Antiretroviral Therapy for the Prevention of HIV-1 Transmission

Substantial decline in heavily treated therapy-experienced persons with HIV with limited antiretroviral treatment options

OBJECTIVE

Historically, a high burden of resistance to antiretroviral therapy (ART) in heavily treatment-experienced (HTE) persons with HIV (PWH) resulted in limited treatment options (LTOs). We evaluated the prevalence, risk factors, and virologic control of HTE PWH with LTO throughout the modern ART era.

DESIGN

We examined all ART-experienced PWH in care between 2000 and 2017 in the Centers for AIDS Research Network of Integrated Clinical Systems cohort.

METHODS

We computed the annual prevalence of HTE PWH with LTO defined as having two or less available classes with two or less active drugs per class based on genotypic data and cumulative antiretroviral resistance. We used multivariable Cox proportional hazards models to examine risk of LTO by 3-year study entry periods adjusting for demographic and clinical characteristics.

RESULTS

Among 27 133 ART-experienced PWH, 916 were classified as having LTO. The prevalence of PWH with LTO was 5.2-7.5% in 2000-2006, decreased to 1.8% in 2007, and remained less than 1% after 2012. Persons entering the study in 2009-2011 had an 80% lower risk of LTO compared with those entering in 2006-2008 (adjusted hazard ratio 0.20; 95% confidence interval: 0.09-0.42). We found a significant increase in undetectable HIV viral loads among PWH ever classified as having LTO from less than 30% in 2001 to more than 80% in 2011, comparable with persons who never had LTO.

CONCLUSION

Results of this large multicenter study show a dramatic decline in the prevalence of PWH with LTO to less than 1% with the availability of more potent drugs and a marked increase in virologic suppression in the current ART era.

Is contact between men who have sex with men and non-governmental organizations providing harm reduction associated with improved HIV outcomes?

Objectives

There is a high prevalence of HIV (5.2% in 2018) among men who have sex with men (MSM) in Ukraine. HIV testing, condom provision and facilitated linkage to HIV treatment have been funded by various bodies through non‐governmental organizations (NGOs). We investigated whether contact with these NGOs was associated with improved prevention and treatment outcomes among MSM in Ukraine.

Methods

Data were taken from four rounds of integrated bio‐behavioural surveys among MSM in Ukraine (2011, N = 5950; 2013, N = 8101; 2015, N = 4550; 2018, N = 5971) including HIV testing combined with questionnaire responses. Data were analysed using mixed‐effect regression models, which estimated associations between being an NGO client and behavioural, HIV testing and HIV treatment outcomes, adjusted for demographic factors.

Results

Those MSM who were NGO clients were more likely than non‐clients to have been HIV tested in the last year [adjusted odds ratio (aOR) = 7.01, 95% confidence interval (CI): 6.45–7.62] or ever (aOR = 11.00, 95% CI: 9.77–12.38), to have used a condom for the last anal sex act (aOR = 1.32, 95% CI: 1.21–1.43), and to have recently either bought or received condoms (aOR = 21.27, 95% CI: 18.01–25.12). HIV‐positive MSM were more likely to have contact with NGOs (aOR = 1.61, 95% CI: 1.39–1.86). Among the HIV‐positive MSM, those who were NGO clients were more likely to be registered at an AIDS centre (aOR = 2.24, 95% CI: 1.61–3.11) and to be on antiretroviral treatment (aOR = 2.20, 95% CI: 1.51–3.20).

Conclusions

In Ukraine, being in contact with MSM‐targeted NGOs is associated with better outcomes for HIV prevention, testing and treatment, suggesting that NGO harm reduction projects for MSM have had a beneficial impact on reducing HIV transmission and morbidity.

Primary Care Guidance for Persons With Human Immunodeficiency Virus: 2020 Update by the HIV Medicine Association of the Infectious Diseases Society of America

Advances in antiretroviral therapy (ART) have made it possible for persons with human immunodeficiency virus (HIV) to live a near expected life span, without progressing to AIDS or transmitting HIV to sexual partners or infants. There is, therefore, increasing emphasis on maintaining health throughout the life span. To receive optimal medical care and achieve desired outcomes, persons with HIV must be consistently engaged in care and able to access uninterrupted treatment, including ART. Comprehensive evidence-based HIV primary care guidance is, therefore, more important than ever. Creating a patient-centered, stigma-free care environment is essential for care engagement. Barriers to care must be decreased at the societal, health system, clinic, and individual levels. As the population ages and noncommunicable diseases arise, providing comprehensive healthcare for persons with HIV becomes increasingly complex, including management of multiple comorbidities and the associated challenges of polypharmacy, while not neglecting HIV-related health concerns. Clinicians must address issues specific to persons of childbearing potential, including care during preconception and pregnancy, and to children, adolescents, and transgender and gender-diverse individuals. This guidance from an expert panel of the HIV Medicine Association of the Infectious Diseases Society of America updates previous 2013 primary care guidelines.

Unintended uses, meanings, and consequences: HIV self-testing among female sex workers in urban Uganda

ABSTRACTFemale sex workers (FSWs) are at increased risk of HIV and face significant barriers to clinic-based HIV testing, including provider stigma and privacy constraints. HIV self-testing (HIVST) has been proven to significantly increase HIV testing among FSWs. Less is known, however, about how FSWs make meaning of oral-fluid HIV self-tests, and the unintended ways they use and understand this novel technology. From October 2016 to March 2017, we conducted 61 in-depth interviews with FSWs (n = 31) in Kampala, Uganda. Eligible participants were: female, ≥18 years, exchanged sex for money or goods, and had not recently tested for HIV. We used inductive coding to identify emerging themes and re-arranged these into an adapted framework. Unintended desirable ways FSWs described self-testing included as a means to test others, to bolster their reputation as a health-conscious sex worker, and to avoid bearing witness to suffering at health facilities. Unintended undesirable meanings ascribed to self-testing included misunderstandings about how HIV is transmitted (via saliva versus blood) and whether self-tests also test for other infections. HIVST can increase FSWs' knowledge of their own HIV status and that of their sexual partners, but messaging and intervention design must address misunderstandings and misuses of self-testing.Trial registration: ClinicalTrials.gov identifier: NCT02846402.

Modified Antiretroviral Treatment Access Study (MARTAS): A Randomized Controlled Trial of the Efficacy of a Linkage-to-Care Intervention Among HIV-Positive Patients in Ukraine

Between October 2015 and March 2018, we conducted the Modified Antiretroviral Treatment Access Study (MARTAS), a nurse-delivered case management intervention to improve linkage-to-care for persons recently tested HIV positive. Adult participants from nine urban clinics in three regions of Ukraine were randomized to either MARTAS or standard of care (SOC) using individual, parallel, two-arm design. The main study outcome was linkage-to-care (defined as registration at an HIV clinic) within a 3-month period from enrollment in the study. Intention-to-treat analysis of MARTAS (n = 135) versus SOC (n = 139) showed intervention efficacy in linkage to HIV care (84.4% vs. 33.8%; adjusted RR 2.45; 95% CI 1.72, 3.47; p < 0.001). MARTAS is recommended for implementation in Ukraine and may be helpful in other countries with similar gaps in linkage-to-care. Clinicaltrials.gov registration number: NCT02338024.

Preparation and evaluation of amphipathic lipopeptide-loaded PLGA microspheres as sustained-release system for AIDS prevention

At present, AIDS drugs are typical inhibitors that cannot achieve permanent effects. Therefore, the research of blocking HIV infection is essential. Especially for people in the high-risk environment, long-term prevention is important, because HIV can easily infect cells once the drug is interrupted. However, there is still no long-acting AIDS prevention drug approved. Hence, the purpose of this study is to prepare a fusion inhibitor loaded poly(d, l-lactic-co-glycolic acid) (PLGA) microspheres as a sustained-release system for long-term AIDS prevention. As the HIV membrane fusion inhibitor (LP-98) used in this research is amphiphilic lipopeptide, W1/O/W2 double-emulsion method was chosen, and premix membrane emulsification technique was used for controlling the uniformity of particle size. Several process parameters that can impact drug loading efficiency were summarized: the concentration of LP-98 and PLGA, and the preparation condition of primary emulsion. Finally, the microspheres with high loading efficiency (>8%) and encapsulation efficiency (>90%) were successfully prepared under optimum conditions. Pharmacokinetic studies showed that LP-98-loaded microspheres were capable to continuously release for 24 days in rats. This research can promote the application of sustained-release microspheres in AIDS prevention, and the embedding technique used in this study can also provide references for the loading of other amphipathic drugs.

HIV-1 Integrase Inhibitors: A Comparative Review of Efficacy and Safety

The newest class of antiretrovirals for all persons living with HIV are the integrase strand transfer inhibitors (INSTIs). Since 2007, five INSTIs have been introduced: raltegravir, elvitegravir, dolutegravir, bictegravir, and cabotegravir. The INSTIs have favorable pharmacokinetic and pharmacodynamic properties, which contribute to both their effectiveness and their ease of use. With the exception of cabotegravir, each INSTI is US Food and Drug Administration approved for treatment-naïve individuals initiating antiretroviral therapy. All of the INSTIs, except raltegravir, are approved for antiretroviral treatment simplification for virologically suppressed patients without INSTI resistance. Data also support the use of dolutegravir and raltegravir in individuals with antiretroviral resistance as part of an optimized antiretroviral regimen. INSTIs are generally well tolerated by people living with HIV compared with older classes of antiretrovirals, but emerging data suggest that some INSTIs contribute to weight gain. Due to their efficacy, safety, and ease of use, HIV treatment guidelines recommend oral INSTIs as preferred components of antiretroviral therapy for individuals initiating therapy. The newest INSTI, cabotegravir, represents an alternative to oral administration of life-long antiretroviral therapy with the availability of a long-acting injectable formulation. This review summarizes the current use of INSTIs in adults living with HIV, highlighting the similarities and differences within the class related to pharmacodynamics, pharmacokinetics, safety, dosing, and administration that contribute to their role in modern antiretroviral therapy.

