HIV Preexposure Prophylaxis, by Race and Ethnicity - United States, 2014-2016

Perspectives and Recommendations From Lesbian, Gay, Bisexual, Transgender, and Queer/Questioning Youth of Color Regarding Engagement in Biomedical HIV Prevention

PURPOSE

Young people of color have high HIV incidence rates and suffer the greatest health inequities with regard to daily oral pre-exposure prophylaxis. Although the next generation of biomedical HIV prevention products is already under clinical development, little research has examined whether such products address the needs of this population or identified specific strategies for educating this population about prevention options that might result in the greatest interest in and uptake of new prevention modalities.

METHODS

We analyzed data from seven focus groups (n = 93) conducted between July 2016 and March 2017 in partnership with a lesbian, gay, bisexual, transgender, and queer/questioning youth-serving community-based organization in the northeastern U.S. The study aimed to understand concerns, priorities, and preferences around biomedical HIV prevention modalities (i.e., daily oral pill, long-acting injectable, and topical microbicide) among lesbian, gay, bisexual, transgender, and queer/questioning youth of color.

RESULTS

Our findings identified four key dynamics specific to educating young people about biomedical prevention, including (1) providing information with a sufficient level of detail and complexity, (2) contextualizing messaging in terms of young people's existing knowledge and beliefs, (3) providing detailed information about side effects, drug- and multi-method interactions, and dosing/usage contingencies, and (4) working proactively to support transgender youth and ensure that prevention products are accessible to them.

CONCLUSIONS

As we plan for a future of choice in biomedical HIV prevention, we should consider how novel products can address inequities in pre-exposure prophylaxis access and HIV incidence by valuing the concerns and needs of this highest priority population.

Brief Report: Impact of PrEP Training for Family Planning Providers on HIV Prevention Counseling and Patient Interest in PrEP in Atlanta, Georgia

BACKGROUND

Safety net family planning (FP) clinics provide vital care for women in high HIV-burden areas and may be ideal pre-exposure prophylaxis (PrEP) delivery sites. Yet, many FP providers lack knowledge about PrEP.

SETTING

Four safety net FP clinics in Atlanta, Georgia.

METHODS

We provided a 1.5-hour PrEP informational training for 28 providers working in these sites. To assess the training's impact on PrEP counseling, we enrolled 500 female patients after training (47% ≤ 28 years; 69% black; 12% Hispanic) and determined their PrEP indication based on CDC guidelines. We conducted a postvisit survey to assess provider counseling and patients' interest in PrEP and acceptance of off-site PrEP referral.

RESULTS

From pre-training to post-training, provider PrEP knowledge and confidence to identify women who may benefit from PrEP significantly increased. Only 19% of women knew about PrEP before the visit. Among 376 sexually active women, 29% had risk consistent with PrEP indication. Among PrEP-indicated women, 66% reported the provider discussed PrEP, 29% were interested in taking PrEP, but only 18% accepted off-site PrEP referral. Most (76%) were more willing to take PrEP if provided by the FP clinic.

CONCLUSIONS

After a brief PrEP training, most women with HIV-risk indicators received PrEP counseling during their visits. Once counseled, women expressed interest if it were offered at the FP clinic rather than through off-site referral. Findings highlight the potential impact that PrEP capacity building within safety net FP clinics in high HIV-burden areas may have on PrEP scale-up for women.

Evaluation of Algorithms Used for PrEP Surveillance Using a Reference Population From New York City, July 2016-June 2018

OBJECTIVE

Daily tenofovir disoproxil fumarate/emtricitabine (TDF/FTC) use as HIV preexposure prophylaxis (PrEP) is monitored by identifying TDF/FTC prescriptions from pharmacy databases and applying diagnosis codes and antiretroviral data to algorithms that exclude TDF/FTC prescribed for HIV postexposure prophylaxis (PEP), HIV treatment, and hepatitis B virus (HBV) treatment. We evaluated the accuracy of 3 algorithms used by the Centers for Disease Control and Prevention (CDC), Gilead Sciences, and the New York State Department of Health (NYSDOH) using a reference population in Bronx, New York.

