The Effect of PrEP on HIV Incidence Among Men Who Have Sex With Men in the Context of Condom Use, Treatment as Prevention, and Seroadaptive Practices

Variations in HIV Prevention Coverage in Subpopulations of Australian Gay and Bisexual Men, 2017-2021: Implications for Reducing Inequities in the Combination Prevention Era

Using repeated behavioural surveillance data collected from gay and bisexual men (GBM) across Australia, we assessed trends in HIV prevention coverage (the level of 'safe sex' achieved in the population by the use of effective prevention methods, including condoms, pre-exposure prophylaxis [PrEP] and having an undetectable viral load). We stratified these trends by age, country of birth/recency of arrival, sexual identity, and the proportion of gay residents in the participant's suburb. Among 25,865 participants with casual male partners, HIV prevention coverage increased from 69.8% in 2017 to 75.2% in 2021, lower than the UNAIDS target of 95%. Higher levels of coverage were achieved among older GBM (≥ 45 years), non-recently-arrived migrants, and in suburbs with ≥ 10% gay residents. The lowest levels of prevention coverage (and highest levels of HIV risk) were recorded among younger GBM (< 25 years) and bisexual and other-identified participants. Younger, recently-arrived, and bisexual GBM were the most likely to use condoms, while PrEP use was concentrated among gay men, 25-44-year-olds, and in suburbs with more gay residents. The use of undetectable viral load was most common among participants aged ≥ 45 years. Our analysis shows that high HIV prevention coverage can be achieved through a mixture of condom use, PrEP use, and undetectable viral load, or by emphasising PrEP use. In the Australian context, younger, bisexual and other-identified GBM should be prioritised for enhanced access to effective HIV prevention methods. We encourage other jurisdictions to assess the level of coverage achieved by combination prevention, and variations in uptake.

Fast-track interventions for HIV and AIDS epidemic control among key populations: A rapid review

BACKGROUND

Targeted interventions for key populations remain critical for realisation of epidemic control for human immunodeficiency virus (HIV) infection because of the causal relationship between HIV infection in the general population and among key population groups.

AIM

To consolidate evidence on the fast-track interventions towards achieving HIV epidemic control among key populations.

METHODS

A rapid scoping review was conducted using the methodological framework by Arksey and O' Malley. The Population, Intervention, Context and Outcome (PICO) framework was used to identify relevant studies using key words with Boolean operators in electronic data bases, namely CINHAL, Web of Science, Psych Info and Sabinet. Studies were extracted using a modified data extraction tool, and results were presented narratively.

RESULTS

A total of 19 articles were included in this review. Most articles were primary studies (n = 17), while another involved the review of existing literature and policies (n = 2) and routinely collected data (n = 1). Most studies were conducted in the United States of America (n = 6), while another were conducted in China, Kenya, Botswana, South Africa and Mozambique. All studies revealed findings on tested interventions to achieve HIV epidemic control among key populations.

CONCLUSION

Effective interventions for HIV epidemic control were stand-alone behavioural preventive interventions, stand-alone biomedical preventive strategies and combination prevention approaches. Furthermore, the findings suggest that effective activities to achieve HIV epidemic control among key populations should be centred around prevention.Contribution: The findings of this study have policy and practice implications for high HIV burden settings such as South Africa in terms of interventions to facilitate realisation of the Joint United Nations Programme on HIV/AIDS (UNAIDS) 95-95-95 targets, thereby contributing to HIV epidemic control.

Influence of families and other adult support on HIV prevention outcomes among black men who have sex with men

BACKGROUND

Prior research has consistently shown that the involvement of families plays a vital role in reducing risk behaviors, such as engaging in condomless sex, and promoting HIV prevention behaviors among young Black men who have sex with men (YBMSM). With the aim of expanding the existing knowledge, this study aimed to examine the specific influence of families and other supportive adults in facilitating casual condom use, partner condom use, HIV testing, and preexposure prophylaxis (PrEP) utilization among young Black MSM.

METHODS

A sample of YBMSM aged 18-29 years (N = 400) was collected online. We used a path analysis to examine the influence of family factors on PrEP stigma and PrEP use. Respondents were recruited from December 1, 2021, to January 31, 2022. We used a path analysis to examine the direct and indirect effects of family factors on PrEP use through HIV testing and encouraging condom use.

RESULTS

Among BMSM, other adult support was positive and directly associated with condom use by both casual partners (β = 0.04, p < .05) and partners (β = 0.17, p < .01). Condom use by casual partners was negative and was directly associated with HIV testing (β = - 0.15, p < .01).

CONCLUSION

The primary aim of this research was to examine the influence of family and adult support on HIV prevention behaviors among young Black MSM, including condom use, HIV testing, and PrEP use. Our findings highlight the significance of implementing interventions that incorporate families and other supportive adults to enhance the engagement of young Black MSM in HIV prevention behaviors.

Optimal strategies to improve uptake of and adherence to HIV prevention among young people at risk for HIV acquisition in the USA (ATN 149): a randomised, controlled, factorial trial

BACKGROUND

Pre-exposure prophylaxis (PrEP), condom use, post-exposure prophylaxis (PEP), and sexual partner reduction help to prevent HIV acquisition but have low uptake among young people. We aimed to assess the efficacy of automated text messaging and monitoring, online peer support, and strengths-based telehealth coaching to improve uptake of and adherence to PrEP, condom use, and PEP among adolescents aged 12-24 years at risk of HIV acquisition in Los Angeles, CA, USA, and New Orleans, LA, USA.

METHODS

We conducted a four-arm randomised controlled factorial trial, assessing interventions designed to support uptake and adherence of HIV prevention options (ie, PrEP, PEP, condom use, and sexual partner reduction). We recruited young people aged 12-24 years who were at risk of HIV acquisition from 13 community-based organisations, adolescent medicine clinics, and organisations serving people who are unstably housed, people who were previously incarcerated, and other vulnerable young people, and through dating apps, peer referrals, and social venues and events in Los Angeles, CA, USA, and New Orleans, LA, USA. Young people who tested seronegative and reported being gay, bisexual, or other men who have sex with men, transgender men or women, or gender diverse (eg. non-binary or genderqueer) were eligible for inclusion. Participants were randomly assigned to one of four intervention groups in a factorial design: automated text messaging and monitoring (AMMI) only, AMMI plus peer support via private social media, AMMI plus strengths-based telehealth coaching by near-peer paraprofessionals, or AMMI plus peer support and coaching. Assignment was further stratified by race or ethnicity and sexual orientation within each interviewer's group of participants. Participants were masked to intervention assignment until after baseline interviews when offered their randomly assigned intervention, and interviewers were masked throughout the study. Interventions were available throughout the 24-month follow-up period, and participants completed baseline and follow-up assessments, including rapid diagnostic tests for sexually transmitted infections, HIV, and substance use, at 4-month intervals over 24 months. The primary outcomes were uptake and adherence to HIV prevention options over 24 months, measured by self-reported PrEP use and adherence, consistent condom use with all partners, PEP prescription and adherence, and number of sexual partners in participants with at least one follow-up. We used Bayesian generalised linear modelling to assess changes in outcomes over time comparing the four study groups. This study is registered with ClinicalTrials.gov (NCT03134833) and is completed.

