Maximizing Response Rates to Ads for Free At-Home HIV Testing on a Men-for-Men Geosocial Sexual Networking App: Lessons Learned and Implications for Researchers and Providers

Factors associated with PrEP-era HIV seroconversion in a 4-year U.S. national cohort of n = 6059 sexual and gender minority individuals who have sex with men, 2017-2022

INTRODUCTION

Community-based cohort studies of HIV seroconversion can identify important avenues for enhancing HIV prevention efforts in the era of pre-exposure prophylaxis (PrEP). Within individuals, one can assess exposure and outcome variables repeatedly and with increased certainty regarding temporal ordering. This cohort study examined the association of several risk factors with subsequent HIV seroconversion.

METHODS

We report data from a 4-year study (2017-2022) of 6059 HIV seronegative sexual and gender minority individuals who have sex with men who had indications for-, but were not using-, PrEP at enrolment. Participants completed repeat exposure assessments and self-collection of biospecimens for HIV testing. We examined the roles of race and ethnicity, socio-economic status, methamphetamine use and PrEP uptake over the course of follow-up in relation to HIV seroconversion.

RESULTS

Over 4 years, 303 of the participants seroconverted across 18,421 person-years (incidence rate = 1.64 [95% CI: 1.59-1.70] per 100 person-years). In multivariable discrete-time survival analysis, factors independently associated with elevated HIV seroconversion risk included being Black/African American (adjusted risk ratio [aRR]: 2.44, 1.79-3.28), Hispanic/Latinx (1.53, 1.19-1.96), housing instability (1.58, 1.22-2.05) and past year methamphetamine use (3.82, 2.74-5.33). Conversely, time since study enrolment (24 vs. 12 months, 0.67, 0.51-0.87; 36 months, 0.60, 0.45-0.80; 48 months, 0.48, 0.35-0.66) and higher education (master's degree or higher vs. less than or equal to high school, 0.36, 0.17-0.66) were associated with reduced seroconversion risk. Compared to non-PrEP users in the past 2 years without a current clinical indication, those who started PrEP but then discontinued had higher seroconversion risk, irrespective of clinical indication (3.23, 1.74-6.46) or lack thereof (4.30, 1.85-9.88). However, those who initiated PrEP in the past year (0.14, 0.04-0.39) or persistently used PrEP in the past 2 years (0.33, 0.14-0.74) had a lower risk of seroconversion. Of all HIV seroconversions observed during follow-up assessments (12, 24, 36 and 48 months), methamphetamine was reported in the 12 months prior 128 (42.2%) times (overall).

CONCLUSIONS

Interventions that acknowledge race and ethnicity, economic variables such as education and housing instability, and methamphetamine use are critically needed. Not only are interventions to engage individuals in PrEP care needed, but those that retain them, and re-engage those who may fall out of care are essential, given the exceptionally high risk of seroconversion in these groups.

Implications and Lessons Learned While Using Social Media Advertisements to Promote Longitudinal Social Network Study Participation in Latino Men Who Have Sex with Men (LMSM): A Brief Report

We assess the effectiveness of paid ads on social media platforms as a research recruitment tool with Latino men who have sex with men (LMSM). We deployed four paid ad campaigns July-September 2022 in English and Spanish on Meta and Grindr featuring happy or risqué images of LMSM, documenting engagement and cost metrics. The four campaigns generated a total of 1,893,738 impressions and 1078 clicks (0.057 click-through rate) with a total cost of $7,989.39. Of the 58 people who accessed the study screener, 31 completed it (53.4%), 13 were eligible (22.4%), but none enrolled. Comparing platforms, Meta had higher engagement metrics than Grindr, while Grindr had higher proportions of those who completed the screener (57.9%) and were eligible (26.3%) than Meta (52.6% and 21.0%, respectively). Challenges to using paid ads as an LMSM recruitment tool included intersecting pandemics (Mpox, COVID-19), and limited connection between platforms and staff for study enrollment.

Self-sampled multi-anatomic site testing for uncovering the community burden of undiagnosed Chlamydia trachomatis and Neisseria gonorrhoeae infection in men who have sex with men

PURPOSE

To detect otherwise undiagnosed asymptomatic sexually transmitted infection (STI), and for estimating prevalence among men who have sex with men (MSM).

METHODS

In this community-based study in Hong Kong, adult MSM were recruited. After completion of an online survey, free multi-anatomic sites self-sampling kits (urine specimens, pharyngeal and rectal swabs) for Chlamydia trachomatis (CT) and Neisseria gonorrhoeae (NG) tests were delivered to requesting participants. Factors associated with STI positivity were analyzed in logistic regression.