Sexual behaviour change following HIV testing services: a systematic review and meta-analysis

INTRODUCTION

Learning one's HIV status through HIV testing services (HTS) is an essential step toward accessing treatment and linking to preventive services for those at high HIV risk. HTS may impact subsequent sexual behaviour, but the degree to which this varies by population or is true in the setting of contemporary HIV prevention activities is largely unknown. As part of the 2019 World Health Organization Consolidated Guidelines on HTS, we undertook a systematic review and meta-analysis to determine the effect of HTS on sexual behaviour.

METHODS

We searched nine electronic databases for studies published between July 2010 and December 2019. We included studies that reported on at least one outcome (condom use [defined as the frequency of condom use or condom-protected sex], number of sex partners, HIV incidence, STI incidence/prevalence). We included studies that prospectively assessed outcomes and that fit into one of three categories: (1) those evaluating more versus less-intensive HTS, (2) those of populations receiving HTS versus not and (3) those evaluating outcomes after versus before HTS. We conducted meta-analyses using random-effects models.

RESULTS AND DISCUSSION

Of 29 980 studies screened, 76 studies were included. Thirty-eight studies were randomized controlled trials, 36 were cohort studies, one was quasi-experimental and one was a serial cross-sectional study. There was no significant difference in condom use among individuals receiving more-intensive HTS compared to less-intensive HTS (relative risk [RR]=1.03; 95% CI: 0.99 to 1.07). Condom use was significantly higher after receiving HTS compared to before HTS for individuals newly diagnosed with HIV (RR = 1.65; 95% CI: 1.36 to 1.99) and marginally significantly higher for individuals receiving an HIV-negative diagnosis (RR = 1.63; 95% CI: 1.01 to 2.62). Individuals receiving more-intensive HTS reported fewer sex partners at follow-up than those receiving less-intensive HTS, but the finding was not statistically significant (mean difference = -0.28; 95% CI: -3.66, 3.10).

CONCLUSIONS

Our findings highlight the importance of using limited resources towards HTS strategies that focus on early HIV diagnosis, treatment and prevention services rather than resources dedicated to supplementing or enhancing HTS with additional counselling or other interventions.

A call to improve understanding of Undetectable equals Untransmittable (U = U) in Brazil: a web-based survey

INTRODUCTION

Currently, the slogan "Undetectable = Untransmittable" (U = U), launched to disseminate scientific evidence on how people living with HIV (PLHIV) on antiretroviral treatment with suppressed viral load cannot transmit HIV to their sexual partners, is still challenged by individuals with differential acceptance across populations. In this study, we documented the perceived accuracy of U = U in Brazil in three different groups: PLHIV, HIV-negative/unknown cisgender gay/bisexual men who have sex with men (GBM) and HIV-negative/unknown other populations (POP).

METHODS

Adult (age ≥ 18y) Brazilians were recruited during October 2019 to complete a web-based survey advertised on Grindr, Facebook and WhatsApp. Perceived accuracy of U = U was assessed with the question: "With regards to HIV-positive individuals transmitting HIV through sexual contact, how accurate do you believe the slogan U = U is?" Response options ranged from 1 (Completely inaccurate) to 4 (Completely accurate) plus a fifth option (I don't know what "undetectable" means). Participants' characteristics were described according to perceived accuracy of U = U. Logistic regression models assessed the factors associated with perceived accuracy of U = U (completely accurate vs. partially accurate/inaccurate or completely inaccurate) by group.

RESULTS

Of 2311 individuals accessing the questionnaire, 1690 (73.1%) met inclusion/exclusion criteria and completed it. Of these, 347 (20.5%) were PLHIV, 785 (46.4%) GBM and 558 (33.0%) POP. More PLHIV perceived U = U as completely accurate (79.0%), compared to 44.2% GBM and 17.2% POP (p < 0.001). Among PLHIV, Black identity was associated with decreased odds of perceiving U = U as completely accurate while having a steady partner was associated with increased odds. Among GBM, being gay, having middle/higher income, being a resident of state capital metropolitan areas and ever testing for HIV were associated with increased odds. Lastly, among POP, ever testing for HIV increased the odds of perceiving U = U as completely accurate.

CONCLUSIONS

There was a significant difference in perceived accuracy of U = U across population groups. Accurate understanding of the slogan needs to be promoted in more vulnerable populations such as PLHIV of Black identity and GBM of lower income to maximize individual and societal prevention benefits. Moreover, broader understating of U = U among the general population can help decrease societal stigma towards PLHIV.

Reducing the Discussion Divide by Digital Questionnaires in Health Care Settings: Disruptive Innovation for HIV Testing and PrEP Screening

BACKGROUND

Health care provider assessment of patient sexual behavior and substance use is essential for determining appropriate prevention interventions-including HIV pre-exposure prophylaxis (PrEP)-for sexual minority men (SMM). We sought to explore acceptability and utility of using electronic surveys to conduct health behavior assessments in clinical settings among SMM.

METHODS

Among a US nationwide sample of SMM (n = 4187; mean age = 38.3 years; 60% white; 82% HIV-negative), we examined associations of demographics, recruitment venue, sexual behavior characteristics, and recent substance use with participants' comfort communicating verbally and through electronic survey with a health care provider about sexual and substance use behavior.

RESULTS

On average, SMM had greater comfort communicating through electronic survey vs. verbally. In our fully adjusted analysis, preference favoring electronic surveys more strongly than verbal communication differed by age (β = -0.07, P ≤ 0.001). SMM with a bachelor's degree or more (β = 0.04, P < 0.05), those recruited from nonclinical settings (β = 0.06, P ≤ 0.001), and those without primary care providers (β = 0.04, P < 0.05) favored electronic surveys more strongly in the fully adjusted multivariable model. SMM who reported any recent casual sex partners (β = 0.05, P < 0.01), those never tested for HIV (β = 0.03, P < 0.05), and HIV-negative/unknown men not on PrEP (compared with PrEP users; β = 0.09, P ≤ 0.001) also favored electronic surveys in the fully adjusted model.

CONCLUSIONS

Reducing communication barriers by incorporating electronic surveys into patient assessments could help identify HIV testing and PrEP needs for SMM most susceptible to HIV acquisition. Nonetheless, no one screening strategy is likely to work for most SMM, and multiple approaches are needed.

Comparative efficacy, tolerability and safety of dolutegravir and efavirenz 400mg among antiretroviral therapies for first-line HIV treatment: A systematic literature review and network meta-analysis

BACKGROUND

To inform World Health Organization (WHO) global guidelines, we updated and expanded the evidence base to assess the comparative efficacy, tolerability, and safety of first-line antiretroviral therapy (ART) regimens.

METHODS

We searched Embase, Medline and CENTRAL on 28 February 2020 to update the systematic literature review of clinical trials comparing recommended first-line ART that informed previous WHO guidelines. Outcomes included viral suppression, change in CD4 cell counts, mortality, serious and overall adverse events (AEs), discontinuation, discontinuations due to AEs (DAEs); and new outcomes: drug-resistance, neuropsychiatric AEs, early viral suppression, weight gain and birth outcomes. Comparative effects were assessed through network meta-analyses and certainty in the evidence was assessed using the GRADE framework.

FINDINGS

We identified 156 publications pertaining to 68 trials for the primary population. Relative to efavirenz, dolutegravir had improved odds of viral suppression across all time points (odds ratio [OR]: 1·94; 95% credible interval [CrI]: 1·48-2·56 at 96 weeks); was protective of drug-resistance (OR: 0·13; 95%CrI: 0·04-0·48); and led to fewer discontinuations (OR: 0·58; 95%CrI: 0·48-0·70). Evidence supported dolutegravir use among TB-HIV co-infected persons and pregnant women. Adverse birth outcomes were observed in 33.2% of dolutegravir-managed pregnancies and 35.0% of efavirenz-managed pregnancies. Low-dose efavirenz had comparable efficacy and safety to standard-dose efavirenz, but led to fewer DAEs (OR: 0·70; 95%CrI: 0·50-0·92).

INTERPRETATION

The evidence supports choosing dolutegravir in combination with lamivudine/emtricitabine and tenofovir disoproxil fumarate as the preferred first-line regimen and low-dose efavirenz-based regimens as an alternative. Dolutegravir can be considered to be effective, safe and tolerable.

FUNDING

WHO.

Cascade of care of people diagnosed with HIV in New Zealand between 2006 and 2017

OBJECTIVES

We estimated the proportion of people reported with HIV in New Zealand between 2006 and 2017, and alive in 2017-2019, who were on antiretroviral therapy (ART) and had a suppressed viral load (VL), and explored their associated characteristics.

METHODS

Data were anonymously linked to information on ART and VL within the data collection period (January 2017 to August 2019) using the National Health Index (NHI), Ministry of Health and laboratory datasets, as well as information from clinical specialists. Logistic regression was used to test for associations. Sensitivity analyses were undertaken to estimate the range for the key proportions.

