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Zhu Y, Gao F, Glidden DV, Donnell D, Janes H. Estimating counterfactual placebo HIV incidence in HIV prevention trials without placebo arms based on markers of HIV exposure. Clin Trials 2024; 21:114-123. [PMID: 37877356 DOI: 10.1177/17407745231203327] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2023]
Abstract
INTRODUCTION Developing alternative approaches to evaluating absolute efficacy of new HIV prevention interventions is a priority, as active-controlled designs, whereby individuals without HIV are randomized to the experimental intervention or an active control known to be effective, are increasing. With this design, however, the efficacy of the experimental intervention to prevent HIV acquisition relative to placebo cannot be evaluated directly. METHODS One proposed approach to estimate absolute prevention efficacy is to use an HIV exposure marker, such as incident rectal gonorrhea, to infer counterfactual placebo HIV incidence. We formalize a statistical framework for this approach, specify working regression and likelihood-based estimation approaches, lay out three assumptions under which valid inference can be achieved, evaluate finite-sample performance, and illustrate the approach using a recent active-controlled HIV prevention trial. RESULTS We find that in finite samples and under correctly specified assumptions accurate and precise estimates of counterfactual placebo incidence and prevention efficacy are produced. Based on data from the DISCOVER trial in men and transgender women who have sex with men, and assuming correctly specified assumptions, the estimated prevention efficacy for tenofovir alafenamide plus emtricitabine is 98.1% (95% confidence interval: 96.4%-99.4%) using the working model approach and 98.1% (95% confidence interval: 96.4%-99.7%) using the likelihood-based approach. CONCLUSION Careful assessment of the underlying assumptions, study of their violation, evaluation of the approach in trials with placebo arms, and advancement of improved exposure markers are needed before the HIV exposure marker approach can be relied upon in practice.
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Affiliation(s)
- Yifan Zhu
- Sanofi US, Bridgewater, NJ, USA
- Vaccine and Infectious Disease Division, Fred Hutchinson Cancer Center, Seattle, WA, USA
| | - Fei Gao
- Vaccine and Infectious Disease Division, Fred Hutchinson Cancer Center, Seattle, WA, USA
| | - David V Glidden
- Department of Epidemiology and Biostatistics, University of California at San Francisco, San Francisco, CA, USA
| | - Deborah Donnell
- Vaccine and Infectious Disease Division, Fred Hutchinson Cancer Center, Seattle, WA, USA
| | - Holly Janes
- Vaccine and Infectious Disease Division, Fred Hutchinson Cancer Center, Seattle, WA, USA
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Donnell D, Kansiime S, Glidden DV, Luedtke A, Gilbert PB, Gao F, Janes H. Study design approaches for future active-controlled HIV prevention trials. STATISTICAL COMMUNICATIONS IN INFECTIOUS DISEASES 2024; 15:20230002. [PMID: 38250627 PMCID: PMC10798828 DOI: 10.1515/scid-2023-0002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/13/2023] [Accepted: 12/30/2023] [Indexed: 01/23/2024]
Abstract
Objectives Vigorous discussions are ongoing about future efficacy trial designs of candidate human immunodeficiency virus (HIV) prevention interventions. The study design challenges of HIV prevention interventions are considerable given rapid evolution of the prevention landscape and evidence of multiple modalities of highly effective products; future trials will likely be 'active-controlled', i.e., not include a placebo arm. Thus, novel design approaches are needed to accurately assess new interventions against these highly effective active controls. Methods To discuss active control design challenges and identify solutions, an initial virtual workshop series was hosted and supported by the International AIDS Enterprise (October 2020-March 2021). Subsequent symposia discussions continue to advance these efforts. As the non-inferiority design is an important conceptual reference design for guiding active control trials, we adopt several of its principles in our proposed design approaches. Results We discuss six potential study design approaches for formally evaluating absolute prevention efficacy given data from an active-controlled HIV prevention trial including using data from: 1) a registrational cohort, 2) recency assays, 3) an external trial placebo arm, 4) a biomarker of HIV incidence/exposure, 5) an anti-retroviral drug concentration as a mediator of prevention efficacy, and 6) immune biomarkers as a mediator of prevention efficacy. Conclusions Our understanding of these proposed novel approaches to future trial designs remains incomplete and there are many future statistical research needs. Yet, each of these approaches, within the context of an active-controlled trial, have the potential to yield reliable evidence of efficacy for future biomedical interventions.
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Affiliation(s)
- Deborah Donnell
- Fred Hutchinson Cancer Center, Seattle, WA, USA
- University of Washington, Seattle, WA, USA
| | - Sheila Kansiime
- Medical Research Council/Uganda Virus Research Council and London School of Hygiene and Tropical Medicine, Uganda Research Unit, Entebbe, Uganda
- Medical Research Council International Statistics and Epidemiology Group, London School of Hygiene and Tropical Medicine, London, UK
| | | | | | - Peter B. Gilbert
- Fred Hutchinson Cancer Center, Seattle, WA, USA
- University of Washington, Seattle, WA, USA
| | - Fei Gao
- Fred Hutchinson Cancer Center, Seattle, WA, USA
- University of Washington, Seattle, WA, USA
| | - Holly Janes
- Fred Hutchinson Cancer Center, Seattle, WA, USA
- University of Washington, Seattle, WA, USA
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Abstract
PURPOSE OF REVIEW Ending the HIV epidemic will require the development of additional effective immune-mediated and nonimmune-mediated means of HIV prevention. Evaluating novel interventions requires large, controlled trials demonstrating efficacy. Recent advances in the field of HIV prevention necessitate new approaches to efficacy trial design. RECENT FINDINGS Three classes of efficacy trial designs are possible: standard of prevention-controlled trials, active-controlled trials, and active-controlled trials augmented with external control data. Recent experience with these approaches provides lessons on considerations around and success of the designs. Additional experience and development is needed for the augmented active-controlled trial design. SUMMARY Efficacy trials of new HIV prevention interventions are feasible but require careful consideration, given the complexity and dynamic state of the prevention field. While standard of prevention-controlled efficacy trials are reasonable approaches for HIV vaccine and monoclonal antibody efficacy trials, trials of new antiretroviral agents may require active-controlled designs.
