Limited Awareness and Low Immediate Uptake of Pre-Exposure Prophylaxis among Men Who Have Sex with Men Using an Internet Social Networking Site

Differences in Awareness of Pre-exposure Prophylaxis and Post-exposure Prophylaxis Among Groups At-Risk for HIV in New York State: New York City and Long Island, NY, 2011-2013

BACKGROUND

Pre-exposure prophylaxis (PrEP) to reduce the risk of HIV was approved in 2012 and post-exposure prophylaxis (PEP) in 2005. We report the differences in awareness of PrEP/PEP and factors associated with awareness by examining 3 risk groups (men who have sex with men (MSM), people who inject drugs, and high-risk heterosexuals).

METHODS

National HIV Behavioral Surveillance system data collected in New York City (NYC) and Long Island, NY in 2011-2013 were used. Logistic regressions by region were developed to estimate adjusted associations [Adjusted Odds Ratios (AOR)] and determine differences in awareness of PrEP/PEP.

RESULTS

Awareness of PrEP/PEP was low for all groups. In multivariate analysis controlling for sociodemographic factors, noninjection drug use, HIV status, and exposure to HIV prevention, males who inject drugs in NYC had significantly decreased odds of PrEP/PEP awareness [AOR: 0.45; confidence interval (CI): 0.25 to 0.81] compared with MSM. MSM aged 18-29 years had increased awareness of PrEP (AOR: 2.94; 95% CI 1.11 to 7.80). On Long Island, females who inject drugs (AOR: 0.18; 95% CI: 0.05 to 0.62), males who inject drugs (AOR: 0.14; 95% CI: 0.05 to 0.39), female heterosexuals (AOR: 0.25; 95% CI: 0.11 to 0.59), and male heterosexuals (AOR: 0.32; 95% CI: 0.14 to 0.73) had significantly decreased odds of PrEP/PEP awareness. Black MSM had increased awareness of PrEP (AOR: 4.08 CI:1.21 to 13.73).

CONCLUSIONS

Large proportions of groups at-risk for HIV were unaware of PrEP/PEP. When comparing risk groups to MSM, we found MSM to have greater awareness in both regions. On Long Island, people who inject drugs and heterosexuals were far less likely to have PrEP/PEP awareness than in NYC. On Long Island, Black MSM had increased PrEP awareness and in NYC MSM aged 18-29 had increased PrEP awareness. These findings suggest that awareness may be spreading through networks and highlight the importance of targeted educational and prevention efforts by group and region.

Trends in HIV Risk, Testing, and Treatment among MSM in Chicago 2004-2014: Implications for HIV Elimination Planning

Men who have sex with men (MSM) in the USA continue to have high rates of HIV infection. Increasingly, in addition to behavioral factors, biomedical interventions have been found to play important roles in HIV prevention. In this analysis, we used four waves of cross-sectional data (2004, 2008, 2011, and 2014) from the National HIV Behavioral Surveillance System (NHBS) to examine trends in key behaviors and biomedical interventions among MSM in Chicago (N = 3298). Logistic regression was used to determine changes in behaviors and use of biomedical interventions. Condomless sex increased significantly in waves 3 and 4, compared to wave 1: wave 3 (AOR = 2.07; 95% CI 1.53, 2.78) and wave 4 (AOR = 2.19; 95% CI 1.62, 2.96). Compared to those aged 18-24, older participants were significantly less likely to be routinely tested for HIV: 30-39 (AOR = 0.63; 95% CI 0.48, 0.83), 40-49 (AOR = 0.40; 95% CI 0.29, 0.55), and >50 (AOR = 0.28; 95% CI 0.18, 0.43). Awareness of both post-exposure prophylaxis (PEP)(​AOR = 3.13; 95% CI 1.22, 8.03) and pre-exposure prophylaxis (PrEP)(​AOR = 10.02; 95% CI 2.95, 34.01) increased significantly in wave 4, compared to wave 3. These results suggest a potential increase in HIV rates among men with main and casual partners and should be monitored closely as PrEP becomes more widespread among MSM of all races and ethnicities in Chicago. This study also suggests that further analyses of the barriers to PEP and PreP uptake among high-risk populations are necessary.

Gay Men's Understanding and Education of New HIV Prevention Technologies in Vancouver, Canada

Effective rollout of HIV treatment-based prevention such as pre-exposure prophylaxis and treatment as prevention has been hampered by poor education, limited acceptability, and stigma among gay men. We undertook a thematic analysis regarding the education sources and acceptability of these New Prevention Technologies (NPTs) using 15 semistructured interviews with gay men in Vancouver, Canada, who were early adopters of NPTs. NPT education was derived from a variety of sources, including the Internet, health care providers, community organizations, sexual partners, and peers; participants also emphasized their own capacities as learners and educators. Acceptable forms of NPT education featured high-quality factual information, personal testimony, and easy access. Stigma was highlighted as a major barrier. For public health, policy makers, and gay communities to optimize the personal and population benefits of NPTs, there is a need for increased community support and dialogue, antistigma efforts, early NPT adopter testimony, and personalized implementation strategies.

PrEP awareness and decision-making for Latino MSM in San Antonio, Texas

Pre-Exposure Prophylaxis (PrEP) has been promoted among high-risk populations as an effective HIV biomedical intervention. However, limited research is available on the significance of culturally informed biomedical interventions for Latino MSM. A total of 159 self-administered Internet surveys were completed by Latino MSM ages 21–30 in San Antonio, Texas. The purpose of this research was to develop an instrument that measured Latino MSM attitudes and beliefs towards PrEP, identify associations between demographic factors and PrEP related factors and to suggest culturally appropriate strategies for the promotion of PrEP among the Latino MSM population. Research findings revealed implications for PrEP at the structural and individual level for Latino MSM. Structural level indicators emphasized the importance for raising PrEP awareness among Latino MSM in regards to PrEP related expenses, ameliorating stigmatization of high-risk populations, enhancing access to PrEP informed medical providers, and address mistrust of the government and medical providers role on addressing health disparities among Latino MSM. Overall, the findings for individual factors emphasize the need for patient-centered interventions for Latino MSM. Latino MSM currently on PrEP require supplemental resources to enhance PrEP adherence. Latino MSM not on PrEP require alternate options for PrEP delivery and/or cognitive behavioral approaches minimizing HIV risk behavior for Latino MSM concerned with PrEP toxicity, which may require non-biomedical interventions. Integration of Latino MSM currently on PrEP as peer educators provides a valuable resource for developing culturally informed PrEP interventions for Latino MSM. Peer educators are able to share their experiential knowledge of PrEP contextualized through cultural norms, beliefs, and values.

Disparities in Awareness of HIV Postexposure and Preexposure Prophylaxis Among Notified Partners of HIV-Positive Individuals, New York City 2015-2017

BACKGROUND

Named sex- or needle-sharing partners of HIV-positive individuals are a priority prevention population due to their known HIV exposure. Understanding postexposure and preexposure prophylaxis (PEP and PrEP) awareness and use among them is important for successful interventions.

METHODS

Data from notified partners of HIV-positive individuals (New York City, May 2015-April 2017) were analyzed to describe PEP/PrEP awareness, provider discussion, and use by sociodemographic and risk characteristics. Multivariate logistic regression was used to generate adjusted odds ratios (aORs) and 95% confidence intervals (CIs) of partners' PEP and PrEP awareness.

RESULTS

Among notified partners (n = 621), PEP and PrEP awareness were 34% and 44%, respectively; provider discussion of PEP was reported by 32% and of PrEP by 42%; PEP use was reported by 2% and PrEP use by 14%. PEP awareness was higher among men who have sex with men sex partners than among heterosexual sex partners (aOR: 4.21; 95% CI: 2.10 to 8.44). Odds of PrEP awareness were lower among black (aOR: 0.34; 95% CI: 0.15 to 0.75) and Hispanic partners (aOR: 0.37; 95% CI: 0.17 to 0.84) than among white partners, and higher among men who have sex with men than heterosexual sex partners (aOR: 4.60; 95% CI: 2.38 to 8.87). Black partners were less likely than whites to report a provider discussion of PrEP. Postnotification HIV-positive test results were significantly lower among partners reporting PEP awareness than among those who had not heard of PEP.

CONCLUSIONS

Low levels of PEP/PrEP awareness and of provider PEP/PrEP discussion among notified partners, particularly blacks, Hispanics, and heterosexual sex partners, indicate the timeliness of tailored prevention messaging, provider training, and sensitization, to avoid disparities in PEP/PrEP use.

