Class Project: Journal-Submittable Team Scoping Reviews

Title

Changes in sexual risk behaviors, PrEP use, and PrEP access during the COVID-19 pandemic among populations at risk for HIV: a scoping review

Authorship

Broussard J, Turner CM

Abstract

Background: Prior to the COVID-19 pandemic, use of pre-exposure prophylaxis (PrEP) had begun to impact rates of new human immunodeficiency virus (HIV) infections in the United States, particularly in regions with high PrEP uptake. Although rates of PrEP were increasing, only a small percentage of individuals at risk for HIV due to substance use or sexual risk were using PrEP, with gender minority, Black, and Latinx populations having lowest use. The COVID-19 pandemic has impacted healthcare delivery and how individuals socialized, which could impact the rates and populations impacted by new HIV infections in the US. Objectives: Compile, review, and synthesize information on changes in sexual risk behaviors and PrEP use during the COVID-19 pandemic for populations at risk for HIV in the United States. Eligibility criteria: beginning of pandemic to present day; English language articles; U.S. populations at risk for HIV; qualitative or quantitative analyses; excludes call to actions. Sources of evidence: TBD. Charting methods: TBD; Search terms: PrEP HIV Pandemic. Results: TBD. Conclusions: TBD.

Introduction

In 2019, the United States Department of Health and Human Services (DHHS) announced the Ending the Epidemic in the U.S.(EHE) plan, which outlined goals including decreasing new HIV infections by 90 percent by 2030 (Fauci et al., 2019). There were an estimated 34,800 new HIV infections in that year, which was an 8 percent decrease since 2015 (DHHS, 2021). Significant disparities in new infections were observed over this period of time. Between 2015 and 2019, new diagnosis increased in adult and adolescent transgender populations. Forty-four percent of newly diagnosed individuals identified as Black in 2019, though 13% of the general population identify as Black. Rates of new infection in the Latinx population is disproportionately high at 30%, with 18% of the general population.

One of the key strategies in the EHE plan is prevention. The antiretroviral Truvada was approved by the U.S. Federal Drug Administration (FDA) in 2012 to be taken daily to prevent HIV acquisition (Centers for Disease Control and Prevention [CDC], 2012). Since then, the number of antiretrovirals approved to prevent HIV has expanded to include Descovy in 2019 and Apretude, a long-acting injectable option, in 2021 (FDA, 2019; FDA, 2021). Additionally, a number of health entities, including the World Health Organization and the International AIDS Society-USA, endorsed on-demand or event-based PrEP dosing (cite). Despite multiple options, PrEP uptake has been slow. Prior to the start of the COVID-19 pandemic, less than 20% of those at risk for HIV were taking PrEP(cite). In regions with high PrEP uptake, such as San Francisco, decreases in new infections were observed(cite).

At the start of 2020, COVID-19 swept the United States with swift, unprecedented impacts on HIV prevention care (the systems level) and sexual behaviors (the individual level). State and local shelter-in-place mandates imposed barriers to engagement in HIV prevention services and spurred changes in HIV-related sexual risk behaviors, especially for populations highest at risk for HIV (Brawley et al., 2020). Moreover, local health departments offering HIV and STI prevention services diverted staff to COVID-19 response efforts (Kelly, 2020) and many local health entities released shame-inducing, unscientific guidelines for sex during the pandemic (cite). At the same time, there was a rise in the availability of telehealth HIV prevention services; however, the impact of this mode of delivery on PrEP behaviors is unknown (Shoptaw et al., 2020; Ridgway et al., 2020; Brawley et al., 2020; Krakower et al., 2020).

In light of these system- and individual-level impacts, researchers started gathering evidence that the pandemic exposed and exacerbated already existing disparities in access to HIV prevention services. Decreases in PrEP use or lapses in PrEP prescription refills during the pandemic were documented in studies of men who have sex with men (MSM) in Australia (Chow et al., 2020) and PrEP-using patients of color at community health centers in Boston (Krakower et al., 2020). One in five young sexual minority men (YSMM) reported barriers to getting PrEP prescriptions during the pandemic and over 14% of YSMM discontinued PrEP, citing decreases in sexual activity as one factor (Hong et al., 2021).

Findings are inconsistent in the US South, with one study reporting decreases in the number of sexual partners and condomless sex in the early pandemic period and increases in these behaviors later on (Pampati et al., 2020). Another study showed increases in sexual partnering and condomless sex throughout the pandemic (Stephenson et al., 2020). One group of researchers compiled electronic health record data of PrEP, HIV, and STI visits at three Southern clinics experiencing disproportionate burdens of HIV. They found that while PrEP visits among cisgender men increased during the pandemic (with the majority of visits being telehealth), HIV and STI testing decreased (Hill et al., 2021).

