Efficacy and Safety of Oral TDF-Based Pre-exposure Prophylaxis for Men Who Have Sex With Men: A Systematic Review and Meta-Analysis

Effectiveness of onsite and online education in enhancing knowledge and use of human immunodeficiency virus pre- and post-exposure prophylaxis

BACKGROUND

Enhancing awareness and use of pre-exposure prophylaxis (PrEP) and post-exposure prophylaxis (PEP) is vital to curb human immunodeficiency virus (HIV) spread. High-risk behaviors prevalent among sexually transmitted infection clinic outpatients underscore the need for increased PrEP/PEP education in this group.

AIM

To investigate the effects of both onsite and online health education on the knowledge of, and willingness to use, PrEP and PEP among individuals receiving PEP services.

METHODS

Participants were drawn from a cohort study on PEP service intervention at an STD/AIDS outpatient clinic in designated HIV/AIDS hospitals in Beijing, conducted from January 1 to June 30, 2022. Health education was provided both onsite and online during follow-up. Surveys assessing knowledge of, and willingness to use, PrEP/PEP were administered at baseline and again at 24 wk post-intervention.

RESULTS

A total of 112 participants were enrolled in the study; 105 completed the follow-up at week 24. The percentage of participants with adequate knowledge of, and willingness to use, PrEP significantly increased from 65.2% and 69.6% at baseline to 83.8% and 82.9% at the end of the intervention (both P < 0.05). Similarly, those with adequate knowledge of, and willingness to use, PEP increased from 74.1% and 77.7% at baseline to 92.4% and 89.5% at week 24 (P < 0.05). Being between 31 years and 40 years of age, having a postgraduate degree or higher, and reporting a monthly expenditure of RMB 5000 or more were found to be significantly associated with knowledge of PrEP and PEP (both P < 0.05).

CONCLUSION

The findings show that both onsite and online health education significantly improved the knowledge of, and increased willingness to use, PrEP and PEP in individuals utilizing PEP services.

Interventions to Improve Adherence to Oral Pre-exposure Prophylaxis: A Systematic Review and Network Meta-analysis

For people at risk of HIV infection, pre-exposure prophylaxis (PrEP) can reduce the risk of infection in anticipation of exposure to HIV. The effectiveness of PrEP relies upon a user's adherence to their PrEP regimen. We sought to assess the effect of PrEP adherence interventions compared to usual care or another intervention for people at risk of HIV. We searched electronic databases from 2010 onwards for randomized controlled trials (RCTs) involving persons at risk of HIV randomized to an adherence promoting intervention vs usual care or another intervention. We used network meta-analyses to compare PrEP adherence for all participant populations. Certainty of evidence was assessed using Confidence in Network Meta-Analysis (CINeMA). 21 trials (N = 4917) were included in qualitative analysis (19 in network meta-analyses (N = 4101)). HIV self-testing interventions with adherence feedback elements improved adherence compared to usual care (risk ratio (RR): 1.83, 95%CI 1.19, 2.82). In contrast, HIV self-testing alone was inferior to HIV self-testing with adherence feedback (RR: 0.58, 95%CI 0.37-0.92). Reminders alone also were inferior to HIV self-testing with adherence feedback on adherence (RR: 0.53, 95%CI 0.34-0.84) and had similar effects on adherence as usual care (RR: 0.98, 95%CI: 0.86-1.11). Interventions with only one component were inferior for adherence than those with two components (RR: 0.74, 95%CI 0.62-0.88) and those with three components (RR: 0.78, 95%CI 0.65-0.93). The certainty of evidence was moderate for HIV self-testing plus adherence feedback and interventions with two or three components. When designing future PrEP adherence interventions, we recommend strategies with more than one but no more than three components.

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.

Factors Associated with PrEP Persistence and Loss of Follow-Up: A 5-Year Historic Cohort

OBJECTIVE

HIV Pre-Exposure Prophylaxis (PrEP) has been used in France since 2016. Its effectiveness is no longer to be demonstrated. However, follow-up and adherence remain the main pitfalls. The main objective of this study was to identify factors associated with persistence or loss of PrEP follow-up.

DESIGN

An historic cohort of PrEP users was compiled from the database of consultations in the Indre-et-Loire dedicated sexual health centers (CeGIDD) from June 2016 to June 2021.

METHODS

Kaplan-Meier curves were performed to compare the group of persistent PrEP users to the discontinuation group. Factors associated with PrEP discontinuation were identified using Cox modelling, considering time-dependent variables. Final variables included in the model were selected based on the Akaike Information Criterion (AIC) and clinical relevance.

RESULTS

Over the period, 568 PrEP users were included in the cohort. Median follow-up was 2.3 years. A quarter of users were lost to follow-up within 3 months after PrEP initiation. Sexual risk reduction AIDS community-based support (HR = 0.65[0.42;0.99]), being in a couple (HR = 0.51[0.38;0.68]), and history of syphilis (HR = 0.57[0.40;0.81]) were significantly associated with persistence of follow-up. Remote consultations (HR = 2.74[1.63;4.61]), chemsex practices (HR = 2.01[1.29;3.14]), and side effects (HR=1.72[1.03;2.88]) were significantly associated with a loss of follow-up.

CONCLUSION

These results suggest that more sexual risk reduction AIDS community-based counseling could be a key, necessary for supporting PrEP users in their follow-up pathway. Indeed, AIDS community-based support could be used to build a basis for developing safe pathways. Remote consultations could represent a response to the issue of access to PrEP. To create a significant impact on global HIV incidence, the PrEP offer must be extended, and at-risk PrEP users supported to maintain PrEP use.

Weekly Oral Tenofovir Alafenamide Protects Macaques from Vaginal and Rectal Simian HIV Infection

Pre-exposure prophylaxis (PrEP) with a weekly oral regimen of antiretroviral drugs could be a suitable preventative option for individuals who struggle with daily PrEP or prefer not to use long-acting injectables. We assessed in macaques the efficacy of weekly oral tenofovir alafenamide (TAF) at doses of 13.7 or 27.4 mg/kg. Macaques received weekly oral TAF for six weeks and were exposed twice-weekly to SHIV vaginally or rectally on day 3 and 6 after each dose. Median TFV-DP levels in PBMCs following the 13.7 mg/kg dose were 3110 and 1137 fmols/106 cells on day 3 and 6, respectively. With the 27.4 mg/kg dose, TFV-DP levels were increased (~2-fold) on day 3 and 6 (6095 and 3290 fmols/106 cells, respectively). Both TAF doses (13.7 and 27.4 mg/kg) conferred high efficacy (94.1% and 93.9%, respectively) against vaginal SHIV infection. Efficacy of the 27.4 mg/kg dose against rectal SHIV infection was 80.7%. We estimate that macaque doses of 13.7 and 27.4 mg/kg are equivalent to approximately 230 and 450 mg of TAF in humans, respectively. Our findings demonstrate the effectiveness of a weekly oral PrEP regimen and suggest that a clinically achievable oral TAF dose could be a promising option for non-daily PrEP.

Willingness to take long-acting injectable pre-exposure prophylaxis among men who have sex with men who participated in the CROPrEP study: a cross-sectional online study

INTRODUCTION

Evidence on the willingness of men who have sex with men (MSM) with oral pre-exposure prophylaxis (PrEP) experience, especially those with suboptimal adherence, to take long-acting injectable PrEP (LAI-PrEP) is critical to guide future LAI-PrEP implementation.

