Helping our patients take HIV pre‐exposure prophylaxis (PrEP): a systematic review of adherence interventions

Abstract

Objectives Adherence is critical for maximizing the effectiveness of preexposure prophylaxis (PrEP) in preventing HIV infection. Strategies for promoting adherence to HIV treatment, and their potential application to PrEP adherence, have received considerable attention. However, adherence promotion strategies for prevention medications have not been well characterized and may be more applicable to PrEP. We aimed to identify adherence support interventions that have been effective in other prevention fields and could be applied in the HIV prevention context to support pill taking among PrEP users. Methods To identify adherence support interventions that could be evaluated and applied in the PrEP context, we conducted a systematic review across the following prevention fields: hypertension, latent tuberculosis infection, hyperlipidemia, oral contraceptives, osteoporosis, malaria prophylaxis, and post-exposure prophylaxis for HIV infection. We included randomized controlled trials that evaluated the efficacy of interventions to improve adherence to daily oral medications prescribed for primary prevention in healthy individuals or for secondary prevention in asymptomatic individuals. Results Our searches identified 585 studies, of which 48 studies met the eligibility criteria and were included in the review; nine evaluated multiple strategies, yielding 64 separately tested interventions. Interventions with the strongest evidence for improving adherence included complex, resource-intensive interventions, which combined multiple adherence support approaches, and low-cost, low-intensity interventions that provided education or telephone calls for adherence support. Conclusions Our review identified adherence interventions with strong evidence of efficacy across prevention fields and provides recommendations for evaluating these interventions in upcoming PrEP studies.

Preexposure Prophylaxis (PrEP) for HIV Prevention: The Primary Care Perspective

“…7,23,38 An evaluation of interventions to promote adherence to PrEP recommended participant-centered approaches, including addressing the specific context in which an individual incorporates and negotiates PrEP use. 41 While complex, resource-intensive interventions are most effective for improving adherence to medical interventions in general, a systematic review also found evidence to support low-cost, low-intensity interventions that provided education or telephone calls.…”

“…41 While complex, resource-intensive interventions are most effective for improving adherence to medical interventions in general, a systematic review also found evidence to support low-cost, low-intensity interventions that provided education or telephone calls. 38 CDC guidelines recommend that clinicians incorporate motivational interviewing into their visits for prescribing PrEP with 4 simple items: (1) When you have taken medications previously? (2) How did you remember to take them?…”

“…38 STI screening Activities that increase risk for HIV also increase risk for other STIs, and screening for STI symptoms may be appropriate. 6 Pregnancy intent and contraception While PrEP is FDA approved for use during pregnancy and is potentially a valuable tool in preventing transmission during that time, the safety of PrEP for the developing fetus is not well studied; this should be discussed with any patient hoping to conceive.…”

Global implementation of PrEP as part of combination HIV prevention - Unsolved challenges

“…For example, a microscale case study has suggested that PrEP should be prioritised first for male sex workers, then for MSM and FSW, in Nairobi (Cremin et al Unpublished data). Stratification of the population by age may also be important, particularly for young women, who have been proposed as a priority group for PrEP implementation [60]. Differences in adherence between women aged 15 to 25 and those over 25 could, for example, raise the relative cost of reaching the younger group.…”

“…As increasing evidence of safety emerges, barriers to access will likely reduce (as happened with hormonal contraception) [59]. There are several new products in the pipeline [60] and services need to be positioned so that they can introduce these as and when they are approved.…”