Introduction
Methods
Results
Study Selection
Characteristics of Included Studies
Characteristics | n (%) |
---|---|
Study location*
| |
United States | 18 |
United Kingdom | 6 |
Australia | 4 |
Brazil | 4 |
Portugal | 3 |
Kenya | 2 |
Belgium | 2 |
South Africa | 2 |
Canada | 1 |
Croatia | 1 |
Ireland | 1 |
Zimbabwe | 1 |
Netherlands | 1 |
Philippines | 1 |
France | 1 |
Global sample | 1 |
Study design
| |
Quantitative | 42 (91.3%) |
Qualitative | 2 (4.3%) |
Mixed methods | 2 (4.3%) |
Study population*
| |
men who have sex with men | 27 |
Transgender women | 4 |
Female sex workers | 2 |
Pregnant women | 1 |
People who inject drugs | 1 |
Changes in PrEP use and Continuation
Author (year) | Country/setting | Study design | Study population | Sample size | Summary of findings |
---|---|---|---|---|---|
Bellman (2022) | San Francisco, USA | Qualitative | n/a | n/a | COVID-19 delayed implementation of SB-159 because of an increase in demand for COVID-19 services at pharmacies (testing and vaccinations), which reduced the resources and number of staff available. Some pharmacies noted a reduced number of requests for PrEP and PEP services, which they believed was due to the effects of social distancing and decreased sexual activity during the pandemic. |
Bogdanić (2020) | Croatia | Quantitative | n/a | n/a | PrEP service had a 50% decline in visits (12 versus 6 visits per week in February and March 2020, respectively). |
Camp (2021) | USA | Quantitative | MSM | n = 140 | The most common reasons for switching from once daily to 2-1-1 PrEP included having sex less frequently and wanting to take fewer pills (46.4%). Participants reported high medication adherence based on each component of 2-1-1 PrEP dosing (> 84%). The most common barriers with 2-1-1 PrEP dosing included unplanned sexual encounters resulting in missing the double-dose pre-sex and trouble remembering doses post-sex. Facilitators of the 2-1-1 PrEP dosing strategy included reductions in sexual encounters, preference to take fewer pills, need to reduce cost, and desire to reduce side effects. Challenges to receiving PrEP services during the pandemic included obtaining laboratory testing and PrEP refills (either receipt of a refill authorization from a healthcare provider or processing of a refill from the pharmacy), being unable to get a healthcare provider appointment, and not being able to communicate with their healthcare provider. |
Chan (2022) | San Francisco, USA | Quantitative | n/a | n = 74 | 67% of participants were taking daily PrEP, 21% were on 2-1-1 PrEP, and 12% had discontinued PrEP. 53% of participants reported challenges with taking PrEP. The most reported challenges were related to health care system access, including inability to go to laboratories for testing, inability to receive PrEP refills, lack of communication with their health care providers, and/or clinics not having available appointments. In addition, 51% of participants noted at least some difficulty getting an HIV test. Nearly 30% of participants were uncertain about taking PrEP while having less sex, with the number of sexual partners significantly reduced from a mean of 4.0 sexual partners per month before SIP to a mean of 2.3 during shelter in place (P < 0.01). |
Chen (2021) | Chicago, USA | Quantitative | Black MSM and TW | n = 222 | Most (83.3% and 78.2%, respectively) reported similar or easier PrEP access during the pandemic. After adjusting for covariates, financial travel burden since the shelter-in-place was significantly associated with perceived difficulty in accessing PrEP [aPR = 3.2 (95% CI: 1.0 to 10.1)] |
Chone (2021) | Portugal | Quantitative | MSM | n = 1301 | 30.6% of participants were using PrEP. Using PrEP was associated with having chemsex during the pandemic (ORa: 4.2, 95%CI 2.71–6.39) |
Chow (2020) | Melbourne, Australia | Quantitative | MSM | n = 204 | One in 4 daily PrEP users stopped taking PrEP during the COVID-19 pandemic, and 5% switched to on-demand PrEP. Most men reduced PrEP use because they stopped having casual sex and reduced the number of casual partners during the COVID-19 pandemic. |