A novel Online-to-Offline (O2O) model for pre-exposure prophylaxis and HIV testing scale up

Introduction: PrEP awareness and uptake among men who have sex with men (MSM) and transgender women (TG) in Thailand remains low. Finding ways to increase HIV testing and PrEP uptake among high-risk groups is a critical priority. This study evaluates the effect of a novel Adam’s Love Online-to-Offline (O2O) model on PrEP and HIV testing uptake among Thai MSM and TG and identifies factors associated with PrEP uptake.

Methods: The O2O model was piloted by Adam’s Love (www.adamslove.org) HIV educational and counselling website. MSM and TG reached online by PrEP promotions and interested in free PrEP and/or HIV testing services contacted Adam’s Love online staff, received real-time PrEP eCounseling, and completed online bookings for receiving services at one of the four sites in Bangkok based on their preference. Auto-generated site- and service-specific e-tickets and Quick Response (QR) codes were sent to their mobile devices enabling monitoring and check-in by offline site staff. Service uptake and participant’s socio-demographic and risk behaviour characteristics were analyzed. Factors associated with PrEP uptake were assessed using multiple logistic regression.

Results: Between January 10th and April 11th, 2016, Adam’s Love reached 272,568 people online via the PrEP O2O promotions. 425 MSM and TG received eCounseling and e-tickets. There were 325 (76.5%) MSM and TG who checked-in at clinics and received HIV testing. Nine (2.8%) were diagnosed with HIV infection. Median (IQR) time between receiving the e-ticket and checking-in was 3 (0–7) days. Of 316 HIV-negative MSM and TG, 168 (53.2%) started PrEP. In a multivariate model, higher education (OR 2.30, 95%CI 1.14–4.66; p = 0.02), seeking sex partners online (OR 2.05, 95%CI 1.19–3.54; p = 0.009), being aware of sexual partners’ HIV status (OR 2.37, 95%CI 1.29–4.35; p = 0.008), ever previously using post-exposure prophylaxis (PEP) (OR 2.46, 95%CI 1.19–5.09; p = 0.01), and enrolment at Adam’s Love clinic compared to the other three sites (OR 3.79, 95%CI 2.06–6.95; p < 0.001) were independently associated with PrEP uptake.

Conclusions: Adam’s Love O2O model is highly effective in linking online at-risk MSM and TG to PrEP and HIV testing services, and has high potential to be replicated and scaled up in other settings with high Internet penetration among key populations.

Willingness to use pre-exposure prophylaxis for HIV prevention among men who have sex with men in Malaysia: Findings from an online survey

Objective

We examined willingness to use pre-exposure prophylaxis (PrEP) for HIV prevention among men who have sex with men (MSM) in Malaysia.

Methods

An online survey of 990 MSM was conducted between March and April 2016. Eligibility criteria included being biological male, Malaysian citizen, 18 years of age or above, identifying as MSM, and being HIV negative or unknown status. Participants’ demographics, sexual and drug use behaviors, attitudes towards PrEP, and preferences regarding future access to PrEP were collected. Bivariate analysis and logistic regression were performed to determine factors associated with willingness to use PrEP.

Results

Fewer than half of participants (44%) knew about PrEP before completing the survey. Overall, 39% of the sample were willing to take PrEP. Multivariate logistic regression indicated that Malay men (AOR: 1.73, 95% CI:1.12, 2.70), having 2 or more male anal sex partners in the past 6 months (AOR: 1.98, 95% CI: 1.29, 3.05), previous knowledge of PrEP (AOR: 1.40, 95%CI: 1.06, 1.86), lack of confidence in practising safer sex (AOR: 1.36, 95% CI: 1.02, 1.81), and having ever paid for sex with a male partner (AOR: 1.39, 95% CI: 1.01, 1.91) were independently associated with greater willingness to use PrEP, while men who identified as heterosexual were less willing to use PrEP (AOR, 0.36, 95% CI: 0.13, 0.97). Majority of participants preferred to access PrEP at affordable cost below 100 Malaysian Ringgit (USD25) per month from community based organisations followed by private or government hospitals.

Conclusions

Overall, MSM in Malaysia reported a relatively low level of willingness to use PrEP, although willingness was higher among those previously aware of PrEP. There is a need to provide PrEP at affordable cost, increase demand and awareness of PrEP, and to provide access to this preventative medication via diverse, integrated and tailored sexual health services.

Barriers to Access and Adoption of Pre-Exposure Prophylaxis for the Prevention of HIV Among Men Who Have Sex With Men (MSM) in a Relatively Rural State

Biomedical intervention approaches, including antiretroviral pre-exposure prophylaxis (PrEP), have been demonstrated to reduce HIV incidence among several at-risk populations and to be cost effective. However, there is limited understanding of PrEP access and uptake among men who have sex with men (MSM) residing in relatively rural states. Twenty semistructured interviews were conducted (August-November 2016) to assess opinions of and perceived barriers to accessing and adopting PrEP among MSM residing in Oklahoma. Participants perceived substantial barriers to accessing PrEP including a stigmatizing environment and less access to quality, LGBT-sensitive medical care. Overall, geographic isolation limits access to health providers and resources that support sexual health for Oklahoma MSM. Addressing stigma situated across ecological levels in an effort to increase adoption of PrEP by MSM residing in rural states remains necessary. Without this, social determinants may continue to negatively influence PrEP adoption and sexual health outcomes.

Willingness to use pre-exposure prophylaxis among Black and White men who have sex with men in Atlanta, Georgia

PrEP willingness may be different among black and white men who have sex with men (MSM) given known disparities in HIV incidence, sociodemographic factors, and healthcare access between these groups. We surveyed 482 black and white HIV-negative MSM in Atlanta, GA about their willingness to use pre-exposure prophylaxis (PrEP) and facilitators and barriers to PrEP willingness. Overall, 45% (215/482) of men indicated interest in using PrEP. Engaging in recent unprotected anal intercourse (UAI) was the only factor significantly associated with PrEP willingness in multivariate analyses (OR 1.73, 95% CI 1.13, 2.65). Willing men identified "extra protection" against HIV as the most common reason for interest in using PrEP, whereas unwilling men most commonly cited not wanting to take medication daily, and this reason was more common among white MSM (42.3% of white MSM vs. 28.9% of black MSM, p = 0.04). Most men indicated willingness to use PrEP if cost was <50 dollars/month; however, more black MSM indicated willingness to use PrEP only if cost were free (17.9% of white MSM vs. 25.9% of black MSM, p = 0.03). Overall, these data are useful to scale up PrEP interventions targeting at-risk MSM in Atlanta and highlight the need for implementation of low cost-programs, which will be especially important for black MSM.

A Multi-US City Assessment of Awareness and Uptake of Pre-exposure Prophylaxis (PrEP) for HIV Prevention Among Black Men and Transgender Women Who Have Sex with Men

The HIV epidemic among Black men and transgender women who have sex with men (BMTW) demands an urgent public health response. HIV point prevalence among this population ranges from 25 to 43%-a rate far exceeding any other group. Pre-exposure prophylaxis (PrEP) for HIV prevention is a very promising prevention tool; however, its full potential to slow the epidemic has yet to be realized. For the current study, random time-location sampling at Black Gay Pride Events was used to collect data from N = 1274 BMTW, from five US cities, reporting HIV-negative/unknown status. In-field HIV testing was also provided to participants. Participants were assessed on awareness and use of PrEP, health care factors, HIV testing history, psychosocial variables, and sex behaviors. About one third of participants were aware of PrEP (39%), and a small percentage of participants were users of PrEP (4.6%). In multivariable analyses, being in a relationship, testing for HIV in the past 6 months, and others being aware of one's sexuality were positively associated with PrEP awareness. Higher levels of internalized homophobia and greater numbers of female sex partners were positively associated with PrEP use, while education and condom use were negatively associated. Based on study findings, messaging and uptake of PrEP needs greater expansion and requires novel approaches for scale-up. Improving linkage to HIV testing services is likely critical for engaging BMTW with PrEP. The potential for PrEP to slow the HIV epidemic is high; however, we must strengthen efforts to ensure universal availability and uptake.

Perceptions of HIV Seriousness, Risk, and Threat Among Online Samples of HIV-Negative Men Who Have Sex With Men in Seven Countries

Background

Rates of new HIV infections continue to increase worldwide among men who have sex with men (MSM). Despite effective prevention strategies such as condoms and pre-exposure prophylaxis (PrEP), low usage of both methods in many parts of the world hinder prevention efforts. An individual’s perceptions of the risk of acquiring HIV and the seriousness they afford to seroconversion are important drivers of behavioral risk-taking. Understanding the behavioral factors suppressing the uptake of HIV prevention services is a critical step in informing strategies to improve interventions to combat the ongoing HIV pandemic among MSM.