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Affiliation(s)
- Holly Janes
- Fred Hutchinson Cancer Center
- University of Washington
| | - Susan Buchbinder
- San Francisco Department of Public Health
- University of California, San Francisco
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Dunn DT, Stirrup OT, McCormack S, Glidden DV. Interpretation of active-control randomised trials: the case for a new analytical perspective involving averted events. BMC Med Res Methodol 2023; 23:149. [PMID: 37365584 DOI: 10.1186/s12874-023-01970-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2022] [Accepted: 06/09/2023] [Indexed: 06/28/2023] Open
Abstract
Active-control trials, where an experimental treatment is compared with an established treatment, are performed when the inclusion of a placebo control group is deemed to be unethical. For time-to-event outcomes, the primary estimand is usually the rate ratio, or the closely-related hazard ratio, comparing the experimental group with the control group. In this article we describe major problems in the interpretation of this estimand, using examples from COVID-19 vaccine and HIV pre-exposure prophylaxis trials. In particular, when the control treatment is highly effective, the rate ratio may indicate that the experimental treatment is clearly statistically inferior even when it is worthwhile from a public health perspective. We argue that it is crucially important to consider averted events as well as observed events in the interpretation of active-control trials. An alternative metric that incorporates this information, the averted events ratio, is proposed and exemplified. Its interpretation is simple and conceptually appealing, namely the proportion of events that would be averted by using the experimental treatment rather than the control treatment. The averted events ratio cannot be directly estimated from the active-control trial, and requires an additional assumption about either: (a) the incidence that would have been observed in a hypothetical placebo arm (the counterfactual incidence) or (b) the efficacy of the control treatment (relative to no treatment) that pertained in the active-control trial. Although estimation of these parameters is not straightforward, this must be attempted in order to draw rational inferences. To date, this method has been applied only within HIV prevention research, but has wider applicability to treatment trials and other disease areas.
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Affiliation(s)
- David T Dunn
- Institute for Global Health, University College London, London, UK.
- MRC Clinical Trials Unit, University College London, 90 High Holborn, London, WC1V 6LJ, UK.
| | - Oliver T Stirrup
- Institute for Global Health, University College London, London, UK
| | - Sheena McCormack
- MRC Clinical Trials Unit, University College London, 90 High Holborn, London, WC1V 6LJ, UK
| | - David V Glidden
- Department of Epidemiology and Biostatistics, University of California San Francisco, San Francisco, CA, USA
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Donnell D, Gao F, Hughes JP, Hanscom B, Corey L, Cohen MS, Edupuganti S, Mgodi N, Rees H, Baeten JM, Gray G, Bekker L, Hosseinipour M, Delany‐Moretlwe S. Counterfactual estimation of efficacy against placebo for novel PrEP agents using external trial data: example of injectable cabotegravir and oral PrEP in women. J Int AIDS Soc 2023; 26:e26118. [PMID: 37363917 PMCID: PMC10292682 DOI: 10.1002/jia2.26118] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2022] [Accepted: 05/12/2023] [Indexed: 06/28/2023] Open
Abstract
INTRODUCTION Multiple antiretroviral agents have demonstrated efficacy for human immunodeficiency virus (HIV) pre-exposure prophylaxis (PrEP). As a result, clinical trials of novel agents have transitioned from placebo- to active-controlled designs; however, active-controlled trials do not provide an estimate of efficacy versus no use of PrEP. Counterfactual placebo comparisons using other data sources could be employed to provide this information. METHODS We compared the active-controlled study (HPTN 084) of injectable cabotegravir (CAB-LA) versus daily oral emtricitabine/tenofovir disoproxil fumarate (FTC/TDF) among women from seven countries in Africa to three external, contemporaneous randomized HIV prevention trials from which we constructed counterfactual placebo estimates. We used direct standardization via analysis weights to achieve the same distribution of person-years between the external study and HPTN 084, across strata predictive of HIV risk (country and selected risk covariates). We estimated prevention efficacy against a counterfactual placebo to provide information on the use of CAB-LA and FTC/TDF compared to no intervention. We compared the counterfactual placebo findings for FTC/TDF to previous placebo-controlled trials, adjusted for observed adherence to daily pills. RESULTS Distribution of age and baseline prevalence of gonorrhoea and chlamydia were similar among matched counterfactual placebo and observed HPTN 084 arms after standardization. Counterfactual estimates of CAB-LA versus placebo in all three settings showed a consistent risk reduction of 93%-94%, with lower bounds of the confidence intervals above 72%. Observed adherence (quantifiable tenofovir in plasma) in HPTN 084 was 54%-56%, and estimated efficacy of daily oral FTC/TDF against a counterfactual placebo was consistent with a predicted risk reduction of 39%-40% for this level of daily pill use. CONCLUSIONS Counterfactual placebo rates of HIV acquisition derived from external trial data in similar locations and time can be used to support estimates of placebo-based efficacy of a novel HIV prevention agent. External trial data must be standardized to be representative of the clinical trial cohort testing the novel HIV prevention agent, accounting for confounders.
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Affiliation(s)
| | - Fei Gao
- Fred Hutchinson Cancer CenterSeattleWashingtonUSA
| | | | | | | | - Myron S. Cohen
- University of North CarolinaChapel HillNorth CarolinaUSA
| | | | - Nyaradzo Mgodi
- University of Zimbabwe Clinical Trials Research CentreHarareZimbabwe
| | | | | | - Glenda Gray
- South Africa Medical Research CouncilTygerbergSouth Africa
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6
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Sullivan PS, Hall E, Bradley H, Sanchez T, Woodyatt CR, Russell ES. Estimating HIV Incident Diagnoses Among Men Who Have Sex With Men Eligible for Pre-exposure Prophylaxis but Not Taking It: Protocol and Feasibility Assessment of Data Sources and Methods. JMIR Res Protoc 2023; 12:e42267. [PMID: 36881450 PMCID: PMC10031441 DOI: 10.2196/42267] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2022] [Revised: 12/27/2022] [Accepted: 01/20/2023] [Indexed: 03/08/2023] Open
Abstract
BACKGROUND HIV incidence estimates are published each year for all Ending the HIV Epidemic (EHE) counties, but they are not stratified by the demographic variables highly associated with risk of infection. Regularly updated estimates of HIV incident diagnoses available at local levels are required to monitor the epidemic in the United States over time and could contribute to background incidence rate estimates for alternative clinical trial designs for new HIV prevention products. OBJECTIVE We describe methods using existing, robust data sources within areas in the United States to reliably estimate longitudinal HIV incident diagnoses stratified by race and age categories among men who have sex with other men (MSM) eligible for pre-exposure prophylaxis (PrEP) but not taking it. METHODS This is a secondary analysis of existing data sources to develop new estimates of incident HIV diagnoses in MSM. We reviewed past methods used to estimate incident diagnoses and explored opportunities to improve these estimates. We will use existing surveillance data sources and population sizes of HIV PrEP-eligible MSM estimated from population-based data sources (eg, US Census data and pharmaceutical prescription databases) to develop metropolitan statistical area-level estimates of new HIV diagnoses among PrEP-eligible MSM. Required parameters are number of new diagnoses among MSM, estimates of MSM with an indication for PrEP, and prevalent PrEP use including median duration of use; these parameters will be stratified by jurisdiction and age group or race or ethnicity. Preliminary outputs will be available in 2023, and updated estimates will be produced annually thereafter. RESULTS Data to parameterize new HIV diagnoses among PrEP-eligible MSM are available with varying levels of public availability and timeliness. In early 2023, the most recent available data on new HIV diagnoses were from the 2020 HIV surveillance report, which reports 30,689 new HIV infections in 2020, and 24,724 of them occurred in an MSA with a population of ≥500,000. Updated estimates for PrEP coverage based on commercial pharmacy claims data through February 2023 will be generated. The rate of new HIV diagnoses among MSM can be estimated from new diagnoses within each demographic group (numerator) and the total person-time at risk of diagnosis for each group (denominator) by metropolitan statistical area and year. To estimate time at risk, the person-time of individuals on PrEP or person-time after incident HIV infection but before diagnosis should be removed from stratified population size estimates of the total number of person-years with indications for PrEP. CONCLUSIONS Reliable, serial, cross-sectional estimates for rates of new HIV diagnoses for MSM with PrEP indications can serve as benchmark community estimates of failures of HIV prevention and opportunities to improve services and will support public health epidemic monitoring and alternative clinical trial designs. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID) DERR1-10.2196/42267.
