Cohort profile: l'Actuel Pre-Exposure Prophylaxis (PrEP) Cohort study in Montreal, Canada

Pre-exposure prophylaxis (PrEP) use trajectories and incidence of HIV and other sexually transmitted infections among PrEP users in Belgium: a cohort analysis of insurance claims data from 2017 to 2019

BACKGROUND

Since June 2017, oral pre-exposure prophylaxis (PrEP) has been reimbursed in Belgium for people at substantial risk of HIV. To inform the national PrEP programme, we described sociodemographic characteristics of PrEP users, PrEP dispensing practices, testing for HIV and sexually transmitted infections (STIs; gonorrhoea, chlamydia and syphilis), and incidence of HIV and STIs.

METHODS

Analysis of routinely collected social health insurance claims data from all individuals who were dispensed at least one PrEP prescription between June 2017 and December 2019. Using logistic regression adjusted for age, we examined associations between sociodemographic characteristics and having been dispensed PrEP only once in the first six months of PrEP use.

RESULTS

Overall, 4559 individuals were dispensed PrEP. Almost all PrEP users were male (99.2%, 4522/4559), with a median age of 37 years (IQR 30-45). A minority were entitled to an increased healthcare allowance (11.4%, 514/4559). 18% (657/3636) were dispensed PrEP only once in the first six months of PrEP use. PrEP users younger than 25 years, unemployed, entitled to an increased healthcare allowance, and who initiated PrEP between January 2019 and June 2019 were more likely to have had no PrEP dispensing after initiation compared to their counterparts. The testing rates for bacterial STIs and HIV were 4.2 tests per person-year (95% CI 4.1-4.2) and 3.6 tests per person-year (95% CI 3.5-3.6), respectively. Twelve individuals were identified to have seroconverted during the study period, resulting in an HIV incidence rate of 0.21/100 person-years (95% CI 0.12-0.36). The incidence of bacterial STIs was 81.2/100 person-years (95% CI 78.7-83.8).

CONCLUSIONS

The study highlights challenges in PrEP persistence and a high incidence of bacterial STIs among individuals receiving PrEP. Tailored prevention support is crucial for individuals with ongoing HIV risk to optimise PrEP effectiveness. Integrated STI testing and prevention interventions within PrEP care are necessary to mitigate STI acquisition and transmission among PrEP users.

Interest in event-driven PrEP among men who have sex with men using daily PrEP in Mexico in 2019-2020: a cross-sectional assessment in a large-scale demonstration project

This study aimed to evaluate the interest in event-driven PrEP (ED-PrEP) among men who have sex with men (MSM) using daily PrEP in Mexico's PrEP demonstration project between 2019 and 2020. We compared participants interested or not in ED-PrEP during their first-month visit and identified associated factors. Of 1,021 MSM attending their first-month visit, 7% had previous knowledge of ED-PrEP, but 40% were interested in ED-PrEP. However, over 50% perceived the scheme as less protective than daily PrEP. Having doubts about ED-PrEP's level of protection was related to less interest in the scheme (aOR = 0.11; CI = 0.07-0.18), just like reporting perceived barriers such as having frequent sex (aOR = 0.06; CI = 0.03-0.14), unplanned sex (aOR = 0.17; CI = 0.11-0.27), forgetting the medicine (aOR = 0.06; CI = 0.03-0.12), or difficulty carrying the medicine (aOR =   0.13; CI = 0.07-0.25). Finally, reporting not taking PrEP for >20 days in the last month (aOR = 0.05; CI = 0.01-0.27) diminished interest in ED-PrEP. In conclusion, few MSM daily PrEP users knew about ED-PrEP yet many were interested in it, suggesting the importance of awareness campaigns regarding ED-PrEP's effectiveness. The lack of interest in ED-PrEP among participants with poor adherence to daily PrEP indicates that they might prefer long-acting PrEP or HIV prevention strategies without medication.

Incidence and factors associated with PrEP discontinuation in France

OBJECTIVES

HIV pre-exposure prophylaxis (PrEP) is effective in preventing HIV, but some seroconversions occur due to poor adherence or PrEP discontinuation. Our objective was to estimate the incidence of PrEP discontinuation and describe the reasons and factors associated with discontinuations.

METHODS

A retrospective cohort was conducted in three French hospitals between January 2016 and June 2022. PrEP users who attended at least twice within 6 months during study period were included and followed up until December 2022. The incidence rate of PrEP discontinuation was estimated by censoring lost to follow up individuals. Factors associated with PrEP discontinuations were identified using a multivariate Cox model.

RESULTS

A total of 2785 PrEP users were included, with 94% men and 5% transgender people. Median age was 35 years. By December 2022, 653 users had stopped PrEP (24%). The incidence rate was 10.8 PrEP discontinuations for 100 person-years (PY). The main causes of discontinuation were being in a stable relationship (32%), and not judging the treatment useful anymore (12%). Individuals who discontinued PrEP were younger [<29, HR = 1.45 (1.17-1.80)], and more likely to be women [HR = 2.44 (1.50-3.96)] or sex workers [HR = 1.53 (0.96-2.44)]. They were more likely to report PrEP side effects [HR = 2.25 (1.83-2.77)] or ≥2 sexually transmitted infections [HR = 1.87 (1.53-2.27)] during the last year.

CONCLUSION

The incidence of PrEP discontinuations was quite low compared to rates observed in other cohorts. Users who stopped PrEP were sometimes still exposed to HIV, emphasizing the need for targeted interventions to prepare and support PrEP discontinuations and limit seroconversion risk.

Behind Prep Decisions: Understanding User Patterns and Discontinuation Factors in Real-World

This study aimed to characterize the epidemiological aspects of PrEP use and barriers to accessing this prophylaxis. This cross-sectional study was conducted between January 2021 and April 2022, encompassing 140 PrEP users treated at the Testing and Counseling Center (CTA) in Campo Grande, Mato Grosso do Sul. Data on sociodemographic characteristics and factors associated with PrEP discontinuation were obtained using a standardized questionnaire. Most PrEP users were cisgender men (92.00%), predominantly white (51.00%), over 30 years of age (56.50%), homosexual-oriented (76.50%), and had a minimum of 12 years of education (77.50%). Approximately 60.00% admitted to inconsistent condom use in recent sexual encounters, primarily involving anal intercourse. Approximately 88.00% perceived themselves as at risk of contracting STIs in the upcoming year. Regarding new presentation forms, 54.00% indicated a willingness to use "on-demand PrEP," and 92.00% expressed interest in using "injectable PrEP." After 6 months of follow-up, 43.60% (95.00% CI: 35.50-52.00) discontinued PrEP use, primarily due to changes in sexual behavior (38.30%) and difficulties accessing healthcare services (21.28%). This study underscores the need to involve diverse key populations and highlights the significance of PrEP as an ongoing monitoring strategy for HIV/STI prevention in addition to the importance of incorporating new formulations such as daily oral PrEP into the Brazilian National Health System (SUS).

PrEP Discontinuation In A US National Cohort Of Sexual And Gender Minority Populations, 2017-22

In the US, sexual and gender minority populations are disproportionately affected by HIV. Pre-exposure prophylaxis (PrEP) is a key prevention method, but its effectiveness relies on consistent usage. Our four-year national cohort study explored PrEP discontinuation among sexual and gender minority people who initiated PrEP. We found a high annual rate of discontinuation (35-40 percent) after PrEP initiation. Multivariable analysis with 6,410 person-years identified housing instability and prior history of PrEP discontinuation as predictors of discontinuation. Conversely, older age, clinical indication for PrEP, and having health insurance were associated with ongoing PrEP use. To promote sustained PrEP use, strategies should focus on supporting those at high risk for discontinuation, such as younger people, those without stable housing or health insurance, and prior PrEP discontinuers.

Oral Pre-Exposure Prophylaxis for HIV Discontinuation in a Large Cohort of Adolescent Men Who Have Sex With Men and Transgender Women in Brazil

PURPOSE

This study aimed to describe pre-exposure prophylaxis (PrEP) for HIV discontinuation in adolescent men who have sex with men (aMSM) and adolescent transgender women (aTGW) and to identify factors associated with discontinuation.