Objective

The study aimed to examine cross-national perceptions of HIV/AIDS seriousness, risk, and threat and the association between these perceptions and sociodemographic characteristics, relationships, and high-risk sexual behaviors among MSM.

Methods

Participants in Australia, Brazil, Canada, Thailand, South Africa, the United Kingdom, and the United States were recruited for a self-administered survey via Facebook (N=1908). Respondents were asked to rate their perceived seriousness from 1 (not at all serious) to 5 (very serious) of contracting HIV, their perceived risk from 1 (no risk) to 10 (very high risk) of contracting HIV based on their current behavior, and their perception of the threat of HIV—measured as their confidence in being able to stay HIV-negative throughout their lifetimes—on a scale from 1 (will not have HIV by the end of his lifetime) to 5 (will have HIV by the end of his lifetime). Covariates included sociodemographic factors, sexual behavior, HIV testing, drug use, and relationship status. Three ordered logistic regression models, one for each outcome variable, were fit for each country.

Results

Contracting HIV was perceived as serious (mean=4.1-4.6), but perceptions of HIV risk (mean=2.7-3.8) and threat of HIV (mean=1.7-2.2) were relatively low across countries. Older age was associated with significantly lower perceived seriousness of acquiring HIV in five countries (Australia: odds ratio, OR 0.97, 95% CI 0.94-0.99; Brazil: OR 0.95, 95% CI 0.91-0.98; Canada: OR 0.96, 95% CI 0.93-0.98; South Africa: OR 0.96, 95% CI 0.94-0.98; United Kingdom: OR 0.95, 95% CI 0.92-0.98). Being in a male-male sexual relationship was associated with significantly lower perceived risk of HIV in four countries (Australia: OR 0.47, 95% CI 0.30-0.75; Canada: OR: 0.54, 95% CI 0.35-0.86; United Kingdom: OR 0.38, 95% CI 0.24-0.60; United States: OR 0.5, 95% CI 0.31-0.82). Drug use in the previous year was associated with greater threat of contracting HIV in two countries (Canada: OR 1.81, 95% CI 1.13-2.91; United Kingdom: OR 1.7, 95% CI 1.06-2.74).

Conclusions

Few measures of behavioral or sexual risk-taking were significantly associated with perceived HIV seriousness, risk, or threat across countries. Overall, low levels of reported risk were identified, and results illustrate important gaps in the understanding of risk among MSM across societies that could be addressed through culturally-tailored prevention messaging.

Preferences for Long-Acting Pre-exposure Prophylaxis (PrEP), Daily Oral PrEP, or Condoms for HIV Prevention Among U.S. Men Who Have Sex with Men

HIV prevention method preferences were evaluated among 512 U.S. men who have sex with men (MSM; median age: 22 years). Approximately 90 % consistently preferred one option across pairwise comparisons of condoms, daily oral pre-exposure prophylaxis (PrEP), and long-acting PrEP delivered via either an injectable or one of two types of PrEP implants differing in visibility. Condoms were most frequently preferred (33.8 %), followed by non-visible implants (21.5 %), and oral PrEP (17.0 %); HIV risk was reported by more choosing implants. In a follow-up question comparing the four PrEP options only, daily oral pills and non-visible implants were most frequently preferred (35.5 and 34.3 %, respectively), followed by injections (25.2 %) and visible implants (4.3 %). An inductive, open-coding approach determined that convenience, duration of protection, and privacy were the most commonly cited reasons for a PrEP method choice, and associated with self-report of HIV risk. Tailoring PrEP product development to privacy and other concerns important to those at highest HIV risk may improve HIV prevention.

Demographic Differences in PrEP-Related Stereotypes: Implications for Implementation

Qualitative interviews about pre-exposure prophylaxis (PrEP) stereotypes were conducted with a subsample of 160 MSM who participated in a PrEP messaging study. Negative stereotypes about PrEP users were identified by 80 % of participants. Two types of stereotypes were most common: PrEP users are HIV-infected (and lying about it), and PrEP users are promiscuous and resistant to condom use. Participants' identification of these stereotype categories differed significantly by demographic factors (i.e., race/ethnicity, education). Expanding access to PrEP requires recognizing potential differences in the experience or anticipation of PrEP-related stereotypes that might impact willingness to discuss PrEP with providers, friends, or partners.

Exploring Patterns of Awareness and Use of HIV Pre-Exposure Prophylaxis Among Young Men Who Have Sex with Men

Pre-exposure prophylaxis (PrEP) has shown promise as a safe and effective HIV prevention strategy, but there is limited research on awareness and use among young men who have sex with men (YMSM). Using baseline data from the "Keep It Up! 2.0" randomized control trial, we examined differences in PrEP awareness and use among racially diverse YMSM (N = 759; mean age = 24.2 years). Participants were recruited from study sites in Atlanta, Chicago, and New York City, as well as through national advertising on social media applications. While 67.5 % of participants reported awareness of PrEP, 8.7 % indicated using the medication. Awareness, but not use, varied by demographic variables. PrEP-users had twice as many condomless anal sex partners (ERR = 2.05) and more condomless anal sex acts (ERR = 1.60) than non-users. Future research should aim to improve PrEP awareness and uptake among YMSM and address condom use.

Awareness and Willingness to Use Pre-exposure Prophylaxis (PrEP) Among Men Who Have Sex with Men and Transgender Women in Brazil

Antiretroviral pre-exposure prophylaxis (PrEP) is recommended to prevent HIV infection among high-risk men who have sex with men (MSM) though not available in Brazil where the HIV epidemic persists unabated in this group. This cross-sectional study describes PrEP awareness and willingness and associated factors among MSM and transvestite/transgender women (trans women) pre-screened for the PrEP Brasil study. Awareness was reported by 61.3 % of the participants and was associated with age, education, site, study period and prior HIV testing. Most participants (82.1 %) were willing to use PrEP, which was associated with site, study period, number of male condomless anal sexual partners and anal sex with HIV positive/unknown partners. PrEP information is need among young and less educated individuals. Willingness to use PrEP was high and future studies should be conducted to confirm PrEP acceptability and the characteristics of the population who chose to adopt this intervention.

Awareness and Acceptability of Pre-exposure HIV Prophylaxis Among Men Who have Sex with Men in Baltimore

This paper assessed characteristics associated with awareness of and willingness to take pre-exposure prophylaxis (PrEP) among Baltimore men who have sex with men (MSM). We used data from BESURE-MSM3, a venue-based cross-sectional HIV surveillance study conducted among MSM in 2011. Multivariate regression was used to identify characteristics associated with PrEP knowledge and acceptability among 399 participants. Eleven percent had heard of PrEP, 48% would be willing to use PrEP, and none had previously used it. In multivariable analysis, black race and perceived discrimination against those with HIV were significantly associated with decreased awareness, and those who perceived higher HIV discrimination reported higher acceptability of PrEP. Our findings indicate a need for further education about the potential utility of PrEP in addition to other prevention methods among MSM. HIV prevention efforts should address the link between discrimination and potential PrEP use, especially among men of color.

Differentiating Nonoccupational Postexposure Prophylaxis Seroconverters and Non-Seroconverters in a Community-Based Clinic in Los Angeles, California

BACKGROUND

Nonoccupational postexposure prophylaxis (nPEP) is a 28-day regimen of antiretroviral medications taken within 72 hours of human immunodeficiency virus (HIV) exposure to prevent HIV acquisition. Although nPEP has been recommended since 1998, few studies have analyzed the characteristics that distinguish nPEP failures (seroconverters) and successes (non-seroconverters).

METHODS

This retrospective study analyzed all nPEP courses prompted by sexual exposure that were prescribed at the Los Angeles LGBT Center between March 2010 and July 2014. Fisher exact tests and logistic regressions were used to determine characteristics that distinguished nPEP seroconverters from non-seroconverters.

RESULTS

Of the nPEP courses administered, 1744 had a follow-up visit for HIV testing within 24 weeks of exposure and 17 individuals seroconverted. Seven reported a known re-exposure, 8 self-reported only condom-protected sex subsequent to the initial exposure, and 2 reported abstinence since the exposure. In multivariable analyses, seroconverters were more likely than non-seroconverters to report methamphetamine use, incomplete medication adherence, and nPEP initiation later in the 72-hour window.

