Oral pre-exposure prophylaxis (PrEP) for prevention of HIV in serodiscordant heterosexual couples in the United States: opportunities and challenges

Decomposing Education-Based Inequalities in Pre-Exposure Prophylaxis Knowledge for HIV Prevention Among Women in Cote d'Ivoire

Background

Antiretroviral chemoprophylaxis is a promising strategy for preventing the spread of human immunodeficiency virus (HIV). The knowledge of pre-exposure prophylaxis (PrEP) is required for intervention uptake and adherence to prevent the spread of HIV. This study aimed to decompose education-based inequalities in PrEP knowledge for HIV prevention among reproductive-aged women in Cote d'Ivoire.

Methods

A cross-sectional study design with a nationally representative sample of 12,934 women aged 15-49 years was analyzed from the 2021 Cote d'Ivoire Demographic and Health Survey. The survey was conducted between September to December, 2021. The outcome variable was the knowledge of PrEP for HIV prevention. Statistical analysis was conducted using percentage, concentration index, and Lorenz curve. The level of significance was set at p<0.05.

Results

A weighted prevalence of 14.5% (95% CI: 12.5-16.3%) was estimated for PrEP knowledge for HIV prevention. Overall, educated women had a higher knowledge of PrEP for HIV prevention (Conc. Index= 0.225; SE= 0.012; p<0.001). Across the levels of women's characteristics, the results showed higher PrEP knowledge for HIV prevention among educated women. Education (Contri: 40.7327%, Ec: 0.5390), exposure to internet (Contri: 20.1039%, Ec: 0.3484), place of residence (Contri: 12.9801%, Ec: -0.0537), household wealth (Contri: 10.0062%, Ec: 0.0642) and religion (Contri: 5.7509%, Ec: 0.0354) were positive contributors to PrEP knowledge for HIV prevention. On the other hand, age (Contri: -8.8298%, Ec: -0.0950) and region (Contri: -3.5942, Ec: -0.0768) were negative contributors to PrEP knowledge regarding HIV prevention among women of reproductive age in Cote d'Ivoire.

Conclusion

There is limited knowledge of PrEP for HIV prevention among women in Cote d'Ivoire. Educated women had greater knowledge of PrEP for HIV prevention. The results of this study could guide interventions targeted to enhance the knowledge of PrEP as an HIV prevention option.

First 15 Years of Assisted Reproductive Technology Using Washed Sperm in HIV-Positive Individuals Under Antiretroviral Therapy: Sweden's Nationwide Outcomes

Antiretroviral therapy has made HIV a chronic infectious disease. In Sweden, assisted reproductive technologies using sperm washing were implemented in 2004 for treatment of all HIV-positive males in serodiscordant couples at Karolinska Hospital in Stockholm. This study aimed to assess efficacy and safety of this approach and to investigate the effect of antiretroviral regimens on sperm quality of men treated for HIV. The study included all HIV-positive men (n = 53) adherent to antiretroviral treatment, including nucleoside/nucleotide analog reverse-transcriptase inhibitors (NRTIs) combined with non-nucleoside reverse-transcriptase inhibitors (NNRTIs) in 22 cases, or with other medication in 31 cases wishing fertility treatment. Sperm was washed using gradient centrifugation with a double tube system, frozen and thawed. Thereafter, single spermatozoa were injected in oocytes by intracytoplasmic sperm injection (ICSI). Treatment outcomes were compared to those of hepatitis B virus (HBV)-seropositive men in serodiscordant couples (n = 56), undergoing similar sperm washing protocols and ICSI at the center. In total, 82 fresh and 39 frozen/thawed embryo transfer (FET) cycles were performed in discordant HIV couples and 92 fresh and 36 FET cycles in HBV. Fertilization rates (69.2% vs. 64.6%, p = 0.310), clinical pregnancy rates (39.2% vs. 32.6%, p = 0.378), and live birth rates (35.8% vs. 31.5%, p = 0.565) were similar between the groups and the cumulative results yielded similar outcomes with a live birth rate of 52.8% and 51.8% (p = 0.913), respectively. No post-wash sperm sample was found positive for HIV viral particles. No partner seroconversion or offspring infection was reported. NNRTI-treated men had significantly lower motile sperm concentration than non-NNRTI-treated patients (54.48% vs. 36.41%, p < 0001). This study showed that in vitro fertilization/ICSI treatment with sperm washing was safe in individuals compliant to antiretroviral treatment and the reproductive outcome was similar to that of HBV-positive men. The observed moderate negative impact on sperm motility of NNRTI regimens may be overcome by using ICSI.

Confidence in Ability to Communicate With Sexual Partners About PrEP Among Black Cisgender Women

This study explored the factors associated with Black women's confidence in their ability to engage male sexual partners in discussions about PrEP. Communication about PrEP with male partners is an important, yet minimally explored, outcome in PrEP research among Black women in heterosexual partnerships. Among 315 respondents, results show significant differences in anticipated stigma and interest in PrEP between a binary outcome variable being confident and not-confident discussing PrEP with sexual partners. Further, factors such as employment, worrying about HIV infection, interest in taking oral PrEP, subjective norms, injunctive norms, and descriptive norms were associated with Black women's higher odds of confidence in their ability to engage sexual partners about PrEP. Conversely, PrEP disapproval and stigma resulted in lower odds of Black women's confidence in their ability to engage sexual partners about PrEP. Results indicate the need for continued investigation of confidence and, relatedly, communication about PrEP among heterosexual couples and communitylevel interventions normalizing PrEP discussions and uptake.

Improving HIV pre-exposure prophylaxis (PrEP) uptake and initiation: process evaluation and recommendation development from a national PrEP program<a href="#FN1">†</a>

BACKGROUND

HIV pre-exposure prophylaxis (PrEP) is key to HIV transmission elimination but implementation is challenging and under-researched. We undertook a process evaluation of the first 2years of a national PrEP program to explore barriers and facilitators to implementation and to develop recommendations to improve implementation, focusing on PrEP uptake and initiation.

METHODS

Stage 1 involved semi-structured telephone interviews and focus groups (September 2018-July 2019) with geographically and demographically diverse patients seeking/using/declining/stopping PrEP (n =39), sexual healthcare professionals (n =54), community-based organisation service users (n =9) and staff (n =15) across Scotland. We used deductive thematic analysis, to derive and then map key barriers and facilitators to priority areas that experts agreed would enhance uptake and initiation. In Stage 2, we used analytic tools from implementation science to systematically generate evidence-based, theoretically-informed recommendations to enhance uptake and initiation of PrEP.

RESULTS

Barriers and facilitators were multi-levelled and interdependent. Barriers included the rapid pace of implementation without additional resource, and a lack of familiarity with PrEP prescribing. Facilitators included opportunities for acquisition of practice-based knowledge and normalisation of initiation activities. We refined our 68 'long-list' recommendations to 41 using expert input and the APEASE (Acceptability, Practicability, Effectiveness, Affordability, Side-effects, and Equity) criteria. Examples include: provision of PrEP in diverse settings to reach all in need; co-produced, culturally sensitive training resources for healthcare professionals, with focused content on non-daily dosing; meaningful collaborative working across all stakeholders.

CONCLUSIONS

These evidence-based, theory informed recommendations provide a robust framework for optimising PrEP uptake and initiation in diverse settings to ensure PrEP reaches all who may benefit.

Motivations and Barriers to Routine HIV Testing Among Men Who Have Sex with Men in New York City

In-depth qualitative interviews explored the experiences and understandings of men 18-39 years old who have sex with men that could facilitate or prevent HIV testing and routine HIV testing. For many men who tested frequently, testing and routine testing were motivated by awareness of the benefit of prompt treatment; public health and provider encouragement to test periodically; responsibility towards sexual partners; and wanting to share a recent HIV-negative test result when seeking sex online. For some men, any testing was impeded by anxiety around possible HIV diagnosis that made testing a stressful occasion that required time and energy to prepare for. This anxiety was often compounded by stigma related to sex between men, having condomless sex, or having HIV. Routine testing could be further stigmatized as some men felt judged by testing providers or partners if they asked for a test or said they tested frequently. We describe efforts to promote testing and routine testing by countering fear and stigma associated with HIV and testing.

