HIV PrEP in the Military: Experience at a Tertiary Care Military Medical Center

HIV Prevention Research With U.S. Military Service Members: A Systematic Review

INTRODUCTION

With the goal of maintaining mission readiness, the U.S. Department of Defense monitors a variety of health behaviors among its active duty military service members, including sexual health, HIV, and other sexually transmitted infections. Newer biomedical approaches to HIV prevention and care (e.g., Treatment as Prevention (TasP) via Pre-exposure Prophylaxis (PrEP) and undetectable = untransmissible of antiretroviral therapy (ART/U = U) have evolved over the last few years and are now available. However, the last systematic review on HIV prevention among military populations was published in 2005, calling for the need to provide an update on what HIV prevention research has been conducted with U.S. active duty service members.

MATERIALS AND METHODS

PRISMA guidelines were followed to identify articles that met pre-determined eligibility criteria. Several electronic databases were searched, including PubMed. The review focused on HIV prevention research conducted with the U.S. Military (i.e., active duty service members). Inclusion criteria for articles centered on population (U.S. active duty service members aged 17 years and older), language (published in English), study focus (epidemiological, intervention), study design (descriptive, quasi-experimental, and experimental), date of publication, and research focus. Studies with a descriptive focus to understand HIV-related risk behaviors, use of prevention strategies (e.g., condoms, testing, PrEP), and prescribing practices for uptake of prevention strategies among U.S. military service members (i.e., by providers, uptake from nonproviders) were included. Studies that focused on intervening or changing HIV risk (i.e., interventions) among U.S. military service members were also included.

RESULTS

The findings in this review were reported based on the PRISMA guidelines. A total of 2,270 articles were identified through electronic databases. Of the 2,270 articles, 809 articles were removed for duplication. Titles and abstracts were reviewed for the remaining 1,461 articles. Of the 1,461 articles, 1,432 were excluded for not meeting the inclusion criteria. In total, 29 studies met the inclusion criteria and were included in this review. Studies were organized into 3 tables based on study focus and target population (e.g., active duty, U.S. Military service members who were providers vs. nonproviders).

CONCLUSIONS

The present systematic review describes 29 HIV prevention studies that have been conducted with active duty service members in the U.S. Military since 2000. Overall, most included studies were descriptive, epidemiological studies conducted with active duty service members who were not providers. There were few interventions that reported some success in improving prevention knowledge and condom use. None of the interventions included newer evidence-based strategies of TasP. Although some research had been conducted about PrEP, particularly with providers, there is a clear need for additional studies and interventions to include TasP, given the evidence base of these approaches for reducing acquisition and/or onward transmission of HIV.

Discontinuation, suboptimal adherence, and reinitiation of oral HIV pre-exposure prophylaxis: a global systematic review and meta-analysis

BACKGROUND

Poor adherence to oral HIV pre-exposure prophylaxis (PrEP) diminishes its clinical and public health benefits. This study synthesises evidence regarding discontinuation, adherence, and reinitiation of PrEP among geographically diverse PrEP users.

METHODS

We did a systematic review and meta-analysis evaluating studies published in MEDLINE, Embase, and Cochrane Central Register of Controlled Trials from inception to Dec 18, 2020. We included longitudinal studies that presented data for PrEP discontinuation, defined as investigator-reported loss to follow-up or participant self-reported PrEP stoppage. Data were extracted from published reports and assessed for risk of bias. We used a random-effects meta-analysis to pool estimates of discontinuation and I2 and τ2 to evaluate heterogeneity. This study is registered with PROSPERO, CRD42020155675.

FINDINGS

We identified 4129 records, of which 59 articles were included (n=43 917 participants). 41·0% (95% CI 18·8-63·5) of participants discontinued PrEP within 6 months, with the highest rates in observational studies. The discontinuation rate in sub-Saharan Africa (47·5%, 95% CI: 29·4-66·4%) was higher than in other regions (p<0·001). Discontinuation rates were lower in studies with adherence interventions than in those without (24·7% vs 36·7%, p=0·015). Gay or bisexual men who have sex with men and transgender women offered daily or non-daily dosing options had lower discontinuation rates than those offered daily dosing alone (21·6% vs 31·5%; p<0·001). The pooled suboptimal adherence within 6 months was 37·7% (95% CI 8·4-66·9). Among people who discontinued PrEP, 47·3% (95% CI 31·5-63·2) reinitiated PrEP within 1 year of PrEP initiation. The included studies had poor quality in terms of study design, with a moderate risk of bias.

