Preexposure Prophylaxis to Prevent Acquisition of HIV: US Preventive Services Task Force Recommendation Statement

Unawareness of partner risk factors thwarts implementation of USPSTF recommendations for HIV pre-exposure prophylaxis in primary care

The United States Preventive Services Task Force recommends pre-exposure chemoprophylaxis for persons at high risk of HIV exposure. The optimal screening strategy for at-risk individuals in primary care is not known. We evaluated the strategy of universal screening and discussed challenges to the implementation of this recommendation in primary care. Around 430 of 500 (86%) screening surveys were completed. Mutual monogamy was common but monogamous partners with recent negative HIV testing were uncommon. Likewise, among heterosexually active men and women, inconsistent condom use was common. Such individuals would be on guideline for HIV pre-exposure prophylaxis (PrEP) if their partner was at risk for HIV exposure. None of these potentially at-risk individuals met the criteria for PrEP, but 13% lacked knowledge of their partners' sexual and behavioral risk factors, preventing a clear decision on whether PrEP should be used. Our screen identified no individuals who clearly met the guideline criteria for HIV PrEP. We conclude that universal screening for HIV PrEP in primary care is unlikely to be an efficient strategy; targeted screening is likely more appropriate. Moreover, the 2019 guidelines for heterosexually active men and women rely on information that is often unknown to the patient, which makes these guidelines difficult to implement. Future guidelines should address these problems.

Pediatrician Preferences for Electronic Clinical Decision Support to Facilitate HIV Pre-Exposure Prophylaxis

PURPOSE

Pediatric primary care clinicians are often uncertain about patients' HIV infection risk and pre-exposure prophylaxis (PrEP) prescribing guidelines. This study was conducted to help identify ways to design and deliver useful electronic health record (EHR)-based alerts for PrEP to help mitigate this issue.

METHODS

Individual interviews and focus groups with pediatricians explored provider preferences for clinical decision support around PrEP in the EHR. Key themes were identified via the immersion-crystallization qualitative analytic technique.

RESULTS

Clinicians described ideal decision support tools as succinct, helpful in identifying patients at risk of acquiring HIV, providing automated follow-up, and linking to evidence-based prescribing guidelines. Concerns emerged about alert fatigue.

DISCUSSION

This study summarizes clinicians' preferences for EHR tool development to support PrEP provision among pediatricians with limited comfort and experience with prescribing PrEP. These findings can inform the development of PrEP decision support by implementing provider-centered feedback.

HIV preexposure prophylaxis in adolescents and young adults: an update

PURPOSE OF REVIEW

This review provides an update of evidence for HIV preexposure prophylaxis (PrEP), including efficacy and safety of newly available medications. It discusses barriers to care that are unique to adolescents and young adults as well as interventions that may help increase uptake, adherence, and retention in care.

RECENT FINDINGS

Tenofovir alafenamide-emtricitabine and cabotegravir are both newly approved medications for the prevention of HIV and are well tolerated and effective for adolescents. These medications, along with tenofovir disoproxil-emtricitabine, offer a variety of PrEP options to choose from.

SUMMARY

Adolescents and young adults have many options when it comes to HIV prevention, but barriers persist in terms of uptake and adherence to PrEP and retention in care. Technology-based interventions, provider education, navigation support, and multiple access options are all tools to help increase PrEP use in young people.

Preventing Behavioral Human Immunodeficiency Virus Infections in Adolescents and Young Adults

HIV prevention in adolescents and young adults (AYA) requires a multi-pronged strategy encompassing behavioral, biologic, and structural approaches. This article reviews the epidemiology of HIV infection in the United States and its pathogenesis and transmission. Prevention approaches are discussed in more detail, with an emphasis on how each approach is relevant to AYA populations. Information is summarized in a resource table with links to references and in-depth discussions of the topics reviewed in this article.

Consensus recommendations for use of long-acting antiretroviral medications in the treatment and prevention of HIV-1: Endorsed by the American Academy of HIV Medicine, American College of Clinical Pharmacy, Canadian HIV and Viral Hepatitis Pharmacists Network, European AIDS Clinical Society, and Society of Infectious Diseases Pharmacists

Five long-acting (LA) antiretrovirals (ARVs) are currently available in a limited number of countries worldwide for HIV-1 prevention or treatment-cabotegravir, rilpivirine, lenacapavir, ibalizumab, and dapivirine. Implementing use of LA ARVs into routine clinical practice requires significant changes to the current framework of HIV-1 prevention, treatment, and service provision. Given the novelty, complexity, and interdisciplinary requirements needed to safely and optimally utilize LA ARVs, consensus recommendations on the use of LA ARVs will assist clinicians in optimizing use of these agents. The purpose of these recommendations is to provide guidance for the clinical use of LA ARVs for HIV-1 treatment and prevention. In addition, future areas of research are also identified and discussed.

