Background:
Post-exposure prophylaxis (PEP) remains underutilized in sub-Saharan Africa. PEP could respond to user preferences for on-demand biomedical prevention, including for vaginal exposures, and could serve as a gateway to PrEP; data are limited on this strategy.
Methods:
We assessed PEP uptake in 3 randomized trials of Dynamic Choice HIV Prevention (DCP) among persons >15 years with current or anticipated HIV risk recruited from Outpatient Departments (OPD), Antenatal Clinics (ANC), and community settings in rural western Kenya and Uganda (SEARCH; NCT04810650). The DCP intervention included structured participant choice of: 1) PrEP or PEP, with option to change over time; 2) service location; 3) HIV self-testing (HIVST) option, together with 24/7 phone access to clinician. Providers were trained on client-centered care, emphasizing support for flexible product choice (PrEP or PEP). In the DCP arm, PEP pill-in-pocket was offered (5 pills with HIVST) for rapid PEP start; participants notified the provider for HIV testing and refill of the remaining PEP supply. In this pre-specified secondary analysis, we conducted a by-arm comparison of self-reported PEP use and describe use patterns across these settings.
Results:
From April-July 2021, 1,233 participants (612 DCP; 621 standard of care [SoC]) enrolled (ANC 400, OPD 403, Community 430): 72% were women, 41% aged 15-24 years. Over 18 months of follow-up, 129 courses of PEP were dispensed. In DCP arm: 101 PEP courses among 50 participants; 28 participants used multiple PEP courses; 10 transitioned to PrEP the month after PEP start. In SoC: 28 PEP courses among 20 participants; 8 participants used multiple PEP courses; 2 participants transitioned to PrEP the month after PEP start. Biomedical covered time (% of follow-up using PrEP or PEP) was 51% (4422/8712) in DCP vs. 16% (1424/8994) in SoC; PEP accounted for ~2% of covered time in both arms (101/4422 vs. 28/1424). Overall, DCP significantly increased PEP covered time (% of follow-up time when using PEP): 1.1%(DCP) vs. 0.3%(SoC); difference of 0.8% (95%CI: 0.1-1.15%) p=0.03. Among DCP participants, PEP covered time was highest in the community (2.2%), men (1.8%) and youth (1.1%). There were no discontinuations for drug toxicity or seroconversions among those who used PEP.
Conclusions:
Across 3 settings in rural Africa, PEP was feasible to deliver, a desired choice for some individuals, and a gateway to PrEP. Event-driven interventions such as PEP should be included in prevention choice approaches.