Increases in Pre-exposure Prophylaxis Use and Decreases in Condom Use: Behavioral Patterns Among HIV-Negative San Francisco Men Who have Sex with Men, 2004-2017

Variations in HIV Prevention Coverage in Subpopulations of Australian Gay and Bisexual Men, 2017-2021: Implications for Reducing Inequities in the Combination Prevention Era

Using repeated behavioural surveillance data collected from gay and bisexual men (GBM) across Australia, we assessed trends in HIV prevention coverage (the level of 'safe sex' achieved in the population by the use of effective prevention methods, including condoms, pre-exposure prophylaxis [PrEP] and having an undetectable viral load). We stratified these trends by age, country of birth/recency of arrival, sexual identity, and the proportion of gay residents in the participant's suburb. Among 25,865 participants with casual male partners, HIV prevention coverage increased from 69.8% in 2017 to 75.2% in 2021, lower than the UNAIDS target of 95%. Higher levels of coverage were achieved among older GBM (≥ 45 years), non-recently-arrived migrants, and in suburbs with ≥ 10% gay residents. The lowest levels of prevention coverage (and highest levels of HIV risk) were recorded among younger GBM (< 25 years) and bisexual and other-identified participants. Younger, recently-arrived, and bisexual GBM were the most likely to use condoms, while PrEP use was concentrated among gay men, 25-44-year-olds, and in suburbs with more gay residents. The use of undetectable viral load was most common among participants aged ≥ 45 years. Our analysis shows that high HIV prevention coverage can be achieved through a mixture of condom use, PrEP use, and undetectable viral load, or by emphasising PrEP use. In the Australian context, younger, bisexual and other-identified GBM should be prioritised for enhanced access to effective HIV prevention methods. We encourage other jurisdictions to assess the level of coverage achieved by combination prevention, and variations in uptake.

Two New Strains of Drug-resistant Neisseria gonorrhoeae in a Bisexual Man having Sex with Men in Wroclaw, Poland

Abstract is missing (Short communication)

Adherence to Oral Pre-Exposure Prophylaxis Intervention by Transgender Women: A Systematic Review

Prevalence of human immunodeficiency virus (HIV) is higher in transgender populations. Pre-exposure prophylaxis (PrEP) intervention is successful in reducing HIV acquisition. We aimed to investigate the adherence to oral PrEP by HIV-negative transgender women (TW). We followed the Cochrane Handbook for Systematic Reviews of Interventions and the PRISMA Statement. We searched in WoS, OVID, Scopus, MEDLINE, and the Cochrane Central Register of Controlled Trials databases. Participation and adherence to the intervention were low for TW compared to cisgender men who have sex with men (cMSM), and it was measured mostly by self-report (72.7%) or tenofovir-diphosphate/emtricitabine triphosphate dried blood spot (45.5%). Awareness should increase and the effect of oral PrEP on gender-affirming hormone therapy should be explained to TW at the beginning of the trials. One limitation is that our sample size was dominated by two Thai studies with TW sex workers. Future studies should evaluate adherence to new PrEP modalities.

Impact of HCV Testing and Treatment on HCV Transmission Among Men Who Have Sex With Men and Who Inject Drugs in San Francisco: A Modelling Analysis

BACKGROUND

Men who have sex with men who ever injected drugs (ever MSM-IDU) carry a high hepatitis C virus (HCV) burden. We estimated whether current HCV testing and treatment in San Francisco can achieve the 2030 World Health Organization (WHO) HCV elimination target on HCV incidence among ever MSM-IDU.

METHODS

A dynamic HCV/HIV transmission model among MSM was calibrated to San Francisco data, including HCV antibody (15.5%, 2011) and HIV prevalence (32.8%, 2017) among ever MSM-IDU. MSM had high HCV testing (79%-86% ever tested, 2011-2019) and diagnosed MSM had high HCV treatment (65% ever treated, 2018). Following coronavirus disease 2019 (COVID-19)-related lockdowns, HCV testing and treatment decreased by 59%.

RESULTS

Among all MSM, 43% of incident HCV infections in 2022 were IDU-related. Among ever MSM-IDU in 2015, HCV incidence was 1.2/100 person-years (95% credibility interval [CrI], 0.8-1.6). Assuming COVID-19-related declines in HCV testing/treatment persist until 2030, HCV incidence among ever MSM-IDU will decrease by 84.9% (95% CrI, 72.3%-90.8%) over 2015-2030. This decline is largely attributed to HCV testing and treatment (75.8%; 95% CrI, 66.7%-89.5%). Slightly greater decreases in HCV incidence (94%-95%) are projected if COVID-19 disruptions recover by 2025 or 2022.

CONCLUSIONS

We estimate that HCV incidence will decline by >80% over 2015-2030 among ever MSM-IDU in San Francisco, achieving the WHO target.

Factors Associated With Willingness to Use Daily Antibiotics as Sexually Transmitted Infection Prophylaxis Among HIV Preexposure Prophylaxis-Experienced Gay and Bisexual Men in Australia

BACKGROUND

Gay and bisexual men (GBM) who use HIV preexposure prophylaxis (HIV-PrEP) have high rates of bacterial sexually transmitted infections (STIs). The use of daily antibiotics as STI preexposure prophylaxis (STI-PrEP) may be appealing to GBM who are using or have previously used HIV-PrEP (HIV-PrEP-experienced) for the prevention of bacterial STIs.

METHODS

We examined willingness to use daily STI-PrEP among a cross-sectional sample of HIV-PrEP-experienced GBM in Australia who participated in an observational online cohort study from August 2018 to March 2020. Factors associated with willingness to use daily STI-PrEP were determined using bivariate and multivariate logistic regression.

