Integrating Pre-Exposure Prophylaxis Delivery in Public Health Family Planning Clinics: Lessons Learned From a Programmatic Implementation Project in Kenya

Sexually active African women are a priority population for HIV prevention due to the disproportionately high frequency of new HIV infections. Family planning (FP) clinics offer an already trusted platform that can be used to reach women for HIV prevention services, including pre-exposure prophylaxis (PrEP). In the recent PrEP Implementation in Young Women and Adolescent (PrIYA program), we piloted PrEP implementation in FP clinics in Kisumu, Kenya, and demonstrated that it was possible to integrate PrEP provision in FP systems with a program-dedicated staff. In this perspective, we describe experiences and strategies employed to introduce PrEP implementation in FP clinics and lessons learned. We identified the following lessons for PrEP introduction in FP clinics in Kenya: (1) possible to integrate and generate high enthusiasm for PrEP delivery in FP clinics but persistence on PrEP is a challenge, (2) involvement of national and regional stakeholders is critical for buy-in, contextualization, and sustainability, (3) delivery models that do not integrate fully with existing staff and systems are less sustainable, (4) creatinine testing at PrEP initiation may not be necessary, (5) fully integrated HIV and FP data systems need to be developed, and (6) incorporating implementation science evaluation is important to understand and document effective implementation strategies. In summary, integration of HIV prevention and FP services provides an opportunity to promote one-stop women-centered care efficiently. However, a broader focus on delivery models that utilize existing staff and novel strategies to help women identify their own risk for HIV are needed to ensure greater success and sustainability.

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Implementation of pre-exposure prophylaxis programme in Spain. Feasibility of four different delivery models

PLoS ONE ◽

10.1371/journal.pone.0246129 ◽

2021 ◽

Vol 16 (2) ◽

pp. e0246129

Author(s):

Carlos Iniesta ◽

Pep Coll ◽

María Jesús Barberá ◽

Miguel García Deltoro ◽

Xabier Camino ◽

...

Keyword(s):

Health Care ◽

Health Care Professionals ◽

Cost Effective ◽

Hiv Infections ◽

Sexually Transmitted ◽

Participant Satisfaction ◽

Prep Implementation ◽

Sex With Men ◽

Exposure Prophylaxis ◽

Delivery Models

Background Pre-exposure prophylaxis (PrEP) is an effective and cost-effective strategy for HIV prevention. Spain carried out an implementation study in order to assess the feasibility of implementing PrEP programmes within its heterogeneous health system. Methods Observational longitudinal study conducted on four different types of health-care setting: a community centre (CC), a sexually transmitted infections clinic (STIC), a hospital-based HIV unit (HBHIVU) and a hospital-based STI unit (HBSTIU). We recruited gay, bisexual and other men who have sex with men (GBSM) and transgender women at risk of HIV infections, gave them PrEP and monitored clinical, behavioural PrEP-related and satisfaction information for 52 weeks. We collected perceptions on PrEP implementation feasibility from health-care professionals participating in the study. Results A total of 321 participants were recruited, with 99.1% being GBMSM. Overall retention was 87.2% and it was highest at the CC (92.6%). Condom use decreased during the study period, while STIs did not increase consistently. The percentage of people who did not miss any doses of PrEP during the previous week remained at over 93%. No HIV seroconversions occurred. We observed overall decreases in GHB (32.5% to 21.8%), cocaine (27.5% to 21.4%), MDMA (25.7% to 14.3%), speed (11.4% to 5.7%) and mephedrone use (10.7% to 5.0%). The overall participant satisfaction with PrEP was 98.6%. Health-care professionals’ perceptions of PrEP feasibility were positive, except for the lack of personnel. Conclusions PrEP implementation is feasible in four types of health-care settings. Local specificities have to be taken into consideration while implementing PrEP.