Chow (2020) | Melbourne, Australia | Quantitative | MSM | n = 192 | 80% PrEP users did not change how they took PrEP. Of the 136 daily PrEP users, 111 (82%) continued to take daily PrEP, 3 (2%) switched to on- demand PrEP, and 22 (16%) stopped PrEP in July–August. Men generally reported that they had no partners or decreased sexual activities during second lockdown compared with post-first lock- down; the number of casual sex partners (43% decreased vs. 3% increased) and the number of kissing partners (36% decreased vs. 3% increased). |
Davey (2020) | South Africa | Quantitative | Pregnant women | n = 455 | During the nationwide lockdown, missed PrEP visits increased significantly to 63% at the 1-month visit and 55% at the 3-month visit. Overall, 34% of women missed visits before lockdown and 57% during lockdown. The relative risk of missing a study visit increased during lockdown compared with before lockdown (odds ratio 2∙36, 95% CI 1∙73–3∙16). |
De Daetselier (2021) | Belgium | Quantitative | n/a | n/a | Approximately the same number of PrEP users was seen in 2020 (n = 905) compared to 2019 (n = 912). However, participants visited the clinic less frequently in 2020 as compared to 2019. For example, the number of PrEP users that visited the clinic more than twice was only half of the number observed in 2020 (17.1% (155/905) versus 34.2% (312/912) in 2020). |
De Sousa (2021) | Brazil/Portugal | Quantitative | MSM | n = 2361 | Notably, among the 652 users of PrEP/Truvada in this study, almost half (301; 46.1%) also stated using this medicine as a preventive measure to COVID-19 transmission. |
Di Ciaccio (2021) | France | Quantitative | MSM | n = 8345 | Among 8345 respondents, 946 were PrEP users before the lockdown, of whom 58.8% (n = 556) reported stopping PrEP during the lockdown and 15.4% (n = 146) were not using PrEP at the time of the survey. Among the 556 who stopped PrEP during lockdown, 86.5% (n = 481) reported no sexual activity; 76.8% (n = 427) restarted PrEP after lockdown. Former PrEP users were more likely to be younger, not living with a stable male sexual partner, report moderate anxiety, report increased psychoactive drug use during the lockdown, and report not having tested for HIV or STI since the end of the lockdown because they did not know where to go, preferred to wait or for another reason. Reporting fewer male sexual partners in the last 6 months was also significantly associated with being a former PrEP user. |
Eustaquio (2022) | Western Visayas, Philippines | Quantitative | Cis-MSM and TGW | n = 647 | Among those non-reactive for HIV testing, all participants were provided prevention services through routine provision of risk reduction counseling and condoms and lubricants. But only 2 (0.3%) were successfully linked to PrEP services. |
Gillespie (2020) | Wales | Quantitative | n/a | n = 56 | On average, 42% of PrEP users reported condomless sex in the period prior to the introduction of social distancing measures and 20% reported condomless sex after (OR = 0.16, 95% CI 0.07 to 0.37, p < 0.001). There was some evidence to suggest that this association was moderated by relationship status (OR for single participants = 0.09, 95% CI 0.06 to 0.23; OR for not single participants = 0.46, 95% CI 0.16 to 1.25). |
Gillespie (2022) | Wales | Quantitative | n/a | n/a | Prior to the introduction of control measures, PrEP was taken on 3791/5785 (66%) days, there were CAS episodes on 506/5559 (9%) days, and 207/406 (51%) of CAS episodes were covered by an adequate amount of daily PrEP. The introduction of pandemic-related control measures was associated with a reduction in PrEP use (OR 0.44, 95%CI 0.20–0.95), CAS (OR 0.35, 95%CI 0.17–0.69), and PrEP adherence (RR = 0.55, 95%CI 0.34–0.89). The odds of participants taking PrEP on a given day were 56% lower following the introduction of control measures (OR 0.44, 95% CI 0.20 to 0.95, z = − 2.09, p = 0.037). |
Grov (2021) | USA | Quantitative | TGW and MSM | n = 789 | Among the 789 participants prescribed HIV pre-exposure prophylaxis (PrEP), 29.9% said they stopped taking their PrEP entirely, and 14.2% started selectively skipping doses. For those who had been taking PrEP, discontinuing PrEP was associated with having no new sex partners (β = 0.90, 95% CI 0.40–1.40). |