OBJECTIVE

The objective was to assess the willingness of MSM with oral PrEP experience to take LAI-PrEP.

METHODS

MSM who participated in the China Real-world Study of Oral PrEP (CROPrEP) were enrolled in this study. Information on the willingness of MSM to take LAI-PrEP and potential correlates was collected using a structured online questionnaire. The main outcomes were the willingness of MSM to take LAI-PrEP and its association with HIV-related behaviours, sexually transmitted infections, and oral PrEP history. Logistic regression was used to identify correlates of the willingness of MSM to take LAI-PrEP.

RESULTS

A total of 612 former CROPrEP participants (FCPs) were included in this study. There were 315 (51.5%) daily oral PrEP (D-PrEP) users and 297 (48.5%) event-driven oral PrEP (ED-PrEP) users at the last follow-up. Most FCPs (77.8%) were willing to take free LAI-PrEP. FCPs with no less than two sexual male partners (aOR = 1.54, [95% CI: 1.04, 2.29], P = 0.031), those with male partners with unknown HIV statuses (aOR = 2.04, [95% CI: 1.31, 3.18], P = 0.002), those with recreational drug use (aOR = 1.58, [95% CI: 1.05, 2.40], P = 0.030), and those with HSV-2 positivity (aOR = 2.15, [95% CI: 1.30, 3.57], P = 0.003) were more willing to take LAI-PrEP, while ED-PrEP users (aOR = 0.66, [95% CI: 0.45, 0.98], P = 0.037) and FCPs with suboptimal oral PrEP adherence (aOR = 0.58, [95% CI: 0.36, 0.94], P = 0.026) were less willing to take LAI-PrEP.

CONCLUSION

LAI-PrEP has good prospects for expanding PrEP coverage. However, FCPs with suboptimal oral PrEP adherence are less likely to take LAI-PrEP. Further intervention and implementation efforts are needed to improve the willingness of MSM to use LAI-PrEP, and sexual health should be considered during the discussion about PrEP initiation.

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.

Pre-exposure prophylaxis uptake concerns in the Democratic Republic of the Congo: Key population and healthcare workers perspectives

Key populations (KP) in the Democratic Republic of the Congo (DRC), including female sex workers (SW), are disproportionally affected by HIV. Quantitative feedback surveys were conducted at seven health facilities in DRC with 70 KP clients enrolled in pre-exposure prophylaxis (PrEP) services to measure benefits and concerns. The surveys also assessed satisfaction with PrEP services and experiences of stigma at the health facilities. Thirty healthcare workers (HCW) were surveyed to measure attitudes, beliefs, and acceptability of providing services to KP. KP client survey participants were primarily female SW. KP clients reported that the primary concern about taking PrEP was fear of side effects (67%) although few KP reported having experienced side effect (14%). HCW concurred with clients that experienced and anticipated side effects were a primary PrEP uptake concern, along with costs of clinic visits.

Willingness to use long-acting injectable PrEP among HIV-negative/unknown men who have sex with men in mainland China: A cross-sectional online survey

BACKGROUND

Men who have sex with men (MSM) are at high risk of HIV acquisition. Long-acting injectable-pre-exposure prophylaxis (LAI-PrEP), requiring less frequent dosing, is being studied as an alternative method to daily oral HIV PrEP. With the addition of this potential new prevention method, it expands the scope for a wider user choice and is expected to increase the acceptability and uptake of HIV prevention measures. The aim of our study was to explore the willingness to use LAI-PrEP and associated influential factors.

METHODS

Participants were recruited from December 2020 to March 2021 through banner advertisements on web- and mobile app-based platforms on Blued, a large gay Chinese social media platform. MSM in our cross-sectional study was HIV-negative and currently lived in mainland China. Participants were asked about their willingness to use LAI-PrEP and reasons why they might be or not be willing to use LAI-PrEP. Multivariable logistic regression was used to analyze the factors associated with the willingness to use LAI-PrEP.

RESULTS

In total, 969 participants met the inclusion criteria and finished the survey. Nearly twenty percent (19.5%) of participants had never tested for HIV; 66.8% of MSM had multiple male partners; and 51.6% of MSM engaged in condomless sex with their partner. About three-fifths (66.3%) of MSM were aware of PrEP, and only 3.9% of MSM had used PrEP before. The willingness to use LAI-PrEP among MSM was 74.0% (95% CI: 71.4%-76.6%). MSM with higher education levels were less likely to show a willingness to use LAI-PrEP (AOR = 0.56, 95%CI: 0.38-0.84). Participants who had a history of HIV test (AOR = 1.68, 95%CI: 1.11-2.55), were willing to use daily oral PrEP (AOR = 10.64, 95%CI:7.43-15.21), had multiple male sexual partners (AOR = 1.33, 95%CI:0.93-1.90), who used rush popper(AOR = 1.49, 95%CI:1.05-2.13), and who were aware of PEP (AOR = 1.66, 95%CI: 1.02-2.70) were more likely to show willingness to use LAI-PrEP.

CONCLUSIONS

In our study, MSM had quite high awareness but low uptake of PrEP. As LAI-PrEP is expected to be approved for use in China in the future, our study of MSM highlights the need for key population-focused education programs about PrEP and healthy sexual behavior. This study also provides some evidence for LAI-PrEP use among the Chinese MSM population in the future.

Willingness to use and intention to adhere to pre-exposure prophylaxis (PrEP) among men who have sex with men in Jiangsu Province, China

ABSTRACTPre-exposure prophylaxis (PrEP) is a biomedical prevention approach that significantly reduces HIV acquisition. Our study aimed to explore factors associated with PrEP willingness and intention to adhere to PrEP among MSM through a cross-sectional survey in Nanjing, Jiangsu province, China. Location sampling (TLS) and online recruitment were used to recruit participants to gauge their PrEP willingness and intention to adhere. Of 309 HIV-negative/unknown serostatus MSM, 75.7% were willing to use PrEP and 55.3% had high intention to take PrEP daily. Willingness to use PrEP was positively associated with having a college degree or higher (AOR = 1.90, 95%CI: 1.11-3.26) and higher anticipated HIV stigma (AOR = 2.74, 95%CI: 1.13-6.61). Facilitators of intention to adhere included higher education levels (AOR = 2.12, 95%CI: 1.33-3.39) and higher anticipated HIV stigma (AOR = 3.65, 95%CI: 1.36-9.80), whereas a primary barrier was community homophobia (AOR = 0.43, 95%CI: 0.20-0.92). This study documented high willingness to use PrEP, yet lower intention to adhere to PrEP in a sample of MSM in China. Public interventions and programs to promote adherence of PrEP for MSM is urgently needed in China. Psychosocial factors should be addressed and taken into consideration for PrEP implementation and adherence programs.