METHODS

The PrEP1519 study included a cohort of aMSM and aTGW aged 15-19 years old, and it was conducted in three large Brazilian capital cities. For this analysis, we included adolescents who initiated PrEP. PrEP discontinuation was defined as no possession of PrEP pills for >90 days. Kaplan-Meier curves were used to analyze the probabilities of discontinuation, and survival distributions stratified by covariates were compared using log-rank or Wilcoxon tests. Cox regression models were used to estimate the adjusted hazard ratio (aHR) with a 95% confidence interval (95% CI).

RESULTS

We included 908 adolescents, 829 (91.30%) aMSM and 79 (8.70%) aTGW, most of whom were 18-19 years (80.29%). The incidence rate of discontinuation was 75.6 per 100 person-years. The probability of discontinuation was 52.61% in the first year. The multivariate analysis demonstrated that the aTGW (aHR = 1.63; 95% CI: 1.02-1.64) and adolescents with a medium (aHR = 1.29; 95% CI: 1.02-1.64) or low (aHR = 1.65; 95% CI: 1.29-2.12) perceived risk of HIV infection had an increased risk of discontinuation, whereas the adolescents with a partner living with HIV had a lower risk of discontinuation (aHR = 0.57; 95% CI: 0.35-0.91).

DISCUSSION

Adolescents with a high risk for discontinuation may need additional support that emphasizes the value of PrEP as a tool for HIV prevention because PrEP discontinuation was associated with a disconnect between HIV risk perception and HIV prevention.

Online distribution of HIV self-testing kits to promote HIV testing among men who have sex with men discontinuing pre-exposure prophylaxis after demonstration project completion in China: a multicentre open-label randomized controlled trial

Background

HIV self-testing (HIVST) offers potential solutions to challenges associated with site-based HIV testing (SBHT). However, the effectiveness of HIVST as an HIV prevention strategy for men who have sex with men (MSM) discontinuing pre-exposure prophylaxis (PrEP) after the completion of PrEP demonstration project has rarely been assessed.

Methods

The China Real-world Study of Oral PrEP (CROPrEP) project was conducted in four cities in China. Participants were directed to community resources to continue their PrEP medication after the discontinuation of project-provided PrEP at the last CROPrEP visit. We conducted a multicentre open-label randomized controlled trial among MSM who had discontinued PrEP induced by the completion of CROPrEP. Eligible participants were randomly assigned to either the intervention group or the control group (1:1). Participants received regular health education and behavioural interventions throughout the trial. The intervention group was given a link to order free HIVST kits online, while the control group received information about free SBHT. Both groups completed internet-based follow-up surveys at three and six months. The primary outcome was the proportion of participants who underwent HIV testing during the six-month follow-up period. This trial was registered at chictr.org.cn (ChiCTR2000038416).

Findings

Between November 2020 and January 2021, we recruited a total of 620 participants (300 in the intervention group and 320 in the control group). The follow-up completion rates were 99·0% and 95·0% in the intervention and control groups, respectively. At baseline, the median age of participants was 32 (interquartile range: 26-37), and 77·7% underwent HIV testing in the past three months. The proportion of participants who underwent HIV testing in the past three months was higher in the intervention group than in the control group at both the three-month (adjusted risk difference [RD]: 36·7, 95% confidence interval [CI]: 35·1-38·5, p < 0·001) and six-month (RD: 26·7, 95% CI: 24·6-28·7 p < 0·001) follow-up periods.

Interpretation

Our study suggests that providing online distribution of HIVST kits for MSM with PrEP discontinuation induced by completion of the PrEP project effectively promoted HIV testing. This digital approach improves access to HIV testing for MSM and can be applicable to other settings where MSM turn to online public health services.

Funding

The study was funded by the Fund of National Natural Science Foundation of China; the Mega-Projects of National Science Research for the 13th Five-Year Plan; and the Liaoning Revitalization Talents Program, China.

Population-level effectiveness of pre-exposure prophylaxis for HIV prevention among men who have sex with men in Montréal (Canada): a modelling study of surveillance and survey data

INTRODUCTION

HIV pre-exposure prophylaxis (PrEP) has been recommended and partly subsidized in Québec, Canada, since 2013. We evaluated the population-level impact of PrEP on HIV transmission among men who have sex with men (MSM) in Montréal, Québec's largest city, over 2013-2021.

METHODS

We used an agent-based mathematical model of sexual HIV transmission to estimate the fraction of HIV acquisitions averted by PrEP compared to a counterfactual scenario without PrEP. The model was calibrated to local MSM survey, surveillance, and cohort data and accounted for COVID-19 pandemic impacts on sexual activity, HIV prevention, and care. PrEP was modelled from 2013 onwards, assuming 86% individual-level effectiveness. The PrEP eligibility criteria were: any anal sex unprotected by condoms (past 6 months) and either multiple partnerships (past 6 months) or multiple uses of post-exposure prophylaxis (lifetime). To assess potential optimization strategies, we modelled hypothetical scenarios prioritizing PrEP to MSM with high sexual activity (≥11 anal sex partners annually) or aged ⩽45 years, increasing coverage to levels achieved in Vancouver, Canada (where PrEP is free-of-charge), and improving retention.

RESULTS

Over 2013-2021, the estimated annual HIV incidence decreased from 0.4 (90% credible interval [CrI]: 0.3-0.6) to 0.2 (90% CrI: 0.1-0.2) per 100 person-years. PrEP coverage among HIV-negative MSM remained low until 2015 (<1%). Afterwards, coverage increased to a maximum of 10% of all HIV-negative MSM, or about 16% of the 62% PrEP-eligible HIV-negative MSM in 2020. Over 2015-2021, PrEP averted an estimated 20% (90% CrI: 11%-30%) of cumulative HIV acquisitions. The hypothetical scenarios modelled showed that, at the same coverage level, prioritizing PrEP to high sexual activity MSM could have averted 30% (90% CrI: 19%-42%) of HIV acquisitions from 2015-2021. Even larger impacts could have resulted from higher coverage. Under the provincial eligibility criteria, reaching 10% coverage among HIV-negative MSM in 2015 and 30% in 2019, like attained in Vancouver, could have averted up to 63% (90% CrI: 54%-70%) of HIV acquisitions from 2015 to 2021.

CONCLUSIONS

PrEP reduced population-level HIV transmission among Montréal MSM. However, our study suggests missed prevention opportunities and adds support for public policies that reduce PrEP barriers, financial or otherwise, to MSM at risk of HIV acquisition.

Uptake and Persistence on HIV Pre-Exposure Prophylaxis Among Female Sex Workers and Men Having Sex with Men in Kigali, Rwanda: A Retrospective Cross-Sectional Study Design

Background

Although HIV pre-exposure prophylaxis (PrEP) is known for its effectiveness in preventing HIV transmission; there is a global rise in HIV infection rates, particularly prominent in sub-Saharan Africa. This health concern is mostly evident among high-risk groups, namely Female Sex Workers (FSWs) and Men who have Sex with Men (MSMs), both of whom are more susceptible to sexually transmissible infections. This research examined the persistence, uptake, and associated predictors of PrEP utilization within the FSW and MSM populations.

Methods

A cross-sectional study design was conducted involving 4872 individuals from the FSW and MSM groups who were enrolled in a PrEP program across 10 health centers participating in a pilot initiative. The study population was subject to a year-long follow-up period commencing on March 1st, 2019. To evaluate the determinants of PrEP utilization within FSW and MSM groups, bivariate logistic analyses and multivariate logistic regression models were employed.

Results

The findings revealed that the occurrence of PrEP uptake was 45.55% (n=2219) among FSWs and 35.42% (n=17 participants) among MSM. Regarding PrEP persistence, MSM (88.24%, n=15 participants) presented higher PrEP proportion than FSWs (78.5%, n=1742 women). Our findings disclosed that individuals aged 25-34 years (aOR=0.82; 95% CI=0.72-0.93, p=0.002), 35-44 years (aOR=0.83; 95% CI=0.71-0.97, p=0.017), and 55 years and older (OR=0.14; 95% CI=0.04-0.48, p=0.002) exhibited lower likelihoods of having low PrEP uptake than those aged 15-19 years. Moreover, individuals residing with their families (aOR=0.71; 95% CI=0.58-0.87, p<0.001), living with roommates (aOR=0.7; 95% CI=0.5-0.97, p=0.032) displayed lower odds for experiencing low PrEP uptake than their counterparts living alone.

