Parrying the Pitfalls of PrEP: Project PEACH

Men who have sex with men (MSM) are disproportionately impacted by the U.S. HIV epidemic. Pre-exposure prophylaxis, or PrEP, is a relatively newer HIV prevention strategy that involves taking HIV antiviral medications either daily or on-demand to prevent HIV infection following high risk sexual activity. Both daily and on-demand PrEP have been shown to prevent infection if taken consistently and correctly. A prior research with this high-risk population in Atlanta, where it was offered daily PrEP to study participants, resulted in significant PrEP interest and initiation however high rates of PrEP discontinuation throughout the study were of great concern and, in some cases, led to HIV infection. Additionally, the study found high rates of bacterial sexually transmitted infection (STI) diagnoses both independent of, and concurrent with, higher PrEP use leading to concerns that condoms are not being used among MSM on PrEP.

The proposed work will expand upon the previous study with an intervention focus for MSM in Atlanta with aims of (1) preventing daily oral PrEP discontinuation; (2) offering on-demand oral PrEP as an alternative for MSM not interested in daily oral PrEP, (3) decreasing the incidence of bacterial STIs by offering STI post-exposure prophylaxis (PEP) which involves taking doxycycline immediately following high risk sexual behavior, 4) to start injectable PrEP as an alternative to daily oral PrEP or on-demand PrEP.

The study will involve a cohort of 200 MSM aged 18-45 in Atlanta who will be followed for two years. Participants will be recruited online from social media and dating websites, and in-person from different venues and events where MSM are known to attend. Men will take a short online eligibility screener either on a tablet, if recruited in-person, or on their own device if recruited online. Participants will be compensated for the various study activities (e.g., study visits, online behavioral surveys, weekly/monthly surveys).

If men screen eligible, they will be invited to a baseline study visit that will occur either in-person at the research clinic or virtually. Because of the ongoing COVID-19 pandemic, the plan is to offer participants the option of conducting study activities virtually or in-person. Consent will occur at the beginning of the baseline visit. Following the baseline visit, all participants will have two more study visits at months 12 and 24. At the three study visits, participants will be tested for HIV, STIs and drugs of abuse and take an online behavioral survey. Participants will also take an online behavioral survey at months 4, 7 and 19.

At all study visits, participants will discuss with the study counselor the various prevention options the study is offering-daily PrEP, on-demand PrEP, STI PEP or injectable PrEP as an alternative to daily oral PrEP or on-demand oral PrEP. If a participant elects to begin any of these, study staff will assist them in accessing oral PrEP from a community pharmacy and STI PEP (doxycycline) from the Emory Investigational Drug Service. Participants who start oral PrEP and/or STI PEP will take short weekly surveys for the first 2 weeks to monitor use and side effects. Following that 2-week period, daily oral PrEP users will get a monthly survey to try and detect warning signs of discontinuation so that the study can intervene to prevent that from happening. On-demand oral PrEP and STI PEP users will continue to get weekly surveys to monitor use and side effects. Oral PrEP and STI PEP users will have a 3-monthly visit-either in-person or virtually-to monitor their use and to test for HIV and STIs. Oral PrEP users will also have their kidney function monitored by creatinine testing. Participants electing to do their study activities virtually will be sent specimen collection kits so that they can self-collect specimens for all the required labs. They will mail back the specimens to the lab in a pre-paid postage mailer. Participants who elect injectable PrEP will be referred to local providers to access the medication; as part of our study, we will monitor their use through monthly surveys. Injectable PrEP Participants will have the option to switch prevention options at any point during the study by indicating their interest during monthly surveys or contacting study staff directly. Study clinicians will develop transition plan based on clinical indications.

All participants will be required to download the study app at the baseline visit and will be oriented to using it to retrieve study communication, surveys, lab results, etc. Additionally, the app will be used to schedule and conduct video conferencing sessions between participants and study clinicians/staff. If a participant reports warning signs of daily PrEP discontinuation, a peer navigator on staff will reach out through the app to try and schedule a counseling session that will use a motivational interviewing approach to support PrEP persistence.

The proposed work is of great significance for the field as novel approaches to preventing early discontinuation of PrEP are of utmost importance for preventing HIV transmission among MSM. If engaging with them frequently and assessing for warning signs of discontinuation is shown to be an effective strategy for intervening and preventing stoppage, then the implications for future interventions by community PrEP providers and clinicians is significant.