RESULTS

Of the 1347 participants, half (54.3%) were willing to use daily STI-PrEP. Factors independently associated with greater willingness to use daily STI-PrEP included having >10 sexual partners in the last 6 months, using methamphetamine in the last 6 months, being more conscious about avoiding STIs, having a greater number of STIs since commencing HIV-PrEP, being willing to take HIV-PrEP for as long as they were at risk of acquiring HIV, and only using condoms when a sexual partner requested them. Conversely, factors associated with less willingness to use daily STI-PrEP included being university educated, using nondaily dosing regimens of HIV-PrEP, preferring event-driven HIV-PrEP, and being concerned about long-term HIV-PrEP adverse effects.

CONCLUSIONS

Sexually transmitted infection PrEP is likely to be appealing to many HIV-PrEP-experienced GBM, especially those who engage in activities associated with a higher risk of STI transmission. However, they are less likely to be willing to use STI-PrEP unless it aligns with their HIV-PrEP dosing regimen, suggesting that research into the safety and efficacy of alternative STI prophylaxis dosing options should be prioritized.

Perceptions of hepatitis C treatment and reinfection risk among HIV-positive men who have sex with men and engage in high risk behaviours for hepatitis C transmission: The CEASE qualitative study

BACKGROUND

Globally, treatment uptake for hepatitis C virus (HCV) infection among HIV-HCV coinfected men who have sex with men (MSM) has substantially increased since the advent of interferon-free direct-acting antivirals (DAA). However, HIV-positive MSM who engage in high risk behaviours are at an increased risk of HCV reinfection post-treatment. The aim of this study was to investigate perceptions of HCV diagnosis, treatment and reinfection risk among HCV-HIV coinfected MSM who engage in drug use and/or high risk sexual behavior in Sydney, Australia.

METHODS

Participants were recruited from the Control and Elimination within AuStralia of HEpatitis C from people living with HIV (CEASE) cohort (n=402) who reported engaging in drug use and/or high risk sexual behavior for transmission of HCV infection. Participants were interviewed about their perceptions of HCV diagnosis, treatment, and reinfection risk. Interview data were transcribed, coded, and analyzed thematically.

RESULTS

Of 33 participants interviewed (mean age 49 years), many participants were 'shocked' by their HCV diagnosis. Participants who believed they acquired HCV infection through sexual exposure felt it was important that their healthcare practitioner agreed with their perspective to mitigate stigmatizing experiences. Overall, participants expressed high satisfaction with their treatment experience due to long-standing therapeutic relationships with their HIV physician. Many participants expressed knowledge of how to prevent HCV reinfection from injection drug use, yet other than condom usage, most were unsure how to reduce high risk sexual activity with such discussions occurring less frequently with healthcare practitioners.

CONCLUSION

Findings indicate that MSM who engage in drug use and high risk sexual activity would benefit from additional education on reducing reinfection risk through sexual activity and services to reduce substance use, if requested.

Sexually transmitted infection prevention behaviours: health impact, prevalence, correlates, and interventions

Sexually transmitted infections (STIs) remain a major public health threat, disproportionately affecting young people, and men who have sex with men. In this narrative review of the current state of behavioural science research on STI prevention, we consider the definition, health impacts, correlates and determinants, and interventions to promote STI prevention behaviour. Research on STI prevention behaviour has extended from a focus on abstinence, partner reduction and condom use, to also include novel preventive behaviours, notably treatment-as-prevention, pre-exposure prophylaxis (i.e., the preventive use of medicines by uninfected people), and vaccination for some STIs. Social-cognitive factors specified by, for instance the theory of planned behaviour, are critical proximal determinants of STI prevention behaviours, and related interventions can effectively promote STI prevention behaviours. Social-ecological perspectives highlight that individual-level determinants are embedded in more distal environmental influences, with social stigma especially affecting STI prevention behaviours and requiring effective intervention. Further to providing a major domain of application, STI prevention also poses critical challenges and opportunities for health psychology theory and research. We identify a need for health behaviour theory that addresses the processes linking multiple levels of influence on behaviour and provides practical guidance for multi-level behaviour change interventions adapted to specific contexts.

Pre-exposure prophylaxis and bacterial sexually transmitted infections (STIs) among gay and bisexual men

OBJECTIVES

While pre-exposure prophylaxis (PrEP) prevents HIV acquisition among gay, bisexual and other men who have sex with men (GBM), PrEP-using GBM may be more likely to engage in sexual behaviours associated with bacterial STIs. We examined associations between PrEP use, condomless anal sex (CAS), number of anal sex partners, oral sex and bacterial STI diagnoses among GBM living in Canada's three largest cities.

METHODS

Among HIV-negative/unknown-status GBM in the baseline of the Engage cohort study, we fit a structural equation model of the associations between any PrEP use, sexual behaviours and bacterial STI diagnosis. We estimated direct and indirect paths between PrEP use and STI via CAS, number of anal sex partners and oral sex.

RESULTS

The sample included 2007 HIV-negative/unknown status GBM in Montreal, Toronto and Vancouver. There was a significant direct association between PrEP use and current STI diagnosis (β=0.181; 95% CI: 0.112 to 0.247; p<0.001), CAS (β=0.275; 95% CI: 0.189 to 0.361; p<0.001) and number of anal sex partners (β=0.193; 95% CI: 0.161 to 0.225; p<0.001). In the mediated model, the direct association between PrEP use and STIs was non-significant. However, the indirect paths from PrEP to CAS to STIs (β=0.064; 95% CI: 0.025 to 0.120; p=0.008), and from PrEP to greater number of anal sex partners to CAS to STIs were significant (β=0.059; 95% CI: 0.024 to 0.108; p=0.007).

