HIV pre-exposure prophylaxis (PrEP): a review of current knowledge of oral systemic HIV PrEP in humans

The Impact of Pre-exposure Prophylaxis for Human Immunodeficiency Virus on Gonorrhea Prevalence

Pre-exposure prophylaxis (PrEP) has been shown to be highly effective in reducing the risk of HIV infection in gay and bisexual men who have sex with men (GbMSM). However, PrEP does not protect against other sexually transmitted infections (STIs). In some populations, PrEP has also led to riskier behavior such as reduced condom usage, with the result that the prevalence of bacterial STIs like gonorrhea has increased. Here, we develop a compartmental model of the transmission of HIV and gonorrhea and the impacts of PrEP, condom usage, STI testing frequency and potential changes in sexual risk behavior stemming from the introduction of PrEP in a population of GbMSM. We find that introducing PrEP causes an increase in gonorrhea prevalence for a wide range of parameter values, including at the currently recommended frequency of STI testing once every three months for individuals on PrEP. Moreover, the model predicts that a higher STI testing frequency alone is not enough to prevent a rise in gonorrhea prevalence, unless the testing frequency is increased to impractical levels. However, testing every 2 months in combination with a 10-25 % reduction in risky behavior by individuals on PrEP would maintain gonorrhea prevalence at pre-PrEP levels. The results emphasize that programs making PrEP more available should be accompanied by efforts to support condom usage and frequent STI testing, in order to avoid an increase in the prevalence of gonorrhea and other bacterial STIs.

Progress and Challenges in "Getting to Zero" New HIV Infections in Miami, Florida

Objectives:

Miami has the highest rate of new HIV diagnoses in the United States. We examined the early successes and challenges in fulfilling recommendations made by the Miami-Dade County HIV/AIDS Getting to Zero Task Force, formed by local experts in 2016.

Methods:

We used a host of surveillance data, published empirical studies, public reports, and unpublished data from partners of the Task Force to evaluate progress and challenges in meeting the recommendations.

Results:

Improvements in prevention and care included routinized HIV testing in emergency departments, moving the linkage-to-care benchmark from 90 to 30 days, increased viral suppression, and awareness of pre-exposure prophylaxis. However, treatment enrollment, viral suppression, and pre-exposure prophylaxis uptake remained low.

Conclusions:

Recommendations from the Task Force provide excellent guidance for implementing evidence-based HIV prevention in Miami, yet success in achieving the recommendations will require continued or increased support in many public health sectors in South Florida.

Good acceptability of HIV, HBV, and HCV screening during immigration medical check-up amongst migrants in France in the STRADA study

Introduction

The prevalence of HIV, hepatitis B, and hepatitis C amongst migrants in France is high. Thus, effective screening and follow-up is needed. The mandatory medical check-up for residency application is an opportunity to offer rapid HIV and hepatitis testing. The main objective of the STRADA study is to create a feasible and acceptable screening strategy for migrants. Within the STRADA study, this qualitative research examined the acceptability of conducting screening tests in the context of residency application.

Methods

We conducted a qualitative study amongst legal migrants over 18 years of age with sufficient knowledge of the French, English, or Arabic language. Interviews were performed following a semi-structured interview guide of open-ended questions. Interviews were transcribed verbatim and subsequently analyzed through thematic analysis.

Results

We interviewed 34 migrants. Mean age was 32.6 (min-max: 19, 59) years. The participants’ region of origin was mostly Sub-Saharan Africa and the main reason for migrating to France was family reunification. Migrants' acceptability of HIV and hepatitis testing was high. Participants who accepted testing indicated a benefit for individual health and to avoid transmission. Most preferred rapid tests; reluctance was related to anxiety about the immediate results and the perceived reliability of rapid tests. Migrants' knowledge about HIV was satisfactory, but inadequate for hepatitis. Screening in the context of a compulsory medical visit did not present an obstacle for acceptability. Some expressed concern in the case of HIV but when explained, the independence between obtaining the residence permit along with screening and access to medical care was well understood.

Discussion

Medical check-ups at immigration centers is an opportunity to screen for HIV and hepatitis which is considered acceptable by migrants. Informing migrants that test results do not affect residency applications, and incorporating their preferences, are all important to optimize the acceptability of screening.

The Effectiveness of Electronic Health Interventions for Promoting HIV-Preventive Behaviors Among Men Who Have Sex With Men: Meta-Analysis Based on an Integrative Framework of Design and Implementation Features

Background

The disproportionately high prevalence of HIV among men who have sex with men (MSM) is a global concern. Despite the increasing utilization of electronic health (eHealth) technology in the delivery of HIV prevention interventions, few studies have systematically explored its effectiveness and association with various intervention characteristics.

Objective

This study aimed to conduct a meta-analysis of the effectiveness of eHealth technology–based interventions for promoting HIV-preventive behaviors among MSM and to determine effectiveness predictors within a framework integrating design and implementation features.

Methods

A systematic literature search using terms related to eHealth technology, HIV, the MSM population, and an experimental study design was performed using 5 databases (ie, MEDLINE, PsycINFO, EMBASE, Web of Science, and ProQuest Dissertations & Theses) and other sources (eg, bibliographies of relevant reviews and JMIR Publications). First, primary meta-analyses were conducted to estimate the effectiveness of eHealth interventions (d₊) in changing 3 HIV-preventive behaviors among MSM: unprotected anal intercourse (UAI), HIV testing, and multiple sex partnership (MSP). Moderation analyses were then conducted to examine a priori effectiveness predictors including behavioral treatment components (eg, theory use, tailoring strategy use, navigation style, and treatment duration), eHealth technology components (eg, operation mode and modality type), and intervention adherence.

Results

A total of 46 studies were included. The overall effect sizes at end point were small but significant for all outcomes (UAI: d₊=−.21, P<.001; HIV testing: d₊=.38, P<.001; MSP: d₊=−.26, P=.02). The intervention effects on UAI were significantly larger when compared with preintervention groups than with concurrent groups. Greater UAI reductions were associated with the increased use of tailoring strategies, provision of feedback, and tunneling navigation in interventions with a concurrent group, whereas reductions were associated with the use of self-paced navigation in interventions with a preintervention group. Greater uptake of HIV testing was associated with longer treatment duration; computer-mediated communication; and the use of messaging, social media, or a combined technology modality. Higher intervention adherence consistently predicted larger effects on UAI and HIV testing.

Conclusions

This study provided empirical evidence for the effectiveness of eHealth interventions in promoting HIV-preventive behaviors among MSM. Features of treatment content and eHealth technology might best predict the intervention effects on UAI and HIV testing, respectively. Most importantly, intervention adherence tended to play an important role in achieving better effectiveness. The findings could help inform the development of efficacious interventions for HIV prevention in the future.

Barriers and motivators to pre-exposure prophylaxis uptake among Black and Latina transgender women in Los Angeles: perspectives of current PrEP users

The purpose of this qualitative study was to identify barriers and motivators to PrEP uptake from the perspective of Black and Latina transgender women (TW) who are currently using PrEP to suggest intervention and outreach activities to increase PrEP uptake in this population. The Information-Motivation-Behavioral Skills Model guided the development of the semi-structured interview guide. A thematic analysis approach was used to analyze the data. Perceived barriers to PrEP uptake included structural and logistic barriers, language and cultural barriers to medical engagement, lack of transgender competent or gender-affirming care, and prioritizing hormone therapy over the use of PrEP. To increase PrEP uptake among BLTW, participants recommended disseminating PrEP information through a variety of methods, highlighting relationship and sexual health benefits of using PrEP, and developing effective patient-provider communication. Our findings highlight several ways to promote PrEP among BLTW. PrEP promotion should be integrated into gender-affirming care and supported by peer education and navigation services that reach BLTW in both clinic and community settings.