METHODS

We extracted diagnosis codes and data on all antiretroviral prescriptions other than TDF/FTC from an electronic health record database for persons aged ≥16 prescribed TDF/FTC during July 2016-June 2018 at Montefiore Medical Center. We reviewed medical records to classify the true indication of first TDF/FTC use as PrEP, PEP, HIV treatment, or HBV treatment. We applied each algorithm to the reference population and compared the results with the medical record review.

RESULTS

Of 2862 patients included in the analysis, 694 used PrEP, 748 used PEP, 1407 received HIV treatment, and 13 received HBV treatment. The algorithms had high specificity (range: 98.4%-99.0%), but the sensitivity of the CDC algorithm using a PEP definition of TDF/FTC prescriptions ≤30 days was lower (80.3%) than the sensitivity of the algorithms developed by Gilead Sciences (94.7%) or NYSDOH (96.1%). Defining PEP as TDF/FTC prescriptions ≤28 days improved CDC algorithm performance (sensitivity, 95.8%; specificity, 98.8%).

CONCLUSIONS

Adopting the definition of PEP as ≤28 days of TDF/FTC in the CDC algorithm should improve the accuracy of national PrEP surveillance.

Low Awareness of and Access to Pre-exposure Prophylaxis But High Interest Among Heterosexual Women in Cleveland, Ohio

Women received <5% of all US pre-exposure prophylaxis (PrEP) prescriptions in 2016. Among 351 heterosexual women surveyed in Cleveland, Ohio, 14.5% were aware of PrEP, 20.5% knew where to access PrEP, 75.9% were willing to try PrEP, and 50.9% expressed interest in more information.

Correlations of HIV Preexposure Prophylaxis Indications and Uptake, Chicago, Illinois, 2015-2018

Objectives. To examine gaps in identification of preexposure prophylaxis (PrEP) candidates, uptake, and use of PrEP by populations most likely to seroconvert.Methods. At a federally qualified health center in Chicago, Illinois, we used electronic medical records, prescription data, and our best approximation of Centers for Disease Control and Prevention PrEP guidelines to determine how many patients were indicated for PrEP relative to HIV diagnoses (indication:HIV), how many were on PrEP relative to indications (PrEP:indication), and how many were on PrEP relative to HIV diagnoses (PrEP:HIV). We compared these ratios across age, gender and orientation, race/ethnicity, and insurance.Results. Overall, there were 32 indications per incident diagnosis and 16 patients on PrEP per incident diagnosis. In adjusted models, Whites had higher indication:HIV and PrEP:HIV ratios compared with Blacks, men who have sex with men had higher indication:HIV and PrEP:HIV ratios compared with transwomen but lower PrEP:indication ratios, and uninsured patients had higher indication:HIV but lower PrEP:indication and PrEP:HIV ratios compared with those with insurance.Conclusions. PrEP use, relative to HIV diagnoses, differs by important patient characteristics. While improved guidelines will address some of the disparity, better approaches for determining PrEP candidates and more normalized patient-provider communication are needed to ensure better PrEP access to all individuals at high risk for HIV.

The Invisible US Hispanic/Latino HIV Crisis: Addressing Gaps in the National Response

The federal government has proposed an end to HIV transmission in the United States by 2030. Although the United States has made substantial overall progress in the fight against HIV/AIDS, data released by the Centers for Disease Control and Prevention have raised concerns about widening, yet largely unrecognized, HIV infection disparities among Hispanic and Latino populations.This commentary identifies underlying drivers of increasing new HIV infections among Hispanics/Latinos, discusses existing national efforts to fight HIV in Hispanic/Latino communities, and points to gaps in the federal response. Consideration of the underlying drivers of increased HIV incidence among Hispanics/Latinos is warranted to achieve the administration's 2030 HIV/AIDS goals.Specifically, the proposed reinforcement of national efforts to end the US HIV epidemic must include focused investment in four priority areas: (1) HIV stigma reduction in Hispanic/Latino communities, (2) the availability and accessibility of HIV treatment of HIV-positive Hispanics/Latinos, (3) the development of behavioral interventions tailored to Hispanic/Latino populations, and (4) the engagement of Hispanic/Latino community leaders.