Spiraling Risk: Visualizing the multilevel factors that socially pattern HIV risk among gay, bisexual & other men who have sex with men using Complex Systems Theory

PURPOSE OF REVIEW

Global disparities in HIV infection, particularly among gay, bisexual, and other men who have sex with men (GBMSM), indicate the importance of exploring the multi-level processes that shape HIV's spread. We used Complex Systems Theory and the PRISMA guidelines to conduct a systematic review of 63 global reviews to understand how HIV is socially patterned among GBMSM. The purpose was to conduct a thematic analysis of the reviews to (1) synthesize the multi-level risk factors of HIV risk, (2) categorize risk across the socioecological model, and (3) develop a conceptual model that visualizes the interrelated factors that shape GBMSMS's HIV "risk."

RECENT FINDINGS

We included 49 studies of high and moderate quality studies. Results indicated that GBMSM's HIV risk stems from the individual, interpersonal, and structural levels of the socioecological model. We identified a few themes that shape GBMSM's risk of HIV infection related to biomedical prevention methods; sexual and sex-seeking behaviors; behavioral prevention methods; individual-level characteristics and syndemic infections; lived experiences and interpersonal relationships; country-level income; country-level HIV prevalence; and structural stigma. The multi-level factors, in tandem, serve to perpetuate GBMSM's risk of HIV infection globally. The amalgamation of our thematic analyses from our systematic reviews of reviews suggests that the risk of HIV infection operates in an emergent, dynamic, and complex nature across multiple levels of the socioecological model. Applying complex systems theory indicates how multilevel factors create a dynamic and reinforcing system of HIV risk among GBMSM.

Identifying Strategies for Improving Pre-exposure Prophylaxis Adherence: Perspectives from a Sample of Highly Adherent Young Men Who have Sex with Men

Most research on pre-exposure prophylaxis (PrEP) adherence and persistence uses a deficit-based approach to identify negative influences on PrEP adherence; however, an alternative set of approaches (such as resilience, asset-based, and positive variation) may identify equally important positive influences on PrEP adherence. Thus, the current study presents qualitative perspectives of PrEP adherence strategies from a sample of adherent YMSM. PrEP-using YMSM living in the Chicago area from a larger cohort study were recruited into a 90-day diary study that measured sexual health behaviors including PrEP use. A subset (n = 28) were then recruited for in-depth interviews between April and September 2020 covering topics of PrEP use and adherence. Thematic analysis was used to interpret patterns within the data. The analytic sample (n = 19) consistently reported high levels of adherence. Adherence strategies were organized into three broader categories: psychological (e.g. mindfulness, pill auditing), technical/instrumental (e.g. automated reminders, pill organizers), and social strategies (e.g. checking in with friends, or getting suggestions from friends). The majority of participants described using multiple strategies and changing strategies to respond to barriers to adherence. Other themes that were related to adherence included having a daily medication history and a generally positive outlook toward the PrEP regimen. Those who had medication histories were able to draw from experience to develop strategies for PrEP adherence. Findings suggest the need for pre-emptive counseling for PrEP-initiators on the use of multiple strategies, how to prepare for PrEP adherence, to adapt to challenges, and to adopt a range of potential strategies for adherence.

Intention to use PrEP among men who have sex with men and engage in chemsex: an international descriptive study

Background

Pre-exposure prophylaxis (PrEP) is a valuable tool in the response to the HIV epidemic, recommended for groups with a higher risk of HIV infection, such as men who have sex with men (MSM), particularly in the context of high-risk sexual behavior such as chemsex.

Purpose

This study aimed to analyze the prevalence and factors associated with the intention to use PrEP among MSM who engage in chemsex in Brazil and Portugal.

Methods

This was a cross-sectional study of a secondary dataset from a larger study conducted between January 2020 and May 2021 throughout Brazil and Portugal involving 1852 MSM who engage in chemsex. An initial descriptive analysis was performed to calculate the absolute and relative frequencies of independent variables related to the intention to use PrEP among MSM. A multivariate regression model was developed to identify factors independently associated with the intention to use PrEP.

Results

Although a high level of PrEP knowledge (85.75%) was observed among MSM who engage in chemsex, the prevalence of intention to use PrEP was only 59.07%. Five variables were associated with a higher prevalence of intention to use PrEP [engaging in double penetration - adjusted prevalence ratio (aPR): 1.56, 95% CI: 1.44-1.69; being assigned female sex at birth - aPR: 1.34, 95% CI: 1.12-1.61; cruising - aPR: 1.21, 95% CI: 1.06-1.38; not using condoms - aPR: 1.20, 95% CI: 1.05-1.36; and being an immigrant - aPR: 1.16; 95% CI: 1.07-1.25], while having knowledge of postexposure prophylaxis (aPR: 0.91; 95% CI: 0.84-0.98), having a casual sexual partner (aPR: 0.86 and 0.85; 95% CI: 0.74-0.99 and 0.74-0.98), and engaging in group sex (aPR: 0.81; 95% CI: 0.73-0.90) were associated with a lower intention to use PrEP.

Conclusion

The intention to use PrEP among MSM who engage in chemsex was high, and several factors were associated with this intention. Understanding the factors associated with the intention to use PrEP among MSM practicing chemsex is crucial for developing targeted interventions to increase PrEP uptake in this population. The results of this study suggest that tailored approaches are necessary to promote PrEP use in this population.

PrEP Access Affected by COVID-19 Is Associated With Increased Odds of HIV Seroconversion

ABSTRACT

Black and Hispanic/Latino sexual minority men and gender diverse (SMMGD) individuals report lower uptake and adherence to pre-exposure prophylaxis (PrEP) compared with White SMMGD. For some, the COVID-19 pandemic has resulted in reduced access to PrEP prescriptions and related changes to PrEP use, yet little is known how pandemic-related changes to PrEP access and sexual activity might influence sexually transmitted infection (STI) status and HIV seroconversion among SMMGD of color. We used data from 4 waves of a national study of Black and Hispanic/Latino SMMGD's HIV, PrEP, and health experiences to assess whether self-reported changes to sexual activity were associated with STI status, and whether self-reported changes to PrEP access were associated with HIV seroconversion. Those who reported greater impact to their sexual activity during the pandemic [adjusted odds ratio (aOR) = 1.24; 95% confidence interval (CI): 1.10 to 1.40] and a greater number of sexual partners (aOR = 1.29; 95% CI: 1.21 to 1.38) were more likely to report a positive STI test. In addition, we found that compared with those who did not report pandemic-related changes to PrEP access, those who did report changes to PrEP access had significantly higher odds of HIV seroconversion during the study period (aOR = 2.80; 95% CI: 1.02 to 7.68). These findings have implications for HIV and STI prevention and highlight the importance of novel interventions to improve PrEP access among Black and Hispanic/Latino SMMGD. Importantly, these findings also demonstrate the need to stay focused on key populations at risk of HIV infection during emerging public health crises to avoid an increase in rates of new diagnoses.

