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

Pre-exposure prophylaxis for HIV prevention preferences among young adult African American men who have sex with men

Pre-exposure prophylaxis (PrEP) is effective in preventing HIV infections among men who have sex with men (MSM). PrEP uptake and adherence remain low and product preferences are unknown, especially among young African American MSM who are most at-risk. We conducted 26 qualitative interviews from 2014-2016 among young adult HIV-negative African American MSM regarding PrEP product preferences in Missouri. While the pill and injectable were most liked of all modalities, about a quarter preferred rectal products or patches. Most participants preferred a long-acting injectable (LAI) to daily oral pills due to better medication adherence and a dislike for taking pills. Many participants preferred daily oral pills to on-demand oral PrEP due to the inability to predict sex and the perception that insufficient time or medication would not achieve HIV protection with on-demand. A fear of needles and the perception that there would not be therapeutic levels for a long duration were concerns with injectable PrEP. Study findings highlight the need for a range of prevention options for African American MSM and can inform PrEP product development as well as dissemination and implementation efforts.

No change in health-related quality of life for at-risk U.S. women and men starting HIV pre-exposure prophylaxis (PrEP): Findings from HPTN 069/ACTG A5305

INTRODUCTION

Tenofovir (TDF)-containing PrEP is effective for HIV prevention, but its effect on health-related quality of life (QOL) is unknown. Using data from HPTN 069/ACTG A5305, a randomized study of potential PrEP regimens comparing maraviroc alone, or together with TDF or emtricitabine (FTC), to TDF + FTC (control), we evaluated the impact of these regimens on QOL in at-risk HIV-uninfected U.S. women and men.

METHODS

QOL was measured at baseline (before starting medications) and every 8 weeks through week 48 using the EQ-5D-3L. Responses were converted to a scale from 0.0 (death) to 1.0 (perfect health), using published valuation weights. Mean scores were compared between groups at each time point using nonparametric testing. Multivariable linear regression was used to adjust for potential confounders.

RESULTS

We analyzed 186 women (median age 35 years, 65% black, 17% Hispanic) and 405 men (median age 30 years, 28% black, 22% Hispanic), including 9 transgender participants analyzed based on sex-at-birth. Mean baseline QOL was 0.91 for women and 0.95 for men. There were minimal changes in mean QOL over time for any regimen (women: p = 0.29; men: p = 0.14). There were no significant differences between participants who continued the regimen compared to participants who discontinued early (women: p = 0.61; men: p = 0.1). Mean QOL did not differ significantly by regimen at any time point, both unadjusted and after adjustment for age, race/ethnicity, adherence, and use of alcohol, marijuana, opiates, and other substances.

CONCLUSIONS

QOL in at-risk individuals starting candidate PrEP regimens in a clinical trial is similar to the general population and maintained over time. This finding did not vary among regimens or when adjusted for demographics, adherence, and substance use. Our findings are the first to show that starting a candidate PrEP regimen in at-risk HIV-uninfected U.S. women and men was not associated with significant changes in QOL.

TRIAL REGISTRATION

Clinicaltrials.gov NCT01505114.

Lymphogranuloma venereum is on the rise in Belgium among HIV negative men who have sex with men: surveillance data from 2011 until the end of June 2017

Background

The number of cases of Lymphogranuloma venereum (LGV) is increasing in Europe. The described epidemic is mostly confined to HIV positive men who have sex with men (MSM). However, dissemination of LGV from HIV positive to HIV negative MSM could take place due to the implementation of pre-exposure prophylaxis (PrEP) and subsequent possible decrease in condom use. We describe here the LGV epidemiology in Belgium before the PrEP-era, starting from 2011 up to the end of the first half of 2017.

Methods

A descriptive analysis of the socio-demographic and clinical characteristics of all LGV cases was performed. Fisher’s exact test was used to compare symptomatic to asymptomatic patients. Logistic regression models were used to check for trends over time for: number of LGV cases, HIV status and symptoms.

Results

The number of LGV cases rose by a factor four, from 21 in 2011 to 88 in 2016, and regression models showed a positive trend estimate of 14% increase per half year (p < 0.001). LGV decreased among HIV positive cases (odds ratio (OR): 0.79, p < 0.001) and increased among HIV negative cases (OR: 1.27, p < 0.001). In addition, a rise in the number of asymptomatic LGV cases (6.7%) was observed (OR:1.39, p = 0.047). Asymptomatic cases were also less likely to be HIV (p = 0.046) or Hepatitis C positive (p = 0.027).

Conclusions

The rise of LGV in HIV negative MSM has now been documented. If we aim to halt the epidemic in HIV negative MSM, future public health strategies should include LGV testing of all Chlamydia trachomatis positive samples from MSM.

Nanoencapsulation introduces long-acting phenomenon to tenofovir alafenamide and emtricitabine drug combination: A comparative pre-exposure prophylaxis efficacy study against HIV-1 vaginal transmission

Daily oral antiretroviral (ARV) drugs for pre-exposure prophylaxis (PrEP) has proven efficacy for diverse groups of high-risk individuals. However, daily dosing regimen has augmented non-adherence. These experiments comparatively investigated the long-acting (LA) PrEP potency of subcutaneous (SubQ) administrated tenofovir alafenamide (TAF) and emtricitabine (FTC) loaded nanoparticles (NPs) to solution in humanized (hu) mice. TAF + FTC NPs and TAF + FTC solution (each drug at 200 mg/kg) were administered to hu-CD34-NSG mice (n = 3/time point) for plasma and tissue pharmacokinetic parameter estimation using LC-MS/MS. NP enhanced tissue ARV assimilation compared to plasma. The same dose was administered for PrEP efficacy in HIV-1 challenged hu-BLT mice (n = 5/group). The hu-BLT mice were vaginally challenged with a transmission-founder (T/F) virus at 5 × 10⁵ TCID₅₀ inoculation, on day 4, 7 and 14 post-SubQ treatments (PT) and were compared to infected-untreated-control hu-BLT mice. By 21 days PT, 100% TAF + FTC solution-treated and control-untreated mice were infected. However, TAF + FTC NPs resulted in significant (p = .0002) protection from HIV-1 (day 4: 80%, day 7 and 14: 60%, respectively) compared to control mice. This proof-of-concept study demonstrated detectable TAF/FTC vaginal levels among TAF + FTC NP-treated hu-BLT mice correlating with prolonged PrEP efficacy, thus establishing long-acting TAF + FTC NPs as a potential PrEP modality.