RESULTS

Overall, 2355 people were reported with HIV, of whom 116 (5%) had died, 337 (14%) were overseas, and 1701 (72%) were alive in New Zealand; for the remaining 201 (9%) the outcome was unknown. Clinical data were available for 1490 people (87.6%): 1408 (94.5%) were on ART, 11 (< 1%) were not on ART, and for 71 (4.8%) this was unknown. Of those on ART, 1156 (82.1%) had a suppressed VL (< 200 copies/mL), 34 (2.4%) were unsuppressed, and for 218 (15.5%) this was unknown. The estimate of the proportion on ART ranged from 99% to 78%, and those with a suppressed VL ranged from 98% to 78%.

CONCLUSIONS

Among people with HIV in New Zealand who are under care, a high proportion were on ART and had suppressed VL. Increasing collection of NHIs and better linkage with laboratory information will reduce the number with unknown information and provide more complete VL results in the future.

Patterns of detectable viral load in a cohort of HIV-positive adolescents on antiretroviral therapy in South Africa

INTRODUCTION

Despite improved treatment and access to care, adolescent AIDS deaths are decreasing more slowly than in any other age group. There is lack of longitudinal data around adolescent adherence and the dynamics of viraemia over time. We aimed to describe patterns of detectable viral load (VL) in a cohort of adolescents attending an ARV clinic in Cape Town, South Africa.

METHODS

We conducted a retrospective cohort study of all patients on antiretroviral therapy aged 10 to 19 years. Participants were included if they underwent at least two VL measurements and remained in care at the Groote Schuur Hospital HIV Clinic for at least 24 months between 2002 and 2016. The primary outcome was two consecutive HIV VL >100 copies/mL, in line with the lower limit of detection of assays in use over the follow-up period.

RESULTS AND DISCUSSION

Of the 482 screened participants, 327 met inclusion criteria. Most participants had perinatally acquired HIV (n = 314; 96%), and 170 (52%) were males. Overall, there were 203 episodes of confirmed detectable VL involving 159 (49% (95% CI 43% to 54%)) participants during the follow-up period. Six participants had genotyped resistance to protease inhibitors. Four of these never suppressed, while two suppressed on salvage regimens. Total follow-up time was 1723 person years (PY), of which 880 (51%) were contributed by the 159 participants who experienced detectable VL. Overall time with detectable VL was 370 PY. This comprised 22% of total follow-up time, and 42% of the follow-up time contributed by those who experienced detectable VL. The rate of detectable VL was 11.8 (95% CI 10.3 to 13.5) episodes per 100 PY. The risk increased by 24% for each year of increasing age (Relative Risk 1.24 (95% CI 1.17 to 1.31); p < 0.0001). There was no sex difference with respect to duration (p = 0.4), prevalence (p = 0.46) and rate (p = 0.608) of detectable VL.

CONCLUSIONS

Clinicians need to be alert to the high prevalence of detectable VL during adolescence so as to pre-empt it and act swiftly once it is diagnosed. This study helps to highlight the risk of detectable VL that is associated with increase in age as well the high proportion of time that poorly adherent adolescents spend in this state.

Potential interactions between the pathways to diagnosis of HIV and other STIs and HIV self-testing: insights from a qualitative study of gay, bisexual and other men who have sex with men in Singapore

Objectives

This study draws on qualitative insights on the barriers and facilitators to HIV testing, as well as perceptions of HIV self-testing (HIVST), to propose a framework to understand not only the benefits but also potential knock-on implications of introducing HIVST in the context of other STI testing.

Methods

We conducted semistructured, in-depth interviews with 30 gay, bisexual and other men who have sex with men aged 18 and 39 years old in Singapore. Interview topics included barriers and facilitators to HIV and other STI testing, as well as perceptions of HIVST. Interviews were audio-recorded, transcribed, coded and analysed using thematic analysis.

Results

For HIV testing, participants cited the perceived risk of acquiring, susceptibility to and symptoms of HIV as internal motivators, while social influence and accessibility of HIV testing services were external motivators. For STI testing, perceived symptoms and partner notification of STI were reported as internal and external motivators, respectively. Availability of bundle tests, starting a new relationship and instances of mandatory testing motivated both simultaneous HIV and other STI testing. The fear of a positive diagnosis and lack of confidentiality were cited as internal and external barriers to HIV testing, respectively, while low perceived severity of other STI and the cost of STI tests were cited as internal and external barriers to other STI testing, respectively. We identified pathways to HIV and other STI testing and discussed how the introduction of HIVST may reduce opportunities for other STI testing.

Conclusions

The findings of this study suggest that introducing HIVST might weaken linkages to other STI testing if alternative strategies of promoting other STI testing are not simultaneously implemented. We recommend that future interventions address both the risks of HIV and other STI simultaneously, and that structural interventions promoting HIV and other STI preventions be balanced accordingly.

Comparing Web-Based Platforms for Promoting HIV Self-Testing and Pre-Exposure Prophylaxis Uptake in High-Risk Men Who Have Sex With Men: Protocol for a Longitudinal Cohort Study

BACKGROUND

The majority of those living with HIV in the United States are men who have sex with men (MSM), and young, minority MSM account for more new HIV infections than any other group. HIV transmission can be reduced through detection and early treatment initiation or by starting pre-exposure prophylaxis (PrEP), but rates of testing are lower than recommended among MSM, and PrEP uptake has been slow. Although promoting HIV testing and PrEP uptake by placing advertisements on web-based platforms - such as social media websites and dating apps - is a promising approach for promoting HIV testing and PrEP, the relative effectiveness of HIV prevention advertising on common web-based platforms is underexamined.

OBJECTIVE

This study aims to evaluate the relative effectiveness of advertisements placed on 3 types of web-based platforms (social media websites, dating apps, and informational websites) for promoting HIV self-testing and PrEP uptake.

METHODS

Advertisements will be placed on social media websites (Facebook, Instagram, and Twitter), dating apps (Grindr, Jack'd, and Hornet), and informational search websites (Google, Yahoo, and Bing) to recruit approximately 400 young (18-30 years old), minority (Black or Latino) MSM at elevated risk of HIV exposure. Recruitment will occur in 3 waves, with each wave running advertisements on 1 website from each type of platform. The number of participants per platform is not prespecified, and recruitment in each wave will occur until approximately 133 HIV self-tests are ordered. Participants will complete a baseline survey assessing risk behavior, substance use, psychological readiness to test, and attitudes and then receive an electronic code to order a free home-based HIV self-test kit. Two follow-ups are planned to assess HIV self-test results and PrEP uptake.

RESULTS

Recruitment was completed in July 2020.

CONCLUSIONS

Findings may improve our understanding of how the platform users' receptivity to test for HIV differs across web-based platforms and thus may assist in facilitating web-based HIV prevention campaigns.

TRIAL REGISTRATION

ClinicalTrials.gov NCT04155502; https://clinicaltrials.gov/ct2/show/NCT04155502.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

DERR1-10.2196/20417.

Impact of viral suppression among persons with HIV upon estimated HIV incidence between 2010 and 2015 in the United States

BACKGROUND

The suppression of viremia among persons with HIV (PWH) using antiretroviral therapy has been hypothesized to reduce HIV incidence at the population level. We investigated the impact of state level viral suppression among PWH in the United States on estimated HIV incidence between 2010 and 2015.

METHODS

Viral suppression data and HIV incidence estimates from the National HIV Surveillance System were available from 29 states and the District of Columbia. We assumed a one year delay for viral suppression to impact incidence. Poisson regression models were used to calculate the estimated annual percent change (EAPC) in incidence rate. We employed a multivariable mixed-effects Poisson regression model to assess the effects of state level race/ethnicity, socioeconomic status, percent men who have sex with men (MSM) and hepatitis C virus prevalence as a proxy for injection drug use on HIV incidence.

FINDINGS

Fitted HIV incidence for 30 jurisdictions declined from 11.5 in 2010 to 10.0 per 100,000 population by 2015 corresponding with an EAPC of -2.67 (95% confidence interval [95%CI] -2.95, -2.38). Southern states experienced the highest estimated incidence by far throughout this period but upon adjustment for viral suppression and demographics there was a 36% lower incidence rate than Northeast states (adjusted rate ratio [aRR] 0.64; 95%CI 0.42, 0.99). For every 10 percentage point (pp) increase in viral suppression there was an adjusted 4% decline in HIV incidence rate in the subsequent year (aRR 0.96; 95%CI 0.93, 0.99). While controlling for viral suppression, HIV incidence rate increased by 42% (aRR 1.42 95%CI 1.31, 1.54) for every 5 pp increase in percent Black race and by 27% (aRR 1.27 95%CI 1.10, 1.48) for every 1 pp increase in percent MSM in states.

INTERPRETATION

A decline in estimated HIV incidence from 2010 to 2015 was associated with increasing viral suppression in the United States. Race and sexual orientation were important HIV acquisition risk factors.

Effects of Urethritis on HIV in Semen: Implications for HIV Prevention and Cure

BACKGROUND

Prior to the widespread availability of antiretroviral therapy (ART), Men living with HIV with urethritis had increased concentration of HIV in semen. This study aims to better evaluate HIV shedding in men with urethritis receiving ART, and implications for the cure of HIV.

METHODS

Men living with HIV with urethritis taking ART ≥12 weeks were enrolled at a sexually transmitted infections clinic in Lilongwe, Malawi. Study follow-up included visits 1, 2, 4, 8, 12, 24, 36, and 48 weeks post urethritis diagnosis and treatment. Matched blood and semen samples were collected at all visits, and all additional episodes of urethritis were followed with extra visits 1, 2, and 4 weeks after treatment.