The Influencing Factors of HIV-Preventive Behavior Based on Health Belief Model among HIV-Negative MSMs in Western China: A Structural Equation Modeling Analysis

(1) Background: Men who have sex with other men (MSMs) are at high risk of being infected by the human immunodeficiency virus (HIV) in western China. Pre-exposure prophylaxis (PrEP) is an efficient way to prevent HIV transmission. However, adherence is the most vital determinant factor affecting PrEP effectiveness. We conducted a study based on the Health Belief Model to explore factors that predict adherence to PrEP among a cohort of 689 MSMs in western China. (2) Methods: We assessed perceived susceptibility, severity, benefits, barriers, self-efficacy, cues to action, and HIV-preventive behavior through a cross-sectional survey. (3) Results: PrEP self-efficacy was directly associated with PrEP behaviors (β = 0.221, p < 0.001), cues to action were directly associated with PrEP behaviors (β = 0.112, p < 0.001), perceived benefits were directly associated with PrEP behaviors (β = 0.101, p < 0.001), and perceived susceptibility was directly associated with PrEP behaviors (β = 0.117, p = 0.043). (4) Conclusion: Medication self-efficacy, perceived susceptibility, and cue to action structures are predictors of the MSMs’ HIV-preventive behavior in western China. These results will provide theoretical plans for promoting PrEP adherence in MSMs.

Using a Structural-Ecological Model to Facilitate Adoption of Preexposure Prophylaxis Among Latinx Sexual Minority Men: A Systematic Literature Review

Research has consistently shown that individual, interpersonal, community and structural factors influence the degree to which individuals' access and utilize health care services, and these factors may play a role in explaining racial and ethnic differences in health care outcomes. Differences in HIV prevalence and treatment between Latinx adults and white adults in the U.S. must be considered in the context of these factors. However, much of the existing research connecting these factors and HIV/AIDS outcomes in Latinxs remains disparate, limited in scope, and has yet not been applied to the use of biomedical HIV preventions. The following systematic literature review examined research related to PrEP in Latinx sexual minority men (SMM) to build a structural-ecological framework of the existing research, while identifying gaps in the literature and areas for future research. We searched two electronic databases using a systematic review protocol, screened 71 unique records, and identified 23 articles analyzing data from Latinx SMM and intended and/or actual PrEP-use in the United States. Based on the present review, disparities in PrEP uptake by Latinx SMM could be explained, in part, by examining how all levels of the structural-ecological framework uniquely contributes to how Latinx SMM engage with HIV prevention measures and come to understand PrEP. It is clear from the existing literature base that some of the most prominent barriers deterring Latinx SMM from seeking PrEP services are the lack of information surrounding PrEP and HIV/gay stigmas. However, higher order structural-level risks can facilitate or reduce access to PrEP. We propose a structural-ecological model to help visualize multi-level domains of unique stressors that limit the implementation of PrEP among Latinxs. At this stage, the available literature provides little guidance beyond suggesting that culturally adapted interventions can be effective in this population. The model developed here provides that needed specificity regarding targeted interventions that will fit the needs of this population.

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

Background

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

Methods

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

Findings

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

Interpretation

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

Funding

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

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

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

PROSPERO REGISTRATION NUMBER

CRD42017065937.

Qualitative assessment of readiness for use of HIV pre-exposure prophylaxis among men who have sex with men (MSM) in Malawi: Qualitative study using key informant interviews and focus group discussions

Background

Men who have sex with men (MSM) are a key group for HIV interventions in Malawi considering their high HIV prevalence (17.5% compared to 8.4% among men in the general population). The use of oral preexposure prophylaxis (PrEP) presents a new opportunity for MSM to be protected. We present the findings from a qualitative assessment designed to assess awareness of and willingness and barriers to using PrEP among MSM in Malawi.

Objective

The 3 main objectives of this assessment were to determine: (1) awareness of PrEP, (2) factors that influence willingness to use PrEP, and (3) potential barriers to PrEP use and adherence among MSM in order to guide the design and implementation of a PrEP program in Malawi.

Methods

Ahead of the introduction of PrEP in Malawi, a qualitative study using in-depth interviews (IDIs) and focus group discussions (FGDs) was conducted in October 2018 in Blantyre, Lilongwe, and rural districts of Mzimba North and Mangochi. With support of members of the population, study participants were purposively recruited from 4 MSM-friendly drop-in centers where MSM receive a range of health services to ensure representativeness across sites and age. Participants were asked what they had heard about PrEP, their willingness to use PrEP, their barriers to PrEP use, and their preferences for service delivery. The data were analyzed using a thematic content analysis framework that was predetermined in line with objectives.

Results

A total of 109 MSM were interviewed—13 through IDIs and 96 through FGDs. Most participants were aware of PrEP as a new HIV intervention but had limited knowledge related to its use. However, the majority were willing to use it and were looking forward to having access to it. IDI participants indicated that they will be more willing to take PrEP if the dosing frequency were appropriate and MSM were involved in information giving and distribution of the drug. FGD participants emphasized that places of distribution and characteristics of the service provider are the key factors that will affect use. Knowing the benefits of PrEP emerged as a key theme in both the IDIs and FGDs. Participants highlighted barriers that would hinder them from taking PrEP such as side effects which were cited in IDIs and FGDs. Key factors from FGDs include cost, fear of being outed, drug stockouts, fear of being known as MSMs by wives, and lack of relevant information. FGDs cited stigma from health care workers, forgetfulness, and community associated factors.

Conclusions

Despite having inadequate knowledge about PrEP, study participants were largely willing to use PrEP if available. Programs should include an effective information, education, and communication component around their preferences and provide PrEP in MSM-friendly sites.

Electrospun fibers for vaginal administration of tenofovir disoproxil fumarate and emtricitabine in the context of topical pre-exposure prophylaxis

Women are particularly vulnerable to sexual HIV-1 transmission. Oral pre-exposure prophylaxis (PrEP) with tenofovir disoproxil fumarate and emtricitabine (TDF/FTC) is highly effective in avoiding new infections in men, but protection has only been shown to be moderate in women. Such differences have been associated, at least partially, to poor drug penetration of the lower female genital tract and the need for strict adherence to continuous daily oral intake of TDF/FTC. On-demand topical microbicide products could help circumvent these limitations. We developed electrospun fibers based on polycaprolactone (PCL fibers) or liposomes associated to poly(vinyl alcohol) (liposomes-in-PVA fibers) for the vaginal co-delivery of TDF and FTC, and assessed their pharmacokinetics in mice. PCL fibers and liposomes-in-PVA fibers were tested for morphological and physicochemical properties using scanning electron microscopy, differential scanning calorimetry and X-ray diffractometry. Fibers featured organoleptic and mechanical properties compatible with their suitable handling and vaginal administration. Fluorescent quenching of mucin in vitro - used as a proxy for mucoadhesion - was intense for PCL fibers, but mild for liposomes-in-PVA fibers. Both fibers were shown safe in vitro and able to rapidly release drug content (15-30 min) under sink conditions. Liposomes-in-PVA fibers allowed increasing genital drug concentrations after a single intravaginal administration when compared to continuous daily treatment for five days with 25-times higher oral doses. For instance, the levels of tenofovir and FTC in vaginal lavage were around 4- and 29-fold higher, respectively. PCL fibers were also superior to oral treatment, although to a minor extent (approximately 2-fold higher drug concentrations in lavage). Vaginal tissue drug levels were generally low for all treatments, while systemic drug exposure was negligible in the case of fibers. These data suggest that proposed fibers may provide an interesting alternative or an ancillary option to oral PrEP in women.

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.

