On-Demand Preexposure Prophylaxis in Men at High Risk for HIV-1 Infection

Current and Future PrEP Medications and Modalities: On-demand, Injectables, and Topicals

PURPOSE OF REVIEW

Pre-exposure prophylaxis (PrEP) is a potent HIV prevention strategy, but uptake of daily oral PrEP remains low. This review covers PrEP agents currently available and agents and modalities under investigation.

RECENT FINDINGS

Injectable ARV preparations have high acceptability among users but are likely to require adherence to 8-week interval injections. Topical microbicide gels and vaginal rings have underperformed by intention-to-treat analyses in efficacy studies, at least in large part due to challenges with adherence and/or sustained use. However, daily oral TDF-FTC also underperformed in randomized, placebo-controlled trials compared to expectations and subsequent real-world pragmatic use. On-demand (2-1-1 dosing strategy for MSM) and injectable PrEP appear to be acceptable among participants in clinical trials. These modalities are particularly compelling alternatives for individuals who either do not want to take a daily medication (both on-demand and injectable) and/or want to take PrEP without a long commitment (on-demand). Emerging modalities such as vaginal films, microneedles, and subdermal implants have numerous advantages but are still in early stages of development.

Efficacy and cost-effectiveness of early antiretroviral therapy and partners' pre-exposure prophylaxis among men who have sex with men in Shenyang, China: a prospective cohort and costing study

BACKGROUND

Biomedical interventions such as antiretroviral therapy (ART) and pre-exposure prophylaxis (PrEP) are highly effective for prevention of human immunodeficiency virus (HIV) infection. However, China has not released national PrEP guidelines, and HIV incidence among men who have sex with men (MSM) is unchanged despite substantial scale-up of ART. We evaluated reductions in HIV transmission that may be achieved through early initiation of ART plus partners' PrEP.

METHODS

Six intervention scenarios were evaluated in terms of their impact on HIV transmission and their cost-effectiveness for 36 months post-infection. Three scenarios were based on observed data: non-ART, standard-ART, and early-ART. Another three scenarios were based on observed and hypothetical data: non-ART plus partners' PrEP, standard-ART plus partners' PrEP, and early-ART plus partners' PrEP. The number of onward transmissions was calculated according to viral load and self-reported sexual behaviors, and calibrated by the prevalence and incidence of HIV among Chinese MSM. Cost-effectiveness outcomes were quality-adjusted life-years (QALYs) and cost-utility ratio (CUR).

RESULTS

The estimated number of onward transmissions by every 100 HIV-positive cases 36 months post-infection was 41.83 (95% credible interval: 30.75-57.69) in the non-ART scenario, 7.95 (5.85-10.95) in the early-ART scenario, and 0.79 (0.58-1.09) in the early-ART plus partners' PrEP scenario. Compared with non-ART, the early-ART and early-ART plus partners' PrEP scenarios were associated with an 81.0 and 98.1% reduction in HIV transmission, and had a CUR of $12,864/QALY and $16,817/QALY, respectively.

CONCLUSIONS

Integrated delivery of early ART and sexual partners' PrEP could nearly eliminate HIV transmission and reduce costs during the first 36 months of HIV infection. Our results suggest a feasible and cost-effective strategy for reversing the HIV epidemic among MSM in China.

Willingness to Use and Adhere to HIV Pre-Exposure Prophylaxis (PrEP) among Men Who Have Sex with Men (MSM) in China

This study aimed to investigate the levels of willingness to use pre-exposure prophylaxis (PrEP) and intention to adhere to PrEP and to further explore factors associated with PrEP uptake among men who have sex with men (MSM) in China. A total of 524 MSM were recruited from Chengdu, China. Half of the participants had heard of PrEP, and the awareness rate varied from 33.8%, 30.7%, and 7.1% for daily oral PrEP, on-demand PrEP, and long-acting injectable PrEP (LAI-PrEP), respectively. The overall willingness to use any type of PrEP in the next six months was 84.9% if PrEP is effective and provided for free. Participants were less likely to say that they would use PrEP if they used a condom consistently with their regular partners. However, participants were more likely to say that they would use PrEP if they had casual partners in the past month and had higher HIV prevention literacy. The majority of participants intended to adhere to PrEP prescription. More than forty percent (43.1%) of the participants reported that they might reduce condom use if they took PrEP. We found that the overall willingness to use PrEP was high among MSM living in China, but willingness varied across the different types of PrEP.

The PrEP You Want: A Web-Based Survey of Online Cross-Border Shopping for HIV Prophylaxis Medications

Background

In response to the high cost of HIV pre-exposure prophylaxis (PrEP) medications in Canada, community organizations have created internet-based guides detailing how to legally order generic medications online and travel to collect them in the United States. However, little is known about the patients following these guides.

Objective

Our primary objective was to measure the proportion of Ontario gay, bisexual, and other men who have sex with men (GBMSM) accessing these online guides who intended to use the border-crossing approach. Our secondary objectives were to explore their demographic characteristics, their completion of the steps in the border-crossing approach, and the barriers they perceived.

Methods

Between July 20, 2017, and May 18, 2018, we administered two online surveys of GBMSM accessing an online border-crossing guide posted by a gay men’s health organization in Ontario. Participants completed an open baseline survey posted on the border-crossing guide’s Web page and a follow-up survey 3 months later. The data were analyzed using descriptive statistics. We used multivariable logistic regression to identify characteristics associated with the intention to use the border-crossing approach.

Results

Most of the 141 participants were young (median age 23, interquartile range 22-25 years) and black (79.4%; 112/141) GBMSM who had completed a college or an undergraduate degree (62.4%; 88/141). In addition, 19.9% (28/141) of them reported a total family income less than Can $30,000 and another 53.9% (76/141) reported income between Can $30,000 and Can $60,000. 54.6% (76/141) paid for medications entirely out of pocket. Most participants indicated that they were likely to complete a border-crossing approach: 80.1% (113/141) at baseline and 79.1% (87/110) at follow-up. The characteristics associated with the intention to use the approach included being black (adjusted odds ratio [aOR] 5.73, 95% CI 2.06-16.61), paying for medications out of pocket (aOR 5.18, 95% CI 1.82-17.04), and having a provider who was thought to be willing to prescribe PrEP (aOR 4.42, 95% CI 1.63-12.41). Comparing baseline and follow-up for the 110 participants who completed both surveys, 65.4% (72/110) and 80.0% (88/110) had discussed PrEP with a health care provider, 18.1% (20/110) and 25.4% (28/110) had obtained a PrEP prescription, and 8.2% (9/110) and 5.5% (6/110) had ordered medications to that mailbox, whereas only 1.0% (1/110) and 0.0% (0/110) had crossed the border to collect them at baseline and follow-up, respectively. Reported barriers included perceived concerns about the approach’s legality (56.0%; 79/141), the security of personal health information (39.0%; 55/141), and the safety of online vendors (38.3%; 54/141).

Conclusions

Despite high interest in pursuing an online border-crossing approach to get PrEP medications, such an approach may not be a viable option for PrEP scale-up among interested GBMSM because of logistical challenges and perceptions of safety and legitimacy.

Mathematical modeling of HIV-1 transmission risk from condomless anal intercourse in HIV-infected MSM by the type of initial ART

Background

Initiation of antiretroviral therapy (ART) for HIV infection using regimens that include integrase strand transfer inhibitors (INSTIs) is associated with a faster decline in HIV-1 RNA than what is observed with regimens that are anchored by other ART drug classes. We compared the impact of ART regimens that include dolutegravir (DTG), raltegravir (RAL), efavirenz (EFV), or darunavir/ritonavir (DRV/r), in treatment naïve men who have sex with men (MSM) on the probability of HIV-1 sexual transmission events (HIV-TE).

Setting

Mathematical model.

Methods

We used discrete event simulation modeling to estimate HIV-TE during the first 8 weeks after initiation of ART. HIV-1 RNA decay in men was modeled from the databases of three clinical trials: Single (DTG vs. EFV), Spring-2 (DTG vs. RAL) and Flamingo (DTG vs. DRV/r).

Results

All regimens substantially reduced the number of HIV-TE compared to no treatment. DTG led to fewer HIV-TE than its comparator in each of the three trials: 22.72% fewer transmissions than EFV; 0.52% fewer transmissions than RAL; and 38.67% fewer transmissions than DRV/r. The number of patients needed to treat with DTG to prevent one transmission event instead of comparator was 48 vs EFV, 2,194 vs RAL, and 31 vs DRV/r.

Conclusion

Unsurprisingly, this mathematical model showed that all regimens reduced HIV-TE compared to no treatment. The results also suggest that that initial use of INSTIs, by virtue of their superior viral decay kinetics, have the potential to reduce HIV-1 horizontal transmission following initiation of ART in naïve MSM.

Trial registration

ClinicalTrials.gov NCT03183154.