FINDINGS

We screened 2314 adolescents beginning May 1, 2017, to enrol 1037 participants (45%) aged 16-24 years between May 6, 2017, and Aug 30, 2019, of whom 895 (86%) had follow-up assessments and were included in the analytical sample (313 assigned to AMMI only, 205 assigned to AMMI plus peer support, 196 assigned to AMMI plus coaching, and 181 assigned to AMMI plus peer support and coaching). Follow-up was completed on Nov 8, 2021. Participants were diverse in race and ethnicity (362 [40%] Black or African American, 257 [29%] Latinx or Hispanic, 184 [21%] White, and 53 [6%] Asian or Pacific Islander) and other sociodemographic factors. At baseline, 591 (66%) participants reported anal sex without a condom in the past 12 months. PrEP use matched that in young people nationally, with 101 (11%) participants reporting current PrEP use at baseline, increasing at 4 months to 132 (15%) and continuing to increase in the AMMI plus peer support and coaching group (odds ratio 2·31, 95% CI 1·28-4·14 vs AMMI control). There was no evidence for intervention effect on condom use, PEP use (ie, prescription or adherence), PrEP adherence, or sexual partner numbers. No unanticipated or study-related adverse events occurred.

INTERPRETATION

Results are consistent with hypothesised synergistic intervention effects of evidence-based functions of informational, motivational, and reminder messaging; peer support for HIV prevention; and strengths-based, goal-focused, and problem-solving telehealth coaching delivered by near-peer paraprofessionals. These core functions could be flexibly scaled via combinations of technology platforms and front-line or telehealth HIV prevention workers.

FUNDING

Adolescent Medicine Trials Network for HIV/AIDS Interventions, US National Institutes of Health.

Perceptions and experiences of daily and long-acting pre-exposure prophylaxis (PrEP) among MSM in India

Oral pre-exposure prophylaxis (PrEP) is an effective HIV prevention strategy with high efficacy. An increased willingness to use PrEP among at-risk Indian men who have sex with men (MSM) population has been reported; however, little is known about their real experiences that guide their key motivators, facilitators, and barriers with using oral and Long-Acting (LA) Injectable PrEP. We recruited participants (n = 18) through active MSM social media networks. The interviews were conducted using teleconferencing software. Interview topics included participants' sources of knowledge, experiences accessing daily PrEP, safe-sex behaviors while on PrEP, barriers and facilitators around PrEP, long-term goals with PrEP, perceptions around LA PrEP, and discussion around decision-making to switch from oral PrEP to LA PrEP. Transcripts were coded according to interview topics, and key themes were analyzed using a topical data analysis approach. Participants (median age 28 years, ranging from 18 to 40) reported a high perceived risk of HIV. This increased perceived risk was a key motivator for oral PrEP uptake. Most participants shared that they accessed PrEP through non-profit organizations serving the MSM community, where doctor consultations and medication were either free or subsidized. Even when participants reported high adherence to oral PrEP, they expressed discontent with the requirement to take it daily. High condom usage was reported concomitantly with PrEP use among most participants, except for a few who preferred bareback sex. Participants shared that they would prefer to continue PrEP until they are in a monogamous, exclusive relationship. The cost and affordability remained recurring themes, and while participants could afford oral PrEP, they wished it was cheaper, making it more accessible to the community at large. Most participants did not have prior knowledge of LA injectable PrEP but welcomed the intervention, alluding to cost and availability as the key decision-making factors affecting switching. MSM from India we interviewed adopted oral PrEP as an additional HIV prevention strategy to condoms through non-profit and private channels. Cost and broader access remains a concern among the MSM community. More acceptability research about long-acting PrEP is needed among MSM in the Indian context, and it is recommended for government interventions to include oral PrEP groups at higher risk of HIV acquisition.

Social disparities on PrEP use and awareness among sexual and gender minorities using smartphones in India

Background

Pre-exposure prophylaxis (PrEP) is a safe and effective HIV prevention strategy. However, in countries such as India where PrEP is driven by the private healthcare system and there is no centralized reporting, it is unknown which populations benefit from PrEP and which populations are being left behind.

Objectives

We examined and characterized PrEP use and awareness among the sexual and gender minorities using smartphones in India and found measures of association of PrEP use.

Design

This is a cross-sectional study design.

Methods

We used Grindr-a widely used geosocial mobile application-to conduct a national cross-sectional survey in India, including respondents who were 18 years or older and reported sex with men (those who identified as cis-gender females were excluded). We examined overall PrEP awareness and PrEP use, then calculated adjusted prevalence odds ratio and 95% confidence intervals to understand PrEP use correlation with socio-behavioral factors.

Results

Out of the total of 3116 eligible participants, 30.3% (N = 947) were aware of PrEP and 3.1% (N = 97) reported current PrEP use. Our multivariate regression model found that there was a statistically significant association of PrEP use with higher income, being employed, preferred language as English for survey, relationship status as single, and use of party drugs. At the same time, there was a statistically significant association of PrEP awareness with age group, having higher education as a graduate or above, higher income, use of party drugs, and multiple sexual partners.

Conclusion

We found overall low awareness and low PrEP use in our cross-sectional sample. PrEP use and awareness were higher among those who belonged to higher-income groups. Including PrEP in existing programmatic interventions by government and NGOs may contribute to PrEP scale-up, which is urgent to stop the HIV epidemic in India.

The Incidence Rate of Sexual Behaviors Among Cisgender Men Who Have Sex with Men Attending a Sexual Health Clinic

Although nuanced parameterization of sexual behavior may improve estimates from mathematical models of human immunodeficiency virus and sexually transmitted infection transmission, prospective estimates of the incidence of specific sexual behaviors among men who have sex with men (MSM) are limited. From December 2014 to July 2018, MSM with and without nongonococcal urethritis (NGU) completed weekly diaries over 3-12 weeks. Incidence rates of any sex, receptive anal sex, insertive anal sex, insertive oral sex, receptive rimming, and receptive hand-penile contact were 1.19, 0.28, 0.66, 0.90, 0.24, and 0.85 episodes per person-week, respectively, among 104 MSM with NGU at baseline, and 1.33, 0.54, 0.32, 0.95, 0.44, and 0.88 episodes per person-week, respectively, among 25 MSM without NGU at baseline. Most receptive anal sex (NGU + 83%, NGU - 86%) and insertive anal sex (NGU + 85%, NGU - 76%) episodes were condomless. MSM engaged in sex just over once per week, and condom use was infrequent. Insertive oral sex and receptive hand-penile contact were the most common behaviors.

Missed opportunities for HIV pre-exposure prophylaxis among people with recent HIV infection: The French ANRS 95041 OMaPrEP study

OBJECTIVES

Our objective was to identify missed opportunities for the use of pre-exposure prophylaxis (PrEP) in people with recently acquired HIV, factors associated with PrEP knowledge, and reasons for not using PrEP.

DESIGN

This was a French national cross-sectional multicentre study enrolling people diagnosed with recent HIV (incomplete Western blot or negative HIV test in the previous 6 months) in 28 HIV clinical centres. Data were gathered using a self-administered questionnaire (SAQ).

