Age-Specific Race and Ethnicity Disparities in HIV Infection and Awareness Among Men Who Have Sex With Men--20 US Cities, 2008-2014

Point-of-care urine tenofovir test predicts future HIV preexposure prophylaxis discontinuation among young users

BACKGROUND

Young men who have sex with men and transgender women (YMSM/TGW) have disproportionately high HIV incidence and lower preexposure prophylaxis (PrEP) adherence. Point-of-care (POC) urine tenofovir (TFV) rapid assay (UTRA) testing permits real-time monitoring for nonadherence within clinical settings. We performed UTRA testing among PrEP users to examine the relationship between low PrEP adherence and future PrEP discontinuation, and the accuracy of POC testing compared to gold-standard liquid chromatography tandem mass spectrometry (LC/MS/MS).

METHODS

YMSM/TGW participants ( n  = 100) were recruited during a daily PrEP visit. Logistic regression models analyzed the relationship between the primary predictor of urine POC assay results (cutoff 1,500 ng/ml) and the primary outcome of PrEP discontinuation, defined as no PrEP follow-up or prescription within 120 days.

RESULTS

Overall, 19% of participants had low urine TFV and 21% discontinued PrEP, while 11% of participants self-reported low PrEP adherence (<4 pills per week), which was only 43% sensitive/84% specific in predicting low TFV levels and was not associated with PrEP discontinuation. Low urine TFV level predicted PrEP discontinuation [adjusted odds ratio (AOR) 6.1; 95% confidence interval (CI): 1.4-11; P  = 0.005] and was 71% sensitive/90% specific for discontinuation after 120 days. Compared to LC/MS/MS, UTRA testing had a 98% positive and 100% negative predictive value.

CONCLUSIONS

In a sample of YMSM/TGW on daily PrEP, POC UTRA testing predicted PrEP discontinuation more accurately than self-reported adherence, with high predictive values compared to LC/MS/MS. UTRA testing may be a clinical tool for directing preventive interventions towards those likelier to discontinue PrEP despite ongoing HIV vulnerability.

Projecting the Potential Clinical and Economic Impact of Human Immunodeficiency Virus Prevention Resource Reallocation in Tennessee

BACKGROUND

In 2023, Tennessee replaced $6.2 M in US Centers for Disease Control and Prevention (CDC) human immunodeficiency virus (HIV) prevention funding with state funds to redirect support away from men who have sex with men (MSM), transgender women (TGW), and heterosexual Black women (HSBW) and to prioritize instead first responders (FR), pregnant people (PP), and survivors of sex trafficking (SST).

METHODS

We used a simulation model of HIV disease to compare the clinical impact of Current, the present allocation of condoms, preexposure prophylaxis (PrEP), and HIV testing to CDC priority risk groups (MSM/TGW/HSBW); with Reallocation, funding instead increased HIV testing and linkage of Tennessee-determined priority populations (FR/PP/SST). Key model inputs included baseline condom use (45%-49%), PrEP provision (0.1%-8%), HIV testing frequency (every 2.5-4.8 years), and 30-day HIV care linkage (57%-65%). We assumed Reallocation would reduce condom use (-4%), PrEP provision (-26%), and HIV testing (-47%) in MSM/TGW/HSBW, whereas it would increase HIV testing among FR (+47%) and HIV care linkage (to 100%/90%) among PP/SST.

RESULTS

Reallocation would lead to 166 additional HIV transmissions, 190 additional deaths, and 843 life-years lost over 10 years. HIV testing reductions were most influential in sensitivity analysis; even a 24% reduction would result in 287 more deaths compared to Current. With pessimistic assumptions, we projected 1359 additional HIV transmissions, 712 additional deaths, and 2778 life-years lost over 10 years.

CONCLUSIONS

Redirecting HIV prevention funding in Tennessee would greatly harm CDC priority populations while conferring minimal benefits to new priority populations.

Potential contribution of PrEP uptake by adolescents 15-17 years old to achieving the "Ending the HIV Epidemic" incidence reduction goals in the US South

BACKGROUND

The "Ending the HIV Epidemic" (EHE) initiative seeks to reduce new HIV infections in the U.S. by prioritizing federal resources towards highly impacted populations. Antiretroviral therapy (ART) and pre-exposure prophylaxis (PrEP) are essential for reaching EHE goals. Adolescents are often at increased risk for HIV because they may lack agency in negotiating their sexual partnerships and may not have the same access to treatment and prevention as adults. This study estimates the potential contribution of expanded PrEP coverage among adolescents ages 15-17 to achieving the EHE goals in the South.

METHODS

An HIV-transmission model was built to simulate the HIV epidemic in the South. Increased ART and PrEP uptake were systematically varied with and without PrEP eligibility including individuals age<18.

RESULTS

Prioritizing PrEP for adolescents had a negligible impact on incidence. At 50% uptake among eligible adolescents and 90% ART coverage, including adolescents only improved the percentage of infections averted from 80.1% to 80.3%. In 10 of 15 scenarios explored, there was no reduction in new infections when PrEP eligibility was expanded to include adolescents age<18. At 95% ART coverage at the population-level incidence among adolescents declined by over 80%, but PrEP uptake among adolescents did not contribute to additional declines in incidence among adolescents.

CONCLUSIONS

Prioritizing PrEP for adolescents did not significantly contribute to reaching EHE incidence reductions goal. Focusing resources to specific adolescent populations at risk, such sexual minority males in high incidence settings, will remain an important public health goal outside the context of EHE.

A qualitative analysis examining intersectional stigma among young adults living with HIV in Atlanta, Georgia

HIV-related stigma is a barrier to engagement in care for young adults living with HIV. Other intersecting forms of stigma (e.g., racism, sexism, homophobia), may worsen HIV-related stigma and impact engagement in care. From November 2020 to February 2021, we conducted 20 in-depth qualitative interviews among young adults living with HIV attending a large, comprehensive HIV care center in Atlanta, Georgia. Semi-structured interview guides based on Earnshaw and Chaudoir's HIV Stigma Framework and the theory of intersectionality facilitated discussion around experiences with various forms of stigma and its possible influence on healthcare engagement. Using the social-ecological model, we used thematic analysis to contextualize how young adults living with HIV experienced intersectional stigma and enacted, anticipated, and internalized HIV stigma in both healthcare and non-healthcare settings. Most participants identified as male, Black/African American, and gay. Participants described stigma at intrapersonal, interpersonal, clinic, and community levels. Intrapersonal stigma was associated with delayed care seeking, isolation, and fear of disclosure. Interpersonal stigma included discrimination from family and friends and avoidance of close relationships to elude disclosure. At the clinic level, stigma included negative experiences with staff in HIV and non-HIV healthcare settings, which contributed to decreased engagement in care. Stigma in the community included differential treatment from employers, community leaders, and religious community and was associated with feelings of helplessness related to current societal inequalities. Coping/motivating mechanisms for stigma included prioritizing health, eliciting support from the medical care team and peers. Our findings show different intersecting stigmas are barriers to healthcare at multiple levels for young adults living with HIV, potentially exacerbating existing health and social disparities. To improve engagement in care among young adults living with HIV, future interventions should address the different mechanisms of stigma at community, clinic, interpersonal and intrapersonal levels by enhancing social support and improving healthcare structural competency.

Feasibility and Acceptability of Online Recruitment and an Online Brief Mindfulness Intervention Among Patients With Sickle Cell Disease

Background Pain among young adult patients with sickle cell disease (PWSCD) is a highly significant public health problem associated with reduced quality of life. Due to issues uniquely affecting PWSCD, including distrust of research, challenging life situations, debilitating pain, stigma, and logistical challenges (e.g., child or elder care and transportation), SCD researchers often find it challenging to meet sample size and enrollment targets. To our knowledge, all known SCD studies have solely recruited participants in person (e.g., clinics and local organizations) and utilized lengthy interventions with suboptimal recruitment and retention results. Newer recruitment methods, such as online recruitment, need to be explored for research among PWSCD. In this pilot project, we sought to address these challenges by investigating: 1) a novel method of using online outreach to recruit/enroll young PWSCD and 2) a novel, brief online mindfulness intervention adapted from Mindfulness-Oriented Recovery Enhancement (MORE): Mini-MORE designed to treat pain among PWSCD.  Methods Participants (N = 32) were recruited online (e.g., paid advertisements on Facebook and NextDoor; free advertisements on Facebook groups and Reddit) and screened by phone from October 25 to November 8, 2022. Participants watched an online Mini-MORE video. Immediately before and after watching the video, participants rated their pain intensity and unpleasantness on an 11-point numeric rating scale (NRS). Afterward, participants were emailed an individualized link to additional audio recordings for ongoing practice. Immediately before and after accessing the additional recordings, participants rated their pain intensity, anxiety, and depression on an 11-point NRS. T-tests were used to examine the impact of Mini MORE on outcomes at two-time points. Results A total of 84 participants completed the self-screening. The majority of self-screeners resulted from free posts in Facebook groups (77%), Reddit (1%), and Craigslist (6%). Thirty-two (32) eligible participants agreed to join a Zoom meeting to watch the video. The entire Mini-MORE video was viewed by 31 of 32 participants (97%). Pain intensity decreased by 1.7 points (p<0.001, Cohen's d=2.19), and pain unpleasantness decreased by 2.1 points (p<0.001, Cohen's d=2.20). Listening to the supplemental recordings was associated with significant, immediate decreases in pain intensity by 1.3 points (p=0.015, Cohen's d=2.05), anxiety by 1.8 points (p=0.022, Cohen's d=3.10), and depression by 1.74 points (p=0.019, Cohen's d=2.94). Conclusions Results suggest that online methods are feasible in recruiting and enrolling young PWSCD, and the online Mini-MORE intervention is acceptable among PWSCD. Future research is needed to assess whether Mini-MORE is associated with decreased pain symptomology in young PWSCD.

