'We go where we know': Reflections from Mobilizing for PrEP and Sexual Health (MobPrESH) - A peer-led PrEP education programme across England, for and by women and non-binary people.

BACKGROUND: Pre-exposure prophylaxis is a highly effective method of HIV prevention but few women know about it, have access to it, or see it as relevant to them. In 2019, grassroots organization PrEPster piloted a peer-led intervention, MobPrESH (Mobilizing for Pre-Exposure prophylaxis (PrEP) and Sexual Health), across three sites in England, to mobilize for PrEP and sexual health with communities of women and non-binary people most affected by HIV, including Black women and non-binary people, people of colour, migrants, and transgender (trans) women. OBJECTIVES: We aimed to explore the accessibility, feasibility, acceptability, and 'fidelity' of MobPrESH, from the perspectives of peer mobilizers and project staff. METHODS: We conducted focus group discussions and qualitative interviews with nine peer mobilizers (most identified as Black cisgender (cis) women) and six project staff (including Black and white cis women and non-binary people). We analysed data thematically, iteratively, and inductively, informed by concepts of reproductive and social justice. RESULTS: We present findings in five thematic areas: connecting and relating to situate sexual health discussions, navigating silence and stigma, connecting within and across communities, competing pressures and structural hostilities, and resources and continuity. Community knowledge-building about PrEP is a slow, iterative process that needs investment and creation of trusted spaces that centre communities' needs and concerns. Peer mobilizers and the communities they engaged with had competing demands in their lives, and knowledge-raising about PrEP was impacted by intersecting stigmas, discrimination, and oppressions around HIV status, racism, misogyny, transphobia, homophobia, and anti-sex worker rhetoric. CONCLUSIONS: Peer-led PrEP interventions require funding and foregrounding, particularly for women and non-binary people who are Black, trans, migrants, and people of colour, situated relative to their wider health needs, life pressures, and priorities. This requires concurrent challenge of the racist and patriarchal structures that continue to obscure the sexual and reproductive health needs of racially minoritized and marginalized women and non-binary people.

Qualitative findings from Girlsplained: a social media application of the Sabido methodology for sexual health and HIV prevention in the United Kingdom.

The health communication strategy known as entertainment-education can be traced in large part to Miguel Sabido and the methodology he developed using telenovelas in Latin America in the 1960s and 1970s. Entertainment-education has evolved from a long-running narrative approach using traditional media to the addition of new media and transmedia formats. In recent years, entertainment-education programs using social media have increased, yet few studies have explored the shared characteristics and experiences of social media users who engage with these programs. This qualitative study aimed TO examine publicly available social media data (i.e. YouTube and Instagram comments) in response to Girlsplained, an online entertainment-education program designed with objectives related to sexual health and HIV prevention among Black, Asian, and minority ethnic women in the United Kingdom. A process of directed content analysis uncovered five themes of engagement: characters and the narrative; social media; gender and race; HIV/PrEP; and sex and pregnancy prevention.

Missed opportunities for sexually transmitted infections testing for HIV pre-exposure prophylaxis users: a systematic review.