CONCLUSIONS

Our study adds to the growing awareness that PrEP use among GBM may be associated with bacterial STIs because PrEP users have more anal sex partners and are more likely to engage in CAS. The results underscore the importance of providing effective STI counselling and regular testing to PrEP users, adapting PrEP care and related STI testing to individual needs, and the need for effective prevention strategies for bacterial STIs.

Three-site screening for STIs in men who have sex with men using online self-testing in an English sexual health service

OBJECTIVES

Among men who have sex with men (MSM) in the UK,Chlamydia trachomatis (CT) and Neisseria gonorrhoea (NG) infections commonly occur asymptomatically at extragenital sites. Therefore, MSM seeking sexual health services are offered three-site (oropharyngeal, rectal and urogenital) STI screening. To increase access to screening, some UK sexual health services enable asymptomatic service users to order free STI screening kits online for self-sampling at home. We sought to assess prevalence of overall and extragenital CT/NG infection among asymptomatic MSM who used online self-testing in Hampshire, UK.

METHODS

We assessed prevalence of CT/NG infections from non-pooled samples among asymptomatic cisgender MSM using an administrative database with results from 5601 STI screening kits returned between 20 December 2016 and 31 January 2020. We compared number of diagnoses of extragenital infection with urogenital results of the same individuals to determine prevalence of infection that would have been missed with urine testing alone.

RESULTS

Among 5051 valid CT and 5040 valid NG asymptomatic test results, overall prevalence was 5.9% (298/5051) and 4.5% (228/5040), respectively. Among MSM with asymptomatic CT, 71.8% (214/298) had extragenital infection only, χ² (1, n=298)=56.71, p<0.001. Among those with asymptomatic NG, 89.9% (205/228) had extragenital infection only, χ² (1, n=228)=145.281, p<0.001.

CONCLUSIONS

Overall, most CT/NG infections among asymptomatic MSM who used online self-testing were extragenital. Given this and the likelihood of onward transmission from asymptomatic infection, it is recommended that three-site testing remain standard for MSM and free screening services be expanded in easily accessible ways.

Information Seeking and MSM's Beliefs about PrEP and Condoms

This study examined how frequently men who have sex with men (MSM) used a selection of sources, including news media, social media, health organizations, and dating/hookup apps, for HIV information. Additionally, the study explored the extent to which MSM's efficacy beliefs about pre-exposure prophylaxis (PrEP) and perceptions of condom importance could be predicted by the sources they used. A sample of MSM (N= 969) were surveyed online. Results showed that respondents obtained information about HIV most often from HIV organizations, LGBT organizations, and dating/hookup apps, particularly the apps Growlr, Scruff, and Grindr. Use of the app Scruff was the strongest source-based predictor of beliefs about both PrEP and condoms. Implications for health promotion are discussed.

A Behavioral Cascade of HIV Seroadaptation Among US Men Who Have Sex with Men in the Era of PrEP and U = U

Seroadaptive behaviors help reduce HIV risk for some men who have sex with men (MSM), and have been well documented across MSM populations. Advancements in biomedical prevention have changed the contexts in which seroadaptive behaviors occur. We thus sought to estimate and compare the prevalence of four stages of the "seroadaptive cascade" by PrEP use in the recent era: knowledge of own serostatus, knowledge of partner serostatus; serosorting (matching by status), and condomless anal intercourse. Serosorting overall appeared to remain common, especially with casual and one-time partners. Although PrEP use did not impact status discussion, it did impact serosorting and the likelihood of having condomless anal intercourse. For respondents not diagnosed with HIV and not on PrEP, condomless anal intercourse occurred in just over half of relationships with HIV-positive partners who were not on treatment. Biomedical prevention has intertwined with rather than supplanted seroadaptive behaviors, while contexts involving neither persist.

Factors associated with transactional sex among a cohort of gay, bisexual, and other men who have sex with men in Vancouver, Canada

Background Gay, bisexual, and other men who have sex with men (GBM) who engage in transactional sex (sex in exchange for drugs, money, or goods) experience increased risk of sexually transmitted infections (STI), including HIV. This study explored additional psychosocial and health-related factors associated with transactional sex among GBM. Methods Respondent-driven sampling was used to recruit GBM in Vancouver, Canada, from 2012 to 2015, with follow up every 6months until July2019. We examined factors associated with transactional sex using multivariable three-level mixed-effects modelling. Results Among 698 GBM, 22.1% reported ever receiving drugs, money, or goods for sex. Transactional sex was more likely to be reported by GBM who were younger (<30years) and who had lower incomes, less education, and insecure housing. GBM reporting transactional sex were more likely to report substance use (i.e. crystal methamphetamine, poppers, GHB, and non-steroid injection drugs) and higher risk sexual behaviours (i.e. more sex partners, sex party attendance, and condomless anal sex with serodifferent or unknown HIV status partners); however, they were no more likely to be living with HIV or to report a recent bacterial STI diagnosis. GBM who reported higher loneliness, anxiety, and cognitive escape were also more likely to report transactional sex. Conclusions More than one-fifth of GBM in Vancouver reported transactional sex and those who did were more likely to also experience psychosocial stressors, increased substance use, and higher risk sexual behaviours. Programs which consider the interconnections of personal, social, and structural challenges faced by GBM engaging in transactional sex are necessary to support improved mental, physical, and sexual health for these men.

Evidence of changing sexual behaviours and clinical attendance patterns, alongside increasing diagnoses of STIs in MSM and TPSM

Background

Due to rising numbers of STI diagnosis and increasing prevalence of antimicrobial resistance, we explored trends in STI testing frequency and diagnoses, alongside sexual decision making and attitudes concerning condom use and HIV pre-exposure prophylaxis (PrEP) at a large urban UK sexual health clinic.

