PrEP Trials Offer Insight for Reaching at-Risk Women

Reaching individuals at high risk of acquiring HIV infection continues to pose a challenge to uptake of HIV pre-exposure prophylaxis (PrEP). A new study looked at PrEP clinical trials in sub-Saharan Africa, examining recruitment strategies to reach women at high risk of contracting HIV.

The study was led by the OPTIONS Consortium and published in PLOS One. The work included involvement from FHI 360, the Wits Reproductive Health and HIV Institute, and AVAC, in completing a retrospective review of 7 clinical trials for antiretroviral-based topical microbicides, oral tablets, and vaginal rings. The review included telephone interviews with staff involved in clinical trials in 5 countries.

“They recommended engaging the local community and potential PrEP users via community events, meetings with gatekeepers, and use of community advisory boards; and they encouraged interpersonal communication like presentations in waiting rooms and door-to-door recruitment to address personal concerns and prevent misinformation,” the investigators reported. “Participants also stressed the importance of addressing the challenges that already exist within the health system to create a more enabling environment and delivering positive messages through a variety of communication channels to normalize PrEP.”

Women in sub-Saharan Africa account for 56% of new HIV infections worldwide, but their access to traditional prevention options is often frustrated by obstacles, including power dynamics in relationships, the study noted. But women can access PrEP without partner consent or knowledge, making it a promising alternative.

The 4 primary strategies for recruiting women to the clinical trials were community engagement, information dissemination, targeted recruitment, and clinician referrals. Promoting acceptance and minimizing stigma through community engagement efforts is an important step in advancing PrEP use, the study noted.

Increasing understanding of PrEP in the overall community through information disseminations efforts such as community events, posting flyers, and use of media was recommended to destigmatize the treatment.

“This study suggests information dissemination approaches should be utilized to reach everyone, not just potential PrEP users, and help normalize this new prevention option,” investigators wrote in the study.

To reach women with a high risk of acquiring HIV infection, the study recommended targeted recruitment efforts tailored to specific areas, including door-to-door and at shopping malls. Providing PrEP as part of integrated services offered at HIV testing centers, family planning clinics, and clinics providing sexually transmitted infection services was also recommended. The study also advised that messages should be positive, focusing on empowerment and protection, avoiding fear-based themes and labeling people as “high risk” or noticeably targeting high-risk groups such as sex workers.

“Materials and messages should be pre-tested locally to ensure they resonate with the target audience,” the study said, adding that peer educators and outreach workers should be available to answer questions 1-son-1.

The study is qualitative and descriptive and lacks data to compare the effectiveness of strategies discussed. It was also limited to clinical trials, which differ from general PrEP rollout initiatives with more financial and technical resources.

“Despite these limitations, this investigation makes an important contribution by including trials testing a range of PrEP products across several countries, and findings were consistent across countries and in multiple settings,” the study noted. “We held validation webinars to discuss the findings with both research staff and people involved in programmatic rollout of PrEP, and we used those insights to translate findings into recommendations for real world PrEP delivery. As such, we believe lessons learned from this work are important to inform future implementation of PrEP.”

The study echoes the results of other research that highlights the importance of spreading awareness and reducing stigma to increase PrEP uptakes. One such study involving women in Atlanta recommended that family planning providers spread awareness via brochures, posters, emails, and direct conversations with patients.

Another study that examined barriers and facilitators to PrEP treatment among young men and transgender women of color, found that barriers include stigma, health system inaccessibility, side effects, competing stressors, and low-risk perception. Facilitators included social support, health systems accessibility, reminders/routines, high-risk perceptions, and personal agency.