RESULTS

111 men enrolled in the study between January 2017 - March 2019, and 77 (69%) were suppressed in the blood (<400 copies/mL). Among the 77 men, 87 episodes of urethritis were evaluated during follow-up. Of the 87 episodes, 15 episodes (17%) had instances of seminal viral shedding ≥400 copies/mL despite viral suppression in the blood. At follow-up of non-urethritis episodes, ≤6% of men at each visit had a viral load ≥400 copies/mL in the semen while maintaining viral suppression in the blood.

CONCLUSIONS

An HIV cure requires the elimination of HIV from every body compartment, but available ART does not currently accomplish this. Our study highlights the male genital tract as a local source of HIV that can be reversibly activated. A better understanding of this phenomenon is important to advance the HIV cure field.

Burden of living with HIV among men who have sex with men: a mixed-methods study

BACKGROUND

With biomedical developments in treatment and prevention of HIV, the implications of living with HIV are considerably more manageable. Within this context, we aimed to describe and quantify the present-day burden of living with HIV among men who have sex with men (MSM) in the Netherlands.

METHODS

In this mixed-methods study, we did in-depth interviews on HIV-related burden with MSM diagnosed with HIV between 2014 and 2018. Interviewees were recruited at three HIV treatment centres and the Public Health Service of Amsterdam in the Netherlands. Using the transcripts from all interviewees, the qualitative analysis was done by two independent researchers applying an open-coding process. Results were used to generate a questionnaire measuring HIV-related burden, which was distributed via gay dating apps or sites and social media. MSM diagnosed with HIV before 2019 who completed the questionnaire were included in the quantitative analyses. Descriptive analyses were used to report burden prevalence and to explore differences in burden among MSM diagnosed at different antiretroviral therapy periods. Sociodemographic determinants of burden were explored using multinomial logistic regression.

FINDINGS

Between May, 2018, and March, 2019, 18 of 25 MSM who consented for further contact were interviewed, after which thematic saturation was reached. The interviewees revealed that aspects related to medicalisation and emotional consequences were burdensome temporarily after diagnosis, whereas aspects related to HIV status disclosure, stigma, and the sexual and social life were mentioned to be burdensome more persistently. Between April and July, 2019, 613 MSM with HIV started the quantitative survey, of whom 438 (71%) completed the questionnaire and were included in the analyses. These 438 MSM were diagnosed with HIV between 1984 and 2018. The median time since HIV diagnosis was 8 years (IQR 4-13). In total, 135 (31%) of 438 online respondents reported that living with HIV was generally experienced as burdensome and 361 (82%) would be relieved if HIV could be cured. Compared with a low level of burden, a moderate level of burden was associated with having another chronic condition (p=0·0030), and a high level of burden was associated with a more recent diagnosis (p=0·0060) and not knowing other individuals with HIV (p=0·0020). Disclosure dilemmas were reported to be the most burdensome, resulting in difficulties initiating sex (122 [32%] of 378 respondents) and establishing relationships (85 [41%] of 207 respondents). The most prevalent emotional consequences were shame (112 [26%] of 438 respondents) and stress (80 [18%] of 438 respondents). Disclosure and taking antiretroviral therapy in the presence of others were experienced as more burdensome among those diagnosed after 2005 than among those diagnosed in or before 2005.

INTERPRETATION

Our findings highlight that despite medical advancements, further stigma reduction programmes and adapted psychosocial support for specific profiles of MSM living with HIV are needed.

FUNDING

HIV Transmission Elimination Amsterdam Initiative.

Rapid Antiretroviral Therapy (ART) Initiation at a Community-Based Clinic in Jackson, MS

Background

Rapid antiretroviral therapy (ART), ideally initiated within twenty-four hours of diagnosis, may be crucial in efforts to increase virologic suppression and reduce HIV transmission. Recent studies, including demonstration projects in large metropolitan areas such as Atlanta, Georgia; New Orleans, Louisiana; San Francisco, California; and Washington D.C., have demonstrated that rapid ART initiation is a novel tool for expediting viral suppression in clinical settings. Here we present an evaluation of the impact of a rapid ART initiation program in a community-based clinic in Jackson, MS.

Methods

We conducted a retrospective chart review of patients who were diagnosed with HIV at Open Arms Healthcare Center or were linked to the clinic for HIV care by the Mississippi State Department of Health Disease Intervention Specialists from January 1, 2016 to December 31, 2018. Initial viral load, CD4+ T cell count, issuance of an electronic prescription (e-script), subsequent viral loads until suppressed and patient demographics were collected for each individual seen in clinic during the review period. Viral suppression was defined as a viral load less than 200 copies/mL. Rapid ART initiation was defined as receiving an e-script for antiretrovirals within seven days of diagnosis.

Results

Between January 1, 2016 and December 31, 2018, 70 individuals were diagnosed with HIV and presented to Open Arms Healthcare Center, of which 63 (90%) completed an initial HIV counseling visit. Twenty-seven percent of patients were provided with an e-script for ART within 7 days of diagnosis. The median time to linkage to care for this sample was 12 days and 5.5 days for rapid ART starters (p < 0.001). Median time from diagnosis to viral suppression was 55 days for rapid ART starters (p = 0.03), a 22 day decrease from standard time to viral suppression.

Conclusion

Our results provide a similar level of evidence that rapid ART initiation is effective in decreasing time to viral suppression. Evidence from this evaluation supports the use of rapid ART initiation after an initial HIV diagnosis, including same-day treatment.

Treatment Is More Than Prevention: Perceived Personal and Social Benefits of Undetectable = Untransmittable Messaging Among Sexual Minority Men Living with HIV

Research suggests that the science of undetectable viral load (VL) status and HIV transmission-conveyed with the slogan "Undetectable = Untransmittable" or "U = U"-has gaps in acceptance despite robust scientific evidence. Nonetheless, growing acceptance of U = U creates conditions for a shift in the sociopolitical and personal implications of viral suppression. We conducted an online survey over a 23-month period in 2018 and 2019 among 30,361 adolescent and adult (aged 13-99) sexual minority men living with HIV (SMM-LHIV) across the United States. We examined the impact of U = U on self-image, potential for changing societal HIV stigma, whether SMM-LHIV had ever spoken with a provider about viral suppression and HIV transmission, and primary sources of hearing about U = U. Approximately 80% of SMM-LHIV reported that U = U was beneficial for their self-image and societal HIV stigma, 58.6% reported it made them feel "much better" about their own HIV status, and 40.6% reporting it had the potential to make HIV stigma "much better." The most consistent factors associated with these beliefs centered around care engagement, particularly self-reported viral suppression and excellent antiretroviral therapy adherence. Two-thirds reported ever talking to a provider about VL and HIV transmission, although the primary sources for having heard about U = U were HIV and lesbian, gay, bisexual, transgender, and queer (LGBTQ) news media and personal profiles on networking apps. These findings demonstrate the significant personal and social importance of U = U for SMM-LHIV that go above-and-beyond the well-documented health benefits of viral suppression, suggesting that providers should consider routinely initiating conversations with patients around the multifaceted benefits (personal health, sexual safety and intimacy, increased self-image, and reduced social stigma) of viral suppression.

Implementing a Status-Neutral Approach to HIV in the Asia-Pacific

PURPOSE OF REVIEW

Globally, "undetectable equals untransmittable (U=U)" and "pre-exposure prophylaxis (PrEP)" have become crucial elements in HIV treatment and prevention programs. We reviewed the implementation of U=U and PrEP among countries in the Asia-Pacific region.

RECENT FINDINGS

U=U and PrEP uptakes were limited and slow in the Asia-Pacific. Inadequate knowledge among health care practitioners and pervasive stigma towards individuals living with HIV and their sexual lives are key barriers for the integration of U=U into clinical practice. Paternalistic and hierarchical health care systems are major obstacles in PrEP implementation and scale-up. Countries with the most advanced PrEP implementation all use community-based, nurse-led, and key population-led service delivery models. To advance U=U and PrEP in the Asia-Pacific, strategies targeting changes to practice norm through wide-scale stakeholders' training and education, making use of online health care professional influencers, and utilizing financial mechanism should be further explored through implementation research.

Cost of Human Immunodeficiency Virus (HIV) and Determinants of Healthcare Costs in HIV-Infected Treatment-Naive Patients Initiated on Antiretroviral Therapy in Germany: Experiences of the PROPHET Study

OBJECTIVES

The purpose of the prospective clinical and pharmacoeconomic outcomes study of different first-line antiretroviral treatment strategies (PROPHET) was to examine the healthcare costs of human immunodeficiency virus (HIV)-infected persons in Germany treated with different antiretroviral therapy (ART) strategies and to identify variables associated with high costs.

METHODS

The setting was a 24-month prospective multicenter observational cohort study in a German HIV-specialized care setting from 2014 to 2017. A microcosting approach was used for the estimation of healthcare costs. Data were obtained via electronic case report forms. The costs were calculated from both the societal and the statutory health insurance perspective. Regression models were performed that took into consideration the impact of several independent variables.

RESULTS

Four hundred thirty-four patients from 24 centers throughout Germany were included. Average annual healthcare costs were €20 118 (standard deviation [SD] €6451) per patient from the societal perspective (n = 336) and €17 306 (SD €4106) from the statutory health insurance perspective (n = 292). Expenditures for the ART medication had the highest impact. Total costs declined in the second year of therapy. There was a significant association between the amount of total cost and clinical or therapeutic variables from both perspectives; a diagnosis of acquired immune deficiency syndrome (AIDS) led to higher costs as well as the chosen ART strategy. Age also increased cost from the statutory health insurance perspective.