Associations Between Relationship Power and Pre-Exposure Prophylaxis (PrEP) Use Among Men Who Have Sex With Men

Few studies have attempted to understand relationship-level factors impacting PrEP utilization among men who have sex with men (MSM). This study examined associations between relationship power and PrEP use among 826 MSM participating in a cross-sectional, Internet-based survey. The results of our analysis indicate that decision-making dominance was positively associated with PrEP use among MSM, but the association between relationship control/overall relationship power and PrEP use was inconclusive. Furthermore, when examining specific types of decision-making dominance, equal and greater dominance compared to one's partner regarding types of sexual activity engaged in, as well as dominance more generally, were positively associated with PrEP use. However, the relationships between decision-making dominance related to condom use/sexual initiation and PrEP use were inconclusive. This study suggests that the promotion of egalitarian relationships-as well as other relationship-level determinants-should be an essential component of biobehavioral interventions targeting this population.

HIV Seroconversion in the Era of Pharmacologic Prevention: A Case-Control Study at a San Francisco STD Clinic

BACKGROUND

The comparative effectiveness of pre- and post-exposure prophylaxis (PrEP and PEP) for men who have sex with men (MSM) is unclear.

SETTING

We conducted a case-control study of MSM who were initially HIV-uninfected during September 1, 2012-June 30, 2016 at San Francisco's only municipal sexually transmitted diseases (STDs) clinic.

METHODS

Each case was matched with up to 3 controls based on age, baseline visit date, and follow-up time. The primary dependent variable was HIV seroconversion; the primary independent variable was exposure to PrEP, PEP, or neither. Conditional logistic regression was used to calculate odds ratios and 95% confidence intervals.

RESULTS

Of 638 MSM (161 cases and 477 controls), 137 reported ever taking PrEP, 98 reported taking PEP-only, and 403 took neither. PrEP takers had more non-HIV sexually transmitted diseases during the analysis (72.3% vs. 55.1% vs. 42.4% P < 0.01) and were more likely to report receptive anal sex in the past 3 months (86.5% vs. 80.4% vs. 73.0%; P < 0.01). In the adjusted model, PrEP was associated with lower odds of HIV seroconversion (odds ratio 0.24; 95% confidence interval: 0.13 to 0.46) while PEP use had no effect on HIV acquisition compared with taking neither.

CONCLUSIONS

MSM who ever used PrEP demonstrated equal or higher sexual risk compared with those using neither PrEP nor PEP but had 76% lower odds of HIV seroconversion. MSM who used PEP but never PrEP were no less likely to seroconvert than those using neither. MSM should be offered PrEP. PEP users with ongoing risk of HIV infection should be connected to PrEP after PEP.

Neuroinflammation and EIF2 Signaling Persist despite Antiretroviral Treatment in an hiPSC Tri-culture Model of HIV Infection

HIV-associated neurocognitive disorders (HAND) affect over half of HIV-infected individuals, despite antiretroviral therapy (ART). Therapeutically targetable mechanisms underlying HAND remain elusive, partly due to a lack of a representative model. We developed a human-induced pluripotent stem cell (hiPSC)-based model, independently differentiating hiPSCs into neurons, astrocytes, and microglia, and systematically combining to generate a tri-culture with or without HIV infection and ART. Single-cell RNA sequencing analysis on tri-cultures with HIV-infected microglia revealed inflammatory signatures in the microglia and EIF2 signaling in all three cell types. Treatment with the antiretroviral compound efavirenz (EFZ) mostly resolved these signatures. However, EFZ increased RhoGDI and CD40 signaling in the HIV-infected microglia. This activation was associated with a persistent increase in transforming growth factor α production by microglia. This work establishes a tri-culture that recapitulates key features of HIV infection in the CNS and provides a new model to examine the effects of infection, its treatment, and other co-morbid conditions.

Pleasure and PrEP: Pleasure-Seeking Plays a Role in Prevention Choices and Could Lead to PrEP Initiation

Pleasure-seeking plays a role in prevention (means choices and use), and in the sexual quality of life of men who have sex with men (MSM). Since HIV is a major threat to MSM health, new means of prevention, like pre-exposure prophylaxis (PrEP), must meet the needs of MSM to be fully efficient. Using a psychosocial approach, we examined how pleasure-seeking plays a role in participation of MSM in “ANRS-IPERGAY,” a community-based trial on sexual health which included sexual on-demand PrEP. Thirteen semistructured collective interviews were conducted with 45 participants. First, we analyzed participants’ search for new prevention means due to previous failures in condom use. We found that participants perceived condoms as a barrier—both materially and symbolically—to pleasure and desire, causing anxiety and stress considering sexual intercourse. Second, we explored representations and attitudes concerning pleasure within the context of PrEP. We found that PrEP allowed participants to freely choose their desired sexual positions and to better enjoy intimacy. Third, we studied the sexual quality of life for PrEP users in ANRS-IPERGAY and found an improvement. Thanks to the community-based design of the trial, this new prevention tool became a means to develop agency and empowerment for participants, not only in negotiating individual prevention but also in opposing the normative and stigmatizing discourse on sexuality and HIV. In conclusion, pleasure-seeking appears to be an essential element of sexual fulfillment that needs to be integrated as a positive notion in the study of HIV prevention.

The significance and expectations of HIV cure research among people living with HIV in Australia

Most people living with HIV (PLHIV) with reliable access to antiretroviral treatment (ART) have a life expectancy similar to uninfected populations. Despite this, HIV can negatively affect their social and psychological wellbeing. This study aimed to enhance understanding of the expectations PLHIV hold for HIV cure research and the implications this has for HIV cure research trials. We interviewed 20 Australian PLHIV about their expectations for HIV cure research outcomes and the impact a potential cure for HIV may have on their everyday lives. Data were analysed thematically, using both inductive and deductive approaches. The significance of a cure for HIV was expressed by participants as something that would offer relief from their sense of vigilance or uncertainty about their health into the future. A cure was also defined in social terms, as alleviation from worry about potential for onward HIV transmission, concerns for friends and family, and the negative impact of HIV-related stigma. Participants did not consider sustained medication-free viral suppression (or remission) as a cure for HIV because this did not offer certainty in remaining virus free in a way that would alleviate these fears and concerns. A cure was seen as complete elimination of HIV from the body. There is an ethical need to consider the expectations of PLHIV in design of, and recruitment for, HIV cure-related research. The language used to describe HIV cure research should differentiate the long-term aspiration of achieving complete elimination of HIV from the body and possible shorter-term therapeutic advances, such as achieving medication free viral suppression.

