Per-contact risk of human immunodeficiency virus transmission between male sexual partners

Development and calibration of a mathematical model of HIV outcomes among Rwandan adults: Informing achievement of global targets across sub-populations in Rwanda

BACKGROUND

We developed and calibrated the Central Africa-International epidemiology Databases to Evaluate AIDS (CA-IeDEA) HIV policy model to inform achievement of global goals, overall and across all sub-populations, in Rwanda.

METHODS

We created a deterministic dynamic model to project adult HIV epidemic and care continuum outcomes, overall and for 35 subpopulations (age group, sex, HIV acquisition risk, urbanicity). Data came from the Rwanda cohort of CA-IeDEA, 2004-2020; Rwanda Demographic and Health Surveys, 2005, 2010, 2015; Rwanda Population-based HIV Impact Assessment, 2019; and literature and reports. We calibrated the model to 47 targets by selecting 50 best-fitting parameter sets. Targets reflected epidemic, global goals and other indicators. Best-fitting sets minimized the summed absolute value of the percentage deviation (AVPD) between projections and targets. Good performance was mean AVPD ≤5% across best-fitting sets and/or projections within target confidence intervals; acceptable was mean AVPD >5%-15%.

RESULTS

Across indicators, 1,843 of 2,350 (78.4%) model projections were a good or acceptable fit to calibration targets. For HIV epidemic indicators, 247 of 300 (82.3%) projections were a good fit to targets, with the model performing better for women (80.3% a good fit) than for men (62.3% a good fit). For global goals indicators, 97 of 100 (97.0%) projections were a good fit; model performance was similar for women and men. For other indicators, 708 of 950 (74.5%) projections were a good or acceptable fit. Fit was better for women than for men (percentage virally suppressed only) and when restricting targets for number on ART to 2013 and beyond.

CONCLUSIONS

The CA-IeDEA HIV policy model fits historical data and can inform policy solutions for achieving global goals across all sub-populations in Rwanda. High-quality population-based data and novel approaches that account for calibration target quality are critical to ongoing use of mathematical models for programmatic planning.

Sustaining Rwanda's HIV response after elimination of PEPFAR funding: a modeling analysis

Introduction

HIV prevention and treatment supported by the United States President's Emergency Plan for AIDS Relief (PEPFAR) have saved millions of lives. Rwanda is among the most successful countries around the world in achieving global targets with PEPFAR support. However, abrupt funding uncertainty around PEPFAR raises concerns about continued HIV epidemic control. We projected the impact of the Government of Rwanda's (GoR's) capacity to offset the elimination of PEPFAR funding on adult HIV epidemic and care continuum outcomes over 10 years.

Methods

Using an HIV policy model calibrated to Rwanda, we assessed: capacity to sustain HIV services at 50% (with no capacity by GoR to cover the PEPFAR funding gap), 75%, 90%, and 100% (with full capacity by GoR to cover the PEPFAR funding gap). Scenarios were operationalized by reducing the number on antiretroviral therapy (ART), with immediate ART discontinuation and proportional decreases in HIV diagnosis, ART initiation, and care re-engagement. We projected HIV epidemic outcomes (HIV prevalence, HIV incidence, number with HIV, new HIV infections, deaths) and care continuum outcomes (percent diagnosed, percent on ART among those diagnosed, percent virally suppressed among those on ART). We calculated differences in projected outcomes for partial or no capacity versus full capacity. Secondary analyses assessed delayed coverage capacity by 1 and 3 years.

Results

Compared to full capacity at 10 years, the model projected a 13.9%-38.7% increase in HIV prevalence and 69.0%-246.7% increase in HIV incidence across coverage capacity scenarios. This translated to 29,000-64,000 additional adults with HIV and 20,000-92,000 cumulative new adult HIV infections. Cumulative projected deaths increased by 10,000-51,200. The model projected continual reductions in percent diagnosed at 10 years; percent virally suppressed among those on ART was similar across scenarios. Higher, and more delayed, coverage capacity had projected outcomes similar to lower, and less delayed, coverage capacity.

Conclusions

Even in countries like Rwanda that have achieved epidemic control, abrupt and persistent elimination of PEPFAR funding could drastically reverse critical gains. Evidence quantifying the consequences of different capacities to sustain HIV services underscores the high stakes of rapid and sufficient action.

A modeling study of pre-exposure prophylaxis to eliminate HIV in Taiwan by 2030

BACKGROUND

The necessity of pre-exposure prophylaxis (PrEP) for ending the global AIDS epidemic by 2030 remains controversial. In Taiwan, the HIV epidemic predominantly affects young, sexually active men who have sex with men (MSM). This study aimed to model the impact and cost-effectiveness of a high-coverage oral emtricitabine/tenofovir PrEP program in Taiwan from an HIV elimination perspective.

METHODS

We applied stochastic and risk/age-structured deterministic modeling to assess the impact of PrEP scale-up on the basic reproduction number (R0) and the trajectory of the HIV epidemic in Taiwan, respectively. Both models were parameterized using the national HIV registry and cascade data. Cost-effectiveness was evaluated from a societal perspective.

RESULTS

Here we show that an intensive HIV test-and-treat strategy targeting HIV-positive individuals alone would substantially decrease HIV transmission but is not sufficient to eliminate the HIV epidemic among MSM at the estimated mixing level. In contrast, a PrEP program covering 50% of young, sexually active, high-risk, HIV-negative MSM would suppress HIV's R0 below 1, facilitating its elimination. It would also reduce HIV incidence to levels below the World Health Organization's HIV elimination threshold (1/1000 person-years) by 2030 and is highly cost-saving, yielding a benefit-cost ratio of 7.16. The program's effectiveness and cost-effectiveness remain robust even under conditions of risk compensation (i.e., no condom use among PrEP users), imperfect adherence (75%), or low-level emtricitabine/tenofovir resistance (1%).

CONCLUSION

Our findings strongly support scaling up PrEP for young, sexually active, high-risk, HIV-negative MSM as a critical strategy to end the HIV epidemic in Taiwan and globally.

Enhanced Cohort Methods for HIV Research and Epidemiology (ENCORE): Protocol for a Nationwide Hybrid Cohort for Transgender Women in the United States

BACKGROUND

In the United States, transgender women are disproportionately impacted by HIV and prioritized in the national strategy to end the epidemic. Individual, interpersonal, and structural vulnerabilities underlie HIV acquisition among transgender women and fuel syndemic conditions, yet no nationwide cohort monitors their HIV and other health outcomes.

OBJECTIVE

Our objective is to develop a nationwide cohort to estimate HIV incidence, identify risk factors, and investigate syndemic conditions co-occurring with HIV vulnerability or acquisition among US transgender women. The study is informed by the Syndemics Framework and the Social Ecological Model, positing that stigma-related conditions are synergistically driven by shared multilevel vulnerabilities.

METHODS

To address logistical and cost challenges while minimizing technology barriers and research distrust, we aim to establish a novel, hybrid community hub-supported digital cohort (N=3000). The digital cohort is the backbone of the study and is enhanced by hubs strategically located across the United States for increased engagement and in-person support. Study participants are English or Spanish speakers, are aged ≥18 years, identify as transgender women or along the transfeminine spectrum, reside in 1 of the 50 states or Puerto Rico, and do not have HIV (laboratory confirmed). Participants are followed for 24 months, with semiannual assessments. These include a questionnaire and laboratory-based HIV testing using self-collected specimens. Using residential zip codes, person-level data will be merged with contextual geolocated data, including population health measures and economic, housing, and other social and structural factors. Analyses will (1) evaluate the contribution of hub support to the digital cohort using descriptive statistics; (2) estimate and characterize syndemic patterns among transgender women using latent class analysis; (3) examine the role of contextual factors in driving syndemics and HIV prevention over time using multilevel regression models; (4) estimate HIV incidence in transgender women and examine the effect of syndemics and contextual factors on HIV incidence using Poisson regression models; and (5) develop dynamic, compartmental models of multilevel combination HIV prevention interventions among transgender women to simulate their impact on HIV incidence through 2030.

RESULTS

Enrollment launched on March 15, 2023, with data collection phases occurring in spring and fall. As of February 24, 2024, a total of 3084 individuals were screened, and 996 (32.3%) met the inclusion criteria and enrolled into the cohort: 2.3% (23/996) enrolled at a hub, and 53.6% (534/996) enrolled through a community hub-supported strategy. Recruitment through purely digital methods contributed 61.5% (1895/3084) of those screened and 42.7% (425/996) of those enrolled in the cohort.

CONCLUSIONS

Study findings will inform the development of evidence-based interventions to reduce HIV acquisition and syndemic conditions among US transgender women and advance efforts to end the US HIV epidemic. Methodological findings will also have critical implications for the design of future innovative approaches to HIV research.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

DERR1-10.2196/59846.