The Connection between the Averted Infections Ratio and the Rate Ratio in Active-control Trials of Pre-exposure Prophylaxis Agents

The design and analysis of active-control trials to evaluate experimental HIV pre-exposure prophylaxis (PrEP) agents pose serious statistical challenges. We recently proposed a new outcome measure, the averted infections ratio (AIR) – the proportion of infections that would be averted by using the experimental agent rather than the control agent (compared to no intervention). The main aim of the current paper is to examine the mathematical connection between AIR and the HIV incidence rate ratio, the standard outcome measure. We also consider the sample size implications of the choice of primary outcome measure and explore the connection between effectiveness and efficacy under a simplified model of adherence.

Becoming adherent to a preventive treatment for HIV: a qualitative approach

The clinical trial ANRS-IPERGAY investigated the efficacy of sexual activity-based (i.e. on demand) HIV pre-exposure prophylaxis (PrEP). Using a qualitative method, we analysed the role of adherence as one of the main elements for PrEP effectiveness and its associated determinants. Data were collected in various French ANRS-IPERGAY sites during the double-blind (2012-2014) and open-label study (2015-2016) phases, through two individual interviews per participant, collective interviews and focus groups. A total of 83 participants participated in the present study. Our analysis included 32 individual interviews (with 16 participants), 13 collective interviews (n = 45) and 8 focus groups (n = 33). We investigated adherence to on-demand pill-intake schedule, focusing especially on PrEP integration into daily life. PrEP intake was regulated through coping strategies to simplify implementation and avoid stigmatizing reactions. We considered self-care and pharmaceuticalization of prevention as specific features of sexual activity-based PrEP. As PrEP is a prophylaxis for seronegative people, it is contributing to the emergence of a new identity in the HIV field. Health-care professionals should take into account the practical implementation of PrEP schedules into daily life, assist PrEP users in personal management of pill intake and, more generally, improve adherence to the prophylaxis.

Are current guidelines adapted for patient eligibility to PrEP? A case report

Background

Despite effective antiretroviral therapy developed over the last decade, HIV infection remains a major worldwide public health problem. Recently, a promising preventive treatment has been made available for HIV prophylaxis, PrEP for pre-ExPosure Prophylaxis. Indeed, it was shown to significantly reduce the risk of HIV infection in patients exposed to high risk of infection such as men having sex with men (MSM), heterosexuals and people who inject drugs. Several issues pertaining to PrEP remain uncertain including short and long-term adverse events, drug resistance, risk compensation and resurgence of other sexually transmitted infections.

Case presentation

We report a case of a 52-year-old MSM eligible for PrEP as he was exposed to a high risk of HIV infection, presented no clinical symptoms of HIV primary infection and was seronegative for HIV. PrEP therapy was then initiated with fixed association of emtricitabine-tenofovir disoproxil. One month later, HIV tests using two different assays were positive, despite perfect compliance reported by the patient and confirmed by plasma drug level. A retrospective search for plasma viral RNA in the blood sample before PrEP initiation turned out positive. Genotyping and treatment sensitivity performed on sample after one month of PrEP showed a virus resistance to lamivudine and emtricitabine.

Similar cases in the literature and pivotal studies have reported HIV infections in patients initiating or undergoing PrEP. These patients where either infected but still seronegative, displaying no clinical symptoms upon enrollment, or became infected during PrEP. Reasons are mainly poor compliance to treatment, resistance to PrEP, and lack of diagnosis before PrEP. Guidelines advocate safe sex behavior before initiation, search for clinical signs of HIV primary infection and two different serologic tests performed with one-month interval.

Discussion and conclusions

Our patient newly HIV infected received PrEP as he was still seronegative. Current recommendations fail to screen recently HIV infected, but still seronegative patients who are initiating PrEP. This issue raises strong concerns regarding the lack of adequate selection for eligibility to PrEP and may contribute to exposing partners to HIV infection and select viral mutations. Infection risk could be minimized by search for plasma viral HIV RNA at pre-inclusion, at least for patients suspected of unsafe behaviors such as non-respect of the non-exposure period before PrEP initiation.

Characterization of a Reservoir-Style Implant for Sustained Release of Tenofovir Alafenamide (TAF) for HIV Pre-Exposure Prophylaxis (PrEP)

Long-acting (LA) HIV pre-exposure prophylaxis (PrEP) offers the potential to improve adherence by lowering the burden of daily or on-demand regimens of antiretroviral (ARV) drugs. This paper details the fabrication and in vitro performance of a subcutaneous and trocar-compatible implant for the LA delivery of tenofovir alafenamide (TAF). The reservoir-style implant comprises an extruded tube of a biodegradable polymer, poly(ε-caprolactone) (PCL), filled with a formulation of TAF and castor oil excipient. Parameters that affect the daily release rates of TAF are described, including the surface area of the implant, the thickness of the PCL tube walls (between 45 and 200 µm), and the properties of the PCL (e.g., crystallinity). In vitro studies show a linear relationship between daily release rates and surface area, demonstrating a membrane-controlled release mechanism from extruded PCL tubes. Release rates of TAF from the implant are inversely proportional to the wall thickness, with release rates between approximately 0.91 and 0.15 mg/day for 45 and 200 µm, respectively. The sustained release of TAF at 0.28 ± 0.06 mg/day over the course of 180 days in vitro was achieved. Progress in the development of this implant platform addresses the need for new biomedical approaches to the LA delivery of ARV drugs.

HIV incidence among gay men and other men who have sex with men in 2020: where is the epidemic heading?

The goal to effectively prevent new HIV infections among gay, bisexual, and other men who have sex with men (MSM) is more challenging now than ever before. Despite declines in the late 1990s and early 2000s, HIV incidence among MSM is now increasing in many low- and high-income settings including the US, with young, adolescent, and racial/ethnic minority MSM being among those at highest risk. Potentiating HIV risks across all settings are individual-, network-, and structural-level factors such as stigma and lack of access to pre-exposure prophylaxis (PrEP) and antiretroviral treatment as prevention. To make a sustained impact on the epidemic, a concerted effort must integrate all evidence-based interventions that will most proximally decrease HIV acquisition and transmission risks, together with structural interventions that will support improved coverage and retention in care. Universal HIV treatment, increased access to HIV testing, and daily oral PrEP have emerged as integral to the prevention of HIV transmission, and such efforts should be immediately expanded for MSM and other populations disproportionately affected by HIV. Respect for human rights and efforts to combat stigma and improve access to prevention services are needed to change the trajectory of the HIV pandemic among MSM.

Dealing with pre-exposure prophylaxis-associated condom migration: changing the paradigm for men who have sex with men

The behavioural aspects of pre-exposure prophylaxis (PrEP) are challenging, particularly the issue of condom migration. Three vital questions are: (1) at the population-level, will condom migration lead to increases in non-viral sexually transmissible infections?; (2) how can clinic-based counselling best promote the dual use of condoms and PrEP?; and (3) in future PrEP trials, what are the 'best practices' that should be used to avoid type 1 and type 2 errors that arise without accounting for condom use behaviours? This communication piece addresses each question and suggests the risk of a 'PrEP only' focus to widening health disparities.

Enhanced use of phylogenetic data to inform public health approaches to HIV among men who have sex with men

The multidimensional nature and continued evolution of HIV epidemics among men who have sex with men (MSM) requires innovative intervention approaches. Strategies are needed that recognise the individual, social and structural factors driving HIV transmission; that can pinpoint networks with heightened transmission risk; and that can help target intervention in real time. HIV phylogenetics is a rapidly evolving field with strong promise for informing innovative responses to the HIV epidemic among MSM. Currently, HIV phylogenetic insights are providing new understandings of characteristics of HIV epidemics involving MSM, social networks influencing transmission, characteristics of HIV transmission clusters involving MSM, targets for antiretroviral and other prevention strategies and dynamics of emergent epidemics. Maximising the potential of HIV phylogenetics for HIV responses among MSM will require attention to key methodological challenges and ethical considerations, as well as resolving key implementation and scientific questions. Enhanced and integrated use of HIV surveillance, sociobehavioural and phylogenetic data resources are becoming increasingly critical for informing public health approaches to HIV among MSM.

A Review of Approaches Used to Increase Awareness of Pre-exposure Prophylaxis (PrEP) in the United States

PrEP is an important and useful HIV prevention strategy, yet awareness remains low among at-risk populations in the United States and elsewhere in the world. As previous studies have shown PrEP awareness to be important to PrEP uptake, understanding approaches to increase PrEP awareness is imperative. The current systematic review provides an overview of published articles and on-going research on PrEP awareness. Using PRISMA guidelines, two published articles and seven on-going research studies were identified that use different approaches to increase PrEP awareness. Findings highlight the need for research to target other at-risk populations and geographic areas. Future research should consider the use of technology and network approaches to assess whether they lead to increased awareness, accurate knowledge, and uptake of PrEP, along with examining which messaging works best for specific targeted, at-risk population(s).

