increasing prep service uptake and retention intervention strategy pdf

Increasing Prep Service Uptake And Retention Intervention Strategy Pdf

By Doug B.
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The National Department of Health has used a phased approach to rollout, allowing for a dynamic learn-and-adapt process which will lead ultimately to scale-up. Phased rollout began with provision of oral PrEP at facilities providing services to sex workers in and was expanded in , first to facilities providing services to MSM and then to students at selected university campus clinics, followed by provision at primary health care facilities.

Implementation Strategies to Increase PrEP Uptake in the South

PLoS Med 14 4 : e This is an open access article distributed under the terms of the Creative Commons Attribution License , which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited. The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript.

Competing interests: The authors have declared that no competing interests exist. These disparities have resulted in a life expectancy gap of up to 10 years between HIV-positive men and women [ 2 — 5 ].

Low male testing and treatment rates also increase HIV transmission to female partners. This can be partially attributable to low testing rates in their male partners.

Men who have sex with men MSM are an underserved group who should not be overlooked. Numerous policy barriers exist that restrict availability and access to HIV-related services for MSM, including police harassment and criminal laws [ 11 ].

Stigma is one potential explanation for low male engagement in the HIV care cascade. HIV-positive persons are often perceived by their community as disabled and incapable of contributing economically to society [ 12 ]. Poverty can also directly affect engagement in care as individuals lack resources required to attend facilities. Further barriers to visiting clinics include confidentiality concerns, costs transport, wait time, and lost wages , inconvenient hours, and the perception that clinics are places for women [ 13 ].

Accurate HIV prevalence estimates are crucial for designing and evaluating prevention programs. However, measuring male HIV prevalence can be difficult as disproportionately more men decline DHS participation although nonparticipation is an issue for both sexes.

Advanced methods to adjust HIV prevalence for nonparticipation including instrumental variables and Heckman-type selection models can generate more accurate estimates [ 15 , 17 , 18 ]. A validation study assessing the ability of 10 mathematical models to predict HIV burden in South Africa found that 8 out of 10 models projected declining male HIV prevalence, whereas empirical data showed increasing prevalence; this may be partly because the models assumed equal ART uptake among men and women [ 20 ].

Future models should account for sex differences in HIV testing, ART initiation, and retention to more accurately estimate the impact of interventions. Ascertaining where losses to follow-up occur across the HIV care cascade is also crucial to targeting interventions.

However, it is challenging to generate accurate HIV-related mortality estimates since many HIV-positive men never access care. Additionally, clinics often do not track outcomes for persons who have dropped out of care, making it difficult to determine if men have transferred to another facility or stopped treatment [ 21 ]. A study conducted in South Africa was able to assess mortality throughout the HIV continuum using a population-based cohort and determining cause of death in all persons, including those not engaged in HIV care [ 22 ].

The authors found that the gap between female and male life expectancy doubled from to and twice as many women initiated ART than men. Improving ART adherence and retention can also reduce the risk of developing and transmitting drug-resistant virus. Facility-based HTC has achieved limited coverage in men. As there is no one-size-fits-all approach, a variety of community-based HTC strategies will likely be needed to achieve high testing coverage Table 1.

Meta-analyses find that community HTC achieves higher population coverage than facility testing [ 27 ], with home and mobile HTC increasing coverage in men mobile having a larger effect than home HTC [ 26 ]. Community HTC reaches more first-time testers, suggesting expanded coverage to persons who may not otherwise undergo facility testing [ 28 ].

This can facilitate earlier linkage to ART, preventing morbidity, mortality, and transmission. However, community HTC should be tailored to the needs of men to optimize coverage and effectiveness. Home HTC with flexible hours and multiple follow-up visits has the potential to test more men.

Finally, partner notification notifying sexual partners of newly diagnosed HIV-positive individuals of their potential exposure and offering HTC reaches more men when using active provider tracing or contract referral compared to passive notification index cases are asked to notify sexual partners and refer them to the clinic.

