Interventions to Reduce Drug Use Among Methamphetamine Users at Risk for HIV

Study protocol of a randomized controlled trial to assess the efficacy of the "PrEPare for Work" intervention to enhance PrEP uptake and optimize adherence for HIV prevention among male sex workers in the U.S

BACKGROUND

Male sex workers (MSWs), specifically cisgender men who exchange sex for money, goods, drugs, or other items of value with other cisgender men, are at high risk for HIV infection. Compared to men not engaged in sex work, MSWs are more likely to engage in frequent condomless sex with paying and non-paying sexual partners. While MSWs are often included as a subgroup of gay and bisexual men, data show that a large proportion identify as heterosexual; additionally, most MSWs do not identify as "sex workers." This places MSWs in a unique position where they may not engage with traditional HIV prevention programs, and when they do, they may not feel comfortable, leading to poor retention. Thus, HIV prevention interventions that address MSWs' unique life circumstances and provide support in exploring their sexual health options are needed.

METHODS

In this protocol paper, we describe the design and procedures for a National Institute of Health-funded, randomized controlled trial testing the efficacy of "PrEPare for Work,"- a theory-based, manualized PrEP uptake and adherence intervention for MSW - using a 2-stage randomization design. Stage 1: MSWs are equally randomized to receive either the "PrEPare for Work Stage 1 intervention" (strength-based case management and facilitated PrEP linkage) or Standard of Care (SOC) to evaluate successful PrEP uptake (prescription filled) within two months post-randomization. Stage 2: Those who initiate PrEP are then equally re-randomized to receive either the "PrEPare for Work Stage 2 intervention" (1-on-1 skills training, problem-solving, and motivational interviewing adherence counseling and personalized, daily text message reminders) or SOC to assess adherence (Tenofovir concentrations in hair) over 12 months of follow up. Planned analyses will examine intervention efficacy, specific conceptual mediators, and hypothesized moderators.

DISCUSSION

Based on our extensive preliminary research, multi-component, theory-informed interventions targeting this subpopulation of MSWs' unique life circumstances are urgently needed. In this study, we are evaluating whether "PrEPare for Work" can improve PrEP uptake and adherence among MSWs. If this intervention is efficacious, it would be readily disseminated to diverse community organizations that serve MSWs and possibly other community or clinic-based settings.

TRIAL REGISTRATION

ClinicalTrials.gov number NCT05736614, registered February 8, 2023.

Association of current substance use treatment with future reduced methamphetamine use in an observational cohort of men who have sex with men in Los Angeles

INTRODUCTION

Methamphetamine use is highly prevalent among men who have sex with men (MSM), but knowledge of the long-term dynamics, and how they are affected by substance use treatment, is limited. This study aimed to describe trajectories of methamphetamine use among MSM, and to evaluate the impact of treatment for any kind of substance use on frequency of methamphetamine use.

METHODS

This analysis used data from a cohort of MSM in Los Angeles, CA, who participated in semi-annual study visits from 2014 to 2022. The study characterized trajectories of methamphetamine use using a continuous time multistate Markov model with three states. States were defined using self-reported frequency of methamphetamine use in the past six months: frequent (daily), occasional (weekly or less), and never. The model estimated the association between receiving treatment for any kind of substance use and changes in state of frequency of methamphetamine use.

RESULTS

This analysis included 2348 study visits among 285 individuals who were followed-up for an average of 4.4 years. Among participants who were in the frequent use state, 65 % (n = 26) of those who were receiving any kind of substance use treatment at a study visit had reduced their methamphetamine use at their next visit, compared to 33 % (n = 95) of those who were not receiving treatment. Controlling for age, race/ethnicity, and HIV-status, those who reported receiving current treatment for substance use were more likely to transition from occasional to no use (HR: 1.63, 95 % CI: 1.10-2.42) and frequent to occasional use (HR: 4.25, 95 % CI: 2.11-8.59) in comparison to those who did not report receiving current treatment for substance use.

CONCLUSIONS

Findings from this dynamic modeling study provide a new method for assessing longitudinal methamphetamine use outcomes and add important evidence outside of clinical trials that substance use treatment may reduce methamphetamine use.