METHOD

We analysed missed opportunities for PrEP use via a retrospective prep cascade. Factors associated with prior knowledge of PrEP and reasons for PrEP non-use among those who knew about PrEP were described using univariate and multivariate logistic regression models.

RESULTS

Of the 224 eligible patients, 185 completed the SAQ and 168 (91%) were eligible for PrEP. Of these, 90% reported seeing at least one physician during the previous year, 26% received information about PrEP, and 5% used PrEP. Factors independently associated with a higher probability of knowing about PrEP were being a man who has sex with men, being aged 25-30 years (vs older), undergoing HIV screening at least once every semester (vs less often; odds ratio [OR] 4.11; 95% confidence interval [CI] 2.00-8.45), and practicing chemsex (OR 3.19; 95% CI 1.12-9.10). Fear of side effects and a low perceived risk of HIV infection were the two most common reasons for not using PrEP (N = 40 [33.33%] and N = 34 [28.3%], respectively).

CONCLUSIONS

We found two gaps in the retrospective PrEP cascade: insufficient provision of PrEP information by healthcare providers (mainly general practitioners) and low PrEP acceptability by informed, eligible patients. More diverse healthcare providers need to be involved in PrEP prescription, and at-risk people need to be sensitized to the risk of HIV infection.

Modeling the Impact of HIV-1 Nucleic Acid Testing Among Symptomatic Adult Outpatients in Kenya

BACKGROUND

Up to 69% of adults who acquire HIV in Kenya seek care before seroconversion, providing an important opportunity for early diagnosis and treatment. The Tambua Mapema Plus (TMP) trial tested a combined HIV-1 nucleic acid testing, linkage, treatment, and partner notification intervention for adults aged 18-39 years with symptoms of acute HIV infection presenting to health facilities in coastal Kenya. We estimated the potential impact of TMP on the Kenyan HIV epidemic.

METHODS

We developed an agent-based network model of HIV-1 transmission using TMP data and Kenyan statistics to estimate potential population-level impact of targeted facility-based testing over 10 years. Three scenarios were modeled: standard care [current use of provider-initiated testing and counseling (PITC)], standard HIV rapid testing scaled to higher coverage obtained in TMP (scaled-up PITC), and the TMP intervention.

RESULTS

Standard care resulted in 90.7% of persons living with HIV (PLWH) knowing their status, with 67.5% of those diagnosed on treatment. Scaled-up PITC resulted in 94.4% of PLWH knowing their status and 70.4% of those diagnosed on treatment. The TMP intervention achieved 97.5% of PLWH knowing their status and 80.6% of those diagnosed on treatment. The percentage of infections averted was 1.0% (95% simulation intervals: -19.2% to 19.9%) for scaled-up PITC and 9.4% (95% simulation intervals: -8.1% to 24.5%) for TMP.

CONCLUSION

Our study suggests that leveraging new technologies to identify acute HIV infection among symptomatic outpatients is superior to scaled-up PITC in this population, resulting in >95% knowledge of HIV status, and would reduce new HIV infections in Kenya.

PrEP in the Context of Other HIV Risk Reduction Strategies Among Men Who Have Sex with Men: Results from the Flash! PrEP in Europe Survey

Combination HIV prevention covers a range of biomedical, behavioral, and socio-structural interventions. Despite the growing availability of pre-exposure prophylaxis (PrEP), it is not always accessible in European Centre for Disease Prevention and Control reporting countries and may not meet the needs of all at-risk populations. Based on the Flash! PrEP in Europe data, multiple correspondence analysis and hierarchical clustering were used to identify patterns in HIV prevention strategies among 9980 men who have sex with men (MSM). PrEP interest was evaluated among four identified clusters: (A) "high condom use, sometimes Treatment as Prevention (TasP)"; (B) "mix of methods, infrequent condom use"; (C) "high condom use, tendency to choose partners based on serological status" and (D) "moderate use of condoms mixed with other prevention strategies". Clusters B and D had higher PrEP interest. These results suggest that MSM use a range of behavioral and biomedical risk reduction strategies that are often combined. On-demand PrEP may meet the needs of MSM who infrequently use condoms and other prevention methods.

A Tale of Three Recent Pandemics: Influenza, HIV and SARS-CoV-2

Emerging infectious diseases are one of the main threats to public health, with the potential to cause a pandemic when the infectious agent manages to spread globally. The first major pandemic to appear in the 20th century was the influenza pandemic of 1918, caused by the influenza A H1N1 strain that is characterized by a high fatality rate. Another major pandemic was caused by the human immunodeficiency virus (HIV), that started early in the 20th century and remained undetected until 1981. The ongoing HIV pandemic demonstrated a high mortality and morbidity rate, with discrepant impacts in different regions around the globe. The most recent major pandemic event, is the ongoing pandemic of COVID-19, caused by the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), which has caused over 5.7 million deaths since its emergence, 2 years ago. The aim of this work is to highlight the main determinants of the emergence, epidemic response and available countermeasures of these three pandemics, as we argue that such knowledge is paramount to prepare for the next pandemic. We analyse these pandemics’ historical and epidemiological contexts and the determinants of their emergence. Furthermore, we compare pharmaceutical and non-pharmaceutical interventions that have been used to slow down these three pandemics and zoom in on the technological advances that were made in the progress. Finally, we discuss the evolution of epidemiological modelling, that has become an essential tool to support public health policy making and discuss it in the context of these three pandemics. While these pandemics are caused by distinct viruses, that ignited in different time periods and in different regions of the globe, our work shows that many of the determinants of their emergence and countermeasures used to halt transmission were common. Therefore, it is important to further improve and optimize such approaches and adapt it to future threatening emerging infectious diseases.

Barriers and Facilitators to HIV Pre-Exposure Prophylaxis Uptake, Adherence, and Persistence Among Transgender Populations in the United States: A Systematic Review

HIV pre-exposure prophylaxis (PrEP) is highly effective at preventing HIV; however, PrEP use among transgender individuals remains low. We conducted a systematic review to identify barriers and facilitators to PrEP uptake, adherence, and persistence among transgender individuals in the United States. We conducted a literature search in PubMed and CINAHL databases in March 2021 and followed PRISMA guidelines. Studies were eligible if they were published in a peer-reviewed journal and reported interest, uptake, adherence, and/or persistence of PrEP use among transgender individuals. Articles that did not disaggregate results for transgender participants were excluded. Data from included articles were coded using content analysis and narratively synthesized using a framework matrix. We screened 254 unique articles published after US Food and Drug Administration approval of PrEP, and 33 articles were included in the review. Five themes were identified in the literature, including (1) PrEP concentrations were lower among individuals taking feminizing hormones, but the difference did not appear clinically significant; (2) concerns regarding interactions between gender-affirming hormone therapy and PrEP remain a large barrier; (3) PrEP initiation may facilitate increased self-advocacy and self-acceptance; (4) lack of trust in medical institutions impacts PrEP uptake; and (5) social networks have a significant influence on PrEP knowledge, interest, and adherence. Additional research is needed involving transgender men and nonbinary persons, and efforts to improve PrEP persistence among the transgender community are needed. Training health care providers to provide inclusive and affirming care is perhaps one of the strongest areas for intervention to increase PrEP uptake and persistence.