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Lessons Learned from Longer Acting Reversible Contraception Applied to Longer Acting HIV Prevention Technologies

Current HIV/AIDS Reports ◽

10.1007/s11904-021-00571-0 ◽

2021 ◽

Author(s):

Rachel Logan ◽

Dominika Seidman

Keyword(s):

Hiv Prevention ◽

Reproductive Health ◽

Sexual Health ◽

Lessons Learned ◽

Reproductive Justice ◽

Holistic View ◽

Marginalized Communities ◽

Exposure Prophylaxis

Abstract Purpose of Review This review describes lessons learned from longer acting contraception and employs a reproductive justice lens to inform expansion of emerging HIV prevention technologies. Recent Findings Reproductive justice is a framework that advocates for the promotion of universal sexual and reproductive freedoms, particularly among historically marginalized communities. This framework takes a holistic view of individuals and sees the interconnections between sexual health, reproductive health, and overall health. Employing a sexual and reproductive justice perspective is essential to understanding and helping to mitigate the role intersecting structural, sexual, and reproductive oppressions, including those demonstrated through promotion of longer acting contraception, and can critically inform rollout of future prevention technologies, such as longer acting HIV pre-exposure prophylaxis. Summary This review highlights the need for researchers, clinicians, and policymakers to apply lessons learned from contraception and specifically focuses on principles of reproductive justice to offer expanding HIV prevention options.

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Factors influencing uptake of pre-exposure prophylaxis: some qualitative insights from an intervention study of men who have sex with men in China

Sexual Health ◽

10.1071/sh17075 ◽

2018 ◽

Vol 15 (1) ◽

pp. 39 ◽

Cited By ~ 11

Author(s):

Chunxing Liu ◽

Yingying Ding ◽

Zhen Ning ◽

Meiyang Gao ◽

Xing Liu ◽

...

Keyword(s):

Hiv Risk ◽

Intervention Study ◽

Implementation Strategies ◽

Self Assessment ◽

Risk Beliefs ◽

Group Data ◽

Prep Implementation ◽

Substantial Risk ◽

Sex With Men ◽

Exposure Prophylaxis

Background: Pre-exposure prophylaxis (PrEP) is a biomedical approach for preventing the acquisition of HIV in populations at substantial risk for HIV. However, its uptake among men who have sex with men (MSM) is low in China. The study aimed to identify factors that might influence MSM’s uptake and use of PrEP. Methods: In-depth interviews were conducted with 32 self-identified MSM from a PrEP intervention study evaluating daily oral tenofovir disoproxil fumarate (TDF) to prevent HIV infection. Of these men, 11 were presently using the ‘TDF’ group; 8 from the ‘change-over’ group (i.e. initially used PrEP but subsequently quitted); and 13 from the non-user group. Data were analysed using thematic approach. Results: Perception of low HIV risk, mistrust of the national PrEP program, and concerns of side effects were the main reasons for not wanting to use PrEP. Also, lack of main sexual partner’s support, difficulties in adhering to the daily TDF regimen, and the inconvenient schedules in securing the medicine were the major reasons for not wanting to use or quitting the use of PrEP. On the other hand, perceived high HIV risk, beliefs in efficacy of PrEP, and worries of transmitting HIV to families were the major motives for PrEP uptake. Conclusions: Findings suggest that PrEP implementation strategies should first address issues including but not limited to accurate self-assessment of HIV risk, mistrust and limited knowledge about medical trials and PrEP, and ease of accessing PrEP.

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Willingness to Use Pre-Exposure Prophylaxis (PrEP) for HIV Prevention and PrEP Implementation Preferences Among Transgender Women in Malaysia

Transgender Health ◽

10.1089/trgh.2020.0003 ◽

2020 ◽

Vol 5 (4) ◽

pp. 258-266

Author(s):

Jonathan M. Galka ◽

Melinda Wang ◽

Iskandar Azwa ◽

Britton Gibson ◽

Sin How Lim ◽

...

