Faculdade de Medicina, Universidade de São Paulo, São Paulo, Brazil.
Centro de Referência e Treinamento DST/Aids, São Paulo, Brazil.
J Int AIDS Soc. 2023 Sep;26(9):e26173. doi: 10.1002/jia2.26173.
Pre-exposure prophylaxis (PrEP) delivery based on user needs can enhance PrEP access and impact. We examined whether telehealth for daily oral PrEP delivery could change the indicators of care related to prophylactic use in five Brazilian public HIV clinics (testing centres, outpatient clinics and infectious disease hospitals).
Between July 2019 and December 2020, clients on PrEP for at least 6 months could transition to telehealth or stay with in-person follow-up. Clients were clinically monitored until June 2021. A desktop or mobile application was developed, comprising three asynchronous consultations and one annual in-person consultation visit. Predictors influencing telehealth preference and care outcomes were examined. The analysis encompassed intent-to-treat (first choice) and adjustments for sexual practices, schooling, age, duration of PrEP use and PrEP status during the choice period.
Of 470 users, 52% chose telehealth, with the adjusted odds ratio (aOR) increasing over time for PrEP use (aOR for 25-months of use: 4.90; 95% CI: 1.32-18.25), having discontinued PrEP at the time of the choice (aOR: 2.91; 95% CI: 1.40-6.06) and having health insurance (aOR: 1.91; 95% CI: 1.24-2.94) and decreasing for those who reported higher-risk behaviour (aOR for unprotected anal sex: 0.51; 95% CI: 0.29-0.88). After an average follow-up period of 1.6 years (95% CI: 1.5-1.7), the risk of discontinuing PrEP (not having the medication for more than 90 days) was 34% lower with telehealth (adjusted hazard ratio: 0.66; 95% CI: 0.45-0.97). When adjusted by mixed linear regression, no differences in adherence (measured by mean medication possession rate) were found between in-person and telehealth (p = 0.486) or at pre- and post-telehealth follow-ups (p = 0.245). Sexually transmitted infections increased between the pre-follow-up and post-follow-up choices and were not associated with in-person or telehealth (p = 0.528). No HIV infections were observed.
Our findings indicate that telehealth for PrEP delivery can enhance service rationalization and reinforce the prevention cascade. This approach reduces prophylaxis interruptions and is mainly preferred by individuals with lower demands for healthcare services.
基于用户需求的暴露前预防（PrEP）给药可以增加 PrEP 的可及性和影响。我们研究了在巴西五家公共艾滋病毒诊所（检测中心、门诊和传染病医院）中，每日口服 PrEP 治疗的远程医疗是否可以改变与预防性使用相关的护理指标。
2019 年 7 月至 2020 年 12 月，至少使用 PrEP 6 个月的患者可以选择远程医疗或继续接受面对面随访。患者一直接受临床监测，直到 2021 年 6 月。开发了一个桌面或移动应用程序，包括三次异步咨询和一次年度面对面咨询。检查了影响远程医疗偏好和护理结果的预测因素。分析包括意向治疗（第一选择）和调整性行为、教育程度、年龄、PrEP 使用时间以及选择期间 PrEP 状态。
在 470 名使用者中，有 52%选择了远程医疗，随着 PrEP 使用时间的增加，调整后的优势比（aOR）也在增加（使用 25 个月的 aOR：4.90；95%CI：1.32-18.25），在选择时已经停止使用 PrEP（aOR：2.91；95%CI：1.40-6.06）和拥有健康保险（aOR：1.91；95%CI：1.24-2.94），而对于报告更高风险行为的人则降低（无保护肛交的 aOR：0.51；95%CI：0.29-0.88）。在平均 1.6 年（95%CI：1.5-1.7）的随访后，远程医疗组停止 PrEP（90 天以上未服药）的风险降低了 34%（调整后的危害比：0.66；95%CI：0.45-0.97）。通过混合线性回归调整后，面对面和远程医疗之间（p = 0.486）或远程医疗前后随访（p = 0.245）的依从性（通过平均药物占有率测量）没有差异。性传播感染在随访前和随访后的选择之间增加，与面对面或远程医疗无关（p = 0.528）。未观察到 HIV 感染。
我们的研究结果表明，PrEP 远程医疗交付可以增强服务合理化，并加强预防级联。这种方法减少了预防中断，主要由对医疗服务需求较低的个体所选择。