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Affiliation(s)
- Patrick Sean Sullivan
- Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, GA, United States
| | - Eric Hall
- Department of Epidemiology, School of Public Health, Oregon Health Sciences University, Portland, OR, United States
| | - Heather Bradley
- Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, GA, United States
| | - Travis Sanchez
- Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, GA, United States
| | - Cory R Woodyatt
- Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, GA, United States
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Daskalopoulou M, Rusconi S, Vielot NA. Research news in clinical context. Sex Transm Infect 2023; 99:147-148. [PMID: 36801833 DOI: 10.1136/sextrans-2022-055705] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/23/2023] Open
Affiliation(s)
| | - Stefano Rusconi
- DIBIC Luigi Sacco, University of Milan, Milan, Italy
- Universita' degli Studi di Milano
| | - Nadja A Vielot
- Department of Family Medicine, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
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8
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Parkin N, Gao F, Grebe E, Cutrell A, Das M, Donnell D, Duerr A, Glidden DV, Hughes JP, Murray J, Robertson MN, Zinserling J, Lau J, Miller V. Facilitating Next-Generation Pre-Exposure Prophylaxis Clinical Trials Using HIV Recent Infection Assays: A Consensus Statement from the Forum HIV Prevention Trial Design Project. Clin Pharmacol Ther 2022. [PMID: 36550769 DOI: 10.1002/cpt.2830] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2022] [Accepted: 12/08/2022] [Indexed: 12/24/2022]
Abstract
Standard-of-care HIV pre-exposure prophylaxis (PrEP) is highly efficacious, but uptake of and persistence on a daily oral pill is low in many settings. Evaluation of alternate PrEP products will require innovation to avoid the unpractically large sample sizes in noninferiority trials. We propose estimating HIV incidence in people not on PrEP as an external counterfactual to which on-PrEP incidence in trial subjects can be compared. HIV recent infection testing algorithms (RITAs), such as the limiting antigen avidity assay plus viral load used on specimens from untreated HIV positive people identified during screening, is one possible approach. Its feasibility is partly dependent on the sample size needed to ensure adequate power, which is impacted by RITA performance, the number of recent infections identified, the expected efficacy of the intervention, and other factors. Screening sample sizes to support detection of an 80% reduction in incidence for 3 key populations are more modest, and comparable to the number of participants in recent phase III PrEP trials. Sample sizes would be significantly larger in populations with lower incidence, where the false recency rate is higher or if PrEP efficacy is expected to be lower. Our proposed counterfactual approach appears to be feasible, offers high statistical power, and is nearly contemporaneous with the on-PrEP population. It will be important to monitor the performance of this approach during new product development for HIV prevention. If successful, it could be a model for preventive HIV vaccines and prevention of other infectious diseases.
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Affiliation(s)
- Neil Parkin
- Data First Consulting, Sebastopol, California, USA
| | - Fei Gao
- Fred Hutchinson Cancer Research Center, Seattle, Washington, USA
| | - Eduard Grebe
- Vitalant Research Institute, San Francisco, California, USA.,Edward Grebe Consulting, Cape Town, South Africa
| | - Amy Cutrell
- ViiV Healthcare, Research Triangle Park, North Carolina, USA
| | - Moupali Das
- Gilead Sciences, Foster City, California, USA
| | - Deborah Donnell
- Fred Hutchinson Cancer Research Center, Seattle, Washington, USA
| | - Ann Duerr
- Fred Hutchinson Cancer Research Center, Seattle, Washington, USA
| | | | | | | | | | - Joerg Zinserling
- Federal Institute for Drugs and Medical Devices (Bundesinstitut für Arzneimittel und Medizinprodukte, BfArM), Bonn, Germany
| | - Joseph Lau
- Forum for Collaborative Research, Washington, DC, USA
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9
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Hunidzarira P, Brown ER, Chirenje ZM, Hillier SL, Marrazzo JM, Palanee-Phillips T, Kiweewa FM, Baeten JM. Population-Level Correlation Between Incidence of Curable Sexually Transmitted Infections and Human Immunodeficiency Virus (HIV)-1 Among African Women Participating in HIV-1 Pre-Exposure Prophylaxis Trials. J Infect Dis 2022; 226:1069-1074. [PMID: 35763413 PMCID: PMC10233491 DOI: 10.1093/infdis/jiac269] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2022] [Accepted: 06/26/2022] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND Highly efficacious oral pre-exposure prophylaxis (PrEP) is the global standard for human immunodeficiency virus (HIV)-1 prevention, including in clinical trials of novel PrEP agents using active-comparator designs. The analysis assessed whether incident sexually transmitted infections (STIs) can serve as a surrogate indicator of HIV-1 incidence that might occur in the absence of PrEP. METHODS We analyzed data from 3256 women randomized to placebo groups of oral and vaginal PrEP trials (MTN-003/VOICE and MTN-020/ASPIRE). Regression modeling assessed the correlation between incident individual STIs (Neisseria gonorrhoeae, Chlamydia trachomatis, and Trichomonas vaginalis, each considered separately) and incident HIV-1. RESULTS Across 18 sites in 4 countries (Malawi, South Africa, Uganda, Zimbabwe), STI and HIV-1 incidences were high: HIV-1 4.9, N gonorrhoeae 5.3, C trachomatis 14.5, and T vaginalis 7.1 per 100 person-years. There was limited correlation between HIV-1 incidence and incidence of individual STIs: N gonorrhoeae (r = 0.02, P = .871), C trachomatis (r = 0.49, P = <.001), and T vaginalis (r = 0.10, P = .481). The modest association with C trachomatis was driven by country-level differences in both C trachomatis and HIV-1, with no statistically significant association within countries. CONCLUSIONS Sexually transmitted infection incidence did not reliably predict HIV-1 incidence at the population level among at-risk African women participating in 2 large PrEP trials.