Long-acting injectable ART to advance health equity: a descriptive analysis of US clinic perspectives on barriers, needed support and programme goals for implementation from applications to the ALAI UP Project

INTRODUCTION

Approval of the first long-acting injectable antiretroviral therapy (LAI ART) medication heralded a new era of HIV treatment. However, the years since approval have been marked by implementation challenges. The "Accelerating Implementation of Multilevel Strategies to Advance Long-Acting Injectable for Underserved Populations (ALAI UP Project)" aims to accelerate the systematic and equitable delivery of LAI ART.

METHODS

We coded and analysed implementation barriers according to the Consolidated Framework for Implementation Research (CFIR) domains, desired resources and programme goals from questionnaire short-answer responses by clinics across the United States responding to ALAI UP's solicitation to participate in the project between November 2022 and January 2023.

RESULTS

Thirty-eight clinics responded to ALAI UP's solicitation. The characteristics of LAI ART as an innovation (cost, complexity of procurement, dosing interval, limited eligibility) precipitated and interacted with barriers in other CFIR domains. Barriers included obtaining coverage for the cost of medication (27/38 clinics) (outer setting); need for new workflows and staffing (12/38) and/or systems to support injection scheduling/coordination (16/38), transportation and expanded clinic hours (13/38) (inner setting); and patient (10/38) and provider (7/38) education (individuals). To support implementation, applicants sought: technical assistance to develop protocols and workflows (18/38), specifically strategies to address payor challenges (8/38); additional staff for care coordination and benefits navigation (17/38); opportunities to share experiences with other implementing clinics (12/38); patient-facing materials to educate and increase demand (7/38); and support engaging communities (6/38). Clinics' LAI ART programme goals varied. Most prioritized delivering LAI ART to their most marginalized patients struggling to achieve viral suppression on oral therapy, despite awareness that current US Food and Drug Administration approval is only for virally suppressed patients. The goal for LAI ART reach after 1 year of implementation ranged from ≤10% of patients with HIV on LAI ART (17/38) to ≥50% of patients (2/38).

CONCLUSIONS

Diverse clinic types are interested in offering LAI ART and most aspire to use LAI ART to support their most vulnerable patients sustain viral suppression. Dedicated resources centred on equity and relevant to context and population are needed to support implementation. Otherwise, the introduction of LAI ART risks exacerbating, not ameliorating, health disparities.

PrEP facilitators and barriers in substance use bridge clinics for women who engage in sex work and who use drugs

BACKGROUND

Women who engage in sex work and use drugs (WSWUD) experience disproportionate HIV risks. Substance use treatment bridge clinics offer an opportunity to increase HIV pre-exposure prophylaxis (PrEP) delivery to WSWUD, but research on best practices is lacking. Therefore, we explored facilitators and barriers to PrEP across the PrEP care continuum in these settings.

METHODS

Bridge clinic and affiliated harm reduction health service providers and WSWUD from Boston were recruited using passive and active outreach between December 2021 and August 2022. Participants were invited to take part in semi-structured phone or in-person interviews to explore HIV prevention and PrEP care experiences overall and within bridge clinic settings. Deductive codes were developed based on HIV risk environment frameworks and the Information-Motivation-Behavioral Skills model and inductive codes were added based on transcript review. Grounded content analysis was used to generate themes organized around the PrEP care continuum.

RESULTS

The sample included 14 providers and 25 WSWUD. Most WSWUD were aware of PrEP and more than half had initiated PrEP at some point. However, most who initiated PrEP did not report success with daily oral adherence. Providers and WSWUD described facilitators and barriers to PrEP across the steps of the care continuum: Awareness, uptake, adherence, and retention. Facilitators for WSWUD included non-stigmatizing communication with providers, rapid wraparound substance use treatment and HIV services, having a PrEP routine, and service structures to support PrEP adherence. Barriers included low HIV risk perceptions and competing drug use and survival priorities. Provider facilitators included clinical note templates prompting HIV risk assessments and training. Barriers included discomfort discussing sex work risks, competing clinical priorities, and a lack of PrEP adherence infrastructure.