INTERPRETATION

Strategies to encourage reinitiating PrEP for new or persistent risk should be a focus of future PrEP implementation strategies.

FUNDING

National Institutes of Health and Nature Science Foundation of China.

Preferences for Long-Acting and Alternative Modalities for PrEP among Military Men Who Have Sex with Men: Segmentation Results of an Adaptive Choice-Based Conjoint Analysis Study

The use of pre-exposure prophylaxis (PrEP) for HIV prevention within the U.S. military is low. Implementing preference-based alternative modalities of PrEP delivery, however, can be an innovative strategy to address the specific barriers to PrEP uptake among military MSM. We sought to identify population-based, segment-specific preferences for longer-acting and alternative PrEP delivery modalities to guide patient-centered strategies to optimize uptake within military-serving healthcare systems. HIV-negative military men who have sex with men (MSM) completed an anonymous, adaptive choice-based conjoint (ACBC) analysis survey consisting of five key attributes of interest (dosing method, provider type, visit location, lab work evaluation location, and dispensing venue). Relative importance and part-worth utility scores were generated using Hierarchical Bayes (HB) estimation, and cluster ensemble analysis grouped participants into "phenotype" segments by preference similarity. The randomized first-choice model was then used to examine changes in program interest rates among segments through market simulation. The 429 participants were segmented into five preference groups. The dosing method attribute was found to be the most important to nearly all segments. Simulations revealed that PrEP program interest among two segments with low interest levels increased when smartphone, civilian-based, and long-acting injectable PrEP options were involved. Findings also suggested a need for clinics to be responsive and sensitive to sexual practices, risk perception, and functional PrEP knowledge. Responsiveness to segment-specific preferences in the design of military PrEP programs and acting on the importance of clinical relationships within the context of PrEP engagement within a military setting may contribute to increasing PrEP uptake.

"That's kind of like the big struggle right now is can we get PrEP?": Facilitators and Barriers to PrEP Uptake Among Active Duty Gay and Bisexual Men

Introduction

The US Military is experiencing a rise in HIV infections among gay and bisexual men (GBM) serving on active duty, yet little is known about this population's uptake of pre-exposure prophylaxis (PrEP), an evidence-based intervention for HIV prevention. This mixed methods study examines the facilitators and barriers to PrEP access and uptake among active duty GBM.

Methods

Active duty GBM were recruited using respondent-driven sampling (2017 and 2018). Participants (n = 93) answered quantitative survey questions on PrEP interest and accessibility. Another set of participants (n = 10) discussed their PrEP experiences in qualitative interviews. We conducted descriptive and bivariate analyses of quantitative data, while qualitative data were analyzed using structural and descriptive coding techniques.

Results

Approximately 71% of active duty GBM indicated interest in accessing PrEP. A greater proportion of those who disclosed (vs. did not disclose) their sexual orientation to their military doctor discussed (p < 0.001) or accessed (p = 0.017) PrEP. The following qualitative themes emerged: (1) providers' negative views and knowledge gaps related to PrEP; (2) lack of a systems approach to PrEP access; (3) confidentiality concerns; and (4) reliance on peer networks for PrEP guidance and support.

Conclusions

Study results indicate that active duty GBM are interested in and want to discuss PrEP with their military doctors, but gaps in providers' PrEP-related knowledge and skills, as well as mistrust in the military health care system, remain.

Policy Implications

A system-wide approach that addresses confidentiality concerns and removes procedural barriers to PrEP access is recommended to improve PrEP uptake in this population.