Effects of gel volume on pharmacokinetics for vaginal and rectal applications of combination DuoGel-IQB4012, a dual chamber-dual drug HIV microbicide gel, in pigtailed macaques

This study evaluated effects of differing gel volumes on pharmacokinetics (PK). IQB4012, a gel containing the non-nucleoside reverse transcriptase inhibitor IQP-0528 and tenofovir (TFV), was applied to the pigtailed macaque vagina and rectum. Vaginal gel volumes (1% loading of both drugs) were 0.5 or 1.5 ml; following wash-out, 1 or 4 ml of gel were then applied rectally. Blood, vaginal, and rectal fluids were collected at 0, 2, 4, and 24 h. Vaginal and rectal tissue biopsies were collected at 4 and 24 h. There were no statistically significant differences in concentrations for either drug between gel volumes within compartments at matched time points. After vaginal gel application, median IQP-0528 concentrations were ~ 10⁴-10⁵ ng/g, 10⁵-10⁶ ng/ml, and 10³-10⁵ ng/ml in vaginal tissues, vaginal fluids, and rectal fluids, respectively (over 24 h). Median vaginal TFV concentrations were 1-2 logs lower than IQP-0528 levels at matched time points. After rectal gel application, median IQP-0528 and TFV concentrations in rectal fluids were ~ 10³-10⁵ ng/ml and ~ 10²-10³ ng/ml, respectively. Concentrations of both drugs sampled in rectal tissues were low (~ 10¹-10³ ng/g). For 1 ml gel, half of sampled rectal tissues had undetectable concentrations of either drug, and over half of sampled rectal fluids had undetectable TFV concentrations. These results indicate differences in drug delivery between the vaginal and rectal compartments, and that smaller vaginal gel volumes may not significantly compromise microbicide PK and prophylactic potential. However, effects of rectal gel volume on PK for both drugs were less definitive.

Sexual safety and HIV prevention in travel medicine: Practical considerations and new approaches

Travellers who engage in sexual contact with a new sexual partner abroad may be at high risk of HIV and other sexually transmitted infections (STIs), but these risks can be reduced through appropriate planning during the pre-travel clinic visit. Here we discuss strategies available to the clinician to maximise travellers' sexual safety during travel. Strategies may include immunizations, condoms, HIV pre-exposure prophylaxis (PrEP), HIV post-exposure prophylaxis (PEP), self-initiated treatment of symptomatic bacterial STIs, post-exposure prophylaxis for bacterial STIs and hormonal contraception. We discuss the role of these different strategies for travellers, and provide resources to assist clinicians in making clinical decisions and in educating travellers about sexual safety.

Incidence of sexually transmitted infections in men who have sex with men and who are at substantial risk of HIV infection - A meta-analysis of data from trials and observational studies of HIV pre-exposure prophylaxis

BACKGROUND

Men who have sex with men (MSM) and who engage in condomless anal intercourse with casual partners are at high risk of acquiring sexually transmitted infections (STIs), but reliable epidemiological data are scarce. Studies on HIV pre-exposure prophylaxis (PrEP) enrol MSM who indicate that they engage in behaviour that puts them at high risk of acquiring HIV. Because they also screen for STIs at regular intervals, these studies may serve as a valuable source to estimate incidence rates of STIs in this subpopulation of MSM.

METHODS

We systematically searched for trials and observational studies of PrEP in MSM that reported data on the incidence of STIs during the study period. Incidence rates were calculated as events per 100 person-years (py) with 95% confidence intervals (CI). Data from individual studies were pooled building subgroups along study types and geography. We performed sensitivity analyses, including data only from studies that met pre-defined quality criteria.

RESULTS

Twenty-four publications on 20 studies were included. The majority of studies reported that sexual behaviour and/or STI incidence remained stable or decreased during the study period. For syphilis, incidence rates ranged from 1.8/100py to 14.9/100py, the pooled estimate was 9.1/100py (95%-CI: 7.7-10.9). Incidence rates for gonorrhoea and chlamydia of any site ranged from 13.3/100py to 43.0/100py and 15.1/100py to 48.5/100py, respectively. Considering only studies that met the criteria for sensitivity analysis yielded pooled estimates of 39.6/100py (95%-CI: 32.9-47.6) and 41.8/100py (95%-CI: 33.9-51.5), respectively. The overall estimate for hepatitis C incidence was 1.3/100py (95%-CI: 1.0-1.8).

CONCLUSIONS

Despite partly heterogeneous results, the data depict high incidence rates of STIs among MSM who engage in higher-risk sexual behaviours such as condomless sex with casual partners. This subpopulation of MSM requires access to STI screening at close intervals. By offering access to structures that provide regular STI monitoring and prompt treatment, PrEP may not only decrease HIV incidence but also have beneficial effects in decreasing the burden of STIs.

HIV, HCV and HBV: A Review of Parallels and Differences

Elimination of the three blood-borne viruses-human immunodeficiency virus (HIV), hepatitis B (HBV) and hepatitis C (HCV)-as public health issues may be plausible in the near future. Spectacular advances have been made with the introduction of highly effective antiviral agents into clinical practice, and prevention strategies are available for all three infections. Effective disease control, laid out by WHO global strategies, is currently feasible for all three viruses. However, for worldwide elimination of these viruses, effective vaccines are required that are currently only available for HBV. In this review differences and parallels among HIV, HCV and HBV will be discussed with a focus on virologic and therapeutic issues, and prospects for the future of HBV will be presented.

HIV Antiretroviral Pre-Exposure Prophylaxis: Development Challenges and Pipeline Promise

The US Food and Drug Administration (FDA) approved oral daily tenofovir/emtricitabine (Truvada) for pre-exposure prophylaxis of human immunodeficiency virus (HIV) infection in 2012 on the basis of two randomized controlled trials (RCTs), one in men who have sex with men (MSM) and another in HIV serodiscordant heterosexual couples. Subsequently, even greater efficacy has been demonstrated in MSM with rapid population-level incidence reductions in some locations. In contrast, studies of antiretroviral pre-exposure prophylaxis (PrEP) in heterosexual women showed only modest or no efficacy, largely attributed to low adherence. The mixed results of antiretroviral-based PrEP bear witness to unique drug development challenges at this complicated intersection of sexual behavior, public health, and drug development. Multiple innovative methods and formulation strategies followed to address unmet medical needs of persons struggling with daily oral PrEP adherence or preference for nonsystemic PrEP options. Clinical pharmacology plays essential roles throughout this PrEP development process, especially in early product development and through pharmacologically informed enhancement and interpretation of clinical trials.

A mathematical model of biomedical interventions for HIV prevention among men who have sex with men in China

Background

The new HIV treatment guidelines in China recommend antiretroviral therapy (ART) for all people living with HIV, but significant gaps in implementation still exist. Pre-exposure prophylaxis (PrEP) can effectively reduce the risk of HIV transmission among men who have sex with men (MSM). This study assessed the epidemiological impact and cost effectiveness of PrEP, enhanced biomedical interventions and their combination among MSM in China.

Methods

A deterministic mathematical model was developed and projected over 20 years to assess the impact of the PrEP, biomedical interventions and their combinations. Incidence and prevalence of HIV were measured, and cost-effectiveness was assessed using incremental cost (international dollars, Int.$) per quality-adjusted life year (QALY) gained.

Results

A total of 0.78 million new HIV infections were estimated to occur over the next 20 years if no additional interventions are implemented among MSM. The PrEP-only strategy covering 25–75% of HIV-negative high-risk MSM can prevent 0.09–0.20 million (12.1–25.7%) new infections, at a cost of 17,277–18,452 Int.$/QALY. The optimal cost-effectiveness path is from test-and-treat to the combination strategy of test-and-treat and PrEP. Some strategies could almost eliminate new HIV infections over the next 20 years.

Conclusions

PrEP, test-and-treat, and their combinations among MSM are effective and cost-effective relative to current policy. PrEP is an important and cost-effective addition to current policy in China.

Electronic supplementary material

The online version of this article (10.1186/s12879-018-3516-8) contains supplementary material, which is available to authorized users.

A systematic review of adherence to oral pre-exposure prophylaxis for HIV - how can we improve uptake and adherence?

