Randomized Trial of Clinical Safety of Daily Oral Tenofovir Disoproxil Fumarate Among HIV-Uninfected Men Who Have Sex With Men in the United States

Pre-exposure prophylaxis program in the Community of Madrid: Two years of experience

INTRODUCTION

Pre-exposure prophylaxis (PrEP) against the human immunodeficiency virus (HIV) is an effective and safe preventive measure. However, it has not reached all target users who could benefit from it. The study aimed to understand the sociodemographic, clinical and behavioral baseline characteristics of PrEP users. As a secondary objective, the use of concomitant medication and drug consumption were described.

METHODOLOGY

Observational, retrospective and descriptive study of the sociodemographic, clinical and behavioral characteristics of the users who were included in the PrEP program of the Community of Madrid during the first two years of experience.

RESULTS

Two thousand two hundred fifty-six PrEP users were included, 99.0% men, with a mean age of 36.9 years (SD 8.68). 33.1% presented a sexually transmitted infection (STI) on the first visit, highlighting chlamydiasis and rectal gonococci. 70.4% reported using drugs associated with sex, and 42.4% participated in chemsex sessions in the last 3 months. A high percentage of users with concomitant medication was observed (37.6%), highlighting drugs related to mental health and alopecia.

CONCLUSIONS

A multidisciplinary approach is required to cover all the needs of PrEP users, including mental health evaluation measures and addiction treatment with the clinical approach.

Significant Publications on Infectious Diseases Pharmacotherapy in 2021

Purpose: To summarize the most noteworthy infectious diseases (ID) pharmacotherapy articles published in peer-reviewed literature in 2021. Summary: Members of the Houston Infectious Diseases Network (HIDN) nominated articles that were deemed to have significant contributions to ID pharmacotherapy in 2021. These nominations included articles pertaining to both general ID, including coronavirus disease 2019 (COVID-19), and human immunodeficiency virus/acquired immunodeficiency syndrome (HIV/AIDS) pharmacotherapy. A total of 35 articles were nominated by HIDN: 30 articles pertaining to general ID pharmacotherapy and 5 articles with HIV/AIDS focus. To select the most influential articles of 2021, a survey was created and distributed to members of the Society of Infectious Diseases Pharmacists (SIDP). Of the 239 SIDP members who responded to the survey, there were 192 recorded votes for the top 10 general ID pharmacotherapy articles and 47 recorded votes for the top HIV/AIDS article, respectively. The top publications are summarized. Conclusion: Antimicrobial stewardship and the optimal management of infectious disease states continues to be a priority in the midst of the ongoing coronavirus disease 2019 (COVID-19) global pandemic. In light of the sheer volume of ID-related articles published in the past year, this review aims to aid clinicians in remaining up-to-date on key practice-changing ID pharmacotherapy publications from 2021.

Characteristics Associated with Pre-Exposure Prophylaxis Discussion and Use Among Transgender Women Without HIV Infection - National HIV Behavioral Surveillance Among Transgender Women, Seven Urban Areas, United States, 2019-2020

CDC recommends pre-exposure prophylaxis (PrEP) for transgender women who have sex with men and who report sexual behaviors that place them at substantial ongoing risk for HIV exposure, including those who engage in nonsterile syringe sharing. Providing transgender women with access to PrEP is a critical strategy for reducing HIV acquisition and ending the HIV epidemic. Survey results from the National HIV Behavioral Surveillance Among Transgender Women were used to assess characteristics associated with past-year discussions of PrEP with a health care provider and PrEP use. Bivariate analyses were conducted to assess the association between covariates (sociodemographic, HIV-associated characteristics, and gender-affirming care) and each outcome, accounting for sampling design. All covariates that were statistically significant at p<0.05 in the bivariate analyses were included in multivariate models, and manual backward elimination was used to obtain final models that retained statistically significant covariates. Among 902 transgender women from seven urban areas in the United States without HIV infection in the analyses, 57% had recently discussed PrEP with a health care provider, and 32% recently had used PrEP. In the final multivariate model, the following subgroups of transgender women were more likely to report recent PrEP use: those who identified as Black or African American or Hispanic or Latina, had two or more sex partners in the past 12 months, had condomless sex in the past 12 months, reported their last sex partner was infected with HIV, had condomless sex with their last sex partner whose HIV status was positive or unknown, ever had transgender-specific health care, and currently had transgender-specific health insurance coverage. Participants who were less likely to have recently used PrEP were those who wanted to but were not currently taking hormones and those aged <40 years. Providing increased access to gender-affirming care and training health care providers who serve transgender women to incorporate PrEP into existing services might increase PrEP use among transgender women.

Perspectives on unhealthy alcohol use among men who have sex with men prescribed HIV pre-exposure prophylaxis: A qualitative study

Unhealthy alcohol use is a common, often unaddressed behavior associated with increased risk for acquisition of HIV and may also be associated with decreased adherence to oral pre-exposure prophylaxis (PrEP) among gay, bisexual, and other men who have sex with men (MSM) living in the United States. To inform future alcohol-reduction interventions among individuals engaging in PrEP care, we sought to explore perspectives on alcohol use, PrEP adherence, and the acceptability of alcohol use treatment options for MSM prescribed oral formulations of PrEP in the Northeastern United States. Between February 2019 and July 2020, we conducted semi-structured interviews with 15 MSM without HIV who were prescribed PrEP and screened positive for unhealthy alcohol use with AUDIT-C ≥ 4 and were receiving care in Providence, Rhode Island or New Haven, Connecticut. Interviews were coded and analyzed using thematic analysis. Three themes emerged: 1) Consequences of fluctuations in drinking 2) Alcohol use negatively impacts health and relationships; and 3) Desire for a multimodal approach to treatment of unhealthy alcohol use. Our findings support the need to raise awareness of potential alcohol-related harms, address the spectrum of unhealthy alcohol use among MSM prescribed PrEP, and the acceptability and preferences for alcohol reduction interventions within PrEP programs.

Adverse effects of daily oral pre-exposure prophylaxis in men who have sex with men and transgender women: a systematic review and meta-analysis

The adverse effects of oral pre-exposure prophylaxis (PrEP) using tenofovir disoproxil fumarate are barriers to PrEP initiation and continuation. Although serious effects are rare and predictable, evidence for this assessment among men who have sex with men (MSM) and transgender women (TGW) is still limited. This study assesses the adverse effects of daily oral PrEP in MSM and TGW. This is a systematic review and meta-analysis of clinical trials and cohort studies on the use of daily oral PrEP selected from the PubMed/MEDLINE, Embase, LILACS, and Cochrane CENTRAL databases. Data extraction included adverse effects and changes in renal and hepatic markers. Random effects models were used to summarize the risk of adverse effects throughout the study. Heterogeneity was assessed using the Cochran's Q test and the inconsistency test (I2). The risk of bias and the certainty of the evidence were assessed using the Cochrane Collaboration recommendations. The search identified 653 references. Of these, 10 were selected. All studies assessed the eligibility of renal and hepatic markers. The use of daily oral PrEP was not associated with grade 3 or 4 adverse events (RR = 0.99; 95%CI: 0.83-1.18; I2 = 26.1%), any serious adverse event (RR = 1.04; 95%CI: 0.58-1.87; I2 = 88.4%), grade 3+4 creatinine level (RR = 0.66; 95%CI: 0.24-1.84; I2 = 79.9%), and grade 3 or 4 hypophosphatemia (RR = 0.56; 95%CI: 0.15-2.10). The certainty of the evidence ranged from high to moderate for the outcomes analyzed. Daily oral PrEP is safe and well tolerated by MSM and TGW. Adverse effects were minimal and evenly distributed between intervention and control.

Demand creation and retention strategies for oral pre-exposure prophylaxis for HIV prevention among men who have sex with men and transgender women: a systematic review and meta-analysis

BACKGROUND

Men who have sex with men (MSM) and transgender women (TGW) have a disproportionately higher risk of human immunodeficiency virus (HIV) infection than other groups. Oral HIV pre-exposure prophylaxis (PrEP) is an effective prevention tool and should be offered to those at higher risk. Identifying demand creation strategies (DCS) and retention strategies (RS) to improve PrEP persistence is essential to control the HIV epidemic.

AIM

We aimed to identify the (DCS and RS with higher proportions among MSM and TGW.

METHODS

A systematic review and meta-analysis of prospective studies were conducted, with studies retrieved from five databases until November, 2022 following the Cochrane and PRISMA guidelines. The study protocol was registered in PROSPERO (CRD42022323220). The outcomes were DCS and RS for PrEP use among MSM and TGW. Strategies used for users enrolled in the PrEP-recruited (DCS) were classified as face-to-face (peer educator recruitment at social venues, nongovernmental organizations, and parties; direct referrals by health services; friends and/or sexual partners); online (chatbot or peer educator recruitment on social media [e.g., , Instagram or Facebook] or dating/hook-up apps [e.g., Grindr, Tinder, Badoo, and Scruff]); and mixed (face-to-face and online). RS was classified as provider counseling (face-to-face by a health professional; prevention of HIV risk counseling, distribution of condoms, lubricants, and testing for HIV or other sexually transmitted infections); online counseling (text messages, chatbots, telephone calls, social media, and peer educators); and mixed (all previous strategies). Subgroup analyses were conducted for each treatment strategy. Meta-analyses were performed using the R software version 4.2.1.