Conclusion

This study highlighted the low uptake of PrEP among participants when compared to previous studies. These results revealed significant influences of age and living conditions on PrEP usage.

Population-level impact of expanding PrEP coverage by offering long-acting injectable PrEP to MSM in three high-resource settings: a model comparison analysis

INTRODUCTION

Long-acting injectable cabotegravir (CAB-LA) demonstrated superiority to daily tenofovir disoproxil fumarate/emtricitabine (TDF/FTC) for HIV pre-exposure prophylaxis (PrEP) in the HPTN 083/084 trials. We compared the potential impact of expanding PrEP coverage by offering CAB-LA to men who have sex with men (MSM) in Atlanta (US), Montreal (Canada) and the Netherlands, settings with different HIV epidemics.

METHODS

Three risk-stratified HIV transmission models were independently parameterized and calibrated to local data. In Atlanta, Montreal and the Netherlands, the models, respectively, estimated mean TDF/FTC coverage starting at 29%, 7% and 4% in 2022, and projected HIV incidence per 100 person-years (PY), respectively, decreasing from 2.06 to 1.62, 0.08 to 0.03 and 0.07 to 0.001 by 2042. Expansion of PrEP coverage was simulated by recruiting new CAB-LA users and by switching different proportions of TDF/FTC users to CAB-LA. Population effectiveness and efficiency of PrEP expansions were evaluated over 20 years in comparison to baseline scenarios with TDF/FTC only.

RESULTS

Increasing PrEP coverage by 11 percentage points (pp) from 29% to 40% by 2032 was expected to avert a median 36% of new HIV acquisitions in Atlanta. Substantially larger increases (by 33 or 26 pp) in PrEP coverage (to 40% or 30%) were needed to achieve comparable reductions in Montreal and the Netherlands, respectively. A median 17 additional PYs on PrEP were needed to prevent one acquisition in Atlanta with 40% PrEP coverage, compared to 1000+ in Montreal and 4000+ in the Netherlands. Reaching 50% PrEP coverage by 2032 by recruiting CAB-LA users among PrEP-eligible MSM could avert >45% of new HIV acquisitions in all settings. Achieving targeted coverage 5 years earlier increased the impact by 5-10 pp. In the Atlanta model, PrEP expansions achieving 40% and 50% coverage reduced differences in PrEP access between PrEP-indicated White and Black MSM from 23 to 9 pp and 4 pp, respectively.

CONCLUSIONS

Achieving high PrEP coverage by offering CAB-LA can impact the HIV epidemic substantially if rolled out without delays. These PrEP expansions may be efficient in settings with high HIV incidence (like Atlanta) but not in settings with low HIV incidence (like Montreal and the Netherlands).

Risk Factors Associated with Loss to Follow-up Among Transgender Women Receiving HIV Pre-exposure Prophylaxis in Chiang Mai province, Thailand

Although HIV pre-exposure prophylaxis (PrEP) is free in Thailand, many transgender women discontinue taking it after initiation. We determined the loss to follow-up (LTFU) rate of transgender women who initiated PrEP at the Mplus Foundation, Chiang Mai, Thailand, and identified associated risk factors using Cox proportional hazard models. Of 235 participants who initiated PrEP, 59 (55%) out of 108 remaining participants had reactive syphilis. The LTFU rate at 6 months was 38% (95% confidence interval [CI]: 29-48%). Multivariable analysis indicates that LTFU is independently associated with age ≥ 26 years old (adjusted hazard ratio [aHR] = 2.09; 95% CI: 1.06-4.14) and reactive syphilis (aHR = 1.98; 95% CI:1.01-3.88). Delayed appointment scheduling by the PrEP providers and the syphilis clinic was associated with transgender women having reactive syphilis, and the lockdown policy during the COVID-19 pandemic might have influenced them to discontinue PrEP and their subsequent LTFU.

The Long-Acting Cabotegravir Tail as an Implementation Challenge: Planning for Safe Discontinuation

The long-acting feature of cabotegravir, an integrase-inhibitor highly effective in preventing acquisition of HIV in adolescents and adults, is both its greatest strength and a challenge to its implementation. Cab-LA is administered at 8-week intervals (after an initial loading dose) but has a long, variable drug "tail" that may leave users vulnerable to future drug resistance if they contract HIV during this critical period. The potential for cab-LA to meaningfully contribute to ending the HIV Epidemic is hindered by, among other factors, limited resources to guide patients and providers on how to safely discontinue injections. We suggest three key strategies to overcome this specific challenge: (1) Comprehensive patient education and counseling about the drug tail; (2) Training and coaching PrEP care teams, including clinical and non-clinical staff, on communication around the tail; (3) Adherence support strategies, including monitoring of cabotegravir drug levels after discontinuation, for a personalized medicine approach to safe discontinuation.

An overview of programmatic indicators to monitor the roll-out of HIV preexposure prophylaxis

Preexposure prophylaxis (PrEP) is increasingly implemented in national HIV prevention programmes through routine care. Monitoring will be vital to understand whether programmes succeed in engaging people into using PrEP appropriately, and in reducing the HIV epidemic. Yet, it is currently unclear which indicators are most suited to monitor PrEP programmes' performance. We therefore aimed to identify and map indicators that are currently used or suggested for monitoring PrEP programmes. We conducted a scoping review based on the framework by Arksey and O'Malley. We combined a systematic search in the peer-reviewed literature with hand-searching grey literature documents describing indicators and strategies that are used or suggested for PrEP monitoring. Only literature published after 2012 was included. No geographical restrictions were set. We charted data on indicator definitions, data sources used, reported experiences with monitoring and any relevant contextual factors. Ultimately, 35 peer-reviewed and 14 grey literature records were included. We identified indicators related to preuptake stages of PrEP, uptake and coverage, and programme impact. The indicators most commonly suggested for national-level monitoring were the number of new and current PrEP users, the number of HIV seroconversions among PrEP users and some variably defined indicators related to continuation and discontinuation of PrEP. Despite its perceived high relevance, studies reported several challenges to routinely monitor the population in need of PrEP and track prevention-effective PrEP use. In conclusion, a variety of indicators is currently used or suggested for monitoring PrEP programmes. Implementing proxy measures that track different aspects of PrEP use over time, and making synergies with research more explicit, could be used as strategies to obtain more granular insights into trends revealed by routine monitoring.

Travestis, transgender women and young MSM are at high risk for PrEP early loss to follow-up in Rio de Janeiro, Brazil

INTRODUCTION

Oral pre-exposure prophylaxis (PrEP) with emtricitabine/tenofovir (FTC/TDF) is highly effective in preventing HIV infection. This study aimed to identify factors associated with PrEP early loss to follow-up (ELFU) among gay, bisexual and other men who have sex with men (MSM), travestis and transgender women (TGW).

METHODOLOGY

This was a prospective cohort study evaluating TGW and MSM who initiated PrEP at the Evandro Chagas National Institute of Infectious Diseases (INI-Fiocruz) from 2014 to 2020. ELFU was defined as not returning for a PrEP visit within 180 days after first dispensation. Exposure variables included age, gender, race, education, transactional sex, condomless anal intercourse [CAI] (both in the past six months), binge drinking and substance use (both in past three months) and syphilis diagnosis at baseline. Multilevel logistic regression models with random intercepts and fixed slopes were used to identify factors associated with ELFU accounting for clustering of participants according to their PrEP initiation study/context (PrEP Brasil, PrEParadas, ImPrEP and PrEP SUS).