Mobile HTC is a promising strategy for reaching men. Integrating HTC into mobile multidisease campaigns has also had success in reaching men [ 38 ]. Community health campaigns can achieve rapid HTC coverage in short time frames e. Studies find that men prefer HIV services that are not separate from other health care services [ 41 ].

HTC for male partners of pregnant woman is another strategy to expand male testing. Home HTC for male partners of pregnant women can overcome barriers of male ANC attendance and achieve high testing coverage.

HIV self-testing kits are also potentially effective in reaching men. Couples-based approaches may increase male testing regardless of female pregnancy status. Community-based educational initiatives to reduce stigma, decrease high-risk sexual behavior, increase HIV testing, and challenge gender norms have had some success Table 2. The SASA! Studies show that social networks are important influences on male HIV testing uptake. Men who believe that at least one close friend has tested for HIV have twice the odds of having undergone HIV testing [ 49 ].

More research is needed on social interventions to increase testing coverage in men in SSA. Particularly, training peer leaders to encourage HIV testing should be explored in future studies. Future interventions should evaluate leveraging social support from primary partners to encourage male engagement in care. HIV self-testing is a relatively low-cost strategy that achieves high uptake in men, particularly young men [ 27 , 55 — 57 ]. Self-testing was the preferred option for future HIV testing among men surveyed in Malawi [ 55 ].

HIV self-testing can overcome concerns regarding confidentiality of provider-administered HTC and stigma associated with facility testing [ 55 ]. Further research is needed on quality, accuracy, distribution channels, and linkage to care after HIV self-testing. Studies show high HIV positivity combined with a high proportion of first-time testers, highlighting the need for service expansion.

Successful testing strategies for MSM are community based particularly mobile , as many MSM are marginalized without adequate access to conventional health systems [ 59 ]. Further, self-testing is useful for groups who benefit from frequent retesting [ 55 ]. Extra support may be needed to ensure linkage in community-based modalities, as they are conducted outside of health care systems [ 27 ]. Community HTC with facilitated linkage e. However, facility linkage rates after community HTC remain lower than what is needed for epidemic control [ 33 , 61 ].

Although community HTC reduces barriers to receiving an HIV test, individuals still must travel and wait at a clinic to obtain treatment. Community-based ART initiation is a convenient alternative to facility linkage. Notably, a recent systematic review found no current or planned trials evaluating community-based ART initiation in men in SSA; likewise, there is a lack of interventions for MSM [ 62 ].

Similar to ART initiation, retention is improved with streamlined services. Interviews with persons who have dropped out of care find that lack of transportation is the most common reason for dropout, followed by lack of money and work commitments [ 21 ]. Distance from clinic has been negatively associated with ART retention [ 63 ]. Food insecurity and long wait times are also reported as barriers to ART pickup [ 50 ]. Community-based ART delivery dispensing ART outside health care systems may overcome these barriers and increase retention.

Home, workplace, or mobile ART pickup sites can be particularly convenient for men. The campaign offered participants ART visits every 3 months with flexible scheduling, viral load counseling, and treatment for other diseases using a stigma-reducing chronic care model. Since men are more likely than women to be lost to follow-up after testing HIV positive, peer support groups can encourage engagement in care.

Studies show men can experience more stigma than women after an HIV diagnosis; they can feel that their masculinity is compromised by admitting they are sick and asking for help [ 64 , 65 ]. Fear of losing respect or being perceived as a failure for acquiring HIV is also a barrier [ 66 ].

Support groups and peer counselling can be difficult for men as they may be viewed as activities for women. Peer support groups for men should emphasize responsible fatherhood and skills training. Messaging that ART can allow men to regain their health, restore masculinity compromised by HIV, and provide for their families particularly children can be powerful motivators for engagement in care [ 64 , 65 ]. Receiving livelihood support e. Livelihood interventions can also reduce the social stigma caused by an HIV diagnosis [ 67 , 68 ].