Hammoud (2021) | Australia | Quantitative | MSM | n = 847 | 41.8% (n = 167) discontinued PrEP use during COVID-19 restrictions. Discontinuing PrEP during COVID-19 restrictions was independently associated with being less likely to have recently tested for HIV (aOR: 0.17; 95% CI: 0.09 to 0.34; P < 0.001) and less likely to report sex with casual partners (aOR: 0.28; 95% CI: 0.14 to 0.54; P < 0.001). Among the 167 men who discontinued using PrEP during COVID-19 restrictions, the majority reported sex with casual partners in the 6 months before survey completion between 2015 (78.3%) and 2019 (69.8%), but this fell to 7.8% during COVID-19 restrictions. Men who discontinued PrEP during COVID-19 restrictions were younger than those who continued using PrEP (mean: 42.44 vs. 45.24; P = 0.031). They were also less likely to have recently tested for both HIV and other sexually transmitted infections (STIs) than those who continued using PrEP. |
Hill (2021) | Arkansas, Missouri, Oklahoma, USA | Quantitative | n/a | n = 80 | Results revealed that a significantly greater proportion of male PrEP visits occurred during the first four months of the COVID-19 pandemic, compared to male PrEP visits during the same time period in the previous year (z = − 3.83, p < 0.001). This difference had a small effect size (d = 0.16). Monthly year-over-year comparisons of male PrEP visits suggest a significantly greater proportion of male visits were used for PrEP for every month during the onset of the pandemic with the exception of May (z = 0, p = 1.0, d = 0.01). |
Hoagland (2021) | Brazil | Quantitative | n/a | n = 2375 | PrEP teleconsultation was experienced by 21.5% of PrEP users (146/680) and 89.0% (130/146) reported feeling satisfied with these new procedures. High acceptability of PrEP teleconsultation was reported by 70%. In ordinal logistic model, having higher education was associated with high acceptability of PrEP tele- consultation (aOR:1.62; 95%CI: 1.07–2.45). |
Hong (2022) | USA | Quantitative | Young MSM | n = 239 | One-in-seven YSMM PrEP users discontinued use during the pandemic, and all those who discontinued PrEP reported a decrease in sexual activity. Among those who met Centers for Disease Control and Prevention criteria for PrEP (n = 104), 86.5% were not currently using PrEP. |
Howarth (2021) | UK | Quantitative | MSM | n = 2018 | Among all participants, 23.4% had ever used PrEP, 5.1% last used it just before lockdown and 15.4% last used PrEP since lockdown began. Among PrEP users (those who reported ever using PrEP), 21.7% had last used PrEP just before lockdown and 65.7% since lockdown began. Those who had last used PrEP since lockdown began were more likely to report one or more new partners since lockdown began (63.8% vs. 19.8%), whereas those who had last used PrEP just before lockdown were more likely to report no new partners since lockdown began (80.2% vs. 36.2%, p < 0.001). |
Hyndman (2021) | UK | Quantitative | MSM | n = 814 | 75% of the MSM were PrEP users. PrEP users had a higher median number of sex partners and were more likely to have sex outside their household than non-PrEP users during lockdown. They were also more likely to engage in chemsex and were more likely to have accessed SHS (all p < 0 0.01), but there was no significant difference in reported STI diagnoses between the two groups. |
Jongen (2021) | Amsterdam, Netherlands | Quantitative | MSM | n = 136 | The proportion of days with PrEP use decreased from 74% before to 58% after March 15, 2020 (P < 0.001). After March 15, 2020, PrEP use during sex decreased with unknown casual partners (b = 20.36; 95% CI = 20.72 to 0.00) but not with steady partners and known casual partners. |
MacCarthy (2020) | California, USA | Mixed methods | Latinx sexual minority men (LSMM) and transgender women (LTGW) | n = 52 | More than one-third (35.6%) reported being on PrEP prior to COVID-19; among those previously taking PrEP, 66.7% have continued taking it and reported getting refills either via telemedicine appointments or office-based visits. One-quarter (25.0%) reported being either concerned or very concerned about their ability to access PrEP during the shelter at home order. The reasons for discontinuing PrEP related to a substantial decrease in the number of their sexual partners, so participants no longer felt like they needed to take it. A few participants drew parallels with HIV, saying they viewed COVID-19 as a highly infectious version of HIV and wanted to avoid it, and therefore continued taking PrEP. |