Sustained-release Griffithsin nanoparticle-fiber composites against HIV-1 and HSV-2 infections

Human immunodeficiency virus (HIV-1) and herpes simplex virus 2 (HSV-2) affect hundreds of millions of people worldwide. The antiviral lectin, Griffithsin (GRFT), has been shown to be both safe and efficacious against HSV-2 and HIV-1 infections in vivo. The goal of this work was to develop a multilayered nanoparticle (NP)-electrospun fiber (EF) composite to provide sustained-release of GRFT, and to examine its safety and efficacy in a murine model of lethal HSV-2 infection. Composites were fabricated from polycaprolactone (PCL) fibers surrounding polyethylene oxide (PEO) fibers that incorporated methoxy poly(ethylene glycol)-b-poly(lactide-co-glycolide) (mPEG-PLGA) GRFT NPs. GRFT loading and release were determined via ELISA, showing that NP-EF composites achieved high GRFT loading, and provided sustained-release of GRFT for up to 90 d. The in vitro efficacy of GRFT NP-EFs was assessed using HIV-1 pseudovirus assays, demonstrating complete in vitro protection against HIV-1 infection. Additionally, sustained-release NP-EFs, administered 24 h prior to infection, prevented against a lethal dose of HSV-2 infection in a murine model. In parallel, histology and cytokine expression from murine reproductive tracts and vaginal lavages collected 24 and 72 h post-administration were similar to untreated mice, suggesting that NP-EF composites may be a promising and safe sustained-delivery platform to prevent HSV-2 infection. Future work will evaluate the ability to provide prolonged protection against multiple virus challenges, and different administration times with respect to infection.

Navigating the Long Road Forward for Maximizing PrEP Impact Among Adolescent Men Who Have Sex with Men

Preexposure prophylaxis (PrEP) has tremendous potential to decrease new HIV infections among populations at high risk, such as men who have sex with men (MSM). That potential is already becoming realized among adult MSM, where PrEP uptake has increased rapidly in the past several years. However, expanding PrEP access to adolescent MSM (AMSM) will be more challenging. This commentary reviews the existing scientific literature relevant to PrEP use for AMSM and highlights critical areas in need of further attention before PrEP is likely to impact the HIV epidemic among adolescents. We highlight concerns that need to be addressed in the areas of (1) achieving adequate coverage of PrEP in the adolescent population, (2) increasing awareness and access, (3) supporting adherence and maintenance, and (4) ensuring that PrEP does not perpetuate existing disparities. Across all of these domains, we highlight the central roles of parents and healthcare providers in supporting AMSM PrEP utilization. Finally, we suggest a number of areas of future research that must be addressed before PrEP is likely to see wide implementation among AMSM.

A Promising PrEP Navigation Intervention for Transgender Women and Men Who Have Sex with Men Experiencing Multiple Syndemic Health Disparities

Transgender women and MSM experience many stigma-related syndemic conditions that exacerbate HIV incidence and prevalence rates. While PrEP is an effective biomedical intervention to reduce HIV transmission, uptake and adherence of PrEP is low among transgender women and MSM experiencing multiple syndemic health disparities. This study tested the feasibility, acceptability and effectiveness of A.S.K.-PrEP (AssistanceServicesKnowledge-PrEP), a five-session peer navigator program, designed to link transgender women and MSM to PrEP. From September 2016 to March 2018, 187 participants (transgender women = 58; MSM = 129) enrolled. Results demonstrated that approximately 90% of transgender women and MSM were linked to PrEP; MSM linked more quickly [KW χ2(1) = 10.9, p < .001]. Most transgender women (80%) and MSM (70%) reported they were still taking PrEP at the 90-day follow-up evaluation. Findings indicated that A.S.K.-PrEP is a promising intervention for PrEP linkage, uptake and preliminary adherence among transgender women and MSM.

Chemsex is not a barrier to self-reported daily PrEP adherence among PROUD study participants

BACKGROUND

Pre-exposure prophylaxis (PrEP) is a novel HIV prevention method whereby HIV-negative individuals take the drugs tenofovir and emtricitabine to prevent HIV acquisition. Optimal adherence is critical for PrEP efficacy. Chemsex describes sexual activity under the influence of psychoactive drugs, in the UK typically; crystal methamphetamine, gamma-hydroxybutyrate(GHB) and/or mephedrone. Chemsex drug use has been associated with increased HIV transmission risk among gay, bisexual and other men who have sex with men (GBM) and poor ART adherence among people living with HIV. This study assessed whether self-reported chemsex events affected self-reported daily PrEP adherence among PROUD study participants.

METHODS

The PROUD study was an open-label, randomised controlled trial, conducted in thirteen English sexual health clinics, assessing effectiveness of TruvadaⓇ-PrEP among 544 HIV-negative GBM. The study reported an 86% risk-reduction of HIV from daily PrEP. Participants were asked about chemsex engagement at follow-up visits. Monthly self-reports of missed PrEP tablets were aggregated to assess adherence between visits. Univariable and multivariable regression analyses were performed to test for associations between chemsex and reporting less than seven out of seven intended doses(<7/7ID) in the 7 days before and/or after last condomless anal intercourse(CAI).

RESULTS

1479 follow-up visit forms and 2260 monthly adherence forms from 388 participants were included in the analyses, with 38.5% visit forms reporting chemsex since last visit and 29.9% follow-up periods reporting <7/7ID. No statistically significant associations were observed between reporting <7/7ID and chemsex (aOR=1.29 [95% CI 0.90-1.87], p = 0.168). Statistically significant associations were seen between reporting <7/7ID and participants perceiving that they would miss PrEP doses during the trial, Asian ethnicity, and reporting unemployment at baseline.

CONCLUSIONS

These analyses suggest PrEP remains a feasible and effective HIV prevention method for GBM engaging in chemsex, a practise which is prevalent in this group and has been associated with increased HIV transmission risk.

PrEP indicators, social capital and social group memberships among gay, bisexual and other men who have sex with men

Efforts to reduce HIV among gay, bisexual and other men who have sex with men include increasing awareness and uptake of pre-exposure prophylaxis (PrEP). Social capital may facilitate engagement in HIV prevention. Membership of social groups including chosen families (i.e. friends as family relationships) - one potential indicator of social capital - may be protective against HIV risk and infection. In this cross-sectional quantitative study, we examined social capital items and social group membership in association with PrEP outcomes. In 2014, the New Orleans arm of the National HIV Behavioral Surveillance recruited 353 HIV-negative men, of whom 46% identified as Black, Latino or Other Race and 54% as Non-Hispanic White, using venue-based sampling to complete a structured survey. Multivariable logistic regression models tested the relations between social group membership and social capital with PrEP indicators. Men who reported community group participation were more likely to be aware of PrEP compared to those who did not. Men in chosen families associated with a family name were least likely to be aware of and willing to take PrEP compared to those not in any other social groups. Social group membership is a potential social capital indicator for assessing HIV prevention among men.