CONCLUSIONS

Nonoccupational postexposure prophylaxis is an important emergency tool for HIV prevention. Our findings corroborate that timing of the initial nPEP dose is an important predictor of seroconversion. Although the current study did not offer the initial nPEP dose at the beginning of the visit, use of this fast-track dosing schedule will ensure that the first dose is taken as early as possible postexposure and may lower the likelihood for seroconversion. Furthermore, we recommend systematic screening for substance use because these individuals may be well suited for pre-exposure prophylaxis given their sustained risk.

Social, structural, behavioral and clinical factors influencing retention in Pre-Exposure Prophylaxis (PrEP) care in Mississippi

Pre-exposure prophylaxis (PrEP) is a biomedical intervention that can reduce rates of HIV transmission when taken once daily by HIV-negative individuals. Little is understood about PrEP uptake and retention in care among the populations most heavily impacted by the HIV epidemic, particularly among young men who have sex with men (YMSM) in the Deep South. Therefore, this study explored the structural, social, behavioral, and clinical factors that affect PrEP use and retention in care among YMSM in Jackson, Mississippi. Thirty MSM who were prescribed PrEP at an outpatient primary care clinic were interviewed and included 23 men who had been retained in PrEP care and seven who had not been retained. The mean age of participants was 26.6 years. Most (23) participants were African American. Major factors affecting PrEP use and retention in PrEP care included 1) structural factors such as cost and access to financial assistance for medications and clinical services; 2) social factors such as stigma and relationship status; 3) behavioral factors including sexual risk behaviors; and 4) clinical factors such as perceived and actual side effects. Many participants also discussed the positive spillover effects of PrEP use and reported that PrEP had a positive impact on their health. Four of the seven individuals who had not been retained re-enrolled in PrEP care after completing their interviews, suggesting that case management and ongoing outreach can enhance retention in PrEP care. Interventions to enhance retention in PrEP care among MSM in the Deep South will be most effective if they address the complex structural, social, clinical, and behavioral factors that influence PrEP uptake and retention in PrEP care.

Brief Report: The Right People, Right Places, and Right Practices: Disparities in PrEP Access Among African American Men, Women, and MSM in the Deep South

Disproportionate rates of HIV are observed in Black women and men, especially in the Southern United States. We observed limited uptake of preexposure prophylaxis (PrEP) services in our Southern community among these groups, particularly Black men who have sex with men relative to new HIV cases in Birmingham, AL; 18% accessed PrEP services compared with 50% of new HIV cases. Further research is needed to understand PrEP access and uptake in high-risk populations.

Brief Report: PrEP Uptake, Adherence, and Discontinuation Among California YMSM Using Geosocial Networking Applications

We investigated pre-exposure prophylaxis (PrEP) uptake, adherence, and discontinuation among young app-using men who have sex with men in California (N = 761). Approximately, 9.7% of participants had ever used PrEP; 87% of those deemed good candidates for screening (indicated by a Centers for Disease Control and Prevention risk index score ≥10) were not current or past users. PrEP use was associated with higher income [adjusted odds ratio (aOR): 4.13; confidence interval (CI): 1.87 to 9.12], receptive condomless anal sex (aOR: 3.41; CI: 1.71 to 6.78), HIV-positive sex partners (aOR: 2.87; CI: 1.53 to 5.38), popper use (aOR: 3.47; CI: 1.96 to 6.13), and recent sexually transmitted infection diagnosis (aOR: 2.90; CI: 1.64 to 5.13). Some users (41.5%) wanted help remembering to take PrEP. The top reason for discontinuation was concern about long-term side effects (33.0%). Young men who have sex with men app users are prime candidates for PrEP, despite low uptake. Apps may be useful tools for PrEP information dissemination, adherence monitoring, and support.

Pre-exposure prophylaxis (PrEP) for men who have sex with men in Europe: review of evidence for a much needed prevention tool

In many Western countries with good coverage of antiretroviral treatment (ART) programmes the annual number of HIV infections is still high and not (yet) declining among men who have sex with men (MSM). This might indicate that antiretroviral treatment roll-out alone will not turn around the course of the epidemic and that new, additional tools are needed. Antiretrovirals used as prevention tools for people not yet infected with HIV, such as pre-exposure prophylaxis (PrEP) could be such important additional tools. PrEP is a new type of biomedical prevention, which involves the use of antiretrovirals before, during and after (periods of) sexual exposure to HIV. In this review, we will focus on PrEP as a new prevention tool for MSM at high risk in Europe, including its evidence for effectiveness, challenges for implementation, ongoing European demonstration studies; as well as how PrEP relates to other existing prevention tools. In light of European Medicines Agency's recent recommendation for approval of PrEP we briefly review the potential implications.

How Different are Men Who Do Not Know Their HIV Status from Those Who Do? Results from an U.S. Online Study of Gay and Bisexual Men

We compared self-described HIV-positive (31.6 %, n = 445), HIV-negative (56.8 %, n = 801), and HIV-unknown (11.6 %, n = 164) gay and bisexual men on sociodemographic and behavioral characteristics. Participants from across the U.S. were enrolled via a popular sexual networking website to complete an online survey. In total, 44.8 % of HIV-negative and HIV-unknown men said they had not been tested for HIV in the CDC-recommended last 6 months. HIV-unknown men significantly differed from HIV-negative and HIV-positive men in sexual behavior and HIV status disclosure patterns. HIV-unknown men were more willing than HIV-negative men to take PrEP; however, HIV-unknown men were significantly less likely than others to have health insurance or a primary care provider. Given the observed differences, researchers should consider analyzing men who are HIV-unknown distinctly from HIV-negative and HIV-positive men.

Antiretroviral pre-exposure prophylaxis preferences among men who have sex with men in Vietnam: results from a nationwide cross-sectional survey

Background: The HIV/AIDS epidemic in Vietnam is concentrated in subgroups of the population, including men who have sex with men (MSM). Pre-exposure prophylaxis (PrEP) is a viable strategy for HIV prevention, but knowledge about and preferences for PrEP delivery among Vietnamese MSM are not well understood. Methods: In 2015, an online survey was conducted with recruitment via social networking websites for MSM and peer recruitment. A description of daily oral, long-acting injectable, and rectal microbicide formulations of PrEP was provided to participants. Participants were asked about their prior awareness of and interest in PrEP, and ranked their most preferred PrEP modality. Multivariable logistic regression models were used to assess factors associated with having heard of PrEP and preference for each PrEP modality. Results: Of 548 participants who answered demographic and PrEP-related questions, 26.8% had previously heard of PrEP and most (65.7%) endorsed rectal microbicides as their most preferred PrEP delivery modality. Commonly-cited perceived barriers to uptake of PrEP included concern about side-effects, perception about being HIV positive, and family or friends finding out about their sexual behaviour. In multivariable models, older participants less often endorsed rectal microbicides (adjusted odds ratio (AOR) 0.95 per year, 95% confidence interval (CI) 0.91-0.99) and more often endorsed long-acting injectables (AOR 1.08 per year, 95% CI 1.03 to 1.14) as their preferred PrEP modality. Participants who were willing to pay more for PrEP less often endorsed rectal microbicides (AOR 0.81, 95% CI 0.72-0.92) and more often endorsed long-acting injectables (AOR 1.17, 95% CI 1.01-1.35) and daily oral pills (AOR 1.16, 95% CI 1.00-1.35) as their preferred form of PrEP. Conclusions: A variety of PrEP modalities were acceptable to MSM in Vietnam, but low knowledge of PrEP may be a barrier to implementation.

Online Hookup Sites for Meeting Sexual Partners Among Men Who Have Sex with Men in Rhode Island, 2013: A Call for Public Health Action

Frequent use of websites and mobile telephone applications (apps) by men who have sex with men (MSM) to meet sexual partners, commonly referred to as "hookup" sites, make them ideal platforms for HIV prevention messaging. This Rhode Island case study demonstrated widespread use of hookup sites among MSM recently diagnosed with HIV. We present the advertising prices and corporate social responsibility (CSR) programs of the top five sites used by newly diagnosed HIV-positive MSM to meet sexual partners: Grindr, Adam4Adam, Manhunt, Scruff, and Craigslist. Craigslist offered universal free advertising. Scruff offered free online advertising to selected nonprofit organizations. Grindr and Manhunt offered reduced, but widely varying, pricing for nonprofit advertisers. More than half (60%, 26/43) of newly diagnosed MSM reported meeting sexual partners online in the 12 months prior to their diagnosis. Opportunities for public health agencies to promote HIV-related health messaging on these sites were limited. Partnering with hookup sites to reach high-risk MSM for HIV prevention and treatment messaging is an important public health opportunity for reducing disease transmission risks in Rhode Island and across the United States.