CONCLUSIONS

The main cost driver of the healthcare costs for HIV-positive patients was antiretroviral drug expenses. Further variables that influenced the costs were identified. The results provide a detailed overview of the resource use of patients in the PROPHET cohort.

Unique Needs for the Implementation of Emergency Department Human Immunodeficiency Virus Screening in Adolescents

BACKGROUND

The Centers for Disease Control and Prevention (CDC) recommend universal human immunodeficiency virus (HIV) screening starting at 13 years, which has been implemented in many general U.S. emergency departments (EDs) but infrequently in pediatric EDs. We aimed to 1) implement a pilot of routine adolescent HIV screening in a pediatric ED and 2) determine the unique barriers to CDC-recommended screening in this region of high HIV prevalence.

METHODS

This was a prospective 4-month implementation of a routine HIV screening pilot in a convenience sample of adolescents 13 to 18 years at a single pediatric ED, based on study personnel availability. Serum-based fourth-generation HIV testing was run through a central laboratory. Parents were allowed to remain in the room for HIV counseling and testing. Data were collected regarding patient characteristics and HIV testing quality metrics. Comparisons were made using chi-square and Fisher's exact tests. Regression analysis was performed to assess for an association between parent presence at the time of enrollment and adolescent decision to participate in HIV screening.

RESULTS

Over 4 months, 344 of 806 adolescents approached consented to HIV screening (57% female, mean ± SD = 15.1 ± 1.6 years). Adolescents with HIV screening were more likely to be older than those who declined (p = 0.025). Other blood tests were collected with the HIV sample for 21% of adolescents; mean time to result was 105 minutes (interquartile range = 69 to 123) and 79% were discharged before the result was available. Having a parent present for enrollment was not associated with adolescent participation (adjusted odds ratio = 1.07, 95% CI = 0.67 to 1.70). Barriers to testing included: fear of needlestick, time to results, cost, and staff availability. One of 344 tests was positive in a young adolescent with Stage 1 HIV.

CONCLUSIONS

Routine HIV screening in adolescents was able to be implemented in this pediatric ED and led to the identification of early infection in a young adolescent who would have otherwise been undetected at this stage of disease. Addressing the unique barriers to adolescent HIV screening is critical in high-prevalence regions and may lead to earlier diagnosis and treatment in this vulnerable population.

Understanding Engagement in HIV Programmes: How Health Services Can Adapt to Ensure No One Is Left Behind

PURPOSE OF REVIEW

Despite the significant progress in the HIV response, gaps remain in ensuring engagement in care to support life-long medication adherence and viral suppression. This review sought to describe the different points in the HIV care cascade where people living with HIV were not engaging and highlight promising interventions.

RECENT FINDINGS

There are opportunities to improve engagement both between testing and treatment and to support re-engagement in care for those in a treatment interruption. The gap between testing and treatment includes people who know their HIV status and people who do not know their status. People in a treatment interruption include those who interrupt immediately following initiation, early on in their treatment (first 6 months) and late (after 6 months or more on ART). For each of these groups, specific interventions are required to support improved engagement. There are diverse needs and specific populations of people living with HIV who are not engaged in care, and differentiated service delivery interventions are required to meet their needs and expectations. For the HIV response to realise the 2030 targets, engagement will need to be supported by quality care and patient choice combined with empowered patients who are treatment literate and have been supported to improve self-management.

Point-of-care and Near Real-time Testing for Antiretroviral Adherence Monitoring to HIV Treatment and Prevention

PURPOSE OF REVIEW

In this report, we review the need for point-of-care (POC) or near real-time testing for antiretrovirals, progress in the field, evidence for guiding implementation of these tests globally, and future directions in objective antiretroviral therapy (ART) or pre-exposure prophylaxis (PrEP) adherence monitoring.

RECENT FINDINGS

Two cornerstones to end the HIV/AIDS pandemic are ART, which provides individual clinical benefits and eliminates forward transmission, and PrEP, which prevents HIV acquisition with high effectiveness. Maximizing the individual and public health benefits of these powerful biomedical tools requires high and sustained antiretroviral adherence. Routine monitoring of medication adherence in individuals receiving ART and PrEP may be an important component in interpreting outcomes and supporting optimal adherence. Existing practices and subjective metrics for adherence monitoring are often inaccurate or unreliable and, therefore, are generally ineffective for improving adherence. Laboratory measures of antiretroviral concentrations using liquid chromatography tandem mass spectrometry have been utilized in research settings to assess medication adherence, although these are too costly and resource-intensive for routine use. Newer, less costly technologies such as antibody-based methods can provide objective drug-level measurement and may allow for POC or near-patient adherence monitoring in clinical settings. When coupled with timely and targeted counseling, POC drug-level measures can support adherence clinic-based interventions to ART or PrEP in near real time.

Rapid ART start in early HIV infection: Time to viral load suppression and retention in care in a London cohort

OBJECTIVES

Rapid antiretroviral therapy (ART) initiation is recommended in early HIV infection (EHI), even in the absence of baseline viral resistance test result. We analysed time to viral suppression according to ART regimen started in a cohort of patients diagnosed with EHI.

METHODS

Clinical records of individuals consecutively diagnosed with EHI between July 2016-June 2018 were reviewed. The distribution of clinical, virological and immunological factors was compared in treatment groups using the Mann-Whitney U-test.

RESULTS

262 individuals (97% MSM) were diagnosed with EHI. 58% of patients agreed to start ART within 14 days of diagnosis. Tenofovir-based combinations were prescribed to all patients. DRV/b was the most commonly prescribed third agent (78%), when genotypic resistance testing was not available at time of ART choice. Switching to INSTI was encouraged once VRT became available and 27% switched from DRV/b to INSTI (mainly RAL) within 28 days from ART start. Those receiving INSTI were more likely to have a baseline viral load exceeding 1 million HIV-1 RNA copies/mL compared with those starting with DRV/b. Rapid start with INSTI regimens resulted in quicker viral suppression than when DRV/b was chosen in EHI, even when that was subsequently switched to INSTI. Retention in care following rapid ART start was achieved by all patients at 24 weeks.

CONCLUSIONS

Starting an INSTI-based ART combination was associated with quicker viral suppression than when a protease inhibitor-based combination was chosen. No differences in the achievement of viral suppression or in retention in care were observed.

Iterative Development of an mHealth Intervention to Support Antiretroviral Therapy Initiation and Adherence Among Female Sex Workers in Mombasa, Kenya

Nurses have an integral role to play in achieving the 95-95-95 goals to stem the HIV epidemic. We used the Information-Motivation-Behavioral Skills (IMB) theoretical model to develop a nurse-delivered, mHealth intervention to support antiretroviral therapy adherence among female sex workers living with HIV in Mombasa, Kenya. Twenty-three purposively sampled female sex workers living with HIV participated in 5 focus group discussions to iteratively develop the message content as well as the format and structure of the nurse-delivered, text-based intervention. Focus group discussion interview guides were developed in accordance with the IMB model. Transcripts were analyzed according to IMB themes, and findings were used to develop the intervention. Information-oriented texts addressed concerns and misconceptions; motivation-oriented texts reinforced women's desires to feel healthy enough to engage in activities; and behavioral skills-oriented texts included strategies to remember medication doses. The nurse-delivered, theory-based, culturally tailored intervention to support medication adherence was evaluated.

Wrong person, place and time: viral load and contact network structure predict SARS-CoV-2 transmission and super-spreading events

SARS-CoV-2 is difficult to contain because many transmissions occur during the pre-symptomatic phase of infection. Moreover, in contrast to influenza, while most SARS-CoV-2 infected people do not transmit the virus to anybody, a small percentage secondarily infect large numbers of people. We designed mathematical models of SARS-CoV-2 and influenza which link observed viral shedding patterns with key epidemiologic features of each virus, including distributions of the number of secondary cases attributed to each infected person (individual R0) and the duration between symptom onset in the transmitter and secondarily infected person (serial interval). We identify that people with SARS-CoV-2 or influenza infections are usually contagious for fewer than one day congruent with peak viral load several days after infection, and that transmission is unlikely below a certain viral load. SARS-CoV-2 super-spreader events with over 10 secondary infections occur when an infected person is briefly shedding at a very high viral load and has a high concurrent number of exposed contacts. The higher predisposition of SARS-CoV-2 towards super-spreading events is not due to its 1-2 additional weeks of viral shedding relative to influenza. Rather, a person infected with SARS-CoV-2 exposes more people within equivalent physical contact networks than a person infected with influenza, likely due to aerosolization of virus. Our results support policies that limit crowd size in indoor spaces and provide viral load benchmarks for infection control and therapeutic interventions intended to prevent secondary transmission.

HIV-positive persons who inject drugs experience poor health outcomes and unmet needs for care services

Comparison of social determinants of health and clinical outcomes between HIV-positive persons who inject drugs (PWID) and HIV-positive persons who do not inject drugs is essential to understanding disparities and informing HIV prevention and care efforts; however, nationally representative estimates are lacking. Interview and medical record data were collected for the Medical Monitoring Project during 2015-2018 among U.S. adults with diagnosed HIV. Among HIV-positive PWID (N=340) and HIV-positive persons who do not inject drugs (N=11,475), we reported weighted percentages and prevalence ratios with predicted marginal means to compare differences between groups (P<.05). Associations with clinical outcomes were adjusted for age, race/ethnicity, and gender. HIV-positive PWID were more likely to be homeless (29.1% vs. 8.1%) and incarcerated (18.3% vs. 4.9%). HIV-positive PWID were less likely to be retained in HIV care (aPR: 0.85 [95% CI: 0.77-0.94]), and were more likely to have poor HIV outcomes, have unmet needs for care services (aPR: 1.50 [1.39-1.61]), seek non-routine care, and experience healthcare discrimination (aPR: 1.42 [1.17-1.73]). Strengthening interventions supporting (1) continuity of care given high levels of incarceration and housing instability, (2) early ART initiation and adherence support, and (3) drug treatment and harm reduction programs to limit transmission risk may improve outcomes among HIV-positive PWID.