RESULTS

From September 2021 to October 2022, 712 MSM were recruited, with 86% aged 18-39, and 16% reported history of chemsex engagement. A majority (81%) had previously undergone HIV testing, 68% had ever tested for STI, and 35% previously diagnosed with STI. Totally 428 (60%) had requested self-sampling kits, and 276 (39%) returned collected samples. Among participants who returned the samples, about half had never been tested in the past and had no history of STI. Overall 21% tested positive for CT and/or NG (CT/NG)-CT positive 16% and NG positive 7%. By anatomic site, 16% of rectal swabs, 7% of pharyngeal swabs, but just 3% of urine specimens were CT/NG positive. The prevalence of CT/NG was not significantly different by history of STI diagnosis and testing.

CONCLUSION

Self-sampled STI testing is a potentially useful means for enhancing uptake of screening in MSM in the community, which could uncover otherwise undiagnosed asymptomatic infections. Internet-based self-sampling for STI testing could complement the current clinic-based STI testing for supporting epidemiologic evaluation of STI control in the community.

PrEP Uptake and Methamphetamine Use Patterns in a 4-Year U.S. National Prospective Cohort Study of Sexual and Gender Minority People, 2017-2022

Methamphetamine use is on the rise among sexual and gender minority people who have sex with men (SGMSM), escalating their HIV risk. Despite pre-exposure prophylaxis (PrEP) being an effective biomedical HIV prevention tool, its uptake in relation to methamphetamine use patterns in SGMSM has not been studied. In a U.S. cohort study from 2017 to 2022, 6,253 HIV-negative SGMSM indicated for but not using PrEP were followed for four years. Methamphetamine use was categorized (i.e., newly initiated, persistently used, never used, used but quit), and PrEP uptake assessed using generalized estimating equation (GEE), adjusted for attrition. Participants had a median age of 29, with 51.9% White, 11.1% Black, 24.5% Latinx, and 12.5% other races/ethnicities. Over the four years, PrEP use increased from 16.3 to 27.2%. GEE models identified risk factors including housing instability and food insecurity. In contrast, older age, health insurance, clinical indications, and prior PrEP use increased uptake. Notably, Latinx participants were more likely to use PrEP than Whites. Regarding methamphetamine use, those who newly initiated it were more likely to use PrEP compared to non-users. However, those who quit methamphetamine and those who persistently used it had PrEP usage rates comparable to those of non-users. Though PrEP uptake increased, it remained low in SGMSM. Methamphetamine use was associated with PrEP uptake. Healthcare providers should assess methamphetamine use for harm reduction. Prioritizing younger, uninsured SGMSM and addressing basic needs can enhance PrEP uptake and reduce HIV vulnerabilities.

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.

Evaluation of Chinese HIV Mobile Apps by Researchers and Patients With HIV: Quality Evaluation Study

BACKGROUND

Against the backdrop of globalization, China remains one of the most heavily burdened countries in Asia with regard to AIDS. However, many high-risk groups and patients affected by AIDS may be less likely to actively seek care from medical institutions because of fear of experiencing shame or discrimination. Mobile apps provide a promising avenue for supporting the prevention, diagnosis, and treatment of AIDS. However, a comprehensive systematic evaluation of these mobile apps' functionality and quality has not been conducted yet.

OBJECTIVE

This study aims to identify the available mobile apps for AIDS in China, assess and discuss the functional features and quality of these Chinese AIDS mobile apps, and offer decision support for patients and clinical practitioners in accessing high-quality AIDS mobile apps. Furthermore, based on the evaluation results, recommendations for improvement will be provided.

METHODS

A systematic search was conducted on the Qimai app data platform, the Aladdin WeChat applet data platform, and WeChat to identify mobile apps related to AIDS. A snowball sampling method was used to supplement the potentially overlooked apps. The selected mobile apps underwent a rigorous screening process based on unified criteria. Subsequently, assessments were independently undertaken by 3 separate researchers and 2 patients with HIV, using both the Mobile App Rating Scale (MARS) and the User Mobile App Rating Scale (uMARS). Quantitative interpretations of the data were facilitated by the MedCalc statistical software (version 20.217, MedCalc Software).

RESULTS

A total of 2901 AIDS mobile apps were included in the study, with 2897 identified through information retrieval and an additional 4 added via snowball sampling. After a rigorous selection process, 21 apps were determined to be usable. Among them, the Hong Feng Wan app achieved the highest combined average score, calculated based on the MARS (3.96, SD 0.33) and uMARS (4.47, SD 0.26). Overall, there was no significant correlation between MARS and uMARS (rapp quality total score=0.41; P=.07; rsubjective quality=0.39; P=.08). A notable issue was the widespread lack of user privacy protection, with only 24% (5/21) of the apps offering this feature.