Methods

We examined 66 528 electronic patient records covering 40 321 attendees between 2016 and 2019, 3977 of whom were men who have sex with men or trans persons who have sex with men (MSM/TPSM). We also explored responses from MSM/TPSM attendees sent an electronic questionnaire between November 2018 and 2019 (n=1975) examining behaviours/attitudes towards PrEP. We measured trends in STI diagnoses and sexual behaviours including condomless anal intercourse (CAI), using linear and logistic regression analyses.

Results

Tests resulting in gonorrhoea, chlamydia or syphilis diagnoses increased among MSM/TPSM from 13.5% to 18.5% between 2016 and 2019 (p<0.001). The average MSM/TPSM STI testing frequency increased from 1.5/person/year to 2.1/person/year (p=0.017). Gay MSM/TPSM had the highest proportions of attendances resulting in diagnoses, increasing from 15.1% to 19.6% between 2016 and 2019 (p<0.001) compared with bisexual/other MSM/TPSM increasing from 6.9% to 14.5% (p<0.001), alongside smaller but significant increases in non-MSM/TPSM from 5.9% to 7.7% (p<0.001).

The proportion of MSM/TPSM clinic attendees reporting CAI in the previous 3 months prior to at least one appointment in a given year increased significantly from 40.6% to 45.5% between 2016 and 2019 (p<0.0001) and average number of partners from 3.8 to 4.5 (p=0.002). Of 617 eligible questionnaire responses, 339/578 (58.7%) HIV-negative and 29/39 (74.4%) HIV-positive MSM/TPSM indicated they would be more likely to have CAI with someone on PrEP versus not on PrEP. 358/578 (61.9%) HIV-negative respondents said that PrEP use would make them more likely to have CAI with HIV-negative partners.

Conclusion

Rising numbers of STI diagnoses among MSM/TPSM are not attributable to increased testing alone. Increased CAI and number of partners may be attributable to evolving sexual decision making among PrEP users and their partners. Proportionally, bisexual/other MSM/TPSM have the steepest increase in STI diagnoses.

Changing Patterns of Sexual Behavior and HIV/STI Among Men Who Have Sex With Men in Seattle, 2002 to 2018

BACKGROUND

The extent to which uptake of biomedical HIV prevention strategies have affected population-level sexual behavior and sexually transmitted infections (STIs) among men who have sex with men (MSM) is not well understood.

METHODS

We collected data as part of routine care from MSM attending the municipal STI clinic in Seattle, Washington, 2002-2018. MSM were asked about condom use in the previous 12 months. We classified behaviors into 4 mutually exclusive categories: no anal sex; consistent condom use for anal sex; serosorting [condomless anal sex (CAS) only with HIV-concordant partners]; and CAS with serodiscordant/unknown-status partners. STI/HIV testing was performed per routine clinic protocol.

RESULTS

There were 45,656 and 6987 visits by MSM without HIV and MSM with HIV, respectively. The use of antiretroviral therapy and preexposure prophylaxis increased substantially during the study period to 94% and 50%, respectively, by 2018. CAS with serodiscordant/unknown-status partners decreased through 2013 but increased thereafter (to 40% among MSM without HIV; 68% among MSM with HIV). Serosorting increased among MSM without HIV but declined after 2013 among MSM with HIV. Consistent condom use declined for all MSM (from 35% to 11% among MSM without HIV; from 20% to 5% among MSM with HIV). HIV test positivity declined substantially (3.5%-0.5%), whereas STI test positivity increased over time.

CONCLUSIONS

Since 2013, CAS with HIV-discordant/unknown-status partners increased substantially concurrent with declining HIV test positivity and increasing STI test positivity. This highlights the success of biomedical HIV prevention strategies to reduce HIV incidence while affirming the need for new approaches to STI prevention.

Temporal Variation in One-Time Partnership Rates Among Young Men Who Have Sex With Men and Transgender Women

BACKGROUND

Volatility in sexual contact rates has been recognized as an important factor influencing HIV transmission dynamics. One-time partnerships may be particularly important given the potential to quickly accumulate large number of contacts. Yet, empirical data documenting individual variation in contact rates remain rare. This study provides much needed data on temporal variation in one-time partners to better understand behavioral dynamics and improve the accuracy of transmission models.

METHODS

Data for this study were obtained from a longitudinal cohort study of young men who have sex with men and transgender women in Chicago. Participants provided sexual network data every 6 months for 2 years. A series of random effects models examined variation in one-time partnership rates and disaggregated within and between associations of exposure variables. Exposure variables included prior number of one-time partners, number of casual partners, and having a main partner.

RESULTS

Results indicated substantial between-person and within-person variation in one-time partners. Casual partnerships were positively associated and main partnerships negatively associated with one-time partnership rates. There remained a small positive association between prior one-time partnerships and the current number of one-time partnerships.

CONCLUSIONS

Despite the preponderance of a low number of one-time partners, substantial variation in one-time partnership rates exists among young men who have sex with men and transgender women. Accordingly, focusing on high contact rate individuals alone may be insufficient to identify periods of highest risk. Future studies should use these estimates to more accurately model how volatility impacts HIV transmission and better understand how this variation influences intervention effectiveness.