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Affiliation(s)
- Portia Hunidzarira
- University of Zimbabwe Clinical Trials Research Centre (UZ-CTRC), Harare, Zimbabwe
| | - Elizabeth R Brown
- Fred Hutchinson Cancer Research Center, Seattle, Washington, USA
- University of Washington, Department of Biostatistics; Seattle, Washington, USA
| | - Z Mike Chirenje
- University of Zimbabwe Clinical Trials Research Centre (UZ-CTRC), Harare, Zimbabwe
| | - Sharon L Hillier
- Magee-Womens Research Institute, Pittsburgh, Pennsylvania, USA
- Department of Obstetrics, Gynecology and Reproductive Sciences, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Jeanne M Marrazzo
- University of Alabama at Birmingham, Department of Medicine, Division of Infectious Diseases, Birmingham, Alabama, USA
| | - Thesla Palanee-Phillips
- University of Washington, Department of Epidemiology; School of Public Health, Seattle, Washington, USA
- Wits Reproductive Health and HIV Institute, University of the Witwatersrand, School of Public Health, South Africa
| | - Flavia M Kiweewa
- Makerere University-Johns Hopkins University Research Collaboration, Kampala, Uganda
| | - Jared M Baeten
- University of Washington, Department of Epidemiology; School of Public Health, Seattle, Washington, USA
- University of Washington, Department of Global Health; Seattle, Washington, USA
- University of Washington, Department of Medicine; Seattle, Washington, USA
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10
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Ooi C, Lewis DA, Newman CE. Engaging hard-to-reach men-who-have-sex-with-men with sexual health screening: Qualitative interviews in an Australian sex-on-premises-venue and sexual health service. PERSPECTIVES ON SEXUAL AND REPRODUCTIVE HEALTH 2022; 54:116-124. [PMID: 35918908 PMCID: PMC9804729 DOI: 10.1363/psrh.12204] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 06/15/2023]
Abstract
CONTEXT Compared with the general population in Australia, men-who-have-sex-with-men (MSM) have higher rates of HIV and sexually transmissible infections (STIs). Despite widespread advice to test regularly, a minority of these men remain "hard to reach." We undertook qualitative interviews with a group of such men in Sydney to better understand their views and experiences in relation to sexual health screening. METHODS We conducted semi-structured interviews with men engaging with HIV/STI screening services at a sex-on-premises-venue and the local Sexual Health Service in Greater Western Sydney. We analyzed these data for content and themes. RESULTS Sexual behaviors and identities were diverse, often discordant and compartmentalized from everyday lives. Overall, reported HIV/STI knowledge was poor and men did not see themselves at risk of HIV/STIs regardless of sexual behavior. Men took calculated risks and balanced with pleasure and escapism. Reasons for avoidance of testing included fear, unwillingness to disclose behavior, privacy concerns, and perceived low risk. Men viewed sexual health care as distinct from general health care. Service delivery preferences varied by service venue. Participants highlighted convenience, confidentiality, and trust as critical factors for a testing service. CONCLUSION A variety of testing options are needed to engage hard-to-reach MSM. Opportunities to enhance testing may include expanding health messaging, demystifying testing, and delinking sexual identity from sexual behavior and risk, thus promoting advantages of testing and establishing testing as standard of care.
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Affiliation(s)
- Catriona Ooi
- Sexual Health Service, Northern Sydney Local Health DistrictSydneyNew South WalesAustralia
- Northern Clinical School, Faculty of Health and MedicineUniversity of SydneySydneyNew South WalesAustralia
| | - David A. Lewis
- Western Sydney Sexual Health CentreWestern Sydney Local Health DistrictParramattaNew South WalesAustralia
- Westmead Clinical School, Faculty of Medicine and HealthUniversity of SydneyWestmeadNew South WalesAustralia
- Sydney Institute for Infectious DiseasesUniversity of SydneyWestmeadNew South WalesAustralia
| | - Christy E. Newman
- Centre for Social Research in Health, Faculty of Arts, Design and ArchitectureUNSW SydneySydneyNew South WalesAustralia
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11
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Donnell D, Zewdie K, Ratna N, Miller V, Saunders JM, Gill ON, Delpech V, Mohammed H. Association between rectal gonorrhoea and HIV incidence in men who have sex with men: a meta-analysis. Sex Transm Infect 2021; 98:492-496. [PMID: 34911750 DOI: 10.1136/sextrans-2021-055254] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2021] [Accepted: 11/26/2021] [Indexed: 11/04/2022] Open
Abstract
BACKGROUND Incidence of rectal gonorrhoea (GC) has been hypothesised as a correlate of HIV exposure in prevention trials of men who have sex with men (MSM). High rectal GC incidence in MSM trials of new biomedical prevention drugs may provide supportive evidence for ongoing HIV risk. Empirical evidence of correlation between rectal GC and HIV incidence is needed to assess whether high rectal GC rates reliably correlate with high risk of HIV. METHODS Rectal GC and HIV are routinely tested in sexual health clinics (SHCs) throughout England. Through routine surveillance data collected at visits to SHCs, we assessed HIV incidence and new rectal GC diagnoses in repeat visits by HIV-negative MSM between 2011 and 2018, predating widespread roll-out of pre-exposure prophylaxis. Meta-analysis regression assessed population-level association between HIV and rectal GC incidence over time. FINDINGS Between 2011 and 2018, HIV and rectal GC incidence was assessed in 541 056 HIV-negative MSM attending SHCs in England. HIV incidence among MSM attending SHCs fell from 1.26/100 person-years (PYs) in 2011 to 0.28/100 PYs in 2018. Rectal GC rates increased from 3.5/100 PYs to 11.1/100 PYs over the same period. The rate of HIV incidence decreased by 22.3% for each percent increase in rectal GC (95% CI -30.8 to -14.7, p<0.001). INTERPRETATION Among the population of MSM attending SHCs in England, rectal GC rates increased substantially while HIV incidence rates decreased between 2011 and 2018. HIV incidence likely decreased through expanded HIV testing, prompt antiretroviral treatment (ART) initiation and increased viral suppression in persons living with HIV, interventions that did not decrease rectal GC. Rectal GC may not be an ideal proxy for HIV incidence in trials, as HIV exposure risk is complex and context dependent, given effective HIV prevention interventions in MSM. INTRODUCTION
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Affiliation(s)
- Deborah Donnell
- Vaccine and Infectious Disease Division, Fred Hutchinson Cancer Research Center, Seattle, Washington, USA
| | - Kidist Zewdie
- Department of Epidemiology, University of Washington, Seattle, Washington, USA
| | - Natasha Ratna
- Blood Safety, Hepatitis, Sexually Transmitted Infections (STI) and HIV Division-National Infection Service, Public Health England, London, UK
| | - Veronica Miller
- School of Public Health, University of California System, Oakland, California, USA.,Forum for Collaborative Research, Washington, District of Columbia, USA
| | - John Michael Saunders
- HIV & STI Department, Public Health England, London, UK.,Research Department of Infection and Population Health, University College London, London, UK
| | - O Noel Gill
- HIV & STI Department, Public Health England, London, UK
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12
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Stenger MR, Pathela P, Schumacher C, Burghardt N, Amiya R, Madera R, Nguyen TQ, Torrone E. Trends in HIV prevalence by self-report among MSM diagnosed and reported with gonorrhea in six United States jurisdictions from 2010 to 2019. AIDS 2021; 35:2523-2530. [PMID: 34510114 PMCID: PMC10750803 DOI: 10.1097/qad.0000000000003067] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND HIV co-infection among persons diagnosed with gonorrhea is not well characterized. Trends in HIV prevalence among persons diagnosed with gonorrhea may have significant implications for HIV prevention interventions, especially for MSM. MSM are increasingly and disproportionately represented among incident gonorrhea cases reported in a multistate sentinel surveillance network. Using data from this network, we estimated HIV prevalence among MSM by self-report and explored trends in co-infection by key demographics. DESIGN Observational study using enhanced surveillance data. METHODS Six geographically diverse jurisdictions in the STD Surveillance Network (SSuN) 2010-2019 randomly sampled laboratory-confirmed gonorrhea cases. Enhanced investigations on sampled cases included patient interviews eliciting demographic, behavioral and HIV testing history. These data were weighted to adjust for study design and nonresponse to estimate trends in HIV prevalence. RESULTS Of 653 522 reported cases, 28 979 were sampled and investigated. The proportion of cases reporting living with diagnosed HIV at the time of their gonorrhea diagnosis increased 61% across the study period from 6.6% in 2010 to 10.8% in 2019. The observed increase in HIV prevalence is concurrent with an increase in the proportion of gonorrhea cases attributable to MSM. HIV prevalence among MSM decreased in two jurisdictions and increasing trends were observed among non-Hispanic Black and Hispanic MSM. HIV prevalence decreased among non-Hispanic white MSM, MSM under 20 and those 40 years of age or older. CONCLUSION Diagnosis with gonorrhea, especially among MSM, should be a sentinel event triggering screening for HIV, referral to high-impact HIV prevention interventions or to HIV primary care.