RESULTS

Among 1,463 participants, the median age was 29 years (interquartile range 24-36), 83% self-identified as MSM, 17% as TGW, 24% were black, 37% mixed-black/pardo and 30% had < 12 years of education. Fifteen percent reported transactional sex, 59% reported CAI, 67% binge drinking, 33% substance use, and 15% had a syphilis diagnosis. Overall, 137 participants (9.7%) had ELFU. Younger age (18-24 years) (adjusted odds ratio [aOR] 1.9, 95%CI:1.2-3.2), TGW (aOR 2.8, 95%CI:1.6-4.8) and education < 12 years (aOR 1.9, 95%CI:1.2-2.9) were associated with greater odds of ELFU.

CONCLUSION

TGW, young individuals and those with lower education were at higher risk of PrEP ELFU. Our results suggest that the development of specific strategies targeting these populations should be a priority, through policies that aim to reduce the incidence of HIV infection.

Chemsex and incidence of sexually transmitted infections among Canadian pre-exposure prophylaxis (PrEP) users in the l'Actuel PrEP Cohort (2013-2020)

OBJECTIVES

Use of illicit substances during sex (chemsex) may increase transmission of HIV and other STIs. Pre-exposure prophylaxis (PrEP) is highly effective at preventing HIV transmission, providing an important prevention tool for those who practise chemsex. However, it does not prevent acquisition of other STIs. We aim to examine the impact of chemsex on STI incidence among gay, bisexual and other men who have sex with men (gbMSM), and transgender women using PrEP in Montréal, Canada.

METHODS

We linked baseline sociodemographic and behavioural data with follow-up STI testing from 2013 to 2020 among PrEP users in the l'Actuel PrEP Cohort (Canada). Focusing on the 24 months following PrEP initiation, we estimated the effect of chemsex reported at baseline on cumulative incidence of gonorrhoea and chlamydia using Kaplan-Meier curves and survival analyses. We investigated the role of polysubstance use and effect modification by sociodemographic factors.

RESULTS

There were 2086 clients (2079 cisgender gbMSM, 3 transgender gbMSM, 4 transgender women) who initiated PrEP, contributing 1477 years of follow-up. There were no incident HIV infections among clients on PrEP. Controlling for sociodemographic confounders, clients reporting chemsex at baseline had a 32% higher hazard of gonorrhoea/chlamydia diagnosis (adjusted HR=1.32; 95% CI: 1.10 to 1.57), equivalent to a risk increase of 8.9 percentage points (95% CI: 8.5 to 9.4) at 12 months. The effect was greater for clients who reported polysubstance use (adjusted HR=1.51; 95% CI: 1.21 to 1.89). The strength of the effect of chemsex on STI incidence varied by age, education and income.

CONCLUSION

Among PrEP users, chemsex at baseline was linked to increased incidence of gonorrhoea and chlamydia. This effect was stronger for people reporting multiple chemsex substances. The high STI incidence among gbMSM who report chemsex highlights the importance of PrEP for this population and the need for integrated services that address the complexities of sexualised substance use.

Retrospective audit of a convenience cohort of individuals on HIV pre-exposure prophylaxis in Alberta, Canada

BACKGROUND

We undertook an audit of a province-wide HIV pre-exposure prophylaxis (PrEP) program in Alberta (Canada).

METHODS

A retrospective record review of individuals accessing PrEP in Alberta included demographics, PrEP indication(s), and reported non-prescription drug and alcohol use from March 2016 to June 2019. Hepatitis A, B, C, HIV and syphilis serology, serum creatinine, and nucleic acid amplification tests testing for chlamydia and gonorrhea were collected. Descriptive statistics, incidence, and prevalence were calculated.

RESULTS

A total of 511 participants were seen at STI, sexual, and reproductive health clinics and private family practitioner (FP) offices; 98.4% (503) were men, median age was 34 years (IQR 28-43 years), and 89.8% (459) were gay or bisexual men who have sex with men. Non-prescription drug use was reported by 39.3% (201) and alcohol use by 55.4% (283). 94.3% (482) reported condomless anal sex in the past 6 months. Testing rates were high (>95%) for all tests except for chlamydia and gonorrhea at the first follow-up visit 89.6%; (3-4 months). There was one HIV seroconversion. The incidence of new bacterial STIs was high: chlamydia 17 cases per 100 person-years (95% CI 13.5% to 21.4%), gonorrhea 11.14 cases per 100 person-years (95% CI 8.3% to 15.0%), and syphilis 1.94 cases per 100 person-years (95% CI 0.73% to 5.12%).

CONCLUSIONS

Following implementation of a provincial program for PrEP in Alberta, PrEP initiation and continuation was feasible in a range of settings and by both specialists and FPs.

Brief Report: Previous Preexposure Prophylaxis Use Among Men Who Have Sex With Men Newly Diagnosed With HIV Infection in King County, WA

BACKGROUND

Preexposure prophylaxis (PrEP) discontinuations are common and are associated with subsequent HIV acquisition. The population-level impact of PrEP discontinuations is unknown.

METHODS

Public health staff routinely asked men who have sex with men (MSM) with newly diagnosed HIV infection about their history of PrEP use as part of partner notification interviews in King County, WA, from 2013 to 2021. We assessed trends in the proportion of MSM who ever took PrEP and described reasons for PrEP discontinuation.

RESULTS

A total of 1098 MSM were newly diagnosed with HIV during the study period; of whom, 797 (73%) were interviewed, and 722 responded to questions about their history of PrEP use. Ninety-four (13%) reported ever taking PrEP. The proportion of MSM who ever used PrEP before HIV diagnosis increased from 2.3% in 2014 to 26.6% in 2020-2021 ( P < 0.001 for trend). The median time from PrEP discontinuation to HIV diagnosis was 152 days, and median duration on PrEP was 214 days. Common reasons for stopping PrEP included self-assessment as being at low risk for HIV, side effects, and insurance issues. Nineteen men were on PrEP at the time of HIV diagnosis; mutations conferring emtricitabine/tenofovir resistance were identified in 8 (53%) of 15 men with available genotype data.

CONCLUSION

More than 25% of MSM with newly diagnosed HIV from 2020 to 2021 had ever used PrEP. More than 50% who discontinued PrEP were diagnosed <6 months after stopping. Strategies to preempt PrEP discontinuations, enhance retention, and facilitate resumption of PrEP are critical to decrease new HIV diagnoses.

A multi-country cross-sectional study to assess predictors of daily versus on-demand oral pre-exposure prophylaxis in youth from South Africa, Uganda and Zimbabwe

INTRODUCTION

Sub-Saharan Africa (SSA) carries the burden of the HIV epidemic, especially among adolescents and young people (AYP). Little is known about pre-exposure prophylaxis (PrEP) uptake and preferences among AYP in SSA. We describe preferences for daily and on-demand PrEP among AYP in South Africa, Uganda and Zimbabwe.

METHODS

A cross-sectional survey was conducted in 2019 among 13- to 24-year olds, capturing socio-demographics, HIV risk behaviours and preferences for daily or on-demand PrEP. Logistic regression models were used to estimate odds ratios, adjusting for site, sex and age.

RESULTS AND DISCUSSION

A total of 1330 participants from Cape Town (n = 239), Johannesburg (n = 200), Entebbe (n = 491) and Chitungwiza (n = 400) were enrolled; 673 (51%) were male, and the median age was 19 years (interquartile range 17-22 years). Of 1287 participants expressing a preference, 60% indicated a preference for on-demand PrEP with differences by site (p < 0.001), sex (p < 0.001) and age group (p = 0.003). On-demand PrEP was most preferred in Entebbe (75%), among males (65%) versus females (54%) and in older participants (62% in 18- to 24-year-olds vs. 47% in 13- to 15-year-olds). After adjusting for site, sex and age group, preference for on-demand PrEP decreased as sex frequency over the past month increased (p-trend = 0.004) and varied with the number of partners in the last 6 months, being least popular among those reporting four or more partners (p = 0.02). Participants knowing further in advance that they were likely to have sex were more likely to prefer on-demand PrEP (p-trend = 0.02). Participants having a larger age gap with their most recent partner and participants whose last partner was a transactional sex partner or client were both less likely to prefer on-demand compared to daily PrEP (p = 0.05 and p = 0.09, respectively). Participants who knew their most recent partner was living with HIV or who did not know the HIV status of their most recent partner were less likely to prefer on-demand PrEP (p = 0.05).