PrEP Use and PrEP Use Disclosure are Associated with Condom Use During Sex: A Multilevel Analysis of Latino MSM Egocentric Sexual Networks

Pre-exposure prophylaxis (PrEP) is integral to HIV prevention; however, the influence of PrEP use and PrEP use disclosure on condom use is unclear among Latinx men who have sex with men (LMSM). This study explored associations of LMSM PrEP use and use disclosure on consistent dyadic condom use in the past 6 months. Participants were 130 HIV-negative PrEP and non-PrEP using LMSM ages 20-39 years. Two-level logistic regression models assessing individual- and dyadic-level predictors on condom use were fitted using R. Participants reported a mean of four sexual partners (n = 507 dyads). Participants who reported using PrEP or having more sexual partners were more likely to use condoms; however, participants who reported disclosing PrEP use were less likely to use condoms. Future longitudinal studies should characterize approaches to increase informed personal health choices and conversations about PrEP, condom use, and other HIV risk-reduction strategies using network methodologies.

The Potential Impact of a Gel-Based Point-of-Sex Intervention in Reducing Gonorrhea Incidence Among Gay and Bisexual Men: A Modeling Study

BACKGROUND

Increases in sexually transmitted infections among gay and bisexual men (GBM) over the past decade have coincided with declines in condom use and rapid uptake of HIV preexposure prophylaxis (PrEP). We explored the impact of an antimicrobial gel-based point-of-sex intervention (gel-PSI) with a lower efficacy for reducing gonorrhea transmission risk than condoms on population-level gonorrhea incidence among GBM in Victoria, Australia.

METHODS

A deterministic compartmental model of HIV and gonorrhea transmission was used to project annual gonorrhea incidence from 2020 to 2025. Individuals were classified as HIV-negative (PrEP or non-PrEP users) or HIV-positive, and further stratified by gonorrhoea risk (high/low). All possible scenarios where between 0% and 100% of GBM using condoms transitioned to gel-PSI (considered a downgrade in protection) and 0% and 100% of GBM not using condoms transitioned to gel-PSI (considered an upgrade in protection), with gel-PSI efficacy ranging from 20% to 50%, were run.

RESULTS

The baseline scenario of no gel-PSI uptake (status quo) projected 94,367 gonorrhea infections between 2020 and 2025, with an exponentially increasing trend in annual infections. For a gel-PSI efficacy of 30%, a net reduction in cumulative gonorrhea incidence was projected, relative to the status quo, for any ratio of proportion of condom users "downgrading" to proportion of noncondom users "upgrading" to gel-PSI use of less than 2.6. Under the supposition of equal proportions of condom users and noncondom users switching to gel-PSI, a relative reduction was projected for any gel-PSI efficacy greater than 16%.

CONCLUSIONS

Our model suggests that the introduction of a gel-PSI could have benefits for controlling gonorrhea transmission among GBM, even in scenarios where the gel-PSI is considerably less efficacious than condoms and when gel-PSI uptake leads to consequent reductions in consistent condom use.

To Pool or Not to Pool Samples for Sexually Transmitted Infections Detection in Men Who Have Sex With Men? An Evaluation of a New Pooling Method Using the GeneXpert Instrument in West Africa

BACKGROUND

Men who have sex with men (MSM) using preexposure prophylaxis (PrEP) are at risk for sexually transmitted infections (STIs). Therefore, PrEP services should include regular screening for Chlamydia trachomatis (CT) and Neisseria gonorrhoeae (NG) at urethra, anorectum, and pharynx. However, financial and logistic challenges arise in low-resource settings. We assessed a new STI sample pooling method using the GeneXpert instrument among MSM initiating PrEP in West Africa.

METHODS

Urine, anorectal, and pharyngeal samples were pooled per individual for analysis. In case of an invalid result only (strategy 1) or a positive result of the pool (strategy 2), samples were analyzed individually to identify the infection's biological location. The results of 2 different pooling strategies were compared against the individual results obtained by a criterion standard.

RESULTS

We found a prevalence of 14.5% for chlamydia and 11.5% for gonorrhea, with a predominance of infections being extragenital (77.6%). The majority of infections were asymptomatic (88.2%). The pooling strategy 1, had a sensitivity, specificity and agreement for CT of 95.4%, 98.7%, and 0.93, respectively; and 92.3%, 99.2%, and 0.93 for pooling strategy 2. For NG, these figures were 88.9%, 97.7%, and 0.85 for strategy 1, and 88.9%, 96.7%, and 0.81 for strategy 2.

CONCLUSIONS

West African MSM have a high prevalence of extragenital and asymptomatic STIs. The GeneXpert method provides an opportunity to move from syndromic toward etiological STI diagnosis in low-income countries, as the platform is available in African countries for tuberculosis testing. Pooling will reduce costs of triple site testing.

Increasing preexposure prophylaxis use and 'net prevention coverage' in behavioural surveillance of Australian gay and bisexual men

OBJECTIVES

To assess trends in HIV prevention strategies among Australian gay and bisexual men (GBM) since the introduction of preexposure prophylaxis (PrEP), the level of net prevention coverage (the use of safe strategies), and the characteristics of HIV-negative and untested GBM who remain at risk of HIV.

DESIGN

Repeated behavioural surveillance of GBM recruited from venues, events and online in seven Australian states and territories.

METHODS

Participants with casual male partners were included. Trends in sexual practices, prevention strategies, net prevention coverage and the characteristics of 'at risk' participants were assessed with binary and multivariate logistic regression.

RESULTS

A total of 32 048 survey responses (2014-2019) were included. The proportion of participants who reported consistent condom use declined (44.6-23.2%). The proportion who reported any condomless anal intercourse with casual partners increased (37.4-62.0%) but net prevention coverage also increased (68.1-74.9%), with higher levels of undetectable viral load among HIV-positive participants and rapidly increasing PrEP use by HIV-negative participants. PrEP became the most commonly reported prevention strategy in 2019 (31.1%). The analysis of 'at risk' participants showed that they became more likely to report frequent condomless anal intercourse with casual partners but had fewer partners and more partners with undetectable viral load or on PrEP. 'At risk' participants became more likely to identify as bisexual and to be born overseas.