High Levels of Syndemics and Their Association with Adherence, Viral Non-suppression, and Biobehavioral Transmission Risk in Miami, a U.S. City with an HIV/AIDS Epidemic

Miami is a Southeastern United States (U.S.) city with high health, mental health, and economic disparities, high ethnic/racial diversity, low resources, and the highest HIV incidence and prevalence in the country. Syndemic theory proposes that multiple, psychosocial comorbidities synergistically fuel the HIV/AIDS epidemic. People living with HIV/AIDS in Miami may be particularly affected by this due to the unique socioeconomic context. From April 2017 to October 2018, 800 persons living with HIV/AIDS in a public HIV clinic in Miami completed an interviewer-administered behavioral and chart-review cross-sectional assessment to examine the prevalence and association of number of syndemics (unstable housing, low education, depression, anxiety, binge drinking, drug use, violence, HIV-related stigma) with poor ART adherence, unsuppressed HIV viral load (≥ 200 copies/mL), and biobehavioral transmission risk (condomless sex in the context of unsuppressed viral load). Overall, the sample had high prevalence of syndemics (M = 3.8), with almost everyone (99%) endorsing at least one. Each syndemic endorsed was associated with greater odds of: less than 80% ART adherence (aOR 1.64, 95% CI 1.38, 1.98); having unsuppressed viral load (aOR 1.16, 95% CI 1.01, 1.33); and engaging in condomless sex in the context of unsuppressed viral load (1.78, 95% CI 1.30, 2.46). The complex syndemic of HIV threatens to undermine the benefits of HIV care and are important to consider in comprehensive efforts to address the disproportionate burden of HIV/AIDS in the Southern U.S. Achieving the 90-90-90 UNAIDS and the recent U.S. "ending the epidemic" targets will require efforts addressing the structural, social, and other syndemic determinants of HIV treatment and prevention.

Next-Generation HIV Pre-Exposure Prophylaxis Preferences Among Men Who Have Sex with Men Taking Daily Oral Pre-Exposure Prophylaxis

Next-generation forms of HIV pre-exposure prophylaxis (PrEP) currently in development, including long-acting injectables (LAIs), rectal microbicides (RMs), antibody infusions (AIs), and subdermal implants (SIs), may address barriers to daily oral PrEP uptake and adherence. The purpose of this study was to evaluate barriers to oral PrEP, preferences for next-generation PrEP modalities, sociodemographic characteristics and sexual behaviors associated with preferences, and reasons for wanting or not wanting each formulation among a sample of men who have sex with men (MSM). We administered a cross-sectional survey to a diverse sample of MSM currently taking oral PrEP (n = 108) at two sexually transmitted disease clinics. We used logistic multivariate analyses to explore preferences, relative to oral PrEP, for each formulation across sociodemographic and sexual behaviors. The most commonly endorsed barriers were finding a PrEP provider and making appointments to get PrEP. Participants were most likely to prefer the SI (45%), followed by the LAI (31%), pill (21%), RM (1%), and AI (1%). Black/African American and Hispanic/Latino MSM were more likely to prefer the LAI over daily oral PrEP (odds ratio: 2.45, 95% confidence interval: 0.86-6.89), and sexual behaviors were most commonly associated with preference for the SI. Top reasons for wanting or not wanting each formulation were most commonly related to perceived ease of use. These findings demonstrate variations in preferences for next-generation PrEP modalities, highlighting a need to ensure comprehensive access to all formulations once they become available.

Temporal Trends and Sociodemographic Correlates of PrEP Uptake in Tennessee, 2017

Client-level data from two Tennessee-based PrEP navigation demonstration projects reported to the Tennessee Department of Health from January to December 2017 were evaluated to determine the proportion of clients who accepted, were linked to, and were prescribed PrEP. Disparities by age, race, transmission risk, and geographic region as well as trends over time were examined via bivariate and multivariable modified Poisson regression models accounting for potential confounders. Among 1385 PrEP-eligible individuals, 50.5% accepted, 33.4% were linked, and 27.3% were prescribed PrEP. PrEP uptake varied by age, race, and HIV transmission risk, and most disparities persisted across Tennessee throughout evaluation period. Multivariable regression models revealed significant independent associations between age, race/ethnicity, transmission risk, and region and PrEP acceptance and linkage. While differences in PrEP acceptance by race narrowed over time, success among black MSM was limited, underscoring a significant need to improve upstream PrEP continuum outcomes for this important population.

A Person-Centered Approach to HIV-Related Protective and Risk Factors for Young Black Men Who Have Sex with Men: Implications for Pre-exposure Prophylaxis and HIV Treatment as Prevention

Although young Black men who have sex with men (YBMSM) are disproportionately affected by HIV, they may be more heterogeneous as a group than is typically appreciated. Thus, the present study used a person-centered data-analytic approach to determine profiles of HIV-related risk among YBMSM and whether these profiles could be distinguished by age, HIV status, and socioeconomic risk (i.e., socioeconomic distress). YBMSM (N = 1808) aged 18 to 29 years completed a survey of sociodemographic characteristics, HIV status, and HIV-related behavioral and attitudinal factors (i.e., safer-sex self-efficacy, negative condom attitudes, being in difficult sexual situations, being in difficult sexual relationships, HIV treatment optimism, perceived HIV stigma). Latent profile analysis was used to identify HIV risk profiles and whether age, HIV status, and socioeconomic distress were associated with these profiles. Four profiles emerged: low-, medium-, and high-risk profiles, respectively, and a mixed profile characterized by a tendency to be in difficult sexual situations and relationships while also reporting high safer-sex self-efficacy and low negative attitudes toward condom use. Difficult sexual situations emerged as the key defining indicator of whether a profile reflected higher or lower risk. Younger age, being HIV-positive, and socioeconomic distress were associated with having a higher-risk profile. Given that unique risk profiles emerged that were differentially predicted by sociodemographic characteristics and HIV status, these findings have implications for tailoring interventions to the needs of different subgroups of YBMSM. Also, disempowering or risky sexual situations and relationships among YBMSM must be addressed.

Acute Trigeminal Neuralgia Associated with Initiation of Emtricitabine/Tenofovir for HIV Pre-Exposure Prophylaxis

HIV pre-exposure prophylaxis (PrEP) with emtricitabine (FTC) and tenofovir disoproxil fumarate (TDF) fixed-dose combination (FTC/TDF) is undergoing rapid scale-up in the United States. While FTC/TDF is typically well tolerated, to our knowledge, cranial nerve pathology associated with FTC/TDF has not been previously described. We report the case of a 35-year-old patient who began FTC/TDF PrEP and developed acute trigeminal neuralgia. The neurologic symptoms resolved after treatment discontinuation and recurred upon rechallenge, resulting in permanent discontinuation of PrEP treatment.

The impact, cost and cost-effectiveness of oral pre-exposure prophylaxis in sub-Saharan Africa: a scoping review of modelling contributions and way forward

INTRODUCTION

Oral pre-exposure prophylaxis (PrEP) is a new form of HIV prevention being considered for inclusion in national prevention portfolios. Many mathematical modelling studies have been undertaken that speak to the impact, cost and cost-effectiveness of PrEP programmes. We assess the available evidence from mathematical modelling studies to inform programme planning and policy decision making for PrEP and further research directions.

METHODS

We conducted a scoping review of the published modelling literature. Articles published in English which modelled oral PrEP in sub-Saharan Africa, or non-specific settings with relevance to generalized HIV epidemic settings, were included. Data were extracted for the strategies of PrEP use modelled, and the impact, cost and cost-effectiveness of PrEP for each strategy. We define an algorithm to assess the quality and relevance of studies included, summarize the available evidence and identify the current gaps in modelling. Recommendations are generated for future modelling applications and data collection.

RESULTS AND DISCUSSION

We reviewed 1924 abstracts and included 44 studies spanning 2007 to 2017. Modelling has reported that PrEP can be a cost-effective addition to HIV prevention portfolios for some use cases, but also that it would not be cost-effective to fund PrEP before other prevention interventions are expanded. However, our assessment of the quality of the modelling indicates cost-effectiveness analyses failed to comply with standards of reporting for economic evaluations and the assessment of relevance highlighted that both key parameters and scenarios are now outdated. Current evidence gaps include modelling to inform service development using updated programmatic information and ex post modelling to evaluate and inform efficient deployment of resources in support of PrEP, especially among key populations, using direct evidence of cost, adherence and uptake patterns.