RESULTS

A total of 1, 129 studies were retrieved from the five databases. After eligibility, 46 studies were included. For MSM, most DCS and RS were online at 91% (95% CI: 0.85-0.97; I2=53%), and 83% (95% CI: 0.80-0.85; I2=17%) respectively. For TGW, mixed DCS and RS were the most frequent at85% (95% CI: 0.60-1.00; I2=91%) and online counseling at 84% (95% CI: 0.64-0.95) compared to other strategies.

CONCLUSION

Critical issues play. Pivotal role in increasing PrEP awareness among MSM and TGW, minimizing access gaps, and ensuring retention of PrEP services. Offering oral PrEP using online DCS and RS can reach and retain high numbers of MSM and TGW, and reduce HIV incidence in these populations.

Sexual Practices and Predisposition to PrEP Use Among Men Ages 50 Years and Older Who Have Sex With Men: A Cross-Sectional Study

ABSTRACT

This study aimed to evaluate the sexual practices of men ages 50 years or older who have sex with men (MSM) and factors influencing their predisposition to use preexposure prophylaxis (PrEP). An analytical cross-sectional study was conducted in Brazil and Portugal with 718 MSM. Of these, 278 (38.7%) were categorized as being at high risk for HIV based on the HIV Incidence Risk Index (HIRI), and 418 (58.2%) expressed a predisposition to use PrEP. Overall, sociodemographic factors and specific sexual practices increased the likelihood of being classified as high risk for HIV, particularly sexual position and sexual activity. However, factors that influenced the predisposition to use PrEP included age group, receptive anal sex, knowledge of postexposure prophylaxis, high HIRI score, and a history of syphilis. These findings underscore the urgent need for health services to provide comprehensive and adequate attention to the realities of this population, considering its complexities and specificities.

Preexposure Prophylaxis for the Prevention of HIV: Updated Evidence Report and Systematic Review for the US Preventive Services Task Force

Importance

A 2019 review for the US Preventive Services Task Force (USPSTF) found oral preexposure prophylaxis (PrEP) associated with decreased HIV infection risk vs placebo or no PrEP in adults at increased HIV acquisition risk. Newer PrEP regimens are available.

Objective

To update the 2019 review on PrEP, to inform the USPSTF.

Data Sources

Ovid MEDLINE, Cochrane Database of Systematic Reviews, Cochrane Central Register of Controlled Trials, and Embase (January 2018 to May 16, 2022); surveillance through March 24, 2023.

Study Selection

Randomized clinical trials of PrEP vs placebo or no PrEP or newer vs older PrEP regimens and diagnostic accuracy studies of instruments for predicting incident HIV infection.

Data Extraction and Synthesis

Dual review of titles and abstracts, full-text articles, study quality, and data abstraction. Data were pooled using the DerSimonian and Laird random-effects model.

Main Outcomes and Measures

HIV acquisition, mortality, and harms; and diagnostic test accuracy.

Results

Thirty-two studies were included in the review (20 randomized clinical trials [N = 36 543] and 12 studies of diagnostic accuracy [N = 5 544 500]). Eleven trials in the 2019 review found oral PrEP associated with decreased HIV infection risk vs placebo or no PrEP (n = 18 172; relative risk [RR], 0.46 [95% CI, 0.33-0.66]). Higher adherence was associated with greater efficacy. One new trial (n = 5335) found oral tenofovir alafenamide/emtricitabine (TAF/FTC) to be noninferior to tenofovir disoproxil fumarate/emtricitabine (TDF/FTC) in men who have sex with men (RR, 0.47 [95% CI, 0.19-1.14]). Two new trials found long-acting injectable cabotegravir associated with decreased risk of HIV infection vs oral TDF/FTC (RR, 0.33 [95% CI, 0.18-0.62] in cisgender men who have sex with men and transgender women [n = 4490] and RR, 0.11 [95% CI, 0.04-0.31] in cisgender women [n = 3178]). Discrimination of instruments for predicting incident HIV infection was moderate in men who have sex with men (5 studies; n = 25 488) and moderate to high in general populations of persons without HIV (2 studies; n = 5 477 291).

Conclusions and Relevance

In adults at increased HIV acquisition risk, oral PrEP was associated with decreased risk of acquiring HIV infection compared with placebo or no PrEP. Oral TAF/FTC was noninferior to oral TDF/FTC, and injectable cabotegravir reduced the risk of HIV infection compared with oral TDF/FTC in the populations studied.

Prevalence of renal and bone risk factors among individuals prescribed oral pre-exposure prophylaxis for HIV

Objectives

The only available oral pre-exposure prophylaxis (PrEP) regimens approved in the United States to prevent HIV infection during the period covered by this study were emtricitabine/tenofovir alafenamide (F/TAF) and emtricitabine/tenofovir disoproxil fumarate (F/TDF). Both agents have similar efficacy, however F/TAF exhibits improved bone and renal health safety endpoints over F/TDF. In 2021, the United States Preventive Services Task Force recommended individuals have access to the most medically appropriate PrEP regimen. To understand the impact of these guidelines, the prevalence of risk factors to renal and bone health was evaluated among individuals prescribed oral PrEP.

Methods

This prevalence study utilized the electronic health records of people prescribed oral PrEP between January 1, 2015 and February 29, 2020. Renal and bone risk factors (age, comorbidities, medication, renal function, and body mass index) were identified using International Classification of Diseases (ICD) and National Drug Code (NDC) codes.

Results

Among 40 621 individuals prescribed oral PrEP, 62% had ≥1 renal risk factor and 68% had ≥1 bone risk factor. Comorbidities were the most frequent (37%) class of renal risk factors. Concomitant medications were the most prominent (46%) class of bone-related risk factors.

Conclusions

The high prevalence of risk factors suggests the importance of their consideration when choosing the most appropriate regimen for individuals who may benefit from PrEP.

Cabotegravir: The First Long-Acting Injectable for HIV Preexposure Prophylaxis

OBJECTIVE

Review the pharmacology, pharmacokinetics, efficacy, safety, and role of long-acting injectable cabotegravir (CAB-LA) in HIV preexposure prophylaxis (PrEP).

DATA SOURCES

A literature search was performed using PubMed and Google Scholar (2012 to April 2022) with the search terms cabotegravir, preexposure prophylaxis, and PrEP. Other resources included abstracts presented at recent conferences, the manufacturer's Web site, prescribing information, and review articles.

STUDY SELECTION AND DATA EXTRACTION

All English-language articles of studies assessing the efficacy and safety of CAB-LA for PrEP were included.

DATA SYNTHESIS

CAB-LA is the first long-acting injectable therapy approved for HIV-1 PrEP in both men and women. It is a suspension given intramuscularly every other month. CAB-LA has been shown to be more effective than daily oral tenofovir disoproxil fumarate/emtricitabine (TDF/FTC) in preventing HIV-1 infection among high-risk individuals. Two phase 3 trials were stopped early on the basis of superior efficacy of CAB-LA. The most common adverse effects were injection site reactions (ISRs), although they tended to decrease over time, and few participants in clinical trials discontinued use due to ISRs.

RELEVANCE TO PATIENT CARE AND CLINICAL PRACTICE

CAB-LA may be particularly useful for individuals with known adherence problems to oral therapy, those with renal impairment, and those with decreased bone mineral density. However, CAB-LA is more expensive than generic TDF/FTC and may be associated with weight gain.

CONCLUSIONS

CAB-LA is the first long-acting injectable agent for HIV PrEP. It is more effective than oral TDF/FTC, is well-tolerated aside from ISRs, and has few clinically significant drug-drug interactions.

Renal impairment associated with tenofovir disoproxil fumarate for antiretroviral therapy and HIV pre-exposure prophylaxis: An observational cohort study

BACKGROUND

Tenofovir disoproxil fumarate (TDF) is associated with adverse renal outcomes when prescribed for HIV infection. There are few data concerning real-world renal outcomes amongst patients prescribed TDF for pre-exposure prophylaxis (PrEP).

METHODS AND FINDINGS

Data were extracted from 52 sexual health clinics across Australia from 2009-2019. All patients prescribed TDF-containing antiretroviral therapy and PrEP were included. Rates of renal impairment (a fall in eGFR to <60 ml/min/1·73m2) were calculated for people living with HIV (PLWHIV) prescribed TDF and HIV negative PrEP-users. Risk factors were assessed using Cox-proportional hazards models. Sensitivity analysis of risk using 1:1 propensity-score matching to adjust for potential imbalance in HIV and PrEP cohorts was conducted. 5,973 patients on PrEP and 1,973 PLWHIV were included. There were 39 (0.7%) instances of renal impairment in the PrEP group and 81 (4.1%) in the PLWHIV cohort (hazard ratio [HR]:0.35 95% confidence interval [CI]: 0.22-0.56). Rates of renal impairment were 4.01/1000 person-years (95%CI:2.93-5.48) in the PrEP cohort and 16.18/1000 person-years (95%CI:13.01-20.11) in the PLWHIV cohort (p<0.001). Predictors of renal impairment were: older age (40-49 years (HR:5.09 95%CI: 2.12-12.17) and 50-82 years (HR:13.69 95%CI: 5.92-31.67) (compared with 30-39 years) and baseline eGFR<90ml/min (HR:61.19 95%CI: 19.27-194.30). After adjusting for age and baseline eGFR the rate of renal impairment remained lower in the PrEP cohort (aHR:0.62 95%CI: 0.40-0.94, p = 0.023). In propensity-matched analysis using 1,622 patients per cohort the risk of renal impairment remained higher in the PLWHIV cohort (log-rank p = 0.001).