Uptake and Acceptability of MyChoices: Results of a Pilot RCT of a Mobile App Designed to Increase HIV Testing and PrEP Uptake Among Young American MSM

Young men who have sex with men (YMSM) remain at disproportionate risk for HIV acquisition in the United States (US), yet use of evidence-based prevention strategies, including routine HIV testing and pre-exposure prophylaxis (PrEP), remain low. Smartphones and mobile app usage are nearly ubiquitous in this population. Given the potential for scalability, a mobile app to increase HIV testing and PrEP use among YMSM has the potential to make an extraordinary public health impact if efficacious. Based on extensive formative, community-engaged research, we developed a theory-driven mobile app-MyChoices-to increase HIV testing and PrEP uptake among YMSM. In a pilot randomized controlled trial (RCT), participants (n = 60) were randomized 2:1 to receive MyChoices or standard of care (SOC). Data from 3 to 6-month post-baseline assessments demonstrate that the app was highly acceptable (System Usability Score; mean = 75.8, SD = 10.7) and feasible (94% used the MyChoices app at least once; mean = 15.3 sessions, SD = 9.8). While not powered to assess efficacy, those in the MyChoices arm had 22% higher prevalence of HIV testing over follow-up compared to those in the SOC arm (NS). There was no difference in PrEP uptake. A fully-powered efficacy trial is warranted; if efficacy is demonstrated, the MyChoices app could be easily scaled to reach YMSM across the US.

Who is using PrEP on-demand? Factors associated with PrEP use modality among Black and Hispanic/Latino emerging adults

Pre-exposure prophylaxis (PrEP) is a highly efficacious HIV prevention medication, yet Black and Hispanic/Latino sexual minority men's and gender diverse individuals' (SMMGD) PrEP use is limited due to factors such as PrEP barriers and anticipated PrEP stigma. Although most individuals who use PrEP take it as a daily regimen, there is evidence that many SMMGD are interested in using "on-demand" (also known as event-driven or intermittent or 2-1-1) PrEP. We used stepwise multinomial logistic regression to explore factors associated with on-demand, daily, and no PrEP use among 820 Black and Hispanic/Latino SMMGD ages 18-29 in the United States. We found that greater reported PrEP barriers were associated with higher odds of using PrEP on-demand or not using PrEP compared to daily PrEP use. More past 3-month sex partners and greater comfort telling others about PrEP use were associated with lower odds of on-demand compared to daily PrEP use. In addition, compared to daily PrEP use, more past 3-month sex partners, greater comfort telling others about PrEP use, and higher anticipated PrEP stigma were associated with lower odds of no current PrEP use compared to daily PrEP use. Findings may inform clinical practices and interventions to promote PrEP uptake and adherence.

Preferences of Young Black Gay, Bisexual, and Other Men Who Have Sex with Men Regarding Integration of HIV and Mental Health Care Services

Optimization of mental health service use is critical to HIV care engagement among young Black gay, bisexual, and other men who have sex with men (YB-GBMSM). Clinic-level interventions to integrate HIV and mental health services have been proposed; however, patient perspectives on such care models are often lacking. We conducted a mixed-methods study consisting of surveys (N = 100) and qualitative in-depth interviews (n = 15) with YB-GBMSM recruited from two Ryan White-funded HIV clinics in Atlanta, Georgia. Most participants (70%) agreed that integration of HIV and mental health services was beneficial to them. Thirty-six percent (36%) desired a higher level of integration than what they perceived was currently available in their clinic setting, 51% believed their clinic was already optimally integrated, and 13% preferred less integration. In the qualitative interviews, participants discussed their support for potential integration strategies such as training HIV providers to prescribe antidepressants, closer in-clinic proximity of HIV and mental health providers, and use of patient navigators to help patients access mental health care and remind them of appointments. Perceived benefits of care integration included easier access to mental health services, enhanced overall well-being, and improved HIV care engagement. In summary, YB-GBMSM were supportive of integrating HIV and mental health services, with varying individual preferences regarding the degree and operationalization of this integration. Improving integration of mental health and HIV services, and tailoring modes of service delivery to individual preferences, has the potential to improve both general well-being and HIV care engagement in this high priority population.

Dismantling Barriers and Transforming the Future of Pre-Exposure Prophylaxis Uptake in Young Black and Latinx Sexual Minority Men and Transgender Women

Pre-exposure prophylaxis (PrEP) has the potential to transform HIV in young Black and Latinx sexual minority men (SMM) and transgender women (TW). Addressing low PrEP uptake in this population depends on the better understanding of barriers to PrEP use. This article uses an ecological framework to explore barriers to daily oral PrEP in a sample of young Black and Latinx SMM and TW in three geographically prioritized cities in the United States. In-depth interviews were completed with 33 young Black and Latinx SMM and TW (22 at risk for and 11 recently diagnosed with HIV), aged 17-24, participating in a randomized trial aimed at increasing PrEP and antiretroviral therapy (ART) uptake and adherence. Interviews were recorded and transcribed, and then analyzed using inductive and deductive coding. Coded transcripts were organized into individual, interpersonal, community, and structural categories, by PrEP use and HIV status. Among participants, nine reported having been prescribed PrEP, with five actively or recently taking PrEP, whereas only one participant diagnosed with HIV had been prescribed PrEP. Major themes related to barriers emerged across the individual, family, community, and structural level. Limited barriers related to partners, instead partners with HIV encouraged PrEP use. Participants commonly reported low perceived HIV risk, fear of disclosure, barriers relating to insurance/cost, and medication use as reasons for nonuse of PrEP. For youth to remain on a healthy life course, HIV preventative measures will need to be adopted early in adolescence for those at risk of HIV acquisition. Interventions need to simultaneously address multilevel barriers that contribute to nonuse in adolescents. Clinical trials registry site and number: ClinicalTrials.gov Identifier: NCT03194477.

HIV Prevalence and Associated Factors Among Men Who have Sex with Men (MSM) in New Jersey, U.S., 2017

This study assessed the HIV prevalence among MSM in the greater Newark New Jersey area including Essex, Hudson, Morris and Union Counties and examined correlates of HIV infection among those men. By analyzing National HIV Behavioral Surveillance data on MSM from four counties in New Jersey (N = 175), which were collected via a venue-based sampling method in 2017, this study shows that HIV prevalence among all races/ethnicities (12.5-31.9%) and all age groups (15.1-47.8%) were high. Casual sex and unprotected sex with male partners were prevalent among these men, regardless of HIV test results. MSM who were tested HIV positive were more likely to have diagnosed any sexual transmitted diseases in the last 12 months (AOR: 6.7; 95% CI 2.2, 21.3) and less likely to have had alcohol use in the past 12 months (AOR: 0.3; 95% CI 0.1, 0.8). Findings from behavioral surveillance strengthens the response to the HIV epidemic by providing policy makers and care/prevention providers with peer reviewed data to base their decisions on.

Under-Reporting of Known HIV-Positive Status Among People Living with HIV: A Systematic Review and Meta-analysis

Monitoring progress towards the UNAIDS 'first 90' target requires accurate estimates of levels of diagnosis among people living with HIV (PLHIV), which is often estimated using self-report. We conducted a systematic review and meta-analysis quantifying under-reporting of known HIV-positive status using objective knowledge proxies. Databases were searched for studies providing self-reported and biological/clinical markers of prior knowledge of HIV-positive status among PLHIV. Random-effects models were used to derive pooled estimates of levels of under-reporting. Thirty-two estimates from 26 studies were included (41,465 PLHIV). The pooled proportion under-reporting known HIV-positive status was 20% (95% confidence interval 13-26%, I2 = 99%). In sub-group analysis, under-reporting was higher among men who have sex with men (32%, number of estimates [Ne] = 10) compared to the general population (9%, Ne = 10) and among Black (18%, Ne = 5) than non-Black (3%, Ne = 3) individuals. Supplementing self-reported data with biological/clinical proxies may improve the validity of the 'first 90' estimates.

Analysis of Reported Health Care Use by Sexual Orientation Among Youth

IMPORTANCE

In the United States, adolescents who are lesbian, gay, or bisexual (LGB) face disparities across physical and mental health outcomes compared with non-LGB youth, yet few studies have looked at patterns of health care utilization by sexual orientation.

OBJECTIVE

To compare health care utilization indicators for LGB and non-LGB youth.