Associations between Drug Use and Sexual Risk Behaviours among Men Who Have Sex with Men in Japan: Results from the Cross-Sectional LASH Study

This study assessed drug use patterns among men who have sex with men (MSM) in Japan, and evaluated their potential associations with sexual risk behaviours. Between September and October 2016, study subjects were recruited through a cross-sectional survey (LASH: Love Life and Sexual Health) using a geosocial networking application for MSM. Of the participants, 25.4% (1756/6921) reported ever having used drugs, and 11.3% (780/6921) reported having done so in the past six months. Those who used drugs were more likely to have greater knowledge of HIV/sexually transmitted infections (STIs). Drug use in the past six months was independently associated with each of the following sexual risk behaviours in the same period: (i) six or more sexual partners (adjusted odds ratio [aOR] = 2.70, 95% confidence interval [CI]: 2.30-3.17); (ii) condomless anal intercourse (aOR = 2.88, 95% CI: 2.43-3.42); (iii) group sex (aOR = 2.60, 95% CI: 2.22-3.05); and (iv) sex work (aOR = 2.30, 95% CI: 1.67-3.16). These results suggest that MSM in Japan who use drugs are more likely to report sexual risk behaviours, while also having greater knowledge of HIV/STIs. Supporting MSM to minimise the harm from drug use may be helpful in reducing HIV transmission among this priority population.

The initial interplay between HIV and mucosal innate immunity

Human Immunodeficiency Virus (HIV) is still one of the major global health issues, and despite significant efforts that have been put into studying the pathogenesis of HIV infection, several aspects need to be clarified, including how innate immunity acts in different anatomical compartments. Given the nature of HIV as a sexually transmitted disease, one of the aspects that demands particular attention is the mucosal innate immune response. Given this scenario, we focused our attention on the interplay between HIV and mucosal innate response: the different mucosae act as a physical barrier, whose integrity can be compromised by the infection, and the virus-cell interaction induces the innate immune response. In addition, we explored the role of the mucosal microbiota in facilitating or preventing HIV infection and highlighted how its changes could influence the development of several opportunistic infections. Although recent progress, a proper characterization of mucosal innate immune response and microbiota is still missing, and further studies are needed to understand how they can be helpful for the formulation of an effective vaccine.

Microbicide Containing Ellagic Acid Can Inhibit HIV-1 Infection

OBJECTIVES

Ellagic acid (EA) has a wide range of biological effects. The purpose of this study was to investigate the in vitro effects of EA on HIV-1 replication, viral enzyme activity and cytokine secretion by infected cells.

METHODS

The anti-HIV-1 activity of EA in solution was determined in vitro using the infection of TZM-bl cells by the nano luciferase-secreting R5-tropic JRCSF strain of HIV-1, which allows for the quantification of viral growth by measuring nano luciferase in the culture supernatants. The effect of EA on the cytokine secretion of TZM-bl cells was determined by a multiplexed bead array after 48 h of HIV-1 exposure. The antiviral effect of EA in the gel formulation (Ellagel), as would be used for vaginal application, was investigated by the inhibition of infection of UC87.CD4.CCR5 cells with R5-tropic pBaLEnv-recombinant HIV-1.

RESULTS

EA in solutions of up to 100 µM was not toxic to TZM-bl cells. EA added either 1 h before or 4 h after HIV-1 exposure suppressed the replication of R5-tropic HIV-1 in TZM-bl cells in a dose-dependent manner, with up to 69% inhibition at 50 µM. EA-containing solutions also exhibited a dose-dependent inhibitory effect on HIV-1 replication in U87 cells. When EA was formulated as a gel, Ellagel containing 25 µM and 50 µM EA inhibited HIV-1 replication in U87 cells by 56% and 84%, respectively. In assays of specific HIV-1 enzyme activity, Ellagel inhibited HIV-1 integrase but not protease. EA did not significantly modulate cytokine secretion.

CONCLUSIONS

We conclude that EA either in solution or in a gel form inhibits HIV infection without adverse effects on target cells. Thus, gel containing EA can be tested as a new microbicide against HIV infection.

MTN-033: a Phase 1 Study Comparing Applicator versus "as Lubricant" Delivery of Rectal Dapivirine Gel

Data to inform behaviorally congruent delivery of rectal microbicides as lubricants are scant. Dapivirine (DPV) is a nonnucleoside reverse transcriptase inhibitor which has been demonstrated to be well-tolerated and efficacious in multiple clinical trials when used in a vaginal ring formulation. DPV gel administered rectally with an applicator was found to be well-tolerated in a phase 1 clinical trial. MTN-033, a single site, open label, sequence randomized, crossover study, enrolled HIV-negative men to receive 0.05% DPV gel intrarectally using an applicator (2.5 g) and self-administered on an artificial phallus as lubricant (up to 10 g). The study evaluated the pharmacokinetics (in plasma, rectal fluid, and mucosal rectal tissue), safety, acceptability, and pharmacodynamics of DPV gel when applied rectally. Statistical comparisons between methods of application were performed using mixed effects models or Wilcoxon's signed rank tests. Sixteen participants used DPV gel by applicator and 15/16 participants used gel as lubricant (mean, 1.8 g; SD, 0.8). DPV plasma AUC0-24h after use as lubricant was estimated to be 0.41 times the AUC0-24h (95% CI 0.24, 0.88) after use with applicator. While DPV was quantifiable in plasma and luminal fluid, it was not quantifiable in tissue for both applicator and as lubricant administration. No related adverse events (AE) were reported, and 15/15 participants felt the gel was easy to use. Evidence of local delivery and systemic absorption of DPV when dosed as an anal lubricant supports the feasibility and potential for development of lubricant-delivered rectal microbicides. There were no safety concerns associated with use of DPV gel and participants reported finding it easy to use. However, lower DPV exposure in plasma and lack of quantifiable DPV in rectal tissue indicate that higher potency, concentration, and longer half-life antiretrovirals with optimized formulations will be needed to achieve protective tissue concentrations.

A Cost-effectiveness Analysis of a Mobile Phone-Based Integrated HIV-Prevention Intervention Among Men Who Have Sex With Men in China: Economic Evaluation

BACKGROUND

Mobile phone-based digital interventions have been shown to be a promising strategy for HIV prevention among men who have sex with men (MSM).

OBJECTIVE

This study aimed to evaluate the cost-effectiveness of a mobile phone-based digital intervention for HIV prevention among MSM in China from the perspective of a public health provider.

METHODS

The cost-effectiveness of the mobile phone-based digital intervention was estimated for a hypothetical cohort of 10,000 HIV-negative MSM who were followed for 1 year. A model was developed with China-specific data to project the clinical impact and cost-effectiveness of two mobile phone-based digital strategies for HIV prevention among MSM. The intervention group received an integrated behavioral intervention that included 1) individualized HIV infection risk assessment, 2) recommendation of centers testing for HIV and other STIs, 3) free online order of condoms and HIV and syphilis self-test kits and 4) educational materials about HIV/AIDS. The control group was only given educational materials about HIV/AIDS. Outcomes of interest were the number of HIV infections among MSM averted by the intervention, intervention costs, cost per HIV infection averted by the mobile phone-based digital intervention, and quality-adjusted life-years (QALYs). Univariate and multivariate sensitivity analyses were also conducted to examine the robustness of the results.

RESULTS

It is estimated that the intervention can prevent 48 MSM from becoming infected with HIV and can save 480 QALYs. The cost of preventing 1 case of HIV infection was US $2599.87, and the cost-utility ratio was less than 0. Sensitivity analysis showed that the cost-effectiveness of the mobile phone-based digital intervention was mainly impacted by the average number of sexual behaviors with each sexual partner. Additionally, the higher the HIV prevalence among MSM, the greater the benefit of the intervention.

CONCLUSIONS

Mobile phone-based digital interventions are a cost-effective HIV-prevention strategy for MSM and could be considered for promotion and application among high-risk MSM subgroups.

Overcoming COVID-19 disruptions: Innovations in product provision in a multi-national clinical trial among cisgender men, transgender men and transgender women in five countries

Clinical trials often depend on participants receiving study product to meet objectives of the protocol. Vitally important are considerations for how sites receive and dispense study product during a study while ensuring appropriate handling, accountability and compliance. The process for provision of study product is detailed in Standard Operating Procedures (SOPs) which are adhered to by the research site throughout the trial. The COVID-19 pandemic unexpectedly affected the ability of study participants to receive study product. We report on the various methods implemented by trial sites to ensure timely provision of study product to participants during this unprecedented pandemic. In MTN-035, participants received 3 potential rectal microbicide formulations in randomized sequences to understand user preferences. Trial sites were permitted to revise dispensing methods to enable participants to continue to receive study product during COVID-19 restrictions. These actions mitigated disruption of study product administration and preserved the integrity of the trial. Out of the 78 participants expecting to receive study products on or after the onset of restrictions due to COVID-19, only four participants (5%) did not receive all three products. Adopting alternative methods to provide product to study participants in extraordinary circumstances was key to successful study completion and maintaining study integrity.

Identities and HIV-Related Risk Behaviors Among Transgender Women in Myanmar: Perspectives from Transgender Women and Service Providers

In Myanmar, transgender women (TGW) have historically been grouped into the men who have sex with men (MSM) population in program and surveillance data. There is no direct translation for the term transgender in Myanmar language, and there are no data on HIV prevalence or HIV-related risk behaviors among TGW. Therefore, this study aimed to explore how TGW identify and express themselves in Myanmar and their HIV-related risk behaviors. This qualitative study consisted of 11 key informant interviews with service providers and 20 in-depth interviews with TGW participants in Yangon in 2017. All participants said that TGW in Myanmar were assigned male at birth, but none identified as men; they all self-identified as women or another gender, such as trans. Such identity emerged from an internal sense of being a woman or an alternative gender. In addition, many participants reported that TGW changed their appearance through changes in clothing or mannerisms. TGW are particularly vulnerable to violence: Often reported during transition, transgender women were exposed to transphobia, violence and discrimination from their family, relatives or workplace. Many participants reported TGW being the receptive partner during sex and engaged in high-risk sexual behaviors, such as sex with multiple partners, group sex, and condomless sex. Our findings can help to define this population in the Myanmar context and assess needs for health services.