Talking to My Partners About PrEP: Factors Associated with PrEP-Related Communication in a Longitudinal US Study of Sexual Minority Men Living with HIV

Treatment as prevention and pre-exposure prophylaxis (PrEP) have reduced HIV transmission among sexual minority men (SMM). However, little is known about PrEP-related communication in serodiscordant partnerships. In 2015-2016, 965 US SMM living with HIV (Mage = 39; 63% White, 19% Black, 18% Latinx) enrolled in a year-long longitudinal study with surveys every 3 months (2,850 surveys). Multilevel models explored factors associated with PrEP-related communication with HIV-negative partners. Most participants (77%) reported PrEP-related communication. Participants were more likely to discuss PrEP during periods with more sexual partners, AOR = 2.89, p < .001, and group sex, AOR = 1.99, p = .001. Those with more partners on average, β = 0.48, p < .001, and those engaging in other drug use more frequently, β = 0.11, p = .002, were more likely to discuss PrEP. PrEP-related communication was more common for men who disclosed their HIV status, β = 0.22, p < .001, and who had undetectable viral loads, β = 0.25, p = .007. Communication was also more common for those with higher incomes, β = 0.12, p = .02, and from larger cities, β = 0.07, p = .048, and less common for Black participants, β =  - 0.29, p = .003, and older participants, β =  - 0.18, p < .001. PrEP-related communication increased over the course of the study, AOR = 1.16, p= .02. PrEP can confer additional HIV prevention benefits within serodiscordant partnerships, and future research should continue to explore the role PrEP plays in these partnerships.

A public health approach to monitoring HIV with resistance to HIV pre-exposure prophylaxis

Background

The risk of HIV pre-exposure prophylaxis (PrEP) failure with sufficient medication adherence is extremely low but has occurred due to transmission of a viral strain with mutations conferring resistance to PrEP components tenofovir (TDF) and emtricitabine (FTC). The extent to which such strains are circulating in the population is unknown.

Methods

We used HIV surveillance data to describe primary and overall TDF/FTC resistance and concurrent viremia among people living with HIV (PLWH). HIV genotypes conducted for clinical purposes are reported as part of HIV surveillance. We examined the prevalence of HIV strains with mutations conferring intermediate to high level resistance to TDF/FTC, defining primary resistance (predominantly K65R and M184I/V mutations) among sequences reported within 3 months of HIV diagnosis and total resistance for sequences reported at any time. We examined trends in primary resistance during 2010–2019 and total resistance among all PLWH in 2019. We also monitored resistance with viremia (≥1,000 copies/mL) at the end of 2019 among PLWH.

Results

Between 2010 and 2019, 2,172 King County residents were diagnosed with HIV; 1,557 (72%) had a genotypic resistance test within three months; three (0.2%) had primary TDF/FTC resistance with both K65R and M184I/V mutations. Adding isolated resistance for each drug resulted in 0.3% with primary TDF resistance and 0.8% with primary FTC resistance. Of 7,056 PLWH in 2019, 4,032 (57%) had genotype results, 241 (6%) had TDF/FTC resistance and 15 (0.4% of those with a genotype result) had viremia and TDF/FTC resistance.

Conclusions

Primary resistance and viremia combined with TDF/FTC resistance are uncommon in King County. Monitoring trends in TDF/FTC resistance coupled with interventions to help ensure PLWH achieve and maintain viral suppression may help ensure that PrEP failure remains rare.

HIV-serodifferent couples' perspectives and practices regarding HIV prevention strategies: A mixed methods study

A substantial proportion of heterosexually acquired HIV infections in the U.S. occur between partners in primary relationships characterized by mixed HIV status. The U.S. Centers for Disease Control and Prevention have issued guidelines prioritizing HIV-serodifferent couples for primary HIV prevention, including treatment-as-prevention and pre-exposure prophylaxis (PrEP). Yet, very little research has been conducted to understand the perspectives and practices of HIV-serodifferent couples regarding HIV prevention strategies in the U.S. To help fill this gap, we conducted a mixed methods study with 27 mostly Black/African American and Latinx HIV-serodifferent heterosexual couples residing in New York City to explore their knowledge, attitudes, practices, and perspectives regarding combination HIV prevention, including condoms, PrEP and viral control. All couples expressed the desire to maintain viral suppression in the HIV-positive partner, which was not always achieved. There was considerable heterogeneity in the use of HIV prevention methods by couples; and several patterns emerged that were largely driven by gender and relationship dynamics. Female partners, in particular, expressed high levels of anxiety around transmission of HIV and thus desired multiple methods of protection. Healthcare providers should consider couples' psychosocial well-being, relationship quality, and other motivational factors when helping to tailor HIV preventative care for mixed-status couples.

Factors Associated With Partner Notification, Testing, and Positivity in HIV Partner Services Programs in the United States, 2013 to 2017

BACKGROUND

Human immunodeficiency virus (HIV) partner services are an essential component of comprehensive HIV prevention and care. We examined factors associated with partner notification, HIV testing, and HIV positivity among partners of HIV-diagnosed persons (index persons) contacted by Centers for Disease Control and Prevention (CDC)-funded state and local health departments.

METHODS

We analyzed partner service data submitted to the CDC by 61 state and local health departments from 2013 to 2017. Using multivariate Poisson regression-adjusted for clustering effects among partners reported by a common index person-we assessed associations between 3 outcomes of interest (partner notification, HIV testing, and HIV positivity) and the demographic characteristics, risk behaviors, geographic region, and service year of index persons and their partners.

RESULTS

A total of 51,368 sexual and/or needle-sharing partners were matched with 33,524 index persons. Of notifiable partners, 97.2% were notified of their potential HIV exposure, and 52.3% were tested for HIV. Among 21,842 notified and tested partners, 23.8% were newly diagnosed with an HIV infection. Partner notification, HIV testing, and HIV positivity were associated with both partner and index person characteristics (individually and interactively), geographic region, and year of service.

CONCLUSIONS

Partner service programs provided through CDC-funded health departments were effective in both partner notification and identification of undiagnosed HIV infection among partners. However, HIV testing rate among notified partners remained low. Implementing strategies to address gaps in HIV testing can contribute toward ending the HIV epidemic in the United States.

Implementation and evaluation of patient navigation in Chicago: Insights on addressing the social determinants of health and integrating HIV prevention and care services

Patient navigation is a primary element in linkage to HIV pre-exposure prophylaxis (PrEP) care and linkage to or re-engagement in HIV care, depending on the HIV status of the individual. However, there is a dearth of literature describing navigation services in these areas. In the context of Chicago Project PrIDE, this project conducted process and implementation evaluations with eight agencies leading demonstration projects to address these gaps. The evaluation team conducted semi-structured, individual interviews with agency staff (N = 20) assessing navigation implementation and fit, as well as project successes and challenges. Additionally, agency staff collected patient surveys (N = 300) assessing services provided, service quality, and satisfaction. The interview transcripts were coded and analyzed thematically and descriptive analyses were performed on the survey data. Analyses indicated that screening for social determinants of health, providing healthcare engagement guidance, and providing service referrals were frequently cited navigation activities. Most staff members indicated that navigation fits well within their agencies, and that limited staff and clinic capacity were often barriers to navigation. Patient navigation to support engagement in HIV prevention and care services is critical due to the extensive support provided by navigators to address social determinants of health impacting HIV disparity populations.

Postpartum Mother-To-Child Transmission of HIV in a Breastfeeding Infant

This article is an examination of MTCT of HIV through breastfeeding in a mother who seroconverted postnatally.

Heterosexual Cisgender Men Partnered with Transgender Women Exhibit Higher HIV/STI Sexual Risk than Their Gay, Bisexual, and Queer Counterparts: Findings from a U.S.-Based Convenience Sample Recruited Online

Cisgender men are frequently vectors for HIV transmission among transgender women. Despite this, the correlates of sexual risk among these men remain under-examined. The purpose of the present study was to explore potential differences in relationship characteristics, sexual risk-taking, and risk-reduction strategies among cisgender men partnered with transgender women. The study utilized secondary screening data provided by adult cis men who reported being in a primary relationship with a trans woman (N = 710). Gay men (18%) were comparatively older, and most likely to report both HIV seropositivity and committed pairings. Heterosexual men (14%) were more likely to report exchange sex, briefer relationships, extra-dyadic sex, lesser serostatus awareness or PrEP uptake. Queer men (7%) were youngest, and most likely to access PrEP. Heterosexual cis men with trans women partners may be subject to unique socio-cultural drivers of sexual risk, such as heteronormative pressures and relationship stigma.