CONCLUSIONS

The number of available Chinese AIDS mobile apps is limited, with WeChat applets dominating the market. Nonetheless, the performance of WeChat mini-apps is generally inferior to that of independent apps, and there may be significant discrepancies between assessments conducted by researchers and those provided by genuine end users, emphasizing the necessity of involving real users in the development and evaluation of HIV mobile apps. In addition, developers of these Chinese HIV mobile apps need to devote attention to improving privacy protection mechanisms, in addition to considering the evaluations of researchers and real users. This will help attract more users and increase user loyalty.

Motivational Enhancement Interventions to Increase Pre-Exposure Prophylaxis Use in Sexual Minority Men Who Use Stimulants: Protocol for a Pilot Sequential Multiple Assignment Randomized Trial

BACKGROUND

Although pre-exposure prophylaxis (PrEP) could substantially mitigate HIV risk, sexual minority men who use stimulants commonly experience difficulties with engaging in PrEP clinical services. Motivational interviewing (MI) and contingency management (CM) reduce substance use and condomless anal sex (CAS) in this population, but these motivational enhancement interventions require modifications to promote engagement along the PrEP care continuum.

OBJECTIVE

PrEP Readiness Interventions for Supporting Motivation (PRISM) is a pilot sequential multiple assignment randomized trial testing the feasibility, acceptability, and preliminary effectiveness of distinct combinations of telehealth MI and CM in 70 cisgender sexual minority men who use stimulants that are not currently taking PrEP.

METHODS

A national sample was recruited via social networking applications to complete a baseline assessment and mail-in HIV testing. Those with nonreactive HIV results were randomized to receive either (1) a 2-session MI intervention focusing on PrEP use (session 1) and concomitant stimulant use or CAS (session 2) or (2) a CM intervention with financial incentives for documented evidence of PrEP clinical evaluation by a medical provider (US $50) and filling a PrEP prescription (US $50). At the 3-month follow-up assessment, participants who reported they had not filled a prescription for PrEP were randomized a second time to either (1) switch to a second-stage intervention (ie, MI+CM or CM+MI) or (2) continue with assessments only. Outcomes for both responders and nonresponders were reassessed at a 6-month follow-up. The primary outcome is documented evidence of filling a PrEP prescription over 6 months. Self-reported secondary outcomes include PrEP clinical evaluation by a medical provider, stimulant use, and CAS. Qualitative exit interviews were conducted with a subgroup of responders and nonresponders to characterize their experiences with the MI and CM interventions.

RESULTS

Implementation of PRISM underscores challenges in reaching sexual minority men who use stimulants to optimize HIV prevention efforts. Approximately 1 in 10 (104/1060) eligible participants have enrolled. Of the 104 who enrolled, 87 (84%) completed mail-in HIV testing. We delivered 5 preliminary HIV-positive results, including posttest counseling with referrals to confirmatory testing.

CONCLUSIONS

Lessons learned from PRISM underscore the central importance of a flexible, participant-centered approach to support the engagement of sexual minority men who use stimulants. Leveraging telehealth platforms to deliver motivational enhancement interventions also expanded their reach and potential public health impact with this high-priority population. Further research is needed to determine the effectiveness of telehealth MI and CM for supporting PrEP use in sexual minority men who use stimulants.

TRIAL REGISTRATION

ClinicalTrials.gov NCT04205487; https://clinicaltrials.gov/study/NCT04205487.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

DERR1-10.2196/48459.

Randomized Controlled Trial of Motivational Enhancement Interventions to Increase Pre-Exposure Prophylaxis Use in Sexual Minority Men Who Use Stimulants

Background

Although pre-exposure prophylaxis (PrEP) could substantially mitigate HIV risk, sexual minority men (SMM) who use stimulants commonly experience difficulties with engaging in PrEP clinical services. Motivational interviewing (MI) and contingency management (CM) reduce substance use and condomless anal sex in this population, but these motivational enhancement interventions require adaptation to promote engagement along the PrEP care continuum.

Methods

PRISM is a pilot sequential multiple assignment randomized trial (SMART) testing the feasibility, acceptability, and preliminary effectiveness of distinct combinations of telehealth MI and CM in 70 cisgender SMM who use stimulants that are not currently taking PrEP. A national sample was recruited via social networking applications to complete a baseline assessment and mail-in HIV testing. Those with non-reactive HIV results are randomized to receive either: 1) a 2-session MI intervention focusing on PrEP use (session 1) and concomitant stimulant use or condomless anal sex (session 2); or 2) a CM intervention with financial incentives for documented evidence of PrEP clinical evaluation by a medical provider ($50) and filling a PrEP prescription ($50). At the 3-month follow-up assessment, participants who report they have not filled a prescription for PrEP are randomized a second time to either: 1) Switch to a second-stage intervention (i.e., MI + CM or CM + MI); or 2) Continue with assessments only. Outcomes for both responders and non-responders are reassessed at a 6-month follow-up. The primary outcome is documented evidence of filling a PrEP prescription. Self-reported, secondary outcomes include PrEP clinical evaluation by a medical provider, stimulant use, and condomless anal sex. Qualitative exit interviews are conducted with a sub-group of responders and non-responders to characterize their experiences with the MI and CM interventions.