A mixed methods investigation of the relationship between blood donor policy, interest in donation, and willingness to donate among gay, bisexual, and other men who have sex with men in Ontario, Canada

BACKGROUND

As of 2019, men who have sex with men (MSM) in Canada are ineligible to donate blood if they have had oral or anal sex with another man in the last 3 months. Deferral policies targeting MSM are largely interpreted as unjust by gay, bisexual, and other men who have sex with men (GBMSM) - shaping their desire to donate blood and engage with blood operators. This mixed methods study explores interest in blood donation among GBMSM as well as willingness (and eligibility) to donate under four different deferral policies.

METHODS

We surveyed 447 GBMSM who were recruited from the Ontario-wide #iCruise study. Participants were asked whether they were interested in blood donation and if they were willing to donate under each of our four deferral policies. We also completed interviews with 31 of these GBMSM. Participants were asked to describe their feelings about blood donation, their views on our different deferral policies, the impact of a policy change, as well as other means of redress.

RESULTS

Most participants (69%) indicated that they were interested in donating blood. Despite this, an interpretation of the MSM deferral policy as discriminatory was common among all participants. Our mixed methods findings indicate that, among those who were interested in blood donation, the adoption of one of the alternative policies presented in this study (specifically Policy 2 or Policy 3) would significantly increase the number of participants willing to donate and be viewed as "a step in the right direction." However, many participants who were not interested in blood donation argued that a gender-neutral deferral policy would need to be implemented for them to donate. Participants recommended that blood operators consider efforts to repair relations with GBMSM beyond policy change, including pop-up clinics in predominantly queer areas and diversity sensitivity training for staff.

CONCLUSION

We argue that the most impactful policy shift would be the implementation of an individual risk-based deferral policy that is applied to all donors regardless of sexual orientation or gender identity. However, given MSM's historical exclusion from blood donations, blood operators should pair this policy shift with community relationship-building efforts.

A Randomized, Open-Label, Crossover Phase 1 Safety and Pharmacokinetic Study of Oral Maraviroc and Maraviroc 1% Gel (the CHARM-03 Study)

The Combination HIV Antiretroviral Rectal Microbicide-3 (CHARM-03) study was a randomized, open-label, crossover Phase 1 safety and pharmacokinetic (PK) study of oral maraviroc (MVC) and MVC 1% gel. At a single site, healthy HIV-uninfected men and women were enrolled and randomized to an open label crossover sequence of eight consecutive daily exposures to MVC 300 mg dosed orally, MCV 1% gel dosed rectally, and MVC 1% gel dosed vaginally. Male participants received oral and rectal dosing and female participants received oral, rectal, and vaginal dosing. Assessments were undertaken at baseline and following each 8-day period and included collection of plasma, rectal/cervical tissue (CT), and rectal/endocervical/vaginal fluids. Eleven men and nine women were enrolled. Two participants withdrew from the study before receiving study product. There were 25 adverse events, of which 24 were Grade 1 (G1) and one was G2 (unrelated). After eight doses, MVC was quantifiable in all samples following oral, rectal, or vaginal product administration. The highest drug concentrations in plasma, rectal tissue (RT), and CT were associated with oral, rectal, and vaginal drug delivery, respectively. There were significant reductions in tissue drug concentrations when rectal and cervical biopsies were incubated in media before tissue processing for PK (p < .0001). Only oral MVC was associated with limited protection in the rectal explant HIV challenge model (p < .05). There were no immunological changes in RT, and all products were acceptable to participants. In conclusion, all products were found to be safe and acceptable and did not induce local inflammation. The lack of ex vivo efficacy demonstrated in study samples may be due to rapid disassociation of MVC from the explant tissue. ClinicalTrials.gov Identifier: NCT02346084.

"I Don't Want to Have Sex as a Woman": A Qualitative Study Exploring Sexuality and Sexual Practices of Drag Queens in Germany

Drag queens are typically gay men who perform as caricature-like women. They thereby publicly challenge "naturally" binary gender role categories, though it remains unclear how that interplays with their private (e.g., sexual) lives. This study seeks to answer this question by exploring the sexuality and sexual practices of drag queens. Employing a critical realist approach, ten semi-structured interviews were conducted in Germany, with questions focusing on the drag queens' views on sexuality and sexual positioning. By adopting a thematic analysis, three main themes were identified: natural versus artificial identity; advocacy for sexuality; and rejection of heteronormativity. Results suggest that the primary intention of drag queens is to challenge heteronorms, while they regularly adhered to these privately. This illustrates the distinction made by the participants between their "public" persona, an artificial character that lacks sexuality, and their "private" life (e.g., sexual practices), shaped by an "inborn" sexuality.

UK guideline for the use of HIV post-exposure prophylaxis 2021

We present the updated British Association for Sexual Health and HIV (BASHH) guidelines for post-exposure prophylaxis (PEP) to HIV following sexual exposures, occupational exposures and other nonoccupational exposures in the community. This serves as an update to the 2015 BASHH guideline on PEP following sexual exposures and the 2008 Expert Advisory Group on AIDS guidelines on HIV PEP. We aim to provide evidence-based guidance on best clinical practice in the provision, monitoring and support of PEP for the prevention of HIV acquisition following sexual, occupational and other nonoccupational exposures in the community. The guideline covers when to prescribe PEP, what antiretroviral agents to use and how to manage PEP. This includes (i) evidence of PEP efficacy; (ii) evidence relating to individual-level efficacy of antiretroviral therapy to prevent the sexual transmission of HIV; (iii) data on the detectable (transmissible) prevalence of HIV in specific populations; (iv) risk of HIV transmission following different types of sexual and occupational exposure; (v) baseline risk assessment; (vi) drug regimens and dosing schedules; (vii) monitoring PEP; (viii) baseline and follow-up blood-borne virus testing; (ix) the role of PEP within broader HIV prevention strategies, for example, HIV pre-exposure prophylaxis (PrEP). The guideline also covers special scenarios such as PEP in pregnancy, breastfeeding and chronic hepatitis B virus infection, and when PEP should be considered in people using HIV PrEP. The guidelines are aimed at clinical professionals directly involved in PEP provision and other stakeholders in the field. A proforma to assist PEP consultations is included. A public consultation process was undertaken prior to finalizing the recommendations.

An Approach to Reducing Problematic Data in an ACASI Sexual Behavior Assessment

Minimizing error in self-reported sexual behavior could reduce investigators' likelihood of rejecting truly successful interventions to decrease HIV and STI transmission risk. Sexual behavior assessments can elicit problematic data. This may manifest in the form of elevated levels of non-response, inaccurate point estimates, or misclassification errors resulting in inappropriately answering or, perhaps more importantly, skipping questions. We programed conversational interviewing elements into 20 sexual behavior questions in an exit survey of gay bathhouse patrons (N = 459) administered using ACASI. Those elements, called alternate pathways, included follow-up questions to responses to confirm that operational definitions were applied in the answer (with return to the initial question if confirmation failed), and assurances of confidentiality and requests for best guesses in reaction to non-response (including "don't know"). These elements were invoked in nearly 10% of participants, and approximately 74% of all invocations resulted in a usable numeric response, or 87% if the data need only estimate prevalence. Almost two-thirds of the problematic data issues occurred in answers to sexual contact questions, with others related to follow-up questions about specific sexual behavior. It is at this level of important filtering questions where the benefits of the approach are likely to be maximized.

Associations Between Social Capital and HIV Risk-Taking Behaviors Among Men Who Have Sex with Men in Japan

Social capital has been positively associated with reduced HIV risk. However, few studies have investigated if associations vary between men who have sex with men (MSM) or heterosexual alters (possessors of actual resources embedded within social capital networks) and HIV risk-taking behaviors. In a cross-sectional survey of 1564 MSM in Greater Tokyo, we investigated whether social capital ascertained from MSM or heterosexual alters influenced HIV risk-taking behaviors (i.e., consistent condom use and lifetime HIV testing). Multiple logistic regression revealed that MSM with high levels of social capital from heterosexual networks were twice as likely to report consistent condom use with casual male partners, while MSM who reported high levels of social capital from MSM networks were over twice as likely to have tested for HIV yet were half as likely to use condoms consistently with regular male partners. Associations between MSM, social capital, and HIV testing indicate the potential for integrating social capital enhancement programs into current HIV interventions.

HIV-1 Nucleic Acids Identify Rectal HIV Exposures in Self-Collected Rectal Swabs, Whereas Y-Chromosome Single Tandem Repeat Mixtures Are Not Reliable Biomarkers of Condomless Receptive Anal Intercourse

BACKGROUND

To focus interventions, biomarkers of HIV-1 exposure could help in identifying subpopulations at highest risk of acquisition. We assessed whether Y-chromosome single tandem repeat (YSTR) mixtures obtained from rectal swabs could serve as a biomarker of condomless receptive anal intercourse (CRAI) among men who have sex with men and transgender women and evaluated the feasibility of detecting HIV-1 virions to assess exposures.