CONCLUSIONS

Our data show that AYP in four SSA communities prefer on-demand over daily PrEP options, with differences seen by site, age and sex. PrEP demand creation needs to be reviewed, optimized and tailored to socio-demographic differences and designed in conjunction with AYP.

Texting Lost-to-follow-up PrEP Patients from a San Francisco Sexual Health Clinic

It is critical to understand what happens when PrEP patients are lost-to-follow-up (LTFU) and, where appropriate, attempt to re-engage them in care with the goal of preventing future human immunodeficiency virus (HIV) acquisition. We evaluated the benefits and limitations of using text-based outreach to re-engage with LTFU PrEP patients and offer re-initiation of PrEP care. Using text-messaging, we surveyed San Francisco City Clinic patients who started PrEP from January 2015 to October 2019 and were LTFU by October 1, 2020. Our goals were to better understand (1) whether our patients remained on PrEP through another provider or source, (2) why patients choose to discontinue PrEP, and (3) whether text-based outreach could successfully re-engage such patients in care. Multiple-choice survey questions were analyzed quantitatively to determine the proportion of respondents selecting each option; free-text responses were analyzed qualitatively using an inductive approach to identify any additional recurring themes. Of 846 eligible survey recipients, 130 responded (overall response rate 15.4%). Forty-two respondents (32.3%) were still on PrEP through another provider while 88 (67.7%) were not. Common reasons for stopping PrEP included: COVID-19–related changes in sex life (32.3% of responses), concerns regarding side effects (17.7%), and the need to take a daily pill (8.3%). Free text responses revealed additional concerns regarding risk compensation. While 32 participants agreed to be contacted by City clinic staff for PrEP counseling, only 6 were reached by phone and none of the six subsequently restarted PrEP. We learned that text messaging is a possible approach to survey certain PrEP program participants to determine who is truly LTFU and off PrEP, and to better understand reasons for PrEP discontinuation. While such information could prove valuable as programs seek to address barriers to PrEP retention, efforts to improve acceptability and increase response rates would be necessary. We were less successful in re-engaging LTFU patients in PrEP care, suggesting that text-messaging may not be the optimal strategy for this purpose.

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

BACKGROUND

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

METHODS

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

FINDINGS

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

INTERPRETATION

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

FUNDING

National Institutes of Health and Nature Science Foundation of China.

Past dynamics of HIV transmission among men who have sex with men in Montréal, Canada: a mathematical modeling study

BACKGROUND

Gay, bisexual, and other men who have sex with men (gbMSM) experience disproportionate risks of HIV acquisition and transmission. In 2017, Montréal became the first Canadian Fast-Track City, setting the 2030 goal of zero new HIV infections. To inform local elimination efforts, we estimate the evolving role of prevention and sexual behaviours on HIV transmission dynamics among gbMSM in Montréal between 1975 and 2019.

METHODS

Data from local bio-behavioural surveys were analyzed to develop, parameterize, and calibrate an agent-based model of sexual HIV transmission. Partnership dynamics, HIV's natural history, and treatment and prevention strategies were considered. The model simulations were analyzed to estimate the fraction of HIV acquisitions and transmissions attributable to specific groups, with a focus on age, sexual partnering level, and gaps in the HIV care-continuum.

RESULTS

The model-estimated HIV incidence peaked in 1985 (2.3 per 100 person years (PY); 90% CrI: 1.4-2.9 per 100 PY) and decreased to 0.1 per 100 PY (90% CrI: 0.04-0.3 per 100 PY) in 2019. Between 2000-2017, the majority of HIV acquisitions and transmissions occurred among men aged 25-44 years, and men aged 35-44 thereafter. The unmet prevention needs of men with > 10 annual anal sex partners contributed 90-93% of transmissions and 67-73% of acquisitions annually. The primary stage of HIV played an increasing role over time, contributing to 11-22% of annual transmissions over 2000-2019. In 2019, approximately 70% of transmission events occurred from men who had discontinued, or never initiated antiretroviral therapy.

CONCLUSIONS

The evolving HIV landscape has contributed to the declining HIV incidence among gbMSM in Montréal. The shifting dynamics identified in this study highlight the need for continued population-level surveillance to identify gaps in the HIV care continuum and core groups on which to prioritize elimination efforts.

Perceptions, motivations, and beliefs about HIV risk and pre-exposure prophylaxis (PrEP) among participants in a nurse-led PrEP service (PrEP-RN)

Background

While HIV pre-exposure prophylaxis (PrEP) has become more readily available in Canada, its uptake among HIV priority populations continues to be affected by system-level and individual factors. Such impediments relate to challenges by healthcare providers in assessing HIV-related risk and variability in patients’ motivations for PrEP initiation and continued engagement in care.

Methods

In Ottawa, Canada, a group of researchers implemented Canada’s first nurse-led HIV prevention program, known as PrEP-RN. As part of this pilot, qualitative interviews were completed with fourteen patients who had accessed PrEP-RN. The purpose of these interviews was to understand participants’ perspectives related to HIV prevention and experiences accessing care through a nurse-led service. Interviews were analyzed using thematic analysis, which were organized into the two major themes of (1) motivations for PrEP initiation and (2) beliefs about the benefits of PrEP.

Results

Findings revealed participants’ motivations for PrEP differed from healthcare provider’s views of risk, which were influenced by external life factors and personal perceptions of risk. In addition, participants discussed the benefits of PrEP in terms of its ability to manage their potential mistrust of sexual partners, control their sexual health, and liberate fears and anxieties related to HIV.

Conclusions

Based on these findings, health and allied providers should consider incorporating individual motivations and beliefs into patient education and counselling about PrEP to better target HIV prevention care at persons are at elevated risk of HIV. These perspectives could also be used to re-structure web and social media campaigns to increase PrEP uptake among HIV priority populations.

Characteristics of new HIV diagnoses over 1995-2019: A clinic-based study in Montréal, Canada

BACKGROUND

Characterization of populations at risk of acquiring HIV is required to inform the public health response to HIV. To identify potential changing needs in HIV prevention and care cascade, we aim to describe how the demographic profiles and exposure categories of newly diagnosed HIV positive individuals attending a large sexual health clinic in Montréal (Canada) evolved since the beginning of the antiretroviral therapy era in the mid-1990s.

METHODS

Using diagnosis data from participants of the Clinique médicale l'Actuel cohort of HIV-positive patients, we examined the distribution of exposure categories (sexual orientation, sexual behaviours, injection drug use, being born in an HIV-endemic country) by gender and year of diagnosis. Time trends in mean age and in the proportion of patients with late (CD4 <350 cells/μL) or advanced stage (CD4 <200 cells/μL) of HIV infection at diagnosis were assessed through meta-regressions.

RESULTS

A total of 2,612 patients diagnosed with HIV between January 1st, 1995 and December 31st, 2019 were included. Overall, mean age was 35 years (standard deviation: 10 years) and remained stable over time. The proportion of patients with advanced stage of HIV infection decreased from 16% in 1995 to 4% in 2019. Although men who have sex with men (MSM) consistently accounted for the highest proportion of new diagnoses (77%, 2,022/2,612 overall), their proportion decreased since 2013. There was also a concomitant decrease in the proportion of people who inject drugs, with none of the newly diagnosed participants reporting injection drug use since 2017, and an important increase in the proportion of patients born in an HIV-endemic country (24%, 7/29 in 2019), especially among women. Compared to patients from non-endemic countries, those from HIV-endemic countries were characterized by higher proportions of heterosexuals (88% vs 17%) and of women (52% vs 7%), and were twice likely to get diagnosed at an advanced stage of HIV infection (32% vs 15%).

CONCLUSIONS

In absolute numbers, MSM continue to account for the largest exposure category. However, patients from HIV-endemic countries, who tend to be diagnosed at later stages of HIV infection, constitute an increasing proportion of newly diagnosed individuals. These persons could face distinct barriers to rapid diagnosis. Tailoring HIV testing strategies and other prevention interventions to the specific unmet prevention needs of these individuals is warranted.