DESIGN, SETTING, AND PARTICIPANTS

This cohort study analyzed wave 3 data from Healthy Passages, a longitudinal observational study of diverse public school students in Birmingham, Alabama; Houston, Texas; and Los Angeles County, California. Multivariable logistic regression models tested sexual-orientation differences in the past 12-month health care utilization measures, controlling for youth age, gender, race and ethnicity, household education, income, and marital status. Data collection began in 2010 when students were in the 5th grade (mean [SE] age, 11.13 [0.01] years) (wave 1) and continued 2 years later (wave 2, 7th grade) and 5 years later (wave 3, 10th grade). Permission to be contacted was provided for 6663 children, and 5147 (77%) participated in audio computer-assisted self-administered interviews. This study included 4256 youth (640 LGB, 3616 non-LGB) who completed interviews at wave 1 and wave 3 and answered key items used in this analysis. Analyses were completed in June 2021.

EXPOSURES

Sexual orientation (LGB vs non-LGB).

MAIN OUTCOMES AND MEASURES

Health care utilization and communication difficulty with a physician in the past 12 months.

RESULTS

Among 4256 youths included in the study at baseline in 5th grade (wave 1), 2171 (48.9%) were female; 1502 (44.5%) were Hispanic or Latino; 1479 (28.9%) were Black; the mean (SE) age was 11.19 (0.03) years; and 640 (14.5%) were LGB at wave 3. Compared with non-LGB youth, a higher proportion of LGB youth reported not receiving needed medical care in the last 12 months (adjusted odds ratio [aOR], 1.68; 95% CI,1.38-2.05), most commonly for sexually transmitted infections, contraception, and substance use. LGB youth more frequently reported difficulty communicating with their physician (aOR, 1.71; 95% CI, 1.27-2.30) than non-LGB youth.

CONCLUSIONS AND RELEVANCE

This study's results found that health care utilization differs by sexual orientation for youth. These findings suggest that clinician training is needed to address the health care needs of LGB youth. Routinely capturing sexual orientation data might enable tracking of health care utilization indicators for LGB youth.

Pre-Exposure Prophylaxis Care Continuum, Barriers, and Facilitators among Black Men Who Have Sex with Men in the United States: A Systematic Review and Meta-Analysis

Pre-exposure prophylaxis (PrEP) represents a viable HIV prevention tool for black men who have sex with men (BMSM). However, aggregated evidence regarding the presentations and determinants of the PrEP continuum (e.g., awareness, willingness, intention, uptake and adherence) remains absent to empirically inform future intervention efforts. We meta-analytically summarized the prevalence and qualitatively synthesized key barriers/facilitators of the stages of the PrEP continuum among a pooled sample of 42,870 BMSM aggregated from 56 published studies. Our random-effect models indicated a pooled prevalence of PrEP awareness (50.8%, 95% CI: 43.6-58.0%, willingness/intention (58.2%, 95% CI: 52.0-68.1%) and uptake (15.5%, 95% CI: 12.8-18.2%). Qualitative summary revealed that perception of HIV risk, intersectional/PrEP-related stigma and medical mistrust were among the most quoted factors that influence PrEP use. BMSM remain underrepresented in key stages of the PrEP continuum. Futures interventions are continuously needed to target multilevel barriers/facilitators to enhance the PrEP continuum among BMSM.

Who Aren't We Reaching? Young Sexual Minority Men's Non-participation in an HIV-Prevention and Mental Health Clinical Trial

Despite many successful clinical trials to test HIV-prevention interventions for sexual minority men (SMM), not all SMM are reached by these trials. Identifying factors associated with non-participation in these trials could help to ensure the benefits of research extend to all SMM. Prospective participants in New York City and Miami were screened to determine eligibility for a baseline assessment for a mental health/HIV-prevention trial (N = 633 eligible on screen). Logistic regression and classification and regression tree (CART) analysis identified predictors of non-participation in the baseline, among those who were screened as eligible and invited to participate. Individuals who reported unknown HIV status were more likely to be non-participators than those who reported being HIV-negative (OR = 2.39; 95% CI 1.41, 4.04). In New York City, Latinx SMM were more likely to be non-participators than non-Latinx white SMM (OR = 1.81; 95% CI, 1.09, 2.98). A CART model pruned two predictors of non-participation: knowledge of HIV status and age, such that SMM with unknown HIV status and SMM ages 18-19 were less likely to participate. Young SMM who did not know their HIV status, and thus are more likely to acquire and transmit HIV, were less likely to participate. Additionally, younger SMM (18-19 years) and Latinx SMM in New York City were less likely to participate. The findings suggest the importance of tailored recruitment to ensure HIV-prevention/mental health trials reach all SMM.

Development and Evaluation of a Mobile App Designed to Increase HIV Testing and Pre-exposure Prophylaxis Use Among Young Men Who Have Sex With Men in the United States: Open Pilot Trial

BACKGROUND

HIV disproportionately affects young men who have sex with men (YMSM) in the United States. Uptake of evidence-based prevention strategies, including routine HIV testing and use of pre-exposure prophylaxis (PrEP), is suboptimal in this population. Novel methods for reaching YMSM are required.

OBJECTIVE

The aim of this study is to describe the development and evaluate the feasibility and acceptability of the MyChoices app, a mobile app designed to increase HIV testing and PrEP use among YMSM in the United States.

METHODS

Informed by the social cognitive theory, the MyChoices app was developed using an iterative process to increase HIV testing and PrEP uptake among YMSM. In 2017, beta theater testing was conducted in two US cities to garner feedback (n=4 groups; n=28 YMSM). These findings were used to refine MyChoices, which was then tested for initial acceptability and usability in a technical pilot (N=11 YMSM). Baseline and 2-month postbaseline assessments and exit interviews were completed. Transcripts were coded using a deductive approach, and thematic analysis was used to synthesize data; app acceptability and use data were also reported.

RESULTS

The MyChoices app includes personalized recommendations for HIV testing frequency and PrEP use; information on types of HIV tests and PrEP; ability to search for nearby HIV testing and PrEP care sites; and ability to order free home HIV and sexually transmitted infection test kits, condoms, and lube. In theater testing, YMSM described that MyChoices appears useful and that they would recommend it to peers. Participants liked the look and feel of the app and believed that the ability to search for and be pinged when near an HIV testing site would be beneficial. Some suggested that portions of the app felt repetitive and preferred using casual language rather than formal or medicalized terms. Following theater testing, the MyChoices app was refined, and participants in the technical pilot used the app, on average, 8 (SD 5.0; range 2-18) times over 2 months, with an average duration of 28 (SD 38.9) minutes per session. At the 2-month follow-up, the mean System Usability Scale (0-100) score was 71 (ie, above average; SD 11.8). Over 80% (9/11) of the participants reported that MyChoices was useful and 91% (10/11) said that they would recommend it to a friend. In exit interviews, there was a high level of acceptability for the content, interface, and features.

CONCLUSIONS

These data show the initial acceptability and user engagement of the MyChoices app. If future studies demonstrate efficacy in increasing HIV testing and PrEP uptake, the app is scalable to reach YMSM across the United States.

TRIAL REGISTRATION

Clinicaltrials.gov NCT03179319; https://clinicaltrials.gov/ct2/show/NCT03179319.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

RR2-10.2196/10694.

HIV antiretroviral therapy and prevention use in US blood donors: a new blood safety concern

Antiretroviral therapy (ART) to treat and pre-exposure prophylaxis (PrEP) to prevent HIV infection are effective tools to help end the HIV epidemic. However, their use could affect HIV transfusion-transmission risk. Three different ART/PrEP prevalence analyses in blood donors were conducted. First, blood samples from HIV-positive and a comparison group of infection-nonreactive donors were tested under blind using liquid chromatography-tandem mass spectrometry for ART. Second, blood donor samples from infection-nonreactive, 18- to 45-year-old, male, first-time blood donors in 6 US locations were tested for emtricitabine and tenofovir. Third, in men who have sex with men (MSM) participating in the 2017 Centers for Disease Control and Prevention National HIV Behavioral Surveillance (NHBS) from 5 US cities, self-reported PrEP use proximate to donation was assessed. In blind testing, no ART was detected in 300 infection-nonreactive donor samples, but in 299 HIV confirmed-infected donor samples, 46 (15.4%; 95% confidence interval [CI], 11.5% to 20.0%) had evidence of ART. Of the 1494 samples tested from first-time male donors, 9 (0.6%; 95% CI, 0.03% to 1.1%) had tenofovir and emtricitabine. In the NHBS MSM survey, 27 of 591 respondents (4.8%; 95% CI, 3.2% to 6.9%) reported donating blood in 2016 or 2017 and PrEP use within the same time frame as blood donation. Persons who are HIV positive and taking ART and persons taking PrEP to prevent HIV infection are donating blood. Both situations could lead to increased risk of HIV transfusion transmission if blood screening assays are unable to detect HIV in donations from infected donors.

Mental Health Service Utilization Among Young Black Gay, Bisexual, and Other Men Who Have Sex with Men in HIV Care: A Retrospective Cohort Study

Young Black gay, bisexual, and other men who have sex with men (YB-GBMSM) face multiple psychosocial stressors, and are disproportionately impacted by HIV. Mental health care engagement is a promising avenue for addressing these disparities. To date, rates of mental health service utilization have not been examined specifically in this population. We conducted a retrospective cohort study among YB-GBMSM receiving care in a Ryan White-funded HIV care center that includes co-located HIV and mental health services. Of 435 unique YB-GBMSM patients, mental health concerns were identified in n = 191 (43.9%). Depressive symptoms were the most common concerns identified, followed by substance use, anxiety, and trauma. Among patients with identified mental health concerns who were not previously in mental health care, 79.1% were referred to mental health care, 56.3% set an appointment with a mental health provider, 40.5% were linked to mental health care (attended an initial visit), and 19.6% remained engaged in mental health care. Younger YB-GBMSM (age 18-24 years), who received care in a more integrated pediatric/adolescent part of the center, were more likely to have an appointment set once a concern was identified (χ² = 7.17; p = 0.007). Even in a setting with co-located HIV and mental health care services, we found significant gaps in engagement at each stage of a newly described mental health care continuum. Implications for intervention at the provider and systems levels are discussed.