CONCLUSIONS

Updated modelling which more appropriately captures PrEP programme delivery, uses current intervention scenarios, and is parameterized with data from demonstration and implementation projects is needed in support of more conclusive findings and actionable recommendations for programmes and policy. Future analyses should address these issues, aligning with countries to support the needs of programme planners and decision makers for models to more directly inform programme planning and policy.

The Law and Economics of Grindr: A Response to Carson

In the Winter 2017 edition of JLME, Dr. Carson outlined an economic approach to the epidemiology of HIV transmission within the gay community, with a special emphasis on mobile apps. His conclusion is that HIV transmission amongst the gay community constitutes a collective action problem, which is resolved by the social norm of using a condom. This article critiques Dr. Carson's approach from an economic perspective. By utilizing classic law and economic theory, this article will argue that HIV transmission may not, in fact, constitute a collective action problem in economic terms, and that instead condom use as a method of disease protection in theory can arise from purely rational, market driven actions. To do so, it borrows from transactional theory of information asymmetry to show the potential to alert counterparts as to serostatus. This conclusion provides an important supplement to Carson: rather than social norms being the core driver in condom usage to prevent HIV, instead condom use may arise solely as a result of rational, private decision making arising from market signaling. The article then critiques its own findings to demonstrate that it is unclear whether Carson's argument or the argument in this paper is, indeed, correct - which may represent a limitation in the analytical techniques advanced.

Performance of HIV pre-exposure prophylaxis indirect adherence measures among men who have sex with men and transgender women: Results from the PrEP Brasil Study

Introduction

Efficacy of daily emtricitabine/tenofovir disoproxil fumarate (FTC/TDF) for PrEP is strongly dependent on the adherence. We examined the concordance between indirect adherence measures and protective drug levels among participants retained through 48 weeks in the PrEP Brasil Study.

Methods

PrEP Brasil was a prospective, multicenter, open-label demonstration project evaluating PrEP provision for men who have sex with men (MSM) and transgender women (TGW) at higher risk for HIV infection within the setting of Brazilian Public Health System. Three indirect adherence measures were obtained at week 48: medication possession ratio (MPR), pill count and self-report (30-days recall). Tenofovir diphosphate (TFV-DP) concentration in Dried Blood Spot (DBS) was measured at week 48. Areas under (AUC) the receiver operating characteristics (ROC) curve were used to evaluate the concordance between achieving protective drug levels (TFV-DP≥700fmol/punch) and the indirect adherence measures. Youden’s index and distance to corner were used to determine the optimal cutoff points for each indirect adherence measure. We calculated sensitivity, specificity, negative (NPV) and positive (PPV) predictive values for the found cutoff points. Finally, Delong test was used to compare AUCs.

Results and discussion

From April, 2014 to July, 2016, 450 participants initiated PrEP, 375(83.3%) were retained through 48 weeks. Of these, 74% (277/375) had TFV-DP ≥700fmol/punch. All adherence measures discriminated between participants with and without protective drug levels (AUC>0.5). High indirect adherence measure was predictive of protective drug levels (PPV>0.8) while low indirect adherence measure was not predictive of lack of protective drug levels (NPV<0.5). No significant differences were found between the adherence methods (p = 0.44).

Conclusions

Low-burden measurements such as MPR and self-report can be used to predict PrEP adherence in a public health context in Brazil for MSM and TGW retained through 48 weeks.

Clinical Trial Number: NCT01989611.

Faith and healthcare providers' perspectives about enhancing HIV biomedical interventions in Western Kenya

Adult HIV prevalence in Kenya was 5.9% in 2017. However, in the counties of Kisumu, Siaya, and Homa Bay, HIV prevalence was over 15%. Biomedical interventions, including home-based testing and counselling (HBTC), HIV treatment and pre-exposure prophylaxis (PrEP) provide opportunities to reduce HIV transmission, particularly in rural communities with limited access to health services. Faith-based institutions play an important role in the Kenyan social fabric, providing over 40% of all health care services in Kenya, but have played limited roles in promoting HIV prevention interventions. We conducted qualitative interviews with 45 medical professionals and focus groups with 93 faith leaders in Kisumu and Busia Counties, Kenya. We explored their knowledge, opinions, and experiences in promoting biomedical HIV prevention modalities, including HBTC and PrEP. Knowledge about and engagement in efforts to promote HIV prevention modalities varied; few health providers had partnered with faith leaders on HIV prevention programmes. Faith leaders and health providers agreed about the importance of increasing faith leaders' participation in HIV prevention and were positive about increasing their HIV prevention partnerships. Most faith leaders requested capacity building to better understand biomedical HIV prevention modalities and expressed interest in collaborating with clinical partners to spread awareness about HIV prevention modalities.

Managing sexually transmitted infections: Beyond the 2015 guidelines

Guidelines for the prevention and management of sexually transmitted infections (STIs) are updated periodically while new science is continuously developed. Advanced practice registered nurses implement clinical decisions based on current guidelines and evidence. This article provides recent updates on managing STIs.

Dual motivational model of pre-exposure prophylaxis use intention: model testing among men who have sex men in Ukraine

The Dual Motivational Model of pre-exposure prophylaxis (PrEP) use intention (DMM) is a new theoretical model recently tested among men who have sex with men (MSM) in the United States. The model posits that there are two main motivational pathways to use PrEP: the Protection Motivation Pathway and the Expectancy Motivation Pathway. The Protection Motivation Pathway suggests that the intention to use PrEP is triggered by the desire to protect oneself from HIV, while the Expectancy Motivation Pathway suggests that PrEP use intention is triggered by the expectation to have better sexual experiences on PrEP. Although both motivators have been tested separately, only the DMM of PrEP use intention suggests that both pathways simultaneously influence an individual's intention to use PrEP. We used data from 1078 MSM in Ukraine to test the DMM. Results show that the relationship of the pathways is similar among Ukrainian and American MSM. Potential explanations for minor differences may be related to cultural and contextual differences, and the different trajectories for PrEP roll-out. Successful validation of the DMM for PrEP use intention as a theoretical model suggests that it may be applied to other cultures contemplating PrEP use delivery to target health promotion among high risk MSM.

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.

