Barriers and facilitators to HIV Pre-Exposure Prophylaxis (PrEP) in Specialist Sexual Health Services in the United Kingdom: A systematic review using the PrEP Care Continuum

Objectives

HIV pre-exposure prophylaxis (PrEP) delivery in the UK is inequitable; over 95% of PrEP users were men who have sex with men (MSM) despite making up less than 50% of new HIV diagnoses. We conducted a systematic review to identify modifiable barriers and facilitators to PrEP delivery in the UK among underserved populations.

Methods

We searched bibliographic/conference databases using the terms HIV, PrEP, barriers, facilitators, underserved populations, and UK. Modifiable factors were mapped along the PrEP Care Continuum (PCC) to identify targets for interventions.

Results

In total, 44 studies were eligible: 29 quantitative, 12 qualitative and three mixed-methods studies. Over half (n = 24 [54.5%]) exclusively recruited MSM, whereas 11 were in mixed populations (all included MSM as a sub-population) and the other nine were in other underserved populations (gender and ethnicity minorities, women, and people who inject drugs). Of the 15 modifiable factors identified, two-thirds were at the PrEP contemplation and PrEParation steps of the PCC. The most reported barriers were lack of PrEP awareness (n = 16), knowledge (n = 19), willingness (n = 16), and access to a PrEP provider (n = 16), whereas the more reported facilitators were prior HIV testing (n = 8), agency and self-care (n = 8). All but three identified factors were at the patient rather than provider or structural level.

Conclusions

This review highlights that the bulk of the scientific literature focuses on MSM and on patient-level factors. Future research needs to ensure underserved populations are included and prioritized (e.g. ethnicity and gender minorities, people who inject drugs) and provider and structural factors are investigated.     

Measuring Acceptability and Preferences for Implementation of Pre-Exposure Prophylaxis (PrEP) Using Conjoint Analysis: An Application to Primary HIV Prevention Among High Risk Drug Users

Although people who use drugs (PWUD) are one of the key risk populations who could benefit from the use of pre-exposure prophylaxis (PrEP), to date, little attention has been given to incorporating PrEP into HIV prevention approaches targeting this underserved group. This study investigated the acceptability of PrEP based on a number of known PrEP attributes among high-risk PWUD in a drug treatment setting. A total of 400 HIV-negative PWUD, who reported drug- and/or sex-related risk behaviors were recruited from a methadone clinic to complete a stated preference (full-profile conjoint) survey. Participants ranked the eight hypothetical PrEP program scenarios with varied combinations of six attributes related to PrEP (cost, dosing, efficacy, side-effects, treatment setting, and frequency of HIV testing). SPSS conjoint procedure was used to estimate the relative importance of each attribute and preferences across eight possible PrEP delivery programs. PrEP acceptability ranged from 30.6 to 86.3% with a mean acceptability of 56.2% across the eight hypothetical PrEP program scenarios. The PrEP program scenario with the highest acceptability had the following attribute levels: insurance covered, daily dosing, 95% effective, no side-effects, treatment at HIV clinic, and HIV testing needed every 6 months. The cost associated with PrEP was the most important attribute (relative importance score: RIS = 38.8), followed by efficacy (RIS = 20.5) and side effects (RIS = 11.9); other attributes had no significant effect. Our findings reported a high acceptability of PrEP in response to different PrEP program scenarios with different attribute profiles. As the result of having this information, researchers and policymakers will be better equipped for evidence informed targeting and dissemination efforts to optimize PrEP uptake among this underserved population.     

Framing HIV Pre-Exposure Prophylaxis (PrEP) for the General Public: How Inclusive Messaging May Prevent Prejudice from Diminishing Public Support

Strategic framing of public messages about HIV pre-exposure prophylaxis (PrEP) may influence public support for policies and programs affecting access. This survey study examined how public attitudes toward PrEP differed based on the social group PrEP was described as benefiting (“beneficiary”) and the moderating effect of prejudice. Members of the general public (n = 154) recruited online were randomly assigned to three beneficiary conditions: general population, gay men, or Black gay men. All participants received identical PrEP background information before completing measures of PrEP attitudes (specifying beneficiary), racism, and heterosexism. Despite anticipating greater PrEP adherence among gay men and Black gay men and perceiving PrEP as especially beneficial to the latter, participants expressed lower support for policies/programs making PrEP affordable for these groups vs. the general population. This disparity in support was stronger among participants reporting greater prejudice. Inclusive framing of PrEP in public discourse may prevent prejudice from undermining implementation efforts.     