Brief Report: Randomized Controlled Trial of an Intervention to Match Young Black Men and Transwomen Who Have Sex With Men or Transwomen to HIV Testing Options in New York City (All About Me)

BACKGROUND

HIV testing is critical to HIV prevention and care. Infrequent HIV testing and late HIV diagnosis have been observed among young Black men who have sex with men and transwomen. Novel interventions to increase HIV testing rates among young Black men who have sex with men and transwomen are needed.

METHODS

A randomized controlled trial among 236 young Black men and transwomen who have sex with men or transwomen evaluated the efficacy of an intervention that included completion of a brief survey and receipt of a personalized recommendation of an optimal HIV testing approach. Participants completed a computerized baseline assessment and were randomized to electronically receive either a personalized recommendation or standard HIV testing information. Follow-up surveys were conducted online at 3 and 6 months.

RESULTS

Retention was 92% and 93% at 3-month and 6-month follow-up, respectively. At baseline, 41% of participants reported that they tested for HIV in the past 3 months and another 25% between 4 and 6 months ago. Intent-to-treat analyses found that participants randomized to the experimental arm (personalized recommendation) were not significantly more likely to test for HIV compared with participants in the standard HIV testing information control arm at 3 months (76% vs. 71%; P = 0.40) and 6 months (73% vs. 72%; P = 0.81), respectively.

CONCLUSIONS

This study evaluated an innovative intervention to increase HIV testing by matching individuals to optimal HIV testing approaches. Participants in both arms increased past 3-month HIV testing, suggesting that providing information on options and/or raising risk awareness is sufficient to significantly increase HIV testing.

TRIAL REGISTRATION

ClinicalTrial.gov NCT02834572 https://clinicaltrials.gov/ct2/show/NCT02834572.

Developing targeted HIV risk predictors for young black men who have sex with men: a two-city comparative study

HIV burden in the United States is geographically and demographically heterogeneous. While efforts over the last few decades have reduced HIV incidence, young black men who have sex with men (YBMSM) account for a significant portion of new HIV diagnoses compared to any other race and age group. The Centers for Disease Control and Prevention has allocated funding to help reduce HIV in the YBMSM community; however, their recommended screening/treatment criteria do not emphasize demographic specificity. To better guide more applicable screening guidelines specifically for YBMSM, we examine demographic, behavioral, sexual network, and biological predictors of HIV status among YBMSM in two demographically distinct cities with high HIV burden in the United States: Chicago, IL and Los Angeles, CA. We perform multivariable logistic regressions to identify predictors of HIV in these populations. We found that having a history of syphilis was the only statistically significant predictor across both cities despite inclusion of other characteristics previously shown to be associated with HIV among YBMSM. Syphilis history could be a powerful HIV risk indicator for YBMSM and, therefore, should be integrated into clinical screening practices for critical biomedical prevention options like HIV pre-exposure prophylaxis.

Social Networks Moderate the Syndemic Effect of Psychosocial and Structural Factors on HIV Risk Among Young Black Transgender Women and Men who have Sex with Men

The interaction between the cumulative effect of psychosocial and structural factors (i.e. syndemic effect) and social networks among young Black transgender women and men who have sex with men (YBTM) remains understudied. A representative cohort of 16-29 year-old YBTM (n = 618) was assessed for syndemic factors [i.e. substance use; community violence; depression; poverty; justice system involvement (JSI)], social network characteristics, condomless anal sex (CAS), group sex (GS), and HIV-infection. The syndemic index significantly increased the odds of CAS, GS, and HIV-infection, and these effects were moderated by network characteristics. Network JSI buffered the effect on CAS, romantic network members buffered the effect on GS, and network age and proportion of family network members buffered the effect on HIV-infection. The proportion of friend network members augmented the effect on GS and HIV-infection. Future research to prevent HIV among YBTM should consider social network approaches that target both structural and psychosocial syndemic factors.

Development and Validation of the Personalized Sexual Health Promotion (SexPro) HIV Risk Prediction Model for Men Who Have Sex with Men in the United States

Accurate HIV risk assessment among men who have sex with men (MSM) is important to help providers assess risk, and target HIV prevention interventions. We sought to develop an evidence-based HIV risk assessment tool for US MSM that is inclusive of Black MSM. Data from four large longitudinal cohorts of MSM were used to develop (EXPLORE), and validate (VAX004, HPTN061, and HVTN505). These data included visits in which participants self-reported HIV risk behavior and underwent HIV testing. We developed a pooled logistic model for incident HIV infection based on self-reported risk behaviors during the 6 months before each study visit. A total of 4069 MSM were used for the development cohort, and 8047 MSM in the three validation cohorts through 2013. The final model includes age (< 35, ≥ 35); Black race and Latino ethnicity; numbers of HIV-negative anal sex partners; number of insertive or receptive anal intercourse episodes; having 1 HIV-negative partner only; self-reported substance use; and bacterial sexually transmitted infection diagnosis. The model showed good discrimination in internal validation (C-statistic = 79.5). The external validation cohorts also showed good discrimination, with C-statistics of 73.1, 71.0, 71.9 in VAX004, HPTN061, and HVTN505 respectively, and acceptable calibration. We developed and validated an HIV risk assessment tool for MSM, which showed good predictive ability, including among the largest cohort of HIV-uninfected Black MSM in the US. This tool is available online (mysexpro.org) and can be used by providers to support targeting of HIV prevention interventions such as pre-exposure prophylaxis for MSM.

Sexual Risk Behaviors in Adolescent Sexual Minority Males: A Systematic Review and Meta-Analysis

Although adolescent sexual minority males (ASMM) are at increased risk for human immunodeficiency virus (HIV) in the United States (US), studies that estimate sexual risk behaviors that contribute to HIV risk in ASMM are limited. We completed a systematic review and meta-analysis to compile available data and estimate the prevalence of risk behaviors in this population. We searched four databases for key terms related to ASMM, defined as males aged 14 through 19 who identified as gay or bisexual, reported sex with a male in their lifetime, and/or were considered sexual minority by the study. Articles eligible for inclusion were in English, from US studies, and reported quantitative data on sexual risk behaviors among ASMM. We extracted data from eligible articles and meta-analyzed outcomes reported in three or more articles using random effects. Of 3864 articles identified, 21 were eligible for data extraction. We meta-analyzed nine outcomes. Sixty-two percent of adolescent males self-identifying as gay or bisexual ever had sex with a male, and 67% of participants from ASMM studies recently had sex. Among ASMM who had sex in the last 6 months or were described as sexually active, 44% had condomless anal intercourse in the past 6 months, 50% did not use a condom at last sex, and 32% used alcohol or drugs at their last sexual experience. Available data indicate that sexual risk behaviors are prevalent among ASMM. We need more data to obtain estimates with better precision and generalizability. Understanding HIV risk in ASMM will assist in intervention development and evaluation, and inform behavioral mathematical models.

Homonegativity Experienced over the Life Course by Young Black Gay, Bisexual and Other Men Who Have Sex with Men (YB-GBMSM) Living with HIV in Atlanta, Georgia

Minority stress theory posits that homonegativity-whether experienced, anticipated, or internalized-adversely impacts health. We conducted qualitative interviews with 28 YB-GBMSM living with HIV to explore manifestations of homonegativity over the life course. Thematic analysis identified patterns in the ways that homonegativity was discussed at different points in participants' lives. Stifling, and sometimes traumatic, familial and religious environments led to experienced homonegativity early in life. These experiences led to anticipated and internalized homonegativity, which in turn shaped sexual identity formation processes in adolescence and into young adulthood. Ultimately, many participants distanced themselves from home environments, seeking and often finding extrafamilial support. Most participants eventually reached self-acceptance of both their sexuality and HIV status. In conclusion, experienced, anticipated and internalized homonegativity were pervasive as YB-GBMSM navigated family and religious environments over the life course. Future interventions should work with youth, families, and churches to prevent these harmful experiences.

