PrEP use and unmet PrEP-need among men who have sex with men in London prior to the implementation of a national PrEP programme, a cross-sectional study from June to August 2019

Barriers to HIV pre-exposure prophylaxis uptake for men who have sex with both men and women: A global scoping review

BACKGROUND

Although PrEP is a highly effective HIV prevention method, some groups are underrepresented in PrEP uptake. Much HIV prevention research groups gay, bisexual and other men who have sex with men together; however, men who have sex with both men and women (MSWM) may have needs distinct from those who identify as exclusively gay. This scoping review aims to explore documented barriers to PrEP use among MSWM.

METHODS

Literature was searched using four databases. Studies were included if data referring to MSWM were reported as a distinct category. Data were extracted using a standardised form, and findings were stratified into relevant categories of the social ecological framework.

RESULTS

Alongside intersectional barriers, MSWM were found to have lower awareness of PrEP, and access sexual health services less than men who have sex only with men. Those who did not identify with the LGBT community often missed out on health promotion messages for this group and were less likely to be offered HIV prevention interventions. MSWM identified more stigmatisation around PrEP use than gay men. However, when aware of PrEP, MSWM were very motivated to use this intervention.

CONCLUSIONS

Not all MSM will identify within the LGBTQ + community and may miss out on valuable opportunities for HIV prevention. PrEP information should be widely available in a variety of health and community settings. Health care professionals should avoid assumptions when assessing patients and provide information about HIV and STI prevention to all attending sexual health services.

Knowledge, uptake and intention to use antibiotic post-exposure prophylaxis and meningococcal B vaccine (4CMenB) for gonorrhoea among a large, online community sample of men and gender-diverse individuals who have sex with men in the UK

Novel STI prevention interventions, including doxycycline post-exposure prophylaxis (doxyPEP) and meningococcal B vaccination (4CMenB) against gonorrhoea, have been increasingly examined as tools to aid STI control. There is evidence of the efficacy of doxyPEP in preventing bacterial STIs; however, limited data exist on the extent of use in the UK. We examined self-reported knowledge and use of antibiotic post-exposure prophylaxis (PEP), and intention to use (ITU) doxyPEP and 4CMenB among a large, community sample of men and gender-diverse individuals who have sex with men in the UK. Using data collected by the RiiSH survey (November/December 2023), part of a series of online surveys of men and other gender-diverse individuals in the UK, we describe (%, [95% CI]) self-reported knowledge and use of antibiotic PEP (including doxyPEP) and doxyPEP and 4CMenB ITU. Using bivariate and multivariable logistic regression, we examined correlates of ever using antibiotic PEP, doxyPEP ITU, and 4CMenB ITU, respectively, adjusting for sociodemographic characteristics and a composite marker of sexual risk defined as reporting (in the last three months): ≥5 condomless anal sex partners, bacterial STI diagnosis, chemsex, and/or meeting partners at sex-on-premises venues, sex parties, or cruising locations. Of 1,106 participants (median age: 44 years [IQR: 34-54]), 34% (30%-37%) knew of antibiotic PEP; 8% (6%-10%) ever reported antibiotic PEP use. Among those who did, most reported use in the last year (84%, 73/87) and exclusively used doxycycline (69%, 60/87). Over half of participants reported doxyPEP ITU (51% [95% CI: 47%-56%], 568/1,106) while over two-thirds (64% [95% CI: 60%-69%], 713/1,106) reported 4CMenB ITU. Participants with markers of sexual risk and with uptake of other preventative interventions were more likely to report ever using antibiotic PEP as well as doxyPEP and 4CMenB ITU, respectively. HIV-PrEP users and people living with HIV (PLWHIV) were more likely to report antibiotic PEP use and doxyPEP and 4CMenB vaccination ITU than HIV-negative participants not reporting recent HIV-PrEP use. Findings demonstrate considerable interest in the use of novel STI prevention interventions, more so for 4CMenB vaccination relative to doxyPEP. Fewer than one in ten participants had reported ever using antibiotic PEP, with most using appropriate, evidence-based antibiotics. The use of antibiotic PEP and the report of doxyPEP ITU and 4CMenB ITU was more common among those at greater risk of STIs.