Matambanadzo (2021) | Zimbabwe | Quantitative | female sex worker | n/a | Beginning May 2020, PrEP uptake increased monthly, peaking at an initiation rate of 51% (n = 1360) in September 2020. Unexpected rise in demand coincided with national commodity shortages between October and December 2020, resulting in restriction of new initiations with sites prioritizing refills. |
Mistler (2021) | Connecticut, USA | Quantitative | Opioid-Dependent people who inject drugs | n = 110 | One-fourth of the 32 participants who were taking PrEP before the onset of COVID-19 reported that they had trouble getting their PrEP prescription due to COVID-19, and some reported that they had difficulty getting the PrEP prescription filled at their pharmacy. |
Muhula (2021) | Kibera, Kenya | Quantitative | n/a | n = 176 | PrEP among discordant couples, the general populations, MSM, female sex workers and people with disabilities significantly increased by 24% |
O’Byrne (2021) | Ottawa, Canada | Quantitative | n/a | n = 202 | In a nurse-led PrEP clinic (PrEP-RN), PrEP linkage to care and follow-up occurred via established protocols. Among these 128 participants, 63.6% (n = 82/129) belonged to an HIV priority group and were offered a referral for HIV PrEP. |
Pampati (2020) | Southern USA | Quantitative | MSM | n = 56 | A fifth of participants discontinued or changed how often they take PrEP because of COVID-19. A quarter of the cohort documented challenges when attempting to access PrEP, HIV testing, or STD testing. Five participants (9%) reported discontinuing PrEP use. Several participants reported difficulties obtaining their PrEP medication (n = 8, 16%), and few participants noted switching to event-based dosing (n = 2, 4%). |
Quirke (2021) | Ireland | Quantitative | n/a | n = 387 | A small number of patients discontinued PrEP themselves during the lockdown period, as they were not at risk of HIV during this time and did not wish to take unnecessary medication. These patients have recommenced PrEP either themselves as they resumed sexual activity outside the home or since the reopening of the PrEP service. Others switched themselves from daily dosing to event-based dosing as required. |
Rao (2021) | 20 countries | Quantitative | MSM | n = 10,654 | 56% (5171/9173) reported perceived interruptions to PrEP. For PrEP, greater proportions reporting perceived interruptions were seen in Mexico and Turkey compared with all other countries. |
Reyniers (2021) | Belgium | Quantitative | MSM | n = 694 | Among those who used PrEP before the lockdown, 47.0% stopped using PrEP, 19.7% used event-driven PrEP and 33.3% used daily PrEP during the lockdown. Almost two-thirds of PrEP users had a PrEP care appointment in the weeks before the lockdown and a minority received follow-up elsewhere or online. Some PrEP users had concerns regarding their follow-up. |
Ringshall (2021) | Brighton, UK | Quantitative | n/a | n = 109 | A small but significant proportion of MSM using HIV-PrEP during the COVID-19 pandemic continued to see the same or increased number of non-steady sexual partners. These MSM were more likely to have engaged in chemsex and use STI-PrEP. |
Roche (2021) | Kenya | Mixed method | n/a | n/a | From the pre- to post-period, average monthly initiations at intervention and control clinics increased by 6 and 2.3, respectively, and percent of expected follow-up visits occurring on time decreased by 18% and 26%, respectively; controlled interrupted time seris analysis of PrEP initiations (n = 1227) and follow-up visits (n = 2696) revealed no significant difference between intervention and control clinics in terms of trends in PrEP initiation and on-time returns (all p > 0.05). |
Rogers (2021) | USA | Quantitative | Cis-gender MSM | n/a | During the Evolving Phase (compared to the Pre- COVID-19 Phase), there was a 6% [incidence rate ratio (IRR):0.94, 95% confidence interval (CI): 0.68–1.30, P = 0.72] reduction in the total number of PrEP visits, a 44% (IRR: 0.56, 95% CI: 0.21–1.50, P = 0.24) reduction in the number of initial PrEP visits, and a 0% (IRR: 1.00, 95% CI: 0.71–1.41, P = 0.99) decrease in the number of follow-up PrEP visits. During the COVID-19 Plateau Phase (com- pared to the Pre-COVID-19 Phase), there was a 16% (IRR: 0.84, 95% CI: 0.58–1.20, P = 0.34) reduction in total PrEP visits, a 49% (IRR: 0.51, 95% CI: 0.18–1.46, P = 0.21) reduction in initial PrEP visits, and a 12% (IRR: 0.88, 95% CI: 0.60–1.29, P = 0.51) reduction in follow-up PrEP visits. No significant decreases in PrEP visits were observed at any time point. |
