Early antiretroviral therapy and daily pre‐exposure prophylaxis for HIV prevention among female sex workers in Cotonou, Benin: a prospective observational demonstration study

Abstract

IntroductionIn sub‐Saharan Africa, HIV prevalence remains high, especially among key populations. In such situations, combination prevention including clinical, behavioural, structural and biological components, as well as adequate treatment are important. We conducted a demonstration project at the Dispensaire IST, a clinic dedicated to female sex workers (FSWs) in Cotonou, on early antiretroviral therapy (E‐ART, or immediate “test‐and‐treat”) and pre‐exposure prophylaxis (PrEP). We present key indicators such as uptake, retention and adherence.MethodsIn this prospective observational study, we recruited FSWs from October 4th 2014 to December 31st 2015 and followed them until December 31st 2016. FSWs were provided with daily tenofovir disoproxil fumarate/emtricitabine (Truvada®) for PrEP or received a first‐line antiretroviral regimen as per Benin guidelines. We used generalized estimating equations to assess trends in adherence and sexual behaviour.ResultsAmong FSWs in the catchment area, HIV testing coverage within the study framework was 95.5% (422/442). At baseline, HIV prevalence was 26.3% (111/422). Among eligible FSWs, 95.5% (105/110) were recruited for E‐ART and 88.3% (256/290) for PrEP. Overall retention at the end of the study was 59.0% (62/105) for E‐ART and 47.3% (121/256) for PrEP. Mean (±SD) duration of follow‐up was 13.4 (±7.9) months for E‐ART and 11.8 (±7.9) months for PrEP. Self‐reported adherence was over 90% among most E‐ART participants. For PrEP, adherence was lower and the proportion with 100% adherence decreased over time from 78.4% to 56.7% (p‐trend < 0.0001). During the 250.1 person‐years of follow‐up among PrEP initiators, two seroconversions occurred (incidence 0.8/100 person‐years (95% confidence interval: 0.3 to 1.9/100 person‐years)). The two seroconverters had stopped using PrEP for at least six months before being found HIV‐infected. In both groups, there was no evidence of reduced condom use.ConclusionsThis study provides data on key indicators for the integration of E‐ART and PrEP into the HIV prevention combination package already offered to FSWs in Benin. PrEP may be more useful as an individual intervention for adherent FSWs rather than a specific public health intervention. E‐ART was a more successful intervention in terms of retention and adherence and is now offered to all key populations in Benin.Study registrationClinicalTrials.gov NCT02237

Acceptability of pre-exposure prophylaxis for HIV prevention: facilitators, barriers and impact on sexual risk behaviors among men who have sex with men in Benin

“…In some studies on the intention to use PrEP, a high level of PrEP acceptability was sometimes related to the intention to enhance risky sexual behaviors, such as stopping condom use and increasing the number of unprotected sexual contacts [40][41][42][43]. No PrEP studies in non-MSM individuals, including heterosexual people of the general population and sex workers, have shown an increase in risky behaviors under PrEP [44][45][46].…”

A Cascade of Interventions to Promote Adherence to Antiretroviral Therapy in African Countries

“…Community outreach for HIV testing and immediate ART prescription at a healthcare centre in Benin resulted in high uptake of HIV testing (96%) and initial ART uptake (96%; p = 0.031) within a prospective observational cohort. However, retention in care was low (59% at a mean of 13 months) [44]. Building on existing community-based testing and ART counselling services in Tanzania showed significant improvement in ART initiation compared to receiving healthcare facility-based care (among the 82% attending the 6-month visit, 100% versus 72%; p = 0.04) [45].…”

HIV pre‐exposure prophylaxis for female sex workers: ensuring women’s family planning needs are not left behind

“…However, modelling among MSM suggest that if PrEP is accompanied by regular STI services, increased detection and treatment may mitigate increases in STI transmission . While there is no current evidence among FSWs of decreasing condom use or other behaviours increasing vulnerability to STIs and unintended pregnancy , implementation data are too limited to discount this possibility. It is possible that risk compensation will increase over time as PrEP becomes more normalized .…”

“…As use of contraception was a condition of enrolment and supplied to participants, this result suggests that PrEP does not reduce the efficacy of hormonal contraception , but it cannot be used to predict the influence of PrEP on behaviour in real‐life settings. Pregnancy incidence has not been reported in contexts that would give a better indication of the real‐world effect of PrEP, specifically among FSWs, such as demonstration studies, open‐label comparisons of women using versus not using PrEP, or monitoring of larger scale PrEP programmes . Nonetheless, pregnancies in PrEP trials were relatively common among both PrEP and control groups with rates comparable to general rates in developing countries , even when baseline criteria had stipulated contraceptive use and no current pregnancy intentions and provided access to at least shorter acting contraceptive methods: the overall pregnancy incidence was 10 per 100 person‐years in both the Partners PrEP and FEM‐PrEP studies , and approximately 8 per 100 person‐years in the FACTS 001 tenofovir gel and VOICE trials .…”