Introduction

Oral pre-exposure prophylaxis (PrEP) is an effective strategy to reduce the risk of HIV transmission in high risk individuals. However, the effectiveness of oral pre-exposure prophylaxis is highly dependent on user adherence, which some previous trials have struggled to optimise particularly in low and middle income settings. This systematic review aims to ascertain the reasons for non-adherence to pre-exposure prophylaxis to guide future implementation.

Methods

We performed structured literature searches of online databases and conference archives between August 8, 2016 and September 16, 2017. In total, 18 prospective randomized control trials and implementation studies investigating oral pre-exposure prophylaxis were reviewed. A structured form was used for data extraction and findings summarized regarding efficacy, effectiveness, adherence and possible reasons for non-adherence.

Results

Adherence varied between differing populations both geographically and socioeconomically. Common reasons for non-adherence reported over multiple studies were; social factors such as stigma, low risk perception, low decision making power, an unacceptable dosing regimen, side effects, and the logistics of daily life. Oral pre-exposure prophylaxis with included antiviral regimens was not associated with a high risk of antiviral resistance development in the reviewed studies.

Conclusion

Our findings indicate that oral pre-exposure prophylaxis should be delivered within a holistic intervention, acknowledging the other needs of the targeted demographic in order to maximise acceptability. Socioeconomic factors and poor governmental policy remain major barriers to widespread implementation of pre-exposure prophylaxis.

Satisfaction and acceptability of cabotegravir long-acting injectable suspension for prevention of HIV: Patient perspectives from the ECLAIR trial

BACKGROUND

Cabotegravir (GSK1265744) is an integrase strand transfer inhibitor in development as a long-acting (LA) intramuscular injectable suspension for HIV-1 pre-exposure prophylaxis (PrEP).

OBJECTIVE

We report participant outcomes from the phase IIa ECLAIR study related to tolerability, acceptability, and satisfaction of cabotegravir LA.

METHODS

The ECLAIR study (ClinicalTrials.gov identifier, NCT02076178) was a randomized, placebo-controlled study in healthy men not at high risk of acquiring HIV-1. Participants were randomized (5:1) to once-daily oral cabotegravir 30 mg or placebo tablets for 4 weeks, followed by gluteal intramuscular injections of cabotegravir LA 800 mg or saline placebo every 12 weeks. The primary objective was to evaluate the safety of cabotegravir LA over three injection cycles (to Week 41). Secondary objectives assessed the tolerability, satisfaction, and acceptability of cabotegravir LA.

RESULTS

Among 115 participants who received injections in the cabotegravir (n = 94) and placebo (n = 21) groups, 93% (n = 87) and 95% (n = 20) completed the injection phase, respectively. Injection intolerability led to withdrawal in 4 participants (4%) receiving cabotegravir LA. The most frequently reported Grade ≥2 adverse event was injection-site pain. Most participants (74% [n = 67]) receiving consecutive injections favored cabotegravir LA vs oral cabotegravir. Most participants were satisfied with cabotegravir LA (75% [n = 64]), were willing to continue (79% [n = 68]), and would recommend (87% [n = 75]) the therapy.

CONCLUSIONS

While Grade ≥2 injection-site pain was common, most participants reported overall satisfaction with and preference for cabotegravir LA, with few discontinuations due to injection intolerance. These findings support investigation of cabotegravir LA as an alternative to daily oral PrEP regimens.

Elimination prospects of the Dutch HIV epidemic among men who have sex with men in the era of preexposure prophylaxis

Objective:

Preexposure prophylaxis (PrEP) is a promising intervention to help end the HIV epidemic among men who have sex with men (MSM) in the Netherlands. We aimed to assess the impact of PrEP on HIV prevalence in this population and to determine the levels of PrEP coverage necessary for HIV elimination.

Design and methods:

We developed a mathematical model of HIV transmission in a population stratified by sexual risk behavior with universal antiretroviral treatment (ART) and daily PrEP use depending on an individual's risk behavior. We computed the effective reproduction number, HIV prevalence, ART and PrEP coverage for increasing ART and PrEP uptake levels, and examined how these were affected by PrEP effectiveness and duration of PrEP use.

Results:

At current levels of ART coverage of 80%, PrEP effectiveness of 86% and PrEP duration of 5 years, HIV elimination required 82% PrEP coverage in the highest risk group (12 000 MSM with more than 18 partners per year). If ART coverage increased by 9%, the elimination threshold was at 70% PrEP coverage. For shorter PrEP duration and lower effectiveness elimination prospects were less favorable. For the same number of PrEP users distributed among two groups with highest risk behavior, prevalence dropped from the current 8 to 4.6%.

Conclusion:

PrEP for HIV prevention among MSM could, in principle, eliminate HIV from this population in the Netherlands. The highest impact of PrEP on prevalence was predicted when ART and PrEP coverage increased simultaneously and PrEP was used by the highest risk individuals.

Effect of On-Demand Oral Pre-exposure Prophylaxis With Tenofovir/Emtricitabine on Herpes Simplex Virus-1/2 Incidence Among Men Who Have Sex With Men: A Substudy of the ANRS IPERGAY Trial

We evaluated the impact of on-demand oral tenofovir disoproxil fumarate (TDF)/emtricitabine (FTC) for pre-exposure prophylaxis (PrEP) on herpes simplex virus (HSV)-1/2 incidence among men who have sex with men (MSM) enrolled in the ANRS IPERGAY trial. Serum samples were tested at baseline and at the last visit for HSV-1/2 antibodies. Overall HSV-1 incidence was 11.7 per 100 person-years; 16.2 and 7.8 per 100 person-years in the TDF/FTC and placebo arm, respectively (P = .19). Overall HSV-2 incidence was 7.6 per 100 person-years; 8.1 and 7.0 per 100 person-years in the TDF/FTC and placebo arm, respectively (P = .75). On-demand oral PrEP with TDF/FTC failed to reduce HSV-1/2 incidence in this population.

HIV pre-exposure prophylaxis in South East Asia: A focused review on present situation

Pre-exposure prophylaxis (PrEP) with the use of antiretrovirals has been approved for HIV prevention in many western countries and internationally. PrEP is however not yet widely available in South East Asia. Awareness of PrEP among MSM in the region is very variable in different countries. While willingness of PrEP uptake is closely related to the extent of awareness, it is largely affected by factors at the individual level, e.g. financial consideration, risk perception, understanding of PrEP and convenience. Removal of social stigmata and secure data confidentiality can improve willingness of uptake. The diverse religious beliefs in South East Asia could have potential influence on PrEP uptake but there was very limited data in the region. There is no strong evidence suggesting substantial risk compensation among MSM who are on PrEP. As in other parts of the world, education on condom use to prevent other sexually transmitted diseases (STD) should be properly addressed rather than blaming PrEP as a sole cause of rise in STD among MSM.

Does pre-exposure prophylaxis for HIV prevention in men who have sex with men change risk behaviour? A systematic review

AIMS AND OBJECTIVES

To review the literature regarding PrEP and sexual behaviour change in MSM.

BACKGROUND

Pre-exposure prophylaxis for HIV has been available since 2012. Even so, pre-exposure prophylaxis has not been widely accepted among healthcare providers and men who have sex with men some of whom are convinced that pre-exposure prophylaxis decreases condom use and increases sexually transmitted infections.

