Geographic Density and Uptake of Pre-exposure Prophylaxis (PrEP) Among Young Gay, Bisexual and Other Sexual Minority Men: A Global Positioning System (GPS) Study

County-Level Factors Associated with Reversal of Insurer-Approved HIV Pre-Exposure Prophylaxis Prescriptions in the United States, 2018

Identifying county-level factors that influence pre-exposure prophylaxis (PrEP) adherence is critical for ending the HIV epidemic in the United States (US). PrEP primary reversal is a term used to describe patients who do not obtain their prescribed medication from the pharmacy. This study sought to identify factors associated with PrEP reversal at the county level in 2018. Data were collected from Symphony Health Analytics, AIDS Vu, the US Census Bureau, and the Centers for Disease Control and Prevention National Prevention Information Network. Bivariate Choropleth maps were created to identify counties with high and low levels of PrEP reversal and HIV incidence. This was followed by bivariate analysis to determine the association between predictor variables and percent PrEP reversal. Finally multivariable logistic regressions were used to assess the association between percent PrEP reversal and variables that were significant from the bivariate analysis. A total of 308 counties were included in this analysis, where the mean number of PrEP prescriptions for counties was 44, with a median of 14 (Interquartile range 7-34). In the multivariable analysis, counties with higher level of unemployment (aOR: 1.10, 95% CI: 1.05-1.16) and rural counties (1.10: 1.04-1.17) had higher odds of PrEP reversal; while counties with higher household crowding (0.97: 0.95-0.99) had lower odds of PrEP reversal. Findings show the need for expanding and implementing programs as well as policies to improve PrEP services that are tailored to local socioeconomic circumstances.

Preferences for Starting Daily, On-Demand, and Long-Acting Injectable HIV Preexposure Prophylaxis Among Men Who Have Sex With Men in the United States (2021-2022): Nationwide Online Cross-Sectional Study

BACKGROUND

Long-acting (LA) injectable preexposure prophylaxis (PrEP) and on-demand PrEP may improve overall PrEP uptake among men who have sex with men (MSM), but little is understood about the PrEP option preferences of MSM in practical scenarios where they may choose between various PrEP options.

OBJECTIVE

This study aims to examine the preferences for starting various PrEP options among a US nationwide online convenience sample of MSM from September 2021 to February 2022.

METHODS

Participants reporting no prior HIV diagnosis were provided brief descriptions of each PrEP option and were asked, "If [PrEP option] were available from your local doctor and you could access it for free, would you go to your doctor in the next month to start [PrEP option]?" Those who said "yes" to multiple options were asked to rank them in order of preference. MSM currently taking daily oral (DO) PrEP were asked whether they would switch to on-demand or LA PrEP options. Log binomial models were created to examine the association between willingness to start or switch to on-demand and LA PrEP with various sociodemographic and behavioral factors.

RESULTS

In the analytic sample (N=7760), among the participants who did not use any PrEP in the past 12 months (n=5108, 66%), 54% (n=2445) reported willingness to start at least 1 PrEP option and 41% (n=1845) of participants showed interest in starting multiple PrEP options. Overall, the highest willingness was reported for on-demand PrEP (n=2235, 44%), followed by DO PrEP (n=2174, 43%) and LA PrEP (n=1482, 29%). LA PrEP was ranked first among those interested in multiple options. Characteristics associated with ranking LA PrEP as a first option to start PrEP versus DO or on-demand PrEP were region of residence (residing in the West vs Northeast), report of sexually transmitted infection diagnosis in the past year, report of illicit drug use other than marijuana in the past year, and prior awareness of LA PrEP. Among current DO PrEP users (n=2379, 31%), 58% (n=1386) were willing to switch to on-demand or LA PrEP, and LA PrEP was ranked first among participants who were open to switching to both options. Willingness to switch to LA PrEP was higher among those who used illicit drugs other than marijuana in the past year, who heard of LA PrEP prior to the survey, and those who took 15 or less doses of oral PrEP in the last 30 days.

CONCLUSIONS

LA PrEP was the highest-ranked option among most MSM who were willing to try multiple options or switch from DO PrEP. These findings highlight that LA PrEP might fill coverage gaps among MSM who use illicit drugs, have had a recent sexually transmitted infection diagnosis, and have less than optimal DO PrEP adherence.

Understanding Typology of Preexposure Prophylaxis (PrEP) Persistence Trajectories Among Male PrEP Users in the United States

Introduction

Understanding longitudinal patterns of preexposure prophylaxis (PrEP) use among men who have sex with men could offer insights for developing efficient and timely interventions to promote PrEP persistence.

Setting

We extracted 2 years of pharmacy fill records for 4000 males who initiated PrEP in 2017 at a national chain pharmacy in the United States.

