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It is feasible to offer pre-exposure prophylaxis (PrEP) as part of community-wide HIV testing campaigns in East Africa, with a fifth of adults who were identified as eligible for PrEP starting it within 30 days, researchers from the SEARCH collaboration report in Clinical Infectious Diseases. Early adopters were more likely to be male, older, in a serodiscordant relationship or in a polygamous marriage.

The authors suggest that understanding the characteristics of early adopters is important – they may be opinion leaders and PrEP champions who could promote further uptake in their communities.

At the same time, identifying people less likely to start PrEP is critical to developing programmes to support them. The researchers found that fewer than a third of community members identified as being at higher risk of acquiring HIV made the same assessment of their risk. Just one in ten of this group took up the offer of PrEP within 30 days.

Until now, there have been very little data from African countries on the uptake of PrEP outside of clinical trials. Moreover, studies have tended to concentrate on targeted populations, such as serodiscordant couples or sex workers.

SEARCH is a large study of a test-and-treat approach in Kenya and Uganda. In rural communities, health campaigns offer testing for HIV, diabetes and hypertension, with linkage to care and antiretroviral therapy for anyone who needs it.

Based on data on new HIV infections in the first two years of SEARCH, the researchers developed a risk score that can identify at least half of people in these communities who will go on to acquire HIV. It is based on demographic data that are easy to collect, with no need to ask questions about sexual behaviour or to test for sexually transmitted infections. The risk score includes age, sex, marital status, polygamy, education, circumcision, occupation, and alcohol use.

In 2016, a PrEP intervention was added in five of the communities taking part in SEARCH. One month of community mobilisation activities on PrEP – including meetings with health workers, religious leaders, young people and workers in the fishing and transport sectors – preceded the testing campaign. Counsellors gave information about PrEP and engaged participants in discussions about their risk of acquiring HIV, as part of the HIV testing process.

For individuals who were assessed as being at higher risk by the risk score, counsellors explained, “From what we have learned from your community, and what you shared at the beginning of the campaign, we think that you would benefit from taking PrEP.” In addition, any individual who decided for themselves that they might benefit from PrEP was offered it, in line with World Health Organization guidance, which recommends offering PrEP to those who request it in the context of a generalised epidemic.

Most people were tested as part of the health campaign at community sites. Individuals who did not come forward for testing were then approached at home, with a further opportunity for testing there. In four of the five communities, a same-day PrEP start was possible at the community testing site (but not at home). Transport was also offered to PrEP clinics, usually on the same day.

Of over 21,000 people tested in the five communities, 2991 were identified as being eligible for PrEP, based on their risk score.

The majority were male (54%), young (56% aged 18–25 years) and uncircumcised (65% of men). Half were married and 14% had migrated outside the community in the past year. One-quarter (26%) were employed in high-risk informal sector occupations, such as fishing, bar work, transportation, or tourism.

Of these 2991 individuals, only 321 (11%) started PrEP within 30 days. Three-quarters of those who did so started on the same day and most others started within a week.

A further 1073 people self-identified as wanting PrEP. They tended to be older (only 25% aged 18-25 years) and three-quarters were married. Most worked in the informal sector, but were less likely than the previous group to work in occupations considered 'high risk'.

A greater proportion of those who requested PrEP themselves (39%) started it within 30 days. Again, three-quarters started on the same day.

Before HIV testing and counselling (which included the discussion about PrEP), participants had been asked whether they thought they were currently at risk of HIV. At this time, only 30% of those assessed by the risk score and 49% of those who subsequently requested PrEP perceived themselves to be at risk.

Among people assessed as being at higher risk by the risk score, early adopters (people who started PrEP within 30 days) were more likely to be male (adjusted odds ratio 1.5), in a polygamous marriage (1.9), have an HIV-positive spouse (3.9), perceive themselves at risk of HIV (1.7) and to have tested at a community site rather than at home (5.2). The last finding may be explained by there being more PrEP education at the community sites, as well as the option to start PrEP on site.

People with a secondary school education or greater were less likely to be early adopters (0.5).

Among people who self-identified for PrEP, early adopters were more likely to be over the age of 46 (2.3) and have an HIV-positive spouse (2.6). People with a primary school education or greater were less likely to be early adopters than people with no formal education (0.5).

These results, from multivariate models, were all statistically significant.

The researchers suggest that efforts to encourage PrEP uptake should be especially focused on younger people and on women. They note that their qualitative research suggests that many women recognise their HIV risk but feel the need to seek consent from their male partners before starting PrEP.

“Our findings demonstrate the feasibility of evaluation for PrEP and rapid initiation in community-based settings and highlight the need for ongoing sensitization and education about PrEP, as well as strategies to facilitate discussions of self-assessment of risk and uptake among those at risk,” they say.

Koss CA et al. Early Adopters of HIV Preexposure Prophylaxis in a Population-based Combination Prevention Study in Rural Kenya and Uganda. Clinical Infectious Diseases, online ahead of print, May 2018.