HIV pre-exposure prophylaxis: assessment of acceptability among members of HIV serodiscordant/serostatus unknown couples

Abstract

Background:

Pre-exposure prophylaxis (PrEP) is effective in preventing HIV infection but is not yet widely available in resource-limited settings such as the Dominican Republic. We aimed to ascertain PrEP acceptability among people living with HIV in the Dominican Republic who are part of HIV serodiscordant partnerships and understand relationships between PrEP acceptability, HIV stigma, and intimate partner violence.Methods: A cross-sectional survey of people in care for HIV infection included acceptability-related questions and assessments of HIV stigma and intimate partner violence. We also explored the expected impact of PrEP on HIV disclosure rates and fertility intentions.Results: Of the 100 participants, 74% had been in their current partnership for >1 year; 38% had not disclosed to their partner; 29% reported condomless sex, and 23% reported sex with multiple partners. PrEP was highly acceptable with 84% of participants saying they were “very likely” to offer PrEP to their partner if available and 21% stating it would allow them to have more children. Of those who had not disclosed to their partner, 71% stated PrEP would help them do so. No relationship was found between PrEP acceptability, HIV stigma, and intimate partner violence. However, higher than expected rates of PrEP acceptability limited the power of these analyses.Conclusion: Pre-exposure prophylaxis was considered to be highly acceptable among people living with HIV in the Dominican Republic who are part of serodiscordant partnerships.

Keywords

Pre-exposure prophylaxis HIV prevention Dominican Republic Caribbean HIV disclosure

Introduction

With an estimated HIV prevalence of approximately 1.2% among the general population, the Caribbean is the geographic region most affected by HIV outside sub-Saharan Africa.¹ The island of Hispaniola, composed of the Dominican Republic (DR) and Haiti, includes close to 62.5% of all people living with HIV (PLHIV) in the Caribbean, with Haiti experiencing higher prevalence (1.6–2.1%)² than the DR (0.7–1.1%)³ but phylogenetic analysis suggests frequent cross-border spread.^4,5 Rates among some key populations are particularly high; the rate in trans women exceeds 25% while other high-risk groups such as Haitian migrants, men who have sex with men (MSM), and commercial sex workers in the DR have HIV rates between 3 and 5%.^6–8 Thus, this is an important setting to target with HIV-prevention initiatives such as provision of pre-exposure prophylaxis (PrEP) to high-risk populations.

Demographic and Health Survey data from the DR characterized HIV serodiscordance patterns and HIV transmission dynamics in stable couples and found that two-thirds of PLHIV reported being part of a stable couple.⁹ Of these stable couples, 70% were serodiscordant. HIV transmission within stable serodiscordant partnerships is estimated to contribute 34.4% of the HIV population-level incidence in the DR and 41.1% of the transmissions within poorer batey communities. Bateyes are small villages traditionally centered around sugar cane plantations that are characterized by a large proportion of Haitian migrants and some of the highest rates of poverty in the DR.^10,11 Female sex workers and their stable partners are another high-risk group in which PrEP could provide substantial benefit.¹²

The World Health Organization recommends PrEP for individuals in HIV-serodiscordant couples globally.¹³ Large, randomized, placebo-controlled studies have shown that the use of oral PrEP by HIV-uninfected persons who are at risk of becoming infected can substantially decrease HIV transmission.^14–17 The most commonly used PrEP modality consists of a fixed-dose combination tablet containing two antiretroviral drugs (e.g. tenofovir and emtricitabine or tenofovir and lamivudine) and it has been shown to be effective among members of HIV-serodiscordant couples¹⁴ as well as other high-risk populations. Studies in serodiscordant couples have shown PrEP is both effective and cost-effective when taken by the HIV-negative partner until the partner who is living with HIV has demonstrated the ability to sustain an undetectable HIV viral load.^17,18