Methods

Group-based trajectory models were used to develop PrEP trajectory clusters, with periods of use defined based on optimal PrEP seroprotection probabilities (ie, PrEP use frequency ≥4 doses/week). Multinomial logistic regressions were used to evaluate the associations between sociodemographic covariates and identified trajectory group membership.

Results

We identified 4 distinct groups of PrEP persistence trajectories: (1) persistent use of PrEP throughout the period (persistent user), (2) brief use followed by sustained cessation of PrEP use (brief user), (3) PrEP use up to the mid-term followed by sustained cessation of PrEP use (mid-term user), and (4) PrEP use, followed by cessation and subsequent reinitiation (PrEP reinitiator). Persistent users and brief users accounted for 40.1% and 22.9% of the population, respectively, whereas mid-term users and reinitiators accounted for 18.9% and 18.2%, respectively. Older age at PrEP initiation, commercial insurance as the primary payer of PrEP, and use of specialty pharmacy were found to be associated with persistent PrEP use over the other patterns of nonpersistence.

Conclusions

Subgroups of PrEP users could benefit from PrEP persistence interventions that target specific timings of likely PrEP cessation or considerations of reinitiation.

Using GPS-defined venue-based affiliation networks among Black sexually minoritized men and transgender women to identify locations for HIV prevention interventions

PURPOSE

HIV biomedical intervention uptake is suboptimal among Black sexually minoritized men (SMM) and transgender women (TW). Venues where people meet and interact shape HIV-related risk and prevention behaviors. We aimed to construct GPS-defined venue-based affiliation networks and identify the unique set of venues that could maximize reach of HIV biomedical interventions among Black SMM and TW.

METHODS

We used baseline survey and GPS data from 272 Black SMM and TW in the Neighborhoods and Networks (N2) Cohort Study in Chicago, Illinois (2018-2019). We mapped participants' GPS data to the nearest pre-identified SMM- and TW-friendly venue (n = 222) to construct affiliation networks. Network analyses were performed to identify influential venues that can yield high reach to intervention candidates.

RESULTS

Participants were affiliated with 75.5 % of all pre-identified venues based on GPS data. Two influential venues were identified in the non-PrEP use network, which when combined, could reach 52.5 % of participants not taking PrEP. Participants that could be reached through these two influential venues reported more non-main sex partners than participants not affiliated with either venue (p = 0.049).

CONCLUSION

We demonstrate a potential for GPS-defined venue-based affiliation networks to identify unique combinations of venues that could maximize the impact of HIV prevention interventions.

Neighborhood violent crime exposure is associated with preexposure prophylaxis nonuse among black sexually minoritized men and transgender women

OBJECTIVE

The objective of this study is to use GPS technology to determine if violent and property crime exposure to participants activity spaces affect outcomes of the HIV prevention and care continuum (PCC) among Young black sexually minoritized men (YBSMM) and transgender women (TGW), a subgroup at high vulnerability for new HIV diagnoses. Exposure to violent and property crime adversely affects a variety of acute and chronic medical conditions; however, the relationship between exposure to violent and property crime and HIV risk [e.g. preexposure prophylaxis (PrEP) nonuse] is unknown. Spatial analytic analysis using dynamic Global Position Systems (GPS) technology can accurately detect geospatial associations between the crime exposure and objective HIV-related outcomes.

METHODS

With the Neighborhoods and Networks (N2) Cohort Study, GPS technology to identify the activity space of 286 [123 people with HIV (PWH) and 163 people without HIV (PWoH)] YBSMM and TGW living in Chicago, Illinois, to identified spatial associations between violent and property crime exposures with HIV PCC outcomes.

RESULTS

We found that YBSMM and TGW with higher exposure areas with higher levels of violent crime were less likely to use HIV PrEP therapy [adjusted odds ratio (aOR) 0.76, 95% confidence interval (CI) 0.63-0.91, P  = 0.03].

CONCLUSION

This study demonstrates the importance of clinical providers to consider violent crime as a potential sociostructural barrier that may impact medication adherence and healthcare outcomes among vulnerable populations. Additionally, GPS technology offers an alternative data analytic process that may be used in future studies to assist in identifying barriers to ending the HIV epidemic.

