Does HIV Pre-Exposure Prophylaxis Modify the Effect of Partnership Characteristics on Condom Use? A Cross-Sectional Study of Sexual Partnerships Among Men Who Have Sex with Men in San Francisco, California

Sexual Mixing by HIV Status and Pre-exposure Prophylaxis Use Among Men Who Have Sex With Men: Addressing Information Bias

BACKGROUND

Population-level estimates of sexual network mixing for parameterizing prediction models of pre-exposure prophylaxis (PrEP) effectiveness are needed to inform prevention of HIV transmission among men who have sex with men (MSM). Estimates obtained by egocentric sampling are vulnerable to information bias due to incomplete respondent knowledge.

METHODS

We estimated patterns of serosorting and PrEP sorting among MSM in the United States using data from a 2017-2019 egocentric sexual network study. Respondents served as proxies to report the HIV status and PrEP use of recent sexual partners. We contrasted results from a complete-case analysis (unknown HIV and PrEP excluded) versus a bias analysis with respondent-reported data stochastically reclassified to simulate unobserved self-reported data from sexual partners.

RESULTS

We found strong evidence of preferential partnering across analytical approaches. The bias analysis showed concordance between sexual partners of HIV diagnosis and PrEP use statuses for MSM with diagnosed HIV (39%; 95% simulation interval: 31, 46), MSM who used PrEP (32%; 21, 37), and MSM who did not use PrEP (83%; 79, 87). The fraction of partners with diagnosed HIV was higher among MSM who used PrEP (11%; 9, 14) compared with MSM who did not use PrEP (4%; 3, 5). Comparatively, across all strata of respondents, the complete-case analysis overestimated the fractions of partners with diagnosed HIV or PrEP use.

CONCLUSIONS

We found evidence consistent with HIV and PrEP sorting among MSM, which may decrease the population-level effectiveness of PrEP. Bias analyses can improve mixing estimates for parameterization of transmission models.

Repeat Syphilis Among HIV-Infected Men in Florida and Louisiana 2000-2018: Implications for Screening Recommendations

Syphilis rates have continued to rise in the United States. Florida and Louisiana consistently report high numbers of cases. We evaluated rates of reinfection to see if frequent rescreening might lead to earlier treatment and prevent infections. All syphilis records of all stages for males and females aged 15-70 years from the Florida and Louisiana Departments of Health surveillance databases 2000-2018 were evaluated. The first episode of syphilis during this period was considered the initial diagnosis for each person. Demographics of cases and repeaters (individuals reported with two or more cases of syphilis) were examined. Percentages of syphilis cases from repeaters by year were calculated as were percentages from HIV+ males. During 2000-2018, 124,827 syphilis cases were reported from 107,405 individuals: 73,811 (68.7%) males; 33,594 (31.3%) females. There were 12,545 individuals (repeaters) with two or more syphilis diagnoses (n = 17,422 cases; range, 2-10). From 2010 to 2018, repeaters accounted for steadily increasing percentage of all syphilis reported: 2010 (11%), 2013 (16%), 2015 (20%), and 2018 (26%). Among HIV+ male cases the percentage from repeaters also increased: 2010 (28%), 2013 (35%), 2015 (42%), and 2018 (50%). In 2018, 19% of all cases (n = 2455) were from HIV+ males who had a previous syphilis diagnosis. Among HIV+ males diagnosed with syphilis in 2015, 34% had a repeat syphilis diagnosis within 3 years. Most syphilis diagnosed in Florida and Louisiana was among persons infected for the first time. However, some subgroups could possibly benefit from more frequent screening. Males living with HIV who had a prior syphilis diagnosis were at very high risk of repeat infection.

Are We Hitting the Target? HIV Pre-Exposure Prophylaxis from 2012 to 2020 in the OPERA Cohort

Preventing HIV transmission is a crucial step in ending the HIV epidemic. Safe and effective pre-exposure prophylaxis (PrEP) has been available in the United States since 2012. We set out to determine if persons at greatest risk for HIV acquisition were receiving HIV PrEP. HIV-negative individuals from the Observational Pharmaco-Epidemiology Research & Analysis (OPERA) cohort who were prescribed daily PrEP were contrasted with newly diagnosed HIV persons without PrEP use between July 16, 2012 and October 31, 2020 to determine if the PrEP prescriptions reached the populations who were seroconverting. Poisson regression was used to estimate incidence rates of seroconversion to HIV among PrEP initiators, as well as new diagnoses of sexually transmitted infections among both the PrEP group and the newly HIV+ group. Out of the 14,598 PrEP users and 3558 persons newly diagnosed with HIV in OPERA, demographics varied widely. Older individuals, those of non-Black race, men, nonintravenous (IV) drug users, and those with commercial insurance were proportionally overrepresented among those prescribed PrEP compared to persons newly diagnosed with HIV during the same time period. Over 82% of new HIV+ individuals received care in the southern United States compared to only 45% of PrEP users. Seroconversion to HIV among PrEP users was generally uncommon, although more frequent among those who identified as Black individuals, especially in the 13-25 years old age range. In conclusion, providers need innovative programs to better identify, educate, and link those at greatest risk of HIV acquisition, especially young people, women, Black individuals, and IV drug users, to PrEP.