Though a number of studies examining systems- and individual-level impacts of the pandemic on HIV prevention have been undertaken, rigorous reviews of study findings and gaps in knowledge have yet to be compiled. Pandemic-related changes in HIV prevention strategies are simultaneously an emerging topic and an age-old tale of gaps in HIV prevention services with potentially the greatest negative impact on those most at risk. At this stage in the research, it is also difficult to know how these systems- and individual-level changes during the pandemic will impact the course of new HIV infections among populations most at risk. On one hand, reductions in sexual partners during the pandemic could reduce new HIV infections; on the other hand, reductions in condom use, HIV testing, PrEP use and adherence would have an even larger-magnitude increase in new HIV infections and HIV-related deaths (Mitchell et al., 2021). Taken together, these observations highlight the need for a scoping review of pandemic-related changes in HIV prevention strategies.

The objective of this scoping review is to evaluate the extent to which the pandemic affected systemic (e.g., access to care, modes of care, clinic closures) and individual PrEP factors (e.g., perception of HIV risk, PrEP use, PrEP adherence and persistence, changes in sexual partnering, number of sexual partners, condom use) for populations at risk for HIV.


References:

Brawley S, Dinger J, Nguyen C, Anderson J. Impact of COVID-19-related shelter-in-place orders on PrEP access, usage and HIV risk behaviors in the United States. In: Paper presented at International AIDS Conference; July 6–10, 2020 (virtual meeting).

Centers for Disease Control and Prevention. (2012). CDC Statement on FDA Approval of Drug for HIV Prevention. Retrieved from https://www.cdc.gov/nchhstp/newsroom/2012/fda-approvesdrugstatement.html


Chow EPF, Hocking JS, Ong JJ, Schmidt T, Buchanan A, Rodriguez E, Maddaford K, Patel P, Fairley CK. Changing the use of HIV pre-exposure prophylaxis among men who have sex with men during the COVID-19 pandemic in Melbourne. Aust Open Forum Infect Dis. 2020;7(7):1–4. [PMC free article] [PubMed] [Google Scholar]

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Fauci AS, Redfield RR, Sigounas G, Weahkee MD, Giroir BP. Ending the HIV Epidemic: A Plan for the United States. JAMA. 2019;321(9):844–845. doi:10.1001/jama.2019.1343

Hill, B. J., Anderson, B., & Lock, L. (2021). COVID-19 pandemic, Pre-Exposure Prophylaxis (PrEP) Care, and HIV/STI testing among patients receiving care in three HIV epidemic priority states. AIDS and Behavior, 25(5), 1361-1365.

Hong, C., Horvath, K. J., Stephenson, R., Nelson, K. M., Petroll, A. E., Walsh, J. L., & John, S. A. (2021). PrEP use and persistence among young sexual minority men 17–24 years old during the COVID-19 pandemic. AIDS and Behavior, 1-8.

Kelly K. LHD HIV, STI, and hepatitis programs respond and adapt to COVID-19 (April 10, 2020). National Association of County and City Health Officials (NACCHO).

Krakower D, Solleveld P, Levine K, Mayer KH. Impact of COVID-19 on HIV pre-exposure prophylaxis care at a Boston community health center. In: Paper presented at International AIDS Conference; July 6–10, 2020 (virtual meeting).

Mitchell, K. M., Dimitrov, D., Silhol, R., Geidelberg, L., Moore, M., Liu, A., ... & Boily, M. C. (2021). The potential effect of COVID-19-related disruptions on HIV incidence and HIV-related mortality among men who have sex with men in the USA: a modelling study. The Lancet HIV, 8(4), e206-e215.

Pampati, S., Emrick, K., Siegler, A. J., & Jones, J. (2020). Changes in sexual behavior, PrEP adherence, and access to sexual health services due to the COVID-19 pandemic among a cohort of PrEP-using MSM in the South. medRxiv.

Ridgway JP, Schmitt J, Friedman E, Taylor M, Devlin S, McNulty M, Pitrak D. HIV care continuum and COVID-19 outcomes among people living with HIV during the COVID-19 pandemic, Chicago IL. AIDS Behav. 2020;24:2770–2772. doi: 10.1007/s10461-020-02905-2. [PMC free article] [PubMed] [CrossRef] [Google Scholar]

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Shoptaw S, Goodman-Meza D, Landovitz RJ. Collective call to action for HIV/AIDS community-based collaborative science in the era of COVID-19. AIDS Behav. 2020;24:2013–2016. doi: 10.1007/s10461-020-02860-y. [PMC free article] [PubMed] [CrossRef] [Google Scholar]

Stephenson R, Chavanduka TMD, Rosso MT, Sullivan SP, Pitter R, Hunter AS, Rogers E. Sex in the time of COVID-19: results from an online survey of gay, bisexual and other men who have sex with men’s experience of sex and HIV prevention during the US COVID-19 epidemic. AIDS Behav. 2020 doi: 10.1007/s10461-020-03024-8. [PMC free article] [PubMed] [CrossRef] [Google Scholar]

Stephenson, R., Walsh, A. R., Chavanduka, T. M., Sallabank, G., Horvath, K. J., Castel, A. D., ... & Sullivan, P. S. (2021). Widespread closure of HIV prevention and care services places youth at higher risk during the COVID-19 pandemic. Plos one, 16(9), e0249740.