Ending the Human Immunodeficiency Virus Pandemic: Optimizing the Prevention and Treatment Toolkits

Unprecedented basic and clinical biomedical research advances over the past 4 decades have led to the development of "toolkits" of highly effective interventions for preventing and treating human immunodeficiency virus (HIV). Despite many successes in decreasing the incidence and mortality of HIV, major challenges remain in the goal of ending the HIV pandemic in the United States and globally. Overcoming these challenges will require optimization of the implementation of existing interventions for HIV prevention and treatment together with the continued development of new and innovative approaches that can be readily utilized by individuals with HIV and those at risk of infection.

Growing Acceptability of Undetectable = Untransmittable but Widespread Misunderstanding of Transmission Risk: Findings From a Very Large Sample of Sexual Minority Men in the United States

BACKGROUND

Several studies have demonstrated no linked HIV transmissions in serodifferent sexual encounters where the partner with HIV has an undetectable viral load. As a result, awareness and dissemination of treatment as prevention, and movements such as "Undetectable = Untransmittable" (U = U), has grown.

SETTING

We conducted an online cross-sectional survey from November 2017 through September 2018 to gather data from a total of 111,747 sexual minority men (SMM) in the United States.

METHODS

Participants provided sociodemographic data and answered questions regarding biomedical status, HIV and STI prevention behaviors, drug use, condomless anal sex, and perceived accuracy of the U = U message. We conducted analyses to understand factors associated with perceived accuracy of U = U stratified by HIV status.

RESULTS

Overall, 53.2% of the sample perceived U = U as accurate, with the highest rates among HIV-positive SMM (83.9%), followed by HIV-negative (53.8%) and status-unknown (39.0%) SMM. Multivariable models showed accuracy beliefs were, on average, 1-2% higher for each consecutive month of recruitment. Consistent with previous work, there was greater heterogeneity among HIV-negative and unknown men, with several factors differentiating perceived accuracy, compared with SMM with HIV. Perceived transmission risk levels with undetectable partners were skewed well above accurate levels, and greater perceived transmission risk was associated with lower perceived accuracy of U = U.

CONCLUSIONS

Public confidence in treatment as prevention and U = U is growing, but clear, unequivocal messaging about the effectiveness of U = U is critical. Owing to misunderstandings of risk, language that focuses on protective benefits rather than transmission risks may reach more people and allow for better comparisons with PrEP and condoms.

Incidence and Correlates of Sexually Transmitted Infections Among Black Men Who Have Sex With Men Participating in the HIV Prevention Trials Network 073 Preexposure Prophylaxis Study

BACKGROUND

The HIV Prevention Trials Network (HPTN) Study 073 (HPTN 073) assessed the feasibility, acceptability, and safety of preexposure prophylaxis (PrEP) for black men who have sex with men (BMSM). The purpose of this analysis was to characterize the relationship between PrEP uptake and use and incident sexually transmitted infections (STIs) among participants enrolled in HPTN 073.

METHODS

A total of 226 human immunodeficiency virus (HIV)-uninfected BMSM were enrolled in 3 US cities; all participants received client-centered care coordination (C4) and were offered daily oral PrEP. Participants were followed for 12 months with STI testing (rectal and urine nucleic acid amplification test for gonorrhea and chlamydia, rapid plasma reagin for syphilis) conducted at baseline, week 26, and week 52. Logistic regression was used to examine associations between STI incidence and PrEP uptake. Generalized estimating equations were used to evaluate associations between age, PrEP acceptance, sexual behaviors, and incident STIs.

RESULTS

Baseline STI prevalence was 14.2%. Men aged <25 years were more likely to have a baseline STI (25.3% vs 6.7%; odds ratio [OR], 4.39; 95% confidence interval [CI:, 1.91, 10.11). Sixty participants (26.5%) acquired ≥1 STI during follow-up; the incidence rate was 34.2 cases per 100 person-years (95% CI, 27.4, 42.9). In adjusted analyses, baseline STI diagnosis (OR, 4.23; 95% CI, 1.82, 9.87; P < .001) and additional C4 time (OR, 1.03; 95% CI, 1.00, 1.06; P = .027) were associated with having an incident STI. STI incidence was not associated with PrEP acceptance or adherence.

CONCLUSIONS

While we found higher rates of STIs in younger BMSM, overall rates of STI were lower than in prior PrEP trials, with no increase over time. BMSM with STIs at PrEP initiation may require additional interventions that target STI acquisition risk.

CLINICAL TRIALS REGISTRATION

NCT01808352.

Association between time spent in the Russian Federation and late presentation for HIV among Tajikistani migrants

BACKGROUND

Between 700 thousand and 1.2 million citizens of Tajikistan currently live in the Russian Federation, one of the only countries where the HIV epidemic continues to worsen. Given the previously reported barriers to healthcare access for migrants to the Russian Federation, and the rapidly expanding HIV epidemic in Eastern Europe and Central Asia, this present study set out to determine whether these barriers impact late presentation with HIV among Tajikistani migrants upon their return to Tajikistan.

METHOD

This study uses data from the Tajikistan Ministry of Health surveillance system (2006 - 2019). At time of diagnosis, patients are interviewed by staff of AIDS centers, and doctors complete routine intake forms and complete medical exams. Descriptive characteristics of migrants with HIV who had lived in the Russian Federation (n=503) were calculated and compared with those of non-migrants with HIV (n=9519). Missing data were imputed using multiple imputation (predictive means matching, logistic regression imputation, and polytomous regression imputation). Two logistic models were created to model the probability of late presentation for HIV. The first model shows unadjusted associations between predictor variables and late presentation for HIV. The second model shows multivariable associations between significant study variables identified in the univariate model, and late presentation.

RESULTS

Compared to non-migrants, migrants with HIV are more likely to be from Gorno-Badakhshan region, are less likely to use illicit drugs, and are more likely to have purchased the services of sex workers. The unadjusted logistic model found that for every year spent in the Russian Federation, the risk of late presentation for a Tajikistani migrant with HIV increases by 4.0% (95% CI: 0.3-7.7). The multivariate model showed that when age, sex, and region of origin are held constant, the risk of late presentation for a Tajikistani migrant with HIV increases by 4.0% (95% CI: 0.1-7.8) for each year spent in the Russian Federation.

CONCLUSION

The results of this paper suggest that if the Russian Federation were to loosen its restrictions on HIV care for foreign nationals, it might improve the treatment outcomes of migrant laborers. As this analysis is only correlational in nature, further research is needed to explicate the causal pathways of the associations found in the present analysis.

Brief Report: Racial and Ethnic Disparities in Sustained Viral Suppression and Transmission Risk Potential Among Persons Aged 13-29 Years Living With Diagnosed HIV Infection, United States, 2016

BACKGROUND

In 2016, persons aged 13-29 years represented 23.1% of the US population, yet accounted for 41.7% of HIV diagnoses. Racial/ethnic minorities are disproportionally affected by HIV. Sustaining viral suppression helps persons living with diagnosed HIV infection (PLWDH) stay healthy and reduces the risk of transmitting HIV. We examined racial/ethnic disparities in sustained viral suppression and transmission risk potential among PLWDH aged 13-29 years.

METHODS

We analyzed data from the National HIV Surveillance System reported through December 2018 from 42 jurisdictions with complete laboratory reporting. We included persons aged 13-29 years who received an HIV diagnosis by December 31, 2015, most recently resided in one of the 42 jurisdictions, and were alive at the end of 2016. Sustained viral suppression was defined as viral load <200 copies/mL for all tests in 2016. Transmission risk potential was estimated using the number of days with viral loads >1500 copies/mL.

RESULTS

Of the 90,812 PLWDH aged 13-29 years included in the analysis, 41.5% had sustained viral suppression in 2016. Across age, sex, and most transmission categories, blacks had the lowest prevalence of sustained viral suppression. Among the 28,154 who were in care but without sustained viral suppression, the average number of days with viral load >1500 copies/mL was 206 days (56.4% of the 12-month period).

CONCLUSIONS

Sustained viral suppression was suboptimal and transmission risk potential was high for PLWDH aged 13-29 years. Racial/ethnic disparities were apparent, calling for strengthening tailored interventions to improve care outcomes.

Prevention and treatment of SHIVAD8 infection in rhesus macaques by a potent d-peptide HIV entry inhibitor

Cholesterol-PIE12-trimer (CPT31) is a potent d-peptide HIV entry inhibitor that targets the highly conserved gp41 N-peptide pocket region. CPT31 exhibited strong inhibitory breadth against diverse panels of primary virus isolates. In a simian-HIV chimeric virus AD8 (SHIVAD8) macaque model, CPT31 prevented infection from a single high-dose rectal challenge. In chronically infected animals, CPT31 monotherapy rapidly reduced viral load by ∼2 logs before rebound occurred due to the emergence of drug resistance. In chronically infected animals with viremia initially controlled by combination antiretroviral therapy (cART), CPT31 monotherapy prevented viral rebound after discontinuation of cART. These data establish CPT31 as a promising candidate for HIV prevention and treatment.

