Posted: Dec 12, 2017
Helping our patients take HIV pre-exposure prophylaxis (PrEP): a systematic review of adherence interventions
Adherence is critical for maximizing the effectiveness of pre-exposure prophylaxis (PrEP) in preventing HIV infection. Strategies for promoting adherence to HIV treatment, and their potential application to PrEP adherence, have received considerable attention. However, adherence promotion strategies for prevention medications have not been well characterized and may be more applicable to PrEP. We aimed to identify adherence support interventions that have been effective in other prevention ﬁelds and could be applied in the HIV prevention context to support pill taking among PrEP users.
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JL Marcus,1,2 T Buisker,2 T Horvath,3 KR Amico,4 JD Fuchs,5 SP Buchbinder,6,7 RM Grant1,7 and AY Liu6
1Gladstone Institute of Virology and Immunology, San Francisco, CA, USA, 2Department of Epidemiology, University of California, Berkeley, CA, USA, 3Global Health Sciences, University of California, San Francisco, CA, USA, 4Center for Health, Intervention and Prevention, University of Connecticut, Storrs, CT, USA, 5Center for Learning and Innovation, San Francisco Department of Public Health, San Francisco, CA, USA, 6Bridge HIV, San Francisco Department of Public Health, San Francisco, CA, USA and 7Department of Medicine, University of California, San Francisco, CA, USA
Posted: Jan 27, 2017
When and why women might suspend PrEP use according to perceived seasons of risk: implications for PrEP-specific risk-reduction counselling
Oral pre-exposure prophylaxis (PrEP) using the antiretroviral drug emtricitabine/tenofovir disoproxil fumarate (Truvada) has been shown to dramatically reduce the risk of HIV acquisition for women at higher risk of infection if taken daily. Understanding when and why women would intentionally stop using an efficacious oral PrEP drug within the context of their ‘normal’ daily lives is essential for delivering effective PrEP risk-reduction counselling. As part of a larger study, we conducted 60 qualitative interviews with women at higher risk of HIV in Bondo, Kenya, and Pretoria, South Africa. Participants charted their sexual contacts over the previous six months, indicated whether they would have taken PrEP if available and discussed whether and why they would have suspended PrEP use. Nearly all participants said they would have used PrEP in the previous six months; half indicated they would have suspended PrEP use at some point. Participants’ reasons for an extended break from PrEP were related to partnership dynamics (e.g., perceived low risk of a stable partner) and phases of life (e.g., trying to conceive). Life events (e.g., holidays and travel) could prompt shorter breaks in PrEP use. These circumstances may or may not correspond to actual contexts of lower risk, highlighting the importance of tailored PrEP risk-reduction counselling.
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Emily Namey, Kawango Agot, Khatija Ahmed, Jacob Odhiambo, Joseph Skhosana, Greg Guest & Amy Corneli (2016): When and why women might suspend PrEP use according to perceived seasons of risk: implications for PrEP-specific risk-reduction counselling, Culture, Health & Sexuality, DOI: 10.1080/13691058.2016.1164899
Posted: Jan 27, 2017
Pre-exposure prophylaxis in Southern Africa: feasible or not?
Introduction: Southern and Eastern Africa bear the brunt of the AIDS epidemic, and current prevention interventions remain inadequate. Antiretroviral-based pre-exposure prophylaxis (PrEP) is gaining momentum as an effective prevention intervention. Discussion: Discussions have been started on how this strategy could be employed in Africa such that the populations most in need can be reached urgently for the greatest impact.This requires the selection of specific risk groups and service environments in which PrEP can be distributed safely and cost effectively while being mindful of any ethical issues.
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Conclusions: Given the need for an integrated public health approach to this, a number of potential populations and opportunities for PrEP distribution exist and are discussed in this commentary.
Venter, W. D. F., Cowan, F., Black, V., Rebe, K., & Bekker, L.-G. (2015). Pre-exposure prophylaxis in Southern Africa: feasible or not? Journal of the International AIDS Society, 18(4Suppl 3), 19979. http://doi.org/10.7448/IAS.18.4.19979
Posted: Jan 17, 2017
Tenofovir Pre-exposure Prophylaxis for Pregnant and Breastfeeding Women at Risk of HIV Infection: The Time is Now
Pre-exposure prophylaxis (PrEP) using either daily oral tenofovir disoproxil fumarate (TDF) or co-formulated TDF/emtricitabine (TDF/FTC) has been shown in clinical trials to be effective for prevention of HIV acquisition in men who have sex with men, heterosexual men and women, and persons who inject drugs . However, unfortunately, the relevant clinical trials excluded pregnant or breastfeeding women; the trials included frequent pregnancy testing, and PrEP was discontinued if pregnancy was recognized (generally at gestation months 1–2).
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Mofenson, L. M. (2016). Tenofovir Pre-exposure Prophylaxis for Pregnant and Breastfeeding Women at Risk of HIV Infection: The Time is Now. PLoS Medicine, 13(9), e1002133. http://doi.org/10.1371/journal.pmed.1002133 Available at: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5038968/pdf/pmed.1002133.pdf
Posted: Jan 17, 2017
Rethinking HIV prevention to prepare for oral PrEP implementation for young African women
Introduction: HIV incidence remains high among young women in sub-Saharan Africa in spite of scale-up of HIV testing, behavioural interventions, antiretroviral treatment and medical male circumcision. There is a critical need to critique past approaches and learn about the most effective implementation of evidence-based HIV prevention strategies, particularly emerging interventions such as pre-exposure prophylaxis (PrEP).
Discussion: Women in sub-Saharan Africa are at increased risk of HIV during adolescence and into their 20s, in part due to contextual factors including gender norms and relationship dynamics, and limited access to reproductive and sexual health services. We reviewed behavioural, behavioural economic and biomedical approaches to HIV prevention for young African women, with a particular focus on the barriers, opportunities and implications for implementing PrEP in this group. Behavioural interventions have had limited impact in part due to not effectively addressing the context, broader sexual norms and expectations, and structural factors that increase risk and vulnerability. Of biomedical HIV prevention strategies that have been tested, daily oral PrEP has the greatest evidence for protection, although adherence was low in two placebo-controlled trials in young African women. Given high efficacy and effectiveness in other populations, demonstration projects of open-label PrEP in young African women are needed to determine the most effective delivery models and whether women at substantial risk are motivated and able to use oral PrEP with sufficient adherence to achieve HIV prevention benefits.
Conclusions: Social marketing, adherence support and behavioural economic interventions should be evaluated as part of PrEP demonstration projects among young African women in terms of their effectiveness in increasing demand and optimizing uptake and effective use of PrEP. Lessons learned through evaluations of implementation strategies for delivering oral PrEP, a first-generation biomedical HIV prevention product, will inform development of new and less user-dependent PrEP formulations and delivery of an expanding choice of prevention options in HIV prevention programmes for young African women.
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Celum, C. L., Delany-Moretlwe, S., McConnell, M., van Rooyen, H., Bekker, L.-G., Kurth, A., … Baeten, J. M. (2015). Rethinking HIV prevention to prepare for oral PrEP implementation for young African women. Journal of the International AIDS Society, 18(4Suppl 3), 20227. http://doi.org/10.7448/IAS.18.4.20227