Awareness of Pre-exposure Prophylaxis for HIV, Willingness to Use It and Potential Barriers or Facilitators to Uptake Among Men Who Have Sex with Men in Spain

There is a lack of data on pre-exposure prophylaxis (PrEP) effectiveness in Spain. We described the awareness of and willingness to use PrEP and examined potential barriers and facilitators to their use among men who have sex with men recruited either online or in voluntary HIV testing centers in Spain. Nearly a third of men (28.7 %) were aware of PrEP and 57.6 % said they would be willing to use it if available, 16.6 % saying they would be unwilling to use PrEP and 25.8 % not being sure. Men who had heard of PrEP were more forceful in their opinions on willingness to use PrEP (willing/not willing: 29.8 %/32.6 % vs. don't know: 21.8 %). The greatest consensus regarding more acceptable PrEP attributes was in the mode of delivery and its cost. Doctors (91 %) or pharmacists (85.3 %) were the preferred providers. The results confirm the need to inform and educate on PrEP and define implementation strategies.

Pre-exposure Prophylaxis Awareness Among Gay and Other Men who have Sex with Men in Vancouver, British Columbia, Canada

Men who have sex with men (MSM) account for approximately half of Canada's new HIV infections. Pre-exposure prophylaxis (PrEP), a recently established and effective HIV prevention tool for MSM is currently not approved nor publicly funded. We recruited MSM via respondent-driven sampling to complete a self-administered computer-based interview. Stratified by HIV status, multivariable logistic regression identified factors associated with PrEP awareness. Of 673 participants, 102/500 (20.9 %) HIV-negative and 63/173 (26.5 %) HIV-positive men were aware of PrEP, but none had used it. One third of PrEP-aware MSM spoke about it with friends or sex partners. Self-declared knowledge was limited. Factors associated with PrEP awareness varied by HIV status, but included greater HAART optimism for HIV-negative MSM. Among HIV-negative MSM, being PrEP unaware was associated with younger age, not always having condoms, and preferring receptive versus insertive anal sex. Future longitudinal research should identify early adopters of PrEP and its associated impacts.

Seasons of Risk: Anticipated Behavior on Vacation and Interest in Episodic Antiretroviral Pre-exposure Prophylaxis (PrEP) Among a Large National Sample of U.S. Men Who have Sex with Men (MSM)

The current analysis evaluates interest in and acceptability of daily PrEP during short episodes of anticipated increased risk (i.e. Epi-PrEP). In 2013, U.S. members of an internet-based MSM sexual networking site were invited to complete a survey about HIV prevention practices in the context of vacationing. 7305 MSM responded to the survey. Of respondents who had vacationed in the past year, 25.6 % reported condomless anal sex (CAS) with new male sex partners while vacationing. Most (92.6 %) respondents agreed that having to use PrEP every day was a barrier to PrEP use and 74.3 % indicated they would take PrEP if they knew it would be helpful for short periods of anticipated increased risk. MSM who reported increased CAS while on vacation in the past year were more likely to indicate that they would take PrEP if it were helpful when used for short periods than respondents who did not (aOR = 2.02, 95 % CI 1.59-2.56, p < 0.001). Studies designed to evaluate uptake, adherence, and protective benefit of short PrEP courses are warranted.

Attitudes Toward HIV Pre-Exposure Prophylaxis in a United States Urban Clinic Population

A majority of US studies on attitudes toward PrEP focus on men who have sex with men with little representation of African Americans. This cross-sectional study seeks to determine openness to PrEP, and examine motivations for openness among Philadelphia residents. Patients undergoing HIV rapid testing between May 2012 and December 2014 in a public setting were administered a survey. Questions included openness to PrEP and reasons for openness to PrEP. Multivariate logistic regression models were used to investigate associations between openness and potential predictors. Analyses were conducted using R version 3.2.4 and the epitools and car packages. Of 5606 respondents, over 90 % were African American. Men were more likely to express openness (61.4 % of men, 54.8 % of women, p < 0.0001). Predictors of openness were younger age, black race, higher perceived risk for HIV by patient or as assessed by Tester, intermittent /no condom use, greater number of partners in 12 months and previous HIV testing. The main reason for openness was fear of HIV, and for disinterest was lack of recognition of risk. Understanding openness to PrEP, and reasons for openness to or disinterest in PrEP are critical to determining the best approaches to facilitate engagement in PrEP care by communities and persons at elevated risk for HIV acquisition. Further study is needed on how best to manage disinterest in PrEP by those at high risk for HIV, and how openness to PrEP translates into concrete steps to take PrEP.

Early Adopters: Correlates of HIV Chemoprophylaxis Use in Recent Online Samples of US Men Who Have Sex with Men

To date, little data on pre-exposure prophylaxis (PrEP) users outside of the clinical trial setting are available. A repeated cross-sectional survey of one of the largest social and sexual networking websites for men who have sex with men (MSM) in the United States was conducted in August 2013 (Wave 1) and January 2014 (Wave 2). Multivariable logistic regression models were used to assess factors associated with having heard of and having taken post-exposure prophylaxis (PEP) and PrEP in Wave 1 (N = 4043) and Wave 2 (N = 2737) separately. In Wave 1, 147 (3.6 %) and 61 (1.5 %) reported using PEP and PrEP, respectively, compared to 119 (4.4 %) and 62 (2.3 %) in Wave 2. Higher-risk sexual behaviors were associated with having taken PEP and PrEP, and previous PEP use was associated with having taken PrEP. Understanding factors that are associated with early use of PrEP may help inform wider utilization of PrEP by at risk MSM.

Explaining the Efficacy of Pre-exposure Prophylaxis (PrEP) for HIV Prevention: A Qualitative Study of Message Framing and Messaging Preferences Among US Men Who have Sex with Men

We investigated message comprehension and message framing preferences for communicating about PrEP efficacy with US MSM. We conducted eight focus groups (n = 38) and n = 56 individual interviews with MSM in Providence, RI. Facilitators probed comprehension, credibility, and acceptability of efficacy messages, including percentages, non-numerical paraphrases, efficacy ranges versus point estimates, and success- versus failure-framed messages. Our findings indicated a range of comprehension and operational understandings of efficacy messages. Participants tended to prefer percentage-based and success-framed messages, although preferences varied for communicating about efficacy using a single percentage versus a range. Participants reported uncertainty about how to interpret numerical estimates, and many questioned whether trial results would predict personal effectiveness. These results suggest that providers and researchers implementing PrEP may face challenges in communicating with users about efficacy. Efforts to educate MSM about PrEP should incorporate percentage-based information, and message framing decisions may influence message credibility and overall PrEP acceptability.

Retention in care outcomes for HIV pre-exposure prophylaxis implementation programmes among men who have sex with men in three US cities

Introduction

Despite the efficacy of pre-exposure prophylaxis (PrEP) in preventing HIV transmission, few studies have evaluated PrEP use and retention in care outcomes in real-world settings outside of clinical trials.

Methods

Data were collected from PrEP clinical care programmes in three mid-size US cities: Providence, Rhode Island (RI); Jackson, Mississippi (MS); and St. Louis, Missouri (MO). We assessed the demographic and social characteristics of patients prescribed PrEP and documented their insurance and copayment experiences. We assessed retention in PrEP care at three and six months. Multivariate analyses were used to predict retention in care among men who have sex with men (MSM). HIV acquisition among the cohort was also assessed.

Results

A total of 267 (RI: 117; MS: 88; MO: 62) patients were prescribed PrEP; 81% filled prescriptions (RI: 73%; MS: 82%; MO: 94%; p<0.001). Patients in MS and MO were more commonly African American than in RI (72% and 26% vs. 7%, respectively), but less frequently Latino (2% and 3% vs. 24%, respectively). More patients reported living below the federal poverty line in MS (52%) compared to MO (23%) and RI (26%). Most patients were MSM (RI: 92%; MS: 88%; MO: 84%). The majority of MSM reported recent condomless anal sex (RI: 70%; MS: 65%; MO: 75%). Among 171 patients prescribed PrEP at least six months beforehand, 72% were retained in care at three months (RI: 68%; MS: 70%; MO: 87%; p=0.12) and 57% were retained in PrEP care at six months (RI: 53%: MS: 61%; MO: 63%; p=0.51). Insurance status and medication costs were not found to be significant barriers for obtaining PrEP. Three patients became infected with HIV during the six-month period after being prescribed PrEP (1.1%; 3/267), including one in RI (suspected acute HIV infection), one in MO (confirmed poor adherence) and one in MS (seroconverted just prior to initiation).