Modeling the population-level impact of treatment on COVID-19 disease and SARS-CoV-2 transmission

Different COVID-19 treatment candidates are under development, and some are becoming available including two promising drugs from Merck and Pfizer. This study provides conceptual frameworks for the effects of three types of treatments, both therapeutic and prophylactic, and to investigate their population-level impact, to inform drug development, licensure, decision-making, and implementation. Different drug efficacies were assessed using an age-structured mathematical model describing SARS-CoV-2 transmission and disease progression, with application to the United States as an illustrative example. Severe and critical infection treatment reduces progression to COVID-19 severe and critical disease and death with small number of treatments needed to avert one disease or death. Post-exposure prophylaxis treatment had a large impact on flattening the epidemic curve, with large reductions in infection, disease, and death, but the impact was strongly age dependent. Pre-exposure prophylaxis treatment had the best impact and effectiveness, with immense reductions in infection, disease, and death, driven by the robust control of infection transmission. Effectiveness of both pre-exposure and post-exposure prophylaxis treatments was disproportionally larger when a larger segment of the population was targeted than a specific age group. Additional downstream potential effects of treatment, beyond the primary outcome, enhance the population-level impact of both treatments. COVID-19 treatments are an important modality in controlling SARS-CoV-2 disease burden. Different types of treatment act synergistically for a larger impact, for these treatments and vaccination.

Countering the rise of syphilis: A role for doxycycline post-exposure prophylaxis?

Doxycycline post-exposure prophylaxis (PEP) holds the potential to mitigate increasing rates of syphilis among sexual minority men (SMM) in the US yet has received limited attention. Since evaluation of this intervention in actual populations is not currently feasible, we used agent-based models (ABM) to assess the population-level impact of this strategy. We adapted ABM of HIV and HPV transmission, representing a population of 10,230 SMM in Philadelphia, Pennsylvania, US. Parameter inputs were derived from the literature, and ABM outputs during the pre-intervention period were calibrated to local surveillance data. Intervention scenarios varied doxycycline uptake by 20, 40, 60, 80 and 100%, while assuming continued condom use and syphilis screening and treatment. Under each intervention scenario, we incorporated treatment adherence at the following levels: 0, 20, 40, 60, 80 and 100%. Long-term population impact of prophylactic doxycycline was measured using the cumulative incidence over the 10-year period and the percentage of infections prevented attributable to doxycycline at year 10. An uptake scenario of 20% with an adherence level of 80% would reduce the cumulative incidence of infections by 10% over the next decade, translating to 57 fewer cases per 1000 SMM. At year 10, under the same uptake and adherence level, 22% of infections would be prevented due to doxycycline PEP in the instances where condoms were not used or failed. Findings suggest that doxycycline PEP will have a modest impact on syphilis incidence when assuming a reasonable level of uptake and adherence. Doxycycline PEP may be most appropriate as a secondary prevention measure to condoms and enhanced syphilis screening for reducing infections among SMM.

Sexual Communication Self-Efficacy and PrEP Literacy Helps to Meet HIV Prevention Outcomes Among Black and Latinx Individuals

Background:

Ending the HIV Epidemic is a campaign dedicated to reducing new HIV infections in the United States by 90% by 2030. Preexposure prophylaxis (PrEP) holds significant promise as a prevention tool. However, uptake has not improved much since then. As a result, this research looked at how PrEP literacy relates to sexual communication self-efficacy

Methods:

Between August 4 and 21, 2020, we performed a community-informed cross-sectional study of Black and Latino residents in Indiana. We collected demographic information as well as PrEP literacy, sexual communication self-efficacy, and awareness of HIV status.

Results:

Being unaware of one’s own HIV status and being unsure of one’s sexual identity were both linked to reduced self-efficacy in the domain of sex communication. Those who had a greater level of PrEP literacy felt more confident in their ability to communicate with others about sexually related topics. People living in rural areas showed a significantly lower degree of sexual communication self-efficacy than participants in urban settings.

Conclusion:

Providing information about PrEP to those at risk of acquiring the virus may help them connect with treatment or prevention services. Healthcare professionals should take the time to understand their patients’ levels of PrEP literacy and communication self-efficacy regarding sexual health.

A Behavioral Cascade of HIV Seroadaptation Among US Men Who Have Sex with Men in the Era of PrEP and U = U

Seroadaptive behaviors help reduce HIV risk for some men who have sex with men (MSM), and have been well documented across MSM populations. Advancements in biomedical prevention have changed the contexts in which seroadaptive behaviors occur. We thus sought to estimate and compare the prevalence of four stages of the "seroadaptive cascade" by PrEP use in the recent era: knowledge of own serostatus, knowledge of partner serostatus; serosorting (matching by status), and condomless anal intercourse. Serosorting overall appeared to remain common, especially with casual and one-time partners. Although PrEP use did not impact status discussion, it did impact serosorting and the likelihood of having condomless anal intercourse. For respondents not diagnosed with HIV and not on PrEP, condomless anal intercourse occurred in just over half of relationships with HIV-positive partners who were not on treatment. Biomedical prevention has intertwined with rather than supplanted seroadaptive behaviors, while contexts involving neither persist.

Population Impact and Efficiency of Improvements to HIV PrEP Under Conditions of High ART Coverage Among San Francisco Men Who Have Sex With Men

BACKGROUND

Key components of Ending the HIV Epidemic (EHE) plan include increasing HIV antiretroviral therapy (ART) and HIV pre-exposure prophylaxis (PrEP) coverage. One complication to addressing this service delivery challenge is the wide heterogeneity of HIV burden and health care access across the United States. It is unclear how the effectiveness and efficiency of expanded PrEP will depend on different baseline ART coverage.

METHODS

We used a network-based model of HIV transmission for men who have sex with men (MSM) in San Francisco. Model scenarios increased varying levels of PrEP coverage relative under current empirical levels of baseline ART coverage and 2 counterfactual levels. We assessed the effectiveness of PrEP with the cumulative percentage of infections averted (PIA) over the next decade and efficiency with the number of additional person-years needed to treat (NNT) by PrEP required to avert one HIV infection.

RESULTS

In our projections, only the highest levels of combined PrEP and ART coverage achieved the EHE goals. Increasing PrEP coverage up to 75% showed that PrEP effectiveness was higher at higher baseline ART coverage. Indeed, the PIA was 61% in the lowest baseline ART coverage population and 75% in the highest. The efficiency declined with increasing ART (NNT range from 41 to 113).

CONCLUSIONS

Improving both PrEP and ART coverage would have a synergistic impact on HIV prevention even in a high baseline coverage city such as San Francisco. Efforts should focus on narrowing the implementation gaps to achieve higher levels of PrEP retention and ART sustained viral suppression.