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Affiliation(s)
- Mark Richard Stenger
- Division of STD Prevention, Centers for Disease Control and Prevention (CDC), Atlanta, Georgia
| | - Preeti Pathela
- New York City Department of Health and Mental Hygiene, New York, New York
| | - Christina Schumacher
- Baltimore City Health Department & Johns Hopkins School of Medicine, Baltimore, Maryland
| | - Nicole Burghardt
- California Department of Public Health, STD Control Branch, Richmond, California
| | - Rachel Amiya
- Washington State Department of Health, Olympia, Washington
| | - Robbie Madera
- Philadelphia Department of Public Health, Philadelphia, Pennsylvania
| | - Trang Q. Nguyen
- San Francisco Department of Public Health, San Francisco, California, USA
| | - Elizabeth Torrone
- Division of STD Prevention, Centers for Disease Control and Prevention (CDC), Atlanta, Georgia
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13
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Grome HN, Rebeiro PF, Brantley M, Herrera-Vasquez D, Mathieson SA, Pettit AC. Risk of HIV Diagnosis Following Bacterial Sexually Transmitted Infections in Tennessee, 2013-2017. Sex Transm Dis 2021; 48:873-880. [PMID: 33859145 PMCID: PMC8514569 DOI: 10.1097/olq.0000000000001440] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Data on associations between sexually transmitted infections (STIs) and incident human immunodeficiency virus (HIV) diagnoses beyond men who have sex with men (MSM) are lacking. Identifying STIs associated with greatest risk of incident HIV diagnosis could help better target HIV testing and prevention interventions. METHODS The STI and HIV surveillance data from individuals 13 years or older in Tennessee from January 2013 to December 2017 were cross-matched. Individuals without diagnosed HIV, but with reportable STIs (chlamydia, gonorrhea, syphilis) were followed up from first STI diagnosis until HIV diagnosis or end of study. Cox regression with time-varying STI exposure was used to estimate adjusted hazard ratios (aHRs) and 95% confidence intervals (CI) for subsequent HIV diagnosis; results were stratified by self-reported MSM. RESULTS We included 148,465 individuals without HIV (3831 MSM; 144,634 non-MSM, including heterosexual men and women) diagnosed with reportable STIs; 473 had incident HIV diagnoses over 377,823 person-years (p-y) of follow-up (median, 2.6 p-y). Controlling for demographic and behavioral factors, diagnoses of gonorrhea, early syphilis, late syphilis, and STI coinfection were independently associated with incident HIV diagnosis compared with chlamydia. Early syphilis was associated with highest HIV diagnosis risk overall (aHR, 5.5; 95% CI, 3.5-5.8); this risk was higher for non-MSM (aHR, 12.3; 95% CI, 6.8-22.3) versus MSM (aHR, 2.9; 95% CI, 1.7-4.7). CONCLUSIONS While public health efforts often focus on MSM, non-MSM with STIs is also a subgroup at high risk of incident HIV diagnosis. Non-MSM and MSM with any STI, particularly syphilis, should be prioritized for HIV testing and prevention interventions.
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Affiliation(s)
- Heather N. Grome
- Division of Infectious Diseases, Department of Internal Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Peter F. Rebeiro
- Division of Infectious Diseases, Department of Internal Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, USA
- Division of Epidemiology, Department of Internal Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Meredith Brantley
- Division of HIV/STD/Viral Hepatitis, Tennessee Department of Health, Nashville, Tennessee, USA
| | - Dyanne Herrera-Vasquez
- Division of HIV/STD/Viral Hepatitis, Tennessee Department of Health, Nashville, Tennessee, USA
| | - Samantha A. Mathieson
- Division of HIV/STD/Viral Hepatitis, Tennessee Department of Health, Nashville, Tennessee, USA
| | - April C. Pettit
- Division of Infectious Diseases, Department of Internal Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, USA
- Division of Epidemiology, Department of Internal Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, USA
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14
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Glidden DV, Das M, Dunn DT, Ebrahimi R, Zhao Y, Stirrup OT, Baeten JM, Anderson PL. Using the adherence-efficacy relationship of emtricitabine and tenofovir disoproxil fumarate to calculate background hiv incidence: a secondary analysis of a randomized, controlled trial. J Int AIDS Soc 2021; 24:e25744. [PMID: 34021709 PMCID: PMC8140182 DOI: 10.1002/jia2.25744] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2020] [Revised: 04/22/2021] [Accepted: 04/26/2021] [Indexed: 12/02/2022] Open
Abstract
INTRODUCTION Randomized trials of new agents for HIV pre-exposure prophylaxis (PrEP) compare against emtricitabine and tenofovir disoproxil fumarate (F/TDF), without a placebo group. We used the well-characterized adherence-efficacy relationship for F/TDF to back-calculate the (non-PrEP) counterfactual background HIV incidence (bHIV) in a randomized trial of a novel PrEP agent and estimate comparative efficacy (to counterfactual bHIV). METHODS The DISCOVER trial (ClinicalTrials.gov: NCT02842086) randomized 5387 men who have sex with men (MSM) and transgender women who have sex with men and demonstrated non-inferiority of emtricitabine and tenofovir alafenamide (F/TAF) to F/TDF (HIV incidence rate ratio [IRR] 0·47, 95% CI: 0·19 to 1.15). Tenofovir diphosphate (TFV-DP) levels in dried blood spots (DBS) were assessed for all diagnosed with HIV and in a random 10% of the cohort. We used a Bayesian model with a diffuse prior distribution, derived from established data relating tenofovir diphosphate levels to HIV prevention efficacy. This prior, combined with the F/TDF seroconversion rate and tenofovir diphosphate levels in DISCOVER, yielded Bayesian inferences on the counterfactual bHIV. RESULTS There were six versus 11 postbaseline HIV infections (0.14 vs. 0.25/100 person-years [PY]) on F/TAF and F/TDF respectively. Of the 11 on F/TDF, 10 had low, none had medium and one had high tenofovir diphosphate levels; among HIV-negative controls, 5% of the person-time years had low, 9% had medium and 86% had high TFV-DP levels. A non-informative prior distribution for counterfactual bHIV, combined with the prior for TFV-DP level-efficacy relationship, yielded a posterior counterfactual bHIV of 3·4 infections/100 PY (0.80 Bayesian credible interval [CrI] 1·9 to 5·9), which suggests a median HIV efficacy of 96% (0.95 CrI [88% to 99%]) for F/TAF and 93% (0.95 CrI [87% to 96%]) for F/TDF compared to bHIV. CONCLUSIONS Based on the established connection of drug concentrations to PrEP prevention efficacy, a Bayesian framework can be used to estimate a synthetic non-PrEP control group in randomized, active-controlled PrEP trials that include a F/TDF-comparator group.