METHODS

Twenty-nine sexually active HIV-seronegative men who have sex with men and one transgender woman from New York City answered on-site and mobile app sexual behavior questionnaires. They were randomized to collecting self-administered rectal swabs every morning or after receptive anal intercourse (RAI). YSTR profiles were assessed from blood sample and swabs; HIV-1 exposure was measured by conducting quantitative polymerase chain reaction in swabs.

RESULTS

After 2 months, the daily mobile survey had 135%-201% more instances of anal sex acts and 170%-193% more RAI than on-site surveys. Daily mobile reporting had 11%-35% less CRAI events than those reported on-site (Pdaily = 0.001; Pper-sex = 0.047). The daily swabbing arm reported less RAI (P < 0.001) and CRAI (P < 0.038) and had 2.95 lower odds of detecting YSTR mixtures (P = 0.021) than the per-sex-event arm. Surprisingly, YSTR detection was not significantly modified by report of bowel movements and lubricant, enema, or condom use. No participant became HIV-1 infected, yet HIV-1 total nucleic acids were detected in 6 independent episodes of CRAI in 2 participants taking pre-exposure prophylaxis.

CONCLUSIONS

YSTR mixtures demonstrated 80% specificity but only 30% sensitivity as a biomarker of CRAI in self-collected rectal swabs. However, detection of HIV-1 exposures in self-collected swabs may help in identifying those needing further HIV risk reduction strategies.

Higher colorectal tissue HIV infectivity in cisgender women compared with MSM before and during oral preexposure prophylaxis

OBJECTIVE

The objective of this study was to compare HIV-negative cisgender women (CGW) with MSM for mucosal tissue differences in pharmacokinetics, HIV infectivity and cell phenotype.

DESIGN

A substudy of HPTN 069/ACTG A5305, 48-week study of three oral candidate preexposure prophylaxis regimens: maraviroc, maraviroc/emtricitabine and maraviroc/tenofovir disoproxil fumarate (TDF) compared with a TDF/emtricitabine control group.

METHODS

Plasma, peripheral blood mononuclear cells and cervical and colorectal tissue biopsies were collected at Baseline (no drug), Week 24 and 48 (on drug), and Week 49 (1-week postdrug). Drug concentrations were assessed in all matrices. HIV infectivity was assessed using tissue biopsy 'explants' challenged with HIV ex vivo followed by HIV p24 measurement. Flow cytometry evaluated colorectal cell phenotype.

RESULTS

Thirty-seven CGW and 54 MSM participated. CGW's colorectal explant p24 was higher than MSM before (0.31 log10, P = 0.046), during (1.01-1.19 log10, P = 0.016) and one week after (0.61 log10, P = 0.011) study drug dosing. Pooling regimens, cervical explant p24 did not differ among visits. CGW had higher plasma maraviroc and colorectal tissue tenofovir diphosphate and lower colorectal tissue emtricitabine (all P < 0.005) compared with MSM. Each study drug's cervical tissue concentrations were more than 10-fold below paired colorectal concentrations (P < 0.001). Cell phenotype sex differences included 4% higher CD38+/CD8+ cells at baseline and 3-7% higher CD69+/CD8+ cells throughout Weeks 24-49 in CGW compared with MSM (P < 0.05).

CONCLUSION

Colorectal explants in CGW demonstrated greater HIV infectivity than MSM with and without study drugs. Small differences in adherence, drug concentration and colorectal tissue flow cytometry cannot fully explain this difference.

Influence of NKG2C Genotypes on HIV Susceptibility and Viral Load Set Point

NKG2C is an activating NK cell receptor encoded by a gene having an unexpressed deletion variant. Cytomegalovirus (CMV) infection expands a population of NKG2C+ NK cells with adaptive-like properties. Previous reports found that carriage of the deleted NKG2C- variant was more frequent in people living with HIV (PLWH) than in HIV- controls unexposed to HIV. The frequency of NKG2C+ NK cells positively correlated with HIV viral load (VL) in some studies and negatively correlated with VL in others. Here, we investigated the link between NKG2C genotype and HIV susceptibility and VL set point in PLWH. NKG2C genotyping was performed on 434 PLWH and 157 HIV-exposed seronegative (HESN) subjects. Comparison of the distributions of the three possible NKG2C genotypes in these populations revealed that the frequencies of NKG2C+/+ and NKG2C+/- carriers did not differ significantly between PLWH and HESN subjects, while that of NKG2C-/- carriers was higher in PLWH than in HESN subjects, in which none were found (P = 0.03, χ2 test). We were unable to replicate that carriage of at least 1 NKG2C- allele was more frequent in PLWH. Information on the pretreatment VL set point was available for 160 NKG2C+/+, 83 NKG2C+/-, and 6 NKG2C-/- PLWH. HIV VL set points were similar between NKG2C genotypes. The frequency of NKG2C+ CD3- CD14- CD19- CD56dim NK cells and the mean fluorescence intensity (MFI) of NKG2C expression on NK cells were higher on cells from CMV+ PLWH who carried 2, versus 1, NKG2C+ alleles. We observed no correlations between VL set point and either the frequency or the MFI of NKG2C expression. IMPORTANCE We compared NKG2C allele and genotype distributions in subjects who remained HIV uninfected despite multiple HIV exposures (HESN subjects) with those in the group PLWH. This allowed us to determine whether NKG2C genotype influenced susceptibility to HIV infection. The absence of the NKG2C-/- genotype among HESN subjects but not PLWH suggested that carriage of this genotype was associated with HIV susceptibility. We calculated the VL set point in a subset of 252 NKG2C-genotyped PLWH. We observed no between-group differences in the VL set point in carriers of the three possible NKG2C genotypes. No significant correlations were seen between the frequency or MFI of NKG2C expression on NK cells and VL set point in cytomegalovirus-coinfected PLWH. These findings suggested that adaptive NK cells played no role in establishing the in VL set point, a parameter that is a predictor of the rate of treatment-naive HIV disease progression.

Examining the Safety, Pharmacokinetics, and Pharmacodynamics of a Rectally Administered IQP-0528 Gel for HIV Pre-Exposure Prophylaxis: A First-In-Human Study

A lubricating microbicide gel designed for rectal and vaginal use would provide a behaviorally congruent strategy to enhance pre-exposure prophylaxis adherence and reduce HIV infection risk. In this study, we report the first-in-human evaluation of such a gel containing 1% IQP-0528, an investigational antiretroviral. Seven HIV-1-negative participants received one 10 mL rectal dose of radiolabeled 1% IQP-0528 gel. We assessed safety; IQP-0528 pharmacokinetics in plasma, and rectal and vaginal tissue; ex vivo local pharmacodynamics (PD); and colorectal distribution. The 1% gel was determined to be safe with one mild event attributed to study product and no effects on rectal tissue histology. All concentrations measured in plasma and vaginal tissue were below the limit of quantitation. Median IQP-0528 concentrations in rectal tissue exceeded the in vitro EC₉₅ against HIV-1 (0.07 ng/mg) by 3-5 h of dosing and remained above this concentration for at least 24 h, despite a 3-log reduction in concentration over this duration of time. Rectal tissue PD-assessed by ex vivo HIV challenge-demonstrated significant p24 antigen reduction 3-5 h postdose compared with baseline (p = .05), but not 24-26 h postdose (p = .75). Single-photon emission computed tomography/computed tomography imaging revealed that product distribution was localized to the rectosigmoid. The IQP-0528 gel possesses desirable features for a topical microbicide including: local safety with no systemic absorption, delivery of locally high IQP-0528 concentrations, and significant reductions in ex vivo HIV infectivity. However, the gel is limited by its rapid clearance and inability to penetrate vaginal tissues following rectal dosing. Clinical Trial Registration number: NCT03082690.

Incidence of Sexually Transmitted Infections After Initiating HIV Pre-Exposure Prophylaxis Among MSM in Southern Denmark

Pre-exposure prophylaxis (PrEP) is a new preventive treatment for individuals at high-risk for HIV infection, such as men who has sex with men (MSM). Studies have confirmed the efficacy but concerns about the potential induction of risk compensation remains. We aimed to assess the incidence of sexually transmitted infections (STIs) after PrEP initiation as a proxy for sexual risk behavior.

This case-crossover study used data from medical records and from the Danish Microbiology Database from patients who initiated PrEP at the Region of Southern Denmark between 2017 and 2019. Poisson regression was used to assess STI incidence 6 months after PrEP initiation versus the 6 months before. To identify potential risk factors, we compared individuals with an increased STI incidence after PrEP initiation with those without, using logistic regression.

In total, 46 MSM initiated PrEP in the study period. We found a significant increase in the number of positive samples for STI after PrEP initiation (IRR 1.83; 95% CI [1.03, 3.26]) and a tendency for higher incidence of STI episodes (1.67; 95% CI [0.91, 3.13]). The increase was concentrated to a group of users, but no significant correlation was found between increasing incidence and the baseline factors examined.

We observed a degree of risk compensation after the implementation of PrEP among MSM, clustering to a group of users. Our results highlight the importance of frequent STI screening among MSM on PrEP as timely diagnosis could contribute to an overall decrease in STI incidence and incidence among MSM.