Game Plan, a Web-Based Intervention to Improve Adherence and Persistence to HIV Pre-exposure Prophylaxis and Reduce Heavy Drinking in Gay, Bisexual, and Other Men Who Have Sex With Men: Usability and User Experience Testing

Background

Encouraging consistent use of pre-exposure prophylaxis (PrEP) is essential for reducing HIV incidence, particularly among gay, bisexual, and other men who have sex with men (GBM), and especially those who engage in heavy drinking. Although practice guidelines recommend providing adherence counseling to PrEP patients, clinics and providers may not have the resources or expertise to provide it. Internet-facilitated interventions have been shown to improve HIV prevention outcomes, including medication and care adherence. Game Plan is a website we created to help users make a tangible plan for reducing their HIV risk. We designed additional components of Game Plan to address key individual level barriers to PrEP use.

Objective

The aim of this mixed methods research is to test the usability and user experience of these components with intended users: GBM who drink heavily and are on PrEP.

Methods

In study 1 (usability), we completed a detailed individual interview in which participants (n=10) walked through a prototype of the website, thinking aloud as they did, and completed a follow-up interview and web-based survey afterward. Study 2 (user experience) involved providing participants (n=40) with a link to the prototype website to explore on their own and asking them to complete the same follow-up survey afterward. Qualitative data were analyzed using thematic analysis, and descriptive statistics were used to analyze quantitative data.

Results

Users in both studies gave the website excellent ratings for usability, overall satisfaction, and quality, and most often described the site as informative, helpful, and supportive. Users also rated the site’s content and feel as respectful of them and their autonomy, empathetic, and they stated that it conveyed confidence in their ability to change. The study 1 interviews highlighted the importance of the website’s esthetics to the participants’ engagement with it and its credibility in prompting genuine reflection.

Conclusions

GBM who reported heavy drinking and used PrEP generally found a website focused on helping them to create a plan to use PrEP consistently to be helpful. Adopting user-centered design methods and attending to the esthetics of mobile health interventions are important steps toward encouraging engagement and reducing at-risk behaviors.

Dramatic decline in new HIV diagnoses in persons born in France in a large nationwide HIV cohort

OBJECTIVES

As trends in new HIV diagnoses represent a measure of the HIV epidemic, we conducted a 6-year longitudinal study to evaluate the change in rates of new HIV diagnosis, stratified by birthplace, HIV risk groups and CD4 cell count at diagnosis in a large French multicentre cohort.

STUDY DESIGN

We performed a retrospective cohort study using data from the mainland French Dat'AIDS cohort.

METHODS

Data were obtained for subjects with a new HIV diagnosis date between 2013 and 2018. HIV diagnosis date was defined as the date of the first known positive HIV serology.

RESULTS

Between 2013 and 2018, a total of 68,376 people living with HIV (PLHIV) were followed in the Dat'AIDS cohort; 9543 persons were newly diagnosed with HIV. The annual number of new HIV diagnoses decreased from 1856 in 2013, to 1149 in 2018 (-38.1%), P = 0.01; it was more pronounced among subjects born in France, from 858 to 484 (-43.6%), P < 0.01, than in those born abroad (-23.8%, from 821 to 626, P = 0.13). Among subjects born in France, the decrease over the period was -46.7% among men who have sex with men (MSM), -43.5% for heterosexual women and -33.3% for heterosexual men.

CONCLUSION

Our findings show changes in HIV epidemiology in PLHIV born in France, with a decline around 40% in new HIV diagnoses, and a more pronounced decrease among MSM and heterosexual women. Our results support the long-term effectiveness of the antiretroviral therapy as a prevention strategy among the various tools for HIV prevention.

Human Immunodeficiency Virus Continuum of Care in 11 European Union Countries at the End of 2016 Overall and by Key Population: Have We Made Progress?

Background

High uptake of antiretroviral treatment (ART) is essential to reduce human immunodeficiency virus (HIV) transmission and related mortality; however, gaps in care exist. We aimed to construct the continuum of HIV care (CoC) in 2016 in 11 European Union (EU) countries, overall and by key population and sex. To estimate progress toward the Joint United Nations Programme on HIV/AIDS (UNAIDS) 90-90-90 target, we compared 2016 to 2013 estimates for the same countries, representing 73% of the population in the region.

Methods

A CoC with the following 4 stages was constructed: number of people living with HIV (PLHIV); proportion of PLHIV diagnosed; proportion of those diagnosed who ever initiated ART; and proportion of those ever treated who achieved viral suppression at their last visit.

Results

We estimated that 87% of PLHIV were diagnosed; 92% of those diagnosed had ever initiated ART; and 91% of those ever on ART, or 73% of all PLHIV, were virally suppressed. Corresponding figures for men having sex with men were: 86%, 93%, 93%, 74%; for people who inject drugs: 94%, 88%, 85%, 70%; and for heterosexuals: 86%, 92%, 91%, 72%. The proportion suppressed of all PLHIV ranged from 59% to 86% across countries.

Conclusions

The EU is close to the 90-90-90 target and achieved the UNAIDS target of 73% of all PLHIV virally suppressed, significant progress since 2013 when 60% of all PLHIV were virally suppressed. Strengthening of testing programs and treatment support, along with prevention interventions, are needed to achieve HIV epidemic control.

Sexual Dysfunction in Men Who Have Sex With Men

INTRODUCTION

Historically, sexual health research has focused on men who have sex with women (MSW) and most research examining the sexual health of men who have sex with men (MSM) has focused on HIV transmission. Despite a high prevalence of sexual health disorders among MSM, there is limited research that has evaluated the diversity of sexual issues in these patients.

OBJECTIVES

The purpose of this review is to describe the unique sexual behaviors, concerns, and dysfunctions of MSM by evaluating the literature on sexual health in this specific patient population.

METHODS

A PubMed literature search was conducted through December 2020 to identify all relevant publications related to the sexual health, sexual practices, and sexual dysfunction of MSM. Original research, review articles, and meta-analyses were reviewed, including comparisons of sexual behavior and dysfunction between MSM and non-MSM populations and between gay/bisexual men and heterosexual men. Approximately 150 relevant articles were reviewed and 100 were included in the manuscript.

RESULTS

Minority stress can lead to an increase in high-risk sexual behavior, sexual dysfunction, and mental health disorders in MSM. MSM engage in a variety of sexual behaviors, which can lead to differences in sexual dysfunction, such as anodyspareunia during receptive anal intercourse. MSM have higher rates of erectile dysfunction than non-MSM counterparts. MSM have unique activators of sexual pathologies, such as insertive anal intercourse for Peyronie's disease. Prostate cancer treatment may cause MSM to change sexual roles and practices following treatment due to ED, anodyspareunia, or decrease in pleasure from receptive anal intercourse after prostatectomy.

CONCLUSION

MSM have been neglected from sexual medicine research, which translates to disparities in health care. Further research that focuses on the MSM population is necessary to better educate healthcare practitioners so that MSM patients can receive adequate care that is tailored to their specific needs. PJ Cheng, Sexual Dysfunction in Men Who Have Sex With Men. Sex Med Rev 2021;XX:XXX-XXX.

