Strategies to improve PrEP uptake among West African men who have sex with men: a multi-country qualitative study

IntroductionWest African men who have sex with men (MSM) remain at substantial risk of contracting HIV. Pre-exposure prophylaxis (PrEP) can be an effective game-changer in reducing the number of HIV infections in MSM communities. To optimize the roll-out of PrEP, we need to better understand how we can increase its uptake. The objective of this study was to explore the perceptions of West African MSM toward PrEP and their proposed strategies to overcome barriers to PrEP uptake within their communities.MethodsBetween April 2019 and November 2021, we conducted 12 focus group discussions with 97 MSM not taking PrEP, and 64 semi-structured interviews with MSM taking PrEP, in Burkina Faso, Côte d'Ivoire, Mali, and Togo. Data collection and analysis were guided and conducted by local research teams, enabling a community-based participatory approach. A coordinating researcher collaborated with these local teams to analyze the data guided by a grounded theory approach.ResultsThe results show that participants were generally positive toward PrEP and that MSM communities have become more aware of PrEP for the study. We identified three main strategies for increasing PrEP uptake. First, participants proposed to raise awareness and improve knowledge of HIV as they considered the self-perceived risk of MSM in their communities to be low. Second, because of existing misconceptions and false information, participants proposed to improve the dissemination of PrEP to allow for informed choices, e.g., via peers or PrEP users themselves. Third, as oral PrEP also entails a risk of being associated with HIV or homosexuality, strategies to avoid stigmatization (e.g., hiding pills) were deemed important.DiscussionThese findings indicate that the roll-out of oral PrEP and other future PrEP modalities should be accompanied by raising awareness and improving knowledge on HIV, and wide dissemination of information that focuses on the health-promoting aspect of these tools. Tailored delivery and long-acting PrEP modalities will be important to avoid potential stigmatization. Sustained efforts to prevent discrimination and stigmatization based on HIV status or sexual orientation continue to be highly important strategies to address the HIV epidemic in West Africa

Unmet needs for modern contraceptive methods among sexually active adolescents and young women in Togo: a nationwide cross-sectional study

BackgroundThe unmet need for modern contraceptives among sexually active adolescent and young women (AYW) in Africa contributes to high morbidity and mortality. To investigate the prevalence of unmet need for modern contraceptives and its associated factors among AYW in Togo, we performed a secondary analysis of data from the MICS-62017 survey.MethodWe extracted data from sexually active AYW aged 15–24  years for the analysis and used multi-level logistic regression models to identify factors associated with unmet need for modern contraceptives.ResultsAmong the AYW, the median age was 20  years. The prevalence of unmet need for modern contraceptives was 27.02%. Factors that increased the likelihood of having unmet need for contraceptives included being in the “Poor” or “Middle” quintile of household wealth, aged 20–24  years, and completing primary or secondary education. Living in a household headed by a woman and having a household head aged 19–38, 39–58, or greater than 78  years decreased the likelihood of unmet need for modern contraceptives.ConclusionThe study highlights the high-unmet need for modern contraceptives among sexually active AYW in Togo and emphasizes the importance of addressing individual and household/community factors to improve their sexual and reproductive health. Interventions such as increasing AYW awareness, providing social marketing campaigns in schools, and targeting men-headed households could help promote modern contraceptive use and improve the sexual and reproductive health of AYW in Togo

Evaluation de la stratégie 'Dépister et Traiter' dans l'infection par le VIH chez des hommes ayant des relations sexuelles avec d'autres hommes en Afrique de l'ouest