Discussion

Implementation of this pilot SMART underscores the challenges in reaching SMM who use stimulants to optimize HIV prevention efforts such that approximately one in ten (104/1,060) eligible participants enrolled. However, 85% (70/82) of enrolled participants with non-reactive HIV results were randomized. Further research is needed to determine the effectiveness of telehealth MI and CM for supporting PrEP use in SMM who use stimulants.

Trial Registration

This protocol was registered on clinicaltrials.gov (NCT04205487) on December 19, 2019.

Using web analytics data to identify platforms and content that best engage high-priority HIV populations in online and social media marketing advertisements

Background

Online advertisements on social media platforms are an important tool for engaging relevant populations in public health research. However, little is known about what platforms and ad characteristics are most effective in engaging high-priority HIV populations, including racial/ethnic and sexual minority individuals.

Methods

Data from this study were drawn from advertising campaigns conducted on popular websites and social media platforms that recruited for several nationwide randomized controlled trials of various HIV prevention and testing strategies among sexual minority men (SMM) from December 2019 until March 2022. Descriptive statistics and LASSO regression models were used to determine which platforms and ad characteristics were associated with significantly higher odds of engagement.

Results

Ads on Google search, Facebook, and Instagram yielded the most cost-effective engagement, while gay-oriented dating platforms and TrafficJunky yielded the highest percentage of users who appeared to meet basic eligibility criteria. The highest percentages of Black users were screened through ads on Jack'd, TrafficJunky, and Google search; for Hispanic/Latino users, Google search, Grindr, Facebook, and Instagram. Analyzing ad characteristics, we found ads that used suggestive content, animation, and included study or institution logos were associated with greater engagement. Ads that emphasized convenience of the research (e.g. mentioned participating "from home") and that depicted people of similar races/ethnicities were also associated with greater engagement among Black and Hispanic/Latino sexual minority men.

Conclusions

We found that advertisements on mainstream social media sites are most cost effective. Although gay-oriented dating platforms were much more effective at reaching the target population, they were considerably more expensive. We also identified ad characteristics that were particularly effective in engaging users. These results could inform the design of online public health outreach campaigns for similar populations to improve their engagement and reach. Findings also demonstrated the value of conducting focused research on the effectiveness of various online marketing strategies.

Acceptability of an existing online sexually transmitted and blood-borne infection testing model among gay, bisexual and other men who have sex with men in Ontario, Canada

Objectives

Gay, bisexual and other men who have sex with men (GBM) are disproportionately affected by sexually transmitted and blood-borne infections (STBBI) due to stigma and other factors such as structural barriers, which delay STBBI testing in this population. Understanding acceptability of online testing is useful in expanding access in this population, thus we examined barriers to clinic-based testing, acceptability of a potential online testing model, and factors associated with acceptability among GBM living in Ontario.

Methods

Sex Now 2019 was a community-based, online, bilingual survey of GBM aged ≥15. Prevalence ratios (PR) and 95% confidence intervals (95%CI) were calculated using modified Poisson regression with robust variances. Multivariable modelling was conducted using the Hosmer-Lemeshow-Sturdivant approach.

Results

Among 1369 participants, many delayed STBBI testing due to being too busy (31%) or inconvenient clinic hours (29%). Acceptability for online testing was high (80%), with saving time (67%) as the most common benefit, and privacy concerns the most common drawback (38%). Statistically significant predictors of acceptability for online testing were younger age (PR  =  0.993; 95%CI: 0.991-0.996); a greater number of different sexual behaviours associated with STBBI transmission (PR  =  1.031; 95%CI: 1.018-1.044); identifying as an Indigenous immigrant (PR  =  1.427; 95%CI: 1.276-1.596) or immigrant of colour (PR  = 1.158; 95%CI: 1.086-1.235) compared with white non-immigrants; and currently using HIV pre-exposure prophylaxis (PrEP) compared to not currently using PrEP (PR  =  0.894; 95%CI: 0.828-0.965).

Conclusions

Acceptability of online testing was high among GBM in Ontario. Implementing online STBBI testing may expand access for certain subpopulations of GBM facing barriers to current in-person testing.