Disparities in Treatment with Direct-Acting Hepatitis C Virus Antivirals Persist Among Adults Coinfected with HIV and Hepatitis C Virus in US Clinics, 2010-2018

Human immunodeficiency virus (HIV) and hepatitis C virus (HCV) coinfection carries substantial risk for all-cause mortality and liver-related morbidity and mortality, yet many persons coinfected with HIV/HCV remain untreated for HCV. We explored demographic, clinical, and sociodemographic factors among participants in routine HIV care associated with prescription of direct-acting antivirals (DAAs). The HIV Outpatient Study (HOPS) is an ongoing longitudinal cohort study of persons with HIV in care at participating clinics since 1993. There are currently eight study sites in six US cities. We analyzed medical records data of HOPS participants diagnosed with HCV since June 2010. Sustained virological response (SVR) was documented with first undetectable HCV viral load (VL). We assessed factors associated with being prescribed DAAs by multi-variable logistic regression and described the cumulative rate of SVR. Among 306 eligible participants, 131 (43%) were prescribed DAA therapy. Factors associated with greater odds of being prescribed DAA were older age, private health insurance, higher CD4 cell count, being a person who injects drugs, and receiving care at publicly funded sites (p < 0.05). Of 127 (97%) participants with at least 1 follow-up HCV VL, 110 (87%) achieved SVR at 12 weeks. Of the total 131 participants, 123 (94%) eventually achieved SVR. Less than half of HIV/HCV coinfected patients in HOPS have been prescribed DAAs. Interventions are needed to address deficits in DAA prescription, including among patients with public or no health insurance, younger age, and lower CD4 cell count.

Provider Comfort with Prescribing HIV Pre-Exposure Prophylaxis to Adolescents

In the United States, Black and Latinx youth remain disproportionately affected by HIV. Oral antiretroviral pre-exposure prophylaxis (PrEP) is a proven effective HIV prevention strategy. PrEP is approved for use in people younger than the age of 18 years, but little is known about provider comfort and preparedness with prescribing it to adolescents. In this study, physicians provide their perspectives on the facilitators and barriers to PrEP access among adolescents. Focus groups (n = 23) were conducted with pediatric and family practitioners practicing in an urban community hospital setting to assess PrEP awareness and receptivity to use among adolescents. Most providers were unfamiliar with clinical guidelines for PrEP use, especially in determining adolescent candidates for PrEP use, including appropriate dosing regimen and follow-up procedures. Overall, providers had low intent on prescribing PrEP, citing concerns about consent, medication adherence, and appropriateness of primary care providers in prescribing and managing adolescent PrEP use. Strategies that will address provider education and comfort in prescribing PrEP to adolescents are required to increase PrEP access and uptake among communities disproportionally affected by HIV.

Predictors and Barriers to Condom Use in the African Cohort Study

Consistent condom use is an inexpensive and efficacious HIV prevention strategy. Understanding factors associated with condom use and barriers to use can inform strategies to increase condom uptake. The ongoing African Cohort Study prospectively enrolls adults at 12 clinical sites in Uganda, Kenya, Tanzania, and Nigeria. At enrollment, participants are asked about condom use at last sex with a regular partner. Robust Poisson regression models were used to evaluate predictors of self-reported condom use. Participants who reported not using condoms were asked to provide reasons. From January 2013 to September 2019, 2482 participants reported having at least one regular sexual partner in the preceding 6 months. Of those, 1577 (63.5%) reported using a condom at last sex. Condom use was more common among older participants, males, HIV-infected participants, and those with an HIV-infected partner. Married participants, those with a partner of unknown HIV status, and those reporting alcohol use were less likely to report condom use at last sex. Condom use at last sex also varied significantly by clinical site. Partner disapproval or refusal to use a condom was a consistent driver of disparities in condom use among participants who were HIV infected, female, and aged 18-24 years. Effective HIV prevention programs should integrate condom education with the tools necessary to negotiate condom use with regular partners.