In West African countries, HIV epidemic is mixed or concentrated in key populations including men who have sex with men (MSM). Since 2010, the World Health Organization (WHO) has recommended to West-African health decision-makers targeting MSM as part of the response to the HIV epidemic. It recommends to propose comprehensive prevention programme including “HIV infection Test and Treat strategy”. HIV testing is a key step in the fight against HIV. It allows to classify as negative or positive the person who undergo it, and then propose the suitable intervention. In addition, when it is regularly administered, it could allow the detection of acute HIV-infection. As of 2015, the WHO has recommended antiretroviral therapy (ART) initiation in all HIV-infected adults irrespective of their clinical stage and CD4 cell count. The “HIV infection Test and Treat strategy” includes these two components of fight against HIV. However, data on HIV infection “Test and Treat” strategy in MSM are lacking. Our work which is performed from “CohMSM ANRS 12324-Expertise France” project aim to assess the HIV infection “Test and Treat” strategy in MSM in West Africa.Our findings show that HIV seronegative MSM adherence to quarterly follow-up visits including HIV testing is good. However, overall HIV incidence remains high as well as specifically by study site. In addition, adherence to quarterly follow-up visits has no impact on new HIV infections. Almost all the HIV seropositive MSM discovering their HIV status accept the proposition to initiate ART immediately. Among them, one quarter initiate it the same day, two third initiate it rapidly (i.e. within seven days of HIV diagnosis). However, retention on ART is sub-optimal. Rapid ART initiation is favorable to HIV viral suppression over time. However, it has neither impact on retention on ART nor on immunologic response.Our study highlights that it is urgent to strengthen HIV prevention services by adding oral HIV pre-exposure prophylaxis (PrEP). Moreover, it supports the WHO recommendation for rapid ART initiation in HIV seropositive MSM. Our results validate the HIV “Test and Treat” strategy in MSM in West Africa.Keywords: HIV; screening; antiretroviral therapy; MSM; Africa.L’épidémie du VIH dans les pays d’Afrique de l’Ouest est mixte ou concentrée parmi les populations clés dont les hommes ayant des relations sexuelles avec d’autres hommes (HSH). Depuis 2010, l’organisation Mondiale de la Santé (OMS) recommande aux décideurs en santé de ces pays de cibler les HSH. Elle recommande une offre globale de prévention du VIH incluant la stratégie « Dépister et Traiter ». Le dépistage du VIH est une étape clé dans la lutte contre le VIH. Elle permet de classer la personne qui le réalise négative ou positive et de proposer ensuite l’action la mieux adaptée. Lorsqu’il est administré régulièrement, il permet la détection précoce des personnes infectées par le VIH. Depuis 2015, l’OMS recommande l’initiation du traitement antirétroviral (ARV) chez toute personne infectée par le VIH indépendamment de son état clinique et/ou biologique. La stratégie « Dépister et Traiter » consiste à coupler ces deux composantes de la lutte contre le VIH. Cependant, des données de cette stratégie chez les HSH sont manquantes. Notre travail de recherche, réalisé à partir du projet CohMSM ANRS 12324-Expertise France a pour objectif d’évaluer la stratégie « Dépister et Traiter » dans l’infection par le VIH chez des HSH en Afrique de l’Ouest.Nos résultats montrent que l’observance au suivi préventif trimestriel incluant le dépistage du VIH chez les HSH séronégatifs est bonne. Cependant, l’incidence du VIH est élevée aussi bien globalement que spécifiquement par site. En plus, l’observance au suivi préventif trimestriel n’a pas d’impact sur la réduction des nouvelles infections par le VIH. Chez les HSH séropositifs qui découvrent leur statut VIH, la grande majorité (95%) accepte d’initier le traitement ARV lorsque celui-ci leur est proposé immédiatement. Parmi eux, 1/4 l’initie le même jour, et 2/3 rapidement (entre 0-7 jours après la découverte du diagnostic positif au VIH). Cependant, leur rétention dans les soins reste sous optimale. L’initiation rapide du traitement ARV favorise la suppression de la charge virale du VIH. Cependant, elle n’a d’impact ni sur la rétention dans les soins des participants sous traitement, ni sur leur réponse immunologique.Notre travail souligne l’urgence de renforcer l’offre de prévention des HSH séronégatifs par l’ajout de la prophylaxie pré-exposition du VIH par voie orale (PrEP). Chez les HSH séropositifs, il supporte les recommandations de l’OMS pour l’initiation rapide du traitement ARV. Nos résultats sont en faveur de la stratégie « Dépister et Traiter » dans l’infection par le VIH chez des HSH en Afrique de l’Ouest.Mots clés: VIH; dépistage; traitement antirétroviral; HSH; Afrique

Evaluation of the HIV 'Test and Treat' strategy in Men who have Sex with Men in West Africa.