CONCLUSION

Patients prescribed TDF-based PrEP had lower rates of renal impairment than patients prescribed TDF for HIV infection. In propensity analysis, after matching for some risk factors, rates of renal impairment remained higher amongst patients with HIV.

Variations in Pre-exposure Prophylaxis (PrEP) Awareness and Healthcare Provider Interactions in a Nationally Representative Sample of American Men Aged 15-49 Years: A Cross-Sectional Study

Awareness of and discussions with a healthcare provider (HCP) around pre-exposure prophylaxis (PrEP), an effective HIV prevention method, are associated with PrEP uptake, yet few studies utilize representative samples or report on these outcomes using distinct behavioral risk subgroups. This cross-sectional study utilized responses given by men on the 2017-2019 National Survey of Family Growth, a nationally representative survey of Americans aged 15-49 years. Multiple logistic regression models were used to determine how respondents' sociodemographic characteristics and HIV risk behaviors were related to PrEP awareness and HCP discussions. PrEP awareness was low (29.40%) as was the proportion who reported ever discussing PrEP with an HCP (4.48%). Odds of being PrEP aware and discussing PrEP with an HCP varied significantly within sexual behavior subgroups based on sociodemographic and behavioral characteristics highlighting the differential risks within distinct behavioral subgroupings of men. Sexual behavior subgroupings should be considered when promoting PrEP awareness and discussions as HIV risk behaviors vary considerably and sexual identity alone may not sufficiently capture one's HIV risk.

Insufficient PrEParation: an assessment of primary care prescribing habits and use of pre-exposure prophylaxis in patients at risk of HIV acquisition at a single medical centre

OBJECTIVES

To assess HIV pre-exposure prophylaxis (PrEP) prescribing habits by primary care providers and the number of patients at risk of HIV acquisition at a single medical centre in the Northwestern USA from 1 July 2018 to 31 June 2020.

METHODS

An electronic cross-sectional survey was administered in April and May 2021 to providers in family medicine, internal medicine, adolescent and young adult health, student health and women's health clinics affiliated with the medical centre with questions pertaining to PrEP prescribing practices. Electronic medical record abstraction was used to quantify the number of eligible patients who sought care in primary care departments and the adherence to PrEP initiation guidelines from 1 July 2018 to 31 June 2020.

RESULTS

74% (61/82) of providers reported familiarity with national clinical practice guidelines for the prevention of HIV infection. 50% (41/82) of respondents were located in family medicine clinics. 57% (47/82) of providers counseled less than one-quarter of those who they identified as at risk of HIV infection. The major barriers to prescribing PrEP were insufficient time and lack of familiarity with guidelines. Of the 4330 eligible patients for PrEP, 8% (337/4330) received at least one PrEP prescription during the study period. For patients newly prescribed PrEP, only 23% (39/170) had appropriate counseling and labs at initiation. The top three qualifying indications for PrEP were identifying as transgender (36%, n=1562), high-risk sexual behaviour (32%, n=1405) and injection drug use (30%, n=1289).

CONCLUSIONS

This study highlights intervention points in the HIV prevention cascade warranting attention in order to achieve the 2025 Ending the HIV Epidemic in the U.S. target for PrEP coverage. These include increasing provider adherence to prescribing guidelines and reducing the logistical barriers to prescribing.

Low rate of pre-exposure prophylaxis and post-exposure prophylaxis uptake and high prevalence of transmitted drug resistance among newly diagnosed primary HIV infections in Shenzhen, China: a real-world retrospective study

BACKGROUND

Understanding the characteristics of newly diagnosed primary human deficiency virus-1 (HIV-1) infection in the context of the post-antiretroviral therapy era and HIV drug prophylaxis is essential for achieving the new target of 95-95-95-95 by 2025. This study reported the characteristics of newly diagnosed primary HIV-1 infection in Shenzhen.

METHODS

This is a real-world retrospective study. Eighty-seven newly diagnosed primary HIV-1-infected patients were recruited from January 2021 to March 2022 at the Third People's Hospital of Shenzhen. Demographic, epidemiological, diagnostic, drug resistance, and medical data were described and analyzed.

RESULTS

Overall, 96.6% (84/87) of the newly identified primary HIV-1-infected patients were male, including 88.5% (77/87) men have sex with men (MSM), with a median age of 29.0 years (Q1-Q3: 24.0-34.0 years); of these, 85.1% (74/87) reported high-risk sexual behaviors with casual partners. The rate of condom usage was only 28.7% (25/87). The overall rate of pre-exposure prophylaxis (PrEP) and post-exposure prophylaxis (PEP) was 8.0% (7/87, including 4 PrEP and 3 PEP cases) around the potential exposure, although 41.4% of the patients had prior awareness of such interventions. Moreover, only 19.5% (17/87) had previously used PrEP or PEP. Of those, 58.8% (10/17) of the patients obtained drugs from the internet, and only 35.3% (6/17) reported good compliance. A total of 54.0% (47/87) of subjects were diagnosed by the HIV nucleic acid test. Acute retroviral syndrome appeared in 54.0% (47/87) of patients. The prevalence of transmitted drug resistance (TDR) mutation was 33.9% (19/56), including 6 (10.7%) against nucleoside reverse transcriptase inhibitor (NRTI) plus non-nucleoside reverse transcriptase inhibitor (NNRTI), 8 (14.3%) against NNRTI, and 5 (8.9%) against protease inhibitor (PI) only.

CONCLUSIONS

Owing to the low utilization rate and incorrect usage of PrEP and PEP, massive efforts are needed to promote HIV-preventive strategies in the MSM population. The extremely high prevalence of TDR mutation in this population implies the need for future pretreatment drug resistance surveillance.

The Relationship Between HIV Pre-exposure Prophylaxis Stigma and Treatment Adherence Among Current HIV Pre-exposure Prophylaxis Users in the Southeastern U.S

Despite efficacy in HIV prevention, Pre-exposure Prophylaxis (PrEP) is underutilized in the US, especially among populations at highest risk. PrEP-related stigma may play a role. We developed measures of PrEP-related stigma dimensions and PrEP adherence. We administered them to current PrEP users. We hypothesized that PrEP-related stigma would negatively impact PrEP adherence. Questionnaire measures were developed using data from previous qualitative work and existing validated HIV-related stigma measures. The resultant survey was administered to current PrEP users from two Birmingham, Alabama PrEP clinics. Plasma tenofovir disoproxil fumarate levels were collected to measure PrEP adherence. Exploratory factor analyses were performed to determine the factor structure of each PrEP-related stigma dimension (internalized, perceived, experienced, anticipated, disclosure concerns). Separate binary logistic (or linear) regressions were performed to assess associations between PrEP-related stigma dimensions and adherence (treatment adherence self-efficacy, self-reported adherence, and plasma tenofovir levels), adjusting for education, race, and time on PrEP. In 2018, 100 participants completed the survey, with 91 identifying as male and 66 as white. Only internalized stigma was associated with lower self-reported PrEP adherence. Exploratory mediation analyses suggested that the association between all stigma dimensions and self-reported PrEP adherence is mediated by PrEP adherence self-efficacy. No associations were found between any PrEP-related stigma measures and plasma tenofovir levels. Internalized PrEP stigma may reduce PrEP adherence, possibly by reducing PrEP adherence self-efficacy among experienced PrEP users. Further investigation of how stigma dimensions affect PrEP adherence in populations at risk for HIV may shed light on drivers of PrEP underutilization.

Feasibility, Acceptability, and Preliminary Efficacy of a Gamified Mobile Health Contingency Management Intervention for PrEP Adherence Among Black MSM

Oral HIV pre-exposure prophylaxis (PrEP) is effective at preventing HIV. However, low adherence is common and undermines these protective effects. This is particularly relevant for groups with disproportionately higher rates of HIV, including Black men who have sex with men (MSM). The current study tested the feasibility, acceptability, and preliminary efficacy of a gamified mobile health contingency management intervention for PrEP adherence-called mSMART (Mobile App-Based Personalized Solutions for Medication Adherence of Rx Pill Tool). Fifteen Black MSM already prescribed PrEP in the community completed baseline and follow-up assessments separated by 8 weeks of using mSMART. Regarding feasibility, there was no study attrition, no mSMART functional difficulties that significantly interfered with use, and a mean rate of 82% daily mSMART use. Acceptability ratings were in the moderately to extremely satisfied range for factors such as willingness to recommend mSMART to others and user-friendliness, and in the low range for ratings on difficulty learning how to use mSMART. Scores on a system usability measure were in the acceptable range for 73% of the sample. Qualitative analysis of follow-up interviews identified individual components of mSMART that could be modified in future iterations to make it more engaging. PrEP composite adherence scores from biomarkers indicated an improvement from baseline to follow-up with a medium effect size, as well as a decrease in the number of perceived barriers to medication adherence. Findings indicate a future efficacy trial is needed to examine the effects of this gamified mobile health contingency management intervention on PrEP adherence.