Preferences for pre-exposure prophylaxis among U.S. military men who have sex with men: results of an adaptive choice based conjoint analysis study

BACKGROUND

Pre-exposure prophylaxis (PrEP) prevents human immunodeficiency virus (HIV) infection, but its use remains low among U.S. military men who have sex with men (MSM), likely due to mis-matching with personal preferences. We conducted a study to characterize preferences to PrEP measures within this population.

METHODS

HIV-negative military MSM were recruited through a closed, Lesbian, Gay, Bisexual, and Transgendered (LGBT) military social media group. The survey was anonymous, and consisted of five experimentally varied attributes in service delivery: dosing method, provider type, visit location, lab work evaluation location, and dispensing venue. Relative importance and part-worth utility scores were generated using hierarchical bayes (HB) estimation, and the randomized first choice model was used to examine participation interest across eight possible PrEP program scenarios.

RESULTS

A total of 429 participants completed the survey. Among the eight scenarios with varying attributes, the most preferred scenario featured a daily tablet, PrEP injection or implant, along with a military provider, smartphone/telehealth visit, and on-base locations for lab evaluation and medication pick-up. The results also emphasized the importance for providers to be familiar with PrEP prescription knowledge, and to provide interactions sensitive to sexual identity and mental health.

CONCLUSION

A PrEP program consisting of daily tablet is preferred in military healthcare settings is preferred. Long-acting implants and injections are also desired.

Provider Knowledge Gaps in HIV PrEP Affect Practice Patterns in the US Navy

INTRODUCTION

Although HIV pre-exposure prophylaxis (PrEP) is available at no cost to personnel in the United States (U.S.) military, uptake has been lower than expected. An online survey was conducted assessing current knowledge, perceptions, and attitudes of primary care providers in the U.S. Navy.

MATERIALS AND METHODS

A cross-sectional anonymous online survey was conducted among U.S. Navy healthcare providers in active service. Providers' demographics, medical practice and PrEP experience, and attitudes regarding PrEP were assessed by self-rated PrEP knowledge.

RESULTS

Greater than half of respondents reported being knowledgeable about PrEP and a majority (78%) supported the provision of PrEP in the military health system. However, only 19% had ever prescribed PrEP. Self-reports of having been questioned by a patient about PrEP, having high levels of comfort discussing sexual risk behaviors, and being in a specialty of infectious disease, occupational health, or preventive medicine were associated with increased knowledge about PrEP. The more knowledgeable a provider was about PrEP, the more likely they were to prescribe it (29% vs. 6%).

CONCLUSIONS

Although Navy providers were supportive of the provision of PrEP by the military, knowledge gaps remain. Training to address the knowledge deficit as well as improving sexual history taking are potential areas to target in implementing PrEP in primary care specialties.

Cross-Sectional Study of Sexual Behavior, Alcohol Use, and Mental Health Conditions Associated With Sexually Transmitted Infections Among Deploying Shipboard US Military Personnel

INTRODUCTION

Limited comprehensive data exist on risk behavior associated with sexually transmitted infections (STI) among ship-assigned US military personnel during the predeployment time period (PDT). This study examined whether sexual risk behaviors, alcohol use, involuntary drug consumption (IDC), posttraumatic stress disorder (PTSD), and depression during the 12 months prior to deployment were associated with provider-diagnosed STIs in this population.

MATERIALS AND METHODS

Using cross-sectional data collected during 2012-2014 among sexually active personnel, multivariable regression assessed factors associated with STIs among all men (n = 1,831). Stratified analyses were conducted among men who have sex with women (MSW, n = 1,530), men who have sex with men or men and women (MSM, n = 83), and excluded those not reporting sexual partner gender (n = 218).

RESULTS

Among MSW, transactional sex (AOR 3.8, 95% CI 1.5-9.4) meeting sexual partners at work (AOR 4.3, 95% CI 2.0-9.2), IDC (AOR 6.6, 95% CI 3.0-14.5), and incomplete mental health assessments (AOR 4.4, 95% CI 1.6-12.0) were significantly associated with STIs after adjustment. Among all men, those who identified as MSM (AOR 4.6, 95% CI 1.9-11.2) and drug screen positive (AOR 3.3, 95% CI 1.3-8.6) were significantly more likely to report an STI.

