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

Prevalence of HIV and STI in a Dutch Transgender Population (TITAN study)

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

Why

In Europe, little is known about the prevalence of HIV and STIs among transgender persons (TGP) 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 called the TITAN study (Prevalence of HIV and STI in a Dutch Transgender populAtioN).

 

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

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

Results

The inclusion of the participants for the TITAN study has started in August 2020. In September 2021, 255 participants were included. The study wishes to include a total of 300 participants. The final analyses are planned for the second quarter of 2022.

 

  • HIV prevalence and STI positivity rates among transgender persons (TGP).
    Research on transgender persons who visit centers for sexual health of the GGD Amsterdam and Haaglanden has brought forward that from 329 persons, the majority is TGP who were assigned male at birth, of whom more than half engaged in sex work. HIV prevalence and STI positivity rates were substantial and much lower among TGP who were assigned female at birth. Click here for the publication of this result.
  • HIV-related characteristics of TGP versus men who have sex with men (MSM) diagnosed with HIV and in treatment in the Netherlands.
    The analysis of this study will be finalized in the last quarter of 2021.
  • HIV prevalence and related factors of TGP as part of the ACOG (Amsterdam Cohort Onderzoek Gender).
    The analysis of this study will be finalized in the second quarter of 2022.

 

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

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.

AMPrEP page Public Health Service Amsterdam (Dutch only)

Approach

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.

 

In 2018 the project was extended until 1 December 2020: AMPrEP Phase 2. Of the 376 enrolled participants, 314 signed the informed consent for AMPrEP phase 2. The extra year gave way for researching the long-term use of PrEP. The final last year was used to link participants to standard PrEP care, which was implemented nationwide from summer 2019 onwards.

Results

Results

The results of the AMPrEP study thus far show that the implementation in regular prevention would be feasible. PrEP is effective and safe. We noticed significant uptake of both daily and event-driven PrEP. There are no signs of increases in STI, but we do see a high baseline prevalence of HCV infection which is higher than at the routine screening among HIV negative MSM at the STI clinic Amsterdam. The latter results indicate that by offering PrEP we may open avenues to reach out to individuals with a high potential risk for HIV and STIs (including HCV) that thus far have been less likely to attend the STI clinic. The results and our experiences from AMPrEP were used in the advice from the Health Council to the Minister of Health.

 

The most important results of the AMPrEP study include:

  1. Men who have sex with men more often chose daily than event-driven use of pre-exposure prophylaxis: baseline analysis of a demonstration study in Amsterdam.
    Click here for the publication.
  2. Change in sexual risk behaviour after six months of pre-exposure prophylaxis use: results from the Amsterdam PrEP demonstration project.
    Click here for the publication.
  3. MSM starting preexposure prophylaxis are at risk of hepatitis C virus infection .
    Click here for the publication of this result.
  4. Acquisition of wild-type HIV-1 infection in a patient on pre-exposure prophylaxis with high intracellular concentrations of tenofovir diphosphate: a case report.
    Click here for the publication of this result.
  5. A mobile application to collect daily data on pre-exposure prophylaxis adherence and sexual behaviour among men who have sex with men: use over time and comparability with conventional data collection.
    Click here for the publication of this result.
  6. Sexual behaviour and incidence of HIV and STI among men who have sex with men using daily and event-driven pre-exposure prophylaxis in Amsterdam: 2-year results from a demonstration project.
    Click here for the publication of this result.
  7. Improving adherence to daily preexposure prophylaxis among MSM in Amsterdam by providing
    feedback via a mobile application.
    Click here for the publication of this result..
  8. Adherence to event-driven HIV PrEP among men who have sex with men in Amsterdam, the Netherlands: analysis based on online diary data, 3-monthly questionnaires and intracellular TFVDP.
    Click here for the publication of this result.
  9. Understanding pre-exposure prophylaxis (PrEP) regimen use: Switching and discontinuing daily and event-driven PrEP among men who have sex with men.
    Click here for the publication of this result.
  10. Offering a choice of daily and event-driven preexposure prophylaxis for men who have sex with men in the Netherlands: a cost-effectiveness analysis.
    Click here for the publication of this result.
  11. Decision-making regarding condom use among daily and event-driven users of preexposure prophylaxis in the Netherlands.
    Click here for the publication of this result.

On 29 September 2019, project leader dr. Elske Hoornenborg received the ZonMW Parel for the AMPrEP project.

Team

  • Elske Hoornenborg
    Elske Hoornenborg

    Project Leader
    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

  • Mark van den Elshout
    Mark van den Elshout

    Member
    GGD Amsterdam

  • Udi Davidovich
    Udi Davidovich

    Member
    GGD Amsterdam

ALL EMPLOYEES OF THE H-TEAM >>

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