Can Japan Achieve Zero Transmission of HIV? Time Series Analysis Using Bayesian Local Linear Trend Model

BACKGROUND

The number of newly diagnosed human immunodeficiency virus (HIV) infections and acquired immune deficiency syndrome (AIDS) patients in Japan appears to be decreasing. However, whether these new infections cease to occur in the future in Japan, similar to abroad, is unclear. To evaluate the feasibility of this achievement, we conducted a time series analysis using Bayesian local linear trend model to evaluate the possibility of zero new infection of HIV/AIDS in Japan.

METHODS

We used quarterly data on HIV/AIDS from the first quarter, 2001 to the second quarter, 2020. Bayesian analyses were conducted using Markov chain Monte Carlo (MCMC) method, and a local linear trend model was constructed for number of newly diagnosed HIV infection without AIDS diagnosis, AIDS cases, and their aggregate. Predictions for the following 60 quarters until the second quarter of 2035 were also made for all models.

RESULTS

The mean aggregate cases of HIV/AIDS patients became 0 by the fourth quarter of 2031 (90% credible interval 0-535). For HIV infections alone, mean cases became 0 by the second quarter of 2030 (90%CrI 0-472). For AIDS alone mean cases were 9 at the second quarter of 2035 (90%CrI 0-231).

CONCLUSION

Our local linear trend model suggested that number of HIV/AIDS cases in Japan could decrease to zero by the first quarter of 2031, if the trend of the infections followed the local linear trend model, yet with rather wide credible interval. Achieving zero new transmission of HIV in Japan is a realistic goal but measures to make it faster may be needed.

Inflammation, HIV, and Immune Quiescence: Leveraging on Immunomodulatory Products to Reduce HIV Susceptibility

The relationship between inflammation and HIV has been a focus of research over the last decade. In HIV-infected individuals, increased HIV-associated immune activation significantly correlated to disease progression. While genital inflammation (GI) has been shown to significantly increase the risk of HIV acquisition and transmission, immune correlates for reduced risk remain limited. In certain HIV-exposed seronegative individuals, an immune quiescent phenotype characterized reduced risk. Immune quiescence is defined by specific, targeted, highly regulated immune responses that hinder overt inflammation or immune activation. Targeted management of inflammation, therefore, is a plausible strategy to mitigate HIV risk and slow disease progression. Nonsteroidal anti-inflammatory drugs (NSAIDs) such as hydroxychloroquine and aspirin have shown encouraging preliminary results in low-risk women by reducing systemic and genital immune activation. A topical NSAID, containing ibuprofen, is effective in treating vulvovaginal inflammation. Additionally, the glucocorticoids (GCs), prednisolone, and dexamethasone are used to treat HIV-associated immune activation. Collectively, these data inform on immune-modulating drugs to reduce HIV risk. However, the prolonged use of these pharmaceutical drugs is associated with adverse effects, both systemically and to a lesser extent topically. Natural products with their reduced side effects coupled with anti-inflammatory properties render them viable options. Lactic acid (LA) has immunomodulatory properties. LA regulates the genital microbiome by facilitating the growth of Lactobacillus species, while simultaneously limiting bacterial species that cause microbial dysbiosis and GI. Glycerol monolaurate, besides being anti-inflammatory, also inhibited SIV infections in rhesus macaques. The proposed pharmaceutical and natural products could be used in combination with either antiretrovirals for treatment or preexposure prophylaxis for HIV prevention. This review provides a summary on the associations between inflammation, HIV risk, and disease progression. Furthermore, we use the knowledge from immune quiescence to exploit the use of pharmaceutical and natural products as strategic interventions to manage inflammation, toward mitigating HIV infections.

Knowledge and barriers of PrEP delivery among diverse groups of potential PrEP users in Central Uganda

BACKGROUND

Scale-up of oral pre-exposure prophylaxis (PrEP) for HIV prevention in Uganda began with serodiscordant couples (SDC) and has expanded to other most at-risk populations (MARPs). We explored knowledge, acceptability, barriers and facilitators of PrEP use among potential PrEP users in four MARPs (SDC; men who have sex with men [MSM]; female sex workers [FSW], and fisher folk).

METHODS

We administered quantitative surveys to potential PrEP users in multiple settings in Central Uganda at baseline and approximately 9 months after healthcare worker (HCW) training on PrEP.

RESULTS

The survey was completed by 250 potential PrEP users at baseline and 125 after HCW training; 55 completed both surveys. For these 250 participants, mean age was 28.5 years (SD 6.9), 47% were male and 6% were transgender women, with approximately even distribution across MARPs and recruitment locations (urban, peri-urban, and rural). Most (65%) had not heard about PrEP. After HCW training, 24% of those sampled were aware of PrEP, and the proportion of those who accurately described PrEP as "antiretrovirals to be used before HIV exposure" increased from 54% in the baseline survey to 74% in the second survey (p<0.001). The proportion of participants who reported HCW as a source of PrEP information increased after training (59% vs 91%, p<0.001). In both surveys, nearly all participants indicated they were willing to take PrEP if offered. The most common anticipated barriers to PrEP were stigma, transportation, accessibility, busy schedules, and forgetfulness. Closeness to home was a common facilitator for all participant categories.

CONCLUSIONS

Initial awareness of PrEP was low, but PrEP knowledge and interest increased among diverse MARPs after HCW training. Demand creation and HCW training will be critical for increasing PrEP awareness among key populations, with support to overcome barriers to PrEP use. These findings should encourage the acceleration of PrEP rollout in Uganda.

Risk-Taking Behaviors and Adherence to HIV Pre-Exposure Prophylaxis in Users of Geosocial Networking Apps: Real-World, Multicenter Study

Background

Over half of men who have sex with men (MSM) use geosocial networking (GSN) apps to encounter sex partners. GSN apps’ users have become a unique large subpopulation among MSM for interventions concerning HIV prevention and control. Pre-exposure prophylaxis (PrEP) is a promising measure for HIV prevention, especially for MSM, but its effectiveness largely depends on medication adherence. However, little is known about PrEP adherence among GSN apps’ users, which is critical to addressing the overall optimization of PrEP compliance outside of clinical trials in the context of large-scale implementation.

Objective

The objective of this study is to understand the correlation between GSN apps’ use and medication adherence among MSM receiving PrEP, with the aim to increase their awareness about PrEP use in order to increase adherence.

Methods

This study based on the China Real-world Oral intake of PrEP (CROPrEP) project, a multicenter, real-world study of Chinese MSM on daily and event-driven PrEP. Eligible participants completed a detailed computer-assisted self-interview on sociodemographic, GSN apps’ use, and sexual behavior. Then participants were followed up for 12 months and assessed for various characteristics (eg, PrEP delivery, adherence assessment, PrEP coverage of sexual activities, and regimens switch). A generalized estimation equation was used to analyze the predictors of medication adherence and regimen conversion among GSN apps’ users and nonusers.

Results

At baseline, 756 of the 1023 eligible participants (73.90%) reported primarily using GSN apps to seek sexual partners, and GSN apps’ users are more likely to have high-risk behaviors such as multiple sex partners and condomless anal intercourse than other nonusers (all P<.05). During follow-up, GSN apps’ users had a significantly low level of pill-counting adherence than nonusers (adjusted odds ratio [aOR] 0.8, 95% CI 0.6-1.0, P=.038). In the event-driven group, GSN apps’ users had marginally lower levels of self-reported adherence (aOR 0.7, 95% CI 0.4-1.0, P=.060) and lower PrEP coverage of sexual practices (aOR 0.6, 95% CI 0.4-1.0, P=.038). Additionally, GSN apps’ users seemed more likely to switch from event-driven to daily regimen (aOR 1.8, 95% CI 0.9-3.3, P=.084).

