The Paradoxes of PrEP: Rejection, Reluctancy, and Novel Gay Identities in Biomedical HIV Prevention in Serbia

This article explores the different ways in which gay men in Serbia perceive PrEP as a novel method of HIV prevention. In the article, I draw on data from my research on PrEP use among thirty gay men in Belgrade. The use of PrEP is still very low amongst gay communities in Serbia due to their rejection of PrEP and due to the stigma around PrEP use. In Serbia, the social significance of PrEP relates to HIV status disclosure on gay social/dating media. Paradoxically, on gay dating sites, the signifier "PrEP" blurs the line between HIV positive gay men – who have achieved undetectable HIV status through a potent ARV therapy – and those HIV negative gay men who use PrEP as a preventative tool against HIV transmission. In the article, I will argue that a new form of gay identity has emerged on gay dating apps in Serbia – "undetectable, on PrEP." This new identity emerges from confusion in HIV risk assessment. The use of PrEP has been seen as a marker to denote someone’s HIV negative status and to protect them from HIV transmission. However, some gay men with an undetectable HIV status would like to be regarded as HIV negative even though they are not, and thus they use the signifier "on PrEP" to highlight their desire to claim an HIV negative status. PrEP has many symbolic valences: from HIV status disclosure to assumed promiscuity. As I will argue, while the health paradigm is of utmost importance for Serbian gay men, internalized stigma additionally drives the low uptake of PrEP amongst gay communities in Serbia, thus contributing to the confusion regarding PrEP use and the overall approach to HIV prevention. This article finds that those respondents who accept PrEP without stigma or confusion regarding their HIV status are also more willing and ready to recommend using PrEP to other gay men.

883. Qualitative Patient-Participant Perspectives on Implementation of Monthly Cabotegravir and Rilpivirine Long Acting (CAB+RPV LA) Injectable in the United States (CUSTOMIZE)

Background CAB+RPV LA administered monthly for HIV treatment is non-inferior to daily oral ART at maintaining viral suppression and preferred by most participants in clinical trials over daily ART. CUSTOMIZE, an implementation-effectiveness study, evaluated facilitators and barriers to clinic implementation of CAB+RPV LA from the patient perspective. Methods 115 participants were enrolled across 8 HIV clinics. Semi-structured phone interviews were conducted with a randomized subgroup of 3-6 participants per site, prior to the 1st (Baseline [BL], N=34) and 12th CAB+RPV LA injections (Month 12 [M12], N=31). Consolidated Framework for Implementation Research-guided interviews were recorded, transcribed, and coded using ATLAS.ti. Results At BL, 97% (n=33) of those interviewed indicated ≥1 challenge taking daily oral ART, including concerns about adherence (n=19; 56%), dosing frequency (n=13; 38%) and side effects (n=12; 35%). Twenty-seven (79%) reported anticipated challenges of CAB+RPV LA such as worry about side effects (n=15; 44%) and discomfort from injections (n=14; 41%). Participants reported at BL that CAB+RPV LA may help with adherence (n=17; 50%) or reduce fears of HIV status disclosure (n=10; 29%). At M12, 35% (n=11) reported some pain/discomfort from injections, but 87% (n=27) reported satisfaction with CAB+RPV LA, most commonly due to preferring the monthly regimen over the daily pill (n=15; 48%). Facilitators reported by participants as most helpful during early implementation were verbal education by clinic staff (14%), reminder texts/calls (13%), and an educational video about the regimen (6%). Most (n=25; 81%) indicated clinic hours were not a barrier, but 19% (n=6) noted taking time off work for the visits. Many participants (n=21; 68%) described positive aspects of going to the clinic each month, none complained about visit length, and 94% (n=29) reported intent to continue CAB+RPV LA after the study. Conclusion Interviewed participants reported several challenges with daily oral ART that monthly CAB+RPV LA may help overcome. Some initial concerns about receiving CAB+RPV LA were reported at BL, but most participants were satisfied with the regimen after one year and plan to continue receiving CAB+RPV LA following the study. Disclosures Cindy Garris, MS, GlaxoSmithKline (Shareholder)ViiV Healthcare (Employee) Larissa Stassek, MPH, GlaxoSmithKline (Consultant, Other Financial or Material Support, My company (Evidera) received funding from GSK to conduct this research. We did not receive funding for work on this abstract.) Ronald D’Amico, DO, MSc, GlaxoSmithKline (Shareholder)ViiV Healthcare (Employee) Marybeth Dalessandro, BS, ViiV Healthcare (Employee, Shareholder) Sheila Adkins, BS, GSK (Employee)GSK (Employee, Stock) Maggie Czarnogorski, MD, MPH, GlaxoSmithKline (Shareholder)ViiV Healthcare (Employee)