DESIGN

A systematic review of the state of the evidence regarding the association of pre-exposure prophylaxis with condom use, sexually transmitted infection incidence and change in sexual risk behaviours in men who have sex with men. A structured search of databases resulted in 142 potential citations, but only 10 publications met inclusion criteria and underwent data abstraction and critical appraisal.

METHODS

An adapted Cochrane Collaboration domain-based assessment tool was used to critically appraise the methodological components of each quantitative study, and the Mixed Methods Appraisal Tool was used to critically appraise qualitative and mixed-methods studies.

RESULTS

Condom use in men who have sex with men using pre-exposure prophylaxis is influenced by multiple factors. Studies indicate rates of sexually transmitted infections in treatment and placebo groups were high. Pre-exposure prophylaxis did not significantly change sexually transmitted infection rates between baseline and follow-up. Reporting of sexual risk improved when questionnaires were completed in private by clients. Our review found that pre-exposure prophylaxis may provide an opportunity for men who have sex with men to access sexual health care, testing, treatment and counselling services. We did not find any conclusive evidence that pre-exposure prophylaxis users increase sexual risk behaviours.

CONCLUSION

The perception among healthcare providers that pre-exposure prophylaxis leads to increased sexual risk behaviours has yet to be confirmed. In order to provide effective sexual health services, clinicians need to be knowledgeable about pre-exposure prophylaxis as an HIV prevention tool.

RELEVANCE TO CLINICAL PRACTICE

In an era where HIV prevention methods are rapidly improving, strategies for sexually transmitted infection testing, treatment, counselling and prevention remain vital to improve health. All healthcare providers are uniquely positioned to promote sexual health through the dissemination of accurate information.

A Pharmacokinetic/Pharmacodynamic Model to Predict Effective HIV Prophylaxis Dosing Strategies for People Who Inject Drugs

The goal of this work was to evaluate dosing strategies for tenofovir disoproxil fumarate (TDF), tenofovir alafenamide (TAF), and emtricitabine (FTC) for pre-exposure prophylaxis (PrEP) with injection drug use with a pharmacokinetic/pharmacodynamics analysis of concentration data generated from two single-dose clinical studies conducted in healthy women. Population pharmacokinetic models were developed using measured intracellular metabolite, endogenous nucleotide competitors, and extracellular parent drug concentrations. Intracellular metabolite concentrations were normalized to endogenous competitors and compared with an EC90 target for PrEP efficacy. Monte Carlo simulations were used to select effective dose strategies of single agents (TAF, TDF, and FTC) and combinations (TDF + FTC and TAF + FTC). Daily, intermittent, and event-driven dosing regimens at varying dosage amounts were explored. When combined, TDF + FTC and TAF + FTC both provided quick (0.5 hours) and durable (up to 84 and 108 hours, respectively) protection of ≥99% after a single dose. When dosed twice per week, protection remained at 100%. Single-agent regimens provided lower estimates of protection than either combination tested. Here, the application of pharmacokinetic modeling to in vitro target concentrations demonstrates the added utility of including FTC in a successful PrEP regimen. While no TAF-based PrEP data are currently available for comparison, this analysis suggests TAF + FTC could completely protect against percutaneous exposure with as little as two doses per week.

Barriers and Facilitators to Oral PrEP Use Among Transgender Women in New York City

Transgender women may face a disparate risk for HIV/AIDS compared to other groups. In 2012, Truvada was approved for daily use as HIV pre-exposure prophylaxis (PrEP). However, there is a dearth of research about barriers and facilitators to PrEP in transgender women. This paper will shed light on transgender women living in New York City's perceived and actual challenges to using PrEP and potential strategies to overcome them. After completing an initial screening process, four 90-min focus groups were completed with n = 18 transgender women. Participants were asked what they like and dislike about PrEP. Participants identified the following barriers: uncomfortable side effects, difficulty taking pills, stigma, exclusion of transgender women in advertising, and lack of research on transgender women and PrEP. Facilitators included: reducing pill size, increasing the types of available HIV prevention products, and conducting scientific studies to evaluate PrEP in transgender women.

The informal use of antiretroviral medications for HIV prevention by men who have sex with men in South Florida: initiation, use practices, medications and motivations

Limited data suggest that some gay and other men who have sex with men are using antiretroviral medications informally, without a prescription, for HIV prevention. This qualitative study examined this phenomenon among gay and other men who have sex with men in South Florida. Participants initiated informal antiretroviral medication use as a means of protecting each other and because of the confidence in knowledge of antiretroviral medications shared by their friends and sex partners. The most commonly used medications included Truvada and Stribild. Motivations for use included condom avoidance, risk reduction, and fear of recent HIV exposure. Participants described positive and negative sentiments related to informal use, including concerns about informal antiretroviral medications offering sufficient protection against HIV, and limited knowledge about pre-exposure prophylaxis (PrEP). Because the antiretroviral medications used for PrEP have the potential to prevent HIV infection, future research must consider the informal antiretroviral medication use and related concerns, including adherence, diversion and viral resistance.

Trends in Awareness and Use of HIV PrEP Among Gay, Bisexual, and Other Men who have Sex with Men in Vancouver, Canada 2012-2016

Gay, bisexual, and other men who have sex with men (gbMSM) are at the highest risk for HIV infection in British Columbia (BC). Pre-exposure prophylaxis (PrEP) has been recently licensed but is currently not publicly funded in BC. Using respondent-driven sampling, we recruited a cohort of gbMSM to complete a computer-assisted self-interview with follow-up every 6 months. Stratified by HIV status, we examined trends in awareness of PrEP from 11/2012 to 02/2016 and factors associated with PrEP awareness. 732 participants responded to the PrEP awareness question. Awareness of PrEP among HIV-negative men increased from 18 to 80% (p < 0.0001 for trend); among HIV-positive men, awareness increased from 36 to 77% (p < 0.0001). PrEP awareness was associated with factors related to HIV risk including sero-adaptive strategies and sexual sensation seeking. Eight HIV-negative men reported using PrEP. Low PrEP uptake highlights that PrEP access should be expanded for at-risk gbMSM in BC.

Poppers and PrEP: Use of Pre-exposure Prophylaxis Among Men Who Have Sex with Men Who Use Inhaled Nitrites

Men who have sex with men (MSM) commonly use inhaled nitrites, or poppers, though their use is a risk factor HIV seroconversion. Pre-exposure prophylaxis, or PrEP, is effective for HIV prevention, but is not widely used, and little is known regarding PrEP use and acceptability among MSM who use inhaled nitrites. We surveyed 580 MSM in Paris, France in 2016 about popper use, sexual behaviors including condomless anal intercourse (CAI), serosorting, and sexual positioning, PrEP use, PrEP candidacy, and interest in alternate PrEP delivery modalities. We included 444 HIV negative participants for the current study. 46.2% reported popper use in the prior 3 months. Using multivariate adjusted logistic regression, we found that popper users were more likely than non-users to consider themselves candidates for PrEP [adjusted relative risk ratio (aRRR) = 2.73; 95% CI 1.54-4.83], but they were not more likely to be current (aRRR = 1.54; 95% CI 0.71-3.33) or past (aRRR = 1.37; 95% CI 0.44-4.28) PrEP users. Mediation analyses indicated that increased CAI and serosorting partly explained the relationship between popper use and PrEP candidacy. There was considerable interest in alternate proposed PrEP delivery modalities, particularly long-acting injectable PrEP [adjusted risk ratio (aRR) = 1.43; 95% CI 1.15-1.79].