Added Benefits of Pre-Exposure Prophylaxis Use on HIV Incidence with Minimal Changes in Efficiency in the Context of High Treatment Engagement Among Men Who Have Sex with Men

Although there is ongoing debate over the need for substantial increases in pre-exposure prophylaxis (PrEP) use when antiretroviral treatment confers the dual benefits of reducing HIV-related morbidity and mortality and the risk of HIV transmission, no studies to date have quantified the potential added benefits of PrEP use and changes in its efficiency in the context of high treatment engagement across multiple US subpopulations. We used a previously published agent-based model to simulate HIV transmission in a dynamic network of Black/African American and White men who have sex with men (MSM) in Atlanta, Georgia (2015-2024) to understand how reductions in HIV incidence attributable to varying levels of PrEP use change when United Nations Joint Programme on HIV/AIDS (UNAIDS) "90-90-90" goals for HIV treatment are achieved and maintained. Even at achievement of "90-90-90" goals, 75% PrEP coverage further reduced incidence by 67.9% and 74.2% to 1.53 [simulation interval (SI): 1.39-1.70] and 0.355 (SI: 0.316-0.391) per 100 person-years for Black/African American and White MSM, respectively, compared with the same scenario with no PrEP use. Increasing PrEP coverage from 15% to 75% under "90-90-90" goals only increased the number of person-years of PrEP use per infection averted by 8.1% and 10.5% to 26.7 (SI: 25.6-28.0) and 73.3 (SI: 70.6-75.7) among Black/African American MSM and White MSM, respectively. Even with high treatment engagement, substantial expansion of PrEP use contributes to meaningful decreases in HIV incidence among MSM with minimal changes in efficiency.

HIV Seroconversion and Types of Relationships Among Men Who Have Sex With Men: A Cohort Study in China

BACKGROUND

The role of partner types in modifying HIV seroconversion risk among men who have sex with men (MSM) is complex. We sought to understand the role of regular sexual partners and risky sexual behavior in contributing to incident HIV infection among MSM.

METHODS

From July 2011 to August 2017, we recruited HIV-negative men who reported having anal or oral homosexual encounters in the past 6 months and they were followed up every 3 months for 2 visits. We collected sociodemographic and behavioral characteristics by a self-administrated questionnaire. HIV status was confirmed by a sequential rapid test and confirmatory test. We used multivariable Cox regression to identify risk factors and interaction models to evaluate the relative excess risk between relevant variables.

RESULTS

Among 1218 participants, the HIV seroconversion rate was 3.66/100 person-years. HIV seroconversion was associated with lower educational attainment [adjusted hazards ratio (aHR)] = 1.73, 95% CI: 1.06 to 2.81), having had penetrative sex with male before age of 18 years (aHR = 2.44, 95% CI: 1.20 to 4.99), not using condoms in the last sexual encounter (aHR = 2.19, 95% CI: 1.29 to 3.71), and having regular but not committed partners (aHR = 3.33, 95% CI: 1.77 to 6.93). Among 890 (73%) of men reported having regular partners, HIV seroconversion was more frequent in men whose stable partners were not committed as boyfriends (aHR = 3.31, 95% CI: 1.73 to 6.36) and in men having unprotected anal sex (aHR = 2.61, 95% CI: 1.42 to 4.80). Interaction between these 2 factors was observed (relative excess risk of interaction = 4.53).

CONCLUSIONS

Incidence among MSM in China was high; unprotected sex with steady but not committed partners was associated with increased seroconversion risk. It is imperative to expand safer sex education and training for MSM to reduce unsafe sexual behaviors, including awareness that casual partners are not the only source of infection.

Oral sex practices among men who have sex with men and transgender women at risk for and living with HIV in Nigeria

Background

Men who have sex with men (MSM) and transgender women (TGW) are at risk for sexually transmitted infections (STIs), including those of the oropharynx. We estimated the prevalence and factors associated with oral sex practices and characterized oropharyngeal STIs among a cohort of MSM and TGW in Nigeria.

Methods

From 2013 to 2018, TRUST/RV368 recruited MSM and TGW into HIV/STI diagnosis and treatment at community-based clinics in Nigeria. Participants who completed HIV testing and oral sex questions at enrollment were selected. Cross-sectional analyses with bivariate and multivariable logistic regression models estimated odds ratios (ORs) and 95% confidence intervals (CIs). Oropharyngeal swab testing for Neisseria gonorrhoeae (NG) and Chlamydia trachomatis (CT) began in 2014 and for those with diagnostic results at enrollment, the unadjusted association of oral sex practices with oropharyngeal STIs was conducted.

Results

A total of 1342 participants had a median age of 25 years (interquartile range: 22–29), 58% were living with HIV, and 69% reported oral sex practices. Factors associated with increased odds of engaging in oral sex included living with HIV (adjusted [a]OR: 1.4, 95% CI: 1.1–1.8), self-identifying as a woman (aOR:1.8, 95% CI: 1.1–2.8), mobile phone ownership (aOR:2.3, 95% CI: 1.3–3.9), receptive anal sex (aOR:1.7, 95% CI:1.3–2.3) and multiple male sexual partners (2 to 4 vs. ≤1, aOR:1.5, 95% CI: 1.0–2.2; 5+ vs ≤1, aOR:2.9, 95% CI:1.9–4.3). Oropharyngeal STI prevalence was 7% (52/752) and higher among those who engaged in oral sex compared to those who did not (unadjusted OR: 2.5, 95% CI:1.2–5.3).

Conclusions

Oral sex was common and associated with an increased odds of oropharyngeal STIs among MSM and TGW from Nigeria. In the absence of screening and treatment guidelines, condoms continue to be the mainstay for oral STI prevention. A pre-exposure prophylaxis for bacterial STIs would complement current prevention strategies to curb transmission.

HIV Preexposure Prophylaxis and Treatment as Prevention - Beliefs and Access Barriers in Men Who Have Sex With Men (MSM) and Transgender Women: A Systematic Review

Purpose

While the annual rate of new HIV infections and diagnoses has remained stable for most groups, troubling increases are seen in transgender women and racial/ethnic-minority men who have sex with men (MSM), groups that are disproportionately affected by HIV. The primary purpose of this systematic review is to examine factors that impact attitudes and beliefs about preexposure prophylaxis (PrEP) and treatment as prevention (TasP) and to explore barriers to PrEP uptake in MSM and transgender women.

Methods

Using MeSH terms and relevant keywords, we conducted a systematic review of studies published between 2010 and 2019. We searched 4 literature databases and identified studies on MSM and transgender women to elucidate perceptions of PrEP and TasP as well as barriers to access.

Results

The search yielded several prominent themes associated with beliefs about HIV prevention approaches and barriers to PrEP access in MSM and transgender women. One was a lack of awareness or insufficient knowledge of PrEP and TasP. Structural barriers and geographic isolation also prevent access to HIV prevention. Sexual minority and HIV-related stigma, internalized homonegativity, and misinterpretations of messages within HIV prevention campaigns have negatively impacted PrEP uptake and beliefs about PrEP and TasP. Quality of the relationship MSM or transgender people have with their health care provider can facilitate or hinder HIV prevention. Finally, variability in beliefs about the efficacy of TasP has negatively affected the impact of TasP messaging campaigns.

Conclusions

Although there is evidence of increasing PrEP use in at-risk individuals, several barriers prevent wider acceptance and uptake. Misunderstanding about the meaning of "undetectable" and skepticism about the evidence behind TasP messaging campaigns are likely to delay the World Health Organization's stated goal of getting to zero transmissions.

