High interest in preexposure prophylaxis among men who have sex with men at risk for HIV infection: baseline data from the US PrEP demonstration project

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.

Partner Disclosure of PrEP Use and Undetectable Viral Load on Geosocial Networking Apps: Frequency of Disclosure and Decisions About Condomless Sex

BACKGROUND

Recent advances in biomedical prevention strategies, including pre-exposure prophylaxis (PrEP) and achieving an undetectable viral load (UVL) among HIV-infected persons, show promise in curbing the rising incidence of HIV among men who have sex with men (MSM) in the United States. This mixed-methods study aimed to investigate the frequency with which MSM encounter potential sex partners on geosocial networking apps who disclose biomedical prevention use, and how MSM make decisions about condom use after these disclosures.

METHOD

Participants were recruited through advertisements placed on a large geosocial networking app for MSM. A total of 668 and 727 participants, respectively, responded to questionnaires assessing partner disclosure of PrEP use and UVL. Each questionnaire included an open-ended item assessing reasons for condomless anal sex (CAS) with partners using biomedical prevention.

RESULTS

Across both surveys, most respondents encountered potential sex partners who disclosed PrEP use or UVL, and the majority of those who met up with these partners engaged in CAS at least once. Qualitative analyses found that most participants who reported CAS did so after making a calculated risk about HIV transmission. We also describe a novel risk reduction strategy, "biomed-matching," or having CAS only when both individuals use PrEP or have UVL. We report serostatus differences in both quantitative and qualitative findings.

CONCLUSIONS

Disclosure of PrEP use and UVL is not uncommon among MSM. Many MSM make accurate appraisals of the risks of CAS with biomedical prevention, and mobile apps may aid with disclosing biomedical prevention use.

Dramatic increase in preexposure prophylaxis use among MSM in Washington state

OBJECTIVE

HIV preexposure prophylaxis (PrEP) is efficacious, but uptake has been slow. In Washington State, most insurance plans, including Medicaid, pay for PrEP, and the state supports a PrEP drug assistance program. We assessed trends in PrEP awareness and use among MSM in Washington.

DESIGN AND SETTING

Serial cross-sectional survey conducted annually at the Seattle Pride Parade between 2009 and 2015.

METHODS

In a convenience sample of MSM who reside in Washington State and deny ever testing HIV positive (n = 2168), we evaluated the association between calendar year and self-report of PrEP uptake and awareness using descriptive statistics and multivariable relative risk and logistic regression. Regression models included HIV risk and demographic covariates.

RESULTS

In 2015, 23% [95% confidence interval (CI): 16%, 31%] of high-risk MSM reported currently taking PrEP. The percentage of high-risk MSM who reported ever taking PrEP increased from 5% in 2012 to 31% in 2015. PrEP use among lower-risk MSM was low and stable, between 1 and 3% in 2012-2015. In multivariable analyses, PrEP use was associated with later calendar years (2015 vs. 2012: adjusted relative risk = 2.29, 95% CI: 1.16, 4.52) and elevated HIV risk (adjusted relative risk = 2.92, 95% CI: 2.00, 4.25). The percentage of high and lower-risk MSM who had heard of PrEP increased from 13 to 86% and from 29 to 58%, respectively.

CONCLUSION

PrEP awareness is high and the use has rapidly increased over the last year among MSM in Seattle, Washington, USA. These findings demonstrate that high levels of PrEP use can be achieved among MSM at high-risk for HIV infection.

Towards preparedness for PrEP: PrEP awareness and acceptability among MSM at high risk of HIV transmission who use sociosexual media in four Celtic nations: Scotland, Wales, Northern Ireland and The Republic of Ireland: an online survey

OBJECTIVE

To assess the awareness and acceptability of pre-exposure prophylaxis (PrEP) among men who have sex with men (MSM) and use sociosexual media at high risk of HIV infection in four Celtic nations.

DESIGN

Cross-sectional study.

METHODS

Online self-complete survey of 386 HIV-negative/status unknown MSM who reported condomless anal intercourse (CAI) with ≥2 men in the last year, recruited from gay sociosexual media.

RESULTS

One-third (34.5%, 132/386) of the participants were aware of PrEP but over half (58.5%, 226/356) reported that they would be willing to use PrEP if it were available to them. Only men who regularly tested for HIV every 6 months (adjusted OR 2.89, 95% CI 1.54 to 5.42) were more likely to be aware of PrEP. PrEP acceptability was only associated with reporting ≥5 CAI partners (OR 2.04, 95% CI 1.2 to 3.46) in the last year.