Participation, retention and uptake in a multicentre pre-exposure prophylaxis cohort using online, smartphone-compatible data collection

Objectives

The aim of the study was to assess the feasibility of a national pre‐exposure prophylaxis (PrEP) programme using smartphone‐compatible data collection.

Methods

This was a multicentre cohort study (NCT03893188) enrolling individuals interested in PrEP in Switzerland. All centres participate in the SwissPrEPared programme, which uses smartphone‐compatible data collection. Feasibility was assessed after centres had enrolled at least one participant. Participants were HIV‐negative individuals presenting for PrEP counselling. Outcomes were participation (number enrolled/number eligible), enrolment rates (number enrolled per month), retention at first follow‐up (number with first follow‐up/number enrolled), and uptake (proportion attending first visit as scheduled). Participant characteristics were compared between those retained after baseline assessment and those who dropped out.

Results

Between April 2019 and January 2020, 987 individuals were assessed for eligibility, of whom 969 were enrolled (participation: 98.2%). The median enrolment rate was 86 per month [interquartile range (IQR) 52–137]. Retention at first follow‐up and uptake were both 80.7% (782/969 and 532/659, respectively). At enrolment, the median age was 40 (IQR 33–47) years, 95% were men who have sex with men, 47% had a university degree, and 75.5% were already taking PrEP. Most reported multiple casual partners (89.2%), previous sexually transmitted infections (74%) and sexualized drug use (73.1%). At baseline, 25.5% tested positive for either syphilis, gonorrhoea or chlamydia. Participants who dropped out were at lower risk of HIV infection than those retained after baseline assessment.

Conclusions

In a national PrEP programme using smartphone‐compatible data collection, participation, retention and uptake were high. Participants retained after baseline assessment were at considerable risk of HIV infection. Younger, less educated individuals were underrepresented in the SwissPrEPared cohort.

Pre-Exposure Prophylaxis Among Gay, Bisexual, and Other Men Who Have Sex With Men in Ottawa: A Real World View With Benefits Beyond HIV Risk Reduction

The number of gay, bisexual, and other men who have sex with men taking pre-exposure prophylaxis (PrEP) has grown since its approval in Canada. While there are sound clinical data on PrEP efficacy, there is less research describing outcomes in routine clinical practice. We conducted a cross-sectional study with 113 men attending our PrEP clinic. Participants completed a one-time survey and chart reviews were conducted. We found that men in our clinic were educated and affluent. While PrEP did not lead to more reported sexual partners, condom use declined, as did sexual anxiety. These results reinforce that PrEP benefits extend beyond HIV prevention.

Chemsex practices and pre-exposure prophylaxis (PrEP) trajectories among individuals consulting for PrEP at a large sexual health clinic in Montréal, Canada (2013-2020)

INTRODUCTION

Chemsex among gay, bisexual and other men who have sex with men (gbMSM) has raised public health concerns because of its association with sexual behaviours that can increase transmission of sexually transmitted infections, including HIV. Pre-exposure prophylaxis (PrEP) is highly effective at blocking HIV acquisition, addressing important prevention needs among individuals practicing chemsex. This study aims to improve our understanding of chemsex practices and PrEP trajectories of gbMSM and transgender women consulting for PrEP.

METHODS

We used data from the PrEP cohort of Clinique médicale l'Actuel, a major sexual health clinic in Montréal. We describe the sociodemographic profile of clients consulting for PrEP, characterize chemsex and polysubstance use trends over time, and evaluate PrEP trajectories using Kaplan-Meier curves.

RESULTS

Among 2923 clients who consulted for PrEP between 2013-2020 (2910 cisgender gbMSM, 6 transgender gbMSM, 7 transgender women), 24 % reported chemsex in the past year and 13 % reported polysubstance use. The most common chemsex substances were ecstasy (14 %), GHB (13 %), and cocaine (12 %). The proportion of clients reporting chemsex and polysubstance use decreased over time. In both the chemsex and no-chemsex group, 73 % of clients initiated PrEP. The median time to discontinuation was similar between the chemsex (6.5 months; 95 %CI: 5.3-7.2) and no-chemsex group (6.9 months; 95 %CI: 6.3-7.5).

CONCLUSION

Chemsex is not a barrier to PrEP initiation or persistence. However, these results suggest a high prevalence of chemsex among gbMSM consulting for PrEP, highlighting the need for services addressing the intersection of sexual health and substance use for this population.

The Role of Phylogenetics in Unravelling Patterns of HIV Transmission towards Epidemic Control: The Quebec Experience (2002-2020)

Phylogenetics has been advanced as a structural framework to infer evolving trends in the regional spread of HIV-1 and guide public health interventions. In Quebec, molecular network analyses tracked HIV transmission dynamics from 2002-2020 using MEGA10-Neighbour-joining, HIV-TRACE, and MicrobeTrace methodologies. Phylogenetics revealed three patterns of viral spread among Men having Sex with Men (MSM, n = 5024) and heterosexuals (HET, n = 1345) harbouring subtype B epidemics as well as B and non-B subtype epidemics (n = 1848) introduced through migration. Notably, half of new subtype B infections amongst MSM and HET segregating as solitary transmissions or small cluster networks (2-5 members) declined by 70% from 2006-2020, concomitant to advances in treatment-as-prevention. Nonetheless, subtype B epidemic control amongst MSM was thwarted by the ongoing genesis and expansion of super-spreader large cluster variants leading to micro-epidemics, averaging 49 members/cluster at the end of 2020. The growth of large clusters was related to forward transmission cascades of untreated early-stage infections, younger at-risk populations, more transmissible/replicative-competent strains, and changing demographics. Subtype B and non-B subtype infections introduced through recent migration now surpass the domestic epidemic amongst MSM. Phylodynamics can assist in predicting and responding to active, recurrent, and newly emergent large cluster networks, as well as the cryptic spread of HIV introduced through migration.

Choosing event-driven and daily HIV pre-exposure prophylaxis - data from two European PrEP demonstration projects among men who have sex with men

INTRODUCTION

Daily and event-driven PrEP are both efficacious in reducing the risk for HIV infection. However, the practice of event-driven PrEP (edPrEP) is less well studied, in particular when provided as an alternative to daily PrEP. We studied regimen preferences and switches, and sexually transmitted infection (STI) incidence.

METHODS

We analysed pooled data from two prospective cohort studies among MSM: Be-PrEP-ared, Belgium and AMPrEP, the Netherlands. In both projects, participants could choose between daily and edPrEP at three-monthly study visits, when they were also screened for sexually transmitted infections including hepatitis C (HCV). We assessed the proportion choosing each regimen, and the determinants of choosing edPrEP at baseline. Additionally, we compared the incidence rates (IRs) of HCV, syphilis and chlamydia or gonorrhoea between regimens using Poisson regression. The study period was from 3 August 2015 until 24 September 2018.

RESULTS AND DISCUSSION

We included 571 MSM, of whom 148 (25.9%) chose edPrEP at baseline. 31.7% of participants switched regimen at least once. After 28 months, 23.5% used edPrEP. Older participants (adjusted odds ratio (aOR) = 1.38 per 10 years, 95% confidence interval (CI) = 1.15 to 1.64) and those unemployed (aOR = 1.68, 95% CI = 1.03 to 1.75) were more likely to initially choose edPrEP. IR of HCV and syphilis did not differ between regimens, but the IR of chlamydia/gonorrhoea was higher among daily users (adjusted incidence rate ratio = 1.61, 95% CI = 1.35 to 1.94).

CONCLUSIONS

A quarter of participants chose edPrEP at baseline and at 28 months this proportion was similar. Although the IR of HCV and syphilis were similar in the two regimens, the lower incidence of chlamydia and gonorrhoea among edPrEP users may suggest that less frequent STI testing of this group could be considered.