HIV serodiscordant and nondisclosure rates among married women living with HIV in a Southern Nigerian region

Objectives: Intimate sexual partners’ disclosure of HIV positive status is vital in the control of HIV/AIDS pandemic globally. The disclosure rates vary from region to region. The aim of this study was to document the prevalence of HIV serodiscordance and partners disclosure rate; and also determine the associated factors among HIV positive married women living in Calabar region of Nigeria. Material and Methods: A cross-sectional survey was conducted among 260 married women, 18 years and above, receiving HIV care at various health institutions in the region. Data were analyzed using SPSS VERSION 23. Their demographic and health profile were presented in simple proportion and percentages while Chi-square test and logistic regression were used to determine the factors influencing patient’s HIV status disclosure with the level of significance set at 0.05. Results: A total of 254 compiled questionnaires were included in the analysis (response rate-97.7%). The serodiscordant rate was 50%. HIV status disclosure to partner was high, 89.4%. The main determinants of HIV status disclosure were good level of education (AOR = 2.2, 95% CI: = 1.75–2.53, P = 0.007) and long duration of ART use (AOR = 3.23, 95% CI = 2.78–4.15, P = 0.001) while women with high discordant rate were more likely to be divorced/separated (P = 0.012, OR = 1.67). Conclusion: Female education is an important factor in HIV control. Disclosure of HIV status is beneficial to the partner as it promotes safe sex practices and increases adherence to ART.

The Kanyakla study: Randomized controlled trial of a microclinic social network intervention for promoting engagement and retention in HIV care in rural western Kenya

Background Existing social relationships are a potential source of “social capital” that can enhance support for sustained retention in HIV care. A previous pilot study of a social network-based ‘microclinic’ intervention, including group health education and facilitated HIV status disclosure, reduced disengagement from HIV care. We conducted a pragmatic randomized trial to evaluate microclinic effectiveness. Methods In nine rural health facilities in western Kenya, we randomized HIV-positive adults with a recent missed clinic visit to either participation in a microclinic or usual care (NCT02474992). We collected visit data at all clinics where participants accessed care and evaluated intervention effect on disengagement from care (≥90-day absence from care after a missed visit) and the proportion of time patients were adherent to clinic visits (‘time-in-care’). We also evaluated changes in social support, HIV status disclosure, and HIV-associated stigma. Results Of 350 eligible patients, 304 (87%) enrolled, with 154 randomized to intervention and 150 to control. Over one year of follow-up, disengagement from care was similar in intervention and control (18% vs 17%, hazard ratio 1.03, 95% CI 0.61–1.75), as was time-in-care (risk difference -2.8%, 95% CI -10.0% to +4.5%). The intervention improved social support for attending clinic appointments (+0.4 units on 5-point scale, 95% CI 0.08–0.63), HIV status disclosure to close social supports (+0.3 persons, 95% CI 0.2–0.5), and reduced stigma (-0.3 units on 5-point scale, 95% CI -0.40 to -0.17). Conclusions The data from our pragmatic randomized trial in rural western Kenya are compatible with the null hypothesis of no difference in HIV care engagement between those who participated in a microclinic intervention and those who did not, despite improvements in proposed intervention mechanisms of action. However, some benefit or harm cannot be ruled out because the confidence intervals were wide. Results differ from a prior quasi-experimental pilot study, highlighting important implementation considerations when evaluating complex social interventions for HIV care. Trial registration Clinical trial number: NCT02474992.