A Person-Centered Approach to HIV-Related Protective and Risk Factors for Young Black Men Who Have Sex with Men: Implications for Pre-exposure Prophylaxis and HIV Treatment as Prevention

Although young Black men who have sex with men (YBMSM) are disproportionately affected by HIV, they may be more heterogeneous as a group than is typically appreciated. Thus, the present study used a person-centered data-analytic approach to determine profiles of HIV-related risk among YBMSM and whether these profiles could be distinguished by age, HIV status, and socioeconomic risk (i.e., socioeconomic distress). YBMSM (N = 1808) aged 18 to 29 years completed a survey of sociodemographic characteristics, HIV status, and HIV-related behavioral and attitudinal factors (i.e., safer-sex self-efficacy, negative condom attitudes, being in difficult sexual situations, being in difficult sexual relationships, HIV treatment optimism, perceived HIV stigma). Latent profile analysis was used to identify HIV risk profiles and whether age, HIV status, and socioeconomic distress were associated with these profiles. Four profiles emerged: low-, medium-, and high-risk profiles, respectively, and a mixed profile characterized by a tendency to be in difficult sexual situations and relationships while also reporting high safer-sex self-efficacy and low negative attitudes toward condom use. Difficult sexual situations emerged as the key defining indicator of whether a profile reflected higher or lower risk. Younger age, being HIV-positive, and socioeconomic distress were associated with having a higher-risk profile. Given that unique risk profiles emerged that were differentially predicted by sociodemographic characteristics and HIV status, these findings have implications for tailoring interventions to the needs of different subgroups of YBMSM. Also, disempowering or risky sexual situations and relationships among YBMSM must be addressed.

New Human Immunodeficiency Virus Diagnoses Among Men Who Have Sex With Men Attending Sexually Transmitted Disease Clinics, STD Surveillance Network, January 2010 to June 2013

To estimate new human immunodeficiency virus (HIV) diagnosis rates among HIV negative men who have sex with men (MSM) who are repeatedly tested for HIV in sexually transmitted disease (STD) clinics and assess the impact of demographic and disease-specific characteristics that are associated with higher HIV diagnosis rates.

STUDY DESIGN

Retrospective analysis using 2010 to 2013 data from the STD Surveillance Network (SSuN), a sentinel surveillance system comprised of health departments in 12 cities conducting sentinel surveillance in 40 STD clinics. We analyzed data from all MSM repeatedly (≥2 times) tested for HIV, with an initial negative HIV test required for staggered cohort entry. Follow-up time was accrued from the date of the first negative HIV test to the most recent negative test or the first positive HIV test. The STD diagnoses during the follow-up period were reviewed. We estimated HIV diagnoses rates (number of HIV diagnoses/total number of person-years [PY] at risk) by demographic and clinical characteristics with 95% confidence intervals (CI) using an inverse variance weighted random effects model, adjusting for heterogeneity between SSuN jurisdictions.

RESULTS

Overall, 640 HIV diagnoses occurred among 14,824 individuals and 20,951.6 PY of observation, for an adjusted incidence of HIV diagnosis of 3.0 per 100 PY (95% CI, 2.6-3.4). Rates varied across race/ethnicity groups with the highest rate among Blacks (4.7/100 PY; 95% CI, 4.1-5.3) followed by Hispanics, whites, and persons of other races/ethnicities. Men who have sex with men having a diagnosis of primary or secondary (P&S) syphilis on or after the first negative HIV test had a higher new HIV diagnosis rate (7.2/100 PY; 95% CI, 5.8-9.0) compared with MSM who did not have a P&S syphilis diagnosis (2.8/100 PY; 95% CI, 2.6-3.1). Men who have sex with men who tested positive for rectal gonorrhea (6.3/100 PY; 95% CI, 5.7-6.9) or rectal chlamydia (5.6/100 PY; 95% CI, 4.6-6.6) had higher rates of new HIV diagnosis when compared to those with negative test results.

CONCLUSIONS

Men who have sex with men attending SSuN STD clinics have high rates of new HIV diagnoses, particularly those with a previous diagnosis of P&S syphilis, rectal chlamydia, and/or gonorrhea. Sexually transmitted disease clinics continue to be important clinical setting for diagnosing HIV among MSM populations.

HIV Coinfection Among Persons Diagnosed As Having Sexually Transmitted Diseases, San Francisco, 2007 to 2014

BACKGROUND

Early syphilis, gonorrhea, and chlamydia but not HIV infections have increased in San Francisco, primarily among men.

METHODS

We linked records of persons reported with early syphilis, gonorrhea, and chlamydia to records of persons reported with HIV to measure the proportion and characteristics of San Francisco residents with HIV-sexually transmitted disease (STD) coinfection between 2007 and 2014. We measured trends in HIV coinfection separately for men and women for each STD.

RESULTS

From 2007 to 2014, of the 5745 early syphilis, 18,037 gonorrhea, and 37,224 chlamydia diagnoses that were reported, 66%, 28%, and 15%, respectively, were among persons coinfected with HIV. Men accounted for most persons with early syphilis, gonorrhea, and chlamydia HIV coinfection. For early syphilis and HIV coinfection, among men who have sex with men (MSM), Latinos were more likely and Asian/Pacific Islanders were less likely to have HIV coinfection compared with whites. Older age at diagnosis and history of an STD were both also significantly associated with early syphilis and HIV coinfection. Transgender persons, older ages, Latino MSM compared with white MSM, and those with a history of STD were more likely to have HIV coinfection, whereas Asian/Pacific Islander MSM were less likely to have HIV coinfection for both gonorrhea and chlamydia, CONCLUSIONS: Our findings highlight the high burden of HIV-STD coinfection in San Francisco. To maintain the current declines in HIV incidence and turn the curve in rising STD incidence, there is an urgent need for collaborative HIV and STD prevention and control efforts.

Modeling the joint effects of adolescent and adult PrEP for sexual minority males in the United States

Background

Pre-exposure prophylaxis (PrEP) is an effective and safe intervention approved for use to prevent HIV transmission. PrEP scale-up strategies and clinical practice are currently being informed by modeling studies, which have estimated the impact of PrEP in adult and adolescent MSM populations separately. This partitioning may miss important effects or yield biased estimates by excluding dependencies between populations.

Methods

We combined two published models of HIV transmission among adults and adolescent MSM. We simulated an HIV epidemic among MSM aged 13–39 without PrEP, with PrEP for adult MSM ages (19–39) and with the addition of PrEP for adolescents ages (16–18), comparing percent of incident infections averted (impact), the number of person-years on PrEP per infection averted (efficiency), and changes in prevalence.

Results

PrEP use among eligible 19–39 year old MSM averted 29.0% of infections and reduced HIV prevalence from 23.2% to 17.0% over ten years in the population as a whole. Despite being ineligible for PrEP in this scenario, prevalence among sexually active 18 year-olds declined from 6.0% to 4.3% due to reduced transmissions across age cohorts. The addition of PrEP for adolescents ages 16–18 had a small impact on the overall epidemic, further reducing overall prevalence from 17.0% to 16.8%; however prevalence among the sexually active 18 year-olds further declined from 4.3% to 3.8%.

Conclusions

PrEP use among adults may significantly reduce HIV prevalence among MSM and may also have significant downstream effects on HIV incidence among adolescents; PrEP targeting adolescents remains an important intervention for HIV prevention.

Addressing Gaps in HIV Preexposure Prophylaxis Care to Reduce Racial Disparities in HIV Incidence in the United States

The potential for human immunodeficiency virus (HIV) preexposure prophylaxis (PrEP) to reduce the racial disparities in HIV incidence in the United States might be limited by racial gaps in PrEP care. We used a network-based mathematical model of HIV transmission for younger black and white men who have sex with men (BMSM and WMSM) in the Atlanta, Georgia, area to evaluate how race-stratified transitions through the PrEP care continuum from initiation to adherence and retention could affect HIV incidence overall and disparities in incidence between races, using current empirical estimates of BMSM continuum parameters. Relative to a no-PrEP scenario, implementing PrEP according to observed BMSM parameters was projected to yield a 23% decline in HIV incidence (hazard ratio = 0.77) among BMSM at year 10. The racial disparity in incidence in this observed scenario was 4.95 per 100 person-years at risk (PYAR), a 19% decline from the 6.08 per 100 PYAR disparity in the no-PrEP scenario. If BMSM parameters were increased to WMSM values, incidence would decline by 47% (hazard ratio = 0.53), with an associated disparity of 3.30 per 100 PYAR (a 46% decline in the disparity). PrEP could simultaneously lower HIV incidence overall and reduce racial disparities despite current gaps in PrEP care. Interventions addressing these gaps will be needed to substantially decrease disparities.

Utilization and avoidance of sexual health services and providers by YMSM and transgender youth assigned male at birth in Chicago

Young men who have sex with men (YMSM) and transgender youth assigned male at birth (AMAB) bear a disproportionate burden of the HIV epidemic, yet are sub optimally engaged by sexual health service providers and HIV prevention services. To increase sexual health and HIV prevention behaviors and address disparities in HIV incidence and outcomes among YMSM and AMAB transgender youth, it is critical to understand patterns of service utilization and avoidance. This study examined how and why YMSM and AMAB transgender youth use or avoid sexual health services and service providers in a large Midwestern city within a survey administered to 890 participants from a longitudinal cohort study (RADAR). Results demonstrate low overall use of sexual health services and minimal interest in seeking pre-exposure prophylaxis (PrEP), consistent with prior research. Low awareness of available services was associated with how and where YMSM and trans youth AMAB seek care, with 76% of our sample reporting this as their primary reason for not seeking specific sexual health services. Additional associations are discussed, and recommendations are made for how to improve available services and access.

Sexual Networks of Racially Diverse Young MSM Differ in Racial Homophily But Not Concurrency

BACKGROUND

Substantial racial disparities exist in HIV infection among young men who have sex with men (YMSM). However, evidence suggests black YMSM do not engage in greater levels of risk behavior. Sexual networks may help explain this paradox. This study used egocentric exponential random graph models to examine variation in concurrency (ie, 2 or more simultaneous partners) and homophily (ie, same race/ethnicity partners) across race/ethnicity groups in a diverse sample of YMSM.