CONCLUSION

There has been a rapid, historic shift in HIV prevention among GBM in Australia. Net prevention coverage has increased among GBM and 'at risk' GBM have become less at risk of HIV, facilitating reductions in HIV transmission.

Low use of condom and high STI incidence among men who have sex with men in PrEP programs

Objective

Since the recent introduction of preexposure prophylaxis (PrEP), several studies have reported a decrease in the use of condoms and a rise in STIs among users. This rise in risk behavior associated with the advent of PrEP is known as “risk compensation.” The aim of this study is to measure clinical and behavioral changes associated with the introduction of PrEP by analyzing condom use for anal intercourse, number of sexual partners, sexualized drug use and STI incidence.

Methods

We performed a retrospective descriptive study of PrEP users followed every 3months over a 2-year period spanning 2017–2019 in a referral clinic specializing in STI/HIV in Madrid, Spain. One hundred ten men who have sex with men and transgender women underwent regular screening for STIs and hepatitis C virus (HCV) infection. Sociodemographic, clinical, and behavioral data were gathered for all subjects studied.

Results

The risk compensation observed in this study consisted primarily of a lower rate of condom use, while the number of sexual partners and recreational drug consumption remained stable. We observed a very high incidence of STIs in this sample, particularly rectal gonorrhea and chlamydia. The factors shown to be independently associated with the presence of an STI on multivariate analysis were age below 30 years and over 10 sexual partners/month.

Conclusion

The incidence of STI acquisition was higher than expected, indicating a need for strategies to minimize this impact, particularly among younger individuals with a higher number of sexual partners.

HIV Pre-Exposure Prophylaxis Prevention Awareness, Willingness, and Perceived Barriers among People Who Inject Drugs in Los Angeles and San Francisco, CA, 2016-2018

BACKGROUND

Pre-exposure prophylaxis (PrEP) for HIV prevention is indicated for people who inject drugs (PWID), yet most studies do not focus on PWID. This study examines factors associated with PrEP awareness and willingness, and identifies perceived barriers to PrEP among PWID. Methods: PWID were interviewed in Los Angeles and San Francisco, CA from 2016 to 2018. We analyzed data from self-reported HIV-negative participants who had injected drugs within the past 6 months (n = 469). Questions on PrEP included awareness, willingness, barriers, and uptake. Multiple logistic regression models of factors associated with awareness of, and willingness to, take PrEP were developed. Descriptive statistics on perceived PrEP barriers are reported. Results: Among HIV-negative PWID, 40% were aware of PrEP, 59% reported willingness to take PrEP, and 2% were currently taking PrEP. In multivariable analysis, PrEP awareness was associated with study site and sexual minority status, higher educational attainment, and HIV testing in the last 6 months. Willingness to take PrEP was associated with self-reported risk (paying sex partner in the last 6 months, sharing drug paraphernalia, and being injected by another PWID) and perceived HIV risk. The most common perceived barriers to PrEP were copays, concerns about increased HIV or sexually transmitted risk with PrEP, and concerns about reduction of medication efficacy without daily use. Conclusion: PrEP awareness among PWID remains inadequate. Willingness to take PrEP was moderate and was most desired by PWID who engaged in high-risk behaviors. Interventions to increase PrEP awareness and willingness, and to facilitate PrEP uptake among PWID are needed.

Evaluation of a Stepped-Care eHealth HIV Prevention Program for Diverse Adolescent Men Who Have Sex With Men: Protocol for a Hybrid Type 1 Effectiveness Implementation Trial of SMART

BACKGROUND

Adolescent men who have sex with men (AMSM), aged 13 to 18 years, account for more than 80% of teen HIV occurrences. Despite this disproportionate burden, there is a conspicuous lack of evidence-based HIV prevention programs. Implementation issues are critical as traditional HIV prevention delivery channels (eg, community-based organizations, schools) have significant access limitations for AMSM. As such, eHealth interventions, such as our proposed SMART program, represent an excellent modality for delivering AMSM-specific intervention material where youth are.

OBJECTIVE

This randomized trial aimed to test the effectiveness of the SMART program in reducing condom-less anal sex and increasing condom self-efficacy, condom use intentions, and HIV testing for AMSM. We also plan to test whether SMART has differential effectiveness across important subgroups of AMSM based on race and ethnicity, urban versus rural residence, age, socioeconomic status, and participation in an English versus a Spanish version of SMART.

METHODS

Using a sequential multiple assignment randomized trial design, we will evaluate the impact of a stepped-care package of increasingly intensive eHealth interventions (ie, the universal, information-based SMART Sex Ed; the more intensive, selective SMART Squad; and a higher cost, indicated SMART Sessions). All intervention content is available in English and Spanish. Participants are recruited primarily from social media sources using paid and unpaid advertisements.

RESULTS

The trial has enrolled 1285 AMSM aged 13 to 18 years, with a target enrollment of 1878. Recruitment concluded in June 2020. Participants were recruited from 49 US states as well as Puerto Rico and the District of Columbia. Assessments of intervention outcomes at 3, 6, 9, and 12 months are ongoing.

CONCLUSIONS

SMART is the first web-based program for AMSM to take a stepped-care approach to sexual education and HIV prevention. This design indicates that SMART delivers resources to all adolescents, but more costly treatments (eg, video chat counseling in SMART Sessions) are conserved for individuals who need them the most. SMART has the potential to reach AMSM to provide them with a sex-positive curriculum that empowers them with the information, motivation, and skills to make better health choices.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier NCT03511131; https://clinicaltrials.gov/ct2/show/NCT03511131.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

DERR1-10.2196/19701.