Representations of Pre-exposure Prophylaxis, Informal Antiretroviral Medication Use for HIV Prevention, and Diversion on Geosocial Networking Apps among Men Who Have Sex with Men

The use of geosocial networking applications (e.g., Grindr) among men who have sex with men (MSM) is common. Yet scant research has examined how antiretroviral medications (ARVs)-including informal use-diversion and pre-exposure prophylaxis (PrEP) are presented inside of the applications. The present study examines this phenomenon. Data are drawn from a qualitative study (N = 39) of the scope and magnitude of the informal market of ARV use for HIV prevention among MSM. Twenty-five participants reported seeing references to ARVs inside the applications. Men described geosocial networking application users' presentations of ARVs as being related to: PrEP use among HIV-negative MSM, the sale and/or use of illicit drugs (e.g., methamphetamine), informal trade/sale for HIV-prevention, and PrEP use among HIV-positive men. Findings suggest continued desire for and acceptability of PrEP as HIV prevention tool and that geosocial networking apps are being used to facilitate the exchange and informal use of ARVs for HIV-prevention. Geosocial networking applications represent a promising and important platform to educate MSM about safe and effective use of PrEP and the risks related to diversion and informal ARV use.

Perceived Candidacy for Pre-exposure Prophylaxis (PrEP) Among Men Who Have Sex with Men in Paris, France

Low perception of HIV risk is a challenge to PrEP implementation. We analyzed associations between perceptions of PrEP candidacy, behavioral indications for PrEP, and sexual behaviors. We recruited a sample of 580 MSM from a geosocial-networking smartphone application in Paris, France. A modified Poisson regression model was conducted to examine associations between perceived candidacy for PrEP and behavioral indications for PrEP, and relationships among engagement in group sex, transactional sex, HIV test history, and indications for PrEP. Adjusted risk ratios (aRR) and 95% confidence intervals (CIs) were calculated. For the outcome of perceived candidacy for PrEP, a multinomial logistic regression was performed, and adjusted relative risk ratios (aRRR) were calculated. Multivariate analyses were adjusted for socio-demographics. Respondents who considered themselves PrEP candidates were more likely to meet PrEP eligibility criteria compared to those who did not consider themselves candidates (aRR 1.65; 95% CI 1.34-2.03). Those who had engaged in group or transactional sex were more likely to have behavioral indications for PrEP (aRR 1.27; 95% CI 1.07-1.50, aRR 1.32; 95% CI 1.13-1.56, respectively), whereas HIV test history was not significantly associated with behavioral indications for PrEP. Respondents who had engaged in group sex or transactional sex were more likely to perceive themselves as candidates for PrEP (aRRR 2.24; 95% CI 1.21-4.16, aRRR 2.58; 95% CI 1.09-6.13, respectively), although those never tested for HIV were less likely to perceive themselves as candidates for PrEP (aRRR 0.18; 95% CI 0.03-0.91). The elucidation of candidacy perceptions and risk behaviors is key to furthering the effective implementation of PrEP engagement interventions.

Effect of Vitamin D Supplementation on Bone Turnover Markers During HIV Pre-Exposure Prophylaxis Using Tenofovir Disoproxil Fumarate-Emtricitabine in Men Who Have Sex with Men

Pre-exposure prophylaxis (PrEP) with tenofovir disoproxil fumarate-emtricitabine (TDF-FTC) reduces bone mineral density in HIV-uninfected men who have sex with men (MSM). We hypothesized that PrEP with TDF-FTC would increase bone turnover markers (BTMs) at week 24 and that vitamin D supplementation from weeks 24 to 48 would blunt this increase. Participants were from a cohort of 398 MSM and transgender women who received daily TDF-FTC for PrEP. At week 24, a prospective intervention group initiated vitamin D3 4,000 IU daily. Concurrent controls were selected from the cohort who took ≤400 IU/day of vitamin D3 matched by age, race, and body mass index. The primary endpoint was the change in procollagen-I N-terminal propeptide (P1NP) from weeks 24 to 48. Paired t-tests were used to compare changes in BTMs between intervention and controls. Among 48 intervention-control pairs, median age was 33 years. At baseline, 68.9% of the intervention group and 77.3% of controls were vitamin D sufficient (≥20 ng/mL, p = .94). P1NP, C-telopeptide, parathyroid hormone (PTH), and 25-OH vitamin D3 did not increase significantly at week 24. P1NP fell by a mean ± SD of -27.6 ± 49.9 pg/mL from weeks 24 to 48 with vitamin D and -2.5 ± 40.2 pg/mL in controls (p = .01). There were no significant between-group differences in the weeks 24-48 change in C-telopeptide, PTH, or 25-OH vitamin D3. Vitamin D3 supplementation with 4,000 IU/day resulted in a significant reduction in the BTM P1NP compared with controls, suggesting that this intervention has potential to improve bone health during PrEP.

Comparing non-occupational post-exposure prophylaxis drug regimens for HIV: insights from a linked HIV surveillance system

Background International non-occupational post-exposure prophylaxis (NPEP) guidelines recommend routine use of three drug NPEP regimens, despite absence of evidence for greater prevention efficacy compared with two drug regimens. This study examines the potential for excess HIV seroconversions among high-risk men who have sex with men (MSM) reporting receptive anal intercourse with a source of unknown HIV serostatus (RAIU) following a two-drug versus a three-drug NPEP regimen.

METHODS

Data for MSM in the Victorian NPEP service database between 10 August 2005 and 31 December 2012 were linked with all Victorian HIV notifications up to 31 December 2013. The primary outcome was NPEP failure following NPEP presentation among MSM reporting RAIU, stratified by the number of drugs prescribed.

RESULTS

Among 1482 MSM reporting 2002 episodes of RAIU and prescribed two- or three-drug NPEP, 70 seroconverted to HIV, but only 19 were considered possible NPEP failures. HIV diagnosis incidence among men reporting RAIU was 1.2/100 person years (PY) (95%CI=1.0-1.6); 1.1/100 PY (95%CI=0.8-1.4) among MSM prescribed two drugs and 2.2/100 PY (95%CI=1.4-3.7) among MSM prescribed three drugs (P<0.01). Of the 19 possible NPEP failures, 13 (0.7%) were prescribed two drugs and six (2.7%) three drugs (P<0.001).

CONCLUSIONS

This study suggests that two-drug NPEP regimens do not result in excess seroconversions compared with three-drug regimens when used following RAIU. Clinical services should carefully consider their use of three drug NPEP and whether resources might be better invested in other prevention strategies, particularly pre-exposure prophylaxis (PrEP).

High Adherence to HIV Pre-exposure Prophylaxis and No HIV Seroconversions Despite High Levels of Risk Behaviour and STIs: The Australian Demonstration Study PrELUDE

PrELUDE study evaluated daily pre-exposure prophylaxis (PrEP) in high-risk individuals in Australia. This open-label, single-arm study tested participants for HIV/STI and collected behavioural information three-monthly. We report trends over 18 months in medication adherence, side-effects, HIV/STI incidence and behaviour. 320 gay/bisexual men (GBM), 4 women and 3 transgender participants, followed on average 461 days, reported taking seven pills/week on 1,591 (88.5%) occasions and 4-6 pills/week on 153 (8.5%) occasions. No HIV infections were observed. STI incidence was high and stable, while gonorrhoea infections declined from 100.0 to 25.8/100 person-years between 6 and 15 months (p < 0.001). The number of HIV-positive and unknown-status sex partners, and condomless anal intercourse, significantly increased. In this high-risk cohort of mainly GBM, increases in risk behaviours and high STI incidence were not accompanied by HIV infections due to high adherence to daily PrEP. The study informed policy and further PrEP implementation among Australian GBM.

Interest in Switching to On-Demand HIV Pre-Exposure Prophylaxis (PrEP) Among Australian Users of Daily PrEP: An Online Survey

We surveyed 970 PrEPX study participants to evaluate interest in switching from daily to on-demand PrEP in a study setting. Interested respondents (n = 469, 48%) more commonly reported PrEP cessation (adjusted odds ratio [aOR], 3.0; P < .001), difficulty with adherence (aOR, 1.6; P = .029), infrequent sex (aOR, 3.7; P < .001), and toxicity concerns (aOR, 2.7; P < .001).

Awareness and Perceived Effectiveness of HIV Treatment as Prevention Among Men Who Have Sex with Men in New York City

To assess perceptions of HIV treatment as prevention (TasP), we conducted an online survey of MSM in New York City (n = 732) asking them to rate the effectiveness of different strategies to reduce HIV risk during serodiscordant condomless anal sex between men. Only 6.1% reported not knowing what TasP was, with significantly less awareness among non-gay-identified MSM, men with less education, men who reported fewer anal sex partners in the prior 3 months, and HIV-negative/unaware men who had never used PrEP. The strategy most frequently perceived to offer "a lot" or "complete" protection from HIV was daily PrEP (70.0%), followed by TasP (39.1%), intermittent PrEP (16.6%), strategic positioning (15.8%), and withdrawal before ejaculation (10.8%). Men who were HIV positive, who had ever used PrEP, and who identified as gay/homosexual were significantly more likely to see TasP as effective. Further studies should investigate MSM's apparent skepticism towards TasP.