Rogers (2022) | USA | Quantitative | MSM | n = 177 | PrEP users reported an average of 2.60 fewer sexual partners (95% CI − 4.04, − 1.40) during the pandemic compared to pre-COVID-19. Rates of depressive symptoms and alcohol use remained stable, and few patients reported substance use. |
Saberi (2021) | San Francisco, USA | Quantitative | n/a | n = 267 | Data indicate no reduction in PrEP use by patients in San Francisco Department of Public Health primary care clinics after the SARS-CoV-2 pandemic shelter-in-place restrictions. |
Saberi (2022) | San Francisco, USA | Quantitative | n/a | Nearly 87.7% PrEP users noted being extremely to moderately satisfied with the ability to complete the laboratory tests without having to come into a clinic. Approximately 49.3% of participants chose this home-collection method as their first choice for providing laboratory samples. | |
Sousa (2020) | Brazil and Portugal | Quantitative | MSM | n = 92 | Not living with the partner (aOR = 1.8; 95%CI: 1.2–2.6) and using PrEP (aOR = 2.6; 95%CI: 1.8–3.7) also substantially increased the odds of engaging in chemsex. |
Stephenson (2021) | USA | Quantitative | MSM | n = 518 | Current PrEP use was relatively high at 18%, with 9% reporting that COVID-19 had prevented them accessing their PrEP prescriptions. |
Stephenson (2022) | USA | Quantitative | MSM | n = 280 | Current PrEP use was relatively high at 21.8%, with 2.5% reporting that COVID-19 had prevented them accessing their PrEP prescriptions. |
Torres (2021) | Brazil | Quantitative | MSM | n = 3486 | A total of 68.5% (502/733) maintained daily oral PrEP during social distancing period, while 27.8% (204/733) stopped it completely, 1.5% (11/733) used ED-PrEP, and 2.2% (16/733), nonstandard PrEP regimens. Main reasons for stopping PrEP use were impediments to pick up PrEP refill at the health service (95/204; 46.6%) and sexual abstinence (81/204; 39.7%). Main reasons for continuing PrEP were fear of HIV infection (327/529; 61.8%), sex with casual partners (90/529; 17.0%), HIV-positive partner (63/529; 11.9%), and belief that PrEP protected against COVID-19 (49/529; 9.3%). |
Traeger (2021) | Australia | Quantitative | n/a | n/a | PrEP prescriptions declined by an estimated 236 at the week following implementation of restrictions, representing an immediate 33.3% decline in prescriptions (P < 0.001). Between 1 April 2020 and 30 June 2020 (during-restrictions period), the average number of PrEP prescriptions per week was 543 (a 24.4% decline compared with the pre-restrictions period overall). There was a nonsignificant increase of 10.6 prescriptions per week during the restrictions period (P 1⁄4 0.178). |
Richardson (2021) | UK | Quantitative | MSM | n = 448 | Overall, 94/448 (21%,95% CI = 17–25) of MSM were using event-based (EBD)-PrEP. New starters were significantly more likely to use EBD-PrEP compared to existing PrEP users (34%.vs.13%, χ2 = 27.6, p < 0.00001). There were 33/38 clinicians who responded to the online survey. Clinicians felt equally confident at delivering daily PrEP as EBD-PrEP (Likert scores = 4.4/5 v 4.2/5, p = 0.2). |
Xavier Hall (2022) | USA | Quantitative | SGM youth and young adults | n = 1142 | This study was not sufficiently powered to observe a statistically significant association between social distancing and PrEP use. While it was not significant, those who reported no COVID-19 protective behaviors had the least amount of PrEP use compared to those with one or more social distancing behaviors. |
Zapata (2022) | USA | Qualitative | Young MSM | n = 41 | By PrEP use status, 22.0% of participants were currently taking PrEP, and 17.1% were former PrEP users. Three participants (7.3%) reported prior PEP use in their lifetime. PrEP services were also disrupted both in maintenance and initiation. Although several participants were on PrEP, they experienced barriers to attending appointments, receiving refills, and/or obtaining their quarterly testing. |
Reasons for Changing PrEP Uptake and Persistence
“I couldn’t get PrEP filled because my appointment was cancelled because of the pandemic.”[29]