Early Colorectal Responses to HIV-1 and Modulation by Antiretroviral Drugs

Innate responses during acute HIV infection correlate with disease progression and pathogenesis. However, limited information is available about the events occurring during the first hours of infection in the mucosal sites of transmission. With an ex vivo HIV-1 challenge model of human colorectal tissue we assessed the mucosal responses induced by R5- and X4-tropic HIV-1 isolates in the first 24 h of exposure. Microscopy studies demonstrated virus penetration of up to 39 μm into the lamina propia within 6 h of inoculation. A rapid, 6 h post-challenge, increase in the level of secretion of inflammatory cytokines, chemokines, interferon- γ (IFN-γ), and granulocyte-macrophage colony-stimulating factor (GM-CSF) was observed following exposure to R5- or X4-tropic isolates. This profile persisted at the later time point measured of 24 h. However, exposure to the X4-tropic isolate tested induced greater changes at the proteomic and transcriptomic levels than the R5-tropic. The X4-isolate induced greater levels of CCR5 ligands (RANTES, MIP-1α and MIP-1β) secretion than R5-HIV-1. Potential drugs candidates for colorectal microbicides, including entry, fusion or reverse transcriptase inhibitors demonstrated differential capacity to modulate these responses. Our findings indicate that in colorectal tissue, inflammatory responses and a Th1 cytokine profile are induced in the first 24 h following viral exposure.

Modelling the impact of an HIV testing intervention on HIV transmission among men who have sex with men in China

OBJECTIVES

An intervention developed through participatory crowdsourcing methods increased HIV self-testing among men who have sex with men [MSM; relative risk (RR) = 1.89]. We estimated the long-term impact of this intervention on HIV transmission among MSM in four cities (Guangzhou, Shenzhen, Jinan and Qingdao).

METHODS

A mathematical model of HIV transmission, testing and treatment among MSM in China was parameterized using city-level demographic and sexual behaviour data and calibrated to HIV prevalence, diagnosis and antiretroviral therapy (ART) coverage data. The model was used to project the HIV infections averted over 20 years (2016-2036) from the intervention to increase self-testing, compared with current testing rates.

RESULTS

Running the intervention once would avert < 2.2% infections over 20 years. Repeating the intervention (RR = 1.89) annually would avert 6.4-10.7% of new infections, while further increases in the self-testing rate (hypothetical RR = 3) would avert 11.7-20.7% of new infections.

CONCLUSIONS

Repeated annual interventions would give a three- to seven-fold increase in long-term impact compared with a one-off intervention. Other interventions will be needed to more effectively reduce the HIV burden in this population.

Pre-exposure Prophylaxis Use and Detected Sexually Transmitted Infections Among Men Who Have Sex With Men in the United States-National HIV Behavioral Surveillance, 5 US Cities, 2017

BACKGROUND

Men who have sex with men (MSM) using HIV pre-exposure prophylaxis (PrEP) may be at high risk for bacterial sexually transmitted infections (STIs). We examined the prevalence of extragenital gonorrhea and chlamydia by PrEP status among a multisite sample of US MSM.

METHODS

MSM aged ≥18 years were recruited through venue-based sampling to participate in the 2017 National HIV Behavioral Surveillance. In 5 cities (San Francisco, Washington DC, New York City, Miami, and Houston), participants completed a questionnaire, HIV testing, and pharyngeal and rectal STI specimen self-collection. We measured prevalence of pharyngeal and rectal gonorrhea and chlamydia among self-reported non-HIV-positive MSM who reported using or not using PrEP in the previous 12 months.

RESULTS

Overall, 29.6% (481/1627) of non-HIV-positive MSM reported PrEP use in the past year. MSM who reported PrEP use were more likely to have any STI (ie, extragenital gonorrhea and/or chlamydia) than MSM not on PrEP [14.6% vs. 12.0%, adjusted prevalence ratio (aPR) = 1.5, 95% confidence interval (CI) : 1.1 to 2.0], reflecting differences in rectal chlamydia prevalence (8.7% vs. 6.0%, aPR = 1.6, 95% CI: 1.1 to 2.4). PrEP use was not associated with pharyngeal chlamydia, pharyngeal gonorrhea, or rectal gonorrhea.

CONCLUSIONS

The prevalence of extragenital STI was high for both MSM on PrEP and those not on PrEP in the past year. MSM on PrEP were more likely to have rectal chlamydia but not pharyngeal STIs or rectal gonorrhea. Our findings support regular STI testing at exposed anatomic sites as recommended for sexually active MSM, including those on PrEP.

Transmission routes of human immunodeficiency virus and affecting factors

Acquired immunodeficiency syndrome (AIDS) was first reported more than 30 years ago among homosexuals in the United States. The epidemiology of this disease indicates that there are three modes of transmission: Blood, mother-to-child, and sexual contact transmission. The pathogen of AIDS is human immunodeficiency virus (HIV), primarily HIV-1. HIV-1 could not break through the structurally and functionally integral skin, and primarily invades the human body through the mucosa irrespective of their integrity. Therefore, the mucosae are the natural transmission routes for HIV-1. The mucosae involved in HIV-1 transmission include the mucosae of the gastrointestinal tract and the urogenital tract. The risks of HIV-1 transmission vary significantly between mucosal sites and individuals, and are associated with mucosal integrity, abundance of target cells, immune status of the host, commensal microbes, and host genetic background. Many factors are closely related to the barrier function of the mucosa, and studies on their roles in HIV-1 invasion could promote the prevention and control of mucosal transmission of HIV-1.

Joint modeling of time-varying HIV exposure and infection for estimation of per-act efficacy in HIV prevention trials

OBJECTIVES

Using the MTN-020/ASPIRE HIV prevention trial as a motivating example, our objective is to construct a joint model for the HIV exposure process through vaginal intercourse and the time to HIV infection in a population of sexually active women. By modeling participants' HIV infection in terms of exposures, rather than time exposed, our aim is to obtain a valid estimate of the per-act efficacy of a preventive intervention.

METHODS

Within the context of HIV prevention trials, in which the frequency of sex acts is self-reported periodically by the participants, we model the exposure process of the trial participants with a non-homogeneous Poisson process. This approach allows for variability in the rate of sexual contacts between participants as well as variability in the rate of sexual contacts over time. The time to HIV infection for each participant is modeled as the time to the exposure that results in HIV infection, based on the modeled sexual contact rate. We propose an empirical Bayes approach for estimation.

RESULTS

We report the results of a simulation study where we evaluate the performance of our proposed approachandcompareittothetraditionalapproachofestimatingtheoverallreductioninHIVincidenceusing a Proportional Hazards Cox model. The proposed approach is also illustrated with data from the MTN-020/ASPIRE trial.

CONCLUSIONS

The proposed joint modeling, along with the proposed empirical Bayes estimation approach, can provide valid estimation of the per-exposure efficacy of a preventive intervention.

Cost-Effectiveness of Therapeutic Use of Safety-Engineered Syringes in Healthcare Facilities in India

BACKGROUND

Globally, 16 billion injections are administered each year of which 95% are for curative care. India contributes 25-30% of the global injection load. Over 63% of these injections are reportedly unsafe or deemed unnecessary.

OBJECTIVES

To assess the incremental cost per quality-adjusted life-year (QALY) gained with the introduction of safety-engineered syringes (SES) as compared to disposable syringes for therapeutic care in India.

METHODS

A decision tree was used to compute the volume of needle-stick injuries (NSIs) and reuse episodes among healthcare professionals and the patient population. Subsequently, three separate Markov models were used to compute lifetime costs and QALYs for individuals infected with hepatitis B virus (HBV), hepatitis C virus (HCV) and human immunodeficiency virus (HIV). Three SES were evaluated-reuse prevention syringe (RUP), sharp injury prevention (SIP) syringe, and syringes with features of both RUP and SIP. A lifetime study horizon starting from a base year of 2017 was considered appropriate to cover all costs and consequences comprehensively. A systematic review was undertaken to assess the SES effects in terms of reduction in NSIs and reuse episodes. These were then modelled in terms of reduction in transmission of blood-borne infections, life-years and QALYs gained. Future costs and consequences were discounted at the rate of 3%. Incremental cost per QALY gained was computed to assess the cost-effectiveness. A probabilistic sensitivity analysis was undertaken to account for parameter uncertainties.

RESULTS

The introduction of RUP, SIP and RUP + SIP syringes in India is estimated to incur an incremental cost of Indian National Rupee (INR) 61,028 (US$939), INR 7,768,215 (US$119,511) and INR 196,135 (US$3017) per QALY gained, respectively. A total of 96,296 HBV, 44,082 HCV and 5632 HIV deaths are estimated to be averted due to RUP in 20 years. RUP has an 84% probability to be cost-effective at a threshold of per capita gross domestic product (GDP). The RUP syringe can become cost saving at a unit price of INR 1.9. Similarly, SIP and RUP + SIP syringes can be cost-effective at a unit price of less than INR 1.2 and INR 5.9, respectively.

CONCLUSION

RUP syringes are estimated to be cost-effective in the Indian context. SIP and RUP + SIP syringes are not cost-effective at the current unit prices. Efforts should be made to bring down the price of SES to improve its cost-effectiveness.