L’épidémie du VIH dans les pays d’Afrique de l’Ouest est mixte ou concentrée parmi les populations clés dont les hommes ayant des relations sexuelles avec d’autres hommes (HSH). Depuis 2010, l’organisation Mondiale de la Santé (OMS) recommande aux décideurs en santé de ces pays de cibler les HSH. Elle recommande une offre globale de prévention du VIH incluant la stratégie « Dépister et Traiter ». Le dépistage du VIH est une étape clé dans la lutte contre le VIH. Elle permet de classer la personne qui le réalise négative ou positive et de proposer ensuite l’action la mieux adaptée. Lorsqu’il est administré régulièrement, il permet la détection précoce des personnes infectées par le VIH. Depuis 2015, l’OMS recommande l’initiation du traitement antirétroviral (ARV) chez toute personne infectée par le VIH indépendamment de son état clinique et/ou biologique. La stratégie « Dépister et Traiter » consiste à coupler ces deux composantes de la lutte contre le VIH. Cependant, des données de cette stratégie chez les HSH sont manquantes. Notre travail de recherche, réalisé à partir du projet CohMSM ANRS 12324-Expertise France a pour objectif d’évaluer la stratégie « Dépister et Traiter » dans l’infection par le VIH chez des HSH en Afrique de l’Ouest.Nos résultats montrent que l’observance au suivi préventif trimestriel incluant le dépistage du VIH chez les HSH séronégatifs est bonne. Cependant, l’incidence du VIH est élevée aussi bien globalement que spécifiquement par site. En plus, l’observance au suivi préventif trimestriel n’a pas d’impact sur la réduction des nouvelles infections par le VIH. Chez les HSH séropositifs qui découvrent leur statut VIH, la grande majorité (95%) accepte d’initier le traitement ARV lorsque celui-ci leur est proposé immédiatement. Parmi eux, 1/4 l’initie le même jour, et 2/3 rapidement (entre 0-7 jours après la découverte du diagnostic positif au VIH). Cependant, leur rétention dans les soins reste sous optimale. L’initiation rapide du traitement ARV favorise la suppression de la charge virale du VIH. Cependant, elle n’a d’impact ni sur la rétention dans les soins des participants sous traitement, ni sur leur réponse immunologique.Notre travail souligne l’urgence de renforcer l’offre de prévention des HSH séronégatifs par l’ajout de la prophylaxie pré-exposition du VIH par voie orale (PrEP). Chez les HSH séropositifs, il supporte les recommandations de l’OMS pour l’initiation rapide du traitement ARV. Nos résultats sont en faveur de la stratégie « Dépister et Traiter » dans l’infection par le VIH chez des HSH en Afrique de l’Ouest.Mots clés: VIH; dépistage; traitement antirétroviral; HSH; Afrique.In West African countries, HIV epidemic is mixed or concentrated in key populations including men who have sex with men (MSM). Since 2010, the World Health Organization (WHO) has recommended to West-African health decision-makers targeting MSM as part of the response to the HIV epidemic. It recommends to propose comprehensive prevention programme including “HIV infection Test and Treat strategy”. HIV testing is a key step in the fight against HIV. It allows to classify as negative or positive the person who undergo it, and then propose the suitable intervention. In addition, when it is regularly administered, it could allow the detection of acute HIV-infection. As of 2015, the WHO has recommended antiretroviral therapy (ART) initiation in all HIV-infected adults irrespective of their clinical stage and CD4 cell count. The “HIV infection Test and Treat strategy” includes these two components of fight against HIV. However, data on HIV infection “Test and Treat” strategy in MSM are lacking. Our work which is performed from “CohMSM ANRS 12324-Expertise France” project aim to assess the HIV infection “Test and Treat” strategy in MSM in West Africa.Our findings show that HIV seronegative MSM adherence to quarterly follow-up visits including HIV testing is good. However, overall HIV incidence remains high as well as specifically by study site. In addition, adherence to quarterly follow-up visits has no impact on new HIV infections. Almost all the HIV seropositive MSM discovering their HIV status accept the proposition to initiate ART immediately. Among them, one quarter initiate it the same day, two third initiate it rapidly (i.e. within seven days of HIV diagnosis). However, retention on ART is sub-optimal. Rapid ART initiation is favorable to HIV viral suppression over time. However, it has neither impact on retention on ART nor on immunologic response.Our study highlights that it is urgent to strengthen HIV prevention services by adding oral HIV pre-exposure prophylaxis (PrEP). Moreover, it supports the WHO recommendation for rapid ART initiation in HIV seropositive MSM. Our results validate the HIV “Test and Treat” strategy in MSM in West Africa.Keywords: HIV; screening; antiretroviral therapy; MSM; Africa