U.S. Federal Drug Administration. (2019). FDA approves second drug to prevent HIV infection as part of ongoing efforts to end the HIV epidemic. Retrieved from ​​https://www.fda.gov/news-events/press-announcements/fda-approves-second-drug-prevent-hiv-infection-part-ongoing-efforts-end-hiv-epidemic.

U.S. Federal Drug Administration. (2021). FDA Approves First Injectable Treatment for HIV Pre-Exposure Prevention. Retrieved from https://www.fda.gov/news-events/press-announcements/fda-approves-first-injectable-treatment-hiv-pre-exposure-prevention.

Methods

The Preferred Reporting Items for Systematic Reviews and Meta-analysis (PRISMA) guidelines were utilized to develop the protocol for this review.

Eligibility Criteria

The purpose of this review is to evaluate changes in individual behavior and healthcare access due to the COVID-19 pandemic that will impact new HIV infections in the United States. Therefore, a primary eligibility criteria was data that was collected during or overlapping the pandemic. Papers published in 2020 or later written in English were included. Due to unique healthcare factors including insurance coverages and federal mandates, as well as federal COVID-19 pandemic response, papers that included samples outside of the U.S. were excluded. Quantitative, qualitative, and mixed-methods studies that included data on HIV infections, HIV PrEP, sexual risk behavior, and clinical settings that include sexual health or PrEP we included. Study Papers that addressed COVID PrEP, medications taken to prevent COVID-19 infection, were excluded. Studies that primarily or exclusively sampled people living with HIV were excluded as well. Lastly, call to actions, letters to the editor, and editorials were excluded.


Information Sources

An experienced librarian was consulted to advise on databases to search and the search strategy. PubMed, EMBASE, and Web of Science were searched on January 31, 2022. All searches were restricted to the year 2020 or later. The PubMed search process is included in this paper.



Table 1. Search Strategy
#1 ("Pre-Exposure Prophylaxis/organization and administration"[MAJR]) AND "COVID-19"[MeSH]
#2 "Pre-Exposure Prophylaxis"[MAJR] AND "COVID-19"[MeSH] AND HIV
#3 HIV AND "COVID-19"[MeSH] AND "Sexual Behavior"[MAJR]
#4 HIV AND "COVID-19"[MeSH] AND "Risk-Taking"[MeSH]
#5 HIV AND "COVID-19"[MeSH] AND "Sexual Partners"[MeSH]
#6 "Sexually Transmitted Diseases/prevention and control"[MeSH] AND "COVID-19"[MeSH] AND "Pre-Exposure Prophylaxis"[MAJR]
#7 PrEP OR pre-exposure prophylaxis OR Tenofovir) AND (risk OR HIV OR sexual risk)) AND (COVID OR coronavirus OR pandemic)
#8 Pandemic PrEP Persistence


Selection of Sources of Evidence

Two researchers independently conducted literature reviews adhering to the eligibility criteria. From there, they compiled a list of eligible manuscripts and removed duplicates.

Inclusion of the list of eligible manuscripts was independently assessed by two researchers. Beforehand, researchers were instructed to base inclusion on titles, abstracts, and availability of data items. When necessary, disagreements were reconciled by a third researcher.

Data Charting Process

A data chart was created by the study researchers prior to charting and was updated iteratively. Specifically, if any of the researchers identified candidate data items not already included in the data chart during the data charting process, all researchers convened and added the data item pending a unanimous agreement. All researchers independently charted the studies included in this scoping review.

Data Items

Data items were iteratively selected through a combination of a priori, clinical knowledge and post hoc abstract review from included articles. First, we noted the last name of the first author, year of publication, name of the journal in which the article was published, article type (quantitative or qualitative analysis), study design (cross-sectional, longitudinal, modeling), data source (survey, electronic health record data), and sample size. For articles containing quantitative analyses, we assessed individual-level and systems-level factors. At the individual level, we extracted information on number of sexual partners, perceived HIV risk, and PrEP use, discontinuation or persistence. Systems-level factors included: total number of people receiving PrEP, number of PrEP starts, number of PrEP discontinuations, clinic closures, modes of PrEP delivery; personnel changes due to the pandemic, funding changes, and total number of new HIV or sexually-transmitted infections. Items extracted from qualitative studies included information on patient or healthcare worker experiences. In all studies, we extracted information on study population demographics (e.g., sexual orientation, gender identity, race/ethnicity, geographic location) to identify disparities in individual- and systems-level factors.