Integrated Next Step Counseling (iNSC) for Sexual Health and PrEP Use Among Young Men Who Have Sex with Men: Implementation and Observations from ATN110/113

Pre-exposure prophylaxis (PrEP) for the prevention of HIV infection among young men who have sex with men is a critical part of the HIV prevention landscape in the US. Given the unique challenges and resources of young MSM negotiating safer sex practices, including PrEP, counseling and supportive discussions to optimize both PrEP use and sexual health protection more generally may facilitate reaching HIV prevention goals. Within the context of a large, open-label PrEP study (ATN110/113), support for sexual health promotion and PrEP use was provided through use of integrated Next Step Counseling (iNSC) as part of study visits. We detail iNSC and, using session documentation collected throughout this study, we characterize iNSC implementation and the content generated from these discussions. We detail features of iNSC, training of counselors and the implementation of iNSC in a multi-site PrEP study with young MSM in the US. Case report forms completed by iNSC counselors at study visits at weeks 4, 8, 12, 24, 36, and 48 were evaluated. Implementation of each intervention step for each discussion is summarized at and across timepoints, as well as features of specific steps (e.g., kinds of facilitators and barriers). Implementation differences by group (e.g., race/ethnicity, age) were examined. iNSC case report forms from 1000 sessions involving 178 unique participants ages 15–22 from sessions conducted between 2013 and 2015 were reviewed. High fidelity to iNSC steps in terms of inclusion in sessions was reported; 98–100% of sessions included critical steps for sexual health protection discussions and 96–98% for PrEP use discussions. The vast majority of sessions appeared to flow in line with iNSC’s emphasis on exploration and open discussion prior to considering specific needs and related strategies. Nearly three-quarters of sessions noted ‘commitment to staying negative’ as a motivator towards sexual health protection (more commonly reported by those identifying as White), while ‘assuming partner is negative’ was the most common challenge (less common for the older cohort), and ‘having access’ to a sexual health protection tool or strategy (besides PrEP) was the most common “need” (more common for those identifying as White or Latino). Carrying dose(s) to have them on-hand when needed was the most common PrEP adherence facilitator, drug and alcohol use was the most common challenge noted, and access to a dose when needed was the most common “need” (more common for participants self-identified as White). iNSC was implemented consistently throughout ATN110/113, and patient-centered discussions about sexual health protection and PrEP-use appeared feasible to incorporate into clinical care visits.

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.

Avirulins, a Novel Class of HIV-1 Reverse Transcriptase Inhibitors Effective in the Female Reproductive Tract Mucosa

While extensive research efforts have decreased human immunodeficiency virus (HIV) transmissions and mortalities, new challenges have arisen in the fight to eradicate HIV. Drug resistance to antiretroviral therapy threatens infected individuals, while the prevalence of heterosexual transmission creates an urgent need for therapies effective in the female reproductive tract (FRT) mucosa. We screened a library of 2095 small molecule compounds comprising a unique chemical space, purchased from Asinex Corporation, for antiviral activity against human immunodeficiency virus type 1 (HIV-1) strain BaL and identified several molecular representatives of a unique class of HIV-1 inhibitors, which we termed “Avirulins.” We determined that Avirulins were active against clinical isolates of HIV-1 from genetically variant subtypes, several of which have reduced sensitivity to other antivirals. Avirulins displayed specific dose-dependent inhibition of the HIV-1 drug target, reverse transcriptase (RT). Avirulins were effective against several nucleoside RT-inhibitor resistant strains of HIV-1, as well as one nonnucleoside RT-inhibitor resistant strain containing a 106A mutation, suggesting a noncompetitive mechanism of action. Drugs, which are damaging to the FRT, can increase the risk of HIV-1 transmission. We therefore explored the cytotoxicity of Avirulins against epithelial cells derived from the FRT and found no significant toxicity, even at the highest concentrations tested. Importantly, Avirulin antiviral activity was not diminished in human cervico–vaginal fluid, suggesting retained potency in the milieu of the FRT. Based on these promising results, Avirulins should be valuable chemical scaffolds for development into next-generation treatments and preventatives that target HIV-1.

Access to HIV Pre-exposure Prophylaxis in Practice Settings: a Qualitative Study of Sexual and Gender Minority Adults' Perspectives

BACKGROUND

Sexual and gender minority (SGM) populations remain at disproportionate risk of HIV infection. Despite the effectiveness of pre-exposure prophylaxis (PrEP) in preventing HIV, PrEP uptake has been slow.

OBJECTIVE

To identify barriers and facilitators of PrEP access by examining SGM patients' experiences with accessing health care systems and engaging with providers about PrEP in a variety of practice settings.

DESIGN

Semi-structured, individual, qualitative interviews.

PARTICIPANTS

Twenty-seven sexual and gender minority adults residing in Oregon.

APPROACH

Interviews were audio-recorded, transcribed, and analyzed using thematic analysis.

KEY RESULTS

We identified three main themes. Participants described the centrality of patient-provider relationships to positive experiences around PrEP, the necessity of personally advocating to access PrEP, and the experience of system-level barriers to PrEP access. Participants also made several suggestions to improve PrEP access including improving provider engagement with SGM patients, encouraging providers to initiate conversations about PrEP, and increasing awareness of medication financial support.

CONCLUSIONS

In order to reduce HIV disparities, improving PrEP access will require additional efforts by providers and resources across health care settings to reduce barriers. Interventions to improve provider education about PrEP and provider communication skills for discussing sexual health are needed. Additionally, there should be system-level improvements to increase coordination between patients, providers, pharmacies, and payers to facilitate PrEP access and uptake.

Pre-exposure Prophylaxis Among Men Who have Sex with Men: Dual Motivational Model of Intention to Use Pre-exposure Prophylaxis

Men who have sex with men (MSM) account for most new HIV infections in the United States. Despite representing a fraction of the population, MSM make up an estimated 65% of new infections. To address this epidemic, pre-exposure prophylaxis (PrEP) is recommended to supplement condom use. Despite its effectiveness, PrEP uptake among MSM is low. Few studies have employed theoretical approaches to understand PrEP use intention. Incorporating factors like safe sex fatigue, expectation of better sexual experiences, and perceived risk are proposed in this dual motivational path model of PrEP use intention. This model hypothesized that PrEP use intention is influenced by two key pathways: (1) protection motivation pathway, and (2) sexual expectancy pathway. Data were collected using social networking applications from 402 MSM. The model was tested using structural equation modeling. We elaborate the complex decision-making process proposed by this novel theoretical model and discuss its practical implications.

"Little Tablets of Gold": An Examination of the Psychological and Social Dimensions of PrEP Among LGBTQ Communities

There are significant psychological, social, and cultural dimensions to the HIV epidemic in the United States, especially among lesbian, gay, bisexual, transgender, and queer (LGBTQ) communities. Biomedical HIV treatment has been shown to impact these dimensions. However, there is little understanding of the real-world psychosocial and sociocultural effects of the latest biomedical HIV prevention strategy, HIV pre-exposure prophylaxis (PrEP). This study explored the psychosocial and sociocultural dimensions of PrEP use among LGBTQ adults. We interviewed 23 LGBTQ adults who were current or former users of PrEP. Results included that PrEP users' experiences were shaped by multiple forms of stigma. Participants were highly motivated to challenge PrEP stigma and to support PrEP use among other community members. Lastly, participants described positive impacts on their individual well-being and their sexual partnerships. Findings suggest that PrEP has significant impacts beyond biomedical outcomes for both the individuals who use PrEP and their communities.

Systematic review of HIV treatment adherence research among people who inject drugs in the United States and Canada: evidence to inform pre-exposure prophylaxis (PrEP) adherence interventions

BACKGROUND

People who inject drugs (PWID) are at increased risk for HIV acquisition and could benefit from antiretroviral pre-exposure prophylaxis (PrEP). However, PrEP has been underutilized in this population, and PrEP adherence intervention needs are understudied.

METHODS

To inform PrEP intervention development, we reviewed evidence on antiretroviral therapy (ART) adherence among HIV-infected PWID. Guided by a behavioral model of healthcare utilization and using the PICOS framework, we conducted a systematic review in four electronic databases to identify original research studies of ART adherence in HIV-infected PWID in the United States and Canada between Jan 1, 2006-Dec 31, 2016. We synthesized and interpreted findings related to developing recommendations for PrEP adherence interventions for PWID.