Long-term protection from HIV infection with oral HIV pre-exposure prophylaxis in gay and bisexual men: findings from the expanded and extended EPIC-NSW prospective implementation study

BACKGROUND

Daily pre-exposure prophylaxis (PrEP) is effective in preventing HIV, but few long-term data are available on effectiveness and adherence in real-world settings. Here, we report trends in HIV incidence over 3 years in individuals at high risk who were prescribed PrEP in New South Wales (NSW), as well as adherence before the transition to subsidised PrEP.

METHODS

Expanded PrEP Implementation in Communities-New South Wales (EPIC-NSW) was a pragmatic, prospective, single-arm, implementation study of daily, oral PrEP in 31 sites (sexual health clinics, general practices, and a hospital) in NSW, Australia. Eligible participants were HIV-negative adults (aged ≥18 years) who were at high risk of HIV infection as defined in local PrEP guidelines. Participants were prescribed coformulated (once-daily, oral tablet) tenofovir disoproxil fumarate (300 mg) and emtricitabine (200 mg) as HIV PrEP and were followed up with HIV testing, sexually transmitted infection testing, and PrEP dispensing. Originally planned for 3700 participants followed for 1 year, the study was expanded so that all eligible participants in the state could obtain PrEP and extended until publicly subsidised PrEP became available in Australia. The primary outcome was new HIV infection among all participants who were dispensed PrEP at least once and had at least one follow-up HIV test result. Adherence was estimated by medication possession ratio (MPR), defined as the proportion of PrEP pills dispensed in 90 days, assuming daily dosing. This study is registered with ClinicalTrials.gov, NCT02870790.

FINDINGS

Between March 1, 2016, and April 30, 2018, we enrolled 9709 participants. 9596 participants were dispensed PrEP, of whom 9448 (98·3%) were gay or bisexual men. Participants were followed up until March 31, 2019, with at least one follow-up HIV test available in 9520 (99·2%) participants. Mean MPR declined from 0·93 to 0·64 from the first to the ninth quarter. There were 30 HIV seroconversions over 18 628 person-years, an incidence of 1·61 per 1000 person-years (95% CI 1·13-2·30). Being younger, living in a postcode with fewer gay men, reporting more risk behaviours at baseline, and having an MPR of less than 0·6 were each univariately associated with increased HIV incidence. In the final year of follow-up, when PrEP was mostly purchased rather than provided free by the study, HIV incidence remained low at 2·24 per 1000 person-years (1·46-3·44).

INTERPRETATION

HIV incidence remained low over up to 3 years of follow-up, including during a transition from study-provided to publicly subsidised PrEP. In a setting of affordable PrEP and associated health-care services, very low HIV incidence of 1 to 2 per 1000 person-years can be maintained in gay and bisexual men who were previously at high risk.

FUNDING

New South Wales Ministry of Health, Australian Capital Territory Health Directorate, Gilead Sciences.

Population-Level Effectiveness of HIV Pre-exposure Prophylaxis Among MSM and Transgender Persons With Bacterial Sexually Transmitted Infections

BACKGROUND

Pre-exposure prophylaxis (PrEP) is highly efficacious, but its effectiveness may be limited by poor adherence or discontinuation. Our objective was to estimate the effectiveness of real-world PrEP use in a population at increased risk of HIV infection.

SETTING

King County, Washington.

METHODS

We conducted a retrospective cohort study using sexually transmitted infection (STI) partner services (PS) interview data collected January 2014-August 2018 in King County, Washington, USA. During PS interviews, men who have sex with men and transgender persons who have sex with men were asked if they were taking PrEP. We linked STI PS data to HIV surveillance data to estimate HIV incidence among self-reported PrEP users vs. nonusers using Cox proportional hazards regression, adjusting for age, race/ethnicity, and calendar year.

RESULTS

Among 4368 individuals, 1206 (28%) were taking PrEP at the time of the PS interview. The median observation time was 14 months (interquartile range 6-23 months). Five (0.4%) of 1206 PrEP users and 97 (3%) of 2162 PrEP nonusers were subsequently diagnosed with HIV (P < 0.001). HIV incidence was lower among PrEP users than nonusers [0.17 vs. 1.86 cases per 100 person-years, adjusted hazards ratio 0.21 (95% confidence interval: 0.08 to 0.58)]. Latinx ethnicity, Native Hawaiian/Pacific Islander ethnicity, gonorrhea, and syphilis were also independently associated with higher HIV risk.

CONCLUSIONS

Self-reported PrEP use was associated with a 79% reduction in HIV incidence among men who have sex with men and transgender persons who have sex with men with STIs in King County.

Profiles of HIV Risk, Sexual Power, and Decision-Making among Sexual Minority Men of Color Who Engage in Transactional Sex: A Latent Profile Analysis

Though the transmission of HIV is preventable, there were still 37,968 new documented cases in the United States in 2018. HIV incidence is disproportionate in sexual minority men of color. The purpose of this study was to examine sexual relationship power risk profiles to identify distinct subgroups within the profiles who carry the highest HIV risk. Latent class profile analysis was used to identify subgroups of sexual minority men of color at the highest risk for contracting HIV based on their sexual power profiles. Among 322 sexual minority men, we identified four latent profiles. Profile 1: Low transactional sex and high power (n = 133; 14.3%); Profile 2: Transactional sex, high decision-making in sexual relationships, and low control in sexual relationship (n = 99; 30.7%); Profile 3: Low transactional sex, low decision-making, and moderate control (n = 43; 13.4%); Profile 4: High transactional sex and low power (n = 47; 14.6%). LPA was useful to identify distinct subgroups based on measures of sexual risk and relationship sexual power. Findings carry significant implications for developing tailored strategies to increase HIV knowledge and related HIV prevention and risk reduction services for sexual minority men of color who engage in transactional sex.

Patterns of PrEP Retention Among HIV Pre-exposure Prophylaxis Users in Baltimore City, Maryland

BACKGROUND

HIV pre-exposure prophylaxis (PrEP) retention, defined as quarterly clinical evaluation, is critical to reducing HIV incidence. Our objectives were to determine: (1) visit- and individual-level PrEP retention patterns; (2) and individual-level characteristics associated with low-level PrEP retention 12 months after initiation among PrEP users in Baltimore City, Maryland.

METHODS

Information was abstracted from medical records among individuals initiating PrEP between October 1, 2015 and February 28, 2018. Visit-level PrEP retention was defined as evidence of PrEP use, documented PrEP prescription, or current PrEP use at each quarterly follow-up visit. Low-level PrEP retention was defined as <3/4 quarters with documented PrEP use. Multilevel mixed effects Poisson regression was used to determine characteristics associated with low-level PrEP retention.

RESULTS

Among 412 individuals initiating PrEP and followed for 12 months, the majority was: cis-gender male (83.7%, n = 345), non-Hispanic Black (56.3%, n = 232) and gay, bisexual, or other man who has sex with men (74.0%, n = 305). By quarterly visits, PrEP retention was: 3-month: 69.4% (n = 286); 6-month: 51.9% (n = 214); 9-month: 44.5% (n = 183); and 12-month: 41.1% (n = 169). Three-fifths (58.5%, n = 241) had low-level PrEP retention. Cis-gender females (vs. cis-gender males) (adjusted relative risk: 1.36, 95% confidence interval: 1.04 to 1.77) were more likely to have low-level PrEP retention.

CONCLUSIONS

Our observed PrEP retention rates are lower than what may be needed to reduce HIV incidence. Future research should examine individual- and clinic-level barriers and facilitators to PrEP retention programs by key population to inform interventions for PrEP retention.

Can the combination of TasP and PrEP eliminate HIV among MSM in British Columbia, Canada?

INTRODUCTION

In British Columbia (BC), the HIV epidemic continues to disproportionally affect the gay, bisexual and other men who have sex with men (MSM). In this study, we aimed to evaluate how Treatment as Prevention (TasP) and pre-exposure prophylaxis (PrEP), if used in combination, could lead to HIV elimination in BC among MSM.

