not differ according to HIV status (adjusted odds ratio, 0.93; 95% confidence interval, 0.82-1.04). CONCLUSIONS: In our status-neutral care setting, HIV-positive status was associated with significantly higher odds of ES, but not chlamydia or gonorrhea. Our findings emphasize the vulnerability of HIV-positive men to syphilis in an era of effective HIV biomedical prevention.