RESULTS

After excluding 618 duplicates and screening 1049 unique records, we retained 20 studies of PWID (mean n = 465) with adherence-related outcomes (via pharmacy records: n = 9; self-report: n = 8; biological markers: n = 5; electronic monitoring: n = 2). Predisposing factors (patient-level barriers to adherence) included younger age, female sex, and structural vulnerability (e.g., incarceration, homelessness). Enabling resources (i.e., facilitators) that could be leveraged or promoted by interventions included self-efficacy, substance use treatment, and high-quality patient-provider relationships. Competing needs that require specific intervention strategies or adaptations included markers of poor physical health, mental health comorbidities (e.g., depression), and engagement in transactional sex.

CONCLUSIONS

HIV treatment adherence research carries important lessons for efforts to optimize PrEP adherence among PWID. Despite limitations, this systematic review suggests that strategies are needed to engage highly vulnerable and marginalized sub-groups of this underserved population (e.g., younger PWID, women who inject drugs) in PrEP adherence-related research and programming.

Circulation of Distinct Treponema pallidum Strains in Individuals with Heterosexual Orientation and Men Who Have Sex with Men

Human treponematosis is caused by various pathogenic Treponema pallidum subspecies, including T. pallidum subsp. pallidum, T. pallidum subsp. pertenue, T. pallidum subsp. endemicum, and Treponema carateum The global prevalence of syphilis has been increasing since the 2000s. Men account for more than 90% of the cases, with the majority being men who have sex with men (MSM). In Japan, the increase in the number of syphilis patients began in 2011, a 10-year delay from the global trend. In 2017, a total of 5,829 syphilis cases (3,934 men and 1,895 women) were reported, with an outstanding increase in cases among young adult women; the number reported for women age 15 to 20 years was 1,100. Hence, a molecular epidemiological study was conducted on circulating T. pallidum strains using two strain typing methods, the enhanced CDC method and sequencing-based molecular typing. Clinical specimens from 95 adults suspected of syphilis were collected from September 2013 to August 2017 in Osaka, Japan. T. pallidum DNA was detected in specimens from 25 males and 11 females, including seven MSM. The majority of the heterosexual patients (66.7% and 90.9% of males and females, respectively) were positive for 14d/f-SSR8. In contrast, the genotypes identified in the MSM group were significantly divergent. T. pallidum subsp. endemicum was notably identified in two MSM patients. Macrolide-sensitive or Nichols-like strains were significantly associated with the MSM group. These data suggest that distinct T. pallidum strains were circulating in the heterosexual and MSM groups. Our findings imply that independent factors may contribute to the increased syphilis prevalence in heterosexual and MSM populations.

Acute Retroviral Syndrome Presenting as Acute Hepatitis

Acute retroviral syndrome (ARS) can present as a wide array of clinical manifestations. Establishing a diagnosis early in the disease course can provide an opportunity to minimize immunosuppression and limit further transmission of human immunodeficiency virus (HIV). We present a case of a previously healthy young male who presented with acute hepatitis, as a manifestation of ARS. Initial HIV antigen/antibody testing was negative; however, a high index of suspicion prompted HIV ribonucleic acid (RNA) virologic testing revealing >10 million RNA copies/mL. Anti-retroviral treatment was initiated, along with supportive measures, accomplishing resolution of the transaminitis and the restoration of CD4 counts within normal at one month. Early in the disease course, HIV screening immunoassay could still be negative; hence, confirmatory testing with HIV RNA virologic testing should be pursued when clinical suspicion is high. Prompt diagnosis and treatment can improve outcome and curtail viral transmission.

Perceived Social Norms About Oral PrEP Use: Differences Between African-American, Latino and White Gay, Bisexual and Other Men Who Have Sex with Men in Texas

Correct and consistent condom use has been the primary method of HIV prevention until the FDA approve the use of PrEP in 2012. While strong evidence existing regarding the efficacy of PrEP, uptake has remained slower than anticipated. While work is underway to better understand the factors impacting uptake, the majority of this work as been focused on white gay, bisexual, and other men who have sex with men (GBMSM) living in metropolitan regions of the coastal U.S. The current study used a community-based framework to assess perceived social norms through a elicitation survey. A total of 104 GBMSM met inclusion criteria for the study. Several analytic categories emerged across questions and a number of differences were found across race and ethnicity such as who would approve or disapprove off PrEP and who would be likely to use PrEP. Further, we found differences between injunctive and descriptive norms. These findings suggest that there are unique factors contributing to PrEP uptake among racial and ethnic minority GBMSM and that to fully understand uptake a more robust measure of perceived norms may be needed.

Injectable anti-malarials revisited: discovery and development of new agents to protect against malaria

Over the last 15 years, the majority of malaria drug discovery and development efforts have focused on new molecules and regimens to treat patients with uncomplicated or severe disease. In addition, a number of new molecular scaffolds have been discovered which block the replication of the parasite in the liver, offering the possibility of new tools for oral prophylaxis or chemoprotection, potentially with once-weekly dosing. However, an intervention which requires less frequent administration than this would be a key tool for the control and elimination of malaria. Recent progress in HIV drug discovery has shown that small molecules can be formulated for injections as native molecules or pro-drugs which provide protection for at least 2 months. Advances in antibody engineering offer an alternative approach whereby a single injection could potentially provide protection for several months. Building on earlier profiles for uncomplicated and severe malaria, a target product profile is proposed here for an injectable medicine providing long-term protection from this disease. As with all of such profiles, factors such as efficacy, cost, safety and tolerability are key, but with the changing disease landscape in Africa, new clinical and regulatory approaches are required to develop prophylactic/chemoprotective medicines. An overall framework for these approaches is suggested here.

Preexposure prophylaxis comprehension and the certainty of willingness to use preexposure prophylaxis among men who have sex with men in China

Preexposure prophylaxis (PrEP) is not available in China and the willingness to use PrEP among Chinese men who have sex with men (MSM) is not clear. The aim of this study was to better understand the association between PrEP comprehension and the willingness to use PrEP under varying conditions among MSM. An online survey investigating personal characteristics, PrEP comprehension, and PrEP willingness among MSM was conducted. A third of respondents (36.2%, 196 out of 541) reported that they would like to use PrEP. Compared with MSM with a basic level of PrEP comprehension, MSM with a high level were more likely to report clear choices: a willingness or unwillingness to use PrEP (82.4% versus 65.7%, p <0.01). Among 350 MSM willing to use PrEP or uncertain about uptake, those with a high level of PrEP comprehension were more likely to use PrEP daily (adjusted odds ratio [AOR] = 1.71, 95% confidence interval 1.04-2.80), and to use PrEP with mild or other side effects (AOR = 2.72 or 2.77). A high level of PrEP comprehension is a key factor in urging MSM to use PrEP under varying conditions. Our findings call attention to the need for health education to improve PrEP comprehension.