METHODS

Data for this study come from a longitudinal cohort study of YMSM. Participants (n = 1012) provided data regarding their sexual contacts during the 6 months before their first study visit. A series of egocentric exponential random graph models examined how providing separate estimates for homophily and concurrency parameters across race/ethnicity improved the fit of these models. Networks were simulated using these parameters to examine how local network characteristics impact risk at the whole network level.

RESULTS

Results indicated that homophily, but not concurrency, varied across race/ethnicity. Black participants witnessed significantly higher race/ethnicity homophily compared with white and Latino peers. Extrapolating from these models, black individuals were more likely to be in a connected component with an HIV-positive individual and closer to HIV-positive individuals. However, white individuals were more likely to be in large connected components.

CONCLUSIONS

These findings suggest that high racial homophily combined with existing disparities in HIV help perpetuate the spread of HIV among black YMSM. Nonetheless, additional work is required to understand these disparities given that homophily alone cannot sustain them indefinitely.

A Mobile-Based App (MyChoices) to Increase Uptake of HIV Testing and Pre-Exposure Prophylaxis by Young Men Who Have Sex With Men: Protocol for a Pilot Randomized Controlled Trial

Background

HIV incidence is growing most rapidly in the United States among young men who have sex with men (YMSM). Overwhelming evidence demonstrates that routine testing and expanded use of pre-exposure prophylaxis (PrEP) would dramatically reduce the population burden of HIV; however, uptake of both interventions is suboptimal among young adults. The use of mobile phone apps by YMSM is ubiquitous and may offer unique opportunities for public health interventions. MyChoices is a theory-driven app to increase HIV testing and PrEP uptake. It was developed by an interdisciplinary team based on feedback from a diverse sample of YMSM.

Objective

The aim of this paper is to describe the protocol for the refinement, beta testing, and pilot randomized controlled trial (RCT) to examine the acceptability and feasibility of the MyChoices app.

Methods

This 3-phase study includes 4 theater testing groups for app refinement with a total of approximately 30 YMSM; for beta testing, including quantitative assessments and exit interviews, with approximately 15 YMSM over a 2-month period; and for a pilot RCT with 60 YMSM. The pilot will assess feasibility, acceptability, and preliminary efficacy of the MyChoices app, compared with referrals only, in increasing HIV testing and PrEP uptake. All participants will be recruited at iTech clinical research sites in Boston, MA, and Bronx, NY.

Results

App refinement is underway. Enrollment for the pilot RCT began in October 2018.

Conclusions

MyChoices is one of the first comprehensive, theory-driven HIV prevention apps designed specifically for YMSM. If MyChoices demonstrates acceptability and feasibility in this pilot RCT, a multicity, 3-arm randomized controlled efficacy trial of this app and another youth-optimized app (LYNX) versus standard of care is planned within iTech. If shown to be efficacious, the app will be scalable, with the ability to reach YMSM across the United States as well as be geographically individualized, with app content integrated with local prevention and testing activities.

International Registered Report Identifier (IRRID)

PRR1-10.2196/10694

Potential Impact of HIV Preexposure Prophylaxis Among Black and White Adolescent Sexual Minority Males

OBJECTIVES

To assess the potential impact of preexposure prophylaxis (PrEP) on the HIV epidemic among Black and White adolescent sexual minority males (ASMM).

METHODS

We used a network model and race-specific data from recent trials to simulate HIV transmission among a population of Black and White 13- to 18-year-old ASMM over 20 years. We estimated the number of infections prevented (impact) and the number needed to treat to prevent an infection (efficiency) under multiple coverage and adherence scenarios.

RESULTS

At modeled coverage and adherence, PrEP could avert 3% to 20% of infections among Black ASMM and 8% to 51% among White ASMM. A larger number, but smaller percentage, of infections were prevented in Black ASMM in all scenarios examined. PrEP was more efficient among Black ASMM (number needed to treat to avert an infection = 25-32) compared with White ASMM (146-237).

CONCLUSIONS

PrEP can reduce HIV incidence among both Black and White ASMM but is far more efficient for Black ASMM because of higher incidence. Public Health Implications. Black ASMM communities suffer disproportionate HIV burden; despite imperfect adherence, PrEP programs could prevent HIV efficiently in these communities.

Biomedical and Behavioral Outcomes of Keep It Up!: An eHealth HIV Prevention Program RCT

INTRODUCTION

HIV diagnoses among young men who have sex with men are increasing, but few effective HIV prevention interventions exist for this population. An RCT was conducted of the online Keep It Up! intervention to determine if it significantly reduced condomless anal sex and sexually transmitted infections compared with an HIV knowledge condition.

STUDY DESIGN

From May 2013 to March 2017, a total of 901 participants were enrolled in a double-blinded RCT of Keep It Up! with 1-year follow-up. After completing baseline surveys and sexually transmitted infection testing, participants were randomized by an eHealth platform to the intervention or control condition.

SETTING/PARTICIPANTS

HIV-negative men who have sex with men reporting condomless anal sex, aged 18-29 years, were recruited through advertising and from HIV testing sites and outreach in Atlanta, Georgia; Chicago, Illinois; and New York, New York.

INTERVENTION

Multimedia was used to address HIV knowledge and motivate safer behaviors. The control condition reflected existing online HIV information.

MAIN OUTCOME MEASURES

Primary outcomes were incident gonorrhea or chlamydia at 12-month follow-up and self-reported condomless anal sex with casual partners at 3-, 6-, and 12-month follow-up.

RESULTS

In 2017, data were analyzed from 445 (49%) participants randomized to the intervention and 456 (51%) to the control. Participants were primarily racial/ethnic minorities (63%). Sexually transmitted infections at Month 12 was 40% lower for intervention participants (risk ratio=0.60, 95% CI=0.38, 0.95, p=0.01). For the primary behavioral outcome, both arms showed reductions over time with 44% of control and 37% of intervention participants reporting condomless anal sex at Month 12 (prevalence ratio=0.83, 95% CI=0.70, 0.99, p=0.04).

CONCLUSIONS

The Keep It Up! intervention resulted in significantly lower sexually transmitted infection incidence and a small but significant decrease in condomless anal sex 12 months post-intervention relative to an online HIV knowledge condition. In addition, this study demonstrated the feasibility and acceptability of at-home sexually transmitted infection testing as part of an eHealth intervention.

TRIAL REGISTRATION

This study is registered at www.clinicaltrials.gov NCT01836445.

Surveillance Among Men Who have Sex with Men in the United States: A Comparison of Web-Based and Venue-Based Samples

Although men who have sex with men (MSM) recruited through web-based and venue-based sampling methods have been compared, no large web-based and venue-based samples using similar survey instruments have been examined in the U.S. This study describes the differences in sociodemographic characteristics and risk behaviors between the 2012 Web-based HIV Behavioral Survey (n = 3221) and 2011 National HIV Behavioral Surveillance (n = 9256). Compared with participants in the venue-based sample, participants in the web-based sample were older, less likely to be black or Hispanic, more likely to have higher socioeconomic status, and more likely to have anal sex without a condom with their last male sex partner. Web-based participants were less likely to have multiple male sex partners, ever injected drugs, been tested for HIV in the past 12 months, and received free condoms than venue-based participants. The method for sampling MSM into a behavioral survey should consider the sub-population of MSM to be reached.

Leveraging a Legacy of Activism: Black Lives Matter and the Future of HIV Prevention for Black MSM

This year marks the 30th anniversary of AIDS Education and Prevention. As we approach the United Nations goal of ending the AIDS epidemic by 2030, it is a useful time to reflect on and learn from history. In the United States, no such endeavor can be successful without addressing the specific context of Black men who have sex with men. In this commentary I highlight factors that led us to a state in which Black MSM represent approximately a quarter of all people living with HIV in the United States. I also look back at the power of activism during the beginning of the HIV epidemic. Using Black Lives Matter as a contemporary framework, I highlight natural linkages between activism 30 years ago, its incarnation and relationship to public health today, and its promise as the way forward in achieving the elimination of AIDS for Black MSM by 2030.

NAFLD and HIV: Do Sex, Race, and Ethnicity Explain HIV-Related Risk?

PURPOSE OF REVIEW

Here, we review the epidemiology, diagnosis, and management of non-alcoholic fatty liver disease (NAFLD) in the general population, discuss HIV-specific differences in NAFLD pathogenesis, and summarize what is known regarding differences in NAFLD by race/ethnicity and sex.

RECENT FINDINGS

The reported prevalence of NAFLD among people living with HIV varies by age, body mass index, comorbidity, and method of NAFLD diagnosis, but is generally thought to be greater among HIV-infected compared to HIV-uninfected populations. Minorities and women tend to experience poorer HIV treatment outcomes (Meditz et al. J Infect Dis. 203(4):442-51, 2011; Beer et al. Medicine (Baltimore). 95(13):e 3171, 2016; Gant et al. MMWR Morb Mortal Wkly Rep. 66(40):1065-72, 2017; Millett et al. Lancet. 380(9839):341-8, 2012; Wejnert et al. J Infect Dis. 213(5):776-83, 2016), and are at the greatest risk for significant weight gain with HIV treatment (Erlandson et al. Medicine (Baltimore). 95(46):e 5399, 2016). Thus, women and minorities living with HIV may be at a higher risk of developing NAFLD and progressive liver disease. Disparities in the diagnosis, progression, and prognosis of NAFLD and HIV-associated NAFLD may be, in part, explained by genetic and sex differences; however, data is limited.