Conclusions

PrEP initiation and retention in care differed across these distinct settings. In contrast, retention in PrEP care was consistently suboptimal across sites. Further research is needed to identify the individual, social and structural factors that may impede or enhance retention in PrEP care

PEP and TasP Awareness among Italian MSM, PLWHA, and High-Risk Heterosexuals and Demographic, Behavioral, and Social Correlates

Post-exposure prophylaxis (PEP) has been proposed as a strategy to prevent the acquisition of HIV infection after certain high-risk exposures, and treatment as prevention (TasP) is also being advocated as a means to reduce sexual transmission of HIV. The aim of this study was to investigate the prevalence of PEP and TasP awareness and their demographic, behavioral, and social correlates in Italy. We conducted a cross-sectional survey of 1,028 high-risk heterosexual men and women, 1,874 non-HIV positive MSM (men who have sex with men), and 694 people living with HIV/AIDS (PLWHA). The majority of the participants was aware of PEP and unaware of TasP. MSM were less knowledgeable about PEP and TasP than were PLWHA and more knowledgeable about PEP and TasP than were high-risk heterosexual participants. The variables most consistently associated with PEP and TasP awareness were contact with HIV/AIDS organizations, HIV testing, and HIV stigma. A positive relationship between unprotected sexual intercourse and PEP and TasP awareness was found among high risk heterosexual participants, while this association was not significant among MSM and PLWHA. Because PEP and TasP are currently recommended, effective educational and dissemination strategies are needed to increase the level of knowledge about PEP and TasP.

Breeding new forms of life: a critical reflection on extreme variances of bareback sex

Many men who have sex with men (MSM) express feeling marginalized by discourses within public health and sexual health nursing that determine bareback sex is deviant and unsafe. Their resistance to risk-based discourses can be seen within radical sex practices such as deliberately becoming-infected with HIV (bug-chasing) and breeding-infection (gift-giving). The metaphors of bug-chasing and gift-giving, particularly those spread across global online spaces, can influence the sexual experiences and practices of MSM. A metaphor analysis was conducted of Internet forums discussing HIV chasing and gifting metaphors, and showed a variety of discursive meanings, tactics and effects to the radical sex practice. A radical research approach was used to explore the processes of becoming-infected and breeding-infection as determinant steps in the symbolic resistance of risk-based discourses, as well as the creation of new forms of life and community among MSM. Our analyses demonstrate how the gifting/chasing metaphors express MSM's marginalization as well as their lines of flight from having their practices captured within public health discourses. We hope to offer alternative nursing approaches for thinking through and engaging with transgressive and queer sexual practices.

Use of an HIV-risk screening tool to identify optimal candidates for PrEP scale-up among men who have sex with men in Toronto, Canada: disconnect between objective and subjective HIV risk

INTRODUCTION

Identifying appropriate pre-exposure prophylaxis (PrEP) candidates is a challenge in planning for the safe and effective roll-out of this strategy. We explored the use of a validated HIV risk screening tool, HIV Incidence Risk Index for Men who have Sex with Men (HIRI-MSM), to identify "optimal" candidates among MSM testing at a busy sexual health clinic's community testing sites in Toronto, Canada.

METHODS

Between November 2014 and April 2015, we surveyed MSM undergoing anonymous HIV testing at community testing sites in Toronto, Canada, to quantify "optimal" candidates for scaling up PrEP roll-out, defined as being at high objective HIV risk (scoring ≥10 on the HIRI-MSM), perceiving oneself at moderate-to-high HIV risk and being willing to use PrEP. Cascades were constructed to identify barriers to broader PrEP uptake. The association between HIRI-MSM score and both willingness to use PrEP and perceived HIV risk were explored in separate multivariable logistic regression analyses.

RESULTS

Of 420 respondents, 64.4% were objectively at high risk, 52.5% were willing to use PrEP and 27.2% perceived themselves at moderate-to-high HIV risk. Only 16.4% were "optimal" candidates. Higher HIRI-MSM scores were positively associated with both willingness to use PrEP (aOR=1.7 per 10 score increase, 95%CI=1.3-2.2) and moderate-to-high perceived HIV risk (aOR=1.7 per 10 score increase, 95%CI=1.2-2.3). The proportion of men who were "optimal" candidates increased to 42.9% when the objective HIV risk cut-off was changed to top quartile of HIRI-MSM scores (≥26). In our full cascade, a very low proportion (5.3%) of MSM surveyed could potentially benefit from PrEP under current conditions. The greatest barrier in the cascade was low perception of HIV risk among high-risk men, but considerable numbers were also lost in downstream cascade steps. Of men at high objective HIV risk, 68.3% did not perceive themselves to be at moderate-to-high HIV risk, 23.6% were unaware of PrEP, 40.1% were not willing to use PrEP, 47.6% lacked a family physician with whom they felt comfortable discussing sexual health, and 31.6% had no means to cover the cost of PrEP.

CONCLUSIONS

A higher HIRI-MSM cut-off may be helpful for identifying candidates for PrEP scale-up. Improving engagement in the PrEP cascade will require interventions to simultaneously address multiple barriers.

The Promise of Pre-Exposure Prophylaxis for Black Men Who Have Sex with Men: An Ecological Approach to Attitudes, Beliefs, and Barriers

Research has demonstrated the clinical effectiveness of pre-exposure prophylaxis (PrEP) for HIV prevention, but little is known about how factors at the individual-, interpersonal-, community-, and structural levels impact PrEP use for black men who have sex with men (BMSM). We advance existing work by examining how all levels of the ecological framework must be addressed for PrEP to be successfully implemented as an effective HIV prevention approach. We interviewed 31 BMSM three times each and 17 community stakeholders once each; interviews were taped, transcribed, and analyzed using the constant comparative method. Factors that influence how BMSM experienced PrEP emerged across all levels of the ecological framework: At the individual level, respondents were wary of giving medication to healthy people and of the potential side-effects. At the interpersonal level, BMSM believed that PrEP use would discourage condom use and that PrEP should only be one option for HIV prevention, not the main option. At the community level, men described not trusting the pharmaceutical industry and described PrEP as an option for others, not for themselves. At the structural level, BMSM talked about HIV and sexuality-related stigmas and how they must overcome those before PrEP engagement. BMSM are a key population in the US National HIV/AIDS Strategy, yet few individuals believe that PrEP would be personally helpful. Our research indicates the urgent need to raise awareness and address structural stigma and policies that could be substantial barriers to the scale-up and implementation of PrEP-related services.

Preexposure Prophylaxis Modality Preferences Among Men Who Have Sex With Men and Use Social Media in the United States

Background

Preexposure prophylaxis (PrEP) is available as a daily pill for preventing infection with the human immunodeficiency virus (HIV). Innovative methods of administering PrEP systemically or topically are being discussed and developed.

Objective

The objective of our study was to assess attitudes toward different experimental modalities of PrEP administration.

Methods

From April to July 2015, we recruited 1106 HIV-negative men who have sex with men through online social media advertisements and surveyed them about their likelihood of using different PrEP modalities. Participants responded to 5-point Likert-scale items indicating how likely they were to use each of the following PrEP modalities: a daily oral pill, on-demand pills, periodic injection, penile gel (either before or after intercourse), rectal gel (before/after), and rectal suppository (before/after). We used Wilcoxon signed rank tests to determine whether the stated likelihood of using any modality differed from daily oral PrEP. Related items were combined to assess differences in likelihood of use based on tissue or time of administration. Participants also ranked their interest in using each modality, and we used the modified Borda count method to determine consensual rankings.

Results

Most participants indicated they would be somewhat likely or very likely to use PrEP as an on-demand pill (685/1105, 61.99%), daily oral pill (528/1036, 50.97%), injection (575/1091, 52.70%), or penile gel (438/755, 58.01% before intercourse; 408/751, 54.33% after). The stated likelihoods of using on-demand pills (median score 4) and of using a penile gel before intercourse (median 4) were both higher than that of using a daily oral pill (median 4, P<.001 and P=.001, respectively). Compared with a daily oral pill, participants reported a significantly lower likelihood of using any of the 4 rectal modalities (Wilcoxon signed rank test, all P<.001). On 10-point Likert scales created by combining application methods, the reported likelihood of using a penile gel (median 7) was higher than that of using a rectal gel (median 6, P<.001), which was higher than the likelihood of using a rectal suppository (median 6, P<.001). The modified Borda count ranked on-demand pills as the most preferred modality. There was no difference in likelihood of use of PrEP (gel or suppository) before or after intercourse.

