Current US Guidelines for Prescribing HIV Pre-exposure Prophylaxis (PrEP) Disqualify Many Women Who Are at Risk and Motivated to Use PrEP

Calabrese, Sarah K.; Willie, Tiara C.; Galvao, Rachel W.; Tekeste, Mehrit; Dovidio, John F.; Safon, Cara B.; Blackstock, Oni J.; Taggart, Tamara; Kaplan, Clair; Caldwell, Abigail; Kershaw, Trace

doi:10.1097/qai.0000000000002042

Cited by 70 publications

(52 citation statements)

References 26 publications

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“…Nevertheless, it is important to highlight that there was a substantial number, varying according to the guideline used, of HIV seroconversions among ineligible participants. It was previously shown that the US CDC criteria failed to identify a considerable proportion of individuals at risk for HIV [9,16,17], and the same was observed in this study and for the other guidelines. Previous research also suggests that people not meeting the eligibility criteria but, for instance, requesting PrEP may be at risk of HIV seroconversion [30,31,32].…”

Section: Discussionsupporting

confidence: 85%

Different guidelines for pre-exposure prophylaxis (PrEP) eligibility estimate HIV risk differently: an incidence study in a cohort of HIV-negative men who have sex with men, Portugal, 2014–2018

Meireles

Plankey

Rocha³

et al. 2020

Eurosurveillance

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We aimed to measure the association between guideline-specific eligibility and HIV seroconversion. Methods: We studied 1,254 participants from the Lisbon Cohort of men who have sex with men with at least two evaluations between March 2014 and March 2018, corresponding to 1,724.54 person-years (PY) of follow-up. We calculated incidence rates (IR) according to each guideline eligibility definition and incident rate ratios (IRR) to test the association between eligibility at baseline and HIV seroconversion. Results: We found 28 incident cases (IR: 1.62/100 PY; 95% confidence interval (CI) 1.12-2.35). Guidelines' sensitivity varied from 60.7% (EACS) to 85.7% (PNHS) and specificity varied from 31.8% (US CDC) to 51.5% (EACS). IR was highest among those defined as eligible by the PNHS guideline (2.46/100 PY; IRR = 4.61; 95% CI: 1.60-13.27) and lowest for the WHO guideline (1.89/100 PY; IRR = 1.52; 95% CI: 0.69-3.35). Conclusions: Being identified as eligible for PrEP was associated with a higher risk of infection. The magnitude of risk varied according to the guideline used. However, the number of HIV infections identified among ineligible participants highlights the potential for missing people who need PrEP.

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Section: Discussionsupporting

confidence: 85%

Different guidelines for pre-exposure prophylaxis (PrEP) eligibility estimate HIV risk differently: an incidence study in a cohort of HIV-negative men who have sex with men, Portugal, 2014–2018

Meireles

Plankey

Rocha³

et al. 2020

Eurosurveillance

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“…Stigma reinforced by the association of PrEP with risky behaviour contributed to the decision of several of the participants to stop PrEP. Unfortunately, for many populations, HIV risk is driven not by behaviour but by one’s sexual network and/or one’s partners’ sexual network [42,43]. For this reason and others, the CDC guidelines predict HIV risk poorly among key populations such as black MSM and heterosexual women [42,43].…”

Section: Discussionmentioning

confidence: 99%

“…Unfortunately, for many populations, HIV risk is driven not by behaviour but by one’s sexual network and/or one’s partners’ sexual network [42,43]. For this reason and others, the CDC guidelines predict HIV risk poorly among key populations such as black MSM and heterosexual women [42,43]. In addition to removing barriers to PrEP delivery, PrEP should be normalized as a routine preventive health procedure for people potentially exposed to HIV.…”

Section: Discussionmentioning

confidence: 99%

Missed opportunities to prevent HIV infections among pre‐exposure prophylaxis users: a population‐based mixed methods study, San Francisco, United States