Associations of spatial mobility with sexual risk behaviors among young men who have sex with men in New York City: A global positioning system (GPS) study

Spatial contexts and spatial mobility are important factors of the HIV epidemic and sexually transmitted infections. Using global positioning system (GPS) devices, we examined the associations of objectively measured spatial mobility with sexual risk behaviors among gay, bisexual and other men who have sex with men (MSM) in New York City. This observational study included a subgroup of 253 HIV-negative MSM from the Project 18 Cohort Study, who participated in the GPS monitoring sub-study. Spatial mobility was measured as (1) distance traveled and (2) activity space size defined as daily path area during 2-week of GPS tracking. We examined the associations of these measures with numbers of male sexual partners and condomless anal intercourse (CAI) acts during last six months using quasi-Poisson models, adjusting for socio-demographics. Results demonstrated that spatial mobility was positively associated with sexual risk behaviors, for example, with CAI (incidence rate ratio [IRR] = 1.01 for a 10 km increase in distance traveled and IRR = 1.04 for a 1 km² increase in 50 m-buffer activity space size). Our findings may enhance the understanding of spatial contexts of HIV risk. Future studies should be conducted to examine the mechanisms for the associations between spatial mobility behaviors with sexual risk behaviors as well as the influence of neighborhood characteristics in various neighborhood contexts, which may guide the place-based HIV prevention services.

A serological divide: men who have sex with men's attitudes on HIV risk reduction strategies

The expanding HIV risk reduction toolkit increases options for men who have sex men (MSM), but increasing options in combination with different preferences may complicate promoting risk reduction. To investigate what strategies MSM prefer, data of 3310 participants in the online survey "Men & Sexuality" (Median age = 37 years, 320 (9.7%) HIV positive) was analysed. Questions assessed attitudes towards HIV risk reduction strategies. Participants had the most positive attitudes regarding PrEP and HIV testing, while withdrawal and strategic positioning were least preferred (all p's < .001). Condoms were seen as acceptable to partners and effective but scored low on sexual pleasure. HIV-positive participants were more negative about condoms and more positive about viral load sorting than HIV-negative participants (F_(12,3297) = 5.09, p < .001, [Formula: see text] = .02). Findings highlight a preference for HIV risk reduction strategies (PrEP and HIV testing) that do not diminish sexual pleasure and can be applied independent of sexual partners. A serological divide was apparent: HIV-negative MSM were less negative about condoms than HIV-positive MSM, suggesting that condom promotion remains a viable strategy for HIV-negative MSM. Taken together, results indicate a need for personalized approaches to the promotion of HIV risk reduction strategies, accounting for individual preferences and strategy effectiveness.

Changes in Characteristics and Behavior Among African American Men Who Have Sex with Men and Women in the Context of Reductions in HIV Diagnoses Among Women

Men who have sex with men and women (MSMW) connect lower prevalence populations of women to higher prevalence populations of men who have sex with men only. We hypothesize that HIV testing and treatment among MSMW have increased in recent years, and this increase can help explain the declining rates of new HIV diagnoses among African American women. We analyzed data from 2008, 2011, and 2014 of the National HIV Behavioral Surveillance system. African American men who have sex with men (MSM) were surveyed from 19 United States cities using venue-based sampling and tested for HIV infection. We used generalized estimating equations, using year of survey as an independent variable, adjusting for age, to determine differences for selected outcomes regarding healthcare and risk behaviors over time. Among the 1299 African American MSMW interviewed, significant increases were observed in the percent of men who had an HIV test in the previous 12 months (2008: 54%, 2011: 69%, and 2014: 68%, p-value < 0.001). Among HIV-positive men, the percentage of men who were aware of their infection at the time of the interview increased significantly over time (26, 35, and 48%, p-value = 0.002). Among those men, the percentage who reported currently being on antiretroviral therapy also increased significantly over time (46, 69, and 72%, p-value = 0.050). The percentage of men reporting high-risk sexual risk behaviors increased or remained stable. Our findings support the hypothesis that HIV testing and treatment has increased among African American MSM from 2008 to 2014. Additional research is needed to fully explore the population-level impact it has on HIV transmission among women.

Differences Between Groups of Pre-exposure Prophylaxis (PrEP) Using Couples in HIV-Negative/Unknown Relationships

BACKGROUND

Epidemiology research is limited on the characteristics of HIV pre-exposure prophylaxis (PrEP) using couples.

SETTING

US nationwide sample recruited online in 2017.

METHODS

HIV negative/unknown gay, bisexual, and other men who have sex with men with HIV negative/unknown partners (n = 3140) were asked about individual and main partner PrEP uptake. Men were coded into the following 5 groups: (1) neither participant nor partner on PrEP, (2) partner only on PrEP, (3) participant only on PrEP, (4) both on PrEP, and (5) unknown partner PrEP use. We examined associations of demographics, relationship factors, condomless anal sex (CAS) with main and causal partners, bacterial sexually transmitted infection diagnoses, and sexual positioning with reported dyadic PrEP use using fully adjusted multinomial logistic regressions.

RESULTS

PrEP use was 3.2% for the partner only, 5.7% for the participant only, and 4.9% for both the participant and partner; 5.6% reported not knowing their partner's PrEP use status. Men who reported any CAS with their main partner or any CAS with male casual partners were both more likely to be classified in the dyadic PrEP use group compared with the neither on PrEP group. Compared with monogamous, men in open arrangements were more likely to be classified in each of the 3 PrEP groups compared with the neither on PrEP group. Six-month bacterial sexually transmitted infection prevalence was 2.8%, 8.1%, 8.3%, 15.6%, and 4.0% for the 5 groups, respectively.

CONCLUSIONS

PrEP use occurred during times of higher risk behavior engagement, but further efforts are needed to expand PrEP use to more partnered gay, bisexual, and other men who have sex with men.

A meta-analysis of the efficacy of HAART on HIV transmission and its impact on sexual risk behaviours among men who have sex with men

Evidence showed preventive impacts of the highly active antiretroviral therapy (HAART) on the Human Immunodeficiency Virus (HIV) transmission amomg heterosexual population, however, that is of deficit among men who have sex with men (MSM). The aim was to systematically examine the efficacy of HAART on HIV transmission and the association between the HAART initiation and unprotected anal intercourse (UAI) in MSM population. Three electronic databases were fully searched for articles published in peer-reviewed journals between 1996 and 2017. Of 1616 identified articles, fifteen articles were eligible for meta-analyses. The summary incidence rate (IR) of HIV was 6.63/100 person-year (95%CI 2.06–11.20/100 person-year)(p = 0.004). The pooled per-contact rate (PCR) of HIV was 0.42% (95% CI 0.21–0.63%)(p < 0.05). The HAART initiation (vs non-HAART) was not associated with engaging in UAI, with odds ratio (OR) 1.09 (95% CI 0.90–1.34)(p > 0.05). In the stratified analysis, participants with no less than 6 months recall period was slightly more likely to engage in UAI (OR 1.32; 95% CI 1.01–1.74)(p < 0.05). It indicated that HAART has potential efficacy on reducing infectivity of HIV positive individuals in anal intercourses. The relationship between the HAART initiation and UAI was not significant and may be influenced by some social-demographic factors. Consistent condom use and education on safe sex among MSM are crucial.

A Proportion of Self-Collected Rectal Swabs Yield Human Immunodeficiency Virus Sequences Phylogenetically Related to Those from Plasma Human Immunodeficiency Virus RNA

We determined HIV-1 pol gene sequences from self-collected rectal swabs of HIV-positive young men who have sex with men and transgender women. HIV-1 pol was amplified from 39/96 (41%) rectal swabs, including 29/77 (38%) prevalent and 10/19 (53%) incident HIV-1 infections (p < .001). Pol did not amplify from rectal swabs from participants with plasma viral load <1,000 copies/mL. Each rectal swab-derived amplicon consensus sequence was most closely related to the paired plasma virion RNA-derived sequence from the same participant. Results document a rectal mucosal source of HIV-1 in infected persons and suggest usefulness for noninvasive study of biological mechanisms underlying the epidemiologic risk to an insertive partner of HIV-1 acquisition during condomless anal sex.

Does HIV infection increase male sexual behavior?

After 40 years of intense study on HIV/AIDS, scientists have identified, among other things, at risk populations, stages of disease progression and treatment strategies. What has received less attention is the possibility that infection might elicit an increase in sexual behavior in humans. In 2000, Starks and colleagues speculated that HIV infection could alter host behavior in a manner that facilitated the spread of the virus. Retrospective and self-report data from five studies now support this hypothesis. Individuals with acute—versus nonacute—stage infections report more sexual partners and more frequent risky sex. Additionally, male sexual behavior increases nonlinearly with HIV viral load, and data suggest a potential threshold viral level above which individuals are more likely to engage in risky sexual behavior. Taken together, these data suggest that HIV infection influences male sexual behavior in a manner beneficial to the virus. Here, we present these findings, highlight their limitations and discuss alternative perspectives. We argue for increased testing of this hypothesis and advocate for increased public health measures to mitigate the putative impact on male sexual behavior.

Lay Summary In 2000, Starks and colleagues speculated that HIV infection could alter host behavior in a manner that facilitated the spread of the virus. Retrospective and self-report data from five studies now support this hypothesis. We argue for increased testing of this hypothesis and advocate for increased public health measures to mitigate the putative impact on male sexual behavior.