Little is known about attitudes towards PrEP in the Caribbean and with few exceptions, PrEP is not yet widely available in this region.^19,20 Thus, a thorough understanding of PrEP acceptability in the DR is important to prepare for PrEP’s future expansion across the country and throughout the region. The purpose of this study was to ascertain PrEP acceptability among PLHIV who are in serodiscordant partnerships (defined as having a steady partner who is known to be HIV negative or whose HIV serostatus in unknown) in the DR to inform future PrEP programs. To identify characteristics that may influence PrEP uptake, we also examined rates of HIV diagnosis disclosure, fertility intentions, HIV-related stigma and incidence of intimate partner violence (IPV) since prior studies identified these as potentially influential barriers and facilitators of PrEP uptake and adherence.^21–24

Materials and methods

Study design and setting

We conducted a cross-sectional stand-alone study of adults enrolled in an HIV treatment program to understand their attitudes towards PrEP and to establish rates of HIV diagnosis disclosure, fertility intentions, HIV-related stigma and IPV. The study was conducted at Clínica de Familia La Romana (CFLR), the largest provider of HIV-specialized outpatient medical care in the eastern region of the DR. CFLR’s clients include over 2500 PLHIV of whom approximately 7% are MSM, 17% are migrants, 2% are commercial sex workers, and 1% are transgender. CFLR also provides primary care, reproductive health, mental health, and other specialized medical services to key populations including some of the poorest and most vulnerable individuals in and around La Romana, including Haitian immigrants, sex workers, MSM, and people living in bateyes. CFLR is centered in the region with the highest HIV prevalence in the country after the capital, Santo Domingo.⁹

Ethical considerations

This study protocol was approved by the Institutional Review Board of the Children’s Hospital of Philadelphia (CHOP) and by the Consejo National de Bioética en Salud (CONABIOS), the ethical review committee in the DR. The study was conducted in full accordance with CHOP Research Policies and Procedures and all applicable regulations in the DR.

Participant eligibility and consent

All individuals presenting to care for HIV treatment were sequentially assessed for eligibility by study staff in March 2018 until the target sample size was achieved. Those who were above 18 years of age and in a stable partnership with an HIV negative or serostatus unknown partner were deemed eligible for the study if they were able to communicate in Spanish.

Procedures

Following informed consent which was conducted in Spanish by a research team member who is also a medical doctor, participants completed a survey either on a tablet or orally in discussion with a research assistant. The survey was developed following meetings with key stakeholders and literature review for relevant previously validated measures. Surveys that existed only in English were translated to Spanish by the bilingual first author. The DR study team pilot-tested the translations to ensure that the language used was easy to understand in the local context. The survey was initially intended to be self-administered on a tablet to decrease social desirability bias. However, given the frequent need for assistance, we transitioned to single investigator administration of the surveys after the 10^th participant. All subsequent surveys were verbally administered by the first author.

The content of the surveys is described below. An introductory statement at the beginning of the survey explained what PrEP is since it was expected that most participants would not be familiar with this modality since it was not available yet in their community.

Demographics and characteristics of relationships

In addition to standard demographic variables such as age and sex, participants were asked how long they had been with their stable sexual partner and if the partner is aware of their HIV status. If they had not disclosed their HIV status to their partner, they were asked to indicate reasons for not disclosing. They were also asked whether they had sex without a condom in the last 30 days and whether they had concurrent sexual partners in addition to the stable partner.

PrEP acceptability

PrEP acceptability questions were developed by the study team to capture a range of culturally relevant aspects of PrEP acceptability and potential barriers and facilitators. PrEP acceptability was measured by asking, “If a pill were available to prevent your partner from acquiring HIV, how likely would you be to discuss it with your partner?” since discussion of PrEP is the first necessary step for uptake. This question was scored using a 5-point Likert Scale ranging from “very unlikely” to “very likely.” Participants who reported that they were “very unlikely,” “unlikely,” or “not sure” whether they would discuss PrEP with their partner were asked to specify the reasons why they might not recommend PrEP to their partners. Pre-specified options included: “because my partner is not aware of my HIV status,” “because I always use condoms,” “because it may be expensive,” “because I think it may have side effects,” and “because he/she may not want to take the medicine every day.” Participants were also encouraged to offer any other reasons why they would not be very likely to discuss PrEP with their partner. Participants who reported that they were “very likely,” “likely,” or “not sure” whether they would discuss PrEP with their partner were asked to specify all reasons why. Pre-specified options included: “I would be able to tell my partner(s) I have HIV,” “We would be able to have more children,” and “I would feel better knowing my partner is protected against HIV.” Participants were also encouraged to offer any other reasons why they would discuss PrEP with their partner.