Association between the geographic accessibility of PrEP and PrEP use among MSM in nonurban areas

PURPOSE

The US HIV epidemic has become a public health issue that increasingly affects men who have sex with men (MSM), including those residing in nonurban areas. Increasing access to pre-exposure prophylaxis (PrEP) in nonurban areas will prevent HIV acquisition and could address the growing HIV epidemic. No studies have quantified the associations between PrEP access and PrEP use among nonurban MSM.

METHODS

Using 2020 PrEP Locator data and American Men's Internet Survey data, we conducted multilevel log-binomial regression to examine the association between area-level geographic accessibility of PrEP-providing clinics and individual-level PrEP use among MSM residing in nonurban areas in the United States.

FINDINGS

Of 4,792 PrEP-eligible nonurban MSM, 20.1% resided in a PrEP desert (defined as more than a 30-minute drive to access PrEP), and 15.2% used PrEP in the past 12 months. In adjusted models, suburban MSM residing in PrEP deserts were less likely to use PrEP in the past year (adjusted prevalence ratio [aPR] = 0.35; 95% confidence interval [CI] = 0.15, 0.80) than suburban MSM not residing in PrEP deserts, and other nonurban MSM residing in PrEP deserts were less likely to use PrEP in the past year (aPR = 0.75; 95% CI = 0.60, 0.95) than other nonurban MSM not residing in PrEP deserts.

CONCLUSIONS

Structural interventions designed to decrease barriers to PrEP access that are unique to nonurban areas in the United States are needed to address the growing HIV epidemic in these communities.

Cost-effectiveness of oral pre-exposure prophylaxis and expanded antiretroviral therapy for preventing HIV infections in the presence of drug resistance among men who have sex with men in China: A mathematical modelling study

Background

Oral pre-exposure prophylaxis (PrEP) and antiretroviral therapy (ART) can effectively prevent HIV infections among men who have sex with men (MSM), but the emergence and transmission of HIV drug-resistance (HIVDR) may compromise their benefits. The costs and benefits of expanding PrEP and ART coverage in the presence of HIVDR in China remain unknown.

Methods

We developed a comprehensive dynamic transmission model incorporating the transmitted (TDR) and acquired (ADR) HIV drug resistance. The model was calibrated by the HIV surveillance data from 2009 to 2019 among MSM in Jiangsu Province, China, and validated by the dynamic prevalence of ADR and TDR. We aimed to investigate the impact of eight intervention scenarios (no PrEP, 20%, 50% or 80% of PrEP, without (77% coverage) or with (90% coverage) expanded ART) on the HIV epidemic trend and cost-effectiveness of PrEP over the next 30 years.

Findings

20% or 50% PrEP + 90% ART would be cost-effective, with an incremental cost-effectiveness ratio (ICER) of 25,417 (95% confidence interval [CI]: 12,390–38,445) or 47,243 (23,756–70,729), and would yield 154,949 (89,662–220,237) or 179,456 (102,570–256,342) incremental quality-adjusted life-years (QALYs) over the next 30 years. No PrEP + 90% ART would yield 125,211 (73,448–176,974) incremental QALYs and be cost-saving. However, 20–80% PrEP + 77% ART and 80% PrEP + 90% ART with ICER of $77,862–$98,338 and $63,332, respectively, and were not cost-effective. A reduction of 64% in the annual cost of oral PrEP would make it highly cost-effective for 50% PrEP + 90% ART.

Interpretation

20% or 50% PrEP + 90% ART is cost-effective for HIV control in the presence of HIVDR. Expanded ART alone may be the optimal policy under the current limited budgets.

Funding

National Natural Science Foundation of China, the National S&T Major Project Foundation of China.

Oral pre-exposure prophylaxis (PrEP) to prevent HIV: a systematic review and meta-analysis of clinical effectiveness, safety, adherence and risk compensation in all populations

OBJECTIVE

To conduct a systematic review and meta-analysis of randomised controlled trials (RCTs) of the effectiveness and safety of oral pre-exposure prophylaxis (PrEP) to prevent HIV.

METHODS

Databases (PubMed, Embase and the Cochrane Register of Controlled Trials) were searched up to 5 July 2020. Search terms for 'HIV' were combined with terms for 'PrEP' or 'tenofovir/emtricitabine'. RCTs were included that compared oral tenofovir-containing PrEP to placebo, no treatment or alternative medication/dosing schedule. The primary outcome was the rate ratio (RR) of HIV infection using a modified intention-to-treat analysis. Secondary outcomes included safety, adherence and risk compensation. All analyses were stratified a priori by population: men who have sex with men (MSM), serodiscordant couples, heterosexuals and people who inject drugs (PWIDs). The quality of individual studies was assessed using the Cochrane risk-of-bias tool, and the certainty of evidence was assessed using GRADE.

RESULTS

Of 2803 unique records, 15 RCTs met our inclusion criteria. Over 25 000 participants were included, encompassing 38 289 person-years of follow-up data. PrEP was found to be effective in MSM (RR 0.25, 95% CI 0.1 to 0.61; absolute rate difference (RD) -0.03, 95% CI -0.01 to -0.05), serodiscordant couples (RR 0.25, 95% CI 0.14 to 0.46; RD -0.01, 95% CI -0.01 to -0.02) and PWID (RR 0.51, 95% CI 0.29 to 0.92; RD -0.00, 95% CI -0.00 to -0.01), but not in heterosexuals (RR 0.77, 95% CI 0.46 to 1.29). Efficacy was strongly associated with adherence (p<0.01). PrEP was found to be safe, but unrecognised HIV at enrolment increased the risk of viral drug resistance mutations. Evidence for behaviour change or an increase in sexually transmitted infections was not found.

CONCLUSIONS

PrEP is safe and effective in MSM, serodiscordant couples and PWIDs. Additional research is needed prior to recommending PrEP in heterosexuals. No RCTs reported effectiveness or safety data for other high-risk groups, such as transgender women and sex workers.

PROSPERO REGISTRATION NUMBER

CRD42017065937.

Kidney function in tenofovir disoproxil fumarate-based oral pre-exposure prophylaxis users: a systematic review and meta-analysis of published literature and a multi-country meta-analysis of individual participant data

BACKGROUND

Previous WHO guidance on tenofovir disoproxil fumarate-based oral pre-exposure prophylaxis (PrEP) suggests measuring creatinine levels at PrEP initiation and regularly afterwards, which might represent barriers to PrEP implementation and uptake. We aimed to systematically review published literature on kidney toxicity among tenofovir disoproxil fumarate-based oral PrEP users and conducted an individual participant data meta-analysis (IPDMA) on kidney function among PrEP users in a global implementation project dataset.

METHODS

In this systematic review and meta-analysis we searched PubMed up to June 30, 2021, for randomised controlled trials (RCTs) or cohort studies that reported on graded kidney-related adverse events among oral PrEP users (tenofovir disoproxil fumarate-based PrEP alone or in combination with emtricitabine or lamivudine). We extracted summary data and conducted meta-analyses with random-effects models to estimate relative risks of grade 1 and higher and grade 2 and higher kidney-related adverse events, measured by elevated serum creatinine or decline in estimated creatinine clearance or estimated glomerular filtration rate. The IPDMA included (largely unpublished) individual participant data from 17 PrEP implementation projects and two RCTs. Estimated baseline creatinine clearance and creatinine clearance change after initiation were described by age, gender, and comorbidities. We used random-effects regressions to estimate the risk in decline of creatinine clearance to less than 60 mL/min.

FINDINGS

We identified 62 unique records and included 17 articles reporting on 11 RCTs with 13 523 participants in meta-analyses. PrEP use was associated with increased risk of grade 1 and higher kidney adverse events (pooled odds ratio [OR] 1·49, 95% CI 1·22-1·81; I2=25%) and grade 2 and higher events (OR 1·75, 0·68-4·49; I2=0%), although the grade 2 and higher association was not statistically significant and events were rare (13 out of 6764 in the intervention group vs six out of 6782 in the control group). The IPDMA included 18 676 individuals from 15 countries (1453 [7·8%] from RCTs) and 79 (0·42%) had a baseline estimated creatinine clearance of less than 60 mL/min (increasing proportions with increasing age). Longitudinal analyses included 14 368 PrEP users and 349 (2·43%) individuals had a decline to less than 60 mL/min creatinine clearance, with higher risks associated with increasing age and baseline creatinine clearance of 60·00-89·99 mL/min (adjusted hazard ratio [aHR] 8·49, 95% CI 6·44-11·20) and less than 60 mL/min (aHR 20·83, 12·83-33·82).

INTERPRETATION

RCTs suggest that risks of kidney-related adverse events among tenofovir disoproxil fumarate-based oral PrEP users are increased but generally mild and small. Our global PrEP user analysis found varying risks by age and baseline creatinine clearance. Kidney function screening and monitoring might focus on older individuals, those with baseline creatinine clearance of less than 90 mL/min, and those with kidney-related comorbidities. Less frequent or optional screening among younger individuals without kidney-related comorbidities may reduce barriers to PrEP implementation and use.

FUNDING

Unitaid, Bill & Melinda Gates Foundation, WHO.

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.