Relative Effectiveness of Social Media, Dating Apps, and Information Search Sites in Promoting HIV Self-testing: Observational Cohort Study

Background

Social media sites, dating apps, and information search sites have been used to reach individuals at high risk for HIV infection. However, it is not clear which platform is the most efficient in promoting home HIV self-testing, given that the users of various platforms may have different characteristics that impact their readiness for HIV testing.

Objective

This study aimed to compare the relative effectiveness of social media sites, dating apps, and information search sites in promoting HIV self-testing among minority men who have sex with men (MSM) at an increased risk of HIV infection. Test kit order rates were used as a proxy to evaluate promotion effectiveness. In addition, we assessed differences in characteristics between participants who ordered and did not order an HIV test kit.

Methods

Culturally appropriate advertisements were placed on popular sites of three different platforms: social media sites (Facebook, Instagram), dating apps (Grindr, Jack’D), and information search sites (Google, Bing). Advertisements targeted young (18-30 years old) and minority (Black or Latinx) MSM at risk of HIV exposure. Recruitment occurred in 2 waves, with each wave running advertisements on 1 platform of each type over the same period. Participants completed a baseline survey assessing sexual or injection use behavior, substance use including alcohol, psychological readiness to test, attitudes toward HIV testing and treatment, and HIV-related stigma. Participants received an electronic code to order a free home-based HIV self-test kit. Follow-up assessments were conducted to assess HIV self-test kit use and uptake of pre-exposure prophylaxis (PrEP) at 14 and 60 days post enrollment.

Results

In total, 271 participants were enrolled, and 254 were included in the final analysis. Among these 254 participants, 177 (69.7%) ordered a home HIV self-test kit. Most of the self-test kits were ordered by participants enrolled from dating apps. Due to waves with low enrollment, between wave statistical comparisons were not feasible. Within wave comparison revealed that Jack’D showed higher order rates (3.29 kits/day) compared to Instagram (0.34 kits/day) and Bing (0 kits/day). There were no associations among self-test kit ordering and HIV-related stigma, perceptions about HIV testing and treatment, and mistrust of medical organizations.

Conclusions

Our findings show that using popular dating apps might be an efficient way to promote HIV self-testing. Stigma, perceptions about HIV testing and treatment, or mistrust of medical organizations may not affect order rates of HIV test kits promoted on the internet.

Trial Registration

ClinicalTrials.gov NCT04155502; https://clinicaltrials.gov/ct2/show/NCT04155502

International Registered Report Identifier (IRRID)

RR2-10.2196/20417

Recruiting Black Men Who Have Sex With Men (MSM) Couples via Dating Apps: Pilot Study on Challenges and Successes

Background

HIV disproportionately impacts Black men who have sex with men (MSM), and targeting the primary relationship (ie, couples) using mobile technology for health holds promise for HIV prevention. Web-based recruitment of MSM is commonly employed in HIV prevention and intervention research. However, little known about recruiting Black MSM couples on the internet in the United States.

Objective

This study describes the process of recruiting Black MSM couples over social networking and dating apps frequented by MSM. We describe the activities for recruiting, screening, and enrolling participants as part of a randomized trial employing a multipronged recruitment approach.

Methods

Black MSM in couples were recruited via three apps (ie, Jack’d, Adam4Adam, and Growlr) between May 2020 and March 2021 during the COVID-19 pandemic in the United States. Black MSM couples were eligible if one or both partners are Black, MSM, and living with HIV, and if both partners were 18 years or older, and have been together for at least 2 months in what they both consider a primary relationship (ie, one in which both partners reported feeling most committed to over any other partner or relationship).

Results

A total of 10 Black MSM couples (n=20) were enrolled via social networking apps. App recruitment activities were a combination of passive (eg, in-app advertisements) and active (eg, direct messaging of users) engagement. Recruitment approaches varied by the social networking app owing to differences in app features. A full-time recruiter experienced challenges such as bugs (ie, technical errors in computer program or system), navigating technical requirements specific to each app, and web-based harassment.

Conclusions

Despite challenges, it was possible to recruit Black MSM couples virtually into research as part of a multipronged recruitment strategy. We identify tips for using web-based dating and other social networking apps as part of a recruitment strategy in future research with Black MSM couples.

