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

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

Loss 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

PrEP and HIV prevention engagement of men who have sex with men receiving a comprehensive sexual health package in community-based clinics in West Africa

L’accès à la prophylaxie préexposition (PrEP) au VIH pour les hommes qui ont des relations sexuelles avec d’autres hommes (HSH) est une priorité stratégique de santé publique, mais l’accès reste difficile pour les HSH en Afrique de l’Ouest. Ce travail de thèse s’appuie sur les données recueillies dans le cadre d’une cohorte prospective (CohMSM-PrEP) offrant une prise en charge globale incluant la PrEP à des HSH séronégatifs dans des cliniques communautaires en Afrique de l'Ouest (Mali, Côte d’Ivoire, Burkina Faso et Togo). Au moment du démarrage de la cohorte, un profil d’utilisateur diffèrent a été découvert basé sur le type de recrutement. Ces derniers avaient un profil plus vulnérable et ont été plus en marge des services VIH et la communauté HSH. En termes d'utilisation de la prévention tout au long du suivi, les taux d'utilisation et d'observance correcte de la PrEP étaient élevés (70% et 73% respectivement), tandis que le taux de protection VIH inefficace était non négligeable (17%). De plus, les utilisateurs de la PrEP à la demande avaient plus d’observance incorrecte par rapport aux utilisateurs de la PrEP continue (33% vs 11%, respectivement). En fin, les taux de perdus de vue étaient élevés (57,5%). Les facteurs associés à nos divers résultats se regroupent en trois catégories différentes : les comportements reflétant la perception du risque de VIH, les obstacles liés à la vulnérabilité des participants et enfin les facilitateurs liés aux aspects communautaires de la cohorte. Les résultats de cette thèse suggèrent que les offres de santé sexuelle adressées aux HSH doivent être multidimensionnelles et tenir compte des différents profils au sein du groupe des HSH.Access to HIV pre-exposure prophylaxis (PrEP) for men who have sex with men (MSM) is a strategic public health priority, but access remains difficult for MSM in West Africa. This thesis is based on data collected as part of a prospective cohort (CohMSM-PrEP) offering a comprehensive sexual health prevention package including PrEP to HIV-negative MSM in community-based clinics in West Africa (Mali, Côte d’Ivoire, Burkina Faso and Togo). At the start of the cohort, a different user profile was discovered based on participants’ recruitment type. The latter had a more vulnerable profile and were more marginalized from HIV services and the MSM community. In terms of prevention use throughout follow-up, the rates of correct PrEP use and adherence were high (70% and 73%, respectively), while the rate of ineffective HIV protection was non-negligible (17%). Additionally, event-driven PrEP users had more incorrect adherence than daily users (33% vs 11%, respectively) and struggled with adherence. Finally, loss to follow-up rates were high (57.5%). Correlates of our various outcomes tended to be grouped into three different categories: behaviors reflecting HIV risk perception, barriers related to participants' socioeconomic and psychosocial vulnerability, and finally facilitators related to community aspects of the cohort. The results of this thesis suggest that sexual health services addressed to MSM must be multidimensional and take into account different profiles within the MSM community

Factors associated with sexual risk taking behavior by precarious urban migrants in French Guiana

International audienceBackground: French Guiana is highly affected by HIV. The migrant population is particularly susceptible. The objective of this study was to evaluate the level of risk of HIV transmission and its perception among migrants in French Guiana and to identify predictive factors. Methods: An HIV/AIDS Knowledge, Attitudes, Behaviors and Practices study was conducted in 2012 among migrants living in precarious neighborhoods of French Guiana. Results: Of the 1039 participants surveyed, 893 were analyzed, of which 35.6% had risky sex during the past 12 months. Sexual risk taking was higher among the migrant population than in the general population. The predictors of sexual risk taking behavior were: younger age groups, males, having a job, not living with a spouse, having first had sex before age 16, using alcohol or drugs before sex, and having engaged in commercial sex recently. The factors associated with not being aware of one's risk were: being a woman, being from Guyana or Suriname, non-systematic use of condoms with a regular partner, and never or not recently having been tested for HIV. Conclusions: The results suggest there is still a need for information on HIV risks in a highly vulnerable population

What can lead to late diagnosis of HIV in an illegal gold mining environment? A qualitative study at the French Guiana’s border with Brazil