Network Modeling of PrEP Uptake on Referral Networks and Health Venue Utilization Among Young Men Who Have Sex with Men

The objective of this study is to identify individual-level factors and health venue utilization patterns associated with uptake of pre-exposure prophylaxis (PrEP) and to evaluate whether PrEP uptake behavior is further diffused among young men who have sex with men (YMSM) through health venue referral networks. A sample of 543 HIV-seronegative YMSM aged 16-29 were recruited in 2014-2016 in Chicago, IL, and Houston, TX. Stochastic social network models were estimated to model PrEP uptake. PrEP uptake was associated with more utilization of health venues in Houston and higher levels of sexual risk behavior in Chicago. In Houston, both Hispanic and Black YMSM compared to White YMSM were less likely to take PrEP. No evidence was found to support the spread of PrEP uptake via referral networks, which highlights the need for more effective PrEP referral network systems to scale up PrEP implementation among at-risk YMSM.

Cohort profile: l'Actuel Pre-Exposure Prophylaxis (PrEP) Cohort study in Montreal, Canada

PURPOSE

The l'Actuel PrEP Cohort was established to monitor the uptake, effectiveness, safety and changes in sexual risk behaviours among individuals receiving pre-exposure prophylaxis (PrEP) for the prevention of HIV. This prospective dynamic cohort is based at Clinique médicale l'Actuel, a large sexual health clinic located in Montreal, Canada.

PARTICIPANTS

Since the cohort inception in January of 2013 through June 2018, 2156 individuals consulted for PrEP as participants in the l'Actuel PrEP Cohort. Median age was 35 years (IQR: 29-44 years) and the majority (96%) were men who have sex with men. Among 1551 individuals who initiated PrEP care, the median duration of follow-up was 9.2 months (IQR: 3.7-19.6), with substantial variation based on year of cohort entry. The l'Actuel PrEP Cohort contains both daily and intermittent 'on-demand' PrEP users and has the largest reported population of intermittent PrEP users (n=406) in North America.

FINDINGS TO DATE

No incident HIV infections have occurred among individuals using PrEP over 1637 person-years of follow-up. However, retention in PrEP care is essential as three individuals who discontinued PrEP subsequently acquired HIV, translating to an HIV incidence of 3.9 cases per 100 person-years (95% CI: 1.3 to 12.1). Among a sample of participants with 1 year of follow-up before and after PrEP initiation (n=109), a moderate increase in sexually transmitted infections was observed following PrEP start.

FUTURE PLANS

The l'Actuel PrEP Cohort continues to grow with new participants starting PrEP monthly and extended follow-up for existing users. The cohort data will be used for ongoing monitoring of PrEP and for population-level modelling of the impact of PrEP on HIV incidence in Montreal.

NZPrEP Demonstration Project: protocol for an open-label, single-arm trial of HIV pre-exposure prophylaxis (PrEP) to determine feasibility, acceptability, adverse and behavioural effects of PrEP provision to gay and bisexual men in publicly funded sexual health clinics in Auckland, New Zealand

INTRODUCTION

New Zealand has experienced a rise in HIV diagnoses in recent years and new interventions are required to address this.

METHODS AND ANALYSIS

NZPrEP (A demonstration project of HIV preexposure prophylaxis in Aotearoa New Zealand) is an open-label, single-arm treatment evaluation study to investigate feasibility, retention, adherence, and clinical and behavioural outcomes of HIV pre-exposure prophylaxis (PrEP) provision to gay and bisexual men (GBM) in a publicly funded secondary sexual health service in Auckland, New Zealand. The sample size is 150 GBM. Inclusion criteria were specific behavioural risk factors indicating an increased risk of HIV infection. Exclusion criteria were hepatitis B infection, any medical contraindications to prescribing tenofovir/emtricitabine or factors limiting ability to adhere to the study protocol. Eligible participants will be screened for HIV and other sexually transmissible infections (STIs) and for any medical contraindications to PrEP, and enrolled for a maximum follow-up period of 96 weeks. They will be required to attend for 3-monthly testing for HIV and STIs and monitoring for renal and liver toxicity. Participants will also be required to complete an online behavioural survey after each study visit. The outcomes of interest are feasibility of PrEP provision in a sexual health clinic setting, PrEP acceptability, and adverse medical and behavioural effects of PrEP. The study sample is limited to 150 participants due to funding and service constraints. Statistical analysis of all primary and secondary outcomes will be performed using Stata V.14 at the University of Auckland. Results for primary and secondary endpoints will be reported after the conclusion of the study in March 2019.

ETHICS AND DISSEMINATION

The study was approved by the Health and Disability Ethics Committee on 15 September 2016 (16/NTA/112). Key findings will be submitted to peer-reviewed journals. A summary report will be circulated to the study and community stakeholders, and to the Auckland District Health Board, Ministry of Health and Pharmac.

TRIAL REGISTRATION NUMBER

ACTRN12616001387415; Pre-results.

Mieux comprendre les défis de la médicalisation de la prévention du VIH en France : la prophylaxie préexposition au prisme des sciences sociales

Résumé : Le recours aux traitements antirétroviraux pour la prévention du VIH transforme en profondeur le contexte des interventions dans ce domaine. La prophylaxie pré-exposition (Prep) en constitue l'une des facettes les plus visibles. Pour autant, l'utilisation de la Prep en France s'avère limitée. L'outil peine à trouver son public parmi les populations ciblées. Comment expliquer la sous-utilisation d'une approche de prévention dont la haute efficacité est pourtant démontrée ? Les réponses à cette question gagneraient à s'enrichir des sciences humaines et sociales tant pour penser les conditions de l'appropriation de l'outil par les publics ciblés que pour identifier les impensés et les logiques qui sous-tendent son déploiement. Loin de se limiter au VIH, la réflexion critique sur le recours aux médicaments comme outils de prévention ouvre des questions pertinentes pour le champ de la promotion de la santé.

Antiretroviral Medications for the Prevention of HIV Infection: A Clinical Approach to Preexposure Prophylaxis, Postexposure Prophylaxis, and Treatment as Prevention

Preventing new human immunodeficiency virus (HIV) infections is essential to halting the global pandemic. HIV prevention strategies include integrating both nonpharmacologic (eg, safe sexual counseling, circumcision) and pharmacologic approaches. Several pharmacologic HIV prevention strategies are increasingly used globally and include postexposure prophylaxis, preexposure prophylaxis, and treatment as prevention. These prevention modalities have enormous clinical and public health appeal, as they effectively reduce HIV acquisition in individuals and also may lower HIV incidence in communities when integrated and implemented broadly. Efforts are now underway to scale HIV prevention programs using these techniques in both high- and low-resource settings.

Update on HIV Preexposure Prophylaxis: Effectiveness, Drug Resistance, and Risk Compensation

PURPOSE OF REVIEW

In 2019, the US government launched an initiative to decrease new HIV infections by 90% over the next decade. Studies have demonstrated the efficacy of HIV preexposure prophylaxis (PrEP) for high-risk populations, and the United States Preventative Services Task Force has issued a grade A recommendation for PrEP, indicating substantial net benefit. However, questions have been raised about the effectiveness of PrEP in clinical settings and whether PrEP use might promote antiretroviral drug resistance and increased sexual risk behaviors, which could increase transmission of bacterial sexually transmitted infections. In this narrative review, we summarize recent evidence of the effectiveness of PrEP when provided in clinical and community settings, the emergence of antiretroviral drug resistance during PrEP use, and associations between PrEP use and increased sexual risk behaviors. We also review novel PrEP modalities that are being developed to optimize PrEP acceptability, adherence, and effectiveness.

RECENT FINDINGS

Studies suggest that PrEP is effective when provided in clinical settings. However, PrEP uptake and impact have been limited in the USA thus far, and major disparities in access to PrEP exist. In addition, there is evidence that drug resistance can occur with PrEP use, particularly with inadvertent PrEP use during undiagnosed acute HIV infection. Risk compensation can also occur with PrEP use and has been associated with increased sexually transmitted infections. Promising new modalities for PrEP could expand options. PrEP has strong potential to decrease HIV incidence. However, disparities in access must be addressed to ensure equity and impact for PrEP. While drug resistance and risk compensation can occur with PrEP use, these are not valid reasons to withhold PrEP from patients given its substantial protective benefits.

High Prevalence of Anal and Oral High-Risk Human Papillomavirus in Human Immunodeficiency Virus-Uninfected French Men Who Have Sex With Men and Use Preexposure Prophylaxis

Background

We assessed the prevalence and risk factors of anal and oral high-risk (HR) human papillomavirus (HPV) infection in human immunodeficiency virus–uninfected men who have sex with men (MSM) and take preexposure prophylaxis (PrEP) in France.

Methods

Anal and oral samples were screened by multiplex real-time polymerase chain reaction (Anyplex II HPV 28; Seegene) for HPV DNA.

Results

A total of 61 unvaccinated MSM (mean age, 36.1 years) were enrolled. Anal HPV and HR-HPV prevalences were 93.4% and 81.9%, respectively, and oral HPV and HR-HPV prevalences, 33.9% and 19.6%, respectively. HR-HPV type 33 was the most detected genotype, in both anal and oral samples. Among MSM, 68.8% carried ≥1 anal HPV type targeted by the 9-valent Gardasil-9 vaccine; all oral HPV-positive samples carried ≥1 strain included in the vaccine. Condomless receptive anal intercourse and history of anal gonorrhea were the main factors associated with increased risk for anal HPV infection (adjusted odds ratio, 10.4) and anal infection with multiple HR-HPV genotypes (5.77), respectively. Conversely, having had <10 partners in the last 12 months was associated with decreased risk for anal carriage of both multiple HPV (adjusted odds ratio, 0.19) and HR-HPV (0.17) types.