Keyword(s):

Hiv Prevention ◽

Transgender Women ◽

Prep Implementation ◽

Willingness To Use ◽

Exposure Prophylaxis

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102. Improving Implementation of HIV Pre-exposure Prophylaxis: Lessons Learned from Young Women in Rural South Africa

Open Forum Infectious Diseases ◽

10.1093/ofid/ofaa439.412 ◽

2020 ◽

Vol 7 (Supplement_1) ◽

pp. S180-S181

Author(s):

Alisse Hannaford ◽

Noxolo Khumalo ◽

Sarah Norton ◽

Anthony Moll ◽

Sheela Shenoi

Keyword(s):

South Africa ◽

Young Women ◽

Health Workers ◽

Lessons Learned ◽

Rural Setting ◽

Patient Centered ◽

Inconsistent Condom ◽

Healthcare Facilities ◽

Exposure Prophylaxis ◽

Delivery Models

Abstract Background Young women in South Africa are at particularly high risk for acquiring HIV, yet implementation of HIV prevention programmes in rural settings lags. We examined the experiences and perceptions of young women initiating pre-exposure prophylaxis (PrEP) in a rural setting under real-world programmatic conditions, in order to strengthen future PrEP delivery to this population. Methods Young women initiating PrEP in Msinga, a municipality in KwaZulu-Natal province, were interviewed about their motivation to start PrEP and their experiences in taking PrEP. Interviews were conducted at PrEP initiation and longitudinally as they returned to clinic monthly for medication refills. Results Among seventeen sexually active at-risk young women (IQR 18–22.5 years old) who initiated PrEP, 71% lived in a household receiving a government grant, 24% had history of an STI and 71% reported inconsistent condom use. All participants disclosed PrEP use to a family member, but only 20% informed their male sexual partner. All expressed uncertainty regarding their partners’ sexual activities as a primary motivation for PrEP initiation. Social support from family and friends as well as interacting with other young women taking PrEP were identified as important facilitators. Barriers to PrEP included lack of community awareness about PrEP, limited clinics offering PrEP, HIV stigma, and logistics of accessing healthcare facilities. Young women valued a peer PrEP champion to facilitate and maintain successful engagement in care, as well as patient-centered PrEP delivery models that allow for care outside traditional clinic facilities. Conclusion Input from young women has the potential to significantly enhance and expand PrEP implementation. Tailored implementation efforts should include strengthening the role of community health workers, improving community-wide PrEP education, empowering women within their relationships, facilitating skill building for PrEP disclosure to partners, incorporating community PrEP champions, and developing alternative PrEP delivery models including community-based delivery. Disclosures All Authors: No reported disclosures

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Acceptability and Feasibility of the CHARISMA Counseling Intervention to Support Women’s Use of Pre-Exposure Prophylaxis

10.21203/rs.3.rs-84883/v1 ◽

2020 ◽

Author(s):

Ellen Wilson ◽

L. Danielle Wagner ◽

Thesla Palanee-Phillips ◽

Sarah T. Roberts ◽

Elizabeth E. Tolley ◽

...

Keyword(s):