Correlates of oral pre-exposure prophylaxis cessation among men who have sex with men in China: implications from a nationally quantitative and qualitative study

BACKGROUND

Several studies have demonstrated the population-level effectiveness of oral PrEP in reducing the risk of HIV infection. However, oral PrEP utilization among MSM in China remains below 1%. While existing literature has primarily focused on oral PrEP preference and willingness, there is limited exploration of the underlying factors contributing to oral PrEP cessation in China. This study aims to fill this gap by investigating the factors associated with oral PrEP cessation among MSM in China.

METHODS

Assisted by MSM community organizations, we collected 6,535 electronic questionnaires from 31 regions across China, excluding Taiwan, Hong Kong, and Macau. The questionnaire focused on investigating MSM's awareness, willingness, usage, and cessation of oral PrEP. Additionally, 40 participants were randomly chosen for key informant interviews. These qualitative interviews aimed to explore the reasons influencing MSM discontinuing oral PrEP.

RESULTS

We eventually enrolled 6535 participants. Among the 685 participants who had used oral PrEP, 19.70% (135/685) ceased oral PrEP. The results indicated that individuals spending > ¥1000 on a bottle of PrEP (aOR = 2.999, 95% CI: 1.886-4.771) were more likely to cease oral PrEP compared to those spending ≤ ¥1000. Conversely, individuals opting for on-demand PrEP (aOR = 0.307, 95% CI: 0.194-0.485) and those using both daily and on-demand PrEP (aOR = 0.114, 95% CI: 0.058-0.226) were less likely to cease PrEP compared to those using daily PrEP. The qualitative analysis uncovered eight themes influencing oral PrEP cessation: (i) High cost and low adherence; (ii) Sexual inactivity; (iii) Lack of knowledge about PrEP; (iv) Trust in current prevention strategies; (v) Poor quality of medical service and counseling; (vi) PrEP stigma; (vii) Partner and relationship factors; (viii) Access challenges.

CONCLUSIONS

The cessation of oral PrEP among MSM in China is associated with various factors, including the cost of oral PrEP medication, regimens, individual perception of HIV risk, stigma, and the quality of medical services. It is recommended to provide appropriate regimens for eligible MSM and develop tailored combinations of strategies to enhance PrEP awareness and acceptance among individuals, medical staff, and the MSM community. The findings from this study can support the refinement of HIV interventions among MSM in China, contributing to efforts to reduce the burden of HIV in this population.

Identifying patterns of sexual behaviors and PrEP uptake characteristics among MSM who were eligible for PrEP: A national cross-section study

Men who have sex with men (MSM) are at a high risk of HIV infection and should be offered effective preventive measures, such as pre-exposure prophylaxis (PrEP). However, PrEP uptake among eligible MSM was not as high as desired. Diverse research findings on how risky sexual behaviors affect PrEP uptake highlight the necessity for a comprehensive investigation. Understanding the interconnectedness of different sexual behaviors is crucial for evaluating their impact on PrEP uptake among eligible MSM. Using a proportional sampling method, we recruited 5877 MSM aged 16 years and above in mainland China according to PrEP eligibility criteria. Through latent class analysis (LCA), three distinct sexual behavior patterns were identified among eligible MSM. Demographic variances and PrEP uptake among the three distinct sexual behavior patterns were examined using chi-squared tests and multinomial logistic regression. LCA revealed three patterns: low-risk (4,815 MSM), medium-risk (516 MSM), and high-risk (546 MSM). MSM aged 25 years or older with a monthly income of ≥¥8,000 were more likely to be in the medium-risk group. Those from areas with high HIV prevalence and engaging as "top" in anal sex were more likely to be in the medium- and high-risk groups. The medium- and high-risk groups had a higher willingness, uptake, and adherence rates for PrEP than the low-risk group. LCA is effective in identifying diverse sexual behavior patterns among MSM, aiding targeted interventions to enhance PrEP uptake. Addressing demographic variations and tailoring interventions for specific risk groups are crucial for promoting PrEP dissemination and reducing HIV infection risk in eligible MSM.