A Gamified Smartphone App to Support Engagement in Care and Medication Adherence for HIV-Positive Young Men Who Have Sex With Men (AllyQuest): Development and Pilot Study

BACKGROUND

HIV disproportionately impacts young men who have sex with men (YMSM) who experience disparities across the HIV care continuum. Addressing antiretroviral therapy (ART) adherence among YMSM is an urgent public health priority. Technology-based interventions-particularly mobile health platforms-can provide tailored adherence interventions and allow YMSM to engage and connect with others.

OBJECTIVE

The objective of this study was to describe the development of AllyQuest, a novel, theoretically-based, smartphone app designed to improve engagement in care and ART adherence and social support among HIV-positive YMSM.

METHODS

AllyQuest was built on an established platform for patient engagement that embeds social networking and fundamental game mechanics, such as challenges, points, and rewards. A medication tracker provides reminders to promote ART adherence via personalized adherence strategies that are user and context specific; a calendar allows for reflection on adherence over time. After iterative development with input from two youth advisory boards, usability testing was conducted to assess app functionality, comprehension of the educational content, use of intervention features, and overall impressions of app relevance and appeal. A 28-day pilot trial was conducted with 20 HIV+ YMSM to evaluate intervention feasibility and acceptability.

RESULTS

Mean age of participants was 21.8 years (range 19-24), and 95% (19/20) of the participants were nonwhite. The mean time of app use was 158.4 min (SD 114.1), with a range of 13 to 441 min. There was a mean of 21.2 days of use (out of a total possible 28 days). There were 222 posts to the daily discussion social wall. Feasibility and acceptability ratings were high. Overall, participants found the app easy to use and navigate, not intrusive, and had few reported technical issues. Higher levels of app usage were positively correlated with HIV self-management outcomes, and there was a statistically significant (P<.05) positive association between the number of days logged into the app and knowledge and confidence in ability to reliably take HIV medications.

CONCLUSIONS

AllyQuest represents a new, highly scalable solution that is well-suited to meet the specific prevention and care needs of HIV+ YMSM. The development of this intervention is both timely and vital, given the urgency of the ongoing HIV epidemic among YMSM.

Targeting Human Immunodeficiency Virus Pre-Exposure Prophylaxis to Adolescent Sexual Minority Males in Higher Prevalence Areas of the United States: A Modeling Study

PURPOSE

Pre-exposure prophylaxis (PrEP) is an effective and safe intervention to prevent human immunodeficiency virus (HIV) transmission in men who have sex with men; current Centers for Disease Control and Prevention guidelines indicate its use among high-risk adults. Adolescent sexual minority males (ASMM) also have significant HIV risk, but implementation strategies are likely to differ for this population. We aimed to estimate impact and efficiency of PrEP for ASMM in higher prevalence US settings, using a variety of implementation strategies and assumptions about coverage, adherence, and background prevalence.

METHODS

We develop a stochastic, dynamic, network-based model, parametrized using numerous ASMM behavioral and clinical data sources. We simulate 10 years with and without PrEP, comparing percent of incident infections averted (impact) and number of person-years on PrEP per infection averted (efficiency).

RESULTS

Our main scenario (PrEP for 16- to 18-year-old ASMM, initiating PrEP 6 months after first anal intercourse, 40% coverage, adherence profiles from the ATN 113 trial; 2.9% background HIV prevalence among ASMM) prevents 27.8% of infections, with 38 person-years on PrEP per infection averted. Expanding implementation to cover younger ages or earlier initiation has small effects on impact and efficiency. Targeting highest risk ASMM increases efficiency, but requires querying sexual histories. Across levels examined, coverage and adherence do not have major impacts on efficiency, whereas background prevalence does.

CONCLUSIONS

PrEP can have a large impact on HIV incidence among ASMM in the United States, especially in settings with high prevalence. However, willingness of, and support for, providers will be central to achieving the coverage needed to make this a success.

Multiple strategies to identify HIV-positive black men who have sex with men and transgender women in New York City: a cross-sectional analysis of recruitment results

INTRODUCTION

Black men who have sex with men and transgender women are at high risk for HIV infection, but are more likely to be unaware of their infection or not in care for diagnosed HIV compared to other races. Respondent driven sampling has been advanced as a method to reach stigmatized and hidden populations for HIV testing. We compared strategies to recruit black, substance-using men who have sex with men and transgender women to identify newly diagnosed HIV infection, or those previously diagnosed but not in care.

METHODS

The STAR (Seek, Test, and Retain) study (ClinicalTrials.gov NCT01790360) used several recruitment strategies to identify black, substance-using men who have sex with men and transgender women with undiagnosed HIV infection or with previously diagnosed HIV infection but who were not in HIV care. Respondent-driven sampling, community-based recruitment and online advertising were used to recruit participants. Incentivized peer referral was integrated into all recruitment strategies. Participants completed interviewer-administered questionnaires and HIV testing. Demographic and HIV risk-related characteristics and recruitment strategy were summarized and stratified by HIV status. Associations were tested using Pearson's chi-squared, Fisher's exact, and Wilcoxon rank sum tests. Factors associated with HIV-positive diagnosis at p < 0.1 were included in a multivariable logistic regression model.

RESULTS

From July 2012 through October 2015, the study enrolled 1929 participants; 96.3% men who have sex with men and 3.7% transgender women. Behavioural risk factors included recent condomless anal sex (55.6%) and recent substance use during sex (73.1%). HIV prevalence was 8.7%. In multivariable analysis, significant associations with HIV infection included being transgender; non-Hispanic black; gay/homosexual orientation; not homeless; and less likely to have insufficient income for necessities. Among recruitment strategies, respondent driven sampling was least effective in identifying HIV-positive participants.

CONCLUSIONS

Integrating multiple recruitment strategies yielded a large sample of black men who have sex with men and transgender women at substantial risk for HIV. Respondent-driven sampling was less effective than other strategies at identifying men who have sex with men and transgender women with HIV.

Acceptability and feasibility of a Peer Mentor program to train young Black men who have sex with men to promote HIV and STI home-testing to their social network members

Young Black men who have sex with men (YBMSM) experience persistently high rates of undiagnosed HIV and other sexually transmitted infections (STIs) and testing rates remain sub-optimal. Home-based testing (HBT) has been found to be acceptable among MSM and while awareness about HBT is relatively high, uptake has been low. Peer-based approaches have been shown to be effective in reducing HIV risk behavior, yet have not been used to increase utilization of HBT. The purpose of this study was to assess acceptability and feasibility of a program to train YBMSM as Peer Mentors to use and promote HIV and STI home-based testing and specimen collection to their social network members. Fifteen YBMSM ages 18-30 completed in-depth structured interviews and were asked to talk with their social network members about home-based testing. Participants reported acceptability of the Peer Mentor role and two-thirds had conversations with diverse social network members (e.g., male and female, sex partners, friends, family). Facilitators of peer outreach included the novelty of home-based testing, confidence about accuracy of the tests, and resources for linkage to care. Barriers included concerns about negative responses and disclosure of sexual identity/behavior. Results of this study suggest that YBMSM are willing and able to promote HBT to their social networks. This is a promising approach to increasing dissemination of HBT kits for both HIV and STI testing.

Blood donation history and eligibility assessment in a community-based sample of men who have sex with men

BACKGROUND

In 2016, the US Food and Drug Administration changed the regulation from a permanent deferral from donation for men who have sex with men (MSM) to a 1-year deferral since last sexual contact. It is unknown what proportions of MSM try to donate and if they would be willing to answer individual risk-based questions to assess their current eligibility.

STUDY DESIGN AND METHODS

The National HIV Behavioral Surveillance surveys periodically measure human immunodeficiency virus (HIV) prevalence and risk behaviors among MSM using a venue-based, time-location sampling method. In the 2014 cycle, that is, before the policy change, investigators in San Francisco and New Orleans added questions about blood donation. Questions inquired into three domains: donation history, policy awareness, and knowledge about HIV testing of donations.

RESULTS

There were 404 and 557 respondents in San Francisco and New Orleans, respectively. Nearly one in three MSM in San Francisco (27.4%) and New Orleans (31.4%) tried to donate after their first MSM contact. A majority (63.1% in San Francisco, 58.8% in New Orleans) somewhat or strongly agreed that they would be willing to be asked detailed questions for donation eligibility assessment.

CONCLUSIONS

The proportion of MSM who reported trying to donate was similar in the two cities. However, a substantial proportion did not agree to be asked more detailed risk behavior questions to assess eligibility. In these two geographic locations, prominent regional differences were not evident.