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Affiliation(s)
- David V Glidden
- School of MedicineUniversity of California San FranciscoSan FranciscoCAUSA
- Department of Epidemiology and BiostatisticsSan FranciscoCAUSA
| | | | - David T Dunn
- Centre for Clinical Research in Infection and Sexual HealthInstitute for Global HealthUniversity College LondonLondonUK
| | | | | | - Oliver T Stirrup
- Centre for Clinical Research in Infection and Sexual HealthInstitute for Global HealthUniversity College LondonLondonUK
| | | | - Peter L Anderson
- University of Colorado Denver ‐ Anschutz Medical CampusAuroraCOUSA
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15
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Gao F, Glidden DV, Hughes JP, Donnell DJ. Sample size calculation for active-arm trial with counterfactual incidence based on recency assay. STATISTICAL COMMUNICATIONS IN INFECTIOUS DISEASES 2021; 13:20200009. [PMID: 35880999 PMCID: PMC8865397 DOI: 10.1515/scid-2020-0009] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/26/2021] [Revised: 09/27/2021] [Accepted: 09/30/2021] [Indexed: 06/15/2023]
Abstract
Objectives The past decade has seen tremendous progress in the development of biomedical agents that are effective as pre-exposure prophylaxis (PrEP) for HIV prevention. To expand the choice of products and delivery methods, new medications and delivery methods are under development. Future trials of non-inferiority, given the high efficacy of ARV-based PrEP products as they become current or future standard of care, would require a large number of participants and long follow-up time that may not be feasible. This motivates the construction of a counterfactual estimate that approximates incidence for a randomized concurrent control group receiving no PrEP. Methods We propose an approach that is to enroll a cohort of prospective PrEP users and aug-ment screening for HIV with laboratory markers of duration of HIV infection to indicate recent infections. We discuss the assumptions under which these data would yield an estimate of the counterfactual HIV incidence and develop sample size and power calculations for comparisons to incidence observed on an investigational PrEP agent. Results We consider two hypothetical trials for men who have sex with men (MSM) and transgender women (TGW) from different regions and young women in sub-Saharan Africa. The calculated sample sizes are reasonable and yield desirable power in simulation studies. Conclusions Future one-arm trials with counterfactual placebo incidence based on a recency assay can be conducted with reasonable total screening sample sizes and adequate power to determine treatment efficacy.
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Affiliation(s)
- Fei Gao
- Fred Hutchinson Cancer Research Center, Seattle, USA
| | - David V. Glidden
- Department of Epidemiology and Biostatistics, University of California San Francisco, San Francisco, CA, USA
| | - James P. Hughes
- Department of Biostatistics, University of Washington, Seattle, WA, USA
| | - Deborah J. Donnell
- Vaccine and Infectious Disease Division, Fred Hutchinson Cancer Research Center, Seattle, WA, USA
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16
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Glidden DV, Stirrup OT, Dunn DT. A Bayesian averted infection framework for PrEP trials with low numbers of HIV infections: application to the results of the DISCOVER trial. Lancet HIV 2020; 7:e791-e796. [PMID: 33128906 PMCID: PMC7664988 DOI: 10.1016/s2352-3018(20)30192-2] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2020] [Revised: 05/04/2020] [Accepted: 05/11/2020] [Indexed: 12/16/2022]
Abstract
Trials of candidate agents for HIV pre-exposure prophylaxis (PrEP) might randomly assign participants to be given a new PrEP agent or oral coformulated tenofovir disoproxil fumarate plus emtricitabine. This design presents unique challenges in interpretation. First, with two active arms, HIV incidence might be low. Second, the effectiveness of tenofovir disoproxil fumarate plus emtricitabine varies across populations; thus, similar HIV incidence between groups could be consistent with a wide range of effectiveness for the new PrEP. We propose a two-part approach to trial results. First, we use Bayesian methods to incorporate assumptions about the background incidence of HIV in the trial in the absence of PrEP, possibly augmented by external data. On the basis of the estimated background incidence, we estimate and compare the number of averted (or prevented) HIV infections in each of the two trial groups, calculating the averted infections ratio. We apply these methods to a completed trial of tenofovir alafenamide plus emtricitabine for PrEP. Our framework shows that leveraging external information to estimate averted infections and the averted infections ratio enhances the efficiency and interpretation of active-controlled PrEP trials.
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Affiliation(s)
- David V Glidden
- Department of Epidemiology and Biostatistics, University of California San Francisco, San Francisco, CA, USA.
| | - Oliver T Stirrup
- Institute for Global Health, University College London, London, UK
| | - David T Dunn
- MRC Clinical Trials Unit, University College London, London, UK
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17
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Beste LA, Maier MM, Borgerding J, Lowy E, Hauser RG, Van Epps P, Ohl M, Ross D, Chartier M. Testing practices and incidence of chlamydial and gonococcal infection in the Veterans Health Administration, 2009-2019. Clin Infect Dis 2020; 73:e3235-e3243. [PMID: 32975293 DOI: 10.1093/cid/ciaa1454] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2020] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND Chlamydia trachomatis and Neisseria gonorrhoeae cases reached a record high in the United States in 2018. Although active duty military servicemembers have high rates of chlamydia and gonorrhea infection, trends in chlamydia and gonorrhea in the Veterans Health Administration (VHA) system have not been previously described, including among patients with human immunodeficiency virus (HIV) and young women. METHODS We identified all Veterans in VHA care from 2009-2019. Tests and cases of chlamydia and gonorrhea were defined based on lab results in the electronic health record. Chlamydia and gonorrhea incidence rates were calculated each year by demographic group and HIV status. RESULTS In 2019, testing for chlamydia and gonorrhea occurred in 2.3% of patients, 22.6% of women ages 18-24, and 34.1% of persons with HIV. 2019 incidence of chlamydia and gonorrhea was 100.8 and 56.3 cases per 100,000 VHA users, an increase of 267% and 294%, respectively, since 2009. Veterans aged <34 years accounted for 9.5% of the VHA population but 66.9% of chlamydia and 42.9% of gonorrhea cases. Chlamydia and gonorrhea incidence rates in persons with HIV were 1,432 and 1,687 per 100,000, respectively. CONCLUSIONS The incidence of chlamydia and gonorrhea rose dramatically from 2009-2019. Among tested persons, those with HIV had a 15.2-fold higher unadjusted incidence of chlamydia and 34.9-fold higher unadjusted incidence of gonorrhea compared to those without HIV. VHA-wide adherence to chlamydia and gonorrhea testing in high-risk groups merits improvement.