PrEParing Women to Prevent HIV: An Integrated Theoretical Framework to PrEP Black Women in the United States

Preexposure prophylaxis (PrEP) with optimal adherence has demonstrated efficacy in reducing HIV incidence in women. Black women are disproportionately burdened by the HIV epidemic, accounting for more than half of all new HIV cases in women, thereby making PrEP an ideal prevention strategy for this group. However, to date, PrEP uptake by women in the United States has been slow. Further domestic research is needed to understand the multilevel factors related to PrEP awareness, uptake, and implementation in Black women. Our purpose was to review the current status of HIV prevention in Black women. We summarize clinical trials germane to federal approval of PrEP; discuss important PrEP studies focused on women, including non-oral options; and review multilevel barriers to PrEP uptake. Lastly, we discuss the use of an integrated theoretical framework to organize multilevel factors related to PrEP uptake by Black women in order to guide intervention development.

Safety, tolerability, and pharmacokinetics of long-acting injectable cabotegravir in low-risk HIV-uninfected individuals: HPTN 077, a phase 2a randomized controlled trial

BACKGROUND

Cabotegravir (CAB) is a novel strand-transfer integrase inhibitor being developed for HIV treatment and prevention. CAB is formulated both as an immediate-release oral tablet for daily administration and as a long-acting injectable suspension (long-acting CAB [CAB LA]) for intramuscular (IM) administration, which delivers prolonged plasma exposure to the drug after IM injection. HIV Prevention Trials Network study 077 (HPTN 077) evaluated the safety, tolerability, and pharmacokinetics of CAB LA in HIV-uninfected males and females at 8 sites in Brazil, Malawi, South Africa, and the United States.

METHODS AND FINDINGS

HPTN 077 was a double-blind, placebo-controlled phase 2a trial. Healthy individuals age 18-65 years at low HIV risk were randomized (3:1) to receive CAB or placebo (PBO). In the initial oral phase, participants received 1 daily oral tablet (CAB or PBO) for 4 weeks. Those without safety concerns in the oral phase continued and received injections in the injection phase (Cohort 1: 3 injections of CAB LA 800 mg or 0.9% saline as PBO IM every 12 weeks for 3 injection cycles; Cohort 2: CAB LA 600 mg or PBO IM for 5 injection cycles; the first 2 injections in Cohort 2 were separated by 4 weeks, the rest by 8 weeks). The primary analysis included weeks 5 to 41 of study participation, encompassing the injection phase. The cohorts were enrolled sequentially. Primary outcomes were safety and tolerability. Secondary outcomes included pharmacokinetics and events occurring during the oral and injection phases. Between February 9, 2015, and May 27, 2016, the study screened 443 individuals and enrolled 110 participants in Cohort 1 and 89 eligible participants in Cohort 2. Participant population characteristics were as follows: 66% female at birth; median age 31 years; 27% non-Hispanic white, 41% non-Hispanic black, 24% Hispanic/Latino, 3% Asian, and 6% mixed/other; and 6 transgender men and 1 transgender woman. Twenty-two (11%) participants discontinued the oral study product; 6 of these were for clinical or laboratory adverse events (AEs). Of those who received at least 1 CAB LA injection, 80% of Cohort 1 and 92% of Cohort 2 participants completed all injections; injection course completion rates were not different from those in the PBO arm. Injection site reactions (ISRs) were common (92% of Cohort 1 and 88% of Cohort 2 participants who received CAB LA reported any ISR). ISRs were mostly Grade 1 (mild) to Grade 2 (moderate), and 1 ISR event (Cohort 1) led to product discontinuation. Grade 2 or higher ISRs were the only AEs reported more commonly among CAB LA recipients than PBO recipients. Two Grade 3 (severe) ISRs occurred in CAB recipients, 1 in each cohort, but did not lead to product discontinuation in either case. Seven incident sexually transmitted infections were diagnosed in 6 participants. One HIV infection occurred in a participant 48 weeks after last injection of CAB LA: CAB was not detectable in plasma both at the time of first reactive HIV test and at the study visit 12 weeks prior to the first reactive test. Participants in Cohort 2 (unlike Cohort 1) consistently met prespecified pharmacokinetic targets of at least 95% of participants maintaining CAB trough concentrations above PA-IC90, and 80% maintaining trough concentrations above 4× PA-IC90. Study limitations include a modest sample size, a short course of injections, and a low-risk study population.

CONCLUSIONS

In this study, CAB LA was well tolerated at the doses and dosing intervals used. ISRs were common, but infrequently led to product discontinuation. CAB LA 600 mg every 8 weeks met pharmacokinetic targets for both male and female study participants. The safety and pharmacokinetic results observed support the further development of CAB LA, and efficacy studies of CAB LA for HIV treatment and prevention are in progress.

TRIAL REGISTRATION

ClinicalTrials.gov Registry: ClinicalTrials.gov Trial number: NCT02178800.

Long-Acting HIV Drugs for Treatment and Prevention

Antiretroviral drugs have revolutionized the treatment and prevention of HIV infection; however, adherence is critical for sustained efficacy. Current HIV treatment consists of three-drug regimens, and current HIV pre-exposure prophylaxis (PrEP) consists of a two-drug regimen; both generally require adherence to once-daily dosing. Long-acting formulations are useful in the treatment and prevention of other conditions (e.g., contraceptives, antipsychotics) and help promote adherence. Newer long-acting formulations of approved and investigational antiretroviral drugs in existing and newer mechanistic classes are under study for HIV treatment and prevention, including some phase III trials. Although long-acting antiretroviral drugs hold promise, some clinical challenges exist, including managing side effects, drug-drug interactions, pregnancy, and long-lasting drug concentrations that could lead to the development of drug resistance. This review aims to summarize currently available information on long-acting antiretroviral drugs for HIV treatment and prevention.

Drug resistance among patients who acquired HIV infection in a preexposure prophylaxis trial

BACKGROUND

The IPERGAY ANRS trial showed that on-demand preexposure prophylaxis (PrEP) with tenofovir (TDF) and emtricitabine (FTC) was highly effective in preventing HIV infection among highly exposed MSM. Here, we analyzed drug resistance-associated mutations (RAMs) among all participants who acquired HIV infection during this trial.

METHODS

Resistance was analyzed on frozen plasma at the time of HIV diagnosis among participants enrolled in the double-blind and open-label phases of the ANRS IPERGAY trial. Reverse transcriptase sequencing was performed, using population-based and ultradeep sequencing (454 GS Flex). Adherence was measured by pill counting and by plasma tenofovir and FTC assay.

RESULTS

During the trial, 31 participants were diagnosed with HIV-1 infection (subtype B, 64.5%), using antigen/antibody immune assay in 29 cases and plasma HIV RNA assay in two. The median plasma HIV-1 RNA level was 5.52 log10 copies/ml. Drug resistance was tested in 12 participants before starting PrEP, in six assigned to TDF/FTC group and in 13 assigned to placebo group. Primary resistance to nucleoside reverse transcriptase inhibitors (zidovudine) and/or nonnucleoside reverse transcriptase inhibitors was detected in six participants (19%; 95% confidence interval 7-42). No major or minor TDF-resistant or FTC-resistant variants were detected.