The Magnetic Couples Study: protocol for a mixed methods prospective cohort study of HIV-serodifferent heterosexual couples' perspectives and use of pre-exposure prophylaxis (PrEP)

INTRODUCTION

HIV transmission within serodifferent heterosexual couples plays a key role in sustaining the global HIV pandemic. In the USA, transmission within established mixed-status couples accounts for up to half of all new HIV infections among heterosexuals. Oral HIV pre-exposure prophylaxis (PrEP) is a highly effective prevention method, although underutilised among serodifferent couples. Moreover, there is a dearth of research on US HIV-serodifferent couples' perspectives and use of PrEP, alone or in combination with other prevention methods. In this paper, we describe the study protocol for the Magnetic Couples Study, designed to fill critical knowledge gaps regarding HIV-serodifferent heterosexual couples' perspectives, experiences and utilisation of PrEP.

METHODS AND ANALYSIS

The Magnetic Couples Study is a mixed methods prospective cohort study designed to describe temporal patterns and identify determinants at multiple levels (individual, couple, HCF) of PrEP outcomes along the care continuum (PrEP awareness, linkage, uptake, retention and medication adherence) among HIV-serodifferent heterosexual couples residing in New York City. The study will also examine clinical management of PrEP, side effects and changes in sexual-related and substance use-related behaviour. A prospective cohort of 230 mixed-status couples already on oral PrEP was recruited, with quarterly assessments over 18 months; in addition, a cross-sectional sample of 150 mixed-status couples not currently on PrEP was recruited. In-depth semistructured qualitative interviews were conducted with a subsample of 25 couples. Actor-partner interdependence modelling using multilevel analysis will be employed for the analysis of longitudinal dyadic data. Framework analysis will be used to analyse qualitative data. A parallel convergent design will be used for mixed methods integration.

ETHICS AND DISSEMINATION

The study was approved by the University of Rochester Institutional Review Board (RSRB00052766). Study findings will be disseminated to community members and providers and to researchers and policy makers.

HIV supply chains in low- and middle-income countries: overview and research opportunities

Purpose

Despite HIV being reported as one of the major global health issues, availability and accessibility of HIV services and supplies remain limited, especially in low- and middle-income countries. The effective and efficient operation of HIV supply chains is critical to tackle this problem. The purpose of this paper is to give an introduction to HIV supply chains in low- and middle-income countries and identify research opportunities for the operations research/operations management (OR/OM) community.

Design/methodology/approach

First, the authors review a combination of the scientific and grey literature, including both qualitative and quantitative papers, to give an overview of HIV supply chain operations in low- and middle-income countries and the challenges that are faced by organizing such supply chains. The authors then classify and discuss the relevant OR/OM literature based on seven classification criteria: decision level, methodology, type of HIV service modeled, challenges, performance measures, real-life applicability and countries covered. Because research on HIV supply chains in low- and middle-income countries is limited in the OR/OM field, this part also includes papers focusing on HIV supply chain modeling in high-income countries.

Findings

The authors conclude this study by identifying several tendencies and gaps and by proposing future research directions for OR/OM research.

Originality/value

To the best of the authors’ knowledge, this paper is the first literature review addressing this specific topic from an OR/OM perspective.

Preexposure prophylaxis strategies for African-American women affected by mass incarceration

OBJECTIVE

We aimed to determine the effectiveness of various preexposure prophylaxis (PrEP) prescription strategies for African-American women impacted by mass incarceration within an urban setting.

DESIGN

An agent-based model was utilized to evaluate prevention strategies in an efficient, ethical manner. By defining agents, their characteristics and relationships, we assessed population-level effects of PrEP on HIV incidence.

METHODS

We tested hypothetical PrEP prescription strategies within a simulation representing the African-American population of Philadelphia, Pennsylvania. Four strategies were evaluated: PrEP for women meeting CDC indicators regarding partner characteristics, PrEP for women with a recently incarcerated male partner, PrEP for women with a recently released male partner and couples-based PrEP at time of release. Interventions occurred alongside scale-up of HAART. We evaluated reductions in HIV transmissions, the number of persons on PrEP needed to avert one HIV transmission (NNT) and the resulting proportions of people on PrEP.

RESULTS

Scenarios prescribing PrEP based on criminal justice system involvement reduced HIV transmissions. The NNT ranged from 147 (couples-based scenario) to 300 (recently released scenario). The percentage of the female population covered by PrEP at any one time ranged from 0.14% (couples-based) to 10.8% (CDC-based). CDC-guideline scenarios were consistently less efficient compared to the justice-involved interventions.

CONCLUSION

Expanding PrEP for African-American women and their male partners affected by incarceration should be considered in national HIV prevention goals and correctional facilities leveraged as intervention sites. Partner characteristics in the current CDC indications may be more effective and efficient if guidelines considered criminal justice involvement.

Pre-exposure prophylaxis (PrEP) awareness, attitudes and uptake willingness among young people: gender differences and associated factors in two South African districts

Background: Pre-exposure prophylaxis (PrEP) for HIV prevention is safe and effective in reducing HIV incidence. However, more evidence of PrEP knowledge, willingness and distribution preferences is required for scale-up among young people at-risk. Objective: To understand young people PrEP awareness, willingness and roll-out preferences. Methods: Young people (18-24y) were selected through multi-stage sampling in a cross-sectional household survey in low-income communities. Self-administered interviews collected participants' data about PrEP awareness, attitudes, willingness and HIV-risk practices. Data were descriptively analysed by gender. Regression models assessed factors associated with PrEP awareness and willingness by district. Results: Of the 1917 participants interviewed 44.6% (men = 39.4% vs women = 49%, p = 0.001) were PrEP aware, 49.0% were willing to use PrEP. Participants most preferred PrEP distribution channels were public clinics (51.2%) and hospitals (23.8%). More men than women preferred distribution through schools (11.9% vs7.8%; p = 0.002) and NGOs (8.5%vs5.4%; p = 0.008). The biggest barrier to PrEP willingness was inadequate PrEP knowledge (10.0%) but more men than women disliked taking pills daily (4.1%vs2.0%; p-value = 0.007). Gendered determinants to use PrEP were side effects (51%; men = 47% vs women = 55%; p = 0.001) and pill effectiveness (29.5%; men = 26.4% vs women = 32.6%; p = 0.003). In both districts PrEP knowledge was associated with being female and media use. The associations between PrEP awareness and having multiple sexual partnerships, HIV knowledge, HIV self-test willingness and belonging to social clubs differed by district. PrEP willingness was positively associated with having TB and PrEP knowledge in each district but district differences were observed in media and occupation factors. Conclusions: The study shows young people's low levels of PrEP awareness. It also shows relatively increased willingness, gendered PrEP awareness and distribution preferences. Promoting youth's PrEP awareness requires a multifarious media strategy. Abbreviations: HIV: human immunodeficiency virus; AIDS: Acquired immunodeficiency syndrome; aOR: Adjusted Odds ratio; PLWH: People living with HIV; PrEP: Pre-exposure Prophylaxis; UNAIDS: Joint United Nations Programme on HIV and AIDS; uOR: Unadjusted odds ratio; TB: Tuberculosis; WHO: World health Organisation; MSM: Men who have sex with men.

Long-acting approaches for delivery of antiretroviral drugs for prevention and treatment of HIV: a review of recent research

INTRODUCTION

Despite significant advances in treatment and prevention of HIV-1 infection, poor adherence to daily combination antiretroviral therapy (ART) regimens remains a major obstacle toward achieving sustained viral suppression and prevention. Adherence to ART could also be compromised by adverse drug reactions and societal factors that limit access to therapy. Therefore, medicines that aim to improve adherence by limiting ART side effects, frequency of dosing and socially acceptable regimens are becoming more attractive.