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Affiliation(s)
- Lauren A Beste
- General Medicine Service, VA Puget Sound Health Care System and Department of Medicine, University of Washington School of Medicine, Seattle, WA, USA
| | - Marissa M Maier
- Division of Infectious Diseases, Department of Medicine, Oregon Health and Sciences University, VA Portland Health Care System, Portland, OR, USA
| | - Joleen Borgerding
- Health Services Research & Development, VA Puget Sound Healthcare System, Seattle, WA, USA
| | - Elliott Lowy
- Health Services Research & Development, VA Puget Sound Healthcare System, University of Washington School of Public Health, Seattle, WA, USA
| | - Ronald G Hauser
- Pathology and Laboratory Medicine Department, Veterans Affairs Connecticut Healthcare, Department of Laboratory Medicine, Yale University School of Medicine, New Haven, CT, USA
| | - Puja Van Epps
- Department of Medicine, Veterans Affairs Northeast Ohio Healthcare System, Case Western Reserve University School of Medicine, Cleveland, Ohio, USA
| | - Michael Ohl
- Center for Access and Delivery Research and Evaluation (CADRE), Department of Medicine, University of Iowa Carver College of Medicine, Iowa City, Iowa, USA
| | - David Ross
- Office of Specialty Care Services, Veterans Health Administration, Washington, D.C., USA
| | - Maggie Chartier
- Office of Specialty Care Services, Veterans Health Administration, Washington, D.C., USA
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18
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Mayer KH, Molina JM, Thompson MA, Anderson PL, Mounzer KC, De Wet JJ, DeJesus E, Jessen H, Grant RM, Ruane PJ, Wong P, Ebrahimi R, Zhong L, Mathias A, Callebaut C, Collins SE, Das M, McCallister S, Brainard DM, Brinson C, Clarke A, Coll P, Post FA, Hare CB. Emtricitabine and tenofovir alafenamide vs emtricitabine and tenofovir disoproxil fumarate for HIV pre-exposure prophylaxis (DISCOVER): primary results from a randomised, double-blind, multicentre, active-controlled, phase 3, non-inferiority trial. Lancet 2020; 396:239-254. [PMID: 32711800 PMCID: PMC9665936 DOI: 10.1016/s0140-6736(20)31065-5] [Citation(s) in RCA: 233] [Impact Index Per Article: 58.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/08/2019] [Revised: 04/20/2020] [Accepted: 04/23/2020] [Indexed: 12/11/2022]
Abstract
BACKGROUND Tenofovir alafenamide shows high antiviral efficacy and improved renal and bone safety compared with tenofovir disoproxil fumarate when used for HIV treatment. Here, we report primary results from a blinded phase 3 study evaluating the efficacy and safety of pre-exposure prophylaxis (PrEP) with emtricitabine and tenofovir alafenamide versus emtricitabine and tenofovir disoproxil fumarate for HIV prevention. METHODS This study is an ongoing, randomised, double-blind, multicentre, active-controlled, phase 3, non-inferiority trial done at 94 community, public health, and hospital-associated clinics located in regions of Europe and North America, where there is a high incidence of HIV or prevalence of people living with HIV, or both. We enrolled adult cisgender men who have sex with men and transgender women who have sex with men, both with a high risk of acquiring HIV on the basis of their self-reported sexual behaviour in the past 12 weeks or their recent history (within 24 weeks of enrolment) of bacterial sexually transmitted infections. Participants with current or previous use of PrEP with emtricitabine and tenofovir disoproxil fumarate were not excluded. We used a computer-generated random allocation sequence to randomly assign (1:1) participants to receive either emtricitabine (200 mg) and tenofovir alafenamide (25 mg) tablets daily, with matched placebo tablets (emtricitabine and tenofovir alafenamide group), or emtricitabine (200 mg) and tenofovir disoproxil fumarate (300 mg) tablets daily, with matched placebo tablets (emtricitabine and tenofovir disoproxil fumarate group). As such, all participants were given two tablets. The trial sponsor, investigators, participants, and the study staff who provided the study drugs, assessed the outcomes, and collected the data were masked to group assignment. The primary efficacy outcome was incident HIV infection, which was assessed when all participants had completed 48 weeks of follow-up and half of all participants had completed 96 weeks of follow-up. This full analysis set included all randomly assigned participants who had received at least one dose of the assigned study drug and had at least one post-baseline HIV test. Non-inferiority of emtricitabine and tenofovir alafenamide to emtricitabine and tenofovir disoproxil fumarate was established if the upper bound of the 95·003% CI of the HIV incidence rate ratio (IRR) was less than the prespecified non-inferiority margin of 1·62. We prespecified six secondary bone mineral density and renal biomarker safety endpoints to evaluate using the safety analysis set. This analysis set included all randomly assigned participants who had received at least one dose of the assigned study drug. This trial is registered with ClinicalTrials.gov, NCT02842086, and is no longer recruiting. FINDINGS Between Sept 13, 2016, and June 30, 2017, 5387 (92%) of 5857 participants were randomly assigned and received emtricitabine and tenofovir alafenamide (n=2694) or emtricitabine and tenofovir disoproxil fumarate (n=2693). At the time of the primary efficacy analysis (ie, when all participants had completed 48 weeks and 50% had completed 96 weeks) emtricitabine and tenofovir alafenamide was non-inferior to emtricitabine and tenofovir disoproxil fumarate for HIV prevention, as the upper limit of the 95% CI of the IRR, was less than the prespecified non-inferiority margin of 1·62 (IRR 0·47 [95% CI 0·19-1·15]). After 8756 person-years of follow-up, 22 participants were diagnosed with HIV, seven participants in the emtricitabine and tenofovir alafenamide group (0·16 infections per 100 person-years [95% CI 0·06-0·33]), and 15 participants in the emtricitabine and tenofovir disoproxil fumarate group (0·34 infections per 100 person-years [0·19-0·56]). Both regimens were well tolerated, with a low number of participants reporting adverse events that led to discontinuation of the study drug (36 [1%] of 2694 participants in the emtricitabine and tenofovir alafenamide group vs 49 [2%] of 2693 participants in the emtricitabine and tenofovir disoproxil fumarate group). Emtricitabine and tenofovir alafenamide was superior to emtricitabine and tenofovir disoproxil fumarate in all six prespecified bone mineral density and renal biomarker safety endpoints. INTERPRETATION Daily emtricitabine and tenofovir alafenamide shows non-inferior efficacy to daily emtricitabine and tenofovir disoproxil fumarate for HIV prevention, and the number of adverse events for both regimens was low. Emtricitabine and tenofovir alafenamide had more favourable effects on bone mineral density and biomarkers of renal safety than emtricitabine and tenofovir disoproxil fumarate. FUNDING Gilead Sciences.