CONCLUSION

No TDF or FTC resistance-associated mutations were found among participants who acquired HIV in the ANRS IPERGAY trial.

Awareness, knowledge, use, willingness to use and need of Pre-Exposure Prophylaxis (PrEP) during World Gay Pride 2017

OBJECTIVE

To assess the awareness, knowledge, use, and willingness to use and need of PrEP among men who have sex with men (MSM) and transgender women (TW) who attended World Gay Pride (WGP) 2017 in Madrid.

DESIGN AND METHODS

Online survey. Participants were recruited through gay-oriented dating apps and HIV Non-Governmental Organizations´ social media. Inclusion criteria included being MSM or TW, age 18 years old or above, and having attended WGP in Madrid. Information regarding the participant's awareness and knowledge, use or willingness to use, and need for PrEP was collected, as well as sociodemographic characteristics. Participants were considered to be in need of PrEP if they met one of the following indication criteria: having practiced unprotected anal intercourse with more than 2 partners, having practiced chemsex, or having engaged in commercial sex-all in the preceding 6 months. Descriptive and multivariable analyses with logistic regression were conducted.

RESULTS

472 participants met the inclusion criteria and completed the questionnaire. The mean age was 38, 97.7% were MSM, 77% had a university education, and 85% were living in Spain, mostly in big cities. Overall, 64% of participants were aware of PrEP, but only 33% knew correctly what PrEP was. 67% of HIV-negative participants were willing to take PrEP, although only 5% were taking it during WGP, mostly due to lack of access. 43% of HIV-negative respondents met at least one PrEP indication criteria. For HIV-negative men living in Spain, university education and living in big cities was associated with PrEP awareness. Lower education level and meeting PrEP criteria was associated with willingness to use PrEP.

CONCLUSIONS

Our study shows that among MSM attending WGP 2017 in Madrid, there was limited PrEP awareness, low accuracy of PrEP knowledge, and a high need and willingness to use PrEP. Health authorities should strengthen existing preventive strategies and implement PrEP.

The estimated number of potential PrEP users among gay-identifying men who have sex with men in Australia

We estimated the size of the population of gay-identified men who have sex with men (gay men) eligible for PrEP in Australia under the current national PrEP guidelines. Using input indicators from the Australian Bureau of Statistics, the national representative survey Second Australian Study of Health and Relationships, and national HIV- behavioural surveillance, we calculated the size of the population of sexually active gay men and estimated a range for the number eligible for PrEP using different scenarios based on the guidelines. In 2015, an estimated 108,850 sexually-active 16-69-year-old gay men were classified as at risk of acquiring HIV in Australia. Of these men, 10,558 to 30,913 (9.7%-28.4%) were classified as being at high risk and therefore eligible for PrEP, most commonly due to recent receptive condomless intercourse with casual partners (6.1% to 15.5%), STI infections (5.4% to 10.6%) or the use of crystal methamphetamine (1.4% to 9.4%). The higher estimates included men who may have been at HIV risk for shorter time periods or with fewer partners. Australian PrEP guidelines recommend targeting PrEP to people at high HIV risk. Our estimation of potential PrEP users informed PrEP implementation in Australia. The choice of PrEP eligibility criteria, and interpretation of the guidelines, strongly affects the population estimates. In the future, higher numbers of gay men may become eligible for PrEP, because the estimates are largely defined by and follow trends in condomless anal intercourse. Our estimation methods can be adapted to other settings.

Noncovalent PEG Coating of Nanoparticle Drug Carriers Improves the Local Pharmacokinetics of Rectal Anti-HIV Microbicides

Antiretroviral drug nanocarriers hold great promise for developing anti-human immunodeficiency virus (HIV) rectal microbicides. However, challenges remain, namely, concerning which properties are more suited for enhancing colorectal distribution and retention of microbicide compounds. In this work, we developed and assessed the in vitro and in vivo performance of poly(lactic- co-glycolic acid) (PLGA)-based nanoparticles (NPs) as carriers for the model drug efavirenz (EFV). We particularly focused on the effect of noncovalent poly(ethylene glycol) coating of PLGA NPs (PEG-PLGA NPs) conferring a mucus-diffusive behavior on the pharmacokinetics (PK) of EFV following rectal administration to mice. Drug-loaded PLGA NPs and PEG-PLGA NPs (200-225 nm) were obtained by nanoprecipitation. Both types of systems were able to retain native antiretroviral activity of EFV in vitro, while featuring lower cytotoxicity against different epithelial cell lines and HIV target cells. Also, PLGA NPs and PEG-PLGA NPs were readily taken up by colorectal cell lines and mildly reduced EFV permeation while increasing membrane retention in Caco-2 and Caco-2/HT29-MTX cell monolayer models. When administered intrarectally to CD-1 mice in phosphate-buffered saline (pH 7.4), EFV-loaded PEG-PLGA NPs consistently provided higher drug levels in colorectal tissues and lavages, as compared to free EFV or drug-loaded PLGA NPs. Mean values for the area-under-the-curve between 15 min and 12 h following administration were particularly higher for PEG-PLGA NPs in distal and middle colorectal tissues, with relative bioavailability values of 3.7 and 29, respectively, as compared to free EFV (2.2 and 6.0 over PLGA NPs, respectively). Systemic exposure to EFV was reduced for all treatments. NPs were further shown safe after once-daily administration for 14 days, as assessed by histological analysis of colorectal tissues and chemokine/cytokine assay of rectal lavages. Overall, PEG-PLGA NPs demonstrated to be safe carriers for rectal microbicide drug delivery and able to provide enhanced local PK that could be valuable in preventing rectal HIV transmission.

Quality of HIV Websites With Information About Pre-Exposure Prophylaxis or Treatment as Prevention for Men Who Have Sex With Men: Systematic Evaluation

Background

Knowledge and uptake of high-efficacy HIV prevention strategies such as pre-exposure prophylaxis (PrEP) and treatment as prevention (TasP) remain low among men who have sex with men (MSM) who are at the highest risk for HIV infection in the United States. Electronic health (eHealth) interventions are promising tools for disseminating information about these critical yet underutilized strategies and addressing key barriers to uptake among target populations. However, existing HIV prevention websites are understudied and unevaluated.

Objective

This study aimed to systematically review and evaluate existing HIV websites that include information about PrEP or TasP for MSM.

Methods

From March 2018 to May 2018, 2 trained research assistants (RAs) entered relevant key words and phrases into 3 commonly used search engines and applied exclusion criteria to all returned results to identify 31 websites included in this review. RAs independently scored each website for authority, usability, interactivity, and PrEP/TasP-related content based on a standardized rating scale and then averaged the results.

Results

No website received a perfect score in any of the 4 categories, and the average website score was 62% (37/60). Less than a quarter of the websites (23%, 7/31) received a score of more than 75% (7.5/10) for content. Approximately two-thirds of the websites (65%, 20/31) received a score of 50% (5/10) or lower for interactivity. The average score in usability was 68% (6.8/10) and in authority was 69% (6.9/10). Other deficiencies observed included difficulty locating relevant content and lack of information targeting audiences with the highest likelihood of HIV infection.

Conclusions

Existing HIV prevention websites with information about PrEP or TasP for MSM fail to provide adequate content as well as present that content to users in an interactive and audience-conscious way. Future eHealth interventions should attempt to rectify these deficiencies to successfully engage and educate MSM at high risk for HIV regarding prevention strategies.