Contingency Management for Integrated Harm Reduction Among Men Who Have Sex with Men Who Use Methamphetamine in Los Angeles: A Pilot Assessment

Methamphetamine (MA) use is associated with HIV transmission among men who have sex with men (MSM) and lapses in medication adherence. Contingency Management (CM) is effective in reducing MA use, but studies of CM to support adherence to HIV prevention or treatment are limited. We conducted a pilot trial of a CM intervention to reduce MA use and improve PrEP/ART adherence among MSM prescribed a tenofovir (TFV)-based regimen for HIV prevention or treatment. Participants were randomly assigned to receive escalating incentives for either MA abstinence or TFV adherence (based on point-of-care urine testing), and to a monitoring schedule of either 2 or 3 visits/week for 4 weeks. 19 MSM were randomized to either CM for MA use or CM for PrEP/ART adherence (median age: 38; IQR: 28-46) and 15 were living with HIV. Participants attended 95.7% (67/70) of scheduled visits in the 2x/week arm and 74.8% (74/99) in the 3x/week arm. TFV adherence was higher among participants in the TFV adherence arm with 93.5% (n = 72/77) of urine samples positive for TFV, compared to 76.6% (n = 49/64) in the MA abstinence arm (p = 0.007). Participants in the MA abstinence arm had more urine samples negative for MA metabolites (20.3%, n = 13/64) than those receiving CM for TFV adherence (6.5%, n = 5/77; p = 0.021). A CM model for MA abstinence and PrEP/ART adherence using twice-weekly visits and urine testing for MA and TFV for MSM who use MA is feasible and potentially effective as an integrated harm reduction strategy.

Social Networks Play a Complex Role in HIV Prevention Knowledge, Attitudes, Practices, and the Uptake of PrEP Through Transgender Women Communities Centered Around Three "Casas Trans" in Lima, Peru: A Qualitative Study

Transgender women's (TW) social networks may facilitate HIV prevention information dissemination and normative reinforcement. We conducted a qualitative study of social networks among 20 TW affiliated with 3 "casas trans" (houses shared among TW) in Lima, Peru, using diffusion of innovations theory to investigate community-level HIV prevention norms. Participants completed demographic questionnaires, social network interviews, and semistructured in-depth interviews. Median age was 26 and all participants engaged in sex work. Interviews revealed high HIV prevention knowledge and positive attitudes, but low engagement in HIV prevention. Respondents primarily discussed HIV prevention with other TW. Network members' opinions about pre-exposure prophylaxis (PrEP) frequently influenced respondents' personal beliefs, including mistrust of healthcare personnel, concern that PrEP efficacy was unproven, fear of adverse effects, and frustration regarding difficulty accessing PrEP. Patterns of influence in TW networks may be leveraged to improve uptake of HIV prevention tools, including PrEP.

Stimulant use interventions may strengthen 'Getting to Zero' HIV elimination initiatives in Illinois: Insights from a modeling study

OBJECTIVE(S)

Getting to Zero (GTZ) is an Illinois-based HIV elimination initiative. GTZ identifies younger Black men who have sex with men (YBMSM) as a population who have experienced disproportionate HIV incidence. Rising stimulant use among YBMSM has been determined to impede engagement in the HIV prevention and treatment continua for reducing onward HIV transmission. Given the limited development of dedicated or culturally appropriate interventions for this population, this modeling study explores the impact of stimulant use on HIV incidence among YBMSM and assesses the impact of interventions to treat stimulant use on downstream HIV transmission to achieve GTZ goals.

METHODS

A previously developed agent-based network model (ABNM), calibrated using data for YBMSM in Illinois, was extended to incorporate the impact of stimulant use (methamphetamines, crack/cocaine, and ecstasy) on sexual networks and engagement in HIV treatment and prevention continua. The model simulated the impact of a residential behavioral intervention (BI) for reducing stimulant use and an outpatient biomedical intervention (mirtazapine) for treating methamphetamine use. The downstream impact of these interventions on population-level HIV incidence was the primary intervention outcome.