“It’s behaviors, not identity”: Attitudes and beliefs related to HIV risk and pre-exposure prophylaxis among transgender women in the Southeastern United States

HIV prevalence is high among transgender women (TGW) in the Southeastern U.S. Uptake of HIV Pre-Exposure Prophylaxis (PrEP) is low among TGW nationwide. We aimed to explore beliefs associated with PrEP among TGW in the Southeastern U.S., framed by the Health Belief Model. HIV-negative TGW ≥18 years old in Alabama participated in virtual focus group discussions. Authors coded and amended transcripts to explore emerging themes. Between July-December 2020, 17 TGW participated in 4 sessions. Mean age was 28.1±8.5 years. Several themes were identified: frustration with conflation of transgender identity and HIV risk, inappropriate transgender representation in PrEP advertising, concerns for interactions between PrEP and hormone therapy, perception that PrEP is meant for cisgender men who have sex with men and limited trans-affirming healthcare. Nuanced messaging is necessary to properly educate and engage TGW in HIV prevention strategies including PrEP given the diversity of this population.

Is tenofovir disoproxil fumarate associated with weight loss?

BACKGROUND

Recent clinical trials have shown weight gain associated with newer antiretrovirals. It is unclear how the nucleoside reverse transcriptase inhibitor backbone affects weight. Recent evidence suggests greater weight gain with tenofovir alafenamide (TAF) compared with tenofovir disoproxil fumarate (TDF). However, it is not fully understood whether TDF contributes to weight suppression.

METHODS

A systematic search of PubMed, Embase and clinicaltrials.gov was conducted to identify all randomized control trials comparing TDF/FTC or TDF to control in HIV-negative individuals. The primary endpoint included the number of events of 5% weight loss. Mantel-Haenszel test with random-effects modelling was used to calculate the odds ratio (OR) and 95% confidence intervals (95% CI). Further analyses of gastrointestinal (GI) adverse events were also undertaken.

RESULTS

Seven PrEP trials: PARTNERS, VOICE, TDF-2, Bangkok PrEP, iPrEX, FEM-PrEP and HPTN 084 were included in the analysis of weight loss, with a total sample size of 19 359. One study (HPTN 084) compared TDF/FTC to cabotegravir (CAB). HIV-negative individuals taking TDF were more likely to experience weight loss compared with control [odds ratio (OR) 1.44; 95% CI 1.12-1.85; P = 0.005). Exposure to TDF was also linked to greater odds of vomiting (OR 1.81; 95% CI 1.20-2.73; P < 0.005). There were no increased odds of nausea, diarrhoea or loss of appetite.

CONCLUSION

There is evidence in HIV-negative individuals that TDF may be associated with weight loss. Further research should be carried out in HIV-positive individuals, and clinical trials of TDF/FTC should publish weight data to widen the evidence base.

Qualitative investigation of factors impacting pre-exposure prophylaxis initiation and adherence in sexual minority men

Introduction

Men who have sex with men continue to account for the majority of new HIV infections in the United States. Many of those with new infections are unaware that they have HIV. Preventative measures continue to be essential in reducing new infections, with pre‐exposure prophylaxis (PrEP) being widely recommended.

Objectives

The overall aim of this qualitative study is to explore the impact of stigma, patient–provider dynamics and patient perception of PrEP on men's engagement with PrEP in a primary care setting.

Methods

The Consensual Qualitative Research Methodology (Hill, 2012) was used to explore the experiences of 14 men receiving care for PrEP at a Family Medicine clinic in the Midwest. Semistructured interviews were conducted to allow for depth of understanding of individuals' experience.

Results

Four major domains were identified: motivation to pursue PrEP, barriers and adherence to care, beliefs about how PrEP is perceived by others and experiences discussing sexual health and PrEP with providers.

Conclusion

It is important to better understand factors contributing to the pursuit of and adherence to HIV prevention measures and HIV care. Further, health systems and providers are encouraged to consider opportunities in terms of how their practice can destigmatize PrEP use and offer a welcoming environment for those pursuing HIV prevention.

Patient or Public Contribution

Patients were involved in the study through their participation in semistructured interviews, which provided the data analysed for this study. There was no additional participation beyond the one‐time interview or follow‐up poststudy. Their interviews helped contribute to our better understanding of the needs and experiences of those receiving PrEP‐related care.

Differences in PrEP Awareness, Discussions with Healthcare Providers, and Use Among Men Who Have Sex with Men in the United States by Urbanicity and Region: A Cross-sectional Analysis

Pre-exposure prophylaxis (PrEP) is a highly effective HIV prevention intervention and is critical to the Ending the HIV Epidemic strategy. Most PrEP research has been conducted among urban populations; less is known about PrEP awareness, willingness to use, and actual use among rural and suburban populations. We examined these PrEP indicators by United States region and urbanicity among men who have sex with men who responded to the 2019 cycle of the American Men's Internet Survey. Rural and suburban men were less likely than urban men to be aware of PrEP, to have discussed PrEP with a healthcare provider in the past 12 months, and to have ever used PrEP. Smaller differences were observed across regions. Notably, willingness to use PrEP was similar across region and urbanicity. Additional work will be needed to increase PrEP awareness and access among rural and suburban populations.

HIV pre-exposure prophylaxis and sexually transmitted infections: intersection and opportunity

Pre-exposure prophylaxis (PrEP) has revolutionized HIV prevention, but PrEP does not protect against other sexually transmitted infections (STIs). Rates of STIs are rising worldwide, with notably high incidences among PrEP-using men who have sex with men in high-income countries; in low-income and middle-income countries, data are sparse, but results from a limited number of studies among African women initiating and taking PrEP have shown high STI prevalence and incidence. Efforts aimed at markedly reducing HIV in populations worldwide include a major focus on increasing PrEP use, along with improving HIV testing and treatment in order to eliminate HIV transmission. Together, these efforts could augment continued expansion of the global STI epidemic, but they could alternatively create an opportunity to improve STI control, including the development of comprehensive sexual health programmes and research to develop new STI prevention strategies. The introduction of PrEP globally has been characterized by challenges and many successes, and its role as part of a range of robust strategies to reduce HIV infections is clear. Looking ahead, understanding rising rates of curable STIs and their relationship to HIV prevention, and considering the future directions for synergies in PrEP and STI prevention will be integral to improving sexual health.

Development of a 2-step algorithm to identify emergency department patients for HIV pre-exposure prophylaxis

BACKGROUND

Expanded access to HIV PrEP is a central pillar of the "Ending the HIV Epidemic" initiative. Identification of PrEP eligible individuals in EDs remains understudied. Our goal was to estimate the accuracy of the Denver HIV Risk Score (DHRS), a quantitative HIV risk tool, for determining PrEP eligibility, and to incorporate it into a novel screening algorithm to optimize sensitivity and specificity.

METHODS

We performed a prospective cross-sectional study in two urban EDs. Patients were eligible if ≥18 years of age and without HIV. Research staff collected individual HIV risk, components of the DHRS, and PrEP eligibility per 2017 CDC guidelines. Accuracy estimates were calculated for the DHRS alone and the DHRS plus additional PrEP-specific questions.

RESULTS

1002 patients were enrolled with a median age of 39 years; 54.8% were male, 29.5% Black/non-Hispanic, and 22.5% Hispanic. Overall, 119 (11.9%, 95% CI: 9.9%-14.0%) were PrEP eligible; 5% endorsed history of sex with a partner at higher risk for HIV or condomless sex with multiple partners, 4% an STI, and 2% sharing IDU equipment. A DHRS ≥25 had a sensitivity of 92.4% (95% CI: 86.1%-96.5%) and a specificity of 17.2% (95% CI: 14.8%-19.9%) for PrEP eligibility. A 2-step algorithm, "DHRS-PrEP", beginning with a DHRS ≥25, followed by a step with questions specific to IDU, STI, and sexual partners improved the specificity to 100% (95% CI: 99.6%-100%).

CONCLUSIONS

Among a heterogeneous ED sample, a substantial proportion was identified as PrEP eligible, and a 2-step algorithm had high sensitivity and specificity for identifying PrEP-eligible patients.

A comparison of covariate selection techniques applied to pre-exposure prophylaxis (PrEP) drug concentration data in men and transgender women at risk for HIV

Pre-exposure prophylaxis (PrEP) containing antiretrovirals tenofovir disoproxil fumarate (TDF) or tenofovir alafenamide (TAF) can reduce the risk of acquiring HIV. Concentrations of intracellular tenofovir-diphosphate (TFV-DP) measured in dried blood spots (DBS) have been used to quantify PrEP adherence; although even under directly observed dosing, unexplained between-subject variation remains. Here, we wish to identify patient-specific factors associated with TFV-DP levels. Data from the iPrEX Open Label Extension (OLE) study were used to compare multiple covariate selection methods for determining demographic and clinical covariates most important for drug concentration estimation. To allow for the possibility of non-linear relationships between drug concentration and explanatory variables, the component selection and smoothing operator (COSSO) was implemented. We compared COSSO to LASSO, a commonly used machine learning approach, and traditional forward and backward selection. Training (N = 387) and test (N = 166) datasets were utilized to compare prediction accuracy across methods. LASSO and COSSO had the best predictive ability for the test data. Both predicted increased drug concentration with increases in age and self-reported adherence, the latter with a steeper trajectory among Asians. TFV-DP reductions were associated with increasing eGFR, hemoglobin and transgender status. COSSO also predicted lower TFV-DP with increasing weight and South American countries. COSSO identified non-linear relationships between log(TFV-DP) and adherence, weight and eGFR, with differing trajectories for some races. COSSO identified non-linear log(TFV-DP) trajectories with a subset of covariates, which may better explain variation and enhance prediction. Future research is needed to examine differences identified in trajectories by race and country.