Conclusion

French MSM using PrEP are at high risk for both anal and oral carriage of HR-HPV that could lead to HPV-related cancers.

Development and Validation of a Personalized Social Media Platform-Based HIV Incidence Risk Assessment Tool for Men Who Have Sex With Men in China

BACKGROUND

Personalized risk assessments can help medical providers determine targeted populations for counseling and risk reduction interventions.

OBJECTIVE

The objective of this study was to develop a social media platform-based HIV risk prediction tool for men who have sex with men (MSM) in China based on an independent MSM cohort to help medical providers determine target populations for counseling and risk reduction treatments.

METHODS

A prospective cohort of MSM from Shenyang, China, followed from 2009 to 2016, was used to develop and validate the prediction model. The eligible MSM were randomly assigned to the training and validation dataset, and Cox proportional hazards regression modeling was conducted using predictors for HIV seroconversion selected by the training dataset. Discrimination and calibration were performed, and the related nomogram and social media platform-based HIV risk assessment tool were constructed.

RESULTS

The characteristics of the sample between the training dataset and the validation dataset were similar. The risk prediction model identified the following predictors for HIV seroconversion: the main venue used to find male sexual partners, had condomless receptive or insertive anal intercourse, and used rush poppers. The model was well calibrated. The bootstrap C-index was 0.75 (95% CI 0.65-0.85) in the training dataset, and 0.60 (95% CI 0.45-0.74) in the validation dataset. The calibration plots showed good agreement between predicted risk and the actual proportion of no HIV infection in both the training and validation datasets. Nomogram and WeChat-based HIV incidence risk assessment tools for MSM were developed.

CONCLUSIONS

This social media platform-based HIV infection risk prediction tool can be distributed easily, improve awareness of personal HIV infection risk, and stratify the MSM population based on HIV risk, thus informing targeted interventions for MSM at greatest risk for HIV infection.

Factors Associated With Willingness to Use Pre-Exposure Prophylaxis in Brazil, Mexico, and Peru: Web-Based Survey Among Men Who Have Sex With Men

Background

HIV disproportionally affects key populations including men who have sex with men (MSM). HIV prevalence among MSM varies from 17% in Brazil and Mexico to 13% in Peru, whereas it is below 0.5% for the general population in each country. Pre-exposure prophylaxis (PrEP) with emtricitabine/tenofovir is being implemented in the context of combination HIV prevention. Reports on willingness to use PrEP among MSM have started to emerge over the last few years. Previously reported factors associated with willingness to use PrEP include awareness, higher sexual risk behavior, and previous sexually transmitted infection.

Objective

This study aimed to evaluate the factors associated with willingness to use daily oral PrEP among MSM in 3 Latin American, middle-income countries (Brazil, Mexico, and Peru).

Methods

This Web-based, cross-sectional survey was advertised in 2 gay social network apps (Grindr and Hornet) used by MSM to find sexual partners and on Facebook during 2 months in 2018. Inclusion criteria were being 18 years or older, cisgender men, and HIV-negative by self-report. Eligible individuals answered questions on demographics, behavior, and PrEP (awareness, willingness to use, barriers, and facilitators). Multivariable logistic regression modeling was performed to assess the factors associated with willingness to use daily oral PrEP in each country.

Results

From a total sample of 43,687 individuals, 44.54% of MSM (19,457/43,687) were eligible and completed the Web-based survey—Brazil: 58.42% (11,367/19,457), Mexico: 30.50% (5934/19,457), and Peru: 11.08% (2156/19,457); median age was 28 years (interquartile range: 24-34), and almost half lived in large urban cities. Most participants were recruited on Grindr (69%, 13,349/19,457). Almost 20% (3862/19,352) had never tested for HIV, and condomless receptive anal sex was reported by 40% (7755/19,326) in the previous 6 months. Whereas 67.51% (13,110/19,376) would be eligible for PrEP, only 9.80% (1858/18,959) of participants had high HIV risk perception. PrEP awareness was reported by 64.92% (12,592/19,396); this was lower in Peru (46.60%, 1002/2156). Overall, willingness to use PrEP was reported by 64.23% (12,498/19,457); it was highest in Mexico (70%, 4158/5934) and lowest in Peru (58%, 1241/2156). In multivariate regression models adjusted for age, schooling, and income in each country, willingness to use PrEP was positively associated with PrEP awareness and PrEP facilitators (eg, free PrEP and HIV testing) and negatively associated with behavioral (eg, concerned by daily pill regimen) and belief barriers (eg, sexual partners may expect condomless sex).

Conclusions

In this first cross-country, Web-based survey in Latin America, willingness to use PrEP was found to be high and directly related to PrEP awareness. Interventions to increase awareness and PrEP knowledge about safety and efficacy are crucial to increase PrEP demand. This study provides important information to support the implementation of PrEP in Brazil, Mexico, and Peru.

Substance Use and Adherence to HIV Preexposure Prophylaxis for Men Who Have Sex with Men1

Substance and alcohol use were not associated with decreased adherence.

The effectiveness of oral HIV preexposure prophylaxis (PrEP) strongly depends on maintaining adherence. We investigated the association between substance use and PrEP adherence, as well as incident sexually transmitted infections (STIs) in a high-risk cohort of 394 participants (391 men who have sex with men and 3 transgender women) who were enrolled in a PrEP demonstration project. We assessed baseline and ongoing substance use over a 48-week period for stimulants and nonstimulant substances and for each substance separately. We measured PrEP adherence by using dried blood spots to obtain levels of tenofovir diphosphate. No differences in these levels were found between substance users and nonsubstance users. Baseline stimulant use was strongly associated (odds ratio 3.4; p<0.001) with incident STIs during the study. Thus, PrEP adherence was not decreased by substance use. Because substance users had increased rates of STIs, indicating higher-risk behavior, they might be excellent candidates for PrEP.

Owens DK, Davidson KW, Krist AH, Barry MJ, Cabana M, Caughey AB, Curry SJ, Doubeni CA, Epling JW, Kubik M, Landefeld CS, Mangione CM, Pbert L, Silverstein M, Simon MA, Tseng CW, Wong JB. Preexposure Prophylaxis for the Prevention of HIV Infection: US Preventive Services Task Force Recommendation Statement

IMPORTANCE

An estimated 1.1 million individuals in the United States are currently living with HIV, and more than 700 000 persons have died of AIDS since the first cases were reported in 1981. In 2017, there were 38 281 new diagnoses of HIV infection reported in the United States; 81% of these new diagnoses were among males and 19% were among females. Although treatable, HIV infection has no cure and has significant health consequences.

OBJECTIVE

To issue a new US Preventive Services Task Force (USPSTF) recommendation on preexposure prophylaxis (PrEP) for the prevention of HIV infection.

EVIDENCE REVIEW

The USPSTF reviewed the evidence on the benefits of PrEP for the prevention of HIV infection with oral tenofovir disoproxil fumarate monotherapy or combined tenofovir disoproxil fumarate and emtricitabine and whether the benefits vary by risk group, population subgroup, or regimen or dosing strategy; the diagnostic accuracy of risk assessment tools to identify persons at high risk of HIV acquisition; the rates of adherence to PrEP in primary care settings; the association between adherence and effectiveness of PrEP; and the harms of PrEP when used for HIV prevention.

FINDINGS

The USPSTF found convincing evidence that PrEP is of substantial benefit in decreasing the risk of HIV infection in persons at high risk of HIV acquisition. The USPSTF also found convincing evidence that adherence to PrEP is highly associated with its efficacy in preventing the acquisition of HIV infection; thus, adherence to PrEP is central to realizing its benefit. The USPSTF found adequate evidence that PrEP is associated with small harms, including kidney and gastrointestinal adverse effects. The USPSTF concludes with high certainty that the magnitude of benefit of PrEP with oral tenofovir disoproxil fumarate-based therapy to reduce the risk of acquisition of HIV infection in persons at high risk is substantial.

CONCLUSIONS AND RECOMMENDATION

The USPSTF recommends offering PrEP with effective antiretroviral therapy to persons at high risk of HIV acquisition. (A recommendation).

The cost-effectiveness of multi-purpose HIV and pregnancy prevention technologies in South Africa

Introduction

A number of antiretroviral HIV prevention products are efficacious in preventing HIV infection. However, the sexual and reproductive health needs of many women extend beyond HIV prevention, and research is ongoing to develop multi‐purpose prevention technologies (MPTs) that offer dual HIV and pregnancy protection. We do not yet know if these products will be an efficient use of constrained health resources. In this paper, we estimate the cost‐effectiveness of combinations of candidate multi‐purpose prevention technologies (MPTs), in South Africa among general population women and female sex workers (FSWs).