Women's Decision-Making about PrEP for HIV Prevention in Drug Treatment Contexts

Despite pre-exposure prophylaxis's (PrEP) efficacy for HIV prevention, uptake has been low among women with substance use disorders (SUDs) and attributed to women's lack of awareness. In semistructured interviews with 20 women with SUD and 15 key stakeholders at drug treatment centers, we assessed PrEP awareness and health-related decision-making. Women often misestimated their own HIV risk and were not aware of PrEP as a personally relevant option. Although women possessed key decision-making skills, behavior was ultimately shaped by their level of motivation to engage in HIV prevention. Motivation was challenged by competing priorities, minimization of perceived risk, and anticipated stigma. Providers were familiar but lacked experience with PrEP and were concerned about women's abilities to action plan in early recovery. HIV prevention for women with SUD should focus on immediately intervenable targets such as making PrEP meaningful to women and pursuing long-term systemic changes in policy and culture. Efforts can be facilitated by partnering with drug treatment centers to reach women and implement PrEP interventions.

Telemedicine: a solution to disparities in human immunodeficiency virus prevention and pre-exposure prophylaxis uptake, and a framework to scalability and equity

As the group with the highest risk and the lowest pre-exposure prophylaxis (PrEP) utilization, black and Hispanic young men who have sex with men (MSM) face the brunt of the current human immunodeficiency virus (HIV) epidemic within the United States. In this narrative review, we summarized recent interventions that utilize technology (telemedicine) to improve HIV PrEP uptake. We examined the general model of those telemedicine programs and evaluated their success and limitations in addressing PrEP accessibility for at-risk individuals. We also identified the current bottlenecks in the scalability of telemedicine programs, offered suggestions to overcome these barriers, and advocated for a centralized source of funding to increase the accessibility of telemedicine programs for PrEP.

Brief Report: PrEP Eligibility Among At-Risk Women in the Southern United States: Associated Factors, Awareness, and Acceptability

BACKGROUND

Among women in the United States, non-Latina black women in the South have disproportionately high rates of new HIV infections but low use of pre-exposure prophylaxis (PrEP). Effective strategies to identify factors associated with PrEP eligibility could facilitate improved screening, offering, and uptake of PrEP among US women at risk of HIV.

SETTING AND METHODS

We applied 2014 CDC criteria for PrEP use to at-risk HIV-negative women enrolled in the Southern US sites (Atlanta, Chapel Hill, Birmingham/Jackson, Miami) of the Women's Interagency HIV Study from 2014 to 2015 to estimate PrEP eligibility and assess PrEP knowledge and acceptability. Factors associated with PrEP eligibility were assessed using multivariable models.

RESULTS

Among 225 women, 72 (32%) were PrEP-eligible; the most common PrEP indicator was condomless sex. The majority of PrEP-eligible women (88%) reported willingness to consider PrEP. Only 24 (11%) PrEP-eligible women had previously heard of PrEP, and only 1 reported previous use. Education level less than high school [adjusted odds ratio (aOR) 2.56; 95% confidence interval (CI): 1.22 to 5.37], history of sexual violence (aOR 4.52; 95% CI: 1.52 to 17.76), and medium to high self-perception of HIV risk (aOR 6.76; 95% CI: 3.26 to 14.05) were significantly associated with PrEP eligibility in adjusted models.