Efficacy of Vaginally Administered Gel Containing Emtricitabine and Tenofovir Against Repeated Rectal Simian Human Immunodeficiency Virus Exposures in Macaques

Vaginal microbicides containing antiretrovirals (ARVs) have shown to prevent vaginally acquired human immunodeficiency virus (HIV), but these products may not protect women who engage in anal sex. Intravaginal dosing with ARVs has shown to result in drug exposures in rectal tissues, thus raising the possibility of dual compartment protection. To test this concept, we investigated whether intravaginal dosing with emtricitabine (FTC)/tenofovir (TFV) gel, which fully protected macaques against repeated vaginal exposures to simian human immunodeficiency virus (SHIV), protects against rectal SHIV exposures. Pharmacokinetic studies revealed rapid distribution of FTC and TFV to rectal tissues and luminal fluids, albeit at concentrations 1-2 log10 lower than those in the vaginal compartment. Efficacy measurements against repeated rectal SHIV challenges demonstrated a 4.5-fold reduction in risk of infection in macaques that received intravaginal FTC/TFV compared to placebo gel (P = .047; log-rank test). These data support the concept of dual compartment protection by vaginal dosing and warrants developing ARV-based vaginal products with improved bidirectional dosing.

Subsequent HIV Diagnosis Risk After Syphilis in a Southern Black Population

BACKGROUND

Southern non-Hispanic black persons are disproportionately represented in the HIV epidemic. Those previously diagnosed as having syphilis are at significant risk to become HIV infected within 36 months. Effective prevention strategies such as preexposure prophylaxis should be offered to those at highest risk to maximize prevention efforts.

METHODS

HIV-negative persons diagnosed as having primary or secondary (P&S) syphilis during 1998-2014 were matched with incident HIV cases diagnosed during 1998-2016 in Shelby County Tennessee. Person-year HIV incidence rate, Kaplan-Meier survival estimates, and Cox proportional regression model analyses were performed to explore predicting risk factors and quantifying risk factors associated with HIV-free survival time frames.

RESULTS

Among 2032 HIV-negative non-Hispanic black Shelby County residents diagnosed as having P&S syphilis, 139 (6.8%) were subsequently diagnosed as having HIV infection. Men who have sex with men (MSM) experienced the highest incidence of HIV diagnosis rate (4.98 per 100 person-years, 95% confidence interval, 4.76-5.2). Being male, MSM, younger than 30 years, or coinfected with gonorrhea increased risk of HIV acquisition 2.32, 11.80, 1.67, and 2.44 times, respectively, compared with being female, heterosexual men, 30+ years old, or not infected with other sexually transmitted infections.

CONCLUSIONS

Among our population diagnosed as having P&S syphilis, 1 in 6 MSM and 1 in 16 persons coinfected with gonorrhea were subsequently diagnosed as having HIV during 36 months of follow-up. These findings have implications for HIV screening and recruitment as priority preexposure prophylaxis candidates.

Rising HIV prevalence among men who have sex with men in Nigeria: a trend analysis

BACKGROUND

Men who have sex with men (MSM) are conservatively estimated to be less than 1% of the Nigerian population yet nationally account for about 20% of new HIV infection. We estimated the trend in HIV prevalence and determined correlates of HIV infection among MSM.

METHODS

This study used data from respondent-driven sampling in three rounds of integrated biological and behavioral surveillance survey (2007, 2010 and 2014) and covered three states in 2007, six states in 2010 and eight states in 2014. Each round used similar methodology and thus allows for comparison. Behavioral data were obtained using a structured pre-coded questionnaire. Differences in categorical variables were assessed with Chi Square. Logistic regression was used to identify factors associated with HIV.

RESULTS

A total of 879, 1545 and 3611 MSM were recruited in 2007, 2010 and 2014 respectively. Median age was 22 years for 2007 and 2014 while it was 24 years in 2010. About one-third of MSM in 2007 and 2014 and about two-fifths in 2010 had engaged in transactional sex. HIV prevalence increased from 14% in 2007 to 17% in 2010 to 23% in 2014 (p < 0.0001). Factors associated with HIV include older age ≥ 25 years (adjusted odds ratio {AOR}:2.41; 95% CI:1.84-3.16); receptive anal sex (AOR:1.92; 95% CI:1.54-2.40) and history of sexually transmitted infections (AOR:1.26; 95% CI:1.02-1.55).

CONCLUSION

There's been a consistent and significant increase in HIV prevalence among MSM with about 10-percentage points relative increase per year over 7 years. Older MSM were more likely to be HIV positive and this may reflect their prolonged exposure to high risk sexual activities. Evidence based interventions are urgently needed to mitigate intra-group HIV transmission and propagation of HIV epidemic between MSM and the general population.

Knowledge of sexually transmitted infections and risky behaviours: a survey among high school and university students

Introduction

STIs are a serious public health problem. Worldwide, 500 million people a year acquire a STI, and young are the most affected.

Methods

This study was conducted administering an anonymous questionnaire to 1228 Sicilian students of high school and university.

Results

The students had variable understanding of STIs and their complications. The results demonstrate an extreme variability in the knowledge of STIs. Multiple linear regression showed that sexual health knowledge was associated with age and sexual orientation.

Conclusions

Our results show that knowledge of STIs is poor and inadequate. This finding can put students at risk of STIs.

Panel Data Analysis via Mechanistic Models

Panel data, also known as longitudinal data, consist of a collection of time series. Each time series, which could itself be multivariate, comprises a sequence of measurements taken on a distinct unit. Mechanistic modeling involves writing down scientifically motivated equations describing the collection of dynamic systems giving rise to the observations on each unit. A defining characteristic of panel systems is that the dynamic interaction between units should be negligible. Panel models therefore consist of a collection of independent stochastic processes, generally linked through shared parameters while also having unit-specific parameters. To give the scientist flexibility in model specification, we are motivated to develop a framework for inference on panel data permitting the consideration of arbitrary nonlinear, partially observed panel models. We build on iterated filtering techniques that provide likelihood-based inference on nonlinear partially observed Markov process models for time series data. Our methodology depends on the latent Markov process only through simulation; this plug-and-play property ensures applicability to a large class of models. We demonstrate our methodology on a toy example and two epidemiological case studies. We address inferential and computational issues arising due to the combination of model complexity and dataset size. Supplementary materials for this article are available online.

HIV Education and Sexual Risk Behaviors Among Young Men Who Have Sex with Men

PURPOSE

Men who have sex with men (MSM) have nearly 80 times the lifetime risk of human immunodeficiency virus (HIV) relative to men who have sex with women only (MSW), and young MSM (YMSM) accounted for 95% of estimated HIV diagnoses among adolescents between 13 and 24 years in 2015. We aimed to evaluate HIV education and sexual risk behaviors among YMSM relative to young MSW (YMSW) and to evaluate the relationship between HIV education and YMSM sexual risk behaviors.

METHODS

We used Youth Risk Behavior Surveillance System data from 13 states that collected information on sex of sexual contacts and on HIV education in 2011 and/or 2013. We assessed HIV education, number of sexual partners ever and in the past three months, and condom use at last sex in logistic regression analyses controlling for age, race/ethnicity, state, and year.

RESULTS

YMSM were less likely to report school-based HIV education and more likely to report sexual risk behaviors relative to YMSW. HIV education was associated with reduced sexual risk behaviors among all students and with significant additional reductions in sexual risk behaviors among YMSM.

CONCLUSION

There is a need for HIV education programs to reach YMSM, who are at increased risk of HIV.

HIV and SIV in Body Fluids: From Breast Milk to the Genitourinary Tract

HIV-1 is present in many secretions including oral, intestinal, genital, and breast milk. However, most people exposed to HIV-1 within these mucosal compartments do not become infected despite often frequent and repetitive exposure over prolonged periods of time. In this review, we discuss what is known about the levels of cell-free HIV RNA, cell-associated HIV DNA and cell-associated HIV RNA in external secretions. Levels of virus are usually lower than contemporaneously obtained blood, increased in settings of inflammation and infection, and decreased in response to antiretroviral therapy. Additionally, each mucosal compartment has unique innate and adaptive immune responses that affect the composition and presence of HIV-1 within each external secretion. We discuss the current state of knowledge about the types and amounts of virus present in the various excretions, touch on innate and adaptive immune responses as they affect viral levels, and highlight important areas for further study.

Oral sex related knowledge and oral sex behavior among homosexual and heterosexual men in Belgrade: A cross-sectional study

Background

Although the risk of sexually transmitted infections is far greater during vaginal and anal sex than during oral sex, increasing practice of oral sex and low rates of barrier method use will probably increase the relative importance of oral sex as a route of transmission for genital pathogens.

Aims

The aim of this study was to evaluate knowledge and attitudes about oral sex and sexually transmitted infections, as well as oral sex practices, both among heterosexuals and homosexual men and to compare those two groups.

Materials and Methods

In this cross-sectional study, data were collected from consecutive sexually active male patients who ever had oral sex and who attended counselling for sexually transmitted infections at the City Institute for Skin and Venereal Diseases in Belgrade from March to June 2016. One dermatologist interviewed all participants.

Results

The study included 359 men who ever had oral sex, 95 (26.5%) homosexual and 264 (73.5%) heterosexual men. In comparison with heterosexual men, homosexual men had considerably more lifetime sexual partners and oral sex partners during the past 3 months, and significantly more frequently practiced oral-anal sex. Oral-sex related knowledge of all participants was unsatisfactory [correct answers were given by 95 (26.5%) to 277 (77.2%) participants], but it was significantly better in homosexual men than in heterosexual. Frequency of condom use and human immunodeficiency virus testing was also significantly higher in the case of homosexual than heterosexual men.