Pilot Study ◽

Hiv Prevention ◽

Positive Impact ◽

Male Partner ◽

Study Participant ◽

Lessons Learned ◽

Vaginal Microbicides ◽

Clinic Staff ◽

Counseling Intervention ◽

Exposure Prophylaxis

Abstract Background: Women may need or seek male partner approval to {Malow, 2000 #18}{Malow, 2000 #18}{Malow, 2000 #18}{Malow, 2000 #18}safely and consistently use oral antiretroviral pre-exposure prophylaxis (PrEP) or vaginal microbicides. We developed CHARISMA, a counseling intervention to support women’s relationships and their ability to consistently use HIV prevention products.Methods: In a pilot study with 95 female participants in Johannesburg, South Africa, lay counselors assessed participants’ relationship(s) with their male partner(s) and barriers or facilitators to HIV prevention method use, and then provided tailored, interactive counseling. We conducted study participant surveys and clinic staff interviews to evaluate CHARISMA’s feasibility and acceptability.Results: The CHARISMA pilot study indicates that a two-session relationship counseling intervention with 6-month follow-up to support women’s ability to safely and effectively use vaginal microbicides was generally acceptable and feasible. Most participants thought CHARISMA was relevant, helpful, and about the right length, and that it had a positive impact on their relationships with their partners and their product use. Staff stated that it was generally feasible to implement. Based on these promising preliminary findings, the project team is currently conducting a randomized controlled trial in which participants are receive either the standard of care for IPV screening and referral (control arm) or the CHARISMA intervention.Conclusions: Clinic staff felt strongly that the length and intensity of CHARISMA were necessary for participants to begin to trust the counselors enough to be open and honest about problems in their relationships, and to begin to overcome the normalization of intimate partner violence. The length and intensity of CHARISMA may not be feasible in some settings, but a shorter version of the intervention may not offer as much support as women and staff need. One possible approach to reduce the burden on clinic staff would be to self-administer the intervention through a computer rather than requiring a counselor. Lessons learned from the pilot study may be relevant to others developing interventions supporting women’s use of oral PrEP or vaginal microbicides.

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Women’s estimated HIV infections from sex in trials of pre-exposure prophylaxis in Africa: Implications for HIV prevention strategies

10.1101/146530 ◽

2017 ◽

Author(s):

David Gisselquist

Keyword(s):

Hiv Prevention ◽

Hiv Infections ◽

Common Belief ◽

Prevention Strategies ◽

Sexual Risks ◽

Hiv Prevention Strategies ◽

Vaginal Gels ◽

Vaginal Rings ◽

Exposure Prophylaxis ◽

Oral Prep

AbstractIntroductionDuring 2004-15, nine randomized controlled trials (RCT) for HIV prevention tested pre-exposure prophylaxis (PrEP) with oral drugs, vaginal gels, or vaginal rings among more than 17,000 women in Africa.MethodsThis study uses information from the nine RCTs to estimate the proportions of HIV from sexual and bloodborne risks, to consider reasons for success or failure with oral PrEP, and to consider risks with vaginal PrEP.ResultsEstimating from women’s reported frequencies of unprotected coital acts in six RCTs, only a minority of women’s infections came from sex. Oral PrEP may have succeeded in at least one trial by reducing infections from both bloodborne and sexual risks. Oral PrEP may have failed in several trials, at least in part, because some women used oral PrEP when they had sexual risks rather than daily as advised. Relatively high incidence with PrEP vaginal gels and rings vs. oral placebo suggests vaginal PrEP had little impact at best and may have been harmful.DiscussionEvidence from this and other studies challenges the common belief most HIV in Africa comes from sex. This challenge has implications for HIV prevention strategies, including: warning about bloodborne risks; and reconsidering PrEP for young women.

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Lessons from a decade of voluntary medical male circumcision implementation and their application to HIV pre-exposure prophylaxis scale up

International Journal of STD & AIDS ◽

10.1177/0956462418787896 ◽

2018 ◽

Vol 29 (14) ◽

pp. 1432-1443 ◽

Cited By ~ 6

Author(s):

Jason B Reed ◽

Rupa R Patel ◽

Rachel Baggaley

Keyword(s):

Male Circumcision ◽

Scale Up ◽

Health Impact ◽

Lessons Learned ◽

Sub Saharan Africa ◽

Voluntary Medical Male Circumcision ◽

Medical Male Circumcision ◽

Prep Implementation ◽

Sub Saharan ◽

Exposure Prophylaxis

Oral pre-exposure prophylaxis (PrEP) has the ability to curb HIV incidence worldwide and bring us closer to ending the HIV epidemic. Scale up of PrEP service delivery has many similar challenges to those faced by voluntary medical male circumcision (VMMC) services roll-out. This article outlines ten important lessons learned during the scale up of VMMC services in sub-Saharan Africa and their application to current oral PrEP implementation efforts to promote faster expansion for public health impact.