Predicting Pharmacokinetics of a Tenofovir Alafenamide Subcutaneous Implant Using Physiologically Based Pharmacokinetic Modelling

Long-acting (LA) administration using a subcutaneous (s.c.) implant presents opportunities to simplify administration of antiretroviral drugs, improve pharmacological profiles, and overcome suboptimal adherence associated with daily oral formulations. Tenofovir alafenamide (TAF) is a highly potent nucleoside reverse transcriptase inhibitor (NRTI) and an attractive agent for LA delivery, with a high potency and long intracellular half-life. The aim of this study was to predict minimum TAF doses required to achieve concentrations effective for HIV preexposure prophylaxis (PrEP). Daily drug release requirements were then ascertained by averaging across the dosing interval. A TAF physiologically based pharmacokinetic (PBPK) model was developed and partially qualified against available oral single- and multiple-dose pharmacokinetics. The models were assumed to be qualified when simulated values were within 2-fold of the observed mean. TAF s.c. implants were simulated in five hundred individuals, reporting predicted TAF plasma and tenofovir (TFV) plasma concentrations for various release rates. Intracellular TFV diphosphate (TFV-DP) concentrations were also simulated in peripheral blood cells and cervical and rectal tissues. The minimum dose predicted to achieve intracellular TFV-DP levels above a target concentration of 48 fmol/10⁶ cells for a month was identified. TAF, TFV, and TFV-DP concentrations for release rates between 1.0 and 1.6 mg/day were simulated. The PBPK model indicated that a minimum release of 1.4 mg/day TAF is necessary to achieve TFV-DP concentrations above the identified target in peripheral blood mononuclear cells (PBMCs). TFV-DP cervical and rectal tissue concentrations were predicted to be between 1.5 and 2.0 fmol/10⁶ cells and 0.9 and 1.1 fmol/10⁶ cells, respectively, for release rates between 1.3 and 1.6 mg/day. These simulations provide target minimum doses for LA TAF PrEP in humans. Based on the generated results, multiple implants delivering a total of 1.4 mg/day of TAF subcutaneously could provide protection levels for approximately 6 months to 1 year. This modeling may inform future design of s.c. implants to mitigate adherence issues for effective PrEP applications.

HIV Testing Among Adolescents With Acute Sexually Transmitted Infections

BACKGROUND AND OBJECTIVES

Rates of sexually transmitted infections (STIs) have increased over the decade. Guidelines recommend HIV testing with incident STIs. Prevalence and factors associated with HIV testing in acute STIs are unknown in adolescents. Our objective was to determine the prevalence of completed HIV testing among adolescents with incident STIs and identify patient and health care factors associated with HIV testing.

METHODS

Retrospective study of STI episodes (gonorrhea, Chlamydia, trichomoniasis, or syphilis) of adolescents between 13 and 24 years old from July 2014 to December 2017 in 2 urban primary care clinics. We performed mixed effects logistic regression modeling to identify patient and health care factors associated with HIV testing within 90 days of STI diagnosis.

RESULTS

The 1313 participants contributed 1816 acute STI episodes. Mean age at STI diagnosis was 17.2 years (SD = 1.7), 75% of episodes occurred in females, and 97% occurred in African Americans. Only half (55%) of acute STI episodes had a completed HIV test. In the adjusted model, female sex, previous STIs, uninsured status, and confidential sexual health encounters were associated with decreased odds of HIV testing. Patients enrolled in primary care at the clinics, compared with those receiving sexual health care alone, and those with multipathogen STI diagnoses were more likely to have HIV testing.

CONCLUSIONS

HIV testing rates among adolescents with acute STIs are suboptimal. Patient and health care factors were found to be associated with receipt of testing and should be considered in clinical practice.

Health related behaviors among HIV-infected people who are successfully linked to care: an institutional-based cross-sectional study

BACKGROUND

By the end of October 2019, there were 958 thousand people were reported living with HIV/AIDS in China. Unhealthy lifestyle factors, such as smoking, drinking alcohol, using illicit drugs and no physical activity have been found to mitigate the positive impact of antiretroviral therapy (ART) on viral load and HIV-related quality of life. Moreover, risky sexual behavior among HIV-positive persons places their partners at risk for HIV transmission and other sexually transmitted infections. The aim of the study is to determine the prevalence of unhealthy behavior of people living with HIV/AIDS and related influencing factors, particularly those that are closely connected with HIV infection and ART effects.

METHODS

An institutional based cross-sectional study design was used to collect data from people living with HIV/AIDS (PLWHA) in Beijing and Yunnan Province. The following information was included in the questionnaire survey: social-demographic characteristics, health behavior information, sexual risk behaviors. Binary logistic regression model was conducted to analyze the influencing factors of unhealthy general health behaviors and risky sexual behaviors.

RESULTS

In total, 2575 PLWHA were included in the study and 78.3% (2017/2575) were male. For the general health behaviors, 34.2% (987/2544) smoke; 33.8% (870/2575) drank alcohol and 2.3% (49/2134) reported the use of illicit drugs in the previous 6 months. From the sexual behaviors perspective, 59.0% (1519/2575) had sex in the previous 6 months. Among people who had sex, 92.0% (1398/1519) had fixed sexual partners. Among those with no fixed sexual partner, 38.0% (46/121) had more than three partners. Among men who had sex, 34.7% (448/1292) reported having sex with men in the previous 6 months and 16.7% (75/448) of these had group sexual activity. Among participants, 72.2% (1053/1458) used condoms every time they had sex while 6.4% (94/1458) of people never used condom. Male people living with HIV/AIDS were more likely to have sexual risk behaviors (adjusted odds ratio [OR] = 2.208, 95% confidence interval [CI]: 1.147-4.252) and unhealthy general health behaviors (adjusted OR = 2.029, 95% CI: 1.480-2.783). The odds of higher risk sexual behaviors was 1.546 times (95% CI: 1.302-1.827, P = 0.001) greater among participants who drank alcohol compared with their non-drinking counterparts.

CONCLUSIONS

PLWHA is a group that is vulnerable to problematic health behaviors, especially for men who were more likely to drink alcohol, have more sexual partners, more sexual risk behaviors including group sexual activity, not using condoms and using drugs. Therefore, interventions focusing on gender-specific risk behaviors reduction for people living with HIV/AIDS are now necessary to control the spread of HIV infection and improve the efficacy of antiviral treatment.

Treatment as prevention enrolling at least 75% of individuals on ART will be needed to significantly reduce HIV prevalence in a HIV cohort

BACKGROUND

"Treatment as Prevention" (TasP) aims to reduce new HIV infections through higher enrolment on suppressive antiretroviral therapy (ART).

OBJECTIVES

We studied the current epidemic and possible impact of TasP in a French HIV cohort including MSM and migrant subjects.

STUDY DESIGN

Socio-demographic, clinical and laboratory variables were collected during the follow-up of 6995 HIV-infected patients. The numbers of individuals living with HIV in each year were estimated from diagnoses up to that year minus recorded deaths. Patients were classified according to gender, transmission mode, country of birth and treatment status.