Pre-exposure prophylaxis among men who have sex with men in the Amsterdam Cohort Studies: Use, eligibility, and intention to use

Objective

Currently, HIV pre-exposure prophylaxis (PrEP) is not covered by health insurance in the Netherlands. We examined time trends in use of PrEP, characteristics of PrEP users, PrEP eligibility and intention to use PrEP among HIV-negative men who have sex with men (MSM) participating in the Amsterdam Cohort Studies (ACS).

Design

Prospective cohort study.

Methods

We used data from four 6-monthly questionnaire waves, collected between 2015–2017. PrEP use over time was examined in logistic regression models using generalized estimating equations. Using descriptive statistics, we compared PrEP users before first-time initiation to non-PrEP-users. We used national guidelines to assess PrEP eligibility.

Results

We included 687 MSM. Median age was 40 (IQR 33–47) years in 2015. Recent PrEP use was reported by 57/687 (8%) MSM. PrEP use increased over calendar time (P<0.001) to 7% in 2017. PrEP users did not differ from non-PrEP users in socio-demographic characteristics, but reported a significantly higher median number of casual sex partners, more often reported condomless anal sex and chemsex with casual partners, and more often had an sexually transmitted infection in the preceding 6 months (all P<0.05). PrEP eligibility increased over time, but the effect was not statistically significant (P = 0.075). PrEP eligibility criteria were met by 149/460 (32%) at wave 4, of whom 31/149 (21%) reported use of PrEP. The proportion with a high intention to use PrEP was greater among eligible than non-eligible MSM (51% vs. 24%, P<0.001).

Conclusion

PrEP use increased over time but remained under 10%, even though 32% met the eligibility criteria, of whom 51% had a high intention to use PrEP. This suggests that a large proportion of Dutch MSM at risk could benefit from PrEP.

Towards an Integration of PrEP into a Safe Sex Ethics Framework for Men Who Have Sex with Men

The ethics of safe sex in the gay community has, for many years, been focused on debates surrounding the responsibility (or lack thereof) regarding the use of condoms to prevent HIV transmission, once the only tool available. With the development of Truvada as a pre-exposure prophylaxis (PrEP) for HIV, for the first time in the history of the HIV/AIDS epidemic there is the potential to significantly reduce the risk of HIV transmission during sex without the use of condoms (without taking into consideration 'treatment as prevention' with HIV-positive people). The introduction of PrEP necessitates a renewed discussion about the politics and ethics of safe sex for men who have sex with men (MSM). We present the arguments of authors who hold radically opposite positions with regard to the ethics of condom use by gay men, but who currently both criticize the use of PrEP. We offer a critique of their arguments and advance the position that the use of PrEP, even without condoms, can be acceptable and part of a safe sex ethics framework for MSM.

Adaptive non-inferiority margins under observable non-constancy

A central assumption in the design and conduct of non-inferiority trials is that the active-control therapy will have the same degree of effectiveness in the planned non-inferiority trial as in the prior placebo-controlled trials used to define the non-inferiority margin. This is referred to as the 'constancy' assumption. If the constancy assumption fails, decisions based on the chosen non-inferiority margin may be incorrect, and the study runs the risk of approving an inferior product or failing to approve a beneficial product. The constancy assumption cannot be validated in a trial without a placebo arm, and it is unlikely ever to be met completely. When there are strong, observable predictors of constancy, such as dosing and adherence to the active-control product, we can specify conditions where the constancy assumption will likely fail. We propose a method for using measurable predictors of active-control effectiveness to specify non-inferiority margins targeted to the planned study population characteristics. We describe a pre-specified method, using baseline characteristics or post-baseline predictors in the active-control arm, to adapt the non-inferiority margin at the end of the study if constancy is violated. Adaptive margins can help adjust for constancy violations that will inevitably occur in real clinical trials, while maintaining pre-specified levels of Type I error and power.

[Occupational and non occupational exposure to viral risk]

The transmission of an infectious disease can occur through exposure to blood or other potentially infectious body fluids, particularly in the event of skin-puncture injuries for healthcare workers, and during sexual intercourse. These situations are known as accidental blood exposures and sexual exposures respectively. Combined actions carried out have allowed to significantly reduce risks, either to healthcare professionals (by standard precautions, provision of safety devices, Hepatitis B vaccination made compulsory in the 1990s, antiretroviral post-exposure prophylaxis that should be initiated as soon as possible after exposure), or to people engaging in unprotected sex (by prevention messages, condom promotion, and antiretroviral post-exposure prophylaxis). In any case, treatment of people infected by chronic diseases such as HBV or HIV, as well as possible drug eradication of HCV, are key for decreasing post-exposure risk of disease transmission. Post-exposure prophylaxis should be initiated as early as possible and intended for use only in patients with high-risk exposures. Knowledge of source person serostatus, information of exposed person on prevention, benefits and risks of treatment, and follow-up procedure are key points. Procedures to be followed in the event of an exposure must be known by all. Arrangements set up to allow risk assessment and management of exposed people rely on hospital services operating on a permanent basis.

Temporal Fluctuations in Behavior, Perceived HIV Risk, and Willingness to Use Pre-Exposure Prophylaxis (PrEP)

Individual perceptions of HIV risk influence willingness to use pre-exposure prophylaxis (PrEP) for HIV prevention. Among men who have sex with men (MSM) and male sex workers (MSWs), temporal or episodic changes in risk behavior may influence perceived risk and PrEP acceptability over time. We investigated fluctuations in perceived HIV risk and PrEP acceptability, comparing MSWs against MSM who do not engage in sex work. We conducted 8 focus groups (n = 38) and 56 individual interviews among MSM and MSWs in Providence, RI. Perceived HIV risk shaped willingness to use PrEP among both MSWs and MSM who did not engage in sex work, and risk perceptions changed over time depending on behavior. For MSWs, perceived risk cycled according to patterns of substance use and sex work activity. These cycles yielded an "access-interest paradox": an inverse relationship between willingness to use and ability to access PrEP. MSM who did not engage in sex work also reported temporal shifts in risk behavior, perceived risk, and willingness to use PrEP, but changes were unrelated to access. MSM attributed fluctuations to seasonal changes, vacations, partnerships, behavioral "phases," and episodic alcohol or drug use. Efforts to implement PrEP among MSM and street-based MSWs should address temporal changes in willingness to use PrEP, which are linked to perceived risk. Among MSWs, confronting the access-interest paradox may require intensive outreach during high-risk times and efforts to address low perceived risk during times of reduced sex work.

Qualitative Consumer Research on Acceptance of Long-Acting Pre-Exposure Prophylaxis Products Among Men Having Sex with Men and Medical Practitioners in the United States

Pre-exposure prophylaxis (PrEP) with oral Truvada^® prevents HIV infection. However, the adherence to pill taking required for efficacy has sparked interest in developing new antiretroviral delivery systems that decrease such demands. Long-acting formulations, such as injections and implants, represent promising options that require less frequent adherence. It is important, however, that development of these new modalities be driven by understanding of the value seen in them by target users to maximize their uptake. To identify the key product features that impact user acceptance, we used a three-phase marketing research approach. In this study, we describe the results of the first-phase, qualitative focus group research performed in Chicago and San Francisco that explored subjective perceptions of oral versus alternative PrEP modalities among men having sex with men (MSM) and medical practitioners caring for MSM. Data revealed that potential value in long-acting PrEP lies more in simplifying the lives of users rather than in making them more confident in their adherence. The results provide an important guidance for designing and promoting these future long-acting products to enhance their contribution to increasing the current limited uptake of PrEP that will better stem the HIV epidemic.