Conclusions

Participants typically prefer systemic PrEP and are less likely to use a modality that is administered rectally. Although most of these modalities are seen as favorable or neutral, attitudes may change as information about efficacy and application becomes available. Further data on modality preference across risk groups will better inform PrEP development.

Perceptions among Dutch men who have sex with men and their willingness to use rectal microbicides and oral pre-exposure prophylaxis to reduce HIV risk--a preliminary study

Oral pre-exposure prophylaxis (PrEP) with antiretroviral (ARV) tablets and topical PrEP or microbicides containing ARV drugs could help to reduce HIV incidence. These methods hold promise for men who have sex with men (MSM) who are at higher risk of acquiring HIV. This mixed-methods study in the Netherlands explored perceptions of MSM and their willingness to use oral PrEP and rectal microbicides (RM) if made available. Recruited through social media (Facebook and Twitter), 108 MSM completed online questionnaires. Seven of them consented to discuss the survey results in semi-structured interviews. Survey participants preferred a RM that could be applied before and after anal intercourse (60.8%) to daily oral PrEP (20.3%). This preference was based on anticipated user friendliness, hypothetically fewer expected adverse events, and perceptions that RM would be less likely to be confused with ARVs for treatment. Those who preferred oral PrEP had stronger beliefs in the effectiveness of pills, perceived its use as easy, and viewed not requiring sexual partner awareness as advantages. No predictive factors were found for the choice of one prevention method over the other. Although Dutch MSM perceive both oral and topical PrEP positively, many barriers exist to the introduction of these products in the Netherlands. These include lack of regulatory approval of oral PrEP, no proven efficacy as yet for RM, and strong HIV stigma within the MSM population. In-depth qualitative research is needed to further explore the perceptions of MSM to inform implementation of programmes should these HIV prevention methods become available.

'Men who use the Internet to seek sex with men': Rethinking sexuality in the transnational context of HIV prevention

MISM (i.e. men who use the Internet to seek sex with men) has emerged in public health literature as a population in need of HIV prevention. In this paper, we argue for the importance of rethinking the dominant notions of the MISM category to uncover its ethnocentric and heteronormative bias. To accomplish this, we conducted a historical, epistemological and transnational analysis of social sciences and health research literature (n = 146) published on MISM between 2000 and 2014. We critically unravel the normative underpinnings of 'westernised' knowledge upon which the MISM category is based. We argue that the essentialist approach of Western scholarship can homogenise MISM by narrowly referring to behavioural aspects of sexuality, thereby rendering multiple sexualities/desires invisible. Furthermore, we argue that a Eurocentric bias, which underlies the MISM category, may hinder our awareness of the transnational dynamics of sexual minority communities, identities, histories and cultures. We propose the conceptualisation of MISM as hybrid cultural subjects that go beyond transnational and social boundaries, and generate conclusions about the future of the MISM category for HIV prevention and health promotion.

Male Escorts' and Male Clients' Sexual Behavior During Their Last Commercial Sexual Encounter: Comparing and Contrasting Findings from Two Online Studies

Much of what is known about commercial sexual encounters between men is based on data gathered from escorts. With few exceptions, studies have not compared male clients' reports of behavior during commercial sexual encounters with male escorts'. The present study draws from two datasets, a 2012 survey of clients (n = 495) and a 2013 survey of escorts (n = 387)--both used virtually identical measures of sexual behavior during the most recent commercial sexual encounter. For clients and escorts, the majority eschewed having sex without a condom, and kissing and oral sex were among the most common behaviors reported. Using logistic regression, both samples were compared across 15 sexual behaviors, finding significant differences in six--the escort sample had greater odds of reporting their last commercial sexual encounter involved watching the client masturbate, viewing porn, role play (dad/son, dominant/submissive), and having prior sexual experience with their commercial partner. The escort sample had lower odds of reporting that the client watched the escort masturbate, and being told partner's HIV status. In multivariable modeling, both samples did not significantly differ in reports of condomless anal sex. Male-male commercial sexual encounters appear to be involved in a wide range of sexual behaviors, many of which convey low-to-no risk of HIV transmission.

Who Will Use Pre-Exposure Prophylaxis (PrEP) and Why?: Understanding PrEP Awareness and Acceptability amongst Men Who Have Sex with Men in the UK--A Mixed Methods Study

BACKGROUND

Recent clinical trials suggest that pre-exposure prophylaxis (PrEP) may reduce HIV transmission by up to 86% for men who have sex with men (MSM), whilst relatively high levels of PrEP acceptability have been reported to date. This study examines PrEP awareness amongst sub-groups of MSM communities and acceptability amongst MSM in a low prevalence region (Scotland, UK), using a mixed methods design.

METHODS

Quantitative surveys of n = 690 MSM recruited online via social and sociosexual media were analysed using descriptive statistics and multivariate logistic regression. In addition, n = 10 in-depth qualitative interviews with MSM were analysed thematically.

RESULTS

Under one third (29.7%) of MSM had heard of PrEP, with awareness related to living in large cities, degree level education, commercial gay scene use and reporting an HIV test in the last year. Just under half of participants (47.8%) were likely to use PrEP if it were available but there was no relationship between PrEP acceptability and previous PrEP awareness. Younger men (18-25 years) and those who report higher risk UAI were significantly more likely to say they would use PrEP. Qualitative data described specific PrEP scenarios, illustrating how risk, patterns of sexual practice and social relationships could affect motivation for and nature of PrEP use.

CONCLUSION

These findings suggest substantial interest PrEP amongst MSM reporting HIV risk behaviours in Scotland. Given the Proud results, there is a strong case to investigate PrEP implementation within the UK. However, it appears that disparities in awareness have already emerged along traditional indicators of inequality. Our research identifies the need for comprehensive support when PrEP is introduced, including a key online component, to ensure equity of awareness across diverse MSM communities (e.g. by geography, education, gay scene use and HIV proximity), as well as to responding to the diverse informational and sexual health needs of all MSM communities.

Low willingness and actual uptake of pre-exposure prophylaxis for HIV-1 prevention among men who have sex with men in Shanghai, China

Little is known about the acceptance and actual uptake of pre-exposure prophylaxis (PrEP) and associated factors in men who have sex with men (MSM) in China. This study is the baseline survey of an intervention study designed to evaluate the effectiveness of tenofovirdisoproxil fumarate (TDF) on a daily use for human immunodeficiency virus (HIV) prevention among MSM in Shanghai, China. From October 2012 to December 2013, a total of 1,033 MSM in Shanghai were recruited by local district Centers for Disease Control and Prevention (CDC) and a MSM community-based non-governmental organization (NGO). Among them, 197 (19.1%) participants expressed willingness to use the TDF group at baseline survey, but only 26 (2.5%) participated in the TDF group and took TDF one tablet a day. Higher willingness to use PrEP was associated with being 45 years or older, non-local residents, having more male sex partners in the past 6 months and not using condom at last anal sex with man. Acutal uptake of PrEP was associated with having ≥ 11 male sex partners in lifetime and reporting no female sex partners in lifetime. Reasons for not participating in TDF group among those who expressed willingness to use PrEP at baseline survey included loss of contact, ineligiblity because of abnormal results for liver or renal function tests, change of mind, and HIV seroconversion before uptake of PrEP. Our findings suggest that promotion of PrEP in MSM remains challenging at current circumstancein China. Future research is needed to solicit effective education and intervention programs to promote acceptance of PrEP among Chinese MSM.

Pre-Exposure Prophylaxis (PrEP) for Safer Conception Among Serodifferent Couples: Findings from Healthcare Providers Serving Patients with HIV in Seven US Cities

Pre-exposure prophylaxis (PrEP) can reduce the risk of HIV transmission among serodifferent couples trying to conceive, yet provider knowledge, attitudes, and experience utilizing PrEP for this purpose are largely unexamined. Trained interviewers conducted phone interviews with healthcare providers treating patients with HIV in seven cities (Atlanta, Baltimore, Houston, Kansas City, Newark, Philadelphia, and San Francisco, N = 85 total). Quantitative and qualitative data were analyzed to describe experience, concerns, and perceived barriers to prescribing PrEP for safer conception. Providers (67.1% female, 43 mean years of age, 70.4% white, 10 mean years treating HIV+ patients, 56% in academic vs. community facilities, 62.2% MD) discussed both benefits and concerns of PrEP for safer conception among serodifferent couples. Only 18.8% of providers reported experience prescribing PrEP, 74.2% were willing to prescribe it under ideal circumstances, and 7.0% were not comfortable prescribing PrEP. Benefits included added protection and a greater sense of control for the HIV-negative partner. Concerns were categorized as clinical, system-level, cost, or behavioral. Significant differences in provider characteristics existed across sites, but experience with PrEP for safer conception did not, p = 0.14. Despite limited experience, most providers were open to recommending PrEP for safer conception as long as patients understood the range of concerns and could make informed decisions. Strategies to identify and link serodifferent couples to PrEP services and clinical guidance specific to PrEP for safer conception are needed.