Examination of multidimensional geographic mobility and sexual behaviour among Black cisgender sexually minoritized men in Chicago

Black sexually minoritized men (BSMM) are the most likely to acquire HIV in Chicago- a racially segregated city where their daily travel may confer different HIV-related risks. From survey and GPS data among participants of the Neighbourhoods and Networks Cohort Study, we examined spatial (proportion of total activity space away from home), temporal (proportion of total GPS points away from home), and motivation-specific (discordance between residential and frequented sex or socializing neighbourhoods) dimensions of mobility. To identify potential drivers of BSMM's risk, we then examined associations between mobility and sexual behaviours known to cause HIV transmission: condomless anal sex, condomless anal sex with a casual partner, transactional sex, group sex, and sex-drug use. Multivariable logistic regression models assessed associations. Of 269 cisgender BSMM, most were 20-29 years old, identified as gay, and lowincome. On average, 96.9% (Standard Deviation: 3.7%) of participants' activity space and 53.9% (Standard Deviation: 38.1%) of participants' GPS points occurred outside their 800m home network buffer. After covariate adjustment, those who reported sex away from home were twice as likely to report condomless sex (Odds Ratio: 2.02, [95% Confidence Interval (CI): 1.08, 3.78]). Those who reported socializing away from home were four times more likely to have condomless sex with a casual partner (Odds Ratio: 4.16 [CI: 0.99, 29.0]). BSMM are on the move in Chicago, but only motivation-specific mobility may increase HIV transmission risk. Multidimensional investigations of mobility can inform place-based strategies for HIV service delivery.

Geographic variations of pre-exposure prophylaxis reversal and abandonment among United States counties

OBJECTIVE

In the United States, one in five newly insurer-approved pre-exposure prophylaxis (PrEP) prescriptions are reversed with over 70% of those reversed, being abandoned. Given the Ending the HIV Epidemic (EHE) initiative's goals, we assessed geographic variations of PrEP reversal and abandonment across EHE and non-EHE counties in the United States.

DESIGN

This was a cross-sectional analysis of secondary data.

METHODS

Data were collected from Symphony Analytics for adults 18 years and older, with a newly prescribed PrEP claim. Using the proportion of PrEP prescriptions by county, hotspot analysis was conducted utilizing Getis Ord Gi∗ statistics stratified by EHE and non EHE counties. Multivariable logistic regression was used to identify factors associated with residing in hotspots of PrEP reversal or PrEP abandonments.

RESULTS

Across 516 counties representing 36,204 patients, the overall PrEP reversal rate was 19.4%, whereas the PrEP abandonment rate was 13.7%. Reversals and abandonments were higher for non-EHE (22.7 and 17.1%) than EHE (15.6 and 10.5%) counties. In both EHE and non-EHE counties, younger age, less education, females, and an out-of-pocket cost of greater than $100, were significantly associated with greater likelihood of residing in hotspots of PrEP reversal or abandonment, while Hispanics, Medicaid recipients, and an out-of-pocket cost of $10 or less had lower likelihood of residing in hotspots of reversal and abandonment.

CONCLUSION

Findings indicate the need for implementation of focused interventions to address disparities observed in PrEP reversal and abandonment. Moreover, to improve primary PrEP adherence, national PrEP access programs should streamline and improve PrEP accessibility across different geographic jurisdictions.

Spatial accessibility of pre-exposure prophylaxis (PrEP): different measure choices and the implications for detecting shortage areas and examining its association with social determinants of health

PURPOSE

We examine how various pre-exposure prophylaxis (PrEP) accessibility measures impact the detection of PrEP shortage areas and the relation of shortage areas to social determinants of health (SDOH).

METHODS

Using ZIP Code Tabulation Areas (ZCTAs) in New York City as a case study, we compared 25 measures of spatial PrEP accessibility across four categories, including density, proximity, two-step floating catchment area (2SFCA), and Gaussian 2SFCA (G2SFCA). Bayesian spatial regression models were used to examine how PrEP accessibility is associated with SDOH.

RESULTS

Using density to measure PrEP accessibility for small areas such as ZCTAs poses challenges to statistical modeling because the measured accessibility values are highly skewed with excess zeros, leading to the necessity of using complex models such as the two-part mixture model. When G2SFCA measures are used, which account for distance decay effects and the competition from the PrEP demand side, findings on PrEP shortage area detection and the association between PrEP accessibility and SDOH were more consistent and less sensitive to spatial scales (i.e., varying from 10- to 30-minute driving).

CONCLUSIONS

This research adds to the nascent research on PrEP accessibility measurement and sheds light on selecting an appropriate measure to assess spatial disparities in PrEP accessibility and its associations with SDOH.

Geographic Disparities in Availability of Spanish-Language PrEP Services Among Latino Sexual Minority Men in South Florida

Latino sexual minority men (LSMM) experience barriers in accessing HIV pre-exposure prophylaxis (PrEP), such as lack of proximate culturally-appropriate PrEP navigation services. We examined associations between LSMM's immigration status and Spanish-language PrEP service availability. LSMM clinically indicated for PrEP were recruited from October 2018 to August 2019 in South Florida and completed an interviewer-administered questionnaire. PrEP service navigators in South Florida were identified using the CDC PrEP Directory. We constructed network service areas of 1-, 2-, and 5-miles from Spanish-speaking PrEP navigators. We used multilevel logistic regression to examine associations of individual (i.e., age, income, immigration status, network density) and zip code-level (i.e., population density, poverty, HIV risk) measures with availability of Spanish-language PrEP navigation services. A total of 131 participants clustered into 60 zip codes in South Florida. Latin American-born LSMM reported higher immigration and discrimination stress, and were 91% less likely to have PrEP navigation service availability, relative to LSMM born in the US. Zip code-level HIV incidence was associated with higher service availability within a 1-mile network of Spanish-speaking PrEP navigators. Spanish-language PrEP navigation services were available in high-HIV incidence zip codes; however, Latin American-born LSMM experienced reduced availability. Immigration and discrimination stress may explain lack of availability.