PrEParing for the unexpected: mechanisms and management of HIV pre-exposure prophylaxis failure

Pre-exposure prophylaxis (PrEP) for HIV is a proven and effective tool for preventing HIV. However, there are instances where individuals taking PrEP have contracted HIV infection. Most of these cases are due to nonadherence to the drug, while other cases of apparent PrEP failure are due to unrecognized HIV infection at baseline. Importantly, there are also now at least three well-documented cases of PrEP failing despite adequate adherence; these are cases of PrEP ‘breakthrough’. This article outlines the potential mechanisms of PrEP failure, as well as how to identify and manage these patients. Finally, we provide a perspective on the future of PrEP as a key tool in preventing HIV worldwide.

Choosing Between Daily and Event-Driven Pre-exposure Prophylaxis: Results of a Belgian PrEP Demonstration Project

BACKGROUND

Daily pre-exposure prophylaxis and event-driven pre-exposure prophylaxis (PrEP) are efficacious in reducing HIV transmission among men who have sex with men (MSM). We analyzed baseline data from a PrEP demonstration project "Be-PrEP-ared" in Antwerp, Belgium, to understand preferences for daily PrEP or event-driven PrEP among MSM at high risk of HIV and factors influencing their initial choice.

METHODS

Cross-sectional data from an open-label prospective cohort study, using mixed methods. Participants who preregistered online were screened for eligibility and tested for sexually transmitted infections (STIs). Eligible participants chose between daily PrEP and event-driven PrEP and reported on behavioral data through an electronic questionnaire. In-depth interviews were conducted with a selected subsample. Bivariate associations were examined between preferred PrEP regimens and sociodemographic factors, sexual behavior, and STIs at screening.

RESULTS

In total, 200 participants were enrolled between October 2015 and December 2016. Self-reported levels of sexual risk-taking before enrollment were high. STI screening revealed that 39.5% had at least 1 bacterial STI. At baseline, 76.5% of participants preferred daily PrEP and 23.5% event-driven PrEP. Feeling able to anticipate HIV risk was the most frequent reason for preferring event-driven PrEP. Regimen choice was associated with sexual risk-taking behavior in the past 3 months. Almost all participants (95.7%) considered it likely that they would change their dosing regimen the following year.

CONCLUSION

Event-driven PrEP was preferred by 23.5% of the participants, which better suits their preventive needs. Event-driven PrEP should be included in PrEP provision as a valuable alternative to daily PrEP for MSM at high risk of HIV.

HIV Preexposure Prophylaxis Initiation at a Large Community Clinic: Differences Between Eligibility, Awareness, and Uptake

OBJECTIVES

To characterize uptake of HIV preexposure prophylaxis (PrEP) in a community setting and to identify disparities in PrEP use by demographic and behavioral factors associated with increased HIV risk.

METHODS

We conducted a cross-sectional study of 19 587 men who have sex with men and transgender people visiting a Los Angeles, California, clinic specializing in lesbian, gay, bisexual, and transgender care between August 2015 and February 2018 by using clinical care data.

RESULTS

Seventy percent of patients met PrEP eligibility criteria, while 10% reported PrEP use. Using sex drugs, reporting both condomless anal intercourse and recent sexually transmitted infection, older age, and higher education level were associated with higher odds of PrEP use given eligibility. Latino or Asian race/ethnicity and bisexual orientation were associated with lower odds of PrEP use given eligibility. Higher odds of perceived need were associated with demographic risk factors but PrEP use was not similarly elevated.

CONCLUSIONS

Discrepancies between PrEP eligibility, perceived need, and use reveal opportunities to improve PrEP delivery in community settings. Public Health Implications. Efforts are needed to facilitate PrEP uptake in populations with highest HIV incidence.

Repeated rectal application of a hyperosmolar lubricant is associated with microbiota shifts but does not affect PrEP drug concentrations: results from a randomized trial in men who have sex with men

INTRODUCTION

Oral pre-exposure prophylaxis (PrEP) with tenofovir disoproxil fumarate (TDF) and emtricitabine (FTC) is highly effective in preventing HIV infection among men who have sex with men (MSM). The effects of consistent personal lubricant use in the rectum on tissue PrEP drug concentrations and the rectal microbiota are unknown. We investigated rectal PrEP drug concentrations and the microbiota in MSM before and after repeated rectal application of a hyperosmolar lubricant.

METHODS

We randomized 60 HIV-negative MSM to apply 4 mL of hyperosmolar rectal lubricant daily (n = 20), take daily oral TDF/FTC (n = 19), or both (n = 21) for seven days. Blood, rectal biopsies and rectal secretions were collected via rigid sigmoidoscopy before and on day 8 after product use. Tenofovir (TFV) and FTC as well as their intracellular metabolites tenofovir-diphosphate (TFV-DP), FTC-triphosphate (FTC-TP) were measured by HPLC-mass spectrometry. Rectal mucosal microbiota was sequenced with 16S rRNA sequencing using Illumina MiSeq.

RESULTS

Seven days of lubricant application was not associated with differences in PrEP drug concentrations in rectal tissue or secretions. Lubricant use was associated with a decrease in the relative abundance of the Bacteroides genus (p = 0.01) and a non-significant increase in the Prevotella genus (p = 0.09) in the rectum. PrEP drug concentrations in rectal tissue and secretions were not associated with microbiota composition or diversity either before or after lubricant use.

CONCLUSIONS

Repeated rectal application of a hyperosmolar lubricant does not affect mucosal PrEP drug concentrations but is associated with changes in the rectal microbiome.

Are Anal Sex Roles Associated with Preferences for Pre-Exposure Prophylaxis Administration Modalities Among Men Who Have Sex with Men?

The current study sought to examine awareness of, willingness to use, and preferences for available and theoretical administration modalities for HIV pre-exposure prophylaxis (PrEP) and the association of anal sex roles with these concepts among a sample of men who have sex with men (MSM) in Paris, France. Broadcast advertisements were placed on a popular geosocial-networking smartphone application for MSM to direct users to complete a Web-based survey. MSM answered questions on their recent engagement in condomless anal intercourse and awareness of and willingness to use PrEP in the form of once daily and event-driven pill regimens, long-acting injections, and penile and rectal microbicides as well as sexual roles. Multinomial regression models were fit to assess the association between behaviorally classified anal sexual role and preferences for one of these biomedical prevention modalities. A total of 482 HIV-uninfected MSM completed the survey, 48.1% of whom engaged in some form of condomless anal intercourse in the preceding 3 months. Most respondents (85.3%) had heard of once daily PrEP, but fewer respondents had heard of other prevention strategies. Assuming equal effectiveness, long-acting injections were the most commonly preferred (21.8%). Behaviorally defined "bottom" and "versatile" MSM more frequently preferred long-acting injections (32.9% of "bottoms" and 25.3% of "versatiles"). The development of long-acting injections to deliver antiretroviral drugs and topical microbicides may offer more convenient and acceptable options for HIV prevention among MSM, as MSM in this sample were willing to use them and would prefer to use them over currently available pill regimens.