RESULTS

Baseline simulated annual HIV incidence in the ABNM was 6.93 [95% Uncertainty Interval (UI): 6.83,7.04] per 100 person years (py) and 453 [95% UI: 445.9,461.2] new infections annually. A residential rehabilitation intervention targeted to 25% of stimulant using persons yielded a 27.1% reduction in the annual number of new infections. Initiating about 50% of methamphetamine using persons on mirtazapine reduced the overall HIV incidence among YBMSM by about 11.2%. A 30% increase in antiretroviral treatment (ART) and preexposure prophylaxis (PrEP) uptake in the non-stimulant using YBMSM population combined with a 25% uptake of BI for stimulant using persons produces an HIV incidence consistent with HIV elimination targets (about 200 infections/year) identified in the GTZ initiative.

CONCLUSIONS

Behavioral and biomedical interventions to treat stimulant use, in addition to expanding overall ART and PrEP uptake, are likely to enhance progress towards achieving GTZ goals.

Contingency management for the treatment of methamphetamine use disorder: A systematic review

Methamphetamine use continues to be an important public health problem. Contingency management is among the most effective interventions for reducing methamphetamine use. It has been more than ten years since the last systematic review of contingency management for methamphetamine use disorder. Since then, an additional ten randomized controlled trials and a variety of other studies have been completed. The present systematic review includes 27 studies. Several factors, most notably problem severity, appear to predict treatment outcome. However, the effectiveness of CM has been demonstrated in studies restricted to MSM, studies restricted to implementation in community programs, and in studies of the general population of methamphetamine users conducted in research treatment programs. There appear to be broad benefits of contingency management intervention, including greater drug abstinence, higher utilization of other treatments and medical services, and reductions in risky sexual behavior. Twenty of the twenty-one studies that reported abstinence outcomes showed an effect of contingency management on abstinence, and seven of the nine studies that reported sexual risk behavior outcomes showed an effect of contingency management in reducing risky sexual behavior. Taken together, recent evidence suggests strongly that outpatient programs that offer treatment for methamphetamine use disorder should prioritize adoption and implementation of contingency management intervention.

Neuroinflammation & pre-mature aging in the context of chronic HIV infection and drug abuse: Role of dysregulated autophagy

In the era of combined antiretroviral therapy (cART), HIV-1 infection has transformed from adeath sentenceto a manageable, chronic disease. Although the lifeexpectancy of HIV+ individuals is comparable to that of the uninfectedsubjects paradoxically, there is increased prevalence ofage-associatedcomorbidities such asatherosclerosis, diabetes, osteoporosis & neurological deficits in the context of HIV infection. Drug abuse is a commoncomorbidityofHIV infection andis often associated withincreased neurological complications. Chronic neuroinflammation (abnormal microglial and astrocyte activation) and neuronal synaptodendritic injury are the features of CNS pathology observed inHIV (+) individualsthat are takingcART & that abuse drugs. Neuroinflammation is thedrivingforceunderlying prematureaging associated with HIV (+) infection, cART and drugs of abuse. Autophagy is a highly conserved process critical for maintaining cellular homeostasis. Dysregulated autophagyhas been shown to be linked with abnormal immune responses & aging. Recent emerging evidence implicatesthe role ofHIV/HIV proteins, cART, & abused drugsin disrupting theautophagy process in brain cells such as microglia, astrocytes, and neurons. It can thus be envisioned that co-exposure of CNS cells to HIV proteins, cART and/or abused drugs couldhavesynergistic effects on theautophagy process, thereby leading to exaggerated microglial/astrocyte activation, ultimately, promotingthe aging process. Restoration of autophagic functioncould thusprovide an alternative therapeuticstrategy formitigating neuroinflammation & ameliorating the premature aging process. The current review aims to unravel the role of dysregulated autophagy in the context of single or co-exposure of microglia, astrocytes, and neurons to HIV/HIV proteins, drugs of abuse &/or cART and will also discuss the pathways involved in dysregulated autophagy-mediated neuroinflammation.