Sex in the Era of COVID-19 in a U.S. National Cohort of Cisgender Men, Transgender Women, and Transgender Men Who Have Sex with Men: April-May 2020

Since the emergence of the COVID-19 pandemic, there has been an increasing body of research focused on the effects that measures like stay-at-home orders and social distancing are having on other aspects of health, including mental health and sexual health. Currently, there are limited extant data on the effects of the pandemic on sexual and gender minorities. Between April 15, 2020, and May 15, 2020, we invited participants in an ongoing U.S. national cohort study (Together 5000) to complete a cross-sectional online survey about the pandemic, and its effects on mental and sexual health and well-being (n = 3991). Nearly all (97.7%) were living in an area where they were told they should only leave their homes for essentials. Most (70.1%) reported reducing their number of sex partners as a result of the pandemic. Among the 789 participants prescribed HIV pre-exposure prophylaxis (PrEP), 29.9% said they stopped taking their PrEP entirely, and 14.2% started selectively skipping doses. For those who had been taking PrEP, discontinuing PrEP was associated with having no new sex partners (β = 0.90, 95% CI 0.40-1.40). Among the 152 HIV-positive participants, 30.9% said they were unable to maintain an HIV-related medical appointment because of the pandemic and 13.8% said they had been unable to retrieve HIV medications. Additionally, 35.3% of participants were experiencing moderate to severe anxiety because of the pandemic and 36.7% reported symptoms of depression. In a multivariable logistic regression, reporting a new sex partner in the prior 30 days was significantly associated with being aged 30 or older (vs. not, AOR = 1.21), being Black (AOR = 1.79) or Latinx (AOR = 1.40, vs. white), and being unsure if they had been in close contact with someone diagnosed with COVID-19 (AOR = 1.32, vs. no contact). It was unassociated with COVID-19-induced anxiety, depression, or knowing someone hospitalized with COVID-19. The pandemic has caused disruptions in sexual behavior (partner reduction) as well as difficulties navigating PrEP and HIV care continua. Findings will guide more comprehensive public health responses to optimize HIV prevention and treatment in the era of COVID-19.

Getting Clear About Rectal Douching Among Men Who Have Sex With Men

Receptive anal sex is the primary means through which HIV is transmitted among men who have sex with men (MSM). Recently, researchers have begun investigating the role that rectal douching may play in amplifying risk for transmission. Yet, there is limited research on the frequency with which MSM douche, the products they use, and how this may vary across sociodemographic characteristics. A U.S. national sample of 4745 MSM completed an online survey that assessed their douching behavior, demographic characteristics, sexual behavior, and their anal sexual positioning (i.e., top, bottom, versatile). Nearly two-thirds (65.8%) had engaged in rectal douching in the last three months. Among those who douched, water was commonly reported (84.2%) and 20.1% reported using commercial enemas (e.g., Fleet), as well as water and soap (15.0%)-numbers exceed 100% as some participants reported more than one. Men who douched reported significantly more receptive and insertive condomless anal sex acts in the prior 3 months. One-in-ten men reported rectal bleeding after douching. Compared to HIV-negative participants who had not taken PrEP, participants had higher odds of reporting douching in the past 3 months if they were HIV-negative and currently on PrEP (AOR = 1.82), HIV-negative and previously used PrEP (AOR = 1.58), and HIV-positive (AOR = 1.83). Douching was common in this sample. Given that douching could amplify risk for HIV transmission, healthcare providers should discuss douching safety with their patients, with a focus on harm reduction (e.g., reduce risk of bleeding, as opposed to abstinence from douching).

Associations of prescription stimulant misuse with subsequent methamphetamine use among a U.S. cohort of HIV-vulnerable sexual and gender minorities who have sex with men

INTRODUCTION

Prescription stimulants and methamphetamine have similarities in chemical structure and impact on biological functioning. However, there is limited literature on prescription stimulant misuse among sexual and gender minorities as well as how prescription misuse may impact later methamphetamine use.

METHODS

We used data collected from a HIV prevention cohort to describe (e.g., frequencies, percentages) prescription stimulant use/misuse and methamphetamine use at baseline and 12-month follow-up (n = 4857). We then used multivariable logistic regression models to determine the impact of baseline prescription stimulant misuse and methamphetamine use on 12-month prescription stimulant misuse and methamphetamine use.

RESULTS

At baseline, 10.2 % of participants misused prescription stimulants and 12 % of participants used methamphetamine in the past 3 months, while at 12-month follow-up 11.6 % of participants misused prescription stimulants and 11.2 % of participants used methamphetamine in the past 3 months. Multivariable regression analyses indicated that participants who misused prescription stimulants (in the absence of methamphetamine) at baseline had 2.51 (95 % CI: 1.44-3.59, ref. no stimulant or methamphetamine use) times the odds of using methamphetamine at 12-month follow-up.

DISCUSSION

Findings suggest that prescription stimulant use is a risk factor for continued meth use. Therefore, earlier and targeted public health interventions could reduce methamphetamine use by disrupting the progression from prescription stimulant misuse to methamphetamine use through early screening and interventions for prescription stimulant misuse.