Methods

We combined a cost model with a static model of product impact based on incidence data in South Africa to estimate the cost‐effectiveness of five candidate co‐formulated or co‐provided MPTs: oral PrEP, intravaginal ring, injectable ARV, microbicide gel and SILCS diaphragm used in concert with gel. We accounted for the preferences of end‐users by predicting uptake using a discrete choice experiment (DCE). Product availability and protection were systematically varied in five potential rollout scenarios. The impact model estimated the number of infections averted through decreased incidence due to product use over one year. The comparator for each scenario was current levels of male condom use, while a health system perspective was used to estimate discounted lifetime treatment costs averted per HIV infection. Product benefit was estimated in disability‐adjusted life years (DALYs) averted. Benefits from contraception were incorporated through adjusting the uptake of these products based on the DCE and through estimating the costs averted from avoiding unwanted pregnancies. We explore the additional impact of STI protection through increased uptake in a sensitivity analysis.

Results

At central incidence rates, all single‐ and multi‐purpose scenarios modelled were cost‐effective among FSWs and women aged 16–24, at a governmental willingness‐to‐pay threshold of $1175/DALY averted (range: $214–$810/DALY averted among non‐dominant scenarios), however, none were cost‐effective among women aged 25–49 (minimum $1706/DALY averted). The cost‐effectiveness of products improved with additional protection from pregnancy. Estimates were sensitive to variation in incidence assumptions, but robust to other parameters.

Conclusions

To the best of our knowledge, this is the first study to estimate the cost‐effectiveness of a range of potential MPTs; suggesting that MPTs will be cost‐effective among higher incidence FSWs or young women, but not among lower incidence older women. More work is needed to make attractive MPTs available to potential users who could use them effectively.

Preexposure Prophylaxis for the Prevention of HIV Infection: Evidence Report and Systematic Review for the US Preventive Services Task Force

IMPORTANCE

Effective prevention strategies for HIV infection are an important public health priority. Preexposure prophylaxis (PrEP) involves use of antiretroviral therapy (ART) daily or before and after sex to decrease risk of acquiring HIV infection.

OBJECTIVE

To synthesize the evidence on the benefits and harms of PrEP, instruments for predicting incident HIV infection, and PrEP adherence to inform the US Preventive Services Task Force.

DATA SOURCES

Ovid MEDLINE, the Cochrane Central Register of Controlled Trials, the Cochrane Database of Systematic Reviews, and EMBASE through June 2018, with surveillance through January 2019.

STUDY SELECTION

English-language placebo-controlled randomized clinical trials of oral PrEP with tenofovir disoproxil fumarate/emtricitabine or tenofovir disoproxil fumarate monotherapy; studies on the diagnostic accuracy of instruments for predicting incident HIV infection; and studies on PrEP adherence.

DATA EXTRACTION AND SYNTHESIS

Dual review of titles and abstracts, full-text articles, study quality, and data abstraction. Data were pooled using the Dersimonian and Laird random-effects model for effects of PrEP on HIV infection, mortality, and harms.

MAIN OUTCOMES AND MEASURES

HIV acquisition, mortality, and harms; adherence to PrEP; and diagnostic test accuracy and discrimination.

RESULTS

Fourteen RCTs (N = 18 837), 8 observational studies (N = 3884), and 7 studies of diagnostic accuracy (N = 32 279) were included. PrEP was associated with decreased risk of HIV infection vs placebo or no PrEP after 4 months to 4 years (11 trials; relative risk [RR], 0.46 [95% CI, 0.33-0.66]; I2 = 67%; absolute risk reduction [ARD], -2.0% [95% CI, -2.8% to -1.2%]). Greater adherence was associated with greater efficacy (RR with adherence ≥70%, 0.27 [95% CI, 0.19-0.39]; I2 = 0%) in 6 trials. PrEP was associated with an increased risk of renal adverse events (12 trials; RR, 1.43 [95% CI, 1.18-1.75]; I2 = 0%; ARD, 0.56% [95% CI, 0.09%-1.04%]) and gastrointestinal adverse events (12 trials; RR, 1.63 [95% CI, 1.26-2.11]; I2 = 43%; ARD, 1.95% [95% CI, 0.48%-3.43%]); most adverse events were mild and reversible. Instruments for predicting incident HIV infection had moderate discrimination (area under the receiver operating characteristic curve, 0.49-0.72) and require further validation. Adherence to PrEP in the United States in men who have sex with men varied widely (22%-90%).

CONCLUSIONS AND RELEVANCE

In adults at increased risk of HIV infection, PrEP with oral tenofovir disoproxil fumarate monotherapy or tenofovir disoproxil fumarate/emtricitabine was associated with decreased risk of acquiring HIV infection compared with placebo or no PrEP, although effectiveness decreased with suboptimal adherence.

Revealing geographical and population heterogeneity in HIV incidence, undiagnosed HIV prevalence and time to diagnosis to improve prevention and care: estimates for France

Introduction

To close gaps in HIV prevention and care, knowledge about locations and populations most affected by HIV is essential. Here, we provide subnational and sub‐population estimates of three key HIV epidemiological indicators, which have been unavailable for most settings.

Methods

We used surveillance data on newly diagnosed HIV cases from 2004 to 2014 and back‐calculation modelling to estimate in France, at national and subnational levels, by exposure group and country of birth: the numbers of new HIV infections, the times to diagnosis, the numbers of undiagnosed HIV infections. The denominators used for rate calculations at national and subnational levels were based on population size (aged 18 to 64) estimates produced by the French National Institute of Statistics and Economic Studies and the latest national surveys on sexual behaviour and drug use.

Results

We estimated that, in 2014, national HIV incidence was 0.17‰ (95% confidence intervals (CI): 0.16 to 0.18) or 6607 (95% CI: 6057 to 7196) adults, undiagnosed HIV prevalence was 0.64‰ (95% CI: 0.57 to 0.70) or 24,197 (95% CI: 22,296 to 25,944) adults and median time to diagnosis over the 2011 to 2014 period was 3.3 years (interquartile range: 1.2 to 5.7). Three mainland regions, including the Paris region, out of the 27 French regions accounted for 56% of the total number of new and undiagnosed infections. Incidence and undiagnosed prevalence rates were 2‐ to 10‐fold higher than the national rates in three overseas regions and in the Paris region (p‐values < 0.001). Rates of incidence and undiagnosed prevalence were higher than the national rates for the following populations (p‐values < 0.001): born‐abroad men who have sex with men (MSM) (respectively, 108‐ and 78‐fold), French‐born MSM (62‐ and 44‐fold), born‐abroad persons who inject drugs (14‐ and 18‐fold), sub‐Saharan African‐born heterosexuals (women 15‐ and 15‐fold, men 11‐ and 13‐fold). Importantly, affected populations varied from one region to another, and in regions apparently less impacted by HIV, some populations could be as impacted as those living in most impacted regions.

Conclusions

In France, some regions and populations have been most impacted by HIV. Subnational and sub‐population estimates of key indicators are not only essential to adapt, design implement and evaluate tailored HIV interventions in France, but also elsewhere where similar heterogeneity is likely to exist.

Uncommon Detection of Mixed HCV Genotype Infections in Recently Infected Men Who Have Sex with Men

INTRODUCTION

Mixed hepatitis C virus (HCV) genotype (GT) infections are clinically important as different genotypes have varied sensitivities to direct-acting antivirals (DAAs). A high prevalence of mixed GT infections was observed in individuals who inject drugs and had multiple HCV exposures. The prevalence of mixed HCV GT infections in men who have sex with men (MSM) and high-risk behaviors was investigated by ultra-deep sequencing (UDS).

METHODS

NS5B fragment was sequenced from viruses of patients with recent HCV infection: there were 50 HIV-positive and 18 HIV-negative patients, including 13 from the ANRS Pre-Exposure Prophylaxis (PrEP) IPERGAY study. UDS data were analysed using Geneious (version 10.3.2). Phylogenetic trees were constructed using FastTree (version 2.1).

RESULTS

HCV sequencing showed GT1a (47.1%), GT4d (41.2%), GT3a (8.8%) and GT2k (2.9%). We detected three (4.4%) mixed GT infections: one between predominant GT4d and minority GT1a, one between predominant GT4d and minority GT1b, and one between predominant GT1a and minority GT4d virus. The rates of minority GT viral populations detected in viruses of the three patients with mixed GT infections were 0.32%, 10.7%, and 1.3%, respectively. The first two patients were HIV co-infected and the third was HIV-negative under PrEP. The anti-HCV treatment was successful in all three patients.

CONCLUSION

This work showed uncommon mixed HCV GT infections in MSM at high risk of multiple HCV exposures. The impact of these infections on treatment response has not been established but further studies on more patients are necessary. To prevent treatment failure in this population, regular monitoring of treatment response is needed, particularly when pan-genotypic treatment is not used.