CONCLUSIONS

Extremely low PrEP awareness and use despite a high proportion of eligibility and acceptability signify a critical need to enhance PrEP education and delivery for women in this region. Supplementing CDC eligibility criteria with questions about history of sexual violence and HIV risk self-assessment may enhance PrEP screening and uptake among US women.

Young black MSM's exposures to and discussions about PrEP while navigating geosocial networking apps

Young Black gay, bisexual and other men who have sex with men (YBMSM) carry a disproportionate HIV burden perpetuated by exposure to sexual networks with higher untreated HIV prevalence and incidence. In Baltimore, these sexual networks include high utilization of geosocial networking apps (GSN-apps). Our prior work suggests these apps can be important access points for targeted interventions like PrEP. To inform online PrEP outreach we explored YBMSM GSN-app users' exposure to and discussions about PrEP while navigating apps. We actively recruited YBMSM (n=17) age 18-24 from the GSN-app most frequently reported by newly diagnosed HIV-infected MSM in Baltimore. Participants were recruited through direct messaging within the GSN-app while logged-on in high HIV transmission areas. Participants completed 60-90 minute semi-structured interviews, which were analyzed using a 3-stage analytic coding strategy. While some participants had not heard of PrEP, the majority described mentions or conversations about PrEP on GSN-apps. Three themes emerged: (1) Mistrust of PrEP, (2) Association with sexual promiscuity, and (3) Concerns about lack of protection from other STIs. Proper messaging, accurate information, and education are needed to account for the negative perceptions that surround PrEP; otherwise, continued underuse among YBMSM will expand rather than reduce HIV disparities.

Vital Signs: Status of Human Immunodeficiency Virus Testing, Viral Suppression, and HIV Preexposure Prophylaxis - United States, 2013-2018

Background

Approximately 38,000 new human immunodeficiency virus (HIV) infections occur in the United States each year; these infections can be prevented. A proposed national initiative, Ending the HIV Epidemic: A Plan for America, incorporates three strategies (diagnose, treat, and prevent HIV infection) and seeks to leverage testing, treatment, and preexposure prophylaxis (PrEP) to reduce new HIV infections in the United States by at least 90% by 2030. Targets to reach this goal include that at least 95% of persons with HIV receive a diagnosis, 95% of persons with diagnosed HIV infection have a suppressed viral load, and 50% of those at increased risk for acquiring HIV are prescribed PrEP. Using surveillance, pharmacy, and other data, CDC determined the current status of these three initiative strategies.

Methods

CDC analyzed HIV surveillance data to estimate annual number of new HIV infections (2013–2017); estimate the percentage of infections that were diagnosed (2017); and determine the percentage of persons with diagnosed HIV infection with viral load suppression (2017). CDC analyzed surveillance, pharmacy, and other data to estimate PrEP coverage, reported as a percentage and calculated as the number of persons who were prescribed PrEP divided by the estimated number of persons with indications for PrEP.

Results

The number of new HIV infections remained stable from 2013 (38,500) to 2017 (37,500) (p = 0.448). In 2017, an estimated 85.8% of infections were diagnosed. Among 854,206 persons with diagnosed HIV infection in 42 jurisdictions with complete reporting of laboratory data, 62.7% had a suppressed viral load. Among an estimated 1.2 million persons with indications for use of PrEP, 18.1% had been prescribed PrEP in 2018.

Conclusion

Accelerated efforts to diagnose, treat, and prevent HIV infection are needed to achieve the U.S. goal of at least 90% reduction in the number of new HIV infections by 2030.