Additionally, support groups that challenge gender norms and stigma can change attitudes about masculinity and HIV and increase engagement in care [ 69 ]. Qualitative research on male engagement and retention on ART is sparse. Financial incentives can increase HIV testing and ART uptake by 1 providing a near-immediate reward for a health behavior and 2 offsetting costs associated with clinic attendance travel and missed work [ 73 ].

They can also reduce structural HIV risk factors by alleviating poverty and increasing access to education. Fewer studies have examined the effects of cash transfers later in the HIV care cascade, although two trials are ongoing: Link4Health—a combination approach of accelerated ART initiation, counselling, and financial incentives for linkage and retention in Swaziland ClinicalTrials.

More research is needed on conditional and unconditional cash transfers and lottery systems for increasing male engagement in the care cascade. Additionally, some beneficial health behaviors are known to diminish after the cessation of cash transfers, so studies are needed to evaluate the long-term effects of financial incentives on ART adherence [ 73 ].

Linkage to care is challenging for MSM since health care workers in SSA typically have little or no training in addressing their health care needs [ 75 ].

Further, MSM report discrimination, harassment, and denial of services [ 76 ]. A study from Kenya found that providing health care workers with a web-based 2-day MSM sensitivity training decreased homophobic attitudes and increased knowledge of MSM-related health issues maintained 3 months postintervention. Encouragingly, the strongest impact was seen in those with the most negative attitudes towards MSM [ 77 ]. However, such training is rare, and the health care workers who attended the training reported experiencing secondary stigma from other health care workers who were not trained [ 75 ].

One of the few studies evaluating this topic found that ART adherence in Kenya was substantially lower in MSM compared to heterosexual men [ 78 ]. Successful strategies will require multiple approaches including pre-exposure prophylaxis PrEP , treatment as prevention, and behavioral risk reduction [ 80 ]. Multicomponent interventions are needed to reduce stigma and address issues of masculinity and health-seeking behavior.

Additionally, leveraging social support and providing poverty alleviation can change norms around testing and treatment while addressing other factors contributing to low engagement in care e. Community-based testing, and potentially community-based ART initiation and medication resupply, can overcome barriers associated with clinics and strengthen male engagement across the care cascade.

A variety of community HTC modalities can be implemented simultaneously to achieve maximum coverage. Targeted messaging to motivate men e. Further, an integrated approach combining testing and treatment with other HIV interventions VMMC and PrEP and chronic disease screening can increase intervention program efficiency while reducing stigma.

Further research is needed on community-based interventions that motivate male engagement in care, particularly later in the cascade i.

Summary points Men in sub-Saharan Africa are less likely than women to engage in HIV services across the care cascade, resulting in poorer clinical outcomes.

Health care facilities have achieved limited HIV testing and treatment coverage in men, with barriers including confidentiality concerns, distance to the facility, inconvenient hours, and perceptions that facilities provide women-centered services.

Other barriers to male engagement include stigma, poverty, and feelings of compromised masculinity associated with seeking health care.

Improving PrEP Implementation Through Multilevel Interventions: A Synthesis of the Literature

We sought to review possible reasons for inequitable uptake of PrEP in the South and identify implementation approaches to increase PrEP uptake in the South. Published literature, data on the locations of PrEP service providers, recent data on PrEP utilization from pharmacy prescription databases, HIV surveillance data and government data on healthcare providers and health literacy indicate a confluence of factors in the South that are likely limiting PrEP uptake. A variety of approaches are needed to address the complex challenges to PrEP implementation in the South. These include considering alternative PrEP provision strategies e. Overcoming the structural, capacity and policy challenges to increasing PrEP uptake in the South will require innovations in clinical approaches, leveraging technologies, and policy changes. The South has unique challenges to achieving equitable PrEP uptake and addressing key barriers to expanded PrEP use will require multisectoral responses.