CONCLUSIONS

Low levels of PrEP awareness were reported across these Celtic nations. Only one-third of high-risk MSM had heard of PrEP but over one-half would be willing to take a daily pill to prevent HIV infection. Sociodemographic factors, commercial gay scene proximity and social network use were unrelated to considering PrEP use. However, those reporting most CAI partners were more likely to consider PrEP use.

What people want from sex and preexposure prophylaxis

PURPOSE OF REVIEW

As demand for preexposure prophylaxis (PrEP) increases, we are learning more about what people want from sex and PrEP.

RECENT FINDINGS

PrEP demand has reached a tipping point in the USA and is increasing rapidly. Although the primary benefit of PrEP use is biological, to reduce risk of HIV infection, PrEP users often express an alternative set of social and emotional benefits that are provided by PrEP. These collateral benefits of PrEP have salience, affect, and are experienced in the present, which are compelling drivers of human behavior. PrEP use has been associated with feeling safe during sex, usually in contrast to ruminations related to fear of HIV or intimate partner violence or control. PrEP can create empowerment, or agency, defined as the capacity and autonomy to act on one's own behalf, because it provides control over one's vulnerability to HIV and relief to women and men who may otherwise worry about whether their partners will use a condom, take antiretroviral therapy, or disclose their HIV status accurately. Planning for sexual and social goals in calm moments is also empowering. These highly desired collateral benefits of PrEP could be undermined, or eliminated, if PrEP is implemented in ways that are coercive or that foment fear of sexual risk compensation, drug resistance, toxicity, or moral judgment.

SUMMARY

Current PrEP implementation provides direct and indirect benefits that are highly desired.

Preexposure Prophylaxis for HIV Infection Integrated With Municipal- and Community-Based Sexual Health Services

IMPORTANCE

Several randomized clinical trials have demonstrated the efficacy of preexposure prophylaxis (PrEP) in preventing human immunodeficiency virus (HIV) acquisition. Little is known about adherence to the regimen, sexual practices, and overall effectiveness when PrEP is implemented in clinics that treat sexually transmitted infections (STIs) and community-based clinics serving men who have sex with men (MSM).

OBJECTIVE

To assess PrEP adherence, sexual behaviors, and the incidence of STIs and HIV infection in a cohort of MSM and transgender women initiating PrEP in the United States.

DESIGN, SETTING, AND PARTICIPANTS

Demonstration project conducted from October 1, 2012, through February 10, 2015 (last date of follow-up), among 557 MSM and transgender women in 2 STI clinics in San Francisco, California, and Miami, Florida, and a community health center in Washington, DC. Data were analyzed from December 18, 2014, through August 8, 2015.

INTERVENTIONS

A combination of daily, oral tenofovir disoproxil fumarate and emtricitabine was provided free of charge for 48 weeks. All participants received HIV testing, brief client-centered counseling, and clinical monitoring.

MAIN OUTCOMES AND MEASURES

Concentrations of tenofovir diphosphate in dried blood spot samples, self-reported numbers of anal sex partners and episodes of condomless receptive anal sex, and incidence of STI and HIV acquisition.

RESULTS

Overall, 557 participants initiated PrEP, and 437 of these (78.5%) were retained through 48 weeks. Based on the findings from the 294 participants who underwent measurement of tenofovir diphosphate levels, 80.0% to 85.6% had protective levels (consistent with ≥4 doses/wk) at follow-up visits. African American participants (56.8% of visits; P = .003) and those from the Miami site (65.1% of visits; P < .001) were less likely to have protective levels, whereas those with stable housing (86.8%; P = .02) and those reporting at least 2 condomless anal sex partners in the past 3 months (88.6%; P = .01) were more likely to have protective levels. The mean number of anal sex partners declined during follow-up from 10.9 to 9.3, whereas the proportion engaging in condomless receptive anal sex remained stable at 65.5% to 65.6%. Overall STI incidence was high (90 per 100 person-years) but did not increase over time. Two individuals became HIV infected during follow-up (HIV incidence, 0.43 [95% CI, 0.05-1.54] infections per 100 person-years); both had tenofovir diphosphate levels consistent with fewer than 2 doses/wk at seroconversion.