Conclusions

GSN apps’ users are highly prevalent among MSM, despite their higher sexual risk and lower adherence levels, suggesting that eHealth needs to be introduced to the GSN platform to promote PrEP adherence.

Trial Registration

Chinese Clinical Trial Registry ChiCTR-IIN-17013762; https://tinyurl.com/yy2mhrv4.

International Registered Report Identifier (IRRID)

RR2-10.1186/s12879-019-4355-y

Betamethasone induces potent immunosuppression and reduces HIV infection in a PBMC in vitro model

Genital inflammation is an established risk factor for increased HIV acquisition risk. Certain HIV-exposed seronegative populations, who are naturally resistant to HIV infection, have an immune quiescent phenotype defined by reduced immune activation and inflammatory cytokines at the genital tract. Therefore, the aim of this study was to create an immune quiescent environment using immunomodulatory drugs to mitigate HIV infection. Using an in vitro peripheral blood mononuclear cell (PBMC) model, we found that inflammation was induced using phytohemagglutinin and Toll-like receptor (TLR) agonists Pam3CSK4 (TLR1/2), lipopolysaccharide (LPS) (TLR4) and R848 (TLR7/8). After treatment with anti-inflammatory drugs, ibuprofen (IBF) and betamethasone (BMS), PBMCs were exposed to HIV NL4-3 AD8. Multiplexed ELISA was used to measure 28 cytokines to assess inflammation. Flow cytometry was used to measure immune activation (CD38, HLA-DR and CCR5) and HIV infection (p24 production) of CD4+ T cells. BMS potently suppressed inflammation (soluble cytokines, p<0.05) and immune activation (CD4+ T cells, p<0.05). BMS significantly reduced HIV infection of CD4+ T cells only in the LPS (0.98%) and unstimulated (1.7%) conditions (p<0.02). In contrast, IBF had minimal anti-inflammatory and immunosuppressive but no anti-HIV effects. BMS demonstrated potent anti-inflammatory effects, regardless of stimulation condition. Despite uniform immunosuppression, BMS differentially affected HIV infection according to the stimulation conditions, highlighting the complex nature of these interactions. Together, these data underscore the importance of interrogating inflammatory signaling pathways to identify novel drug targets to mitigate HIV infection.

HIV and other STIs self-testing to reduce risk compensation among men who have sex with men who use oral pre-exposure prophylaxis in China: protocol for a randomised waitlist-controlled trial

INTRODUCTION

Pre-exposure prophylaxis (PrEP) reduces the risk of HIV infection among men who have sex with men by up to 99%. However, in real-world settings, PrEP users may exhibit risk compensation after uptake of PrEP, including more condomless anal intercourse (CAI) and increased sexually transmitted infection (STI) acquisition. HIV self-testing (HIVST) decreases CAI among men who have sex with men (MSM) by providing awareness of the HIV status of oneself and one's sexual partners. Here, we describe the rationale and design of a randomised waitlist-controlled trial to examine the impact of HIVST on risk compensation among PrEP users.

METHODS AND ANALYSIS

The study is a two-arm randomised waitlist-controlled trial with 1000 HIV-negative MSM in four major cities in China who will be taking oral PrEP (involving tenofovir disoproxil fumarate/emtricitabine) either daily (n=500) or in an event-driven regimen (n=500). The participants will be randomised (1:1) to either the immediate HIVST intervention arm (HIVST plus standard facility-based counselling and testing from 0 to 12 months) or the waitlist arm (standard facility-based counselling and testing from 0 to 6 months, then crossover to receive the HIVST intervention in months 7-12). Participants will provide blood samples to assess the incidence of syphilis and herpes simplex virus type 2 (HSV-2) during a follow-up. The primary outcomes will be the occurrence of CAI, number of sexual partners and incidence of syphilis and HSV-2 during a follow-up. The secondary outcomes will be the HIV and STI testing frequency and STI treatment adherence during a follow-up. The planned start and end dates for the study is 26 December 2018 and 31 December 2020.

ETHICS AND DISSEMINATION

The Medical Science Research Ethics Committee of The First Affiliated Hospital of China Medical University has approved the study (IRB(2018)273).

TRIAL REGISTRATION NUMBER

ChiCTR1800020374.

Pre-exposure prophylaxis among men who have sex with men in Côte d'Ivoire: a quantitative study of acceptability

This cross sectional study was conducted in 2018 in Côte d'Ivoire to assess PrEP acceptability among men who have sex with men (MSM). Two hundred and one men were asked on their intention to use PrEP if made available. Logistic regression accounting for the sampling design was used to analyze associations between high PrEP acceptability and different independent variables including barriers and facilitators. Participants were mostly young (mean age = 25 years), educated (82% with secondary/postsecondary education) and single (95.5%). On average, 3.4 episodes of anal sex were reported monthly and 37.8% of men did not use a condom at last sex. Most MSM (72.6%) had heard of PrEP before enrollment. Overall, 35.3% reported that they would use PrEP very probably if made available. In multivariate analysis, factors associated with high PrEP acceptability were condom use at last sexual intercourse (Odds ratio (OR) = 2.51; 95%Confidence interval (95%CI) = 1.45-4.33); insertive sex as compared to versatile sex (OR = 2.56; 95%CI = 1.14-5.67); free PrEP delivery (OR = 2.45; 95%CI = 1.07-5.59), concerns about side effects (OR = 0.66; 95%CI = 0.48-0.90), and being preoccupied by the fact that post-PrEP antiretroviral therapy could be inefficient (OR = 0.25; 95%CI = 0.14-0.44). PrEP implementation among MSM in Côte d'Ivoire should be accompanied by awareness raising campaigns explaining its utility.

Pre-exposure Prophylaxis Use and Medication Adherence Among Men Who Have Sex With Men: A Systematic Review of the Literature

The appropriate use of pre-exposure prophylaxis (PrEP) by men who have sex with men (MSM) can be highly effective at reducing HIV transmission. Our review examined prevalence estimates, sexual behaviors, and medication adherence among MSM PrEP users in high-income countries. Articles published between January 2008 and December 2018 were identified through Medline, Web of Science, CINAHL, and CENTRAL. The search identified 643 publications, of which 52 were included in the final synthesis. We found that PrEP initiation was not consistently associated with significant changes in sexual behavior, but some users may have risk compensated. A minority of MSM used PrEP, and they had high levels of adherence. PrEP-related stigma, side effects, and psychosocial factors lead to nonadherence. A daily routine, pill boxes, alarms/texts, and education can promote adherence. Further research is required to examine PrEP impact on sexual behavior and factors that influence adherence in high-risk MSM subpopulations.