AREAS COVERED

This review highlights recent advances and challenges in the development of long-acting drug delivery strategies for HIV prevention and treatment. Approaches for extended oral and transdermal deliveries, microbicides, broadly neutralizing antibodies, and long-acting implantable and injectable deliveries are reviewed.

EXPERT OPINION

Emerging approaches on long-acting antiretroviral therapies and broadly neutralizing antibody technologies are currently at various stages of development. Such efforts, if successful and become broadly accepted by clinicians and users, will provide newer and simpler options for prevention and treatment of HIV infection.

Preconception Care Uptake and Immediate Outcomes among Discordant Couples Accessing Routine HIV Care in Kenya

Introduction

A large proportion of new HIV infections occur within discordant partnerships making discordance a significant contributor to new HIV infections in Africa. Despite the role of preconception care for HIV discordant couples, there is little data on fertility desire and preconception care uptake. This study aimed at documenting fertility desire (desire to conceive), determining the uptake of preconception care, identifying HIV prevention strategies used during preconception care, and determining immediate conception outcomes among HIV discordant couples in Kenya.

Methods

We retrospectively extracted electronic medical record data on discordant couples at an HIV care discordant couples' clinic. We included data on couples who expressed a desire to conceive and were offered preconception care and followed up for 29 months. We collected data on sociodemographic characteristics, preconception prevention methods, and associated outcomes.

Results

Among couples, with male HIV-positive partners, there was a twofold likelihood of accepting preconception services (OR = 2.3, CI 95% (1, 1, 5.0)). A shorter discordant union was independently associated with the uptake of preconception services (OR = 0.92, CI 95% (0.86, 0.98)). The most used prevention intervention (38.5%) among discordant couples was a combination of pre-exposure prophylaxis (PrEP) by the uninfected partner, alongside HAART by the partner living with HIV. Pregnancy rates did not significantly (p  =  0.06) differ among those who took up preconception care versus those who did not. HIV-negative partners of couples who declined preconception care had a significantly (p  =  0.04) higher attrition from clinic follow-up. One confirmed seroconversion occurred; an HIV incidence rate of 0.19 per 100 person-years.

Conclusion

The study demonstrates the feasibility of implementing safe and effective preconception servicesas part of routine HIV care for discordant couples living in low resource settings. The provision and the utilisation of safer conception services may be hindered by the poor retention to follow-up and care of HIV-negative partners. This challenge may impede the expected benefits of preconception care as an HIV prevention intervention.

Rapid-Release Griffithsin Fibers for Dual Prevention of HSV-2 and HIV-1 Infections

The biologic griffithsin (GRFT) has recently emerged as a candidate to safely prevent sexually transmitted infections (STIs), including human immunodeficiency virus type 1 (HIV-1) and herpes simplex virus 2 (HSV-2). However, to date, there are few delivery platforms that are available to effectively deliver biologics to the female reproductive tract (FRT). The goal of this work was to evaluate rapid-release polyethylene oxide (PEO), polyvinyl alcohol (PVA), and polyvinylpyrrolidone (PVP) fibers that incorporate GRFT in in vitro (HIV-1 and HSV-2) and in vivo (HSV-2) infection models. GRFT loading was determined via enzyme-linked immunosorbent assay (ELISA), and the bioactivity of GRFT fibers was assessed using in vitro HIV-1 pseudovirus and HSV-2 plaque assays. Afterwards, the efficacy of GRFT fibers was assessed in a murine model of lethal HSV-2 infection. Finally, murine reproductive tracts and vaginal lavage samples were evaluated for histology and cytokine expression, 24 and 72 h after fiber administration, to determine safety. All rapid-release formulations achieved high levels of GRFT incorporation and were completely efficacious against in vitro HIV-1 and HSV-2 infections. Importantly, all rapid-release GRFT fibers provided potent protection in a murine model of HSV-2 infection. Moreover, histology and cytokine levels, evaluated from collected murine reproductive tissues and vaginal lavage samples treated with blank fibers, showed no increased cytokine production or histological aberrations, demonstrating the preliminary safety of rapid-release GRFT fibers in vaginal tissue.

Human Immunodeficiency Virus Diagnosis After a Syphilis, Gonorrhea, or Repeat Diagnosis Among Males Including non-Men Who Have Sex With Men: What Is the Incidence?

One in 10 and 1 in 50 syphilis or gonorrhea diagnoses were followed by an human immunodeficiency virus diagnosis within 2 years among men who have sex with men and non–men who have sex with men males, respectively, in Baltimore City.

Background

The release of the first drug for human immunodeficiency virus (HIV) preexposure prophylaxis (PrEP) in 2012 marked the beginning of a new era of HIV prevention. Although PrEP is highly efficacious, identifying and ultimately increasing uptake among the highest risk male subgroups remains a challenge.

Methods

Public health surveillance data from 2009 to 2016 was used to evaluate the risk of an HIV diagnosis after a syphilis (ie, primary, secondary, or early latent), gonorrhea, and repeat diagnoses among urban males, including men who have sex with men (MSM) and non-MSM in Baltimore City.

Results

Of the 1531 males with 898 syphilis diagnoses and 1243 gonorrhea diagnoses, 6.8% (n = 104) were subsequently diagnosed with HIV. Within 2 years, 1 in 10 syphilis or gonorrhea diagnoses were followed by an HIV diagnosis among MSM, and 1 in 50 syphilis or gonorrhea diagnoses were followed by an HIV diagnosis among non-MSM. Among non-MSM with gonorrhea, the rate of HIV incidence was 5.36 (95% confidence interval, 2.37–12.14) times higher in those with (vs. without) a subsequent syphilis diagnosis or gonorrhea diagnosis.

Conclusions

Local health care providers should offer PrEP to MSM diagnosed with syphilis or gonorrhea and to non-MSM with a previous gonorrhea diagnosis at time of a syphilis or gonorrhea diagnosis. The high proportion and short time to an HIV diagnosis among MSM after a syphilis or gonorrhea diagnosis suggest immediate PrEP initiation.

"Now that PrEP is reducing the risk of transmission of HIV, why then do you still insist that we use condoms?" the condom quandary among PrEP users and health care providers in Kenya

Communication around condom use in the context of PrEP services presents a potential conundrum for patients and providers. Within the Partners Scale-Up Project, which supports integration of PrEP delivery in HIV care clinics, we interviewed 41 providers and 61 PrEP users and identified themes relating to condom messaging and use. Most providers counselled PrEP initiators to always use both PrEP and condoms, except when trying to conceive. However, others reported contexts and rationales for not emphasizing condom use. Providers reported that PrEP users were sometimes confused, even frustrated, with their insistence on using condoms in addition to PrEP. PrEP users generally regarded PrEP as a more feasible and desirable HIV prevention method than condoms, enabling increased sexual pleasure and conception, and reducing the conflict and stigma associated with condom use. Innovative approaches to condom counselling in PrEP programs are needed.

Sustained-release Griffithsin nanoparticle-fiber composites against HIV-1 and HSV-2 infections

Human immunodeficiency virus (HIV-1) and herpes simplex virus 2 (HSV-2) affect hundreds of millions of people worldwide. The antiviral lectin, Griffithsin (GRFT), has been shown to be both safe and efficacious against HSV-2 and HIV-1 infections in vivo. The goal of this work was to develop a multilayered nanoparticle (NP)-electrospun fiber (EF) composite to provide sustained-release of GRFT, and to examine its safety and efficacy in a murine model of lethal HSV-2 infection. Composites were fabricated from polycaprolactone (PCL) fibers surrounding polyethylene oxide (PEO) fibers that incorporated methoxy poly(ethylene glycol)-b-poly(lactide-co-glycolide) (mPEG-PLGA) GRFT NPs. GRFT loading and release were determined via ELISA, showing that NP-EF composites achieved high GRFT loading, and provided sustained-release of GRFT for up to 90 d. The in vitro efficacy of GRFT NP-EFs was assessed using HIV-1 pseudovirus assays, demonstrating complete in vitro protection against HIV-1 infection. Additionally, sustained-release NP-EFs, administered 24 h prior to infection, prevented against a lethal dose of HSV-2 infection in a murine model. In parallel, histology and cytokine expression from murine reproductive tracts and vaginal lavages collected 24 and 72 h post-administration were similar to untreated mice, suggesting that NP-EF composites may be a promising and safe sustained-delivery platform to prevent HSV-2 infection. Future work will evaluate the ability to provide prolonged protection against multiple virus challenges, and different administration times with respect to infection.