HIV Pre-Exposure Prophylaxis Implementation Cascade Among Health Care Professionals in the United States: Implications from a Systematic Review and Meta-Analysis

Although pre-exposure prophylaxis (PrEP) has been approved for primary HIV prevention for individuals aged 18 years or older since 2012, PrEP utilization has been suboptimal. To understand trends in PrEP provision from the health care providers' perspective, we systematically assessed each specific stage along the PrEP implementation cascade (i.e., awareness, willingness, consultation, and prescription) among health care professionals (HCPs) in the United States. Between June and December 2018, we conducted a systematic review of published studies on this topic. A total of 36 eligible studies were identified and included in the analyses. Random-effect models were employed to examine the pooled prevalence of each key stage along the cascade. Time trend and subgroup analyses were conducted. A thematic analysis was used to identify barriers and facilitators along the PrEP cascade. In this study, a total of 18,265 HCPs representing diverse demographics were included. The pooled prevalence of PrEP awareness was 68% [95% confidence interval (CI) = 55-80%], willingness to prescribe PrEP was 66% (95% CI = 54-77%), PrEP consultation was 37% (95% CI = 25-51%), and prescription provision was 24% (95% CI = 17-32%). Subgroup analyses revealed that PrEP provision among HCPs was lowest in the south, but has been improving annually nationwide. Infectious disease specialists [odds ratio (OR) = 4.06, 95% CI = 3.12-5.28; compared with primary care providers] and advanced practice registered nurses/physician assistants (OR = 1.51, 95% CI = 1.09-2.09; compared with physicians) had higher odds of prescribing PrEP. Barriers and facilitators regarding optimal PrEP implementation were embedded within individual, dyadic, social, and structural levels. This meta-analysis has comprehensively examined the trend and pattern of PrEP implementation among HCPs. To achieve optimal implementation of the PrEP cascade in the United States, tailored training and programs need to be provided to HCPs.

Area-level HIV risk and socioeconomic factors associated with willingness to use PrEP among Black people in the U.S. South

Purpose:

In the United States (U.S.), southern states have the highest HIV incidence. Uptake of pre-exposure prophylaxis (PrEP) has been slow among Black people, particularly in the South. We know little about how area-level HIV risk influences one's willingness to use PrEP.

Methods:

169 Black participants across 142 ZIP codes in the South completed the 2016 National Survey on HIV in the Black Community. We performed log-binomial regression to estimate the prevalence risk associated with residing in the upper 25th percentile of increases in new HIV diagnosis (2014–2015) within ZIP code and an individual's willingness to use PrEP, adjusting for individual and area-level covariates.

Results:

Participants were 68% female, mean age of 36 years, and 24% willing to use PrEP. Among the ZIP codes, 23% were within Atlanta, GA. The median increase in new HIV diagnoses was 25 per 100,000 population from 2014 to 2015 (IQR, 14–49). Participants living in ZIP codes within the upper 25th (compared-to-lower 75th) percentile of new HIV diagnoses were more willing to use PrEP (adjusted prevalence ratio (aPR) = 2.02, 95% CI = 1.06–3.86, P = .03). Area-level socioeconomic factors attenuated that association (aPR = 1.63, 95% CI = 0.78–3.39, P = .19).

Conclusions:

Area-level factors may influence PrEP uptake among Black people in the South.

PrEP Stigma, HIV Stigma, and Intention to Use PrEP among Women in New York City and Philadelphia

Background

Stigma is an important contributor to the continued HIV epidemic in the United States (US). In 2016, women made up nearly one in five of all new infections. Pre-exposure HIV Prophylaxis or PrEP is a medication that can be taken to prevent HIV acquisition; however, PrEP is significantly underutilized by women at risk for infection. How PrEP stigma relates to PrEP initiation among women is not well understood.

Methods

Surveys were completed by 160 PrEP-eligible women aged 18-55 in Philadelphia, PA and New York City, NY. Associations between PrEP stigma, HIV stigma, and PrEP initiation intention were modeled using multinomial logistic regression, controlling for sociodemographic and theoretically-relevant variables.

Results

Participants ranged in age from 18 to 55 years (M = 40.2; SD = 11.78). Most (79%) identified as Black or African-American and/or Latina and 36% had completed high-school or less. Higher PrEP stigma was significantly associated with lower PrEP initiation intention, while controlling for other theoretically-relevant and sociodemographic variables. HIV stigma was not related to PrEP initiation intention.