Limitations

The study was not performed in representative sample of population. It was restricted to the patients. Consequently it is questionable whether the results obtained could be generalized.

Conclusion

Oral sex related knowledge deficits and risky oral sex practice exist in both homosexual and heterosexual men. These findings indicate a need for effective public health campaign and patient education about the risks of unprotected oral sex.

Prevalence and Factors Associated with Inconsistent Condom Use among Men who Have Sex with Men (MSM) who use Mobile Geo-Social Networking Applications in Greater Tokyo

This study examined the prevalence and factors associated with inconsistent condom use among men who have sex with men (MSM) who use gay mobile geo-social networking applications (gay mobile apps) in Greater Tokyo. Among a sample of 1657 MSM recruited through advertisements on gay mobile apps, inconsistent condom use was reported by over one-third (37%) of participants with regular male partners, 18% with casual male partners, and 20% with female partners. In multiple regression analysis, inconsistent condom use with both regular and casual male partners was more commonly reported among participants without a university education, and among participants reporting lower self-efficacy for safer sex. Inconsistent condom use with casual male partners was more commonly reported among participants living in the central 23 wards of Tokyo. Inconsistent condom use with regular male partners was more commonly reported among participants who identified as a member of the gay community, and who only had male partners. These results indicate that a substantial proportion of Greater Tokyo gay mobile app users use condoms inconsistently, particularly with regular partners, and may be at risk for HIV. This paper provides useful information to help design tailored strategies to reduce inconsistent condom use.

Latent Classes of Sexual Risk Among Black Men Who Have Sex with Men and Women

Black men who have sex with men and women (BMSMW) are at high risk for HIV and other sexually transmitted infections (STIs). Despite knowing that HIV/STI risk varies by sexual positioning practices, limited data have characterized the risk profiles of BSMW. This study utilized latent class analysis (LCA) to explore BMSMW's sexual risk profiles regarding condomless sexual positioning practices. Participants were BMSMW in intervention studies in Los Angeles, Chicago, and Philadelphia. LCA was used to characterize their sexual risk profiles. Age, study location, HIV status, social support, and internalized homophobia were used as covariates in a multinomial regression model predicting the likelihood of class membership. Among the 546 participants, three latent classes of risk were identified: Seropositive Serosorters, Seronegative/unknown Serosorters, and Main Partners Only. All groups had the greatest probabilities of condomless sex with main partners. Seropositive Serosorters had the highest probabilities of condomless sex with HIV-positive partners. Seronegative/unknown Serosorters had the highest probabilities of condomless sex with HIV-negative or unknown status partners. HIV-positive BMSMW had 87% lower odds of being classified as Seronegative/unknown Serosorters than Seropositive Serosorters than HIV-negative/unknown status BMSMW (AOR = 0.13, 95% CI 0.06, 0.28). HIV-positive BMSMW had 71% lower odds of being classified as Main Partners Only than Seropositive Serosorters than HIV-negative/unknown status BMSMW (AOR = 0.29, 95% CI 0.16, 0.51). Findings highlight opportunities for clinicians to promote condom use and risk reduction among BMSMW with differing sexual risk profiles. Increased understanding of sexual positioning practices among BMSMW might help address HIV/STIs among this group.

Does per-act HIV-1 transmission risk through anal sex vary by gender? An updated systematic review and meta-analysis

Quantifying HIV-1 transmission risk per-act of anal intercourse (AI) is important for HIV-1 prevention. We updated previous reviews by searching Medline and Embase to 02/2018. We derived pooled estimates of receptive AI (URAI) and insertive AI (UIAI) risk unprotected by condoms using random-effects models. Subgroup analyses were conducted by gender, study design, and whether antiretroviral treatment (ART) had been introduced by the time of the study. Two new relevant studies were identified, one of which met inclusion criteria, adding three new cohorts and increasing number of individuals/partnerships included from 1869 to 14 277. Four studies, all from high-income countries, were included. Pooled HIV-1 risk was higher for URAI (1.25%, 95% CI 0.55%-2.23%, N = 5, I²  = 87%) than UIAI (0.17%, 95 % CI 0.09%-0.26%, N = 3, I²  = 0%). The sole heterosexual URAI estimate (3.38%, 95% CI 1.85%-4.91%), from a study of 72 women published in a peer-reviewed journal, was significantly higher than the men-who-have-sex-with-men (MSM) pooled estimate (0.75%, 95% CI 0.56%-0.98%, N = 4, P < 0.0001) and higher than the only other heterosexual estimate identified (0.4%, 95% CI 0.08%-2.0%, based on 59 women, excluded for being a pre-2013 abstract). Pooled per-act URAI risk varied by study design (retrospective-partner studies: 2.56%, 95% CI 1.20%-4.42%, N = 2 (one MSM, one heterosexual); prospective studies: 0.71%, 95% CI 0.51%-0.93%, N = 3 MSM, P < 0.0001). URAI risk was lower for studies conducted in the ART era (0.75%, 95% CI 0.52%-1.03%) than pre-ART (1.67%, 95% CI 0.44%-3.67%) but not significantly so (P = 0.537). Prevention messages must emphasize that HIV-1 infectiousness through AI remains high, even in the ART era. Further studies, particularly among heterosexual populations and in resource-limited settings, are required to elucidate whether AI risk differs by gender, region and following population-level ART scale-up.

Belgian guidelines for non-occupational HIV post-exposure prophylaxis 2017

We present the updated Belgian guidelines for the use of non-occupational HIV post-exposure prophylaxis (NONOPEP). This document is inspired by UK guidelines 2015, adapted to the Belgian situation and approved by all AIDS reference centers in Belgium. When recommended, NONOPEP should be initiated as soon as possible, preferably within 24 h of exposure but can be offered up to 72 h. The duration of NONOPEP should be 28 days. These current guidelines include epidemiologic estimations, which can be used to calculate the risk of infection after a potential exposure and help to decide whether or not to start prophylaxis. We review which medications to use in the context of the last Belgian NONOPEP convention, provide a checklist for initial assessment, and make recommendations for monitoring individuals receiving NONOPEP.

Expert consensus statement on the science of HIV in the context of criminal law

INTRODUCTION

Globally, prosecutions for non-disclosure, exposure or transmission of HIV frequently relate to sexual activity, biting, or spitting. This includes instances in which no harm was intended, HIV transmission did not occur, and HIV transmission was extremely unlikely or not possible. This suggests prosecutions are not always guided by the best available scientific and medical evidence.

DISCUSSION

Twenty scientists from regions across the world developed this Expert Consensus Statement to address the use of HIV science by the criminal justice system. A detailed analysis of the best available scientific and medical research data on HIV transmission, treatment effectiveness and forensic phylogenetic evidence was performed and described so it may be better understood in criminal law contexts. Description of the possibility of HIV transmission was limited to acts most often at issue in criminal cases. The possibility of HIV transmission during a single, specific act was positioned along a continuum of risk, noting that the possibility of HIV transmission varies according to a range of intersecting factors including viral load, condom use, and other risk reduction practices. Current evidence suggests the possibility of HIV transmission during a single episode of sex, biting or spitting ranges from no possibility to low possibility. Further research considered the positive health impact of modern antiretroviral therapies that have improved the life expectancy of most people living with HIV to a point similar to their HIV-negative counterparts, transforming HIV infection into a chronic, manageable health condition. Lastly, consideration of the use of scientific evidence in court found that phylogenetic analysis alone cannot prove beyond reasonable doubt that one person infected another although it can be used to exonerate a defendant.

CONCLUSIONS

The application of up-to-date scientific evidence in criminal cases has the potential to limit unjust prosecutions and convictions. The authors recommend that caution be exercised when considering prosecution, and encourage governments and those working in legal and judicial systems to pay close attention to the significant advances in HIV science that have occurred over the last three decades to ensure current scientific knowledge informs application of the law in cases related to HIV.

Full depth measurement of tenofovir transport in rectal mucosa using confocal Raman spectroscopy and optical coherence tomography

The prophylactic activity of antiretroviral drugs applied as microbicides against sexually transmitted HIV is dependent upon their concentrations in infectable host cells. Within mucosal sites of infection (e.g., vaginal and rectal mucosa), those cells exist primarily in the stromal layer of the tissue. Traditional pharmacokinetic studies of these drugs have been challenged by poor temporal and spatial specificity. Newer techniques to measure drug concentrations, involving Raman spectroscopy, have been limited by laser penetration depth into tissue. Utilizing confocal Raman spectroscopy (RS) in conjunction with optical coherence tomography (OCT), a new lateral imaging assay enabled concentration distributions to be imaged with spatial and temporal specificity throughout the full depth of a tissue specimen. The new methodology was applied in rectal tissue using a clinical rectal gel formulation of 1% tenofovir (TFV). Confocal RS revealed diffusion-like behavior of TFV through the tissue specimen, with significant partitioning of the drug at the interface between the stromal and adipose tissue layers. This has implications for drug delivery to infectable tissue sites. The new assay can be applied to rigorously analyze microbicide transport and delineate fundamental transport parameters of the drugs (released from a variety of delivery vehicles) throughout the mucosa, thus informing microbicide product design.