A Cross-sectional Survey of Internal Medicine Resident Knowledge, Attitudes, Behaviors, and Experiences Regarding Pre-Exposure Prophylaxis for HIV Infection

BACKGROUND

Pre-exposure prophylaxis (PrEP) for HIV is effective, yet many providers continue to lack knowledge and comfort in providing this intervention. It remains unclear whether internal medicine (IM) residents receive appropriate training in PrEP care and if this affects their future practices.

OBJECTIVE

We sought to evaluate the relationship between current IM residents' prior PrEP training and knowledge, comfort, and practice regarding the provision of PrEP.

DESIGN AND PARTICIPANTS

We created an online survey to assess IM residents' knowledge, attitudes, and behaviors related to PrEP. The survey was distributed among five IM programs across the USA.

KEY RESULTS

We had a 35% response rate. Of 229 respondents, 96% (n = 220) had heard of PrEP but only 25% (n = 51) had received prior training and 11% (n = 24) had prescribed PrEP. Compared with those without, those with prior training reported good to excellent knowledge scores regarding PrEP (80% versus 33%, p < 0.001), more frequent prescribing (28% versus 7%, p = 0.001), and higher comfort levels with evaluating risk for HIV, educating patients, and monitoring aspects of PrEP (75% versus 26%, 56% versus 16%, and 47% versus 8%, respectively; all p values < 0.0001). While only 25% (n = 51) had received prior training, 75% (n = 103) of respondents reported that training all providers at their continuity clinic sites would improve implementation.

CONCLUSIONS

We found that prior training was associated with higher levels of self-reported PrEP knowledge, comfort, and prescribing behaviors. Given the significant need for PrEP, IM residents should be trained to achieve adequate knowledge and comfort levels to prescribe it. This study demonstrates that providing appropriate PrEP training for IM residents may lead to an increase in the pool of graduating IM residents prescribing PrEP.

Semi-solid prodrug nanoparticles for long-acting delivery of water-soluble antiretroviral drugs within combination HIV therapies

The increasing global prevalence of human immunodeficiency virus (HIV) is estimated at 36.7 million people currently infected. Lifelong antiretroviral (ARV) drug combination dosing allows management as a chronic condition by suppressing circulating viral load to allow for a near-normal life; however, the daily burden of oral administration may lead to non-adherence and drug resistance development. Long-acting (LA) depot injections of nanomilled poorly water-soluble ARVs have shown highly promising clinical results with drug exposure largely maintained over months after a single injection. ARV oral combinations rely on water-soluble backbone drugs which are not compatible with nanomilling. Here, we evaluate a unique prodrug/nanoparticle formation strategy to facilitate semi-solid prodrug nanoparticles (SSPNs) of the highly water-soluble nucleoside reverse transcriptase inhibitor (NRTI) emtricitabine (FTC), and injectable aqueous nanodispersions; in vitro to in vivo extrapolation (IVIVE) modelling predicts sustained prodrug release, with activation in relevant biological environments, representing a first step towards complete injectable LA regimens containing NRTIs.

Non-adherence to daily drug regimens is responsible for many negative clinical effects including drug resistance in life-long treatments for HIV. Here, the authors report on a HIV prodrug nanoparticle platform for long-acting sustained release of water-soluble drug compounds following injection.

Effects of gel volume on pharmacokinetics for vaginal and rectal applications of combination DuoGel-IQB4012, a dual chamber-dual drug HIV microbicide gel, in pigtailed macaques

This study evaluated effects of differing gel volumes on pharmacokinetics (PK). IQB4012, a gel containing the non-nucleoside reverse transcriptase inhibitor IQP-0528 and tenofovir (TFV), was applied to the pigtailed macaque vagina and rectum. Vaginal gel volumes (1% loading of both drugs) were 0.5 or 1.5 ml; following wash-out, 1 or 4 ml of gel were then applied rectally. Blood, vaginal, and rectal fluids were collected at 0, 2, 4, and 24 h. Vaginal and rectal tissue biopsies were collected at 4 and 24 h. There were no statistically significant differences in concentrations for either drug between gel volumes within compartments at matched time points. After vaginal gel application, median IQP-0528 concentrations were ~ 10⁴-10⁵ ng/g, 10⁵-10⁶ ng/ml, and 10³-10⁵ ng/ml in vaginal tissues, vaginal fluids, and rectal fluids, respectively (over 24 h). Median vaginal TFV concentrations were 1-2 logs lower than IQP-0528 levels at matched time points. After rectal gel application, median IQP-0528 and TFV concentrations in rectal fluids were ~ 10³-10⁵ ng/ml and ~ 10²-10³ ng/ml, respectively. Concentrations of both drugs sampled in rectal tissues were low (~ 10¹-10³ ng/g). For 1 ml gel, half of sampled rectal tissues had undetectable concentrations of either drug, and over half of sampled rectal fluids had undetectable TFV concentrations. These results indicate differences in drug delivery between the vaginal and rectal compartments, and that smaller vaginal gel volumes may not significantly compromise microbicide PK and prophylactic potential. However, effects of rectal gel volume on PK for both drugs were less definitive.

PrEParing Women to Prevent HIV: An Integrated Theoretical Framework to PrEP Black Women in the United States

Preexposure prophylaxis (PrEP) with optimal adherence has demonstrated efficacy in reducing HIV incidence in women. Black women are disproportionately burdened by the HIV epidemic, accounting for more than half of all new HIV cases in women, thereby making PrEP an ideal prevention strategy for this group. However, to date, PrEP uptake by women in the United States has been slow. Further domestic research is needed to understand the multilevel factors related to PrEP awareness, uptake, and implementation in Black women. Our purpose was to review the current status of HIV prevention in Black women. We summarize clinical trials germane to federal approval of PrEP; discuss important PrEP studies focused on women, including non-oral options; and review multilevel barriers to PrEP uptake. Lastly, we discuss the use of an integrated theoretical framework to organize multilevel factors related to PrEP uptake by Black women in order to guide intervention development.

Improving PrEP Implementation Through Multilevel Interventions: A Synthesis of the Literature

There are many challenges to accessing PrEP and thus low uptake in the United States. This review (2007–2017) of PrEP implementation identified barriers to PrEP and interventions to match those barriers. The final set of articles (n = 47) included content on cognitive aspects of HIV service providers and individuals at risk for infection, reviews, and case studies. Cognitive barriers and interventions regarding patients and providers included knowledge, attitudes, and beliefs about PrEP. The “purview paradox” was identified as a key barrier—HIV specialists often do not see HIV-negative patients, while primary care physicians, who often see uninfected patients, are not trained to provide PrEP. Healthcare systems barriers included lack of communication about, funding for, and access to PrEP. The intersection between PrEP-stigma, HIV-stigma, transphobia, homophobia, and disparities across gender, racial, and ethnic groups were identified; but few interventions addressed these barriers. We recommend multilevel interventions targeting barriers at multiple socioecological domains.

To switch or not to switch: Intentions to switch to injectable PrEP among gay and bisexual men with at least twelve months oral PrEP experience

BACKGROUND

Phase III trials of long-acting injectable (LAI) PrEP, currently underway, have great potential for expanding the menu of HIV prevention options. Imagining a future in which multiple PrEP modalities are available to potential users of biomedical HIV prevention, we investigated which factors might help direct a patient-physician shared-decision making process to optimize the choice of biomedical HIV prevention method.

METHODS

Participants (n = 105; ages 19-63; 46.7% men of color) were former participants in a PrEP demonstration project and had taken daily oral PrEP for ≥ 12 months. Participants were given information about LAI PrEP and asked whether they would be interested in switching from oral to LAI PrEP. Participants were also asked about specific pros/cons of LAI PrEP, PrEP attitudes and experiences, and personality factors.