Conclusions

HIV prevention interventions seeking to increase PrEP initiation among PrEP-eligible, urban women need to address the role that PrEP stigma plays in PrEP uptake.

Preferences for implementation of HIV pre-exposure prophylaxis (PrEP): Results from a survey of primary care providers

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PrEP implementation in primary care has been slow.

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Primary care providers equally favor training all vs. having a PrEP specialist.

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Efforts to promote knowledge of clinical guidelines may enhance PrEP implementation.

Primary care physicians (PCPs) are critical for promoting HIV prevention by prescribing pre-exposure prophylaxis (PrEP). Yet, there are limited data regarding PCP’s preferred approaches for PrEP implementation. In 2015, we conducted an online survey of PCPs’ PrEP prescribing and implementation. Participants were general internists recruited from a national professional organization. We examined provider and practice characteristics and perceived implementation barriers and facilitators associated with preferred models for PrEP implementation. Among 240 participants, the majority (85%) favored integrating PrEP into primary care, either by training all providers (“all trained”) (42%) or having an onsite PrEP specialist (“on-site specialist”) (43%). Only 15% preferred referring patients out of the practice to a specialist (“refer out”). Compared to those who preferred to “refer out,” participants who preferred the “all trained” model were more likely to spend most of their time delivering direct patient care and to practice in the Northeast. Compared to participants who preferred the “refer out” or on-site specialist” models, PCPs preferring the all trained model were less likely to perceive lack of clinic PrEP guidelines/protocols as a barrier to PrEP. Most PCPs favored integrating PrEP into primary care by either training all providers or having an on-site specialist. Time devoted to clinical care and geography may influence preferences for PrEP implementation. Establishing clinic-specific PrEP protocols may promote on-site PrEP implementation. Future studies should focus on evaluating the effectiveness of different PrEP implementation models on PrEP delivery.

A Gap Between Willingness and Uptake: Findings From Mixed Methods Research on HIV Prevention Among Black and Latina Transgender Women

BACKGROUND

Black and Latina transgender women (BLTW) face significant HIV disparities with estimated HIV prevalence up to 50% and annual incidence rates as high as 2.8 per 100 person-years. However, few studies have evaluated the acceptability and uptake of high-impact HIV prevention interventions among BLTW.

SETTING

Data collection took place in Baltimore, MD and Washington, DC from May 2015 to May 2017.

METHODS

This mixed methods study included quantitative interviewer-administered surveys, key informant interviews, and focus group discussions. Rapid HIV testing followed each survey. Logistic regression models tested associations between legal gender affirmation (ie, desired name and gender marker on identity documents), transgender pride, history of exchange sex, HIV risk perception, and willingness to take pre-exposure prophylaxis (PrEP). Transcripts of qualitative data were coded to identify common themes related to engagement in HIV prevention.

RESULTS

Among 201 BLTW, 56% tested HIV-positive and 87% had heard of PrEP. Only 18% who had heard of PrEP had ever taken it. Of the 72 self-reported HIV-negative or status-unknown BLTW who had never taken PrEP, 75% were willing to take it. In multivariable analyses, history of exchange sex was associated with willingness to take PrEP, whereas greater HIV knowledge and transgender pride were associated with lower likelihood of willingness to take PrEP. Concern about drug interactions with hormone therapy was the most frequently reported barrier to PrEP uptake.

CONCLUSIONS

Noting the disconnect between PrEP willingness and uptake among BLTW, HIV prevention programs could bridge this gap by responding to identified access barriers and incorporating community-derived strategies.