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Where’S the “Everyday Black Woman”? an Intersectional Qualitative Analysis of Black Women’S Decision-Making Regarding HIV Pre-Exposure Prophylaxis (PrEP) in Mississippi

10.21203/rs.3.rs-1090446/v1 ◽

2021 ◽

Author(s):

Tiara C. Willie ◽

Deja Knight ◽

Stefan D. Baral ◽

Philip A. Chan ◽

Trace Kershaw ◽

...

Keyword(s):

Black Women ◽

Hiv Infections ◽

Positive Influence ◽

Effective Response ◽

The Us ◽

Prep Implementation ◽

Prep Awareness ◽

Exposure Prophylaxis ◽

Benefits And Costs ◽

Specific Education

Abstract Background Black cisgender women in the U.S. South bear a disproportionate burden of HIV compared to cisgender women in other racial and ethnic groups and in any other part of the US. Critical to decreasing new HIV infections is the improved delivery of pre-exposure prophylaxis (PrEP) for Black cisgender women as it remains underutilized in 2021. Informed by intersectionality, the study sought to characterize the sociostructural influences on Black cisgender women’s deliberations about PrEP within the context of interlocking systems of oppression including racism, sexism, and classism. Methods Six focus groups were conducted with 37 Black women residing in Jackson, Mississippi. This sample was purposively recruited to include Black cisgender women who were eligible for PrEP but had never received a PrEP prescription. Results Six themes were identified as obstacles during PrEP deliberation among Black women: 1) limited PrEP awareness, 2) low perceived HIV risk, 3) concerns about side effects, 4) concerns about costs, 5) limited marketing, and 6) distrust in the healthcare system. Three themes were identified as facilitators during PrEP deliberations: 1) women’s empowerment and advocacy, 2) need for increased PrEP-specific education, and 3) the positive influence of PrEP-engaged women’s testimonials. Black women shared a limited awareness of PrEP exacerbated by the lack of Black women-specific marketing. Opportunities to support Black women-specific social marketing could increase awareness and knowledge regarding PrEP’s benefits and costs. Black women also shared their concerns about discrimination in healthcare and distrust, but they felt that these barriers may be addressed by patient testimonials from PrEP-engaged Black women, empowerment strategies, and directly addressing provider biases. Conclusions An effective response to PrEP implementation among Black women in the South requires developing programs to center the needs of Black women and carry out active strategies that prioritize peer advocacy while reinforcing positive and mitigating negative influences from broader social and historical contexts.

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Acceptability and Feasibility of Pharmacy-Based Delivery of Pre-Exposure Prophylaxis in Kenya: A Qualitative Study of Client and Provider Perspectives

AIDS and Behavior ◽

10.1007/s10461-021-03229-5 ◽

2021 ◽

Author(s):

Stephanie D. Roche ◽

Njeri Wairimu ◽

Peter Mogere ◽

Kevin Kamolloh ◽

Josephine Odoyo ◽

...

Keyword(s):

Scale Up ◽

Strong Support ◽

Pharmacy Practice ◽

Implementation Strategies ◽

Future Research ◽

Retail Pharmacy ◽

Staffing Levels ◽

Provider Perspectives ◽

Exposure Prophylaxis ◽

Delivery Models

AbstractAs countries scale up pre-exposure prophylaxis (PrEP) for HIV prevention, diverse PrEP delivery models are needed to expand access to populations at HIV risk that are unwilling or unable to access clinic-based PrEP care. To identify factors that may influence implementation of retail pharmacy-based PrEP delivery in Kenya, we conducted in-depth interviews with 40 pharmacy clients, 16 pharmacy providers, 16 PrEP clients, and 10 PrEP providers from two provinces. Most participants expressed strong support for expanding PrEP to retail pharmacies, though conditioned their acceptance on assurances that care would be private, respectful, safe, and affordable. Participant-reported determinants of feasibility centered primarily on ensuring that the intervention is compatible with retail pharmacy operations (e.g., staffing levels, documentation requirements). Future research is needed to develop and test tailored packages of implementation strategies that are most effective at integrating PrEP delivery into routine pharmacy practice in Kenya and other high HIV prevalence settings.

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