CONCLUSIONS

Previously unreported factors significantly associated with STIs at the PDT among MSW in the adjusted analysis were meeting sexual partners at work and IDC. IDC during the PDT warrants further exploration. These results can inform tailored STI reduction interventions among shipboard personnel and similarly aged civilians undergoing similar transition/travel experiences.

Global Epidemiologic Characteristics of Sexually Transmitted Infections Among Individuals Using Preexposure Prophylaxis for the Prevention of HIV Infection: A Systematic Review and Meta-analysis

IMPORTANCE

Despite a global increase in sexually transmitted infections (STIs), there is limited focus and investment in STI management within HIV programs, in which risks for STIs are likely to be elevated.

OBJECTIVE

To estimate the prevalence of STIs at initiation of HIV preexposure prophylaxis (PrEP; emtricitabine and tenofovir disoproxil fumarate) and the incidence of STIs during PrEP use.

DATA SOURCES

Nine databases were searched up to November 20, 2018, without language restrictions. The implementers of PrEP were also approached for additional unpublished data.

STUDY SELECTION

Studies reporting STI prevalence and/or incidence among PrEP users were included.

DATA EXTRACTION AND SYNTHESIS

Data were extracted independently by at least 2 reviewers. The methodological quality of studies was assessed using the Joanna Briggs Institute critical assessment tool for prevalence and incidence studies. Random-effects meta-analysis was performed.

MAIN OUTCOMES AND MEASURES

Pooled STI prevalence (ie, within 3 months of PrEP initiation) and STI incidence (ie, during PrEP use, after 3 months).

RESULTS

Of the 3325 articles identified, 88 were included (71 published and 17 unpublished). Data came from 26 countries; 62 studies (70%) were from high-income countries, and 58 studies (66%) were from programs only for men who have sex with men. In studies reporting a composite outcome of chlamydia, gonorrhea, and early syphilis, the pooled prevalence was 23.9% (95% CI, 18.6%-29.6%) before starting PrEP. The prevalence of the STI pathogen by anatomical site showed that prevalence was highest in the anorectum (chlamydia, 8.5% [95% CI, 6.3%-11.0%]; gonorrhea, 9.3% [95% CI, 4.7%-15.2%]) compared with genital sites (chlamydia, 4.0% [95% CI, 2.0%-6.6%]; gonorrhea, 2.1% [95% CI, 0.9%-3.7%]) and oropharyngeal sites (chlamydia, 2.4% [95% CI, 0.9%-4.5%]; gonorrhea, 4.9% [95% CI, 1.9%-9.1%]). The pooled incidence of studies reporting the composite outcome of chlamydia, gonorrhea, and early syphilis was 72.2 per 100 person-years (95% CI, 60.5-86.2 per 100 person-years).

CONCLUSIONS AND RELEVANCE

Given the high burden of STIs among individuals initiating PrEP as well as persistent users of PrEP, this study highlights the need for active integration of HIV and STI services for an at-risk and underserved population.

Expanding Knowledge About Implementation of Pre-exposure Prophylaxis (PrEP): A Methodological Review

Methodological limitations in PrEP implementation studies may explain why PrEP implementation is lagging. This methodological review provides a description and critique of the methods used to identify barriers to PrEP implementation in the United States (2007-18). For each selected article, we provide: (1) research questions; (2) measures; (3) design; (4) sample (size and type); and (5) theoretical orientation. Among 79 articles which identified knowledge, attitudes, and behavioral and social/structural barriers to PrEP implementation, 51 (65%) were quantitative; 25 (32%) qualitative; and 3 (4%) were mixed-methods; overall, just one-half described a conceptual approach. About two-thirds of articles were conducted with patients and one-third with healthcare providers. Our review reveals a paucity of longitudinal, mixed-methods, and ethnographic/observational research and guiding theoretical frameworks; thus, the applicability of results are limited. We recommend that interventions aimed at PrEP implementation address barriers situated at multiple ecological domains, and thus improve PrEP access, uptake, and adherence.