INTRODUCTION: Given the synergistic relationship between HIV and sexually transmitted infections (STI), the integration of services has the potential to reduce the incidence of both HIV and STIs. We explored the extent to which STI testing has been offered within HIV pre-exposure prophylaxis (PrEP) programmes worldwide. METHODS: We conducted a systematic review of PrEP programmes implementing STI testing services in nine databases. We approached PrEP implementers for additional unpublished data and implementation details. Descriptive statistics were used to present the characteristics of STI testing within PrEP programmes. Content analysis of the input from PrEP implementers was conducted to summarize the barriers to and facilitators of STI testing. RESULTS: Of 9,161 citations, 91 studies conducted in 32 countries were included: 69% from high-income countries (HICs) and 64% from programmes targeting men who have sex with men (MSM) and transgender women (TGW) only. The majority of programmes (70%, 64/91) conducted STI testing before the initiation of PrEP. The most common STIs tested were gonorrhoea (86%, 78/91), chlamydia (84%, 76/91) and syphilis (84%, 76/91). The majority provided STI testing at three-month intervals (70%, 53/76, for syphilis; 70% 53/78, for chlamydia; 68%, 53/78, for gonorrhoea). Relative to low- and middle-income countries (LMICs), a higher proportion of PrEP programmes in HICs offered testing for gonorrhoea (92% vs. 71%, p < 0.05), chlamydia (92% vs. 64%, p < 0.01), syphilis (87% vs. 75%, p < 0.05), hepatitis A (18% vs. 4%, p < 0.05) and hepatitis C (43% vs. 21%, p < 0.05); offered testing for a higher number of STIs (mean 3.75 vs. 3.04, p < 0.05); and offered triple (throat, genital/urine and anorectal) anatomical site screening (54% vs. 18%, p < 0.001). Common implementation challenges included costs, access to STI diagnostics, programme logistics of integrating STI testing into PrEP delivery models and lack of capacity building for staff involved in PrEP provision. CONCLUSIONS: Significant gaps and challenges remain in the provision of STI testing services within HIV PrEP programmes. We recommend more active integration of STI testing and management into PrEP programmes, supported by standardized practice guidelines, staff capacity building training and adequate funding. This could lead to improved sexual health and HIV outcomes in key populations.

Global Epidemiologic Characteristics of Sexually Transmitted Infections Among Individuals Using Preexposure Prophylaxis for the Prevention of HIV Infection: A Systematic Review and Meta-analysis.

Importance: Despite a global increase in sexually transmitted infections (STIs), there is limited focus and investment in STI management within HIV programs, in which risks for STIs are likely to be elevated. Objective: To estimate the prevalence of STIs at initiation of HIV preexposure prophylaxis (PrEP; emtricitabine and tenofovir disoproxil fumarate) and the incidence of STIs during PrEP use. Data Sources: Nine databases were searched up to November 20, 2018, without language restrictions. The implementers of PrEP were also approached for additional unpublished data. Study Selection: Studies reporting STI prevalence and/or incidence among PrEP users were included. Data Extraction and Synthesis: Data were extracted independently by at least 2 reviewers. The methodological quality of studies was assessed using the Joanna Briggs Institute critical assessment tool for prevalence and incidence studies. Random-effects meta-analysis was performed. Main Outcomes and Measures: Pooled STI prevalence (ie, within 3 months of PrEP initiation) and STI incidence (ie, during PrEP use, after 3 months). Results: Of the 3325 articles identified, 88 were included (71 published and 17 unpublished). Data came from 26 countries; 62 studies (70%) were from high-income countries, and 58 studies (66%) were from programs only for men who have sex with men. In studies reporting a composite outcome of chlamydia, gonorrhea, and early syphilis, the pooled prevalence was 23.9% (95% CI, 18.6%-29.6%) before starting PrEP. The prevalence of the STI pathogen by anatomical site showed that prevalence was highest in the anorectum (chlamydia, 8.5% [95% CI, 6.3%-11.0%]; gonorrhea, 9.3% [95% CI, 4.7%-15.2%]) compared with genital sites (chlamydia, 4.0% [95% CI, 2.0%-6.6%]; gonorrhea, 2.1% [95% CI, 0.9%-3.7%]) and oropharyngeal sites (chlamydia, 2.4% [95% CI, 0.9%-4.5%]; gonorrhea, 4.9% [95% CI, 1.9%-9.1%]). The pooled incidence of studies reporting the composite outcome of chlamydia, gonorrhea, and early syphilis was 72.2 per 100 person-years (95% CI, 60.5-86.2 per 100 person-years). Conclusions and Relevance: Given the high burden of STIs among individuals initiating PrEP as well as persistent users of PrEP, this study highlights the need for active integration of HIV and STI services for an at-risk and underserved population.