RESULTS

The cohort includes 6995 individuals diagnosed from 1985 to 2015, of whom 72% were men. Unprotected sexual intercourse was the main mode of transmission. Women were more likely to be migrants (45% versus 13%), whereas men were more likely to have been born in France (52% versus 27%). Diagnoses were more correlated with untreated than treated prevalence in each group. MSM diagnoses was strongly correlated to untreated prevalence whatever the country of birth (p < 0.0001). However, heterosexual diagnoses were better correlated with prevalence within individual country groups (b = 0.29 female diagnoses/year per untreated male born in France, compared to b = 0.73 for foreigners). Using these transmission rates, mathematical modelling estimated that enrolling 75% of untreated individuals per year would decrease diagnoses ten-fold by 2021.

CONCLUSIONS

Enrolling at least 75% of individuals on ART is necessary to substantially impact numbers of new HIV infections in this cohort. Treatment as prevention will actually be effective to reduce HIV prevalence.

Perceived barriers to pre-exposure prophylaxis use among HIV-negative men who have sex with men in Tijuana, Mexico: A latent class analysis

BACKGROUND

Given the slow uptake of PrEP among cisgender men who have sex with men (MSM) in high-income countries, efforts to roll-out PrEP in low- and middle-income countries (LMIC) should address barriers to PrEP use to facilitate its more rapid uptake. To inform PrEP programs in LMIC, we examined patterns of perceived barriers to PrEP use among HIV-negative MSM in Tijuana, Mexico.

METHODS

From 03/2016-09/2017, 364 MSM completed interviewer-administered surveys assessing perceived barriers to PrEP use across 4 domains: PrEP attribute, individual, interpersonal, and structural. Latent class analysis was performed to identify distinct classes with respect to perceived barriers to PrEP use. Multinomial logistic regression was used to identify factors associated with class membership.

RESULTS

We identified three classes characterized by (1) high levels of perceived barriers across domains (12%), (2) low levels of perceived barriers across domains (43%), and (3) perceived PrEP attribute barriers (i.e., side-effects and cost) (45%). Membership in the high level of perceived barriers class (vs. the low level of perceived barriers class) was positively associated with having a history of incarceration (AOR: 2.44; 95% CI: 1.04, 5.73) and negatively associated with more social support (AOR: 0.99; 95% CI: 0.98, 1.00). Membership in the perceived PrEP attribute barriers class was positively associated with having seen a healthcare provider in the past year (AOR: 2.78; 95% CI: 1.41, 5.45) and negatively associated with having any HIV-positive or status unknown partners (AOR: 0.56; 95% CI: 0.31, 1.01).

CONCLUSIONS

Since most participants were in either the low level of perceived barriers class or the perceived PrEP attribute barriers class, future PrEP uptake may be high among MSM in Tijuana. However, these findings suggest that achieving sufficient PrEP uptake and adherence among MSM in Tijuana may require a range of comprehensive HIV prevention interventions.

Missed opportunities of HIV pre-exposure prophylaxis in France: a retrospective analysis in the French DAT'AIDS cohort

BACKGROUND

HIV pre-exposure prophylaxis (PrEP) was implemented in France in November 2015 based on individual-level risk factors for HIV infection. We evaluated the proportion of missed opportunities for PrEP among newly HIV-diagnosed people entering the Dat'AIDS cohort in 2016.

METHODS

Multicenter retrospective analysis in 15 French HIV clinical centers of patients with a new diagnosis of HIV infection. Among them we differentiated patients according to the estimated date of infection: those occurring in the PrEP area (a previous negative HIV test in the last 12 months or those with an incomplete HIV-1 western blot (WB) with no HIV-1 anti-Pol-antibody at time of HIV diagnosis) and those in the pre-PrEP area (older infections). Epidemiological, biological and clinical data at HIV diagnosis were collected. Clinicians retrospectively identified potential eligibility for PrEP based on individual-level risk factors for HIV infection among those infected in the PrEP area.

RESULTS

Among 966 patients with a new HIV diagnosis, 225 (23.3%) were infected in the PrEP area and 121 (53.8%) had complete data allowing evaluation of PrEP eligibility. Among them, 110 (91%) would have been eligible for PrEP, median age 31 years, with 68 (75.6%) born in France and 10 (11.1%) in Central/West Africa, with more than one previous STI in 19 (15.7%). The main eligibility criteria for PrEP were being a man who had sex with men or transgender 91 (82.7%) with at least one of the following criteria: unprotected anal sex with ≥2 partners in the last 6 months: 67 (60.9%); bacterial sexually transmitted infection in the last 12 months: 33 (30%); Use of psychoactive substances in a sexual context (chemsex): 16 (14.5%). PrEP was indicated for other HIV risk factors in 25 (22.7%).

CONCLUSION

With 91% (110/121) of patients infected in the PrEP area eligible for PrEP, this study highlights the high potential of PrEP in avoiding new infection in France but also shows a persistent delay in HIV testing. Thus, an important limit on PrEP implementation in France could be insufficient screening and care access.

Effect of Racial Inequities in Pre-exposure Prophylaxis Use on Racial Disparities in HIV Incidence Among Men Who Have Sex With Men: A Modeling Study

BACKGROUND

Pre-exposure prophylaxis (PrEP) uptake has been slow among African American men who have sex with men (AAMSM) in the United States. We used an agent-based model (ABM) to simulate race-specific PrEP coverage to estimate their impact on racial disparities in HIV incidence among MSM in Atlanta, GA.

METHODS

An ABM was constructed to simulate HIV transmission in a dynamic network of 10,000 MSM over 10 years, beginning in 2015. We modeled a base scenario with estimated PrEP coverage of 2.5% among AAMSM and 5.0% among white MSM (WMSM). We then compared HIV incidence over 10 years and calculated a disparity ratio of AAMSM to WMSM incidence rates across varying PrEP scale-up scenarios, with equal and unequal coverage among AAMSM and WMSM.

RESULTS

Assuming current coverage remains constant, the model predicts HIV incidence rates of 2.95 and 1.76 per 100 person-years among AAMSM and WMSM, respectively, with a disparity ratio of 1.68. If PrEP coverage was to increase 6-fold without addressing inequities in PrEP uptake, the model predicts incidences of 2.65 and 1.34, corresponding to a mean decrease of 10.4% and 24.0% in HIV incidence, respectively. This stronger benefit for WMSM increased the disparity ratio to 1.98. Equal PrEP coverage among AAMSM and WMSM resulted in lower incidence rates overall with lower disparity ratios.

CONCLUSIONS

Lower uptake among AAMSM relative to WMSM may limit the population-level impact of PrEP use among AAMSM, which may ultimately culminate in wider racial disparities in HIV incidence among MSM.

Management of Human Immunodeficiency Virus in the Emergency Department

Over the past 30 years, significant advances have transformed the landscape of human immunodeficiency virus (HIV) care in the emergency department. Diagnosis and management of HIV has improved, resulting in a decline in the incidence of acquired immunodeficiency syndrome (AIDS)-defining infections. Advances in pharmacology have led to fewer serious medication toxicities and more tolerable regimens. Emergency providers have played an increasingly important role in HIV screening and diagnosis of acute infection. Provision of postexposure prophylaxis is expanding from a focus on occupational exposure to include all high-risk cases.