Low hepatitis C virus reinfection rate despite ongoing risk following universal access to direct-acting antiviral therapy among people living with HIV

OBJECTIVE(S)

To evaluate changes in injecting and sexual risk behaviours, and hepatitis C virus (HCV) reinfection incidence among people with HIV/HCV coinfection following unrestricted access to direct-acting antiviral therapy in Australia.

DESIGN

Prospective observational cohort study (2014-2018).

METHODS

Among people enrolled in the Control and Elimination of HCV from HIV-infected individuals within Australia study, changes in injecting and sexual behaviour were evaluated, including injecting drug use (IDU) in the last 6 months and last month, frequency of IDU and equipment sharing, condom-less anal intercourse with casual male partner(s), and group sex. HCV reinfection incidence was evaluated with follow-up through May 2018.

RESULTS

Overall, 272 HIV/HCV antibody-positive participants [median age; 50 years, 96% male, 83% identified as gay and bisexual men (GBM)] had behavioural data at enrolment and follow-up (median 2.91 years) available for analysis. The proportion reporting IDU in the last 6 months remained stable from enrolment (35%) to follow-up (39%). Among GBM, the proportion reporting condom-less anal intercourse with casual partner(s) at enrolment (48%) and follow-up (46%) was also similar. Reinfection was detected in five individuals (all GBM) during total follow-up of 474 person-years for an overall incidence of 1.05 per 100 person-years (95% confidence interval, 0.44-2.53).

CONCLUSION

No change was observed in levels of injecting or sexual risk behaviour for HCV infection following unrestricted access to direct-acting antiviral therapy in an Australian HIV/HCV cohort. Incidence of HCV reinfection was low potentially reflecting high levels of treatment coverage within this population. Continued screening and rapid retreatment of reinfection will be required to maintain progress towards elimination.

Disparities in the PrEP continuum for trans women compared to MSM in San Francisco, California: results from population-based cross-sectional behavioural surveillance studies

INTRODUCTION

Although transgender women (trans women) often are conflated with men who have sex with men  (MSM) in HIV research and services, there are distinct population differences that are important for implementing effective HIV prevention. Our objective was to examine pre-exposure prophylaxis (PrEP) disparities between the two populations and compare individual, social and structural factors that influence differences between MSM and trans women along the PrEP continuum.

METHODS

We analysed data from two population-based studies, one with trans women (Trans*National Study, 2016 - 18) and the other with MSM (National HIV Behavioral Surveillance, 2017). Trans women were recruited via respondent-driven sampling and MSM using time location sampling. Key indicators of the PrEP continuum were evaluated, including awareness, health insurance, provider discussions, recent use and adherence. Associations were also examined for PrEP continuum indicators and structural barriers (e.g. employment, homelessness).

RESULTS

Transwomen were more likely than MSM to be Latino/a (30.4% vs. 25.8%; prevalence ratio (PR)=1.08, 95% CI 1.02 to 1.14) or African American (7.1% vs. 4.5%; PR = 1.12, 1.02 to 1.24), live at or below the poverty limit (70.7% vs. 15.8%; PR = 1.47; 1.41 to 1.53), be unemployed (50.1% vs. 26.3%; PR = 1.18, 1.13 to 1.24), be homeless (8.4% vs. 3.5%; PR = 1.15, 1.06 to 1.25) and to have less than a college degree (PR = 1.41, 1.34 to 1.48). Trans women were more likely than MSM to have health insurance (95.7% vs. 89.7%, PR = 1.17, 1.06 to 1.28), but less likely than MSM to have heard of PrEP (79.1% vs. 96.7%; PR = 0.77, 0.73 to 0.81), talked with a provider about PrEP (35.5% vs. 54.9%; PR = 0.87, 0.83 to 0.91) and less likely than MSM to have used PrEP in the past six months (14.6% vs. 39.8%; PR = 0.80, 0.76 to 0.84). Among PrEP users, trans women were less likely to report being adherent to PrEP than MSM (70.4% vs. 87.4%; PR = 0.80, 0.70 to 0.91).

CONCLUSIONS

We found PrEP disparities for trans women compared to MSM and the need for differentiated implementation strategies to meet the specific PrEP barriers trans women face. Inclusion of trans women's HIV risks is needed in CDC guidance for PrEP. Interventions to increase trans women's awareness of PrEP including at the provider and community level are also needed. Finally, programming that addresses trans women's barriers to housing and income is also needed to reduce PrEP disparities.

Integrated Cognitive-Behavioral Therapy for Social Anxiety and HIV/STI Prevention for Gay and Bisexual Men: A Pilot Intervention Trial

Given the alarmingly high HIV and sexually transmitted infection (STI) incidence among gay and bisexual men (GBM) worldwide, there is a critical need for HIV prevention interventions specifically for GBM. Social anxiety, or anxiety about being evaluated in interpersonal situations, is a risk factor for condomless anal sex (CAS) among GBM (e.g., Hart & Heimberg, 2005; Hart, James, Purcell, & Farber, 2008). Social anxiety may also increase substance use in sexual situations, which is another risk factor for HIV/STIs in this risk group (Semple, Strathdee, Zians, McQuaid, & Patterson, 2011). The goal of the Sexual Confidence Study was to provide initial evidence of efficacy for a 10-session integrated cognitive-behavioral therapy for social anxiety, substance use management in sexual situations, and HIV sexual risk reduction for HIV-negative GBM. Diagnostic and self-report assessments were completed at baseline, posttreatment, 3-month follow-up, and 6-month follow-up. In this open trial design, we observed a 50% reduction in engagement in HIV/STI sexual risk behavior at 6-month follow-up. We also observed large uncontrolled treatment effect sizes for reductions in social anxiety disorder and problematic alcohol use. These preliminary findings suggest that the present treatment may offer an efficient way of concurrently reducing social anxiety, problematic alcohol use, and the risk of contracting HIV and STIs via CAS with serodiscordant partners among HIV-negative GBM.