The spatiotemporal distribution of pre-exposure prophylaxis accessibility in the United States, 2016-2020

PURPOSE

Residing in areas with little spatial accessibility to HIV pre-exposure prophylaxis (PrEP) providers, or PrEP deserts, contributes to low PrEP uptake. This study examines and characterizes the spatial distribution of PrEP accessibility in the United States over time.

METHODS

We conducted spatial network analyses and geographic mapping to explore the spatiotemporal distribution of persistent PrEP deserts (census tracts with suboptimal accessibility in 2016 and 2020), new PrEP deserts (tracts with suboptimal accessibility in 2020 but not 2016), new PrEP oases (tracts with suboptimal accessibility in 2016 but not 2020), and persistent PrEP oases (tracts with optimal accessibility in 2016 and 2020). We used polytomous logistic regression to determine area-level factors associated with these four spatiotemporal PrEP accessibility types.

RESULTS

There was a reduction of 52.8% in the prevalence of 30-minute PrEP deserts from 2016 (28,055 tracts) to 2020 (13,240 tracts) and an increase of 33.5% in 30-minute PrEP oases from 2016 (44,259 tracts) to 2020 (59,074 tracts). Of all tracts, 12,487 (17.3%) were persistent PrEP deserts, 753 (1.0%) were new PrEP deserts, 15,568 (21.5%) were new PrEP oases, and 43,506 (60.1%) were persistent PrEP oases. Overall, persistent PrEP oases were more likely to be of higher socioeconomic status, racially/ethnically diverse, located in urban areas, and located in the Northeast compared with other spatiotemporal PrEP accessibility types, with variation by urbanicity and U.S. Census region.

CONCLUSIONS

Efforts to improve PrEP accessibility should be especially focused in disadvantaged communities in nonurban areas and the South, Midwest, and West. Monitoring changes in the spatial accessibility of PrEP over time and determining the factors associated with such changes can help to evaluate progress made towards improving PrEP accessibility.

Characterizing Biomedical HIV Prevention Awareness and Use Among Black Transgender Women in the United States

Black transgender women (BTW) in the United States experience disproportionate rates of HIV despite biomedical prevention interventions such as pre-exposure prophylaxis (PrEP) and non-occupational post-exposure prophylaxis (nPEP). Using a sample of 490 BTW collected from 2014 to 2017, bivariate, multivariable, and multinomial analyses were conducted to determine factors associated with awareness and use of PrEP and nPEP. BTW living with HIV were more aware of PrEP than HIV-negative BTW. Structural, demographic, and trans-specific factors (e.g., experiences of homelessness, violence, and current hormone use) related to HIV risk were associated with PrEP and nPEP awareness. PrEP use was associated with behavioral HIV risks (e.g., STI diagnosis, having an HIV-positive partner, and needle-sharing) and may demonstrate risk recognition among BTW. Knowing someone using PrEP was significantly positively associated with PrEP use. Development of guidelines for PrEP and nPEP use for BTW should leverage the strengths of guidelines for other populations, while also acknowledging the unique risks for this population.

Pre-exposure Prophylaxis (PrEP) Information on Instagram: Content Analysis

Background

There is still an HIV epidemic in the United States, which is a substantial issue for populations bearing a disproportionate burden of HIV infections. Daily oral pre-exposure prophylaxis (PrEP) has proven to be safe and effective in reducing HIV acquisition risk. However, studies document that PrEP awareness/usage is low. There is also limited understanding of social media platforms, such as Instagram, as PrEP information sources.

Objective

Given the paucity of research on PrEP-related Instagram posts and popularity of this social media platform, the purpose of this research is to describe the source characteristics, image types, and textual contents of PrEP-related posts on Instagram.

Methods

Using Crowdtangle Search, a public insights tool owned/operated by Facebook, we retrieved publicly accessible and English-language-only Instagram posts for the 12-month period preceding April 22, 2020, using the following terms: Truvada or “pre-exposure prophylaxis” or #truvada or #truvadaprep or #truvadawhore or #truvadaforprep. We employed a qualitative coding methodology to manually extract information from posts. Using a pretested codebook, we performed content analysis on 250 posts, examining message and source characteristics (ie, organization type [eg, government, news] and individual type [eg, physician]), including information about PrEP (eg, how it works, cost), and indicated users. Frequencies and percentages were calculated for all categorical variables. A Chi-square test was conducted to determine differences between source types on a variety of message characteristics.

Results

Three-quarters of the posts (193/250, 77.2%) were posted by organizations. Of the 250 posts reviewed, approximately two-thirds (174/250, 69.6%) included a photograph, more than half (142/250, 56.8%) included an infographic, and approximately one-tenth (30/250, 12%) included a video. More than half defined PrEP (137/250, 54.8%), but fewer posts promoted PrEP use, explained how PrEP works, and included information on the effectiveness of PrEP or who can use it. The most commonly hashtagged populations among posts were men who have sex with men (MSM), but not necessarily bisexual men. Few posts contained race-/ethnicity-related hashtags (11/250, 4.4%). Fewer posts contained transgender-associated tags (eg, #transgirl; 5/250, 2%). No posts contained tags related to heterosexuals or injection drug users. We found statistical differences between source types (ie, individual versus organization). Specifically, posts from organizations more frequently contained information about who can use PrEP, whereas posts from individuals more frequently contained information describing adverse effects.

Conclusions

This study is among the first to review Instagram for PrEP-related content, and it answers the National AIDS Strategy’s call for a clearer articulation of the science surrounding HIV risk/prevention through better understanding of the current public information environment. This study offers a snapshot of how PrEP is being discussed (and by whom) on one of the most popular social media platforms and provides a foundation for developing and implementing PrEP promotion interventions on Instagram.

Sexually Transmitted Infections Treatment Guidelines, 2021

These guidelines for the treatment of persons who have or are at risk for sexually transmitted infections (STIs) were updated by CDC after consultation with professionals knowledgeable in the field of STIs who met in Atlanta, Georgia, June 11–14, 2019. The information in this report updates the 2015 guidelines. These guidelines discuss 1) updated recommendations for treatment of Neisseria gonorrhoeae, Chlamydia trachomatis, and Trichomonas vaginalis; 2) addition of metronidazole to the recommended treatment regimen for pelvic inflammatory disease; 3) alternative treatment options for bacterial vaginosis; 4) management of Mycoplasma genitalium; 5) human papillomavirus vaccine recommendations and counseling messages; 6) expanded risk factors for syphilis testing among pregnant women; 7) one-time testing for hepatitis C infection; 8) evaluation of men who have sex with men after sexual assault; and 9) two-step testing for serologic diagnosis of genital herpes simplex virus. Physicians and other health care providers can use these guidelines to assist in prevention and treatment of STIs.

Sexually Transmitted Infection Testing and Prevalence Before and After Preexposure Prophylaxis Initiation Among Men Aged ≥18 Years in US Private Settings

BACKGROUND

The Centers for Disease Control and Prevention recommends initial and follow-up sexually transmitted infection (STI) and HIV testing when taking HIV preexposure prophylaxis (PrEP). We assessed frequencies of STIs and HIV testing and rates of STIs before and after PrEP initiation among men aged ≥18 years.

METHODS

We used the OptumLabs database for this cohort study. We measured STI/HIV testing rates and prevalence in 2 time intervals: (1) within 90 days before and on the date of PrEP initiation and (2) within 45 days of the 180th day after the date of PrEP initiation.

RESULTS

Of 4210 men who initiated PrEP in 2016 to 2017 and continuously used PrEP for ≥180 days, 45.7%, 45.7%, and 56.0% were tested for chlamydia, gonorrhea, and HIV, respectively, at the second time interval. These percentages were significantly lower than those at the first time interval (58.3%, 57.9%, and 73.5%, respectively; P < 0.01). Chlamydia and gonorrhea prevalence rates at the second time interval were 6.5% and 6.2%, respectively, versus 5.0% and 4.7%, respectively, at the first time interval. Most gonorrhea or chlamydia infections at the second time intervals seem to be new infections new infections.

CONCLUSIONS

Sexually transmitted infection/HIV testing for PrEP users in the real-world private settings is much lower than in clinical trials. High STI prevalence before and after PrEP initiation in this study suggests that patients taking PrEP have an increased risk of acquiring STI. Interventions to improve provider adherence for PrEP users are urgently needed.

Cost-Effectiveness Analysis of a National Pre-Exposure Prophylaxis (PrEP) Program in Ireland

OBJECTIVES

To estimate the cost-effectiveness of introducing a publicly funded pre-exposure prophylaxis (PrEP) program in Ireland.

METHODS

We constructed a state-transition Markov model. This was a cross-sectional population model that tracked all HIV-negative men who have sex with men (MSM) in Ireland over their lifetime. Access to a publicly funded PrEP program (medications + frequent monitoring) in high-risk MSM was compared with no PrEP. The primary outcome measure was the incremental cost-effectiveness ratio (ICER).