A qualitative study of the stigmatization and coping mechanisms among pregnant teenagers living with HIV in Thailand

PurposeThis aim of this study was to explore the experiences of stigmatization and coping mechanisms during pregnancy among pregnant women who are living with HIV in Thailand. The secondary objective was to determine factors contributing to stigma during motherhood among HIV-infected women as well as explore how they cope with the discrimination from society.Design/methodology/approachQualitative data were collected using in-depth interviews to obtain different versions of stigmatized experience from 16 pregnant women living with HIV on stigmatization and coping mechanisms. There were 5 pregnant adolescents living with HIV and 11 adult pregnant women living with HIV. The content analysis was used to examine patterns of stigmatizations and attributed factors.FindingsPersonal stigma was found among pregnant women living with HIV regardless of age. HIV status disclosure was the crucial barrier of accessing to care for people experiencing stigmatizations. Personal stigma associated with higher HIV status was not disclosed. Interestingly, all teenage mothers who participated in this study disclosed their HIV-status to their family. People who have social support especially from family and significant others are found to be able to cope and get through the difficulties better than those who lack those social support.Originality/valueThis study yields outcomes similar to several other studies that have been conducted either in Thailand or other countries. This study found that family support was crucial in reducing HIV stigma. Furthermore, HIV-infected pregnant female adults were more afraid to disclose their HIV status to their husbands, other family members and their work colleagues.

Challenges of HIV Self-Test Distribution for Index Testing When HIV Status Disclosure Is Low: Preliminary Results of a Qualitative Study in Bamako (Mali) as Part of the ATLAS Project

Context: The rate of HIV status disclosure to partners is low in Mali, a West African country with a national HIV prevalence of 1.2%. HIV self-testing (HIVST) could increase testing coverage among partners of people living with HIV (PLHIV). The AutoTest-VIH, Libre d'accéder à la connaissance de son Statut (ATLAS) program was launched in West Africa with the objective of distributing nearly half a million HIV self-tests from 2019 to 2021 in Côte d'Ivoire, Mali, and Senegal. The ATLAS program integrates several research activities. This article presents the preliminary results of the qualitative study of the ATLAS program in Mali. This study aims to improve our understanding of the practices, limitations and issues related to the distribution of HIV self-tests to PLHIV so that they can offer the tests to their sexual partners.Methods: This qualitative study was conducted in 2019 in an HIV care clinic in Bamako. It consisted of (i) individual interviews with eight health professionals involved in the distribution of HIV self-tests; (ii) 591 observations of medical consultations, including social service consultations, with PLHIV; (iii) seven observations of peer educator-led PLHIV group discussions. The interviews with health professionals and the observations notes have been subject to content analysis.Results: HIVST was discussed in only 9% of the observed consultations (51/591). When HIVST was discussed, the discussion was almost always initiated by the health professional rather than PLHIV. HIVST was discussed infrequently because, in most of the consultations, it was not appropriate to propose partner HIVST (e.g., when PLHIV were widowed, did not have partners, or had delegated someone to renew their prescriptions). Some PLHIV had not disclosed their HIV status to their partners. Dispensing HIV self-tests was time-consuming, and medical consultations were very short. Three main barriers to HIVST distribution when HIV status had not been disclosed to partners were identified: (1) almost all health professionals avoided offering HIVST to PLHIV when they thought or knew that the PLHIV had not disclosed their HIV status to partners; (2) PLHIV were reluctant to offer HIVST to their partners if they had not disclosed their HIV-positive status to them; (3) there was limited use of strategies to support the disclosure of HIV status.Conclusion: It is essential to strengthen strategies to support the disclosure of HIV+ status. It is necessary to develop a specific approach for the provision of HIV self-tests for the partners of PLHIV by rethinking the involvement of stakeholders. This approach should provide them with training tailored to the issues related to the (non)disclosure of HIV status and gender inequalities, and improving counseling for PLHIV.