CONCLUSION

WSWUD and bridge clinic providers favored integrated HIV prevention and substance use services in harm reduction and bridge clinic settings. Harm reduction and bridge clinic programs played a key role in HIV prevention and PrEP education for WSWUD. Effective behavioral and structural interventions are still needed to improve PrEP adherence for WSWUD.

Using Electronic Health Records to Improve HIV Preexposure Prophylaxis Care: A Randomized Trial

BACKGROUND

Preexposure prophylaxis (PrEP) use remains limited and inequitable, and strategies are needed to improve PrEP provision in primary care.

METHODS

We conducted a cluster randomized trial at Kaiser Permanente, San Francisco, to evaluate the effectiveness of a clinical decision support intervention guided by an electronic health record (EHR)-based HIV risk prediction model to improve PrEP provision. Primary care providers (PCPs) were randomized to usual care or intervention, with PCPs who provide care to people with HIV balanced between arms. PCPs in the intervention arm received an EHR-based staff message with prompts to discuss HIV prevention and PrEP before upcoming in-person or video visits with patients whose predicted 3-year HIV risk was above a prespecified threshold. The main study outcome was initiation of PrEP care within 90 days, defined as PrEP discussions, referrals, or prescription fills.

RESULTS

One hundred twenty-one PCPs had 5051 appointments with eligible patients (2580 usual care; 2471 intervention). There was a nonsignificant increase in initiation of PrEP care in the intervention arm (6.0% vs 4.5%, HR 1.32, 95% CI: 0.84 to 2.1). There was a significant interaction by HIV provider status, with an intervention HR of 2.59 (95% CI: 1.30 to 5.16) for HIV providers and 0.89 (95% CI: 0.59 to 1.35) for non-HIV providers (P-interaction <0.001).

CONCLUSION

An EHR-based intervention guided by an HIV risk prediction model substantially increased initiation of PrEP care among patients of PCPs who also care for people with HIV. Higher-intensity interventions may be needed to improve PrEP provision among PCPs less familiar with PrEP and HIV care.

How Would You Manage HIV Pre-exposure Prophylaxis in This Patient With Medical Comorbidities? : Grand Rounds Discussion From Beth Israel Deaconess Medical Center

Despite advances in treatment, HIV infection remains an important cause of morbidity and mortality, with more than 30 000 new cases diagnosed in the United States each year. There are several interventions traditionally used to prevent HIV transmission, but these vary in effectiveness and there are challenges to their implementation. In 2014, the Centers for Disease Control and Prevention published initial guidance on the use of antiretroviral pre-exposure prophylaxis (PrEP) to prevent transmission of HIV infection in persons at risk based on multiple studies that showed it to be highly efficacious in various populations. It was updated in 2021 to reflect new drug options. The U.S. Preventive Services Task Force also recently updated its recommendations for PrEP, which strongly support its use in persons at risk. Despite its well-established effectiveness, the implementation of PrEP in clinical practice has been variable, especially among populations underserved by the medical system and marginalized by society. Fewer than one third of persons in the United States who are eligible for PrEP currently receive it. Here, 2 physicians experienced in HIV PrEP debate how best to identify patients who might benefit from PrEP, how to decide what regimen to use, and how to monitor therapy.

PrEP Discontinuation In A US National Cohort Of Sexual And Gender Minority Populations, 2017-22

In the US, sexual and gender minority populations are disproportionately affected by HIV. Pre-exposure prophylaxis (PrEP) is a key prevention method, but its effectiveness relies on consistent usage. Our four-year national cohort study explored PrEP discontinuation among sexual and gender minority people who initiated PrEP. We found a high annual rate of discontinuation (35-40 percent) after PrEP initiation. Multivariable analysis with 6,410 person-years identified housing instability and prior history of PrEP discontinuation as predictors of discontinuation. Conversely, older age, clinical indication for PrEP, and having health insurance were associated with ongoing PrEP use. To promote sustained PrEP use, strategies should focus on supporting those at high risk for discontinuation, such as younger people, those without stable housing or health insurance, and prior PrEP discontinuers.

Neurosyphilis: insights into its pathogenesis, susceptibility, diagnosis, treatment, and prevention

Background and aim

Invasion of the central nervous system by Treponema pallidum can occur at any stage of syphilis. In the event that T. pallidum is not cleared promptly, certain individuals may experience progression to neurosyphilis, which manifests as cognitive and behavioral abnormalities, limb paralysis, and potentially fatal outcomes. Early identification or prevention of neurosyphilis is therefore crucial. The aim of this paper is to conduct a critical and narrative review of the latest information focusing exclusively to the pathogenesis and clinical management of neurosyphilis.