Low Seroprevalence of Hepatitis C Among Men Who Have Sex With Men in West Africa

International audienceNo abstract availabl

Rapid antiretroviral therapy initiation and its effect on treatment response in MSM in West Africa

International audienceObjective: To assess the time from HIV diagnosis to ART initiation and the effect of rapid ART initiation (i.e. within 7 days of HIV diagnosis) on attrition and virologic and immunologic responses among MSM in Burkina Faso, Côte d'Ivoire, Mali, and Togo.Design: Prospective cohort study between 2015 and 2019.Methods: MSM aged 18 years or older newly diagnosed with HIV infection were eligible to participate. ART was proposed to participants upon HIV diagnosis, irrespective of clinical stage and CD4+ cell count, and was initiated as soon as possible, with no specific time frame. Determinants of rapid ART initiation and its effect on treatment outcomes were assessed using multivariate analyses.Results: Of 350 MSM, 335 (95.7%) initiated ART after a median time of 5 days. Of the latter, 216 (64.5%) had rapid ART initiation. The 335 participants were followed up for a median time of 24.1 months. One hundred and eleven (33.1%) were not retained in care. Rapid ART initiation was less likely in participants with a CD4+ cell count at least 200 cells/μl [adjusted odds ratio (aOR) 0.37, 95% confidence interval (CI) 0.15-0.88]. It improved viral load suppression (aOR 6.96, 95% CI 1.98-24.46) but had no effect on attrition (aOR 0.87, 95% CI 0.57-1.33) or CD4+ cell count increase (adjusted coefficient 28.23, 95% CI -17.00 to 73.45).Conclusion: These results in MSM in West Africa support the WHO recommendation for rapid ART initiation. Clinics need to develop context-specific strategies for rapid ART initiation and for retaining MSM in HIV care.ClinicalTrials.gov, number NCT02626286

Hepatitis B Virus Prevalence and Vaccination in Men Who Have Sex With Men in West Africa (CohMSM ANRS 12324—Expertise France)

International audienceBackground.Although men who have sex with men (MSM) are at high risk of hepatitis B virus (HBV) infection, they do not have access to vaccination in West Africa, which is a highly endemic region. We investigated HBV prevalence and associated factors, as well as acceptability and difficulties of vaccination in MSM enrolled in an operational research program in Burkina Faso, Côte d’Ivoire, Mali, and Togo.Methods.We followed up 779 MSM in 2015–2018. Participants who were negative for both hepatitis B surface antigen (HBsAg) and antibodies (anti-HBs) at enrollment were offered HBV vaccination. Factors associated with HBV infection were identified using logistic regression models.Results.Overall, HBV prevalence was 11.2% (95% confidence interval [CI], 9.0%–13.6%). It was lower in Togo than in Côte d’Ivoire (2.7% vs 17.3%; adjusted odds ratio [aOR], 0.12; 95% CI, 0.02–0.28) and higher in participants with 6+ recent male sexual partners (21.0% vs 9.3%; aOR, 1.48; 95% CI, 1.12–1.97). Of 528 participants eligible for vaccination, 484 (91.7%) were willing to be vaccinated and received at least 1 dose (ranging from 68.2% in Abidjan to 96.4% in Bamako; P < .001). Of the latter, 390 (80.6%) re-ceived 3 or 4 doses. The proportion of participants for whom the minimum required time between each dose was respected ranged from 10.9% in Bamako to 88.6% in Lomé (P < .001).Conclusions.MSM in West Africa should be targeted more for HBV screening and vaccination. Although vaccination is well accepted by MSM, greater training of health care workers and education of MSM are required