RESULTS

Two-thirds (66.7%) of current oral PrEP users would switch to LAI PrEP. Intention to switch was associated with product-level and psychosocial factors. Attitudes towards logistical factors (i.e. getting to regular clinic visits for recurring shots) featured more prominently than factors related to the physical experience of PrEP modality (i.e., concerns about injection pain) as motivators for switching. In a multivariate regression model, psychosocial factors including the emotional burden of daily pill taking, deriving a sense of responsibility from PrEP use, and self-identifying as an early adopter, were the strongest predictors of switching.

CONCLUSIONS

These data underscore the importance of attending not only to product-level factors, but also to the logistical and psychological experience of prevention methods for users. Findings have significant implications for the development of patient education materials and patient-provider shared decision aids.

Host and Viral Factors Influencing Interplay between the Macrophage and HIV-1

HIV-1 persists in cellular reservoirs that cannot be eliminated by antiretroviral therapy (ART). The major reservoir in infected individuals on effective ART is composed of resting memory CD4+ T cells that harbor proviral cDNA, and undergo a state of latency in which viral gene expression is minimal to absent. The CD4+ T cell reservoir has been extensively characterized. However, other HIV-1-permissive cells may contribute to HIV-1 persistence. Lentiviruses have a long recognized association with macrophages. However, the role, if any, played by macrophages in HIV-1 persistence is not well understood. Macrophages are resistant to cell death upon HIV-1 infection, and can survive for long periods of time, making them ideal host cells in which the virus might persist. Studying macrophages is challenging, as these cells reside in nearly all tissues. Moreover, detecting viral DNA or RNA in macrophages does not necessarily indicate that these cells will produce replication-competent viral particles. Currently, the gold standard assay to detect cellular reservoirs is the ex vivo quantitative viral outgrowth assay (QVOA), which requires a patient blood draw. However, macrophages reside deep within tissues that are inaccessible in living subjects, such as the central nervous system (CNS). Therefore, tools other than QVOA must be developed to identify cellular reservoirs that reside in the tissues. In this review, we will focus on the main aspects involved in HIV-1 persistence, including the molecular mechanisms of viral evasion, the main cell types responsible for harboring persistent HIV-1 and the tissue compartments that are likely to be reservoirs for HIV-1.

Molecular Docking Studies of HIV-1 Resistance to Reverse Transcriptase Inhibitors: Mini-Review

Currently, millions of people are living with human immunodeficiency virus type 1 (HIV-1), which causes acquired immunodeficiency syndrome. However, the spread of the HIV-1 resistance to antiviral agents is the major problem in the antiretroviral therapy and medical management of HIV-infected patients. HIV-1 reverse transcriptase (RT) is one of the key viral targets for HIV-1 inhibition. Therefore, the studies on the combatting the HIV resistance that occurs due to the structural changes in RT, are in great demand. This work aims to provide an overview of the state-of-the-art molecular docking approaches applied to the studies of the HIV-1 resistance, associated with RT structure changes. We have reviewed recent studies using molecular docking with mutant forms of RT. The work discusses the modifications of molecular docking, which have been developed to find the novel molecules active against resistance mutants of RT and/or recombinant strains of HIV-1. The perspectives of the existing algorithms of molecular docking to the studies on molecular mechanisms of resistance and selection of the correct binding poses for the reverse transcriptase inhibitors are discussed.

Evolving Models and Ongoing Challenges for HIV Preexposure Prophylaxis Implementation in the United States

BACKGROUND

The use of preexposure prophylaxis (PrEP) for HIV prevention was approved by the Food and Drug Administration in 2012, but delivery to at-risk persons has lagged. This critical review analyzes the current state of PrEP implementation in the United States, by reviewing barriers and innovative solutions to enhance PrEP access and uptake.

SETTING

Clinical care settings, public health programs, and community-based organizations (CBOs).

METHODS

Critical review of recent peer-reviewed literature.

RESULTS

More than 100 papers were reviewed. PrEP is currently provided in diverse settings. Care models include sexually transmitted disease clinics, community health centers, CBOs, pharmacies, and private primary care providers (PCPs). Sexually transmitted disease clinics have staff trained in sexual health counseling and are linked to public health programs (eg, partner notification services), whereas PCPs and community health centers may be less comfortable counseling and feel time-constrained in managing PrEP. However, PCPs may be ideal PrEP providers, given their long-term relationships with patients, integrating PrEP into routine care. Collaborations with CBOs can expand PrEP care through adherence support and insurance navigation. Pharmacies can deliver PrEP, given their experience with medication dispensing and counseling, and may be more accessible for some patients, but to address other health concerns, liaisons with PCPs may be needed.

CONCLUSIONS

PrEP implementation in the United States is moving forward with the development of diverse models of delivery. Optimal scale-up will require learning about the best features of each model and providing choices to consumers that enhance engagement and uptake.

Multipurpose tenofovir disoproxil fumarate electrospun fibers for the prevention of HIV-1 and HSV-2 infections in vitro

Sexually transmitted infections affect hundreds of millions of people worldwide. Both human immunodeficiency virus (HIV-1 and -2) and herpes simplex virus-2 (HSV-2) remain incurable, urging the development of new prevention strategies. While current prophylactic technologies are dependent on strict user adherence to achieve efficacy, there is a dearth of delivery vehicles that provide discreet and convenient administration, combined with prolonged-delivery of active agents. To address these needs, we created electrospun fibers (EFs) comprised of FDA-approved polymers, poly(lactic-co-glycolic acid) (PLGA) and poly(DL-lactide-co-ε-caprolactone) (PLCL), to provide sustained-release and in vitro protection against HIV-1 and HSV-2. PLGA and PLCL EFs, incorporating the antiretroviral, tenofovir disoproxil fumarate (TDF), exhibited sustained-release for up to 4 weeks, and provided complete in vitro protection against HSV-2 and HIV-1 for 24h and 1 wk, respectively, based on the doses tested. In vitro cell culture and EpiVaginal tissue tests confirmed the safety of fibers in vaginal and cervical cells, highlighting the potential of PLGA and PLCL EFs as multipurpose next-generation drug delivery vehicles.

Experiences Using Pre-Exposure Prophylaxis for Safer Conception Among HIV Serodiscordant Heterosexual Couples in the United States

Antiretroviral pre-exposure prophylaxis (PrEP) is a promising HIV prevention strategy for HIV serodiscordant couples (HIV-infected male, uninfected female) seeking safer conception. However, most research on PrEP for safer conception has focused on couples in sub-Saharan Africa; little is known about the perspectives or experiences of heterosexual couples in the United States. We conducted qualitative interviews with six couples (six women and five of their male partners) receiving PrEP for conception services at an urban safety net hospital in the US Northeast. In-depth interview guides explored couple relationships and contextual factors and attitudes, perceptions, and decision-making processes surrounding PrEP for safer conception. Thematic analyses focused on identifying the following emergent themes. We found that couple relationships were situated within broader social and cultural contexts of immigration, family, and community that shaped their experiences with HIV and serodiscordant relationship status. Despite strong partner support within relationships, HIV stigma and disapproval of serodiscordant relationships contributed to couples' feelings of social isolation and subsequent aspirations to have "normal" families. By enabling "natural" conception through condomless sex, PrEP for safer conception provided a sense of enhanced relationship intimacy. Couples called for increasing public awareness of PrEP through positive messaging as a way to combat HIV stigma. Findings suggest that relationship dynamics and broader social contexts appear to shape HIV serodiscordant couples' fertility desires and motivations to use PrEP. However, increased public awareness of PrEP for safer conception may be needed to combat HIV stigma at the community level.

HIV Testing and Positivity Patterns of Partners of HIV-Diagnosed People in Partner Services Programs, United States, 2013-2014

OBJECTIVE

Human immunodeficiency virus (HIV) partner services are an integral part of comprehensive HIV prevention programs. We examined the patterns of HIV testing and positivity among partners of HIV-diagnosed people who participated in partner services programs in CDC-funded state and local health departments.

METHODS

We analyzed data on 21 484 partners submitted in 2013-2014 by 55 health departments. We conducted descriptive and multivariate analyses to examine patterns of HIV testing and positivity by demographic characteristics and geographic region.