Methodology

To compile this review, we have conducted electronic literature searches from the PubMed database relating to neurosyphilis. Priority was given to studies published from the past 10 years (from 2013 to 2023) and other studies if they were of significant importance (from 1985 to 2012), including whole genome sequencing results, cell structure of T. pallidum, history of genotyping, and other related topics. These studies are classic or reflect a developmental process.

Results

Neurosyphilis has garnered global attention, yet susceptibility to and the pathogenesis of this condition remain under investigation. Cerebrospinal fluid examination plays an important role in the diagnosis of neurosyphilis, but lacks the gold standard. Intravenous aqueous crystalline penicillin G continues to be the recommended therapeutic approach for neurosyphilis. Considering its sustained prominence, it is imperative to develop novel public health tactics in order to manage the resurgence of neurosyphilis.

Conclusion

This review gives an updated narrative description of neurosyphilis with special emphasis on its pathogenesis, susceptibility, diagnosis, treatment, and prevention.

Barriers and facilitators to pre-exposure prophylaxis uptake among Black/African American men who have sex with other men in Iowa: COM-B model analysis

Background

In Iowa, men who have sex with men (MSM) accounted for 54% of persons with HIV in 2022 and Non-Hispanic Black/African Americans were over 10 times more likely to be diagnosed with HIV than Non-Hispanic white Iowans. To address this disparity in HIV incidence and prevalence, the United States (US) government ending the HIV epidemic (EHE) initiative seeks to expand pre-exposure prophylaxis (PrEP) coverage across the United States. Recent data showed that PrEP coverage is suboptimal in Iowa (a rural state), and Black Iowans were less likely to engage with PrEP services.

Objectives

Using capability, opportunity, motivation and behavior (COM-B) model for behavior change, this study sought to identify the key barriers and facilitators to PrEP uptake among Black/African American MSM in small urban areas in Iowa.

Design

This was a phenomenological study aimed to explore subjective views of Black MSM on PrEP use.

Methods

In-depth semistructured interviews were conducted with 12 Black MSM aged 20-42 years in two small urban counties. Broad themes identified from the interview transcripts were analyzed inductively and mapped onto the COM-B constructs deductively.

Results

Results showed that barriers to PrEP uptake were closely associated with five (of six) COM-B subcomponents: physical capability, psychological capability, social opportunity, reflective motivation, and automatic motivation. The thematized barriers were (1) lack of medical insurance; (2) limited PrEP awareness; (3) PrEP stigma; (4) fear of distrust among partners; (5) anticipated side effects; and (6) doubt about PrEP effectiveness. Similarly, facilitators to PrEP uptake were aligned with four subcomponents of COM-B model: physical capability, psychological capability, social opportunity, and physical opportunity. The thematized facilitators were (1) increased PrEP awareness; (2) PrEP access without discrimination; (3) state provision of PrEP to uninsured; and (4) physicians buy-in and recommendation. No motivation-related facilitators were reported.

Conclusion

To reduce the current disparity in HIV incidence and to achieve the EHE goals of expanding PrEP coverage in Iowa, efforts should be directed toward the provision of low-cost or free PrEP services, healthcare providers' training on cultural competence, and the development of culturally appropriate strategies to deliver PrEP to the Black MSM community.

Knowledge, sex, and region associated with primary care providers prescribing adolescents HIV pre-exposure prophylaxis

Although HIV pre-exposure prophylaxis (PrEP) effectively and safely prevents HIV among adolescents, uptake of PrEP is low. Adolescents must have primary care providers (PCPs) prescribe them PrEP, making PCPs critical actors in PrEP delivery. However, research has primarily investigated determinants of PCPs' intention to prescribe adolescents PrEP rather than the determinants of performing the behavior itself. We examined the demographic, clinical practice, and implementation determinants of PCPs previously prescribing PrEP to adolescents. PCPs were recruited from a national Qualtrics panel of licensed medical providers in the United States from July 15-August 19, 2022. The Theoretical Domains Framework informed the implementation determinants measured. A multivariable logistic regression was used. PCPs who were more knowledgeable of the CDC guidelines (aOR 2.97, 95% CI 2.16-4.10), who were assigned male at birth (aOR 1.64, 95% CI 1.03-2.59), and who practiced in the Western region (aOR 1.85, 95% CI 1.04-3.30) had greater odds of prior prescribing adolescents PrEP. Provider-based educational interventions should be designed, implemented, and tested to encourage PCPs to prescribe PrEP to eligible adolescents.