Facilitators and Barriers to Pre-Exposure Prophylaxis (PrEP) Use Among Black Individuals in the United States: Results from the National Survey on HIV in the Black Community (NSHBC)

This study explores willingness to use PrEP among Black individuals in the US. From February to April 2016, an online survey was administered to a nationally representative sample of Black individuals. 855 individuals who were HIV negative by self-report participated [mean age: 33.6 (SD 9.2); 45.5% male]. Among all respondents, 14.5% were aware of, and 26.0% would be willing to use PrEP. Among high-risk individuals (N = 327), 19.8% knew about and 35.1% would be willing to use PrEP. The most common reason for lack of willingness among high-risk individuals was low self-perceived risk (65.1%). In multivariate analysis, individuals reporting single marital status [OR 1.8 (1.2, 2.5), p = 0.002], depressive symptoms [OR 1.6 (1.2, 2.2), p = 0.0054], arrest history [OR 1.7(1.2, 2.4), p = 0.0003], PrEP knowledge [OR 1.5 (1.0, 2.3), p = 0.0247] and belief in HIV conspiracies [OR 1.3 (1.1, 1.5), p = 0.0075] were more willing to use PrEP. Participants who saw a health care provider less frequently were less willing to use PrEP [OR 0.5 (0.4, 0.8), p = 0.0044]. Among a nationally representative sample of Black individuals, few high risk individuals were willing to use PrEP. Interventions to increase risk awareness, PrEP knowledge and access to care are necessary to improve PrEP uptake.     

Willingness to Use Pre-Exposure Prophylaxis (PrEP): An Empirical Test of the Information-Motivation-Behavioral Skills (IMB) Model among High-Risk Drug Users in Treatment

Evidence from recent pre-exposure prophylaxis (PrEP) trials has demonstrated its safety and efficacy in significantly reducing the risk of HIV acquisition for those who are at considerable risk of acquiring HIV infection. With a rapid increase in the amount of research on the efficacy of PrEP for HIV prevention, complementary research on the willingness to use PrEP has grown, especially among MSM, but limited research has been focused among people who use drugs (PWUD). As part of the formative process, we utilized the information-motivation-behavioral skills (IMB) model of health behavior change to characterize and guide intervention development for promoting willingness to use PrEP among high-risk PWUD. The analysis included 400 HIV-negative high-risk PWUD enrolled in a community-based methadone maintenance treatment who reported drug- and/or sex-related HIV risk behaviors in the past 6-months. Analyses revealed support for the IMB model as PrEP-related behavioral skills were found to mediate the influence of PrEP-related information and motivation on willingness to use PrEP. The results provide evidence as to the utility of the IMB model to increase willingness to use PrEP among high-risk PWUD. It therefore makes an important contribution to our understanding of the applicability of theoretically-grounded models of willingness to use PrEP among high-risk PWUD, who are one of the key risk populations who could benefit from the use of PrEP.     

Use of Pre-exposure Prophylaxis (PrEP) in Young Men Who Have Sex with Men is Associated with Race,Sexual Risk Behavior and Peer Network Size

Pre-exposure prophylaxis (PrEP) is efficacious to prevent HIV infection, however, uptake among young men who have sex with men (YMSM) is relatively low. The purpose of this study was to describe PrEP use and related factors in a representative sample of YMSM in two cities, Chicago and Houston. YMSM, ages 16–29, were recruited via respondent-driven sampling (RDS) from 2014 to 2016. Correlates of PrEP uptake were assessed in weighted multivariable logistic regression models. A total of 12.2% of participants (of 394) reported ever taking PrEP; Black YMSM had the lowest rates of uptake (4.7%) and Whites the highest (29.5%). In a multivariable regression model, having an HIV positive sex partner, reporting recent group sex, peer network size, and city (Chicago) were significantly and positively associated with use of PrEP, while Black race was negatively associated with it. Given evidence of racial/ethnic disparities in PrEP uptake in this study, further research is needed to identify potential mechanisms of action and points of intervention.     

High Burden of HIV,Syphilis and HSV-2 and Factors Associated with HIV Infection Among Female Sex Workers in Tanzania: Implications for Early Treatment of HIV and Pre-exposure Prophylaxis (PrEP)

This paper estimates population-based prevalence of HIV, syphilis, HSV-2 and factors influencing HIV infection using a national sample of 1914 female sex workers (FSWs) in 7 regions in Tanzania. Additionally, HIV incidence was estimated by comparing biological HIV results with self-reported HIV status. The average HIV prevalence among FSWs in all 7 regions was 28%, ranging from 14% in Tabora to 38% in Shinyanga. HIV incidence was found to be 13 per 100 person-years. Syphilis prevalence was 8% with significantly higher burden found in Iringa (11%), Mbeya (13%), and Shinyanga (12%). Nearly 60% of the study population was infected with HSV-2. The high HIV prevalence and incidence coupled with suboptimal condom use indicate an urgent need to roll out the “Treat-All” approach and provide antiretroviral therapy to FSWs living with HIV regardless of their CD4 count. In addition, antiretroviral-based prevention technologies such as oral pre-exposure prophylaxis and microbicides should be piloted and evaluated.     