RESULTS

Of 21 484 partners, 16 275 (75.8%) were tested for HIV; 4503 of 12 886 (34.9%) partners with test results were identified as newly HIV-positive. Compared with partners aged 13-24, partners aged 35-44 were less likely to be tested for HIV (adjusted odds ratio [aOR] = 0.86; 95% confidence interval [CI], 0.78-0.95) and more likely to be HIV-positive (aOR = 1.35; 95% CI, 1.20-1.52). Partners who were male (aOR = 0.89; 95% CI, 0.81-0.97) and non-Hispanic black (aOR = 0.68; 95% CI, 0.63-0.74) were less likely to be tested but more likely to be HIV-positive (male aOR = 1.81; 95% CI, 1.64-2.01; non-Hispanic black aOR = 1.52; 95% CI, 1.38-1.66) than partners who were female and non-Hispanic white, respectively. Partners in the South were more likely than partners in the Midwest to be tested for HIV (aOR = 1.56; 95% CI, 1.35-1.80) and to be HIV-positive (aOR = 2.18; 95% CI, 1.81-2.65).

CONCLUSIONS

Partner services programs implemented by CDC-funded health departments are successful in providing HIV testing services and identifying previously undiagnosed HIV infections among partners of HIV-diagnosed people. Demographic and regional differences suggest the need to tailor these programs to address unique needs of the target populations.

Predictors of HIV-related risk perception and PrEP acceptability among young adult female family planning patients

HIV pre-exposure prophylaxis (PrEP) presents new opportunities for HIV prevention. While women comprise approximately 20% of new HIV infections in the US, significant questions remain about how to most effectively facilitate PrEP uptake for this population. Family planning clinics are a dominant source of health care for young women and support an estimated 4.5 million women annually. We explore characteristics associated with HIV risk perception and PrEP acceptability among young adult women seeking reproductive health services in a high-prevalence setting. A cross-sectional, clinic-based survey was conducted with women ages 18-35 (n = 146) seeking health care at two family planning clinics in the greater Baltimore, Maryland area, from January to April 2014. An estimated 22% of women reported being worried about HIV risk, and 60% reported they would consider taking a pill daily to prevent HIV. In adjusted models, HIV-related worry was associated with having no college education, being single or dating more than one person, practicing consistent condom use during vaginal sex, and having ever traded sex. PrEP acceptability was significantly associated with being Black (71% vs. 49%, AOR 2.23, CI: 1.89-2.64) and having ever traded sex (83% vs. 58%, AOR 4.94, CI: 2.00-12.22). For women with a history of intimate partner violence (IPV), PrEP acceptability was significantly lower (57% vs. 62%, AOR .71, CI: .59-.85) relative to their non-abused counterparts. Results suggest that family planning clinics may be a natural setting for PrEP discussion and roll-out. They should be considered in the context of integrating HIV prevention with reproductive health services. Women with a trauma history may need additional support for implementing HIV prevention in the form of PrEP.

HIV-Enhancing and HIV-Inhibiting Properties of Cationic Peptides and Proteins

Cationic antimicrobial peptides and proteins have historically been ascribed roles in innate immunity that infer killing of microbial and viral pathogens and protection of the host. In the context of sexually transmitted HIV-1, we take an unconventional approach that questions this paradigm. It is becoming increasingly apparent that many of the cationic polypeptides present in the human genital or anorectal mucosa, or human semen, are capable of enhancing HIV-1 infection, often in addition to other reported roles as viral inhibitors. We explore how the in vivo environment may select for or against the HIV-enhancing aspects of these cationic polypeptides by focusing on biological relevance. We stress that the distinction between enhancing and inhibiting HIV-1 infection is not mutually exclusive to specific classes of cationic polypeptides. Understanding how virally enhancing peptides and proteins act to promote sexual transmission of HIV-1 would be important for the design of topical microbicides, mucosal vaccines, and other preventative measures.

Pre- and post-sexual exposure prophylaxis of HIV: An update

Pitfalls in current HIV prevention strategies include late HIV testing, vulnerability among youth and females; lack of emphasis on treatment, low acceptance of circumcision, and nonavailability of protective vaccines. Continuing high-risk sexual behavior, forceful sex, coercive and nonconsensual sex, rape, and unprotected sexual activities make women the most vulnerable to acquisition of sexually transmitted infection/HIV and necessitates a more radical approach of prevention in high-risk individuals who do not have HIV. Preexposure prophylaxis is defined as the administration of antiretroviral drugs to an uninfected person before potential HIV exposure to reduce the risk of infection and continued during risk. The rationale of this approach is to administer preventive dose of drug(s) before exposure to HIV so the moment virus enters the body, HIV replication is inhibited and HIV is not able to establish permanent infection. Postexposure prophylaxis (PEP) following potential sexual exposure is an important form of nonoccupational PEP which is an emergency intervention to abort HIV acquisition arising from exposure to HIV-infected blood or potentially infectious bodily fluids following sexual exposure.

Influences of geo-spatial location on pre-exposure prophylaxis use in South Africa: positioning microbicides for better product uptake

Young women bear a disproportionately high burden of HIV infection in sub-Saharan Africa, prioritising pre-exposure prophylaxis (PrEP) can be an integral part of HIV prevention combination strategies. Women initiated HIV prevention technology options will require consistent adherence, an imperative for product effectiveness. With several PrEP clinical trials underway; exploring women's acceptability to advances in HIV prevention technologies can better facilitate demand creation for future PrEP roll out. This study utilised the opportunity of post-trial access to CAPRISA 008 women (trial) and non-trial women from three geo-spatial settings (urban, rural and peri-urban) to identify microbicide acceptability and how product associations of microbicides can influence future HIV prevention choices. Six participatory workshops using participatory action research with art-based activities and discussion groups were conducted in KwaZulu-Natal with 104 women from various geo-spatial locations and social status to understand microbicide acceptability and product associations. The data were analysed using thematic analysis. The study found that women's acceptability and product association of the tenofovir gel microbicide differed according to rural and urban areas. Most urban women identified confidence, sexiness and classiness as key associations that will encourage microbicide acceptability and use, while rural women identified respect, responsibility and confidence as the key product associations, with increased focus on the individual and collective family/community benefits of product acceptance and use. Urban-rural differences suggest a market segmentation that is contextualised to be locally responsive to promote HIV prevention technologies. Various sexual encounters further determined the types of HIV prevention technologies women would consider. In line with WHO's recommendation that PrEP should be an additional prevention choice for people at risk of HIV, this study underscores the importance of user engagement, understanding product associations and how this can influence product acceptability and promotion of HIV prevention technologies.

Couples Living with HIV

BACKGROUND

Desires to have children are not lessened by a woman's HIV status. Couples may lack information to conceive safely, and men may be especially uninformed. This study examined reproductive intentions, practices, and attitudes among men in HIV-infected couples, including attitudes regarding the perceived risk of vertical and horizontal transmission, safer conception, and preconception planning.

METHODS

Men ( n = 12) in HIV-infected couples were interviewed regarding reproductive intentions, attitudes, and knowledge and qualitative assessments were coded for dominant themes.

RESULTS

Themes primarily addressed concerns about the health of the baby, men's involvement in pregnancy, safer conception, concerns about HIV transmission and antiretroviral therapy, and HIV infection. Men lacked information on safer conception and newer HIV prevention strategies, such as pre-exposure prophylaxis (PrEP).

DISCUSSION

Gaps in knowledge regarding preconception practices among men in HIV-infected couples were identified. Results highlight men's desire for involvement in preconception planning, and opportunities for providers to facilitate this practice and to increase patient education and the use of PrEP are discussed.

Pregnancy Desire, Partner Serodiscordance, and Partner HIV Disclosure among Reproductive Age HIV-Infected Women in an Urban Clinic

Women comprise 25% of the US HIV epidemic, with many women of reproductive age. There is a need for providers to address the reproductive needs and desires of women with HIV given that effective antiretroviral therapy has transformed HIV into a chronic disease. This cross-sectional study shows high rates of partner serodiscordance (61%) and moderate HIV disclosure to partners (61%). Patients surveyed reported practitioners discuss condoms (94%) and contraception (71%) more often than pregnancy desire (38%). In our sample, 44% of the surveyed women intended future pregnancy, whereas women who did not intend future pregnancy cited HIV/health and serodiscordance as the most common reasons (56% and 35%, resp.). There was no difference in the knowledge of mother-to-child transmission risk between women who intended or did not intend future pregnancy (p = 0.71). These results underline the need for provider training in reproductive counseling to promote risk reduction and education.

