A UCLA Health-led study found a combination of interventions of one-on-one telehealth coaching, peer support forums, and automated text messages more than doubled the use of the HIV prevention strategy, called PrEP, among younger, at-risk Americans, a group that historically has had low use of the medication.

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Source: NIAID

Colorized transmission electron micrograph of HIV-1 virus particles (yellow and red) budding from the plasma membrane of an infected H9 T cell (burgundy).

The randomized controlled trial results, published in the journal Lancet Digital Health, tested combinations of interventions to improve HIV prevention behaviors, including pre-exposure prophylaxis, or PrEP, among younger Americans who have historically had the lowest rate of uptake of the drug among the 1.2 million people in the U.S. the Centers for Disease Control and Prevention (CDC) estimates would benefit from the medication.

Approved by the U.S. Food and Drug Administration in 2012, PrEP is administered as a pill or injection to prevent infection of HIV. The drug reduces the risk of HIV infection from sex by 99% when taken as prescribed, according to the CDC.

For Americans ages 16-24, only 15% are estimated to use PrEP compared to the national average of 25% among all ages combined. Uptake is lowest among Americans who are Black (8%) and Latino (14%), according to the CDC.

Low use factors

Dallas Swendeman, study lead author and professor in the UCLA Department of Psychiatry and Biobehavioral Sciences, said there are several factors behind the low use including medical mistrust, affordability, access to health care, being on a parent’s insurance plan, discomfort in discussing sexual activity with doctors, substance use and basic survival needs including housing, food and income.

The two-year study recruited nearly 900 residents from Los Angeles and New Orleans who identified as gay, bisexual, transgender or other sexual gender minority youth. About 40% of participants were Black, 29% were Latino, 21% were white and 6% were Asian or Pacific Islander.

Participants were divided randomly into four groups, each of which had different combinations of interventions including automated text messages, private social media forums and one-on-one, strengths-based telehealth coaching by near peer paraprofessionals.

PrEP uptake rate

After the first eight months, PrEP uptake rate among the group that received all three interventions increased from a baseline of 11% to more than 20%, which was the highest among all four groups and sustained through the 24 months of follow-up. The study’s authors said this increase, if implemented nationally, could help to bend the curve on new HIV infections in the absence of other prevention strategies among younger Americans. PrEP use in the other three study groups increased to about 15% through 8 months but then declined after.

“Science is developing biomedical innovations at an impressive rate but getting people to use them is very challenging as we saw with COVID vaccines and as we’re seeing with PrEP for HIV prevention,” Swendeman said. “We still need behavioral interventions and wraparound services to support people in their whole person care to prioritize HIV prevention as well as the other competing needs and priorities they have in their lives.”

Additionally, researchers found in a separate analysis that participants assigned to the two study groups that included telehealth coaching stayed more engaged in mental health and supportive services for housing, food, and economic security over time compared the groups with just automated texting and online peer support.

Real-world context

The study also researched whether the interventions affected use of condoms; use of post-exposure prophylaxis (PEP), a medication used to prevent HIV infection after potential exposure; and partner numbers. Swendeman said no impact was observed in these areas.

While the study results show promise, Swendeman said they need to be tested in more real-world contexts for scale up. He is now leading another federally funded implementation science study partnering with community-based organizations to identify barriers, facilitators, and optimal implementation strategies for these interventions in real-world practice.

“We need to be more proactive with behavioral and implementation science to bridge translational gaps between biomedical discoveries, uptake and impact.” Swendeman said.

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