Acceptability and Barriers to HIV Pre-Exposure Prophylaxis in Atlanta's Adolescents and Their Parents

Adolescents aged 13-24 years account for 23% of new HIV infections in Atlanta, indicating need for better HIV prevention strategies in this population. Pre-exposure prophylaxis (PrEP) is now approved for adolescent use. This study aims to understand the acceptability of and barriers to PrEP in adolescents and parents. We administered PrEP acceptability and barrier measures to HIV(-) 13-17 year olds and their parents from January to April 2016 in an adolescent clinic and emergency department in Atlanta, GA, stratifying by adolescent sexual activity. Acceptability scores (AS) and barrier scores (BS) were calculated by averaging survey answers 1-3. For AS, 1 was very unlikely to accept PrEP; concomitantly, BS near 3 indicated fewer barriers. Two-sample hypothesis testing, Pearson correlations, and linear regression were used. Of the 102 adolescent/parent dyads, 67% of adolescents were female, 94% black, with a mean age of 15.7 ± 1.5 years, and 31% were sexually active. Parents were 94% female, 96% black, with a mean age of 42.4 ± 8.9 years. AS averaged between somewhat to very likely to accept PrEP (2.4 ± 0.5 and 2.2 ± 0.6) in adolescents and parents, respectively. BS averaged between unlikely and somewhat likely to perceive barriers to PrEP (2.0 ± 0.4 and 1.9 ± 0.5) in adolescents and parents, respectively. The adolescent/parent dyad is likely to accept PrEP, regardless of sexual activity. Limitations include that nearly 70% of adolescents were not sexually active, and the study was conducted before PrEP approval by the Food and Drug Administration for those who are younger than 18 years. These results support future parent and adolescent education on PrEP.

Location of Pre-exposure Prophylaxis Services Across New York City Neighborhoods: Do Neighborhood Socio-demographic Characteristics and HIV Incidence Matter?

Despite an increasing pre-exposure prophylaxis (PrEP) use among populations at highest risk of HIV acquisition, comprehensive and easy access to PrEP is limited among racial/ethnic minorities and low-income populations. The present study analyzed the geographic distribution of PrEP providers and the relationship between their location, neighborhood characteristics, and HIV incidence using spatial analytic methods. PrEP provider density, socio-demographics, healthcare availability, and HIV incidence data were collected by ZIP-code tabulation area in New York City (NYC). Neighborhood socio-demographic measures of race/ethnicity, income, insurance coverage, or same-sex couple household, were not associated with PrEP provider density, after adjusting for spatial autocorrelation, and PrEP providers were located in high HIV incidence neighborhoods (P < 0.01). These findings validate the need for ongoing policy interventions (e.g. public health detailing) vis-à-vis PrEP provider locations in NYC and inform the design of future PrEP implementation strategies, such as public health campaigns and navigation assistance for low-cost insurance.

Lack of health insurance is associated with delays in PrEP initiation among young black men who have sex with men in Atlanta, US: a longitudinal cohort study

INTRODUCTION

Delays between receiving a PrEP prescription and taking a first dose increase the risk of HIV infection. This is especially relevant in populations with high HIV incidence, such as young black men who have sex with men (YBMSM) in the United States. Additionally, YBMSM have relatively low levels of health insurance. We investigated whether lack of health insurance and reliance on PrEP funding through the manufacturer assistance programme (MAP) leads to delays in initiation of PrEP.

METHODS

HIV-negative YBMSM were offered PrEP as part of a prospective cohort. Enrolment began in June 2015 with follow-up through February 2019. Interested participants attended a PrEP clinician visit and received a prescription. Those with health insurance received a copay assistance card; those without insurance accessed PrEP using the MAP. The primary outcome was the days between prescription and initiation. The effect of insurance status on this delay was modelled using a Cox proportional hazards model.