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Affiliation(s)
- Kenneth H Mayer
- The Fenway Institute, Fenway Health, Boston, MA, USA; Department of Medicine, Harvard Medical School, Boston, MA, USA
| | - Jean-Michel Molina
- Infectious Diseases Department, Hopitaux Saint-Louis Lariboisière, University of Paris and INSERM U944, Paris, France
| | | | - Peter L Anderson
- Department of Pharmaceutical Sciences, Skaggs School of Pharmacy and Pharmaceutical Sciences, University of Colorado, Aurora, CO, USA
| | | | | | | | | | - Robert M Grant
- San Francisco AIDS Foundation, and University of California, San Francisco, CA, USA
| | - Peter J Ruane
- Ruane Medical and Liver Health Institute, Los Angeles, CA, USA
| | - Pamela Wong
- Department of Biometrics, Gilead Sciences, Foster City, CA, USA
| | - Ramin Ebrahimi
- Department of Biometrics, Gilead Sciences, Foster City, CA, USA
| | - Lijie Zhong
- Department of Biometrics, Gilead Sciences, Foster City, CA, USA
| | - Anita Mathias
- Department of Clinical Pharmacology, Gilead Sciences, Foster City, CA, USA
| | | | - Sean E Collins
- Department of HIV and Emerging Viral Infections Clinical Research, Gilead Sciences, Foster City, CA, USA
| | - Moupali Das
- Department of HIV and Emerging Viral Infections Clinical Research, Gilead Sciences, Foster City, CA, USA.
| | - Scott McCallister
- Department of HIV and Emerging Viral Infections Clinical Research, Gilead Sciences, Foster City, CA, USA
| | - Diana M Brainard
- Department of HIV and Emerging Viral Infections Clinical Research, Gilead Sciences, Foster City, CA, USA
| | | | - Amanda Clarke
- Royal Sussex County Hospital, Brighton and Sussex University Hospitals National Health Service (NHS) Trust, Brighton, UK
| | - Pep Coll
- BCN Checkpoint and IrsiCaixa-AIDS Research Institute, Barcelona, Spain
| | - Frank A Post
- King's College Hospital NHS Foundation Trust, King's College Hospital, London, UK
| | - C Bradley Hare
- Department of Adult and Family Medicine, Kaiser Permanente San Francisco Medical Center, San Francisco, CA, USA
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Chaillon A, Hoenigl M, Freitas L, Feldman H, Tilghman W, Wang L, Smith D, Little S, Mehta SR. Optimizing Screening for HIV. Open Forum Infect Dis 2020; 7:ofaa024. [PMID: 32055638 PMCID: PMC7009491 DOI: 10.1093/ofid/ofaa024] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2019] [Accepted: 01/14/2020] [Indexed: 01/04/2023] Open
Abstract
BACKGROUND The HIV epidemic is unevenly distributed throughout the United States, even within neighborhoods. This study evaluated how effectively current testing approaches reached persons at risk for HIV infection across San Diego (SD) County, California. METHODS HIV case and testing data, sexually transmitted infection (STI) data, and sociodemographic data for SD County were collected from the SD Health and Human Services Agency and the "Early Test" community-based HIV screening program between 1998 and 2016. Relationships between HIV diagnoses, HIV prevalence, and STI diagnoses with screening at the ZIP code level were evaluated. RESULTS Overall, 379 074 HIV tests were performed. The numbers of HIV tests performed on persons residing in a ZIP code or region overall strongly correlated with prevalent HIV cases (R 2 = .714), new HIV diagnoses (R 2 = .798), and STI diagnoses (R 2 = .768 [chlamydia], .836 [gonorrhea], .655 [syphilis]) in those regions. ZIP codes with the highest HIV prevalence had the highest number of tests per resident and fewest number of tests per diagnosis. Even though most screening tests occurred at fixed venues located in high-prevalence areas, screening of residents from lower-prevalence areas was mostly proportional to the prevalence of HIV and rates of new HIV and STI diagnoses in those locales. CONCLUSIONS This study supported the ability of a small number of standalone testing centers to reach at-risk populations dispersed across SD County. These methods can also be used to highlight geographic areas or demographic segments that may benefit from more intensive screening.
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Affiliation(s)
- Antoine Chaillon
- Department of Medicine, University of California San Diego, San Diego, California, USA
| | - Martin Hoenigl
- Department of Medicine, University of California San Diego, San Diego, California, USA
| | - Lorri Freitas
- County of San Diego Health and Human Services Agency, Division of Public Health Services, San Diego, California, USA
| | - Haruna Feldman
- County of San Diego Health and Human Services Agency, Division of Public Health Services, San Diego, California, USA
| | - Winston Tilghman
- County of San Diego Health and Human Services Agency, Division of Public Health Services, San Diego, California, USA
| | - Lawrence Wang
- County of San Diego Health and Human Services Agency, Division of Public Health Services, San Diego, California, USA
| | - Davey Smith
- Department of Medicine, University of California San Diego, San Diego, California, USA
- Department of Medicine, San Diego Veterans Affairs Medical Center, San Diego, California, USA
| | - Susan Little
- Department of Medicine, University of California San Diego, San Diego, California, USA
| | - Sanjay R Mehta
- Department of Medicine, University of California San Diego, San Diego, California, USA
- Department of Medicine, San Diego Veterans Affairs Medical Center, San Diego, California, USA
- Department of Pathology, University of California San Diego, San Diego, California, USA
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Cohen MS, Donnell D. Novel Approaches for Development of Human Immunodeficiency Virus Preexposure Prophylaxis Agents. J Infect Dis 2020; 221:172-174. [PMID: 30715403 PMCID: PMC6936000 DOI: 10.1093/infdis/jiz041] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2019] [Accepted: 01/18/2019] [Indexed: 11/13/2022] Open
Affiliation(s)
- Myron S Cohen
- Institute for Global Health and Infectious Diseases, School of Medicine, University of North Carolina at Chapel Hill
| | - Deborah Donnell
- Vaccine and Infectious Disease Division, Fred Hutchinson Cancer Research Center, Seattle, Washington
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21
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Abstract
With the scale-up of HIV pre-exposure prophylaxis (PrEP) with tenofovir (TDF) with or without emtricitabine (FTC), we have entered an era of highly effective HIV prevention with a growing pipeline of potential products to be studied. These studies are likely to be randomized trials with an oral TDF/FTC control arm. These studies require comparison of incident infections and can be time and resource intensive. Conventional approaches for design and analysis active controlled trial can lead to very large sample sizes. We demonstrate the important of assumptions about background infections for interpreting trial results and suggest alternative criteria for demonstrating the efficacy and effectiveness of potential PrEP agents.
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Affiliation(s)
- David V Glidden
- University of California San Francisco, San Francisco, CA, USA
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