[HIV pre-exposure prophylaxis care in intersectoral collaboration : Interim analysis of a monocentric, prospective study in Germany]

BACKGROUND

HIV pre-exposure prophylaxis (PrEP), a further opportunity to prevent HIV, is available at the WIR-Walk In Ruhr, Centre for Sexual Health and Medicine, as part of an innovative model project for intersectoral PrEP care.

RESEARCH OBJECTIVES

The present study describes the collective of persons provided with PrEP and how PrEP use influences sexual risk behaviour, the incidence of sexually transmitted diseases (STD) and adverse drug reactions.

METHODS

A total of 139 men who started PrEP between 10/2017 and 12/2018 have been included in the study. During a period of 13 months of PrEP treatment, all PrEP users received questionnaires; side effects, HIV and other STI were also monitored via clinical laboratory examinations.

RESULTS

The participants' average age was 38 years and 98.6% of them were men who had sex with men (MSM). Most of them had a high educational background; the unemployment rate was low. The average number of sexual partners within the last 6 months increased significantly, while the use of condoms decreased. In all, 44 STI were found in 34 participants within the first 4 months. No one was infected with HIV. Within the first 4 weeks of PrEP, 38.8% of the participants suffered from side effects, mainly gastrointestinal symptoms.

CONCLUSION

Most of the participants were working in a job or a vocational training. The sexual risk behaviour increased in the course of using PrEP resulting in a high incidence of STD. Side effects appeared most frequently in the first few weeks after starting PrEP.

Sexually transmitted infections and sexual behaviors of men who have sex with men in an American Deep South PrEP clinic

HIV pre-exposure prophylaxis (PrEP) effectively prevents HIV acquisition among men who have sex with men (MSM), but PrEP uptake has been associated with sexually transmitted infections (STIs). The effect of PrEP on STIs in MSM in the Deep South of the United States is unknown. We performed a retrospective analysis of adult MSM at an American Deep South PrEP clinic to calculate the prevalence and incidence rate of bacterial STIs (chlamydia, gonorrhea, and syphilis) and identify associated risk factors by linking incident STI to patient-reported outcomes; 139 MSM accessed the clinic between 2014 and 2018 with baseline bacterial STI prevalence of 11%. Twenty-six of 81 eligible MSM on PrEP had incident STIs with an incidence rate of 33.1 cases per 100 person-years. Significantly higher proportions of high PrEP adherence, multiple sexual partners, and inconsistent condom use were seen in those with incident STI, and we identified MSM with both high PrEP adherence and multiple sexual partners as being at especially high risk for bacterial STIs (hazard ratio: 7.57, 95% confidence interval: 1.75–32.74). Bacterial STIs are common after initiating PrEP in this clinic, and MSM reporting high PrEP adherence and multiple sexual partners have a significant risk for incident STI. Highrisk sexual behaviors persisted after starting PrEP, highlighting the importance of ongoing, intensive sexual health screening and interventions.

HIV and bacterial sexually transmitted infections (STIs) disproportionately affect men who have sex with men (MSM) in the American Deep South. We found a high incidence among MSM after starting PrEP and identified MSM with high PrEP adherence and multiple sexual partners as highest risk for STI. Our findings signal a need for intensive, targeted sexual health counseling and intervention to curb the rise in STIs.

Inequities in consistent condom use among sexually experienced undergraduates in mainland China: implications for planning interventions

BACKGROUND

Since pre-exposure prophylaxis (PrEP) is mainly prescribed to high-risk uninfected individuals, consistent condom use (CCU) continues to be recommended as an inexpensive, feasible, practical and acceptable way to prevent the general population from acquiring and transmitting HIV through sexual intercourse. The objective of this cross-sectional study was to compare the relative importance of various determinants of CCU among sexually experienced undergraduates in mainland China so as to assess and subsequently to suggest ways to eliminate inequities in its use.

METHOD

From September 10, 2018, to January 9, 2019, an anonymous self-administered online questionnaire was voluntarily completed by 12,750 participants distributed across 30 provinces in mainland China (except for Tibet). The present analysis was restricted to 2054 sexually experienced undergraduates. Pearson's chi-square test and Logistic regression models were chosen to analyze the factors associated with CCU.

RESULTS

The overall rate of CCU was 61.3% [95% confidence interval (CI) = 59.2-63.4%]. CCU was inequitably distributed since enabling factors exerted greater effects than predisposing and need variables. Compared with heterosexual men, heterosexual women [adjusted odds ratio (AOR) = 0.78, 95% confidence interval (CI):0.64-0.96)], non-heterosexuals men (AOR = 0.64, 95% CI:0.45-0.92) and women (AOR = 0.68, 95% CI:0.47-0.99) were less prone to using condoms consistently. Those with more resources [i.e., higher levels of self- efficacy for condom use (AOR = 2.86, 95% CI:2.35-3.49) and being knowledgeable of the national AIDS policy (AOR = 1.50, 95% CI:1.23-1.82)], and those with lower need for condoms [i.e., late initiation of sexual activity (AOR = 1.34, 95% CI:1.09-1.64) and single sexual partner (AOR = 1.68,95% CI:1.21-2.33)] were more likely to be consistent condom users.

CONCLUSIONS

In order to increase consistency of condom use and simultaneously reduce the remaining inequities, a comprehensive intervention measure should be taken to target heterosexual women, non-heterosexual men and women, and those with higher need for condoms, improve their condom use self- efficacy and raise their awareness of the national AIDS policy.