METHODS

Considering the heterogeneity in HIV transmission risk, we developed a compartmental model stratified by age and risk-taking behaviour for the HIV epidemic among MSM in BC, informed by clinical, behavioural and epidemiological data. Key outcome measures included the World Health Organization (WHO) threshold for disease elimination as a public health concern and the effective reproduction number (R_e). Model interventions focused on the optimization of different TasP and PrEP components. Sensitivity analysis was done to evaluate the impact of sexual mixing patterns, PrEP effectiveness and increasing risk-taking behaviour.

RESULTS

The incidence rate was estimated to be 1.2 (0.9-1.9) per 1000 susceptible MSM under the Status Quo scenario by the end of 2029. Optimizing all aspects of TasP and the simultaneous provision of PrEP to high-risk MSM resulted in an HIV incidence rate as low as 0.4 (0.3-0.6) per 1000 susceptible MSM, and an R_e as low as 0.7 (0.6-0.9), indicating that disease elimination was possible when TasP and PrEP were combined. Provision of PrEP to younger MSM or high-risk and younger MSM resulted in a similar HIV incidence rate, but an R_e with credible intervals that crossed one.

CONCLUSION

Further optimizing all aspects of TasP and prioritizing PrEP to high-risk MSM can achieve the goal of disease elimination in BC. These results should inform public health policy development and intervention programs that address the HIV epidemic in BC and in other similar settings where MSM are disproportionately affected.

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.

Use of HIV pre-exposure prophylaxis among urban Canadian gay, bisexual and other men who have sex with men: a cross-sectional analysis of the Engage cohort study

BACKGROUND

In Canada, gay, bisexual and other men who have sex with men (GBM) are disproportionately affected by HIV. Our objective was to describe access to HIV pre-exposure prophylaxis (PrEP) and identify factors associated with not using PrEP among self-reported HIV-negative or HIV-unknown GBM.

METHODS

This was a cross-sectional analysis of the Engage study cohort. Between 2017 and 2019, sexually active GBM aged 16 years or more in Montréal, Toronto and Vancouver were recruited via respondent-driven sampling (RDS). Participation included testing for HIV and sexually transmitted and blood-borne infections, and completion of a questionnaire. We examined PrEP access using a health care services model and fit RDS-adjusted logistic regressions to determine correlates of not using PrEP among those for whom PrEP was clinically recommended and who were aware of the intervention.

RESULTS

A total of 2449 GBM were recruited, of whom 2008 were HIV-negative or HIV-unknown; 1159 (511 in Montréal, 247 in Toronto and 401 in Vancouver) met clinical recommendations for PrEP. Of the 1159, 1100 were aware of PrEP (RDS-adjusted proportion: Montréal 84.6%, Toronto 94.2%, Vancouver 92.7%), 678 had felt the need for PrEP in the previous 6 months (RDS-adjusted proportion: Montréal 39.2%, Toronto 56.1%, Vancouver 49.0%), 406 had tried to access PrEP in the previous 6 months (RDS-adjusted proportion: Montréal 20.6%, Toronto 33.2%, Vancouver 29.6%) and 319 had used PrEP in the previous 6 months (RDS-adjusted proportion: Montréal 14.5%, Toronto 21.6%, Vancouver 21.8%). Not using PrEP was associated with several factors, including not feeling at high enough risk, viewing PrEP as not completely effective, not having a primary care provider and lacking medication insurance.

INTERPRETATION

Although half of GBM met clinical recommendations for PrEP, less than a quarter of them reported use. Despite high levels of awareness, a programmatic response that addresses PrEP-related perceptions and health care system barriers is needed to scale up PrEP access among GBM in Canada.

Combination HIV Prevention Strategies Among Montreal Gay, Bisexual, and Other Men Who Have Sex with Men in the PrEP Era: A Latent Class Analysis

Pre-exposure prophylaxis (PrEP) became publicly available in Quebec for gay, bisexual and other men who have sex with men (GBM) in 2013. We used baseline data from Engage, a cohort of GBM recruited by respondent-driven sampling, to examine patterns of combination HIV prevention use among Montreal GBM since PrEP became available. Latent class analysis, stratified by HIV status, was used to categorize GBM by self-reported use of biomedical and behavioural prevention strategies. Correlates of resulting classes were identified using multinomial logistic regression. Among HIV-negative/unknown GBM (n = 968), we identified four classes: low use of prevention (32%), condoms (40%), seroadaptive behaviour (21%), and biomedical (including PrEP; 7%). Those using prevention (condoms, seroadaptive behaviour, and biomedical) had a higher number of anal sex partners and were more likely to report a recent sexually transmitted infection diagnosis. GBM using biomedical prevention also had a higher level of formal education. Among GBM living with HIV (n = 200), we identified three classes: mainly antiretroviral treatment (ART) with viral suppression (53%), ART with viral suppression and condoms (19%), and ART with viral suppression and seroadaptive behaviour (18%). Again, the number of anal sex partners was higher among those using condoms and seroadaptive behaviours. Our findings show antiretroviral-based prevention, either alone or in combination with other strategies, is clearly a component of the HIV prevention landscape for GBM in Montreal. Nevertheless, PrEP uptake remains low, and there is a need to promote its availability more widely.

Initiation, discontinuation, and restarting HIV pre-exposure prophylaxis: ongoing implementation strategies

When used appropriately, pre-exposure prophylaxis (PrEP) substantially reduces the risk of HIV acquisition. Early implementation outcomes often suggest poor PrEP adherence and persistence; however, this intervention is time-limited and the need for PrEP fluctuates as risk behaviours change. In this Viewpoint we examine the current guidelines and early programmatic outcomes after starting, stopping, and restarting PrEP, and we review the implications of PrEP in relation to HIV testing algorithms. Guidelines suggest to discontinue PrEP when a person is no longer at risk for HIV, but effectively implementing this strategy requires support tools to make the decision of stopping and restarting PrEP that considers the complex relationship between risk perceptions and risk behaviours. Safely discontinuing PrEP also requires greater understanding of the daily dosing duration that is needed to protect the person after their last HIV exposure. Additionally, clear strategies are needed to re-engage a person as their HIV exposure risk changes over time.

Missed opportunities to prevent HIV infections among pre-exposure prophylaxis users: a population-based mixed methods study, San Francisco, United States

INTRODUCTION

Pre-exposure prophylaxis (PrEP) is highly effective, although PrEP adherence and persistence has been variable during real world implementation. Little is known about missed opportunities to enhance PrEP adherence among individuals who later HIV seroconverted after using PrEP. The goal of this analysis was to identify all HIV infections among individuals who had accessed PrEP in an integrated health system in San Francisco, and to identify potentially intervenable factors that could have prevented HIV infection through in-depth interviews with people who HIV seroconverted after using PrEP.

METHODS

We identified individuals who initiated PrEP in an integrated safety-net public health system and performed in-depth chart review to determine person-time on and after stopping PrEP over six years. We identified all PrEP seroconversions using the Centers for Disease Control and Prevention's Enhanced HIV/AIDS Reporting System and then calculated HIV incidence while using PrEP and during gaps in use. We then performed in-depth interviews with those who seroconverted.

RESULTS

Overall, 986 initiated PrEP across the San Francisco Department of Public Health from July 2012 to November 2018. Data were gathered from 895 person-years on PrEP and 953 after stopping PrEP. The HIV incidence was 7.5-fold higher after stopping PrEP compared to while on PrEP (95% CI 1 to 336). Of the eight individuals who HIV seroconverted; only one was taking PrEP at the time of seroconversion but was using on-demand PrEP inconsistently. All eight agreed to qualitative interviews. Major barriers to PrEP persistence included substance use, mental health and housing loss; difficulty accessing PrEP due to cost, insurance, and the cost and time of medical visits; difficulty weighing PrEP's benefit versus self-perceived risk; and entering a primary partnership. The individual who developed HIV using on-demand PrEP reported confusion about the dosing regimen and which sexual encounters required accompanying PrEP dosing.

CONCLUSIONS

HIV incidence during gaps in PrEP use was nearly eight-fold higher than while on PrEP in this large cohort in San Francisco. Many individuals who stop PrEP remain at risk of HIV, and participants reported that proactive outreach could potentially have prevented HIV infections. Individuals using non-daily PrEP may require additional education and support in the United States.