Pre-Exposure Prophylaxis (PrEP) for Safer Conception Among Serodifferent Couples: Findings from Healthcare Providers Serving Patients with HIV in Seven US Cities

Pre-exposure prophylaxis (PrEP) can reduce the risk of HIV transmission among serodifferent couples trying to conceive, yet provider knowledge, attitudes, and experience utilizing PrEP for this purpose are largely unexamined. Trained interviewers conducted phone interviews with healthcare providers treating patients with HIV in seven cities (Atlanta, Baltimore, Houston, Kansas City, Newark, Philadelphia, and San Francisco, N = 85 total). Quantitative and qualitative data were analyzed to describe experience, concerns, and perceived barriers to prescribing PrEP for safer conception. Providers (67.1% female, 43 mean years of age, 70.4% white, 10 mean years treating HIV+ patients, 56% in academic vs. community facilities, 62.2% MD) discussed both benefits and concerns of PrEP for safer conception among serodifferent couples. Only 18.8% of providers reported experience prescribing PrEP, 74.2% were willing to prescribe it under ideal circumstances, and 7.0% were not comfortable prescribing PrEP. Benefits included added protection and a greater sense of control for the HIV-negative partner. Concerns were categorized as clinical, system-level, cost, or behavioral. Significant differences in provider characteristics existed across sites, but experience with PrEP for safer conception did not, p = 0.14. Despite limited experience, most providers were open to recommending PrEP for safer conception as long as patients understood the range of concerns and could make informed decisions. Strategies to identify and link serodifferent couples to PrEP services and clinical guidance specific to PrEP for safer conception are needed.

"Everything I Needed from Her Was Everything She Gave Back to Me:" An Evaluation of Preconception Counseling for U.S. HIV-serodiscordant Couples Desiring Pregnancy

OBJECTIVES

We sought to evaluate preconception counseling (PCC) through a qualitative examination of the experiences of couples with serodiscordant human immunodeficiency virus (HIV) status desiring pregnancy.

METHODS

Patients involved in HIV-serodiscordant relationships who received PCC between January 2013 and January 2015 were recruited to participate in 40-minute semistructured telephone interviews. Participants were asked about their experiences with PCC and the impact of counseling on their knowledge of safer conception strategies and reproductive decisions. Two researchers independently coded interview transcripts, and delineated common ideas to generate emerging themes from participants' responses.

RESULTS

Eleven respondents completed the interviews, including nine women and two men. Six respondents were HIV positive. Our thematic analysis revealed that patients gained knowledge and confidence through PCC that conception was both possible and safe. They had varied reactions to assisted reproductive technologies that correlated with income level, and explored complicated weighing of personal risk of HIV transmission. Patients reported major challenges including poor access to PCC, difficulty identifying peak fertility periods, and lack of long-term conception follow-up.

DISCUSSION

PCC is a valuable resource for patients involved in HIV-serodiscordant relationships. We recommend the following opportunities for improvement: developing practical safer conception clinical and counseling guidelines for HIV-affected couples, increasing patient access to and awareness of PCC services, distributing more helpful resources to identify peak fertility, and providing long-term support for patients.

Perceived Advantages and Disadvantages of Using Pre-Exposure Prophylaxis (PrEP) among Sexually Active Black Women: An Exploratory Study

Knowledge of pre-exposure prophylaxis (PrEP) continues to remain scarce among Black women who are disproportionally affected by HIV in the United States. A thematic analysis of open-ended questions from a sample of Black women (n=119) who completed a mix-methods, online, e-health study was conducted to examine the perceived advantages and disadvantages of using PrEP. Being a female controlled method, empowerment, option for women with risky sex partners, and serodiscordant couples were advantages described. Disadvantages of PrEP were identified as the complexity of the choice, encouragement of sex with risky partners, increased burden, promotion of unprotected sex, and newness of the drug.

Pharmacologic prevention of human immunodeficiency virus in women: practical approaches for the obstetrician and gynecologist

IMPORTANCE

Obstetricians and gynecologists (Ob-Gyns) play a crucial role in efforts to detect and prevent human immunodeficiency virus (HIV) infection in women. Multiple strategies can be implemented into general practice as part of a comprehensive primary women's health care agenda. Educational and behavioral strategies to reduce HIV acquisition in women can now be supplemented with pharmacologic measures.

OBJECTIVE

This article aimed to review the literature regarding preexposure prophylaxis (PrEP) for HIV prevention in women. After reading this article, readers should be able to describe available methods to prevent HIV acquisition in women, select appropriate candidates for PrEP, and outline the steps necessary for initiation of PrEP.

EVIDENCE ACQUISITION

A review of the available literature was obtained by a PubMed search of HIV prevention, women, preexposure prophylaxis, and PrEP. Additional information was obtained from the Centers for Disease Control and Prevention; the American Congress of Obstetricians and Gynecologists; and expert opinion in the fields of obstetrics and gynecology, infectious diseases, and reproductive infectious diseases.

RESULTS

This review of the literature summarizes the efficacy of PrEP in HIV prevention and identifies limitations and barriers of PrEP. Women who are at risk for HIV acquisition and candidates for PrEP are clearly defined. Certain populations face unique challenges in HIV prevention and the administration of PrEP, and clinical guidelines and references are provided. This article provides a practical guide for the initiation, maintenance, and discontinuation of PrEP for the general Ob-Gyn.

CONCLUSIONS

Preexposure prophylaxis is an effective measure to prevent HIV in women. The Ob-Gyn plays a key role in the identification of at-risk women and the initiation of HIV prevention.

RELEVANCE

This information is relevant to general Ob-Gyns and other women's health providers.

Minimal Awareness and Stalled Uptake of Pre-Exposure Prophylaxis (PrEP) Among at Risk, HIV-Negative, Black Men Who Have Sex with Men

In the United States, rates of HIV infection are highest among black men who have sex with men (BMSM). Pre-exposure prophylaxis (PrEP) is a highly effective form of HIV prevention, but the uptake of this strategy has been slow since FDA approval in 2012, and it is unknown whether information about PrEP is reaching BMSM. Four hundred and thirty-six BMSM in Atlanta, GA were surveyed from January 2012 (6 months prior to PrEP approval) to March 2014 (20 months after approval). Analyses revealed no association between date of survey assessment and awareness of PrEP (20.5% were aware of PrEP before approval and 23.4% were aware after approval; OR=0.99 [0.98-1.02], p=0.952). In a multivariate model, BMSM unaware of PrEP reported lower rates of HIV testing knowledge, fewer experiences with HIV testing, and higher rates of transactional sex than BMSM who were aware of PrEP. Our findings suggest that there is limited understanding of PrEP and that there is considerable groundwork that needs to be achieved in order to reap the full benefits of PrEP. The current findings call attention to the need to both prioritize and better understand how to strengthen the bridge between medical advances and community uptake.

Beyond "getting drugs into bodies": social science perspectives on pre-exposure prophylaxis for HIV

Social scientists have much to contribute to the analysis of the real and potential contribution of pre-exposure prophylaxis (PrEP) to HIV prevention around the world. Beyond just a matter of clinical efficacy and getting pills into people's mouths, PrEP raises a number of important social-psychological questions that must be attended to in order to translate biomedical and clinical findings into uptake of PrEP among enough people at risk of HIV infection to produce population-level effectiveness. PrEP is a dynamic phenomenon with “dialectical” attributes that invite both optimism and cynicism as a desirable and effective HIV prevention strategy. PrEP disrupts traditional notions of “safe” and “unsafe” sex; it confers on its users a level of agency and control not generally achieved with condoms; and it affects sexual practices and sexual cultures in meaningful ways. As these dynamics play out in different contexts, and as new modes of PrEP administration emerge, it will be important for social scientists to be engaged in assessing their impact on PrEP implementation and effectiveness.