CONCLUSIONS AND RELEVANCE

The incidence of HIV acquisition was extremely low despite a high incidence of STIs in a large US PrEP demonstration project. Adherence was higher among those participants who reported more risk behaviors. Interventions that address racial and geographic disparities and housing instability may increase the impact of PrEP.

Acceptability of HIV Pre-Exposure Prophylaxis (PrEP) and Implementation Challenges Among Men Who Have Sex with Men in India: A Qualitative Investigation

This qualitative study explored the acceptability of HIV pre-exposure prophylaxis (PrEP) among MSM in India, and identified facilitators and barriers to future PrEP uptake. In 2014, we conducted 10 focus groups (n=61) among a purposive sample of diverse MSM recruited through community-based organizations in Chennai and Mumbai, and 10 key informant interviews with community leaders and health care providers. Participants' mean age was 26.1 years (SD 4.8); 62% completed secondary education, and 42% engaged in sex work. No focus group participants had heard of PrEP, but once explained, most reported they would likely use it. PrEP was alternately perceived as a 'back-up plan', a condom substitute, or a burden with concurrent condom use. Facilitators were potential for covert use, sex without condoms, and anxiety-less sex. Potential barriers emerged around stigma associated with PrEP use, fear of disclosures to one's family, wife, or male steady partner, and being labeled as HIV-positive or promiscuous by peers. Preferences emerged for intermittent rather than daily PrEP use, injectable PrEP, and free or subsidized access through community organizations or government hospitals. Key informants expressed additional concerns about risk compensation, non-adherence, and impact on ART availability for treatment. Demonstration projects are needed in India to support PrEP implementation tailored for at-risk MSM. Educational interventions for MSM should address concerns about PrEP effectiveness, side effects, and mitigate risk compensation. Community engagement may facilitate broad acceptability and challenge stigma around PrEP use. Importantly, provision of free or subsidized PrEP is necessary to making implementation feasible among low socioeconomic status MSM in India.

No New HIV Infections With Increasing Use of HIV Preexposure Prophylaxis in a Clinical Practice Setting

Referrals for and initiation of preexposure prophylaxis (PrEP) for human immunodeficiency virus (HIV) infection increased dramatically in a large clinical practice setting since 2012. Despite high rates of sexually transmitted infections among PrEP users and reported decreases in condom use in a subset, there were no new HIV infections in this population.

Clinical Treatment Options Infectious Diseases: Update on PrEP Implementation, Adherence, and Advances in Delivery

Pre-exposure prophylaxis (PrEP) is an effective and evidence-based HIV-prevention option and is recommended for individuals with substantial risk for HIV infection [1]. Randomized controlled trials have demonstrated that daily oral PrEP dramatically reduces the risk of HIV infection when it is taken as directed. Concerns regarding widespread emergence of antiretroviral resistance attributable to PrEP and behavioral disinhibition have to date not been observed in clinical trials and open-label demonstration projects. PrEP has great potential as part of an HIV risk reduction strategy and barriers to wider implementation including community education, prescriber availability, and elimination of financial barriers should be aggressively pursued. Adherence is critical to PrEP efficacy and has varied across study populations; developing and refining ways of measuring and supporting adherence is essential to the success of PrEP. Evaluation of long-acting medications and alternative formulations for PrEP is underway and may lead to the wider implementation and impact of PrEP.

CROI 2015: Advances in HIV Testing and Prevention Strategies

HIV testing rates and awareness of HIV serostatus have improved globally, but disparities continue between black and white men who have sex with men (MSM) in the United States, and between women and men globally. The 2015 Conference on Retroviruses and Opportunistic Infections (CROI) was a watershed moment for preexposure prophylaxis (PrEP). Two efficacy trials conducted in MSM were stopped early because of an 86% reduction in the risk of HIV acquisition among men taking tenofovir and emtricitabine. New drugs, long-acting formulations, and different patterns of dosing are undergoing evaluation. Poor adherence has limited PrEP effectiveness in some populations, and new measures of drug levels in dried blood spots and hair appear to be promising new tools. Pharmacokinetic differences of PrEP agents in rectal versus vaginal tissue preclude extrapolating PrEP trial results among MSM to women. Several studies reported no HIV transmissions between HIV-serodiscordant couples when the seropositive partner was successfully treated for 6 months. However, consistent viral suppression does not occur in a substantial minority of patients in many clinics, reducing the potential impact of treatment as prevention.