Cost-effectiveness analysis of pre-exposure prophylaxis for the prevention of HIV in men who have sex with men in South Korea: a mathematical modelling study

In February 2018, the Ministry of Food and Drug Safety in Korea approved tenofovir disoproxil fumarate and emtricitabine (TDF/FTC) co-formulate for use in pre-exposure prophylaxis (PrEP) for the prevention of human immunodeficiency virus (HIV) infection. This study aimed to estimate the cost-effectiveness of PrEP in men who have sex with men (MSM), a major risk group emerging in Korea. A dynamic compartmental model was developed for HIV transmission and progression in MSM aged 15-64 years. With a combined model including economic analysis, we estimated averted HIV infections, changes in HIV prevalence, discounted costs, quality-adjusted life-years (QALYs), and incremental cost-effectiveness ratios (ICERs). PrEP was evaluated in both the general MSM and high-risk MSM populations and was assumed to reduce infection risk by 80%. Implementing PrEP in all MSM would avert 75.2% HIV infections and facilitate a gain of 37,372 QALYs at a cost of $274,822 per QALY gained over 20 years relative to the status quo. Initiating PrEP in high-risk MSM with an average of eight partners per year (around 20% of MSM) would improve the cost-effectiveness, averting 78.0% HIV infections and add 29,242 QALYs at a cost of $51,597 per QALY gained, which is within the willingness-to-pay threshold for Korea of $56,000/QALY gained. This result was highly sensitive to annual PrEP costs, quality-of-life for people who are on PrEP, and initial HIV prevalence. Initiating PrEP in a larger proportion of MSM in Korea would prevent more HIV infections, but at an increasing cost per QALY gained. Focusing PrEP on higher risk MSM and any reduction in PrEP cost would improve cost-effectiveness.

Universal test and treat in relation to HIV disease progression: results from a stepped-wedge trial in Eswatini

OBJECTIVES

Universal test and treat (UTT) is recommended for people living with HIV (PLHIV) to reduce morbidity/mortality and minimize transmission. However, concerns exist that this strategy may lead to more crowded hospitals, longer wait times and poorer service, adversely impacting health outcomes for clients with severe disease. We assessed how UTT was related to markers of disease progression in PLHIV overall and specifically among clients with low CD4 count/high World Health Organization (WHO) stage.

METHODS

The analysis was conducted using data from a stepped-wedge trial of UTT in 14 government-managed health facilities in Eswatini from 2014 to 2017. Disease progression was defined as CD4 count falling below 200 cells/µL or baseline value, > 10% weight loss, body mass index (BMI) dropping below 18.5, incident tuberculosis (TB) or HIV-related death; these outcomes also were assessed individually. We assessed multivariate Cox proportional hazard models overall and specifically among clients with CD4 count < 350 cells/μL or WHO stage 3-4 at enrolment.

RESULTS

Eight hundred and seven of 3176 clients demonstrated at least one marker of disease progression over 2339 person-years of follow-up. Overall, 62.4% of clients were female; 57.2% were < 35 years old. Compared to clients not exposed to UTT, those exposed to UTT had a lower rate of disease progression overall [adjusted hazard ratio (aHR) 0.60; 95% confidence interval (CI) 0.46-0.78] and a lower rate of CD4 decline (aHR 0.40; 95% CI 0.27-0.58). When the analysis was limited to clients with CD4 count < 350 cells/μL or WHO stage 3-4, UTT was not associated with disease progression (aHR 0.92; 95% CI 0.66-1.29).

CONCLUSIONS

UTT reduced HIV disease progression overall and was not detrimental for clients with more severe disease.

<p>Risky Sexual Practice, Sexually Transmitted Infection and Associated Factors Among Newly Diagnosed HIV-positive People in Northwest Ethiopia</p>

Purpose

Risky sexual practice expose for the acquisition of sexually transmitted infection (STI) including human immunodeficiency virus (HIV). This study was conducted to fill the knowledge gap on the prevalence of risky sexual practice, STIs and associated factors among newly diagnosed HIV-positive people in northwest Ethiopia.

Patients and Methods

This study was a cross-sectional study design which was conducted on 745 newly diagnosed HIV patients. An interviewer-administered questionnaire was used to interview patients within seven days of HIV diagnosis using client exit interview approach. Data were entered to EpiData and exported to SPSS version 24 for analysis. Binary logistic regression analysis was employed to select factors for multivariate logistic regression at p-value of less than 0.25. Two separate logistic regression models were used for risky sexual practice and STI as dependent variables. The strength of statistical association was quantified using an adjusted odds ratio (AOR) with a 95% confidence level.

Results

The prevalence of risky sexual practices and STIs among newly diagnosed HIV-positive people were 15.8% (95%CI: 13.1–18.4) and 6.6% (95%CI: 4.8–8.5), respectively. Although there were no statistically significant factors associated with STI, having two or more lifetime sexual partners (AOR=3.19; 95%CI: 1.57–6.49) and frequent use of alcohol (AOR=3.10; 95%CI: 1.34–7.19) were the factors associated with risky sexual practice.

Conclusion

Risky sexual practice and STI were found to be low among newly identified HIV patients. Factors associated with risky sexual practice failed to explain STI diagnosis using the syndromic approach. Therefore, revisiting the definition of risky sexual practice is necessary for the universal test and treat approach since sustained viral suppression may leave the need for consistent use of condoms among HIV patients who are on ART especially with regular sexual partners. Further study is also recommended to measure changes in sexual practice after initiating antiretroviral therapy.

Factors Associated with General Sexual Functioning and Sexual Satisfaction among People Living with HIV: A Systematic Review

Sexual difficulties, experienced by half of the people living with HIV (PLWH), not only affect quality of life but have been associated with lower adherence to antiretroviral medication. This systematic review synthesizes studies published since 1997 which used statistical methods to investigate factors associated with general sexual functioning or sexual satisfaction of PLWH. We searched Medline, PsycINFO, Embase, Cinahl and Scopus with terms: HIV AND sexual dysfunction AND factors. Of 5552 records, 26 studies met selection criteria. Twenty-one studies on general sexual function, and five studies on sexual satisfaction. Two researchers separately extracted data and applied standardized quality assessment criteria. (Registration: CRD42018094146.) Regarding general sexual dysfunction, older age, general physical health, depression, body image and psychological distress were the most relevant factors. There was inconsistent evidence for: CD4, viral load, HIV symptom severity, HIV disease progression and time since diagnosis. From limited available evidence on sexual satisfaction, age, unemployment, and psychosocial factors were significant. Overall, anxiety and relational factors were under-researched, treatment center studies were over-represented and non-validated measurement of outcomes was common. Future research is required to build theoretical models of sexual well-being specific to PLWH to guide effective research and intervention to promote sexual quality of life of PLWH.

Asymptomatic Adolescent HIV: Identifying a Role for Universal HIV Screening in the Pediatric Emergency Department

Adolescents account for most undiagnosed HIV infections in the United States. Although the Centers for Disease Control and Prevention (CDC) recommends universal HIV screening for all patients ≥13 years, <10% of adolescents have been tested for HIV. To identify earlier opportunities for adolescent HIV prevention and diagnosis in a region of high HIV prevalence, we sought to describe pediatric emergency department (PED) visits made by a retrospective cohort of adolescents who were later diagnosed with HIV as young adults (<25 years) through an adult emergency department (ED) universal HIV screening program. CD4+ count was used to estimate the time of HIV infection before diagnosis and all PED visits in the 10 years before diagnosis were analyzed. Universal HIV screening in the adult ED diagnosed 193 young adults (median 22 years; 90% men; 29% stage 3); 70% had CD4+ at diagnosis that was used to estimate time of infection (mean 3.8 years). Thirty-eight HIV-infected young adults had a total of 109 PED visits in the 10 years before HIV diagnosis. Sexual history was documented in 12% of PED visits and a sexually transmitted infection test was sent in 6%. Ten HIV-infected young adults had 26 PED visits during the time in which they were likely already infected with HIV, each a potential missed opportunity for earlier diagnosis. HIV-infected and at-risk adolescents are underrecognized in PED visits. Implementation of CDC-recommended universal screening may lead to earlier diagnoses and improve outcomes; the PED may also be critical in identifying adolescents eligible for preexposure prophylaxis.

The usefulness of HIV partner services in the age of treatment as prevention: a registry-based study

BACKGROUND

Partner services are effective tools to identify new cases among sex or needle-sharing partners of people with a new HIV diagnosis. Little is known about partners previously diagnosed with HIV who are not in care or are in care with unsuppressed HIV viral load. We aimed to quantify the previously diagnosed partners of people with a new HIV infection and examine their HIV care status and viral suppression in the 12 months before elicitation.

METHODS

We did a registry-based study. We used the New York City HIV Surveillance Registry to determine HIV care status and viral load of partners elicited from newly diagnosed people between Jan 1, 2007, and Dec 31, 2018. Previously diagnosed partners with no report of CD4 count or viral load in the preceding 12 months were presumed not to be in care, viral load suppression (<200 copies per mL) was based on the last viral load in the year preceding elicitation, and viraemia was defined as a viral load of 200 copies per mL or more. We used multinomial logistic regression to generate covariates of care and viral load status and their marginal effects.