Metrics details. HIV incidence in adolescent girls and young women remains high in sub-Saharan Africa. Progress towards uptake of HIV prevention methods remains low. Studies of oral pre-exposure prophylaxis PrEP have shown that uptake and adherence may be low due to low-risk perception and ambivalence around using antiretrovirals for prevention. No evidence exists on whether an interactive intervention aimed at adjusting risk perception and addressing the uncertainty around PrEP will improve uptake.


Implementation Strategies to Increase PrEP Uptake in the South Published literature, data on the locations of PrEP service providers, recent data on PrEP is a prevention intervention that requires detailed risk assessment, /national-hiv​-aids-strategy/stthomasbarrowford.org (last accessed November 1, ).


Young men who have sex with men are among the most vulnerable to human immunodeficiency virus HIV infection. Although preexposure prophylaxis PrEP has demonstrated effectiveness, adherence and retention have been low among youth. We conducted a randomized controlled trial to evaluate the impact of a youth-tailored, bidirectional text-messaging intervention PrEPmate on study retention and PrEP adherence. The impact of PrEPmate on retention and adherence was evaluated using generalized estimating equation logistic models with robust standard errors. An interactive text-messaging intervention had high acceptability and significantly increased study-visit retention and PrEP adherence among young individuals at risk for HIV acquisition.

Published on Authors of this article:. This is a significant issue because 8 of the 10 states with the highest rates of new HIV infections are in the South.

Javascript is currently disabled in your browser. Several features of this site will not function whilst javascript is disabled. Received 16 March Published 28 July Volume Pages — Review by Single anonymous peer review. Editor who approved publication: Professor Bassel Sawaya. Certain subpopulations are disproportionately affected by this problem.

PLoS Med 14 4 : e This is an open access article distributed under the terms of the Creative Commons Attribution License , which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited. The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript.


There are many challenges to accessing PrEP and thus low uptake in the United States. This review (–) of PrEP implementation.


Background

Published on Authors of this article:. This is a significant issue because 8 of the 10 states with the highest rates of new HIV infections are in the South. This study will develop and test an engaging, interactive, and cost-effective mobile messaging intervention to improve engagement in PrEP care for BMSM aged 18 to 35 years living in Jackson, MS. Methods: This research protocol will be conducted in 2 phases. These interviews will allow researchers to select the texted material that will be sent out during the intervention. The second phase will consist of an unblinded, small, randomized controlled trial among 66 new participants to examine the preliminary efficacy of the intervention compared with enhanced standard of care ESC on attendance at a PrEP services appointment the first step in initiating PrEP care and receipt of a PrEP prescription, based on self-report and electronic medical records.

Cognitive barriers and interventions regarding patients and providers included knowledge, attitudes, and beliefs about PrEP. Healthcare systems barriers included lack of communication about, funding for, and access to PrEP. The intersection between PrEP-stigma, HIV-stigma, transphobia, homophobia, and disparities across gender, racial, and ethnic groups were identified; but few interventions addressed these barriers. We recommend multilevel interventions targeting barriers at multiple socioecological domains. Las barreras cognitivas y las intervenciones con respecto a los pacientes y proveedores incluyeron el conocimiento, las actitudes y las creencias sobre la PrEP. Research regarding low access, uptake, and adherence to PrEP in the US has focused mostly on breakdowns in the healthcare systems implementing PrEP, lack of provider awareness and willingness to prescribe PrEP [ 9 , 14 ], and unfavorable patient and community attitudes about PrEP [ 15 , 16 ]. Our aim therefore is to comprehensively review this literature, focusing on how barriers to PrEP uptake might affect both individual actors and healthcare systems.

Metrics details. Oral pre-exposure prophylaxis PrEP is an effective strategy to reduce the risk of HIV transmission in high risk individuals. However, the effectiveness of oral pre-exposure prophylaxis is highly dependent on user adherence, which some previous trials have struggled to optimise particularly in low and middle income settings. This systematic review aims to ascertain the reasons for non-adherence to pre-exposure prophylaxis to guide future implementation. We performed structured literature searches of online databases and conference archives between August 8, and September 16,

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