HIV-related stigma

We used the 10-item revised HIV stigma scale to measure HIV-related stigma.²⁵ The scale was scored on a 4-point Likert Scale according to participant’s choice of responses ranging from “strongly disagree” to “strongly agree”. The total was summed for each individual and HIV Stigma score was analyzed as a continuous variable from 10 to 40 as reported in other contexts.^26–28 Higher scores indicate increased levels of stigma with items addressing experienced stigma, internalized stigma, and anticipated stigma.

Intimate partner violence

The 4-question HITS (Hit, Insult, Threaten, and Scream) screening tool was used to measure IPV.²⁹ The HITS Score indicates whether the partner never (1), rarely (2), sometimes (3), fairly often (4), or frequently (5) physically hurts, insults, threatens or screams at the respondent. Scores of 10 or higher are considered problematic. HITS scores were also analyzed as a continuous variable.

Clinical data extraction

A chart review was conducted to extract relevant clinical variables including time on treatment, nadir CD4⁺ T-lymphocyte count, and most recent quantitative plasma HIV RNA (viral load--within the past 6 months). On-treatment viral loads were dichotomized as <400 copies/mL or ≥400 copies/mL.

Sample size

The sample size of 100 was chosen with the aim of assessing a difference in score of 5 or more on the HIV Stigma Scale between those who did and those who did not anticipate recommending PrEP for their partners as we believed that this would be the smallest clinically meaningful difference. We anticipated that the proportion of PrEP-accepting versus non-PrEP-accepting individuals would be between 1:1 and 1:4. In previous studies utilizing the HIV Stigma Scale, the scores were normally distributed and the standard deviation ranged widely.^27,28 With 20% of participants accepting PrEP, a standard deviation between 5 and 7 on the HIV Stigma Scale, 100 subjects provided >80% power to detect a difference of at least 5 points with a two-sided alpha level of 0.05.

Data analysis

PrEP acceptability and participant demographics were characterized using standard descriptive statistics, stratified by whether or not the participant has disclosed their HIV status to their partner. We assessed continuous variables for normality graphically. We examined PrEP acceptability and associations between PrEP acceptability, HIV stigma and reported IPV rates. Chi² test was used to assess the association between viral suppression and PrEP acceptability. We assessed for an association between HIV-related stigma and PrEP acceptability and separately for an association between IPV and PrEP acceptability using a Wilcoxon rank sum test.

Results

Baseline demographics and partnership characteristics

The majority (65%) of the 100 participants were between the ages of 30 and 49 years and most (64%) knew that they had been living with HIV for over 5 years, with another 25% having lived with HIV between 1 and 5 years. Additional demographic characteristics are outlined in Table 1.

Table 1.

Demographic characteristics of participants and characteristics of the partnership.

Age category	Disclosed to partner (N = 62)	Not disclosed to partner (N = 38)	Total (N = 100)
18–24	1 (1.6%)	4 (10.5%)	5
25–34	16 (25.8%)	11 (29.0%)	27
35–44	21 (33.9%)	13 (34.2%)	34
45–54	12 (19.4%)	7 (18.4%)	19
55–64	8 (12.9%)	3 (7.9%)	11
>65	4 (6.5%)	0	4
Gender
Cisgender Male	28 (45.2%)	13 (34.2%)	41
Cisgender Female	34 (54.8%)	24 (63.2%)	58
Transgender female	0	1 (2.6%)	1
Time on ART^a
Less than 1 year	5 (8.1%)	4 (10.5%)	9
Between 1 and 5 years	21 (33.9%)	14 (36.8%)	35
Greater than 5 years	31 (50%)	17 (44.7%)	48
Not on ART	5 (8.1%)	2 (5.3%)	7
Time with current partner
≤1 year	9 (14.5%)	17 (44.7%)	26
>1 year	53 (85.5%)	21 (55.3%)	74
Intimate partner status
Married or living with partner	46 (74.2%)	13 (34.2%)	59
Not married or living with partner	16 (25.8%)	25 (65.8%)	41
Last viral load^a
<400 copies/mL	50 (80.6%)	25 (65.8%)	75
≥400 copies/mL	12 (19.4%)	12 (31.6%)	24
Unknown	0	1 (2.6%)	1

^aclinical data were not available for one participant in the non-disclosed group.