Sexual behaviour and incidence of HIV and sexually transmitted infections among men who have sex with men using daily and event-driven pre-exposure prophylaxis in AMPrEP: 2 year results from a demonstration study

BACKGROUND

Pre-exposure prophylaxis (PrEP) for HIV might induce risk compensation, defined as increased sexual risk behaviour leading to increased incidence of bacterial sexually transmitted infections (STIs). We examined the incidence of HIV, STIs, and sexual behaviour after initiating daily and event-driven PrEP.

METHODS

AMPrEP is a demonstration study that assessed the incidence of HIV and bacterial STIs and sexual behaviour among PrEP users at the STI clinic of the Public Health Service of Amsterdam (Amsterdam, the Netherlands). Eligible adults (aged ≥18 years) were HIV-negative men who have sex with men (MSM) and transgender people who had reported one or more of the following in the previous 6 months: condomless anal sex with casual partners, at least one bacterial STI, use of post-exposure prophylaxis after a sexual risk incident, or an HIV-positive sexual partner with detectable viral load. Participants were given a choice of daily PrEP or event-driven PrEP regimens. Participants were seen every 3 months for HIV and STI testing. Participants also completed self-administered questionnaires about sexual behaviour at each visit. Over the first 2 years, we assessed the number and incidence rate of HIV and chlamydia, gonorrhoea, and syphilis, including STIs diagnosed in between study visits and assessed changes in incidence over time using piecewise exponential survival models. The number of sexual acts and sexual partners were also analysed and changes over time were assessed using negative binomial regression models. This study is ongoing; the data cutoff for this analysis was June 30, 2018.

FINDINGS

Between Aug 3, 2015, and May 31, 2016, 376 participants were recruited, of whom nine participants were lost to follow-up, thus 367 participants were included in the analysis. Overall, 365 MSM and two transgender women were included, contributing 681·7 person-years of follow-up. At enrolment, 269 (73%) of 367 participants chose daily PrEP and 98 (27%) participants chose event-driven PrEP. Two individuals in the daily PrEP group became HIV-positive; overall HIV incidence rate was 0·30 per 100 person-years (95% CI 0·07-1·19). 253 participants were diagnosed with one or more STI during the first 2 years (incidence rate 90·4 per 100 person-years). STI incidence did not change over time (adjusted incidence rate ratio [aIRR] 1·00 per 3 month follow-up, 95% CI 0·93-1·07). More than a quarter of all STIs were diagnosed from tests done in between study visits. STI incidence was lower in the event-driven PrEP group than the daily PrEP group (aIRR 0·59, 95% CI 0·46-0·75). The number of condomless anal sex acts with casual partners per 3 months increased, but the number of partners and sex acts remained stable.

INTERPRETATION

Although the overall incidence of STIs did not change during 2 years of PrEP use, the incidence of STIs was higher among participants using daily PrEP than those using event-driven PrEP, which is likely a result of differences in sexual behaviour. This finding suggests the need to tailor STI prevention interventions according to behavioural profiles.

FUNDING

ZonMw, H-TEAM, Internal GGD research funds, Aidsfonds, Stichting AmsterdamDiner Foundation, Gilead Sciences, Janssen Pharmaceutica, M A C AIDS Fund, and ViiV Healthcare.

Community-Based Care in the ANRS-IPERGAY Trial: The Challenges of Combination Prevention

ANRS-IPERGAY was a community-based randomized trial investigating the efficacy of sexual activity-based HIV pre-exposure prophylaxis (PrEP) in a population of males and transgender females who had sex with men and were at high risk of HIV infection. We qualitatively analyzed the support provided to participants by community-based health workers (CBHW) throughout the trial's double-blind and open-label extension phases. In particular, we showed that the relationship between participants and CBHW strongly influenced self-managed pill intake. The delicate construction of this relationship, balanced between trust and dependence, played an important role in PrEP adherence. CBHW had to deal with various issues surrounding participants' feelings of empowerment regarding their role in the trial, as well as related tensions between various logics and rationalities. They were essential to participants' continued involvement.

Rectal Douching Practices Associated with Anal Intercourse: Implications for the Development of a Behaviorally Congruent HIV-Prevention Rectal Microbicide Douche

Tenofovir administration via rectal douching results in higher rectal-mucosa drug concentration than oral administration. Many who engage in receptive anal intercourse (RAI) use cleansing rectal douches. To inform development of a behaviorally-congruent tenofovir douche, 4751 individuals ≥ 18 years-old, born male, from all US states/territories, who engaged in anal intercourse responded to an online survey. Of those who reported RAI in the prior 3 months, 80% douched beforehand, 82% within 1 h, mean 2.9 consecutive applications; 27% douched afterwards, 83% within 1 h, mean 1.7 consecutive applications. Among multidose users, 78% applied doses within 2 min, and 76% retained liquid < 1 min. Most used tap water (89%) in an enema bottle (50%) or rubber bulb (43%), and douched for cleanliness (97%), to avoid smelling bad (65%), and to enhance pleasure (24%). 98% reported high likelihood of using an HIV-prevention douche. An ideal product will protect within a user's typical number of applications, within 1 h, and be dissolvable in tap water.

Predictors of Long-Term HIV Pre-exposure Prophylaxis Adherence After Study Participation in Men Who Have Sex With Men

BACKGROUND

Efficacy of HIV pre-exposure prophylaxis (PrEP) among men who have sex with men is well documented in randomized trials. After trial completion, participants are challenged with acquiring PrEP on their own and remaining adherent.

METHODS

This was a follow-up study of the TAPIR randomized controlled multicenter PrEP trial. Participants were contacted after their last TAPIR visit (ie, after study-provided PrEP was discontinued) to attend observational posttrial visits 24 and 48 weeks later. Adherence during TAPIR and posttrial visits was estimated by dried blood spot intracellular tenofovir diphosphate levels (adequate adherence defined as tenofovir diphosphate levels >719 fmol/punch). Binary logistic regression analysis assessed predictors of completing posttrial visits and PrEP adherence among participants completing ≥1 visit.

RESULTS

Of 395 TAPIR participants who were on PrEP as part of the TAPIR trial for a median of 597 days (range 3-757 days), 122 (31%) completed ≥1 posttrial visit (57% of University of California San Diego participants completed posttrial visits, whereas this was 13% or lower for other study sites). Among participants who completed ≥1 posttrial visit, 57% had adequate adherence posttrial. Significant predictors of adequate adherence posttrial were less problematic substance use, higher risk behavior, and adequate adherence in year 1 of TAPIR.

CONCLUSION

More than half of PrEP users followed after trial completion had successfully acquired PrEP and showed adequate adherence. Additional adherence monitoring and intervention measures may be needed for those with low PrEP adherence and problematic substance use during the first year of trial.

Combination prevention and HIV: a cross-sectional community survey of gay and bisexual men in London, October to December 2016

BackgroundMen who have sex with men (MSM) are at risk of HIV and are an important population to monitor and ameliorate combination prevention efforts.AimTo estimate HIV prevalence and identify factors associated with frequent HIV testing (≥ 2 HIV tests in the last year) and pre-exposure prophylaxis (PrEP) use among MSM in London.MethodsFor this cross-sectional study, MSM recruited from 22 social venues provided oral-fluid samples for anonymous HIV antibody (Ab) testing and completed a questionnaire. Factors associated with frequent HIV testing and PrEP use were identified through logistic regression.ResultsOf 767 men recruited, 545 provided an eligible oral specimen. Among these, 38 MSM (7.0%) were anti-HIV positive including five (13.2%; 5/38) who reported their status as negative. Condomless anal sex within the previous 3 months was reported by 60.1% (412/685) men. Frequent HIV testing was associated with, in the past year, a reported sexually transmitted infection (adjusted odds ratio (AOR): 5.05; 95% confidence interval (CI): 2.66-9.58) or ≥ 2 casual condomless partners (AOR 2-4 partners: 3.65 (95% CI: 1.87-7.10); AOR 5-10 partners: 3.34(95% CI: 1.32-8.49). Age ≥ 35 years was related to less frequent HIV testing (AOR 35-44 years: 0.34 (95% CI: 0.16-0.72); AOR ≥ 45 years: 0.29 (95% CI: 0.12-0.69). PrEP use in the past year was reported by 6.2% (46/744) of MSM and associated with ≥ 2 casual condomless sex partners (AOR: 2.86; 95% CI: 1.17-6.98) or chemsex (AOR: 2.31; 95% CI: 1.09-4.91).ConclusionThis bio-behavioural study of MSM found high rates of behaviours associated with increased risk of HIV transmission. Combination prevention, including frequent HIV testing and use of PrEP, remains crucial in London.

Measuring the impact of an HIV rotation on trainees' knowledge and confidence level: The importance of inviting recent graduates

BACKGROUND

The new Canadian Residency Accreditation Consortium (CanRAC) standards recommend surveying recently graduated trainees to target improvements in training programs. The goal of this study was to estimate the impact of a rotation in an HIV clinic on trainees' related knowledge, confidence, and practice profile at the Université de Montréal.

METHODS

An electronic survey was sent to practising physicians who completed the rotation between 2006 and 2016. Participants were asked to rate their agreement and level of confidence toward HIV- and HCV-related topics using 5-point Likert scales (0 to 4). Descriptive statistics and mean comparisons were calculated.