RESULTS

In the base case, introducing a PrEP program was considered cost saving and provided significant health benefits to the population. Univariate sensitivity analysis demonstrated that PrEP efficacy and HIV incidence had the greatest impact on cost-effectiveness. Including an increase in sexually transmitted infections had a negligible impact on the results. Efficacy was a significant driver in the model. PrEP was cost saving at all efficacy values above 60%, and at the lowest reported efficacy in MSM (44% in the iPrEX trial), the ICER was €4711/QALY (highly cost-effective). Event-based dosing (administration during high-risk periods only) was associated with additional cost savings. We estimated that 1705 individuals (95% CI: 617-3452) would join the program in year 1. The incremental budget impact was €1.5m (95% CI: €0.5m to €3m) in the first year and €5.4m over 5 years (95% CI: €1.8m to €11.5m), with 173 cases of HIV averted over 5 years.

CONCLUSION

We found that the introduction of a PrEP program would be considered cost saving in the first cost-effectiveness analysis of its kind in Ireland.

HIV Risk and Pre-Exposure Prophylaxis Eligibility Among Emergency Department Patients

Our objective was to estimate the prevalence of pre-exposure prophylaxis (PrEP) eligibility, characterize self-perceived and quantified human immunodeficiency virus (HIV) risk, and assess PrEP knowledge and receptiveness of initiating PrEP among emergency department (ED) patients. We performed an IRB-approved cross-sectional study from two urban EDs. Patients were eligible if ≥18 years of age and not known to have HIV. Research staff obtained verbal consent and used a structured 29-item instrument to assess HIV risk, PrEP eligibility based on 2017 Centers for Disease Control and Prevention (CDC) guidelines, and general PrEP knowledge among unselected and enriched patient samples, the latter informed by the Denver HIV Risk Score (DHRS). We enrolled 1002 patients with a median age of 39 years; 54.8% were male, 30.9% White/non-Hispanic, 29.5% Black/non-Hispanic, and 22.5% Hispanic. In the full cohort, 119 [11.9%, 95% confidence interval (CI): 9.9-14.0%] were PrEP eligible, and among the unselected cohort, 36 (7.1%, 95% CI: 5.1-9.8%) were PrEP eligible. Using the DHRS, 100 patients were considered "high risk" with 32 (32.0%) reporting zero perceived risk. Correlation between the DHRS and self-perceived HIV risk was low (r = 0.13). Of the full cohort, 203 (20.3%) had heard of PrEP, and of these, 33 (16.3%) were PrEP eligible with 25 (75.8%) willing to start PrEP immediately. Yet, of the 119 patients who were PrEP eligible, only 34 (28.6%) had heard of PrEP. In summary, among a heterogeneous ED population, there was discordance in self-perceived and quantified HIV risk. HIV PrEP eligibility was ∼7% with the highest eligibility among those identified as DHRS "high risk." A significant opportunity exists to identify and initiate PrEP among ED patients.

Hepatotoxicity of Contemporary Antiretroviral Drugs: A Review and Evaluation of Published Clinical Data

Contemporary antiretroviral agents afford enhanced potency and safety for patients living with HIV. Newer antiretroviral drugs are often better tolerated than those initially approved in the early stages of the HIV epidemic. While the safety profile has improved, adverse drug reactions still occur. We have segregated the antiretroviral agents used in contemporary practice into class groupings based on their mechanism of antiviral activity (non-nucleoside reverse transcriptase inhibitors, nucleoside reverse transcriptase inhibitors, integrase inhibitors, protease inhibitors, and entry inhibitors) while providing a review and discussion of the hepatoxicity seen in the most relevant clinical literature published to date. Clinical literature for individual agents is discussed and agent comparisons afforded within each group in tabular format. Our review will provide a summative overview of the incidence and medications associated with hepatic adverse reactions linked to the use of contemporary antiretroviral drugs.

Pre-exposure Prophylaxis Uptake Among Men Who Have Sex With Men Who Used nPEP: A Longitudinal Analysis of Attendees at a Large Sexual Health Clinic in Montréal (Canada)

BACKGROUND

Reducing HIV transmission using pre-exposure prophylaxis (PrEP) requires focussing on individuals at high acquisition risk, such as men who have sex with men with a history of nonoccupational post-exposure prophylaxis (nPEP). This study aims to characterize longitudinal trends in PrEP uptake and its determinants among nPEP users in Montréal.

METHODS

Eligible attendees at Clinique médicale l'Actuel were recruited prospectively starting in October 2000 (nPEP) and January 2013 (PrEP). Linking these cohorts, we characterized the nPEP-to-PrEP cascade, examined the determinants of PrEP uptake after nPEP consultation using a Cox proportional-hazard model, and assessed whether PrEP persistence differed by nPEP history using Kaplan-Meier curves.

RESULTS

As of August 2019, 31% of 2682 nPEP cohort participants had 2 or more nPEP consultations. Subsequent PrEP consultations occurred among 36% of nPEP users, of which 17% sought nPEP again afterward. Among 2718 PrEP cohort participants, 46% reported previous nPEP use. Among nPEP users, those aged 25-49 years [hazard ratio (HR) = 1.3, 95% confidence interval (CI): 1.1 to 1.7], with more nPEP episodes (HR = 1.4, 95% CI: 1.3 to 1.5), who reported chemsex (HR = 1.3, 95% CI: 1.1 to 1.7), with a sexually transmitted infection history (HR = 1.5; 95% CI: 1.3 to 1.7), and who returned for their first nPEP follow-up visit (HR = 3.4, 95% CI: 2.7 to 4.2) had higher rates of PrEP linkage. There was no difference in PrEP persistence between nPEP-to-PrEP and PrEP only participants.

CONCLUSION

Over one-third of nPEP users were subsequently prescribed PrEP. However, the large proportion of men who repeatedly use nPEP calls for more efficient PrEP-linkage services and, among those who use PrEP, improved persistence should be encouraged.

Successful integration of HIV pre-exposure prophylaxis into a community-based HIV prevention program for female sex workers in Kolkata, India

We assessed the impact of pre-exposure prophylaxis (PrEP) in the context of a community-based HIV program among female sex workers (FSWs) in Kolkata, India. This was an open-label, uncontrolled demonstration trial. HIV seronegative FSWs over 18 years were eligible. Participants were administered daily tenofovir/emtricitabine (TDF-FTC) with follow-up visits at months 1, 3, 6, 9, 12, and 15. Drug adherence was monitored by self-report, and a random subset of participants underwent plasma TDF testing. 843 women were screened and 678 enrolled and started on PrEP. Seventy-nine women (11%) did not complete all scheduled visits: four women died of reasons unrelated to PrEP and 75 withdrew, for a 15-month retention rate of 89%. Self-reported daily adherence was over 70%. Among those tested for TDF, the percentage of women whose level reached ≥40 ng/mL was 65% by their final visit. There were no HIV seroconversions, and no evidence of significant changes in sexual behavior. This study demonstrated the feasibility and effectiveness of PrEP for FSWs in Kolkata, with very high levels of adherence to PrEP and no HIV seroconversions. The integration of PrEP into an existing community-based HIV prevention program ensured community support and facilitated adherence.

Low use of condom and high STI incidence among men who have sex with men in PrEP programs

Objective

Since the recent introduction of preexposure prophylaxis (PrEP), several studies have reported a decrease in the use of condoms and a rise in STIs among users. This rise in risk behavior associated with the advent of PrEP is known as “risk compensation.” The aim of this study is to measure clinical and behavioral changes associated with the introduction of PrEP by analyzing condom use for anal intercourse, number of sexual partners, sexualized drug use and STI incidence.

Methods

We performed a retrospective descriptive study of PrEP users followed every 3months over a 2-year period spanning 2017–2019 in a referral clinic specializing in STI/HIV in Madrid, Spain. One hundred ten men who have sex with men and transgender women underwent regular screening for STIs and hepatitis C virus (HCV) infection. Sociodemographic, clinical, and behavioral data were gathered for all subjects studied.

Results

The risk compensation observed in this study consisted primarily of a lower rate of condom use, while the number of sexual partners and recreational drug consumption remained stable. We observed a very high incidence of STIs in this sample, particularly rectal gonorrhea and chlamydia. The factors shown to be independently associated with the presence of an STI on multivariate analysis were age below 30 years and over 10 sexual partners/month.

Conclusion

The incidence of STI acquisition was higher than expected, indicating a need for strategies to minimize this impact, particularly among younger individuals with a higher number of sexual partners.

Acquired immune deficiency syndrome (AIDS) and late presentation in Poland - data from Test and Keep in Care (TAK) Polska project

OBJECTIVES

Late presentation (LP) at HIV diagnosis is associated with worse prognosis and an increase in the number of new infections. We analyse the proportion of patients diagnosed late and factors related to LP in Poland in 2016-2017.

METHODS

Data were obtained from 13 out of 17 HIV centres in Poland from 2016 and 2017, including date of diagnosis, age, sex, transmission route, anti-hepatitis C virus (anti-HCV), Venereal Diseases Research Laboratory (VDRL) antibodies, AIDS diagnosis, baseline HIV viral load and CD4 count.