The majority (74%) of participants had been in their serodiscordant partnership for greater than 1 year and 38% had not disclosed their HIV status to their partner. Those who had been in their partnership for >1 year were more likely to have disclosed than those who had been in their partnership for less time (83% vs. 35%). Reasons for not notifying their partner included concerns that their partner would leave (37%), accuse them of infidelity (26%), think negatively of them (63%), hurt them physically (32%), or that their partner simply did not need to know (37%). Of the 38% of participants who had not disclosed to their partner, 23% endorsed more than one reason for not doing so. Sex without a condom in the last 30 days was reported by 29 participants, 8 (27.6%) of whom had an HIV viral load >400 copies/mL. Close to a third of participants (29%) reported having multiple sexual partners and 10 of these (34.5%) also reported having condomless

PrEP acceptability

PrEP acceptability was higher than anticipated with 84% of participants stating they were “very likely” to offer PrEP to their partner if it were available. The participants’ responses to the PrEP acceptability question are outlined in Table 2. The majority of those (94%) stated they would feel better knowing their partner was protected from HIV. Of 10 participants who answered they were “very unlikely”, “not likely”, or “not sure” whether they would offer PrEP to their partner, 8 had not disclosed their HIV status to their partner. Of the 38 participants who had not disclosed their HIV status to their partner, 27 (71%) said PrEP would help them do so. Some participants also reported that their fertility intentions would be altered by PrEP availability, with 21% saying PrEP would allow them to have more children. PrEP acceptability did not differ between those with and without a detectable HIV viral load with 87% of those without and 75% of those with detectable viral loads saying that they were very likely to recommend PrEP to their partners (p = 0.18). Table 3 outlines the reasons why participants said they would or would not discuss PrEP with their steady partner. Only one participant who would discuss PrEP with their partner and one who would not discuss PrEP with their partner offered a reason that was not pre-specified. The person who offered another reason to discuss PrEP had an undetectable viral load and indicated that PrEP would keep her partner from acquiring HIV from anyone else. The individual who offered a reason for not discussing PrEP indicated that she was afraid her partner would be physically violent.

Table 2.

Summary of PrEP acceptability.

Participant characteristic	If a pill that could protect your partner from HIV were available, how likely would you be to talk about it with your partner?
Participant characteristic	Very unlikely	Not likely	Likely	Very likely	Unsure
All participants (N = 100)	4 (4%)	4 (4%)	6 (6%)	84 (84%)	2 (2%)
Participants who had disclosed their HIV status to their partner (N = 62)	0	2 (3.2%)	2 (3.2)	58 (93.6%)	0

Table 3.

Reasons why participants would or would not discuss PrEP with their partner.

Reason	Frequency (%) endorsing response^a
Reasons for not discussing^b
Partner unaware of status	8 (80%)
Always use condoms	4 (40%)
May be expensive	3 (30%)
May have side effects	2 (20%)
Partner may not want to take it daily	4 (40%)
Worried what people will think	3 (30%)
Reasons for discussing^b
Would be able to disclose	23 (26%)
Would be able to have more children	19 (21%)
Would feel better knowing my partner is protected	87 (97%)

^aMany participants endorsed more than one reason.

^bN = 10 for individuals asked why they would not discuss PrEP with their partner (answered that they were “very unlikely” (4), unlikely” (4), or “not sure” (2) whether they would discuss PrEP with their partner.) N = 90 for individuals asked why they would discuss PrEP with their partner (answered that they were “very likely” (84) or “likely” (6) to discuss PrEP with their partner.

Stigma and IPV

The median score on the HIV Stigma Scale was 24 (IQR 10, 29.5). The median HITS score was 4 (IQR 4,4) and 79% of participants reporting “never” experiencing any of the IPV-related issues asked, including insults, screaming, threats and physical violence. Only 7 individuals (all female) met the threshold for a positive HITS score. Neither the HIV Stigma Scale nor HITS scores were associated with PrEP acceptability (p > 0.2).