FINDINGS

11 964 partners were elicited; 2603 (33%) were previously diagnosed and 485 (20%) were not in care. 1153 (49%) of 2343 with a viral load report were in care and viraemic at elicitation. The odds of being not in care were higher in non-Hispanic black than non-Hispanic white or other partners (adjusted odds ratio 1·89, 95% CI 1·09-3·27) and lower in partners with male-to-male sex transmission risk (0·37, 0·26-0·51) and country of birth other than the USA (0·57, 0·39-0·85). The odds of being viraemic were higher in partners younger than 30 years than in those aged 30 years or older (1·68, 1·35-2·09) and lower among people with male-to-male sex transmission risk (0·36, 0·29-0·44) and country of birth other than the USA (0·78, 0·66-0·97).

INTERPRETATION

People with HIV should receive ongoing HIV prevention counselling and partner services data should inform engagement in care for previously diagnosed partners.

FUNDING

None.

Promoting Undetectable Equals Untransmittable in Sub-Saharan Africa: Implication for Clinical Practice and ART Adherence

In the last decade, reliable scientific evidence has emerged to support the concept that undetectable viral loads prevent human immunodeficiency virus (HIV). Undetectable equals untransmissible (U = U) is a simple message that everyone can understand. The success of this concept depends on strict adherence to antiretroviral therapy (ART) and the attainment of suppressed viral loads (VLs). To achieve U = U in sub-Saharan Africa (SSA), poor adherence to ART, persistent low-level viremia, and the emergence of drug-resistant mutants are challenges that cannot be overlooked. Short of a cure for HIV, U = U can substantially reduce the burden and change the landscape of HIV epidemiology on the continent. From a public health perspective, the U = U concept will reduce stigmatization in persons living with HIV (PLWHIV) in SSA and strengthen public opinion to accept that HIV infection is not a death sentence. This will also promote ART adherence because PLWHIV will aim to achieve U = U within the shortest possible time. This article highlights challenges and barriers to achieving U = U and suggests how to promote the concept to make it beneficial and applicable in SSA. This concept, if expertly packaged by policy-makers, clinicians, health service providers, and HIV control programs, will help to stem the tide of the epidemic in SSA.

A stepped-wedge randomised trial on the impact of early ART initiation on HIV-patients' economic outcomes in Eswatini

Background

Since 2015, the World Health Organisation (WHO) recommends immediate initiation of antiretroviral therapy (ART) for all HIV-positive patients. Epidemiological evidence points to important health benefits of immediate ART initiation; however, the policy’s impact on the economic aspects of patients' lives remains unknown.

Methods

We conducted a stepped-wedge cluster-randomised controlled trial in Eswatini to determine the causal impact of immediate ART initiation on patients’ individual- and household-level economic outcomes. Fourteen healthcare facilities were non-randomly matched into pairs and then randomly allocated to transition from the standard of care (ART eligibility at CD4 counts of <350 cells/mm3 until September 2016 and <500 cells/mm3 thereafter) to the ‘Early Initiation of ART for All’ (EAAA) intervention at one of seven timepoints. Patients, healthcare personnel, and outcome assessors remained unblinded. Data were collected via standardised paper-based surveys with HIV-positive adults who were neither pregnant nor breastfeeding. Outcomes were patients’ time use, employment status, household expenditures, and household living standards.

Results

A total sample of 3019 participants were interviewed over the duration of the study. The mean number of participants approached at each facility per time step varied from 4 to 112 participants. Using mixed-effects negative binomial regressions accounting for time trends and clustering at the level of the healthcare facility, we found no significant difference between study arms for any economic outcome. Specifically, the EAAA intervention had no significant effect on non-resting time use (RR = 1.00 [CI: 0.96, 1.05, p=0.93]) or income-generating time use (RR = 0.94, [CI: 0.73,1.20, p=0.61]). Employment and household expenditures decreased slightly but not significantly in the EAAA group, with risk ratios of 0.93 [CI: 0.82, 1.04, p=0.21] and 0.92 [CI: 0.79, 1.06, p=0.26], respectively. We also found no significant treatment effect on households’ asset ownership and living standards (RR = 0.96, [CI 0.92, 1.00, p=0.253]). Lastly, there was no evidence of heterogeneity in effect estimates by patients’ sex, age, education, timing of HIV diagnosis and ART initiation.

Conclusions

Our findings do not provide evidence that should discourage further investments into scaling up immediate ART for all HIV patients.

Funding

Funded by the Dutch Postcode Lottery in the Netherlands, Alexander von Humboldt-Stiftung (Humboldt-Stiftung), the Embassy of the Kingdom of the Netherlands in South Africa/Mozambique, British Columbia Centre of Excellence in Canada, Doctors Without Borders (MSF USA), National Center for Advancing Translational Sciences of the National Institutes of Health and Joachim Herz Foundation.

Clinical trial number

NCT02909218 and NCT03789448.

Block and Lock HIV Cure Strategies to Control the Latent Reservoir

The HIV latent reservoir represents the major challenge to cure development. Residing in resting CD4+ T cells and myeloid cells at multiple locations in the body, including sanctuary sites such as the brain, the latent reservoir is not eliminated by ART and has the ability to reactivate virus replication to pre-therapy levels when ART is ceased. There are four broad areas of HIV cure research. The only successful cure strategy, thus far, is stem cell transplantation using naturally HIV resistant CCR5Δ32 stem cells. A second potential cure approach uses gene editing technology, such as zinc-finger nucleases and CRISPR/Cas9. Another two cure strategies aim to control the HIV reservoir, with polar opposite concepts; The "shock and kill" approach, which aims to "shock" or reactivate the latent virus and then "kill" infected cells via targeted immune responses. Lastly, the "block and lock" approach, which aims to enhance the latent virus state by "blocking" HIV transcription and "locking" the HIV promoter in a deep latent state via epigenetic modifications. "Shock and kill" approaches are a major focus of cure studies, however we predict that the increased specificity of "block and lock" approaches will be required for the successful development of a sustained HIV clinical remission in the absence of ART. This review focuses on the current research of novel "block and lock" approaches being explored to generate an HIV cure via induction of epigenetic silencing. We will also discuss potential future therapeutic delivery and the challenges associated with progressing "block and lock" cure approaches as these move toward clinical trials.

Roles for Pharmacists in the "Ending the HIV Epidemic: A Plan for America" Initiative

In 2019, President Trump announced a new initiative, Ending the HIV Epidemic: A Plan for America (EHE). EHE will use 3 key strategies-diagnose, treat, and prevent-to reduce new HIV infections at least 90% by 2030, as well as new laboratory methods and epidemiological techniques to respond quickly to potential outbreaks. Partnerships are an important component in the initiative's success. Pharmacists and pharmacies can play important roles in EHE, including dispensing antiretroviral therapy and providing HIV screening, adherence counseling, medication therapy management, preexposure prophylaxis, and nonprescription syringe sales. The objective of this report is to discuss potential roles that pharmacists and pharmacies can play under the key strategies of EHE.

Perspectives of HIV-positive and -negative people who use drugs regarding the criminalization of HIV non-disclosure in Canada: a qualitative study

Background

While previous research has identified how criminalization of HIV non-disclosure can have deleterious effects on those living with HIV, the perspectives of people who use drugs – a population disproportionately affected by HIV– should be more meaningfully considered in these discussions.

Methods

Using constant comparative techniques, data from 60 interviews with men and women living with and without HIV and who use drugs in Vancouver were analyzed to explore their perceptions about Canada’s HIV non-disclosure legal framework.

Results

Participants’ perspectives on the framework involved three themes: understandings of HIV risk; HIV-related stigma; and their own experiences with HIV. While several participants favored the punitive character of the legal framework, these arguments were premised on misinformed and stigmatized assumptions regarding HIV.

Conclusions

The paper concludes by discussing the challenges and opportunities for resisting HIV stigma and misconceptions about HIV within the context of personal accounts that, at times, support criminalization of non-disclosure.

Sexual risk and HIV testing disconnect in men who have sex with men (MSM) recruited to an online HIV self-testing trial

OBJECTIVES

We report the frequency of previous HIV testing at baseline in men who have sex with men (MSM) who enrolled in an HIV self-testing (HIVST) randomized controlled trial [an HIV self-testing public health intervention (SELPHI)].

METHODS

Criteria for enrolment were age ≥ 16 years, being a man (including trans men) who ever had anal intercourse (AI) with a man, not being known to be HIV positive and having consented to national HIV database linkage. Using online survey baseline data (2017-2018), we assessed associations with never having tested for HIV and not testing in the previous 6 months, among men who reported at least two recent condomless AI (CAI) partners.

RESULTS

A total of 10 111 men were randomized; the median age was 33 years [interquartile range (IQR) 26-44 years], 89% were white, 20% were born outside the UK, 0.8% were trans men, 47% were degree educated, and 8% and 4% had ever used and were currently using pre-exposure prophylaxis (PrEP), respectively. In the previous 3 months, 89% reported AI and 72% reported CAI with at least one male partner. Overall, 17%, 33%, 54%, and 72% had tested for HIV in the last 3 months, 6 months, 12 months and 2 years, respectively; 13% had tested more than 2 years ago and 15% had never tested. Among 3972 men reporting at least two recent CAI partners, only 22% had tested in the previous 3 months. Region of residence and education level were independently associated with recent HIV testing. Among current PrEP users, 15% had not tested in the previous 6 months.

CONCLUSIONS

Most men in SELPHI, particularly those reporting at least two CAI partners and current PrEP users, were not testing in line with current UK recommendations. The results of the trial will inform whether online promotion of HIVST addresses ongoing testing barriers.