RESULTS

Out of 1522 patients, 88.9% were male with median age of 33.6 years. Men who have sex with men (MSM) comprised 69.4% of all new infections, heterosexual route of transmission (HTX) 18.2% and injecting drug use (IDU) 4.7%. Late presenters comprised 44.8% of the study group. Factors associated with LP were female sex [odds ratio (OR) = 1.5, 95% confidence interval (95% CI): 1.09-2.08], older age (OR = 1.59, 95% CI: 1.42-1.79 per decade), route of transmission (HTX: OR = 1.96, 95% CI: 1.50-2.56; IDU: OR = 3.17, 95% CI: 1.92-5.37), positive HCV results (OR = 1.90, 95% CI: 1.23-2.95) and syphilis diagnosis (OR = 2.06, 95% CI: 2.29-3.31). Adjusting for these factors, the only independent factors associated with LP were age (OR = 1.52, 95% CI: 1.35-1.71) and route of transmission (HTX: OR = 1.73, 95% CI: 1.23-2.44; IDU: OR = 2.24, 95% CI: 1.25-4.10).

CONCLUSIONS

Late presentation in Poland follows European trends. A total of 44.8% of all newly diagnosed patients in Poland continue to present late or at the AIDS stage. Independent factors associated with LP/AIDS were older age, IDU and HTX. Patients from these groups should be targeted to improve early diagnosis and medical care.

Primary HIV-1 infection in users of pre-exposure prophylaxis

Pre-exposure prophylaxis (PrEP) has proven to be a highly effective and safe way to prevent HIV infection. Seroconversion and primary HIV infection are exceptional if adherence to PrEP is good. However, primary HIV infection while using PrEP can occur, albeit rarely, and HIV drug resistance might develop. Furthermore, the scope of PrEP is expected to expand, and clinicians might face potential seroconversions and primary HIV infection in patients starting or taking PrEP. The characteristics of primary HIV infection in users of PrEP are poorly described. PrEP users present a lower viral load peak during primary HIV infection and, frequently, fewer symptoms than individuals not exposed to PrEP. Additionally, PrEP prolongs the stages of seroconversion, thus potentially complicating diagnosis of primary HIV infection. Drug resistance is rare, occurring mostly when PrEP is initiated in undiagnosed patients who are at an extremely early stage of infection, in whom detection of HIV-RNA was not used to rule out HIV infection. Therefore, careful exclusion of primary HIV infection before starting PrEP is crucial. In patients presenting with primary HIV infection while on PrEP, a drug with a high genetic barrier (or even two) should be added to tenofovir disoproxil fumarate-emtricitabine until test results for resistance are available.

Attitude of infectious diseases physicians in Turkey about HIV pre-exposure prophylaxis: results of an online survey

Pre-exposure prophylaxis (PrEP) is the provision of antiretroviral drugs before HIV exposure to prevent infection for those in whom it is indicated. We conducted an online survey about PrEP in a national sample of infectious diseases physicians in Turkey. They were surveyed from March to April 2019 and they were asked about their attitudes, knowledge and clinical practise about PrEP. Overall, 209 of 2100 (10%) completed the survey, of whom 66.3% were female, 69.5% were specialist and 41.1% were working at education and research hospitals. Most of the participants reported their PrEP knowledge as 'low'. Men who have sex with men was the most suitable group for PrEP according to participants. 27.9% of them were requested to prescribe PrEP which was to be paid by individuals themselves and 24.2% of the participants had recommended PrEP in their clinical practice. The primary concerns among those who would not recommend PrEP were the possible increase in sexually transmitted infections, the potential low cost-effectiveness of PrEP, the ineffectiveness of PrEP in HIV transmission and the time lost to following-up the individuals taking PrEP. Developing a national guideline would support clinicians in order to change their attitudes and to find answers to their concerns.

Simulating the End of AIDS in New York: Using Participatory Dynamic Modeling to Improve Implementation of the Ending the Epidemic Initiative

OBJECTIVES

In 2014, the governor of New York announced the Ending the Epidemic (ETE) plan to reduce annual new HIV infections from 3000 to 750, achieve a first-ever decrease in HIV prevalence, and reduce AIDS progression by the end of 2020. The state health department undertook participatory simulation modeling to develop a baseline for comparing epidemic trends and feedback on ETE strategies.

METHODS

A dynamic compartmental model projected the individual and combined effects of 3 ETE initiatives: enhanced linkage to and retention in HIV treatment, increased preexposure prophylaxis (PrEP) among men who have sex with men, and expanded housing assistance. Data inputs for model calibration and low-, medium-, and high-implementation scenarios (stakeholders' rollout predictions, and lower and upper bounds) came from surveillance and program data through 2014, the literature, and expert judgment.

RESULTS

Without ETE (baseline scenario), new HIV infections would decline but remain >750, and HIV prevalence would continue to increase by 2020. Concurrently implementing the 3 programs would lower annual new HIV infections by 16.0%, 28.1%, and 45.7% compared with baseline in the low-, medium-, and high-implementation scenarios, respectively. In all concurrent implementation scenarios, although annual new HIV infections would remain >750, there would be fewer new HIV infections than deaths, yielding the first-ever decrease in HIV prevalence. PrEP and enhanced linkage and retention would confer the largest population-level changes.

CONCLUSIONS

New York State will achieve 1 ETE benchmark under the most realistic (medium) implementation scenario. Findings facilitated framing of ETE goals and underscored the need to prioritize men who have sex with men and maintain ETE's multipronged approach, including other programs not modeled here.

A Mobile Sexual Health App on Empowerment, Education, and Prevention for Young Adult Men (MyPEEPS Mobile): Acceptability and Usability Evaluation

BACKGROUND

HIV incidence among young adult men who have sex with men (MSM), particularly among black and Latino men, continues to rise. As such, continued HIV prevention interventions for young MSM of color are of utmost importance. Male Youth Pursuing Empowerment, Education and Prevention around Sexuality (MyPEEPS) Mobile is a comprehensive HIV prevention and sexual health education smartphone app initially created to promote sexual health and HIV prevention among adolescent sexual minority young men aged 13 to 18 years.

OBJECTIVE

The objective of this study was to critically appraise the acceptability and usability of MyPEEPS Mobile for young adult MSM aged 19 to 25 years.

METHODS

Study participants used the mobile app, completed usability questionnaires and in-depth interviews, and reported their experience using the app. Analysis of interview data was guided by the Unified Theory of Acceptance and Use of Technology (UTAUT) to better understand the usability and acceptability of this intervention for young adults. Interview data were coded using the following constructs from the UTAUT model: performance expectancy, effort expectancy, and social influence.

RESULTS

A total of 20 young adult MSM (n=10 in Chicago, Illinois, and n=10 in New York, New York) were enrolled in the study. Participants reported that MyPEEPS Mobile was free of functional problems (Health Information Technology Usability Evaluation Scale scores and Post-Study System Usability Questionnaire scores consistent with high usability), easy to use, and useful, with an engaging approach that increased acceptability, including the use of avatars and animation, and inclusive representation of the diverse identities by race and ethnicity, gender identity, and sexual orientation. Recommended areas for improving MyPEEPS Mobile for the target demographic included more adult-oriented graphics, advanced educational content, scenarios for youth with more sexual experience, and search function to increase accessibility of key content.

CONCLUSIONS

Overall, young adult MSM aged 19 to 25 years described the MyPEEPS Mobile as educational, informative, and usable for their sexual health education and HIV prevention needs, and they provided actionable recommendations to optimize its use and applicability for this age group.

The effect of tenofovir disoproxil fumarate on bone mineral density: a systematic review and meta-analysis

BACKGROUND

We conducted a systematic review and meta-analysis (CRD#42017070552) to quantify the impact of oral tenofovir disoproxil fumarate/emtricitabine (TDF/FTC) on bone mineral density (BMD) and the risk of osteoporosis, low bone mass and fractures, among people taking it as pre-exposure prophylaxis (PrEP), HIV treatment and HBV treatment.

METHODS

We searched MEDLINE and EMBASE for randomized controlled trials published from 1997-2018 reporting BMD, osteoporosis, low bone mass and/or fractures in treatment-naive patients taking compared with not taking TDF for 48 ±4 weeks. We pooled outcomes using DerSimonian random-effects models.

RESULTS

Our search yielded 5,178 abstracts, representing 3,865 articles, with 25 meeting the inclusion criteria. TDF was associated with greater BMD decline when taken as PrEP (lumbar spine: mean difference [MD]=-0.82%, 95% CI=-1.28, -0.37%, I²=38%; total hip: MD=-0.81%, 95% CI=-1.22, -0.40%, I²=48%) and HIV treatment (lumbar spine: MD=-1.62%, 95% CI=-2.30, -0.95%, I²=93%; total hip: MD=-1.75%, 95% CI=-2.08, -1.42%, I²=83%; femoral neck: MD=-1.26%, 95% CI=-2.15, -0.38%, I²=43%) in comparison to those not taking TDF. Eight studies reported on incident osteoporosis or low bone mass, with variable results. Pooled results from five PrEP studies showed that TDF was not associated with increased fractures compared with no PrEP (RR=1.12, 95% CI=0.752, 1.74, I²=26%).

CONCLUSIONS

TDF caused greater decreases in BMD than did comparators when used for all three indications and the magnitude of this decrease was larger for HIV treatment compared with PrEP. Fractures were not increased among PrEP patients. The clinically significant BMD decline caused by TDF and current expansion of PrEP use suggest attention to the adverse bone effects of TDF will increase in importance.