Why Are Patients Switching from Tenofovir Disoproxil Fumarate/Emtricitabine (Truvada) to Tenofovir Alafenamide/Emtricitabine (Descovy) for Pre-Exposure Prophylaxis?

Safety differences between tenofovir alafenamide/emtricitabine (TAF) and tenofovir disoproxil fumarate/emtricitabine (TDF/FTC)-formulated pre-exposure prophylaxis (PrEP) appear to have little clinical significance for most PrEP users. Furthermore, generic TDF-formulated PrEP is projected to decrease the price of PrEP. Thus, efforts to shift PrEP users to TAF-formulated PrEP should be considered in light of their potential to undermine efforts to scale-up PrEP nationally. Data are taken from Together 5,000, a US national cohort study predominantly composed of cisgender gay and bisexual men. In 2019-2020, 5034 participants completed their 24-month assessment, which measured whether participants were switching from TDF (Truvada) to TAF (Descovy) for PrEP, and why. Of those reporting PrEP-use (n = 1009), 277 reported using Descovy for PrEP, and 223 provided a reason for switching to Descovy. A content analysis was used to code participant's reasons for switching. Over half (56%) of participants reported that their doctor recommended switching to Descovy. Without mentioning a provider recommendation, 32% of participants reported that perceived improved safety of Descovy, compared with Truvada, motivated their decision to change their prescription. Other factors cited included the smaller size of the pill and "newness" of Descovy. Further, several participants mentioned negative advertising about Truvada as rationale for switching. Although scientific consensus supports the safety of both TDF/FTC and TAF, our results suggest that current messaging through physicians and other sources have emphasized superior safety of TAF-implying that TDF/FTC may not be safe in the long term. Efforts to shift users onto TAF may undermine public perception of TDF-formulated PrEP.

Marketing of Tenofovir Disoproxil Fumarate (TDF) Lawsuits and Social Media Misinformation Campaigns' Impact on PrEP Uptake Among Gender and Sexual Minority Individuals

There has been an influx of ads on social media seeking plaintiffs in lawsuits for harms/side-effects caused by tenofovir disoproxil fumarate/Emtricitabine (TDF/FTC, Truvada) for PrEP. Community groups and researchers have suggested these ads may be undermining efforts to disseminate PrEP to key populations. In October 2019, we began assessing the impact of injury lawsuit ads on social media platforms in an ongoing U.S. national cohort study of HIV-negative cis men, trans men, and trans women who have sex with men. Although assessments are ongoing, given the alarming nature of our findings, we report data collected as of March 2020 (n = 2078). Most (59.9%) said they had seen ads for TDF-related lawsuits on social media. Twenty-eight percent said they would probably or definitely not start PrEP and 22.1% said they would not stay on PrEP (were they on it) as a result of seeing these ads. Next, 38.2% agreed or strongly agreed that seeing these ads made them think that TDF/FTC for PrEP was not safe. Black, Latinx, and/or multiracial individuals were most likely to be negatively impacted by the ads including perceptions that these ads made them think PrEP is not safe. In contrast, past year experience taking PrEP was positively associated with intentions to start and/or stay on PrEP despite seeing the ads. Due to forthcoming affordable/generic options, TDF/FTC is projected to become the most scalable option for disseminating PrEP to key populations. Results suggest that ads for TDF lawsuits on social media are having a negative impact on individual PrEP decision-making. Our findings highlight the urgency for accurate and balanced messaging on the benefits and risks of PrEP, so that individuals can make informed choices about whether PrEP is right for them.

Breaking Inertia: Movement Along the PrEP Cascade in a Longitudinal US National Cohort of Sexual Minority Individuals at Risk for HIV

BACKGROUND

The pre-exposure prophylaxis (PrEP) cascade outlines sequential steps to maximize PrEP's impact and highlights potential intervention targets to improve PrEP implementation. We evaluate the PrEP cascade in the Together 5000 study (T5K).

METHODS

T5K is an internet-based, US national cohort study of PrEP-eligible men and trans persons who have sex with men who were not taking PrEP at enrollment. Using longitudinal data from baseline (2017-2018) and year 1 follow-up (2018-2019, n = 4229), we evaluated 5 steps of the PrEP cascade-PrEP contemplation: believes they are a good candidate for PrEP; PrEParation: plans to initiate PrEP; PrEP action: speaks to a provider about PrEP; PrEP initiation: receives a prescription for PrEP; and PrEP maintenance: continues to take PrEP. We compared the cascade across geographic region and identified factors associated with gaps in the cascade.