Unraveling Health Disparities Among Sexual and Gender Minorities: A Commentary on the Persistent Impact of Stigma

LGBT (lesbian, gay, bisexual, and transgender) populations experience disparities in health outcomes, both physical and mental, compared to their heterosexual and cisgender peers. This commentary confronts the view held by some researchers that the disparate rates of mental health problems reported among LGBT populations are the consequences of pursuing a particular life trajectory, rather than resulting from the corrosive and persistent impact of stigma. Suggesting that mental health disparities among LGBT populations arise internally, de novo, when individuals express non-heterosexual and non-conforming gender identities ignores the vast body of evidence documenting the destructive impact of socially mediated stigma and systemic discrimination on health outcomes for a number of minorities, including sexual and gender minorities. Furthermore, such thinking is antithetical to widely accepted standards of health and wellbeing because it implies that LGBT persons should adopt and live out identities that contradict or deny their innermost feelings of self.

Intervention to Match Young Black Men and Transwomen Who Have Sex With Men or Transwomen to HIV Testing Options (All About Me): Protocol for a Randomized Controlled Trial

Background

HIV testing is a critical component of HIV prevention and care. Interventions to increase HIV testing rates among young black men who have sex with men (MSM) and black transgender women (transwomen) are needed. Personalized recommendations for an individual’s optimal HIV testing approach may increase testing.

Objective

This randomized trial tests the hypothesis that a personalized recommendation of an optimal HIV testing approach will increase HIV testing more than standard HIV testing information.

Methods

A randomized trial among 236 young black men and transwomen who have sex with men or transwomen is being conducted. Participants complete a computerized baseline assessment and are randomized to electronically receive a personalized HIV testing recommendation or standard HIV testing information. Follow-up surveys are conducted online at 3 and 6 months after baseline.

Results

The All About Me randomized trial was launched in June 2016. Enrollment is completed and 3-month retention is 92.4% (218/236) and has exceeded study target goals.

Conclusions

The All About Me intervention is an innovative approach to increase HIV testing by providing a personalized recommendation of a person’s optimal HIV testing approach. If successful, optimizing this intervention for mobile devices will widen access to large numbers of individuals.

Trial Registration

ClinicalTrial.gov NCT02834572; https://clinicaltrials.gov/ct2/show/NCT02834572 (Archived by WebCite at http://www.webcitation.org/6vLJWOS1B)

HIV risk and multiple sources of heterosexism among young Black men who have sex with men

OBJECTIVE

This study examined whether the association between social support and condom self-efficacy would be moderated by (a) internalized heterosexism among and (b) enacted heterosexism experienced by young Black men who have sex with men (YBMSM), who contend with high HIV incidence, heterosexism, and low uptake of preexposure prophylaxis.

METHOD

Participants were 1,210 YBMSM (ages 18-29) who completed measures of social support, internalized and enacted heterosexism, and condom self-efficacy in 2 large cities in the southern United States as part of a community-level HIV-prevention study.

RESULTS

A significant 3-way interaction between social support and both hypothesized moderators, internalized and enacted heterosexism, showed that social support was positively associated with condom self-efficacy when both internalized and enacted heterosexism were high (1 SD above the mean; b = .177, 95% confidence interval [CI: .088, .266]). However, social support was not associated with condom self-efficacy when scores were low (1 SD below the mean) on both internalized and enacted heterosexism (b = .024, 95% CI [-.054, .101]), low on internalized and high on enacted heterosexism (b = .058, 95% CI [-.061, .117]), or high on internalized and low on enacted heterosexism (b = .039, 95% CI [-.083, .161]).

CONCLUSIONS

YBMSM who are high in both internalized and enacted heterosexism may see greater benefits from social support on condom self-efficacy than would YBMSM who grapple with less heterosexism. In addition to promoting social support, interventions should aim to assess and reduce multiple forms of stigma. (PsycINFO Database Record

Pre-exposure prophylaxis for MSM and transgender persons in early adopting countries

: Pre-exposure prophylaxis (PrEP) is a potent and underutilized HIV prevention tool. In this paper we review the state of knowledge regarding PrEP implementation for men who have sex with men and transgender persons in early adopting countries. We focus on implementation of PrEP in demonstration projects and clinical care, and describe the status of PrEP availability and uptake. We report on approaches to identifying appropriate PrEP candidates in real-world settings and on best practices for clinical monitoring. This includes the exclusion of undiagnosed HIV infection prior to PrEP initiation and longitudinal measurement of renal function, in light of safety data. Since adherence is the primary factor moderating the effectiveness of PrEP, we discuss effective adherence support interventions. Additionally, we review the evidence for risk compensation with PrEP use and opportunities to provide PrEP as part of comprehensive and inclusive preventive health programs. We summarize cost-effectiveness studies, including their variable conclusions because of differing underlying assumptions, and discuss the importance of budgetary impact for public health programs and health care insurers. Further, we emphasize a need for greater engagement of health care providers in PrEP to increase access. We conclude with recommendations for ways to improve future efforts at implementing PrEP.

The Clinical and Economic Impact of Attaining National HIV/AIDS Strategy Treatment Targets in the United States

Background

The US National HIV/AIDS Strategy (NHAS) aims for 72% (90% diagnosed times 80% of those virally suppressed) viral suppression among persons with human immunodeficiency virus (HIV) by 2020. We examined the clinical and economic impact of reaching this target, in the general US population and among black men who have sex with men (MSM), the group with the highest HIV prevalence.

Methods

Using a mathematical simulation, we project the 5- and 20-year clinical outcomes, costs, and incremental cost-effectiveness ratios for (1) Current Pace of detection, linkage, retention, and virologic suppression and (2) NHAS investments in expanded testing ($24-$74 per test) and adherence ($400 per person-year), calibrated to achieve 72% suppression by 2020. We examined alternative rates of testing, retention, and suppression and the efficacy and cost of adherence interventions.

Results

Compared with Current Pace over 20 years, NHAS averted 280000 HIV transmissions (80000 in black MSM) and 199000 (45000) deaths and saved 2138000 (453000) years of life, while increasing costs by 23%. The incremental cost-effectiveness ratio for NHAS compared with Current Pace was $68900 per quality-adjusted life-year ($38300 for black MSM) and was most sensitive to antiretroviral therapy costs.

Conclusions

Reaching NHAS targets would yield substantial clinical benefits and be cost-effective in both the general US and black MSM populations.

Trends in Internet Use Among Men Who Have Sex With Men in the United States

BACKGROUND

Internet-based platforms are increasingly prominent interfaces for social and sexual networking among men who have sex with men (MSM).

METHODS

MSM were recruited through venue-based sampling in 2008, 2011, and 2014 in 20 US cities. We examined changes in internet use (IU) to meet men and in meeting the last partner online among MSM from 2008 to 2014 using Poisson regression with generalized estimating equations to calculate adjusted prevalence ratios (APRs). We also examined factors associated with increased frequency of IU using data from 2014. IU was categorized as never, infrequent use (<once a week), and frequent use (≥once a week).

RESULTS

Frequent IU increased from 21% in 2008 to 44% in 2014 (APR = 1.39, 95% confidence interval: 1.36 to 1.42), and having met the last partner online increased from 19% in 2008 to 32% in 2014 (APR = 1.30, 95% confidence interval: 1.26 to 1.34). Those who never used the internet had fewer partners (median of 2 in the past 12 months, interquartile range: 1-4) compared with infrequent (4, 2-7) and frequent users (5, 3-12). HIV testing in the past 12 months also increased with increasing IU (58%, 68%, and 71%, respectively, P < 0.0001). Among HIV-positive participants, the percent HIV-positive awareness increased as IU increased (71%, 75%, and 79%, P < 0.005).

CONCLUSIONS

Both IU to meet men and meeting the last partner online increased since 2008. Although men who used the internet more frequently reported more partners in the past 12 months, they were also more likely to report testing in the past 12 months and were more likely to be HIV-positive aware.

Trends in HIV Risk, Testing, and Treatment among MSM in Chicago 2004-2014: Implications for HIV Elimination Planning

Men who have sex with men (MSM) in the USA continue to have high rates of HIV infection. Increasingly, in addition to behavioral factors, biomedical interventions have been found to play important roles in HIV prevention. In this analysis, we used four waves of cross-sectional data (2004, 2008, 2011, and 2014) from the National HIV Behavioral Surveillance System (NHBS) to examine trends in key behaviors and biomedical interventions among MSM in Chicago (N = 3298). Logistic regression was used to determine changes in behaviors and use of biomedical interventions. Condomless sex increased significantly in waves 3 and 4, compared to wave 1: wave 3 (AOR = 2.07; 95% CI 1.53, 2.78) and wave 4 (AOR = 2.19; 95% CI 1.62, 2.96). Compared to those aged 18-24, older participants were significantly less likely to be routinely tested for HIV: 30-39 (AOR = 0.63; 95% CI 0.48, 0.83), 40-49 (AOR = 0.40; 95% CI 0.29, 0.55), and >50 (AOR = 0.28; 95% CI 0.18, 0.43). Awareness of both post-exposure prophylaxis (PEP)(​AOR = 3.13; 95% CI 1.22, 8.03) and pre-exposure prophylaxis (PrEP)(​AOR = 10.02; 95% CI 2.95, 34.01) increased significantly in wave 4, compared to wave 3. These results suggest a potential increase in HIV rates among men with main and casual partners and should be monitored closely as PrEP becomes more widespread among MSM of all races and ethnicities in Chicago. This study also suggests that further analyses of the barriers to PEP and PreP uptake among high-risk populations are necessary.