Combined Impact of Sexual Risk Behaviors for HIV Seroconversion Among Women in Durban, South Africa: Implications for Prevention Policy and Planning

The objective of this study was to estimate the joint impact of demographic and sexual risk behaviors on HIV acquisition. A total of 2,523 HIV seronegative women were recruited through three community based studies in Durban, South Africa. Point and interval estimates of partial population attributable risk (PAR) were used to quantify the proportion of HIV seroconversions which can be prevented if a combination of risk factors is eliminated from a target population. More than 80% of the observed HIV acquisitions were attributed to five risk factors: lack of cohabitation, frequency of sex, sexually transmitted infections (STIs), incidence of pregnancy and not being employed/no income. Structural factors such as minimizing migratory patterns by ensuring cohabitation of partners, access to treatment of STIs, income generation and safe sex negotiation skills are likely to play an important role in future prevention strategies.     

Values and Preferences on the Use of Oral Pre-exposure Prophylaxis (PrEP) for HIV Prevention Among Multiple Populations: A Systematic Review of the Literature

Daily oral pre-exposure prophylaxis (PrEP) is the use of antiretroviral drugs by HIV-negative people to prevent HIV infection. WHO released new guidelines in 2015 recommending PrEP for all populations at substantial risk of HIV infection. To prepare these guidelines, we conducted a systematic review of values and preferences among populations that might benefit from PrEP, women, heterosexual men, young women and adolescent girls, female sex workers, serodiscordant couples, transgender people and people who inject drugs, and among healthcare providers who may prescribe PrEP. A comprehensive search strategy reviewed three electronic databases of articles and HIV-related conference abstracts (January 1990–April 2015). Data abstraction used standardised forms to categorise by population groups and relevant themes. Of 3068 citations screened, 76 peer-reviewed articles and 28 conference abstracts were included. Geographic coverage was global. Most studies (N = 78) evaluated hypothetical use of PrEP, while 26 studies included individuals who actually took PrEP or placebo. Awareness of PrEP was low, but once participants were presented with information about PrEP, the majority said they would consider using it. Concerns about safety, side effects, cost and effectiveness were the most frequently cited barriers to use. There was little indication of risk compensation. Healthcare providers would consider prescribing PrEP, but need more information before doing so. Findings from a rapidly expanding evidence base suggest that the majority of populations most likely to benefit from PrEP feel positively towards it. These same populations would benefit from overcoming current implementation challenges with the shortest possible delay.     

PrEP Use in Times of COVID-19 in the Netherlands: Men Who Have Sex With Men (MSM) on PrEP Test Less for HIV and Renal Functioning During a COVID-19 Related Lockdown

AIDS and Behavior - As a result of the COVID-19 pandemic, HIV care and prevention efforts have been disrupted. We investigated pre-exposure prophylaxis (PrEP) use and testing behaviors among MSM in...     

The Use of Online Posts to Identify Barriers to and Facilitators of HIV Pre-exposure Prophylaxis (PrEP) Among Men Who Have Sex with Men: A Comparison to a Systematic Review of the Peer-Reviewed Literature

Pre-exposure prophylaxis (PrEP) remains an under-utilized HIV prevention tool among men who have sex with men (MSM). To more comprehensively elucidate barriers and facilitators to PrEP use among US MSM, we conducted a systematic review of peer-reviewed published articles and content analysis of online posts about PrEP. We searched peer-reviewed databases (Medline, Web of Science, Google Scholar) using MESH headings and keywords about PrEP and/or HIV prevention from 2005 to 2015. We included original studies among MSM in the US that reported on barriers, facilitators, or other factors related to PrEP use. We also searched online posts and associated comments (news articles, opinion pieces, blogs and other social media posts) in diverse venues (Facebook, Slate Outward, Huffington Post Gay Voices, Queerty, and My PrEP Experience blog) to identify posts about PrEP. We used content analysis to identify themes and compare potential differences between the peer-reviewed literature and online posts. We identified 25 peer-reviewed articles and 28 online posts meeting inclusion criteria. We identified 48 unique barriers and 46 facilitators to using PrEP. These 94 themes fit into six overarching categories: (1) access (n = 14), (2) attitudes/beliefs (n = 24), (3) attributes of PrEP (n = 13), (4) behaviors (n = 11), (5) sociodemographic characteristics (n = 8), and (6) social network (n = 6). In all categories, analysis of online posts resulted in identification of a greater number of unique themes. Thirty-eight themes were identified in the online posts that were not identified in the peer-reviewed literature. We identified barriers and facilitators to PrEP in online posts that were not identified in a systematic review of the peer-reviewed literature. By incorporating data both from a systematic review of peer-reviewed articles and from online posts, we have identified salient and novel information about barriers to and facilitators of PrEP use. Traditional research approaches may not comprehensively capture current factors important for designing and implementing PrEP related interventions.     