Structural racism and homophobia evaluated through social media sentiment combined with activity spaces and associations with mental health among young sexual minority men

BACKGROUND

Research suggests that structural racism and homophobia are associated with mental well-being. However, structural discrimination measures which are relevant to lived experiences and that evade self-report biases are needed. Social media and global-positioning systems (GPS) offer opportunity to measure place-based negative racial sentiment linked to relevant locations via precise geo-coding of activity spaces. This is vital for young sexual minority men (YSMM) of color who may experience both racial and sexual minority discrimination and subsequently poorer mental well-being.

METHODS

P18 Neighborhood Study (n = 147) data were used. Measures of place-based negative racial and sexual-orientation sentiment were created using geo-located social media as a proxy for racial climate via socially-meaningfully-defined places. Exposure to place-based negative sentiment was computed as an average of discrimination by places frequented using activity space measures per person. Outcomes were number of days of reported poor mental health in last 30 days. Zero-inflated Poisson regression analyses were used to assess influence of and type of relationship between place-based negative racial or sexual-orientation sentiment exposure and mental well-being, including the moderating effect of race/ethnicity.

RESULTS

We found evidence for a non-linear relationship between place-based negative racial sentiment and mental well-being among our racially and ethnically diverse sample of YSMM (p < .05), and significant differences in the relationship for different race/ethnicity groups (p < .05). The most pronounced differences were detected between Black and White non-Hispanic vs. Hispanic sexual minority men. At two standard deviations above the overall mean of negative racial sentiment exposure based on activity spaces, Black and White YSMM reported significantly more poor mental health days in comparison to Hispanic YSMM.

CONCLUSIONS

Effects of discrimination can vary by race/ethnicity and discrimination type. Experiencing place-based negative racial sentiment may have implications for mental well-being among YSMM regardless of race/ethnicity, which should be explored in future research including with larger samples sizes.

Objective and Subjective Neighborhood Crime Associated with Poor Sleep among Young Sexual Minority Men: a GPS Study

Sleep disparities in sexual minority male (SMM) populations have received relatively little attention but they may be critical to explaining other health disparities seen among SMM, via neural or hormonal pathways. Recent research suggests that crime may be a psychosocial stressor that contributes to sleep disparities but that finding has been based on subjective measures of crime. We conducted the P18 Neighborhood Study of 250 SMM in New York City, including 211 with adequate GPS tracking data. We used the GPS tracking data to define daily path area activity spaces and tested the associations of violent crime in those activity spaces and in the subject's residential neighborhood, perceived neighborhood safety, and witnessing crime with a subjective measure of sleep. Using quasi-Poisson regression, adjusted for individual and neighborhood socio-demographics, we found that SMM who witnessed more types of crime experienced significantly more nights of poor sleep over the course of a month (RR: 1.16, 95%CI: 1.05-1.27, p-value: < 0.01). We did not find any associations between violent crime rates in either the activity area or residential area and sleep. Our findings support the conclusion that personal exposure to crime is associated with sleep problems and provide further evidence for the pathway between stress and sleep. The lack of association between neighborhood crime levels and sleep suggests that there must be personal experience with crime and ambient presence is insufficient to produce an effect.

Disrupting the Systems: Opportunities to Enhance Methodological Approaches to Address Socio-Structural Determinants of HIV and End the Epidemic Through Effective Community Engagement

A world without HIV is only possible by addressing the socio-structural determinants of health. Our understanding of socio-structural determinants is constantly changing, and parallel changes must occur with the methodologies used to explain the drivers of the HIV epidemic. We argue for the need to engage communities in the planning, implementation, and dissemination of research on the socio-structural determinants of HIV. Community engagement should cross-cut various types of research including rigorous measurement development of socio-structural determinants and novel analytic techniques to model their role in the trajectory of the epidemic and the impact of interventions. Considering the role of place, we recommend collaboration between scientists and communities in the interpretation of results from studies that map HIV-related behaviors and movement. As we collectively delve into historically oppressive systems with colonial antecedents, we must be ready to challenge these systems and replace them with collaborative models. The success of research-driven HIV policy and programming will best be evaluated with methodologies derived from the insights of the very individuals that these policies and programs aim to serve.