et al. 2020

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Introduction Pre‐exposure prophylaxis (PrEP) is highly effective, although PrEP adherence and persistence has been variable during real world implementation. Little is known about missed opportunities to enhance PrEP adherence among individuals who later HIV seroconverted after using PrEP. The goal of this analysis was to identify all HIV infections among individuals who had accessed PrEP in an integrated health system in San Francisco, and to identify potentially intervenable factors that could have prevented HIV infection through in‐depth interviews with people who HIV seroconverted after using PrEP. Methods We identified individuals who initiated PrEP in an integrated safety‐net public health system and performed in‐depth chart review to determine person‐time on and after stopping PrEP over six years. We identified all PrEP seroconversions using the Centers for Disease Control and Prevention’s Enhanced HIV/AIDS Reporting System and then calculated HIV incidence while using PrEP and during gaps in use. We then performed in‐depth interviews with those who seroconverted. Results Overall, 986 initiated PrEP across the San Francisco Department of Public Health from July 2012 to November 2018. Data were gathered from 895 person‐years on PrEP and 953 after stopping PrEP. The HIV incidence was 7.5‐fold higher after stopping PrEP compared to while on PrEP (95% CI 1 to 336). Of the eight individuals who HIV seroconverted; only one was taking PrEP at the time of seroconversion but was using on‐demand PrEP inconsistently. All eight agreed to qualitative interviews. Major barriers to PrEP persistence included substance use, mental health and housing loss; difficulty accessing PrEP due to cost, insurance, and the cost and time of medical visits; difficulty weighing PrEP’s benefit versus self‐perceived risk; and entering a primary partnership. The individual who developed HIV using on‐demand PrEP reported confusion about the dosing regimen and which sexual encounters required accompanying PrEP dosing. Conclusions HIV incidence during gaps in PrEP use was nearly eight‐fold higher than while on PrEP in this large cohort in San Francisco. Many individuals who stop PrEP remain at risk of HIV, and participants reported that proactive outreach could potentially have prevented HIV infections. Individuals using non‐daily PrEP may require additional education and support in the United States.

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“…Consequently, there is a growing need for gender-speci c interventions targeting women at risk for HIV, including women with OUD. There is also concern that current PrEP prescribing guidelines may inadvertently disqualify women at risk for HIV (37).…”

Section: Discussionmentioning

confidence: 99%

“I think everybody should take it if they’re doing drugs, doing heroin, or having sex for money”: A qualitative study exploring perceptions of pre-exposure prophylaxis among female participants in an opioid intervention court program

Przybyla

Cerulli

Wilson

et al. 2020

Preprint

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Background: Women’s rise in opioid use disorder has increased their presence in the criminal justice system and related risk behaviors for HIV infection. Although pre-exposure prophylaxis (PrEP) is an effective biomedical HIV prevention treatment, uptake among this high-risk population has been particularly low. Considerably little is known about the interplay between justice-involved women with opioid use disorder and HIV prevention. The aim of this study was to explore PrEP knowledge, attitudes, and perceptions for personal and partner use among women participants in the nation’s first ever opiate intervention court program.Methods: The authors conducted semi-structured, in-depth interviews with 31 women recruited from an Opioid Intervention Court, a recent fast-track treatment response to combat overdose deaths. We utilized a consensual qualitative research approach to explore attitudes, perceptions, and preferences about PrEP from women at risk for HIV transmission via sexual and drug-related behavior and used thematic analysis methods to code and interpret the data. Results: PrEP interest and motivation were impacted by various factors influencing the decision to consider PrEP initiation or comfort with partner use. Three primary themes emerged regarding HIV risk perceptions, barriers and facilitators to personal PrEP utilization, and perspectives on PrEP use by sexual partners. Conclusions: Findings suggest courts may provide a venue to offer women PrEP education and HIV risk assessments. Study findings inform public health, substance use, and criminal justice research and practice with justice-involved participants experiencing opioid use disorder on the development of gender-specific PrEP interventions with the ultimate goal of reducing HIV incidence.

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Current US Guidelines for Prescribing HIV Pre-exposure Prophylaxis (PrEP) Disqualify Many Women Who Are at Risk and Motivated to Use PrEP

Cited by 70 publications

References 26 publications

Different guidelines for pre-exposure prophylaxis (PrEP) eligibility estimate HIV risk differently: an incidence study in a cohort of HIV-negative men who have sex with men, Portugal, 2014–2018

Different guidelines for pre-exposure prophylaxis (PrEP) eligibility estimate HIV risk differently: an incidence study in a cohort of HIV-negative men who have sex with men, Portugal, 2014–2018

Missed opportunities to prevent HIV infections among pre‐exposure prophylaxis users: a population‐based mixed methods study, San Francisco, United States

“I think everybody should take it if they’re doing drugs, doing heroin, or having sex for money”: A qualitative study exploring perceptions of pre-exposure prophylaxis among female participants in an opioid intervention court program

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