What qualities in a potential HIV pre-exposure prophylaxis service are valued by black men who have sex with men in London? A qualitative acceptability study

Black men who have sex with men (BMSM) have higher HIV incidence and prevalence when compared to other MSM, despite similar levels of condom use and testing. Pre-exposure prophylaxis (PrEP) could be a useful intervention to reduce these inequalities. This research therefore aims to understand the dimensions of acceptability of a potential PrEP service for BMSM aged 18-45 years in London. In-depth semi-structured interviews were conducted with 25 PrEP-eligible BMSM between April and August 2016. Interviews were recorded and transcribed verbatim, then subject to a thematic framework analysis, informed by intersectionality theory. BMSM had distinct preferences for sexual health services, which have implications for PrEP service development. Three primary domains emerged in our analysis: proximity and anonymity; quality, efficiency and reassurance; and understanding, empathy and identity. These relate, respectively, to preferences regarding clinic location and divisions from community, features of service delivery and staff characteristics. Due to concerns about confidentiality, community-based services may not be useful for this group. Careful consideration in regards to components used in service development will facilitate ongoing engagement. Interpersonal skills of staff are central to service acceptability, particularly when staff are perceived to be from similar cultural backgrounds as their patients.

HIV epidemic among men who have sex with men in the Czech Republic, 2016: high time for targeted action

Reported incidence of human immunodeficiency virus (HIV) infection in the Czech Republic increased steeply over the past decade from 90 new cases in 2005 to 266 in 2015. This increase is almost exclusively attributed to sexual transmissions between men who have sex with men (MSM). In 2015, there were 79% (n=210) newly diagnosed cases among MSM, 17% (n=45) were attributed to heterosexual transmission and 1% (n=3) to people who inject drugs. Interventions targeted at MSM have not yet been prioritised in the broadly focused national HIV prevention strategy which this is envisaged to change in the programme set out for 2018 to 2022. The national budget for HIV prevention has been reduced, however, and this remains. Availability of voluntary counselling and testing has decreased substantially in the past decade. Post- and pre-exposure prophylaxis for sexual intercourse among MSM are not part of the HIV prevention policy and the concept of treatment as prevention is not fully recognised. Provision of a combined prevention strategy with a focus on MSM, reflecting the above factors including stigmatisation, should contribute to reverse the development of a concentrated HIV epidemic among MSM in the Czech Republic.

In what circumstances could nondaily preexposure prophylaxis for HIV substantially reduce program costs?

Supplemental Digital Content is available in the text

Objectives:

To review the main factors influencing the costs of nondaily oral preexposure prophylaxis (PrEP) with tenofovir (±emtricitabine). To estimate the cost reductions possible with nondaily PrEP compared with daily PrEP for different populations (MSM and heterosexual populations).

Design:

Systematic review and data triangulation.

Methods:

We estimated the required number of tablets/person/week for dosing regimens used in the HPTN 067/ADAPT (daily/time-driven/event-driven) and IPERGAY (on-demand) trials for different patterns of sexual intercourse. Using trial data, and behavioural and cost data obtained through systematic literature reviews, we estimated cost savings resulting from tablet reductions for nondaily versus daily oral PrEP, assuming 100% adherence.

Results:

Among different populations being prioritized for PrEP, the median reported number of days of sexual activity varied between 0 and 2 days/week (0–1.5 days/week for MSM, 1–2 days/week for heterosexual populations). With 100% adherence and two or fewer sex-days/week, HPTN 067/ADAPT nondaily regimens reduced the number of tablets/week by more than 40% compared with daily PrEP. PrEP program costs were reduced the most in settings with high drug costs, for example, by 66–69% with event-driven PrEP for French/US populations reporting on average one sex-day/week.

Conclusion:

Nondaily oral PrEP could lower costs substantially (>50%) compared with daily PrEP, particularly in high-income countries. Adherence and efficacy data are needed to determine cost-effectiveness.

2016 PREP attitudes in Germany: high awareness and acceptance in MSM at risk of HIV

PRUPOSE

To examine current risk behavior, awareness, experience, and attitudes towards pre-exposure-prophylaxis (PrEP), and to estimate a potential impact on the prevention of HIV transmission among HIV-negative MSM in Germany. PrEP was not officially licensed at the time of survey.

METHODS

Web-based questionnaire from 03-06/2016. Potential participants were informed through social media, flyers, and advertisements. Risk contacts were defined as unprotected sexual intercourse under the influence of recreational drugs in the past 6 months.

RESULTS

In total, 1208 subjects participated, 342 subjects were excluded for being HIV-infected or non-MSM, leaving 866 subjects to be evaluated in this analysis. Mean age was 37.0 ± 10.4 years. 593 participants (68.5%) were tested for HIV within the past 12 months. A total of 206 STDs in the past 6 months were reported by 144 (16.6%). Aware of PrEP was 748 (86.4%) respondents, while 65.1% reported willingness to use it. Risk behavior was significantly associated with higher PrEP acceptance (OR 2.90, 95% CI 2.14-3.90), as was a history of STDs (OR 1.85, 95% CI 1.17-2.91). The use of condoms would forgo 52.3% of subjects if taking PrEP. Sixty-five respondents (7.5%) reported PrEP use. Only 19 (29.2%) had accessed PrEP under medical supervision. PrEP use was reported by 14.8% with > 5 risk contacts in the past 6 months, compared to 6.3% with one risk contact (p < 0.001).

CONCLUSION

We found a high PrEP awareness and acceptance, especially among subgroups of MSM at highest risk of HIV infection. Structured access and availability of PrEP to this population may have an important impact on the HIV epidemic in Germany.

Prevalence of asymptomatic sexually transmitted infections in HIV-positive men who have sex with men in Germany: results of a multicentre cross-sectional study

PURPOSE

Sexually transmitted infections (STIs) occur frequently in risk populations. Hereby, the role of screening-programmes remains controversial. Our study aimed to determine the prevalence of STI infections in HIV-positive men-who-have-sex-with-men (MSM).

METHODS

We enrolled asymptomatic, HIV-MSM in a prospective cross-sectional study from February to August 2016 at seven German HIV-centres. All subjects were screened for Treponema-pallidum (TP) and hepatitis-B/C-infection. HIV RNA and screening for oral, rectal and urethral colonisation by Chlamydia-trachomatis (CT) and/or Neisseria-gonorrhoeae (NG) was performed. All subjects were asked to complete a sexual-risk-behaviour-questionnaire.

RESULTS

In total, 296 subjects with a median age of 43.2 (36.2-49.5) years were enrolled; 99.3% were on ART for 5.5 (2.3-11.2) years. HIV RNA was < 50 copies/mL in 93.6%. Active syphilis infection was found in 5.0% of all patients, whereas 55.4% had history of infection. HCV seropositivity was found in 33 patients (13.2%) and positive HCV RNA was available in 39.4%. 66/294 (22.5%) showed negative anti-HBs-antibodies, indicating lack of immunity. Overall, 40/296 (13.5%) had positive CT/NG swabs (CT in 8.8%; 7.3% anorectal, 1.7% oropharyngeal, 1.0% urethral and NG in 6.8%; 4.5% anal, 2.0% oropharyngeal, 1.4% urethral). Time since HIV infection < 7 years (OR 2.6 (1.2-5.5); p = 0.012), the use of inhalative nitrites ("poppers") (OR 2.8 (1.3-5.9; p = 0.008) and reporting unprotected intercourse with > 20 partners within the last 6 months [OR 3.0 (1.2-7.8); p = 0.003] were significantly associated in multivariate analysis.

CONCLUSION

We found high numbers of asymptomatic syphilis, hepatitis-C and CT/NG infections in HIV-MSM, remarkably in patients with shorter duration of HIV-infection with more sexual partners within last 6 months.