RESULTS

After 1 year, 1092 (26%) participants had initiated PrEP, 709 (17%) were still using PrEP, and 177 (4%) were no longer clinically indicated for PrEP. Participants in the South and Midwest were less likely to speak to a provider about PrEP or initiate PrEP. Baseline characteristics associated with lower odds of PrEP initiation at year 1 include: not having a college degree; earning <$20,000/year; not having health insurance; having very low food security; and not having a primary care doctor.

CONCLUSIONS

Lack of health care access is a major barrier to PrEP implementation and may exacerbate disparities in PrEP uptake across geographic regions.

The Crisis We Are Not Talking About: One-in-Three Annual HIV Seroconversions Among Sexual and Gender Minorities Were Persistent Methamphetamine Users

INTRODUCTION

Methamphetamine use is once again on the rise among sexual and gender minorities who have sex with men (SGMSM).

METHODS

Baseline and 12-month data are taken from an ongoing cohort study of n = 4786 SGMSM aged 16-49 at risk for HIV from across the United States. Participants completed annual online surveys and at-home HIV testing (oral fluid samples returned through mail).

RESULTS

Overall, 2.47 per 100 persons seroconverted over 12 months. In addition, 13.8% of participants reported any methamphetamine use over the 12-month study period. Nearly three-fourths (74.7%; 422 of 565) of those who reported using methamphetamine at baseline were persistent users at 12 months. In adjusted analyses, compared with those who did not use methamphetamine, incident methamphetamine users (ie, those who indicated use between baseline and follow-up) and persistent methamphetamine users had significantly higher odds of HIV seroconverting (adjusted odds ratio = 3.95, 95% confidence interval: 1.64 to 9.47; and 7.11, 4.53 to 11.17, respectively). Persistent methamphetamine users accounted for one-third of all observed HIV seroconversions (41 of 115).

DISCUSSION

Among SGMSM at elevated risk for HIV, persistent methamphetamine use was prevalent and associated with substantially amplified risk for HIV seroconversion. Expanded efforts are needed to test implementation strategies for scalable, evidence-based interventions to reduce HIV risk in SGMSM who use methamphetamine.

Experiences Receiving HIV-Positive Results by Phone: Acceptability and Implications for Clinical and Behavioral Research

Improving HIV testing rates and increasing early detection among men who have sex with men (MSM) are critical strategies for enhancing overall health and decreasing HIV transmission. Remote testing and phone delivery of HIV test results may reduce barriers such as geographic isolation or HIV-related stigma. In 2018-19, 50 MSM completed qualitative interviews about their experience receiving a positive HIV test result via phone through their participation in a research study that included remote HIV testing. Interview topics included the acceptability of, and concerns about, phone delivery of HIV results, as well as suggestions for improvement. Interviews were transcribed, coded, and analysed using an inductive thematic approach. Overall, participants reported high acceptability of phone delivery of HIV-positive results. Participants praised the support and information provided by study staff. Benefits identified included increased convenience compared to in-person medical visits, allowing participants to emotionally process their test results privately, as well as receiving the results from supportive and responsive staff members. A few participants indicated drawbacks to phone-based HIV test result delivery, such as logistical concerns about receiving a phone call during the day (e.g., while at work), reduced confidentiality, and the lack of in-person emotional support. Overall, participants described phone delivery of positive HIV-results as acceptable. At-home testing with phone delivery has the potential to increase HIV testing access, especially to geographically isolated or medically underserved patients.

Are we on the precipice of a new epidemic? Risk for hepatitis C among HIV-negative men-, trans women-, and trans men- who have sex with men in the United States

Emerging data from Europe have documented increases in diagnoses of acute hepatitis C virus (HCV) infection among HIV-negative men who have sex with men. We investigated risk factors for HCV and their correlates in the Together 5000 study, a U.S. national cohort study of HIV-negative men (n = 6089), transgender women (n = 40), and transgender men (n = 42) who have sex with men. We used bivariate and multivariable analyses to determine demographic and behavioral factors associated with high risk for acute HCV infection (using the HCV-MOSAIC risk indicator with a score ≥ 2.0). Mean HCV risk score was 1.38 (SD = 1.09) and 27.3% of participants had HCV risk scores ≥ 2.0. In multivariable modeling, being cisgender male (vs. not) was associated with having a lower HCV-MOSAIC risk score. Meanwhile, being white, having been incarcerated, prior use of HIV pre- or post-exposure prophylaxis, having ever been tested for HIV, and recent methamphetamine use were associated with high risk for HCV. More than one-in-four participants exceeded the threshold score for HCV risk. Those with high HCV-MOSAIC risk scores were more likely to have been in settings where they could be tested for acute HCV (i.e., HIV testing, PrEP care, PEP care, incarceration), suggesting opportunities to engage them in HCV screening, prevention, and treatment.