The Perceived Added Value of Bimonthly Injectable Pre-Exposure Prophylaxis According to West African Men Who Have Sex with Men: A Focus Group Study

Bimonthly long-acting injectable pre-exposure prophylaxis (LAI-PrEP) can become an important additional tool for HIV prevention among West African men who have sex with men (MSM). The objective was to explore the perceived added value of LAI-PrEP as an HIV prevention tool among MSM in Burkina Faso, Côte d'Ivoire, Mali, and Togo. We conducted eight focus group discussions among 62 HIV-negative MSM between April and May 2021. Participants were recruited via local community-based clinics. Data collection and analysis were guided by grounded theory and community-based participatory approaches. Participants were generally knowledgeable about HIV, and explained particular barriers for HIV prevention in their communities (e.g., denial of HIV). The added value of LAI-PrEP relative to condoms was similar to oral pre-exposure prophylaxis (PrEP) in terms of perceived advantages (e.g., improved sexual satisfaction) or disadvantages (e.g., no protection against other sexually transmitted infections). Compared with oral PrEP, LAI-PrEP was perceived to provide better protection against HIV and to be more convenient (e.g., no need to be mindful of intake and less risk for stigma). Concerns included fear of needles, doubts about efficacy, potential side effects, and difficulties for ensuring timely injections (e.g., when traveling abroad). The results demonstrate that injectable PrEP can be of particular interest to subgroups of West African MSM, although existing HIV prevention tools such as condoms and oral PrEP will remain valuable alongside of, or instead of, LAI-PrEP. Increasing awareness about HIV and tackling discrimination based on sexual orientation continue to be crucial factors to be addressed for HIV prevention

Loss to Follow-Up from HIV Pre-Exposure Prophylaxis Care in Men Who Have Sex with Men in West Africa

International audienceLoss to follow-up (LTFU) from HIV pre-exposure prophylaxis (PrEP) care compromises the goal of HIV elimination. We investigated the proportion of LTFU and associated risk factors among men who have sex with men (MSM) enrolled in a PrEP demonstration project in Burkina Faso, Côte d’Ivoire, Mali, and Togo. CohMSM-PrEP, a prospective cohort study, was conducted between November 2017 and June 2021 in community-based clinics. MSM aged 18 years or older at substantial risk of HIV infection received a comprehensive prevention package, including PrEP and peer education. LTFU was defined as not returning to the clinic for six months. Associated risk factors were investigated using a time-varying Cox’s model. Of 647 participants followed up for a median time of 15 months, 372 were LTFU (57.5%). LTFU was associated with younger age (adjusted hazard ratio [95% Confidence Interval]; 1.50 [1.17–1.94]), unemployment (1.33 [1.03–1.71]), depression (1.63 [1.12–2.38]), and perceiving no HIV risk with stable male partners (1.61 [1.23–2.10]). Contacting peer educators outside of scheduled visits was protective (0.74 [0.56–0.97]). Our findings show that LTFU from PrEP care in West African MSM is a major challenge to achieving HIV elimination, but that the involvement of peer educators in PrEP delivery helps to limit LTFU by providing users with adequate support

Rate and Predictors of Ineffective HIV Protection in African Men Who Have Sex with Men Taking Pre-Exposure Prophylaxis

International audienceWe investigated the rate and predictors of ineffective HIV protection in men who have sex with men (MSM) taking pre-exposure prophylaxis (PrEP) in a prospective cohort study from November 2017 to November 2020 in Mali, Côte d'Ivoire, Burkina Faso, and Togo. MSM had to be 18 years or older and at high risk of HIV infection to participate. They also received a comprehensive sexual health prevention package, including PrEP, in community-based clinics as part of the cohort study. Using socio-behavioral/clinical data, HIV protection during their most recent anal intercourse with a male partner was categorized as effective or ineffective (i.e., incorrect PrEP adherence and no condom use). Seventeen percent (500/2839) of intercourses were ineffectively protected for the 520 study participants. Predictors of ineffective HIV protection included being an event-driven user with financial difficulties, having a high alcohol misuse score, and not being a member of a community association. PrEP programs in West Africa must be tailored to socially vulnerable MSM who struggle to adopt PrEP