Preventing infections: PrEP for MSM and HIV prevention care for transgender persons

To further decrease the number of new HIV infections, novel biomedical interventions are needed. For this reason, the H-TEAM is investigating how sexually-transmitted infection (STI) and HIV prevention care can be tailored to transgender persons (TGP). In 2015, the H-TEAM also started a study on the use of PrEP (pre-exposure prophylaxis) for HIV prevention: the AMPrEP (Amsterdam PrEP) project.

What is a biomedical intervention?

A biomedical intervention aims to block HIV infections and other STIs or aims to reduce vulnerability to infection and to detect and treat infections at an early stage to reduce risk of transmission.

 Soa Aids Nederland

HIV prevention and STI care for transgender persons

International studies show that, in addition to men who have sex with men (MSM), transgender persons (TGP) also have an increased risk of acquiring HIV. Together with the VUmc gender team, the H-TEAM is investigating how STI and HIV prevention care can be tailored to TGP.

Why

In Europe, little is known about the prevalence of HIV and STIs among transgender women and transgender men who have sex with men. To gain more insight into those specific subgroups within the overall transgender population that are at risk of HIV and might be eligible for PrEP, the H-TEAM is launching a research project on HIV and STI testing for transgender persons.

 

Aim

 

To gain more insights into HIV and STI prevalence among transgender persons, more HIV and STI testing is necessary in transgender populations. However, these groups are not routinely seen in the STI clinic or in the AMPrEP study, where only 2 of the 376 participants are TGP. Therefore, we want to determine HIV and STI prevalence among TGP and, where possible, split these results into different subgroups.

Approach

To collect accurate data on HIV and STIs among TGP, a gender-affirmative approach is necessary, with explicit transgender acceptance and STI tests taken from the correct anatomical locations by skilled professionals.

 

The project consists of 4 steps:

 

  1. STI and HIV prevalence measurement among TGP visitors of the STI clinic and an inventory will be made of STI and HIV prevalence among TG sex workers.
  2. STI and HIV prevalence will be measured within the gender cohort at the VUmc. Review of literature to evaluate how Amsterdam data relate to data from other cities or countries.
  3. Focus groups with various TG community groups and TG visitors of the VUmc clinic on how gender-affirmative STI and HIV (prevention) care should be provided.
  4. Start prospective research on STI and HIV screening and counseling on sexual health among visitors of the gender clinic. This will be followed by an evaluation.

Results

This project started on 1 September 2018.

AMPrEP study

To further decrease the number of new HIV infections, innovative methods like PrEP are needed. PrEP (pre-exposure prophylaxis) is a pill containing HIV inhibitors that can prevent an HIV infection. Within the H-TEAM, the Public Health Service Amsterdam (GGD Amsterdam) is investigating the use of PrEP for HIV prevention: the AMPrEP (Amsterdam PrEP) project.

What is PrEP?

PrEP is a pill containing HIV inhibitors that can prevent an HIV infection. The pill is meant for people who are not living with HIV, but who run a high risk of infection. PrEP is short for pre-exposure prophylaxis. This means you take it before you are exposed to the virus. PrEP consists of one pill, Truvada. It contains two medications that are also used for HIV treatment: emtricitabine and tenofovir disoproxil. PrEP makes it more difficult for HIV to infect cells and to multiply. This considerably reduces the risk of an HIV infection.

Why

PrEP complements existing prevention strategies such as condom use and regular testing for HIV and other STDs. The pill is meant for people who are not living with HIV, but who run a high risk of infection. In 2015, 65% of new HIV infections were found in homosexual men. This group was therefore selected as the target group for this research project.

 

Aim

 

The project aims to investigate the use of PrEP for HIV prevention. The research focuses on how many homosexual men want to use PrEP, whether they adhere to the therapy, the overall experiences of people using PrEP, and whether it affects condom use. It is the first time that PrEP is being investigated in the Netherlands and our project is the first to offer participants a choice: PrEP use on a daily basis or PrEP use according to a fixed schedule based around sex.

Approach

Between August 2015 and June 2016, 376 people started taking PrEP: 374 homosexual men and other men who have sex with men, and two transgender women. Of them, 273 started using PrEP on a daily basis. The other participants chose to take PrEP occasionally, that is, around sex.

 

Participants are seen on a three-monthly basis at the GGD Amsterdam STI outpatients’ clinic. During these visits, participants take STI, HIV and other tests, and receive counseling.

Results

During the screening visits, an STI was detected in about 20% of all participants. Unfortunately, one person was found to be HIV positive during the screening visits. At baseline a high prevalence of Hepatitis C virus (HCV) infections was observed (4.8 percent), as well as a high incidence of HCV.

 

During the study, there have been no signs of increases in STI over time. These results show that by offering PrEP we may be opening new avenues by which to reach individuals with a high potential risk for HIV and STIs (including HCV) who have to date been less likely to attend the STI clinic.

Publications on the AMPrEP project can be found here: hteam.nl/publications.

 

Advice Health Council

 

These results and our experiences from AMPrEP were used in the advice issued on 27 March 2018 by the Health Council of the Netherlands on the use of PrEP. The Health Council advised the minister for medical care to provide PrEP to men who have sex with men (MSM) who are at high risk of acquiring HIV and to ensure adequate clinical monitoring.

 

AMPrEP will end in December 2020. The end date has been postponed as PrEP is currently (mid 2019) not yet available in standard care in the Netherlands, and it would be undesirable to have gaps in PrEP provision for the participants. In addition, studying long-term PrEP use will fill important research gaps, especially for event-driven (intermittent) use. The final last year will be used to link participants to standard PrEP care, which will be implemented on a national scale from autumn 2019 onwards.

Team

  • Gerard Sonder
    Gerard Sonder

    Member
    GGD Amsterdam

  • Yvonne van Duijnhoven
    Yvonne van Duijnhoven

    Member
    GGD Amsterdam

  • Roel Achterbergh
    Roel Achterbergh

    Member
    GGD Amsterdam

  • Henry de Vries
    Henry de Vries

    Principal Investigator
    GGD Amsterdam
    Amsterdam UMC

  • Maarten Schim van der Loeff
    Maarten Schim van der Loeff

    Member
    GGD Amsterdam

  • Udi Davidovich
    Udi Davidovich

    Member
    GGD Amsterdam

  • Elske Hoornenborg
    Elske Hoornenborg

    Project Leader
    GGD Amsterdam

  • Maria Prins
    Maria Prins

    Principal Investigator
    GGD Amsterdam
    Amsterdam UMC

  • Arjan Hogewoning
    Arjan Hogewoning

    Member
    GGD Amsterdam
    Amsterdam UMC