HIV / STI
An enhanced PrEP/STI implementation strategy improves HIV oral pre-exposure prophylaxis persistence at an STI clinic in urban Malawi Grace E. Mulholland* Grace Mulholland Mitch Matoga Jane S. Chen Esther Mathiya Griffin J. Bell Beatrice Ndalama Tapiwa Munthali Naomi Nyirenda Naomi Bonongwe Claire Pedersen Edward Jere Mina C. Hosseinipour Zakaliah Mphande Irving F. Hoffman Sarah E. Rutstein
HIV remains a serious global health threat. Efforts to reduce incidence include scale-up of pre-exposure prophylaxis (PrEP), but effectiveness of PrEP hinges on coverage during periods of HIV risk. Persistent PrEP use is critical for those at elevated risk of HIV, including people with sexually transmitted infections (STIs).
The enhanced PrEP STI study (“ePrEP”) explored a strategy to improve PrEP use, recruiting clients seeking STI care at an STI clinic in Lilongwe, Malawi. ePrEP provided assisted partner notification services and etiologic STI testing to participants who newly initiated PrEP in March-December 2022 (n=173). Participants were compensated for periodic study visits, even if they discontinued PrEP. Other clients who sought STI care and initiated PrEP in the same period (n=300) received only Malawi’s standard PrEP care. We examined the effect of ePrEP participation on PrEP persistence, defined as continued engagement in PrEP services without missing ≥7 doses. We used routine PrEP records data to code persistence using visit dates, pill counts, and client-reported missed doses. Because ePrEP recruitment was not random, we used inverse probability weights to balance baseline differences in age, sex, and PrEP indication between ePrEP participants and other clients.
37% of clients were female. At PrEP initiation, median age was 27 (IQR: 23, 33), 22% had a partner with an unsuppressed HIV viral load, and 47% had bought or sold sex. Among ePrEP participants, 40% named ≥1 partner for assisted notification, and STI incidence during follow-up was 61.3 per 100 person-years. We estimated that, had all clients participated in ePrEP, 32% (95% CI: 25%, 40%) would have persisted on PrEP at 6 months, compared to 3% (95% CI: 1%, 5%) had all clients received only standard PrEP care.
ePrEP participation was strongly associated with higher PrEP persistence. Our findings suggest that ePrEP may be a promising strategy to improve PrEP persistence among people seeking STI care.