Pleasure and PrEP: Pleasure-Seeking Plays a Role in Prevention Choices and Could Lead to PrEP Initiation

Pleasure-seeking plays a role in prevention (means choices and use), and in the sexual quality of life of men who have sex with men (MSM). Since HIV is a major threat to MSM health, new means of prevention, like pre-exposure prophylaxis (PrEP), must meet the needs of MSM to be fully efficient. Using a psychosocial approach, we examined how pleasure-seeking plays a role in participation of MSM in “ANRS-IPERGAY,” a community-based trial on sexual health which included sexual on-demand PrEP. Thirteen semistructured collective interviews were conducted with 45 participants. First, we analyzed participants’ search for new prevention means due to previous failures in condom use. We found that participants perceived condoms as a barrier—both materially and symbolically—to pleasure and desire, causing anxiety and stress considering sexual intercourse. Second, we explored representations and attitudes concerning pleasure within the context of PrEP. We found that PrEP allowed participants to freely choose their desired sexual positions and to better enjoy intimacy. Third, we studied the sexual quality of life for PrEP users in ANRS-IPERGAY and found an improvement. Thanks to the community-based design of the trial, this new prevention tool became a means to develop agency and empowerment for participants, not only in negotiating individual prevention but also in opposing the normative and stigmatizing discourse on sexuality and HIV. In conclusion, pleasure-seeking appears to be an essential element of sexual fulfillment that needs to be integrated as a positive notion in the study of HIV prevention.

Pre-exposure prophylaxis use among men who have sex with men who have experienced problematic chemsex

Men who have sex with men (MSM) who experience problematic chemsex are at high risk of acquiring HIV due to combined drug use and sexual behaviours. Pre-exposure prophylaxis (PrEP) could substantially reduce the risk of HIV transmission in this group of men. The aim of this study was to examine the biopsychosocial characteristics associated with PrEP use among HIV-negative MSM who have experienced problematic chemsex. This was a cross-sectional analysis of secondary data collected during client assessments at a specialist alcohol and drug service based within the United Kingdom. We compared the socio-demographics, substance use, sexual behaviours and mental health of MSM who reported ever using PrEP to those who reported never using PrEP. Statistical analysis was conducted using the Mann–Whitney U-test for continuous variables and Fisher’s exact test for categorical variables. Between August 2016 and July 2018, 165 HIV-negative MSM who engaged in chemsex had an assessment completed. Thirty-four per cent (n = 50/145) had ever used PrEP. The median age was 36 years (IQR: 30–42), 92% identified as gay (n = 152/165) and 79% were of white ethnicity (n = 130/164). The use of crystal methamphetamine was associated with higher levels of men ever using PrEP (40% versus 21%) (p= 0.047). Men who had ever used PrEP had a higher median number of sexual partners in the previous three months (20 versus 10) (p= 0.004) and had lower level of condom use in their sex lives (median reported 5% versus 50%) (p= 0.010) in comparison to men who had never used PrEP. It is encouraging that men having higher-risk sex had been accessing PrEP. However, further research is required to explore PrEP uptake, retention and adherence in this high-risk group.

[HIV pre-exposure prophylaxis care in intersectoral collaboration : Interim analysis of a monocentric, prospective study in Germany]

BACKGROUND

HIV pre-exposure prophylaxis (PrEP), a further opportunity to prevent HIV, is available at the WIR-Walk In Ruhr, Centre for Sexual Health and Medicine, as part of an innovative model project for intersectoral PrEP care.

RESEARCH OBJECTIVES

The present study describes the collective of persons provided with PrEP and how PrEP use influences sexual risk behaviour, the incidence of sexually transmitted diseases (STD) and adverse drug reactions.

METHODS

A total of 139 men who started PrEP between 10/2017 and 12/2018 have been included in the study. During a period of 13 months of PrEP treatment, all PrEP users received questionnaires; side effects, HIV and other STI were also monitored via clinical laboratory examinations.

RESULTS

The participants' average age was 38 years and 98.6% of them were men who had sex with men (MSM). Most of them had a high educational background; the unemployment rate was low. The average number of sexual partners within the last 6 months increased significantly, while the use of condoms decreased. In all, 44 STI were found in 34 participants within the first 4 months. No one was infected with HIV. Within the first 4 weeks of PrEP, 38.8% of the participants suffered from side effects, mainly gastrointestinal symptoms.

CONCLUSION

Most of the participants were working in a job or a vocational training. The sexual risk behaviour increased in the course of using PrEP resulting in a high incidence of STD. Side effects appeared most frequently in the first few weeks after starting PrEP.

CE: HIV Update: An Epidemic Transformed

: The field of HIV treatment and prevention has evolved rapidly over the past four decades. New therapies that are more potent and streamlined have transformed HIV into a chronic disease, while the use of such preventive strategies as preexposure prophylaxis and postexposure prophylaxis provide effective options for reducing the risk of HIV infection. These medical breakthroughs have enabled more people living with HIV (PLWH) to reach older adulthood. But they also mean that nurses are seeing more PLWH who have developed long-term complications of living with HIV or of exposure to antiretroviral therapy, as well as concurrent chronic conditions associated with advanced age. Nurses play a critical role in caring for PLWH and those at risk for HIV infection. This article discusses HIV epidemiology, describes the current state of HIV treatment and prevention, and highlights common comorbidities often seen in PLWH who are over age 50.

A Promising PrEP Navigation Intervention for Transgender Women and Men Who Have Sex with Men Experiencing Multiple Syndemic Health Disparities

Transgender women and MSM experience many stigma-related syndemic conditions that exacerbate HIV incidence and prevalence rates. While PrEP is an effective biomedical intervention to reduce HIV transmission, uptake and adherence of PrEP is low among transgender women and MSM experiencing multiple syndemic health disparities. This study tested the feasibility, acceptability and effectiveness of A.S.K.-PrEP (AssistanceServicesKnowledge-PrEP), a five-session peer navigator program, designed to link transgender women and MSM to PrEP. From September 2016 to March 2018, 187 participants (transgender women = 58; MSM = 129) enrolled. Results demonstrated that approximately 90% of transgender women and MSM were linked to PrEP; MSM linked more quickly [KW χ2(1) = 10.9, p < .001]. Most transgender women (80%) and MSM (70%) reported they were still taking PrEP at the 90-day follow-up evaluation. Findings indicated that A.S.K.-PrEP is a promising intervention for PrEP linkage, uptake and preliminary adherence among transgender women and MSM.

Chemsex is not a barrier to self-reported daily PrEP adherence among PROUD study participants

BACKGROUND

Pre-exposure prophylaxis (PrEP) is a novel HIV prevention method whereby HIV-negative individuals take the drugs tenofovir and emtricitabine to prevent HIV acquisition. Optimal adherence is critical for PrEP efficacy. Chemsex describes sexual activity under the influence of psychoactive drugs, in the UK typically; crystal methamphetamine, gamma-hydroxybutyrate(GHB) and/or mephedrone. Chemsex drug use has been associated with increased HIV transmission risk among gay, bisexual and other men who have sex with men (GBM) and poor ART adherence among people living with HIV. This study assessed whether self-reported chemsex events affected self-reported daily PrEP adherence among PROUD study participants.

METHODS

The PROUD study was an open-label, randomised controlled trial, conducted in thirteen English sexual health clinics, assessing effectiveness of TruvadaⓇ-PrEP among 544 HIV-negative GBM. The study reported an 86% risk-reduction of HIV from daily PrEP. Participants were asked about chemsex engagement at follow-up visits. Monthly self-reports of missed PrEP tablets were aggregated to assess adherence between visits. Univariable and multivariable regression analyses were performed to test for associations between chemsex and reporting less than seven out of seven intended doses(<7/7ID) in the 7 days before and/or after last condomless anal intercourse(CAI).

