Background

A disproportionate number of new HIV infections in South Africa are among female sex workers; pre-exposure prophylaxis (PrEP) for HIV prevention is freely available to female sex workers in the country, but unique barriers challenge PrEP persistence. TB HIV Care, a large South African non-profit organisation that provides daily oral PrEP (tenofovir disoproxil fumarate and emtricitabine), has implemented multiple strategies to improve PrEP persistence. We aimed to evaluate the effect of different implementation strategies on PrEP persistence in a large-scale real-world setting.

Methods

In this interrupted time series study, we estimated level changes in 1-month oral PrEP persistence associated with roll-out of various implementation strategies among female sex workers across nine districts in South Africa. We used routinely collected data from TB HIV Care programme files from June 7, 2016, to April 30, 2021. Poisson regression of 1-month persistence was used to assess the effect of these strategies. In secondary analyses, we tested the association between each of the strategies and 4-month persistence.

Findings

The median 1-month PrEP persistence for female sex workers was 33% (IQR 27–40). SMS support and refill reminders were associated with an 11% relative increase in 1-month persistence (risk ratio [RR] 1·11, 95% CI 1·02–1·26) and clinical mentoring for PrEP providers was associated with a 127% relative increase (RR 2·27, 95% CI 1·94–2·66) among female sex workers. The loyalty rewards programme was negatively associated with 1-month persistence (RR 0·71, 95% CI 0·67–0·83). Although clinical mentoring improved 4-month persistence, SMS support text messages had no significant effect.

Interpretation

Identification and subsequent use of clinical mentoring for PrEP providers and SMS support and refill reminders might improve the usefulness of PrEP overall to prevent new HIV infections among female sex workers. PrEP persistence remains an important issue, and strategies to build on our findings are needed.

Funding

National Institute of Mental Health and National Institute of Allergy and Infectious Diseases.

中文翻译：

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实施策略对南非女性性工作者暴露前预防持续性的影响：一项间断时间序列研究

背景

南非新增艾滋病毒感染者中女性性工作者的比例过高；该国的女性性工作者可以免费获得用于预防艾滋病毒的暴露前预防（PrEP），但独特的障碍挑战了 PrEP 的持久性。TB HIV Care 是一家提供每日口服 PrEP（富马酸替诺福韦二吡呋酯和恩曲他滨）的南非大型非营利组织，该组织已实施多种策略来提高 PrEP 的持久性。我们的目的是在大规模的现实环境中评估不同实施策略对 PrEP 持久性的影响。

方法

在这项间断时间序列研究中，我们估计了南非九个地区女性性工作者中与推出各种实施策略相关的 1 个月口服 PrEP 持续性水平变化。我们使用从 2016 年 6 月 7 日至 2021 年 4 月 30 日从结核病艾滋病毒护理计划文件中常规收集的数据。使用 1 个月持续性的泊松回归来评估这些策略的效果。在二次分析中，我们测试了每种策略与 4 个月坚持性之间的关联。

发现

女性性工作者 1 个月 PrEP 持续率中位数为 33% (IQR 27-40)。短信支持和补充提醒与 1 个月持续性相对增加 11% 相关（风险比 [RR] 1·11，95% CI 1·02–1·26），PrEP 提供者的临床指导与 127女性性工作者的相对增加百分比（RR 2·27，95% CI 1·94–2·66）。忠诚度奖励计划与 1 个月的坚持呈负相关（RR 0·71，95% CI 0·67–0·83）。尽管临床指导提高了 4 个月的持久性，但短信支持短信没有显着效果。

解释

对 PrEP 提供者进行临床指导以及短信支持和补充提醒的识别和后续使用可能会提高 PrEP 的整体有效性，以预防女性性工作者中新的艾滋病毒感染。PrEP 的持久性仍然是一个重要问题，需要根据我们的发现制定策略。

资金

国家心理健康研究所和国家过敏和传染病研究所。