International audienceObjective The present study aimed to understand what factors can lead to late HIV diagnosis of illegal gold miners at French Guiana's border with Brazil. Design An exploratory qualitative study with in-depth interviews and observations was conducted between November 2019 and February 2020. Setting The study was conducted in the main medical healthcare service and two non-governmental organisation premises in the Oyapock border region, which is a supply area for illegal gold mining sites. Participants Fifteen people living with HIV diagnosed with CD4 count <350 cells 10 6 /L were interviewed. Seven women and eight men participated; they were between 31 and 79 years old, and the median time since HIV diagnosis was 6 years. Eight had links to illegal gold mining. Findings Three key themes for late HIV diagnosis emerged: (1) the presence of economic and political structural factors which constitute risks for this illegal activity, specifically the repression of gold mining sites by French Armed Forces and the distance from healthcare facilities; (2) representations of the body and health, related to the living conditions of this population; prioritisation of health emergencies and long-term selfmedication; and (3) gender roles shaping masculinity and heterosexuality contributing to a perception of not being at risk of HIV and delaying testing. Conclusion This study highlights structural, group-based and individual factors that reduce access to HIV testing and healthcare in general for a population of migrant workers in an illegal gold mining area. Faced with harsh living conditions and state repression, these workers develop a vision of health which prioritises the functionality of the body. Associated with gender roles which are partly shaped both by the mining activity and its geographical location, this vision can lead to late HIV diagnosis

Additional file 1: of Factors associated with sexual risk taking behavior by precarious urban migrants in French Guiana

Table S1. Breakdown of risky behavior, comparison between the general population in French Guiana and the migrant population in French Guiana (DOCX 15 kb

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

Socio-behavioral correlates of pre-exposure prophylaxis use and correct adherence in men who have sex with men in West Africa

International audienceBackground: Multiple barriers compromise pre-exposure prophylaxis (PrEP) engagement (i.e., use and adherence) in men who have sex with men (MSM). In low/middle-income countries, little is known about PrEP engagement in this population. In West Africa, the CohMSM-PrEP study was one of the rare interventions providing PrEP to MSM. We estimated PrEP use and correct adherence rates in CohMSM-PrEP, together with associated factors over time. METHODS: CohMSM-PrEP recruited MSM in four community-based clinics in Mali, Côte d'Ivoire, Burkina Faso, and Togo. Quarterly follow-up included collecting socio-behavioral data, and providing a comprehensive HIV prevention package, PrEP (daily or event-driven), and peer educator (PE)-led counselling. Using repeated measures, multivariate generalized estimating equations models were used to identify factors associated with self-reported i) PrEP use and ii) correct PrEP adherence during participants' most recent anal intercourse (defined as four pills/week for daily users and 2 + 1 + 1 for event-driven users).Results: Five hundred twenty participants were included with a median follow-up time of 12 months (IQR 6-21). Of the 2839 intercourses declared over the follow-up period, PrEP use was self-reported for 1996 (70%), and correct PrEP adherence for 1461 (73%) of the latter. PrEP use was higher in participants who also attended participating clinics outside of scheduled visits (adjusted odds ratio (aOR) [95% Confidence Interval, CI], p-value; 1.32[1.01-1.71], 0.040), and in those who practiced condomless anal sex (1.86[1.54-2.24], < 0.001). Correct adherence was higher in those who often contacted PE outside of scheduled visits (2.16[1.01-4.64], 0.047) and in participants who adopted receptive/versatile sexual positions with stable partners (1.36[1.03-1.81], 0.030). Instead, after an interaction effect between financial situation and regimen was tested, it was lower in event-driven users with a difficult/very difficult financial situation (comfortable/just making ends meet & daily, 4.19[2.56-6.86], < 0.001; difficult/very difficult & daily, 6.47[4.05-10.30], < 0.001; comfortable/just making ends meet & event-driven, 1.63[1.22-2.17], 0.001), and in participants who felt alone (0.76[0.58-0.99], 0.042).Conclusions: Community-based clinic attendance and PE contact outside of scheduled visits were both associated with higher PrEP engagement, but some socially and economically marginalized participants struggled with adherence. As scale-up continues in West Africa, we recommend implementing community-based interventions and providing extra support for vulnerable users to ensure adequate PrEP engagement