RESULTS

1479 follow-up visit forms and 2260 monthly adherence forms from 388 participants were included in the analyses, with 38.5% visit forms reporting chemsex since last visit and 29.9% follow-up periods reporting <7/7ID. No statistically significant associations were observed between reporting <7/7ID and chemsex (aOR=1.29 [95% CI 0.90-1.87], p = 0.168). Statistically significant associations were seen between reporting <7/7ID and participants perceiving that they would miss PrEP doses during the trial, Asian ethnicity, and reporting unemployment at baseline.

CONCLUSIONS

These analyses suggest PrEP remains a feasible and effective HIV prevention method for GBM engaging in chemsex, a practise which is prevalent in this group and has been associated with increased HIV transmission risk.

Efficacy and cost-effectiveness of early antiretroviral therapy and partners' pre-exposure prophylaxis among men who have sex with men in Shenyang, China: a prospective cohort and costing study

BACKGROUND

Biomedical interventions such as antiretroviral therapy (ART) and pre-exposure prophylaxis (PrEP) are highly effective for prevention of human immunodeficiency virus (HIV) infection. However, China has not released national PrEP guidelines, and HIV incidence among men who have sex with men (MSM) is unchanged despite substantial scale-up of ART. We evaluated reductions in HIV transmission that may be achieved through early initiation of ART plus partners' PrEP.

METHODS

Six intervention scenarios were evaluated in terms of their impact on HIV transmission and their cost-effectiveness for 36 months post-infection. Three scenarios were based on observed data: non-ART, standard-ART, and early-ART. Another three scenarios were based on observed and hypothetical data: non-ART plus partners' PrEP, standard-ART plus partners' PrEP, and early-ART plus partners' PrEP. The number of onward transmissions was calculated according to viral load and self-reported sexual behaviors, and calibrated by the prevalence and incidence of HIV among Chinese MSM. Cost-effectiveness outcomes were quality-adjusted life-years (QALYs) and cost-utility ratio (CUR).

RESULTS

The estimated number of onward transmissions by every 100 HIV-positive cases 36 months post-infection was 41.83 (95% credible interval: 30.75-57.69) in the non-ART scenario, 7.95 (5.85-10.95) in the early-ART scenario, and 0.79 (0.58-1.09) in the early-ART plus partners' PrEP scenario. Compared with non-ART, the early-ART and early-ART plus partners' PrEP scenarios were associated with an 81.0 and 98.1% reduction in HIV transmission, and had a CUR of $12,864/QALY and $16,817/QALY, respectively.

CONCLUSIONS

Integrated delivery of early ART and sexual partners' PrEP could nearly eliminate HIV transmission and reduce costs during the first 36 months of HIV infection. Our results suggest a feasible and cost-effective strategy for reversing the HIV epidemic among MSM in China.

Willingness to Use and Adhere to HIV Pre-Exposure Prophylaxis (PrEP) among Men Who Have Sex with Men (MSM) in China

This study aimed to investigate the levels of willingness to use pre-exposure prophylaxis (PrEP) and intention to adhere to PrEP and to further explore factors associated with PrEP uptake among men who have sex with men (MSM) in China. A total of 524 MSM were recruited from Chengdu, China. Half of the participants had heard of PrEP, and the awareness rate varied from 33.8%, 30.7%, and 7.1% for daily oral PrEP, on-demand PrEP, and long-acting injectable PrEP (LAI-PrEP), respectively. The overall willingness to use any type of PrEP in the next six months was 84.9% if PrEP is effective and provided for free. Participants were less likely to say that they would use PrEP if they used a condom consistently with their regular partners. However, participants were more likely to say that they would use PrEP if they had casual partners in the past month and had higher HIV prevention literacy. The majority of participants intended to adhere to PrEP prescription. More than forty percent (43.1%) of the participants reported that they might reduce condom use if they took PrEP. We found that the overall willingness to use PrEP was high among MSM living in China, but willingness varied across the different types of PrEP.

Implementing condom distribution programs in the United States: Qualitative insights from program planners

With the growing number of sexually transmitted infections (STIs) among young people (15-24) in the US, condom distribution programs (CDP) remain an integral part of prevention strategies. The objective of the study was to gather qualitative insights from CDP planners to inform effective CDP implementation. Ten semi-structured interviews with program planners were conducted via telephone (response rate of 58.8%). Condom distribution channels included site-based distribution (n = 6), web-based distribution (n = 4), and distribution via Uber (n = 1). Site-based distribution programs had distribution networks ranging from 100 to 3500 sites in a given jurisdiction. Planners of site-based CDPs experienced challenges with ensuring quality control at sites and supplying condoms to sites. Web-based CDPs allow individuals to order free condoms online. These CDP planners reported growing demand for this discreet service, particularly among young people. Web-based CDPs leveraged e-mail surveys to collect data on sexual behavior and behavior change, yielding response rates as high as 63%. All CDPs emphasized the importance of supplying a variety of products. Total supplies distributed (male condoms, internal condoms, lubricant sachets) ranged from 16,000 to 45 million per year. Novel channels of distribution should be explored to ensure reach to adolescents and young adults.

PrEP uptake preferences among men who have sex with men in China: results from a National Internet Survey

INTRODUCTION

HIV incidence among men who have sex with men (MSM) is high in China. Pre-exposure prophylaxis (PrEP) is a promising mean to prevent HIV transmission but it is not widely available in China. We conducted a large Internet-based online survey to assess the willingness of Chinese MSM to take PrEP and associated factors to their uptake preferences.

METHODS

Between 19 January and 6 February, 2017, 4581 MSM aged over 15 years were recruited via a social networking app to take an online PrEP survey. HIV status at the time of the survey being conducted was not one of recruitment criteria. Participants were asked if they had heard of PrEP, if they had concerns about PrEP, and if they would be ready to uptake PrEP should it be provided. When asked if participants were willing to take PrEP, they were asked to select from the following responses: "definitely not," "probably not," "not sure," "probably yes," and "definitely yes." In the final analysis, we grouped these five-level Likert scale responses into three-level responses as "definitely yes," "probably yes," and "no (definitely not/probably not/not sure)." Descriptive analysis and multinomial logistic regressions were conducted to assess the associations of PrEP adoption readiness and uptake concerns with HIV risk behaviours and demographic characteristics.

RESULTS

MSM from 33 geographical regions of China participated in the survey. The majority were younger than 25 (65.2%) and had attended college (68.6%). HIV prevalence was high (6.8%) and 43.3% reported a history of unprotected anal sex. Only 22.4% of participants had heard of PrEP. When asked if they would uptake PrEP, 26.0% said "definitely yes," 49.6% were "probably yes," and 24.4% said "no." PrEP adoption readiness was associated with having previously heard of PrEP and expressing concerns about accessibility and cost. Worries about side effects, low perceived HIV risk, preference for condoms, and never having received HIV testing were negatively associated with PrEP uptake willingness.

CONCLUSION

Young and well-educated Chinese MSM reported a low willingness to uptake PrEP despite being high-risk for HIV. Effective education, especially through online mediums, will be critical to optimize this group's PrEP uptake.