Discussion

In this study, Dominicans living with HIV who are in serodiscordant relationships reported high rates of PrEP acceptability. Although most participants had been with the same sexual partner for over a year, a high proportion had not disclosed their HIV status to their partner, with many indicating that PrEP availability would make it easier for them to do so. Previous studies have similarly reported that PrEP availability would likely decrease risk by increasing the willingness of PLHIV to communicate with their presumed HIV-uninfected partners about their HIV status.³⁰ However, the extent to which PrEP availability will change these partner dynamics in settings such as the DR is not yet known. Currently, few countries in Latin America and the Caribbean have national policies that include provision of PrEP in the public sector,³¹ despite its known public health benefits.³²

The high rates of HIV-related stigma observed in our study population were consistent with known national trends.⁹ However, because PrEP was acceptable to such a high proportion of the study participants, we were not able to distinguish a relationship between stigma and PrEP acceptability as hypothesized.

The proportion of females in our sample who reported experiencing IPV in the last 12 months was consistent with national estimates. Recent estimates of 12-month physical IPV prevalence among women in the DR report rates from 12-16%.^33,34 Our study is among the first to report IPV prevalence among PLHIV in the DR and is not consistent with studies in other settings showing higher rates of IPV among PLHIV compared with the general population.³⁵ IPV is associated with lower adherence to antiretroviral therapy and lower odds of viral suppression and thus also identifies a population likely to benefit disproportionately from PrEP.³⁶

One limitation of this study was that we did not ask about sexual orientation. Thus, we are not aware of what proportion of men in the study have sex with men. HIV transmission in the DR, however, is thought to be predominantly due to unprotected heterosexual sex.⁴ With our study utilizing in-person interviews for all but the first 10 enrollees, social desirability bias could have influenced participants to under-report socially undesirable outcomes. However, high reported rates of stigma and IPV indicate that participants were open about admitting challenges in these sensitive areas. The fact all participants were recruited from the same clinic may limit generalizability. However, our recruitment site is the largest provider of HIV services in the Eastern DR. The treatment clinic setting is an ideal site to introduce PrEP for partners. Thus, we sought through this study to define the extent to which PLWH would be open to favorably discussing PrEP with their partners. If the study had focused on enrolling seronegative people in serodiscordant partnerships, we would not have been able to include those who are unaware of their partners’ HIV status although their lack of knowledge of their risk increases their vulnerability to HIV. It should be noted that willingness of the PLHIV to recommend PrEP for their partners is only a first step in getting the vulnerable individual to initiate and maintain adherence to PrEP.

Lastly, the survey was conducted in a one-month period and may not capture changing attitudes as provision of PrEP has begun on a limited basis at several clinical sites in the DR, including at CFLR. As of January 2022, 205 individuals have initiated PrEP at CFLR, of whom 72% are MSM. Other eligible groups include trans women, commercial sex workers, Haitian migrants and people in serodiscordant relationships. However, since eligibility was expanded to include serodiscordant couples in late 2021, no new clients have been able to initiate PrEP due to drug shortages. PrEP is now being rolled out at several public health sites throughout the country and the purchasing of PrEP is now included in the annual projections for ART procurement. In order to expand PrEP availability more widely, training will need to be provided to health providers and steps taken by the Ministry of Health in order to ensure the constant supply of the PrEP medications.

When PrEP is more widely available, implementation studies should address how to minimize the impact of non-disclosure, stigma, and IPV as potential barriers to PrEP uptake. This study suggests that even in this clinic-based population endorsing high rates of stigma and nondisclosure, the desire to involve their partners in discussions about PrEP is high.

Conclusions

This study indicates PrEP would be highly acceptable among a population whose partners are likely to benefit from PrEP in the DR, adults living with HIV who are in serodiscordant couples. Although stigma did not appear to impact pre-implementation acceptability, it will be important to assess whether it impacts uptake, particularly among those who have not disclosed to their partners.

Footnotes

Declaration of conflicting interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This study was supported by National Institutes of Health; K23 MH119976, K99 NR017829, P30 AI034008, R00 NR017829.

ORCID iD

Elizabeth Lowenthal

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