Validating Alcohol Use Measures Among Male Drinkers in Goa: Implications for Research on Alcohol,Sexual Risk,and HIV in India

Assessment of heavy drinking patterns is vital for HIV/AIDs studies in India and developing countries. A population survey in northern Goa included urban and rural male drinkers (n = 743) who completed a new Fractional Graduated Frequencies (F-GF) alcohol patterns measure assessing seven beverage types and drink sizes for the largest daily amount, then drinking frequencies at fractional amounts. The new measure was compared to a simpler quantity-frequency (QF) summary and, in a validity subsample of hazardous drinkers (n = 56), 28-day diaries of drinking events. Approximately 56% of total volume came from peak drinking (averaging 60 g ethanol/day). For AUDIT-based Hazardous Drinkers, QF and F-GF volumes (drinks/day) were not significantly different from diary volume (correlations 0.65 and 0.57, respectively). F-GF well captured the profile of daily amounts in drinking event data. In addition, the F-GF showed evidence of better predicting any sexual risk behavior or partner violence perpetration than the QF measure. Summary drinking pattern measures, especially the new F-GF, are more cost efficient than intensive event records, and appear valid when carefully assessing quantities with local beverage types and drink ethanol content.     

Explaining the Efficacy of Pre-exposure Prophylaxis (PrEP) for HIV Prevention: A Qualitative Study of Message Framing and Messaging Preferences Among US Men Who have Sex with Men

We investigated message comprehension and message framing preferences for communicating about PrEP efficacy with US MSM. We conducted eight focus groups (n = 38) and n = 56 individual interviews with MSM in Providence, RI. Facilitators probed comprehension, credibility, and acceptability of efficacy messages, including percentages, non-numerical paraphrases, efficacy ranges versus point estimates, and success- versus failure-framed messages. Our findings indicated a range of comprehension and operational understandings of efficacy messages. Participants tended to prefer percentage-based and success-framed messages, although preferences varied for communicating about efficacy using a single percentage versus a range. Participants reported uncertainty about how to interpret numerical estimates, and many questioned whether trial results would predict personal effectiveness. These results suggest that providers and researchers implementing PrEP may face challenges in communicating with users about efficacy. Efforts to educate MSM about PrEP should incorporate percentage-based information, and message framing decisions may influence message credibility and overall PrEP acceptability.     

Adherence to Daily Oral TDF/FTC for PrEP in Community Health Center Populations: The Sustainable Health Center Implementation PrEP Pilot (SHIPP) Study

AIDS and Behavior - The prevention effectiveness of oral preexposure prophylaxis (PrEP) is highly dependent on medication adherence but no validated longer term PrEP adherence measures are readily...     

Seasons of Risk: Anticipated Behavior on Vacation and Interest in Episodic Antiretroviral Pre-exposure Prophylaxis (PrEP) Among a Large National Sample of U.S. Men Who have Sex with Men (MSM)

The current analysis evaluates interest in and acceptability of daily PrEP during short episodes of anticipated increased risk (i.e. Epi-PrEP). In 2013, U.S. members of an internet-based MSM sexual networking site were invited to complete a survey about HIV prevention practices in the context of vacationing. 7305 MSM responded to the survey. Of respondents who had vacationed in the past year, 25.6 % reported condomless anal sex (CAS) with new male sex partners while vacationing. Most (92.6 %) respondents agreed that having to use PrEP every day was a barrier to PrEP use and 74.3 % indicated they would take PrEP if they knew it would be helpful for short periods of anticipated increased risk. MSM who reported increased CAS while on vacation in the past year were more likely to indicate that they would take PrEP if it were helpful when used for short periods than respondents who did not (aOR = 2.02, 95 % CI 1.59–2.56, p < 0.001). Studies designed to evaluate uptake, adherence, and protective benefit of short PrEP courses are warranted.