Antiretrovirals for primary HIV prevention: the current status of pre- and post-exposure prophylaxis

In light of the 2 million HIV infections that occur globally each year, there is a need to optimize strategies that integrate biomedical and behavioral approaches to HIV prevention. Post-exposure prophylaxis (PEP) immediately after acute high-risk exposures and pre-exposure prophylaxis (PrEP) for those who engage in recurrent high-risk behaviors are promising bio-behavioral approaches to decreasing HIV transmission. Guidelines have recommended PEP for occupational and non-occupational exposures for over 15 years, but uptake of PEP has been limited, partly as a result of insufficient awareness of this intervention among persons at highest risk for acquiring HIV. However, since the publication of large randomized clinical trials demonstrating the efficacy of PrEP, and the dissemination of guidelines endorsing its use, there is a renewed focus on bio-behavioral prevention. Numerous studies have recently assessed the acceptability of bio-behavioral prevention programs among diverse populations or described experiences implementing these programs in "real-world" settings. As research and clinical data informing optimal utilization of PEP and PrEP are rapidly accumulating, this review provides a timely summary of recent progress in bio-behavioral prevention. By contextualizing the most noteworthy recent findings regarding PEP and PrEP, this review seeks to inform the successful implementation of these promising prevention approaches.

The preexposure prophylaxis revolution: from clinical trials to routine practice: implementation view from the USA

PURPOSE OF REVIEW

This article describes the use of tenofovir/emtricitabine (Truvada) as prevention for exposure to HIV [preexposure prophylaxis (PrEP)] infection in the USA. The use of PrEP and the challenges of implementation are very instructive as other countries adopt this intervention and it becomes a fundamental part of worldwide efforts for HIV prevention and much can be learned from the first 3 years in the USA.

RECENT FINDINGS

Randomized trials and demonstration projects have shown the benefits of PrEP for men and women who are at risk for HIV. Numerous studies have showed that the level of prevention is excellent when the drug is taken at least four times weekly, once adequate levels are obtained. However, adherence remains a critical issue as well as tailoring delivery models for specific populations. Six recent studies are discussed, that support excellent efficacy and significantly support PrEP as a means of prevention. These projects have shown high acceptance of PrEP with excellent adherence by individuals demonstrated by those at risk remaining free of HIV over extended periods of time.

SUMMARY

The USA faces three significant challenges in scaling up PrEP. The first challenge in implementation in the USA is to get individuals to recognize the actual risks that their behaviors represent and to engage with providers to address these issues. The second challenge is getting a population of providers to recognize the exact same issues and offer PrEP in a compassionate, nonjudgmental fashion. The third challenge is identifying the set of providers and locations to scale-up the response in a timely, cost-effective fashion.

Sexual Behavior Patterns and PrEP Dosing Preferences in a Large Sample of North American Men Who Have Sex With Men

INTRODUCTION

Pre-exposure prophylaxis (PrEP), taken as a single daily coformulated pill containing tenofovir -emtricitabine, is a promising intervention to reduce the likelihood of HIV acquisition in at-risk individuals, including men who have sex with men. Little is known about the acceptability of less than daily, intermittent PrEP regimens.

METHODS

We conducted an online survey of North American men who have sex with men to characterize their sexual frequency and planning behaviors and correlate these with PrEP dosing preferences.

RESULTS

Of the 3217 respondents who completed the survey, 46% reported engaging in unplanned condomless anal intercourse (CAI) at least once in previous 3 months and 8% reported engaging in CAI more than once per week. In multivariable analysis, reporting unplanned CAI was associated with lower educational level, identifying as homosexual/gay as compared with bisexual, being in a monogamous relationship, having a higher self-perceived risk of HIV acquisition, reporting higher income, engaging in CAI more than five times in the last 3 months, and not having visited a health care provider in the previous year. Frequent CAI (>1 time per week) was associated with being younger, identifying as homosexual/gay as compared with bisexual, being in a monogamous relationship, and having a higher self-perceived risk of HIV. Having only planned sex over the last 3 months was associated with a preference for event-based PrEP, whereas having frequent or unplanned CAI was associated with a preference for daily or time-driven PrEP regimens, respectively.

CONCLUSION

Our findings suggest that preferences for different PrEP regimens are associated with the sexual frequency and planning behaviors of potential users.

Agent-based computational model of the prevalence of gonococcal infections after the implementation of HIV pre-exposure prophylaxis guidelines

Recently, the first comprehensive guidelines were published for pre-exposure prophylaxis (PrEP) for the prevention of HIV infection in populations with substantial risk of infection. Guidelines include a daily regimen of emtricitabine/tenofovir disoproxil fumarate (TDF/FTC) as well as condom usage during sexual activity. The relationship between the TDF/FTC intake regimen and condom usage is not yet fully understood. If men who have sex with men (MSM,) engage in high-risk sexual activities without using condoms when prescribed TDF/FTC they might be at an increased risk for other sexually transmitted diseases (STD). Our study focuses on the possible occurrence of behavioral changes among MSM in the United States over time with regard to condom usage. In particular, we were interested in creating a model of how increased uptake of TDF/FTC might cause a decline in condom usage, causing significant increases in non-HIV STD incidence, using gonococcal infection incidence as a biological endpoint. We used the agent-based modeling software NetLogo, building upon an existing model of HIV infection. We found no significant evidence for increased gonorrhea prevalence due to increased PrEP usage at any level of sample-wide usage, with a range of 0-90% PrEP usage. However, we did find significant evidence for decreased prevalence of HIV, with a maximal effect being reached when 5% to 10% of the MSM population used PrEP. Our findings appear to indicate that attitudes of aversion, within the medical community, toward the promotion of PrEP due to the potential risk of increased STD transmission are unfounded.

Intimacy motivations and pre-exposure prophylaxis (PrEP) adoption intentions among HIV-negative men who have sex with men (MSM) in romantic relationships

BACKGROUND

In the USA, men who have sex with men (MSM) in primary partnerships are at elevated risk for human immunodeficiency virus (HIV) infection. Pre-exposure prophylaxis (PrEP), a new biomedical prevention strategy, has potential to reduce HIV transmission. This study examined predictors of PrEP adoption intentions among HIV-negative MSM in primary partnerships.

METHODS

The sample included HIV-negative MSM (n = 164) who participated in an ongoing cross-sectional study with an in-person interview examining PrEP adoption intentions.

RESULTS

Higher HIV risk perception, intimacy motivations for condomless sex, recent condomless anal sex with outside partners, education, and age were each independently associated with PrEP adoption intentions. In a multivariate model, only age, education, and intimacy motivations for condomless sex were significantly associated with PrEP adoption intentions.

CONCLUSIONS

Intimacy motivations may play a central role in PrEP adoption for MSM couples. Incorporating relationship dynamics into biomedical strategies is a promising avenue for research and intervention.

Perceptions of and intentions to adopt HIV pre-exposure prophylaxis among black men who have sex with men in Los Angeles

This study assessed perceptions of pre-exposure prophylaxis (PrEP) and their association with PrEP adoption intention among a convenience sample of 224 low socioeconomic status black men who have sex with men (BMSM) residing in Los Angeles. Participants received educational information about PrEP and completed an in-person interview. More than half (60%) of the participants indicated a high intention to adopt PrEP. Younger BMSM (18-29 years) were twice as likely to report a high intention to adopt PrEP compared to older BMSM (30+ years). Only 33% of participants were aware of PrEP and no participant had ever used PrEP. Negative perceptions were associated with a lower PrEP adoption intention and included being uncomfortable taking an HIV medicine when HIV-negative and not knowing if there are long-term side effects of taking an HIV medication. These findings suggest that BMSM may adopt PrEP but that negative perceptions may limit its uptake among this population. In order to facilitate PrEP adoption among BMSM targeted educational and community awareness programmes are needed to provide accurate information on the benefits of PrEP and to address the negative perceptions of PrEP held by local BMSM populations.