Mpox Diagnosis, Behavioral Risk Modification, and Vaccination Uptake among Gay, Bisexual, and Other Men Who Have Sex with Men, United Kingdom, 2022

During the 2022 multicountry mpox outbreak, the United Kingdom identified cases beginning in May. UK cases increased in June, peaked in July, then rapidly declined after September 2022. Public health responses included community-supported messaging and targeted mpox vaccination among eligible gay, bisexual, and other men who have sex with men (GBMSM). Using data from an online survey of GBMSM during November-December 2022, we examined self-reported mpox diagnoses, behavioral risk modification, and mpox vaccination offer and uptake. Among 1,333 participants, only 35 (2.6%) ever tested mpox-positive, but 707 (53%) reported behavior modification to avoid mpox. Among vaccine-eligible GBMSM, uptake was 69% (95% CI 65%-72%; 601/875) and was 92% (95% CI 89%-94%; 601/655) among those offered vaccine. GBMSM self-identifying as bisexual, reporting lower educational qualifications, or identifying as unemployed were less likely to be vaccinated. Equitable offer and provision of mpox vaccine are needed to minimize the risk for future outbreaks and mpox-related health inequalities.

Impact of national commissioning of pre-exposure prophylaxis (PrEP) on equity of access in England: a PrEP-to-need ratio investigation

OBJECTIVES

HIV pre-exposure prophylaxis (PrEP) is highly effective in preventing HIV acquisition. In England, NHS availability was limited to participants of the PrEP Impact Trial until late 2020. Some key populations at greater risk of HIV were under-represented in the trial suggesting inequities in trial PrEP access. We used the PrEP-to-need ratio (PnR; number of PrEP users divided by new HIV diagnoses) to investigate whether PrEP access improved following routine commissioning in October 2020 and identify populations most underserved by PrEP.

METHODS

Aggregated numbers of people receiving ≥1 PrEP prescription and non-late new HIV diagnoses (epidemiological proxy for PrEP need) were taken from national surveillance data sets. We calculated the PnR across socio-demographics during Impact (October 2017 to February 2020; pre-COVID-19 pandemic) and post-commissioning PrEP era (2021) in England.

RESULTS

PnR increased >11 fold, from 4.2 precommissioning to 48.9 in 2021, due to a fourfold reduction in non-late new HIV diagnoses and near threefold increase in PrEP users. PnR increased across genders, however, the men's PnR increased 12-fold (from 5.4 precommissioning to 63.9 postcommissioning) while the women's increased sevenfold (0.5 to 3.5). This increasing gender-based inequity was observed across age, ethnicity and region of residence: white men had the highest PnR, increasing >13 fold (7.1 to 96.0), while Black African women consistently had the lowest PnR, only increasing slightly (0.1 to 0.3) postcommissioning, suggesting they were the most underserved group. Precommissioning, the PnR was 78-fold higher among white men than Black women, increasing to 278-fold postcommissioning.

CONCLUSIONS

Despite the overall increase in PrEP use, substantial PrEP Impact trial inequities widened postcommissioning in England, particularly across gender, ethnicity and region of residence. This study emphasises the need to guide HIV combination prevention based on equity metrics relative to the HIV epidemic. The PnR could support the optimisation of combination prevention to achieve zero new HIV infections in England by 2030.

Clinical Presentation of Mpox in People With and Without HIV in the United Kingdom During the 2022 Global Outbreak

Early UK surveillance data revealed that people living with HIV were overrepresented among cases of monkeypox (mpox). However, it remains unknown whether mpox infection is more severe in people living with well-controlled HIV. All laboratory-confirmed mpox cases presenting between May and December 2022 to one London hospital service were identified via pathology reporting systems. We extracted demographic and clinical data to allow comparison of clinical presentation and severity of mpox among people with and without HIV. We identified 150 people with mpox (median age 36 years, 99.3% male, 92.7% reporting sex with other men). HIV status was available for 144 individuals, 58 (40.3%) of whom were HIV positive (only 3/58 had CD4 cell counts <200 cells/mm3 and 5/58 had HIV RNA >200 copies/mL). People with HIV had similar clinical presentations to those without HIV, including indicators of more widespread disease, such as extragenital lesions (74.1% vs. 64.0%, p = .20) and nondermatological symptoms (87.9% vs. 82.6%, p = .38). People with HIV also experienced a similar time from onset of symptoms to discharge from all inpatient or outpatient clinical follow-up (p = .63) and total time under follow-up (p = .88) compared with people without HIV. A similar proportion of people with HIV required review in the hospital emergency department (36.2% vs. 25.6%, p = .17) or admission to hospital (19.0% vs. 9.3%, p = .09). There were no recorded deaths. In this cohort of people with mpox, there was a high prevalence of HIV coinfection, the majority of which was well-controlled. We find no evidence that people with well-controlled HIV experienced more severe mpox infection.