Youth‐friendly services and a mobile phone application to promote adherence to pre‐exposure prophylaxis among adolescent men who have sex with men and transgender women at‐risk for HIV in Thailand: a randomized control trial

Abstract

Introduction Strategies are needed to curb the increasing HIV incidence in young men who have sex with men (YMSM) and transgender women (YTGW) worldwide. We assessed the impact of youth‐friendly services (YFS) and a mobile phone application (app) on adherence to pre‐exposure prophylaxis (PrEP) in YMSM and YTGW in Thailand. Methods A randomized control trial was conducted in YMSM and YTGW aged 15 to 19 years. Participants were provided daily oral tenofovir disoproxil fumerate/emtricitabine (TDF/FTC), condoms and randomized to receive either YFS or YFS plus a PrEP app (YFS + APP), whose features included self‐assessment of HIV acquisition risk, point rewards and reminders for PrEP and clinic appointments. Clinic visits occurred at zero, one, three and six months and telephone contact at two, four and five months. HIV testing was performed at every clinic visit. PrEP adherence was evaluated with intracellular tenofovir diphosphate (TFV‐DP) concentrations in dried blood spot (DBS) samples at months 3 and 6. The primary endpoint assessed was “PrEP adherence” defined as TFV‐DP DBS concentrations ≥700 fmol/punch (equivalent to ≥4 doses of TDF/week). Results Between March 2018 and June 2019, 489 adolescents were screened at three centres in Bangkok. Twenty‐seven (6%) adolescents tested positive for HIV and 200 (41%) adolescents participated in the study. Of these, 147 were YMSM (74%) and 53 YTGW (26%). At baseline, median age was 18 years (IQR 17 to 19), 66% reported inconsistent condom use in the past month. Sexually transmitted infection prevalence was 23%. Retention at six months was 73%. In the YFS + APP arm, median app use duration was three months (IQR 1 to 5). PrEP adherence at month 3 was 51% in YFS and 54% in YFS + APP (p‐value 0.64) and at month 6 was 44% in YFS and 49% in YFS + APP (p‐value 0.54). No HIV seroconversions occurred during 75 person years of follow‐up. Conclusions Youth‐friendly PrEP services enabled good adherence among half of adolescent PrEP users. However, the mobile phone application tested did not provide additional PrEP adherence benefit in this randomized trial. Adolescent risk behaviours are dynamic and require adaptive programmes that focus on “prevention‐effective adherence.”

Novel Platforms for Biomedical HIV Prevention Delivery to Key Populations — Community Mobile Clinics, Peer-Supported, Pharmacy-Led PrEP Delivery, and the Use of Telemedicine

“…Some mhealth platforms have applied a PrEP Information-Motivation-Behavior-skills (IBM) model tailored to key populations to promote PrEP adherence or reduction in risk behaviors [ 57 – 59 ]. mHealth applications use videos, games, animation, or chatbots to deliver personalized care to users in the form of self-risk evaluation, pill-taking reminders, addressing peer and social norms, considering disclosure, or scheduling follow-up health appointments [ 60 ]. Telehealth aims to reach individuals at high risk of HIV acquisition and promote PrEP uptake by connecting persons directly to providers and connecting providers to other providers or specialists for clinical training or support.…”

Sexually transmitted infections incidence in young Thai men who have sex with men and transgender women using HIV pre-exposure prophylaxis

“…From March 2018 to June 2019, 200 adolescents (147 MSM, 53 TGW) with a median (IQR) age of 18 17,19 were enrolled. Median (IQR) age at first sexual intercourse was 16 15,17 years. Half of the population studied had been sexually active for less than a year.…”

“…From March 2018 to June 2019, 200 young men who have sex with men (YMSM) and young transgender women (YTGW) received oral daily PrEP at three clinics; King Chulalongkorn Memorial Hospital (KCMH) ( n = 135) and two community-based organizations (CBOs) ( n = 65); Rainbow Sky Association Thailand (RSAT) Bangkok and Sex Workers in Action Group (SWING) Bangkok. 15 Patients were eligible if they were HIV-negative, aged 15–19 years old and were at risk of HIV acquisition due to at least one of: inconsistent condom use during sexual intercourse, having more than one sexual partner in the last 6 months, or having an HIV-positive sexual partner. Participants completed monthly self-reported questionnaires on past-month condom use, and past-month sexual history, self-administered either in-person at months 0, 1, 3, and 6 or online at months 2, 4, and 5, and at baseline and month 6 received routine screening for STIs including blood testing for syphilis serology as well as nucleic acid amplification testing (NAAT) for NG and CT on urine samples and anal swabs.…”

Condomless Anal Sex Associated With Heterogeneous Profiles Of HIV Pre-Exposure Prophylaxis Use and Sexual Activities Among Men Who Have Sex With Men: A Latent Class Analysis Using Sex Diary Data on a Mobile App

“…Some studies asked participants whether they used condoms during the last anal sex event to reduce the recall bias [16][17][18], but a one-time sex event neither reflects the long-term decision-making of condom use nor assesses the longitudinal change of PrEP adherence. Although self-reporting bias is still inevitable, using a website survey or mobile apps to measure condom and PrEP use can be more immediate than traditional surveys [19][20][21][22]. Additionally, PrEP adherence could be measured by drug concentrations in hair or dried blood spots and Wisepill bottle openings [23].…”

“…There has been no perfect measurement for condom and PrEP use until now, but a mobile app that allows users to log their PrEP use and sex diary at any time or place may be more suitable for monitoring HIV risk in MSM. Sex diaries have been used to track sexual encounters, reduce risky sexual behavior [19][20][21], and facilitate PrEP uptake [19]. Therefore, a sex diary on a mobile app that gathers the information of each sex event, such as condom use and partner's HIV status, is important for researchers to examine condom use with different sexual partners and track whether or not PrEP is taken correctly.…”