RESULTS

Among invited participants, 27 of 45 (60%) completed the questionnaire. The majority of respondents were infectious diseases physicians (48%) or family physicians (37%) and had an outpatient caseload of <10 HIV patients/year (80%). For 37% of the respondents, the rotation had a large or very large impact on their career path. They considered that the rotation had increased their knowledge on the overall management of HIV (mean 3.2/4 [95% CI 2.9 to 3.4]), but less on pre-exposure prophylaxis (PrEP) (mean 1.5/4 [95% CI 1.1 to 2.0]) or HCV care (mean 1.9/4 [95% CI 1.4 to 2.3]). Participants felt less confident with genotyping interpretation (mean 2.6/4 [95% CI 2.2 to 2.9]) and PrEP (mean 2.4/4 [95% CI 2.0 to 2.8]).

CONCLUSIONS

These results suggest that a rotation in an HIV clinic improves knowledge related to HIV care. Feedback from past graduates helped us identify gaps in knowledge or level of confidence in PrEP and HCV care, which will feed curriculum improvement.

A Mobile Application to Collect Daily Data on Preexposure Prophylaxis Adherence and Sexual Behavior Among Men Who Have Sex With Men: Use Over Time and Comparability With Conventional Data Collection

BACKGROUND

We studied the use of a mobile application (app) to measure human immunodeficiency virus (HIV) preexposure prophylaxis (PrEP) adherence and sexual behavior, assessed determinants of app use, and we compared data in app and questionnaires.

METHODS

Men who have sex with men participating in the Amsterdam PrEP project (AMPrEP) on daily or event-driven PrEP at the Public Health Service of Amsterdam completed the data on sexual risk behavior and PrEP adherence through a standard questionnaire every 3 months and on a daily basis using the project's app. Regression analyses were used to assess factors associated with app use. Among those who reported 90% or greater of data in the app, the number of PrEP pills taken and number of unknown casual sex partners were compared between the app and the questionnaires by Wilcoxon signed-rank test.

RESULTS

Of all participants (n = 374), 94% (352 of 374) reported data in the app at least once; 72% (261 of 362) reported data ≥90% of the days in the sixth month and 62% (222 of 359) in the 12th month following PrEP initiation.Factors associated with reporting data in the app were using daily PrEP and recent initiation of PrEP. The reported numbers of pills taken and unknown sexual partners were comparable between app and questionnaires.

CONCLUSIONS

The AMPrEP app was used frequently, especially by those using a daily PrEP regimen. Data collected by app regarding adherence and sexual risk behavior were consistent with questionnaire data among those who used the app consistently. An app is a promising tool to measure PrEP adherence and sexual risk behavior.

Self-initiated continuation of and adherence to HIV pre-exposure prophylaxis (PrEP) after PrEP demonstration project roll-off in men who have sex with men: associations with risky decision making, impulsivity/disinhibition, and sensation seeking

The objective of this study was to examine differences in the levels of risky decision making and other frontal system behavior constructs in relation to self-initiated continuance of HIV pre-exposure prophylaxis (PrEP) and PrEP adherence outcomes among men who have sex with men (MSM) following completion of a clinical PrEP trial. At the last PrEP trial visit, study provided PrEP was discontinued and participants were navigated to the community for PrEP continuation. In this cross-sectional analysis, 84/187 (45%) MSM who completed a prospective observational post-PrEP trial follow-up visit at the University of California San Diego were included. PrEP adherence was measured using dried blood spot tenofovir diphosphate (TFV-DP) levels. Risky decision making was assessed using the Iowa Gambling Task (IGT) and the Balloon Analogue Risk Task (BART), while impulsivity/disinhibition, sensation seeking, and substance use were assessed via standardized self-report questionnaires. A total of 58/84 (69%) of MSM who completed the 12-month post-study visit continued PrEP. Of those, n = 46 (79%) reached TFV-DP levels associated with adequate adherence. Individuals who elected to continue PrEP 12 months post-trial had riskier decision making on BART, but less impulsivity/disinhibition compared to individuals who did not continue PrEP. Neither risky decision making nor impulsivity/disinhibition/sensation seeking nor substance use correlated with PrEP adherence. Our findings suggest that those with risky decision making may have greater insight into their HIV risks, and therefore be more likely to continue to use PrEP. However, elevated impulsivity/disinhibition, indicative of greater neurobehavioral alterations, was negatively associated with PrEP continuance and is a potential target for future interventions to help people link to PrEP.

Summary of German-Austrian HIV PrEP guideline

OBJECTIVES

HIV Pre-Exposure prophylaxis (PrEP) is a strategy to reduce HIV transmission in people at risk. Aim of this first German-Austrian PrEP guideline is to provide professional guidance on: when and in whom to use PrEP, recommended laboratory tests before and while on PrEP, selection of drugs, prevention of adverse events as a consequence of missing accompanying medical care, and general handling of PrEP in adults and adolescents.

METHODS

Commented summary of of the S2k PrEP consensus guidelines released by the German and Austrian HIV medical societies to highlight the key recommendations of the guidelines.

CONTENT

Detailed information about effectiveness of PrEP, when and in whom to use PrEP, as well as about additional monitoring of HIV PrEP are included in the HIV PrEP guidelines. Therewith detailed guidance for people being involved in PrEP counseling and associated care is provided.

Transactional sex, condomless anal sex, and HIV risk among men who have sex with men

To understand the HIV epidemic among men who have sex with men who engage in transactional sex (MSM-TS) in Paris, France, we sought to examine the association between engagement in transactional sex and HIV risk behaviors among MSM in Paris, France. Users of a geosocial-networking application in Paris were provided an anonymous web-based survey ( N = 580), which included questions about transactional sex and behavioral risk factors for HIV along with sexually transmitted infection (STI)/HIV status. Multivariate analyses showed that engagement in transactional sex was associated with condomless receptive and insertive anal intercourse (adjusted relative risk [aRR] = 1.34, 95% confidence interval [CI] = 1.04–1.72 and aRR = 1.41, 95% CI = 1.04–1.91, respectively). MSM-TS were more likely to have engaged in substance use before or during sex (aRR = 1.35, 95% CI = 1.13–1.62), to have participated in group sex (aRR = 1.37, CI = 1.13–1.62), and to have had an STI during the last year (aRR = 1.68, 95% CI = 1.16–2.45). Transactional sex was not associated with HIV status. MSM-TS in Paris engaged in higher HIV risk behaviors, however, did not have higher rates of HIV infection. Sexual health interventions should continue to target MSM-TS; however, future studies should characterize the social, cultural, and structural factors that interact with individual behaviors to elevate HIV risk for MSM-TS.

Open pilot trial of a brief motivational interviewing-based HIV pre-exposure prophylaxis intervention for men who have sex with men: preliminary effects, and evidence of feasibility and acceptability

Gay, bisexual and other men who have sex with men (MSM) are at high-risk of HIV infection in the United States. Daily oral pre-exposure prophylaxis (PrEP) has demonstrated efficacy in reducing HIV acquisition among MSM. However, PrEP uptake in real-world clinical settings has been slow and uneven. Guided by Self-Regulation Theory, we developed and evaluated a brief (15-25 min) motivational interviewing (MI)-based intervention to promote PrEP uptake in an uncontrolled pilot trial. Nineteen MSM were recruited during the course of routine HIV screening at a sexually transmitted diseases clinic. We administered the 2-session intervention in-person and by telephone. Thirteen (72%) participants completed baseline and 1-month follow-up assessments; all found the intervention and its components highly acceptable. Over the 1-month period, seven participants (37%) obtained a PrEP prescription, more than tripling the rate previously observed with PrEP counseling and referrals alone (11%). The most common barrier to uptake was out-of-pocket costs. This approach was feasible and underscored the need for financial assistance and other PrEP navigation services to supplement behavioral interventions to enhance PrEP uptake.

Acceptability of pre-exposure prophylaxis (PrEP) among men who have sex with men (MSM) in Benin: a qualitative study

In Benin, consistent condom use among men who have sex with men (MSM)  is relatively low and providing them with Pre-exposure prophylaxis (PrEP) could be of great relevance. We aimed to describe PrEP knowledge and intention to use it; identify key facilitators and barriers to PrEP; and describe the perceived impact of PrEP on unsafe sexual behavior. MSM, 18 years or older, HIV-negative or of unknown status, were enrolled in five cities of Benin. Intention to use PrEP was assessed through five focus groups (FG). Data were analyzed using manual thematic sorting. Thirty MSM (six per city) participated in the FG. Mean age (standard deviation) was 27.1 (5.0) years. All participants expressed the intention to use PrEP if made available. Facilitators of PrEP use were: availability of medication, safety, absence of constraints as well as freedom to have multiple sex partners and sex with HIV-positive friends. Barriers were: complex procedures for obtaining medication, size and taste of medication, cost of medication, poor PrEP awareness.. Eighteen men admitted that PrEP could lead to decrease in or even abandonment of condom use. In conclusion, MSM showed openness to use PrEP if available, although they recognized that it could lead to risk compensation.