RESULTS AND DISCUSSION

The median delay between receipt of a PrEP prescription and taking a first dose was 12 days (IQR 3 to 32). Compared to uninsured participants, the adjusted hazard ratio for PrEP initiation for those with insurance was 2.72 (95% CI 1.82 to 4.06). The adjusted median time to initiation for insured participants was 5 days versus 21 days for those without insurance (p < 0.0001). Older age and STI diagnosis were also associated with faster PrEP initiation. Despite equivalent access to PrEP provided by the study, YBMSM without insurance had longer delays in initiation after receipt of a prescription. Overall, the observed delay in PrEP initiation increases the chances of HIV infection and the possibility of PrEP initiation after undetected seroconversion.

CONCLUSIONS

The extended time period between PrEP prescription and taking a first dose increases the risk of HIV transmission. Younger YBMSM and those without health insurance had longer delays in PrEP initiation. Immediate PrEP initiation programmes could decrease the likelihood of this occurrence and mitigate the disparity in initiation between those with and without health insurance. Clinical Trial Number: NCT02503618.

Community Levels of PrEP Use Among Men Who Have Sex with Men by Race/Ethnicity, San Francisco, 2017

Efforts in San Francisco are maximizing the use of pre-exposure prophylaxis (PrEP) among men who have sex with men (MSM) where high levels of use are needed to maximize reducing new HIV infections. National HIV Behavioral Surveillance surveys MSM in San Francisco. Demographics, health care and risk behaviors are assessed. PrEP use is measured for 12 month, 6 month and 30 day periods. Of 399 HIV uninfected men sampled in 2017, 43.4% used PrEP in the past 12 months. Proportions of men using PrEP by race/ethnicity were not significant at any time point. Decreases between 6 month and 30 day use were highest among African American and Latino men. These men had the highest proportion of intermittent use in the past 30 days but not significantly. While our data suggest the disparity in PrEP use by race/ethnicity has narrowed in San Francisco, novel delivery of PrEP may narrow disparity further.

PrEP Implementation and Persistence in a County Health Department Setting in Atlanta, GA

For marginalized populations, county health departments may be important PrEP access points; however, there are little data on successful PrEP programs at these venues outside of incentivized demonstration projects. Therefore, we implemented an open-access, free PrEP clinic at a county health department in Atlanta, GA to promote PrEP uptake among high-risk clients. The Fulton County Board of Health PrEP clinic launched in October 2015, and eligible clients who expressed interest initiated PrEP and attended follow-up visits per CDC guidelines. Clients engaged in quarterly follow-up and seen within the last 6 months were defined as "persistent", whereas clients with a lapse in follow-up of > 6 months were defined as "not persistent." Factors associated with PrEP persistence were assessed with unadjusted odds ratios. Between October 2015 and June 2017, 399 clients were screened for PrEP, almost all were eligible [392/399 (98%)]; however, 158/392 (40%) did not return to start PrEP after screening. Of 234 patients, 216 (92%) received a prescription for PrEP. As of June 2017, only 69/216 (32%) clients remained persistent in PrEP care, and the only evaluated factor significantly associated with PrEP persistence was age ≥ 30 years (OR 1.86, 95% CI 1.02, 3.42). Implementation of PrEP in the county health department setting is feasible; however, we have identified significant challenges with PrEP uptake and persistence in our setting. Further research is needed to fully understand mediators of PrEP persistence and inform interventions to optimize health department-based PrEP services.

Demographic characteristics associated with the use of HIV pre-exposure prophylaxis (PrEP) in an urban, community health center

Individuals who are at high risk of contracting HIV should have equitable access to preventive measures, such as pre-exposure prophylaxis (PrEP). We conducted a retrospective data extract from the electronic medical records of federally-qualified health centers in New York City from 2016 to 2018. Descriptive statistics are presented, stratified by those who have been prescribed PrEP and those who have not. We created a variable called "ever-female" which includes individuals assigned female at birth or who have ever identified as female. A chi-square test was performed to determine the statistical significance between variables as p < .05. A total of 9659 patients met inclusion criteria for the study. Patients who were prescribed PrEP were significantly associated with being white and never-female, with 38.2% of those prescribed PrEP identifying as white and 83.8% of those prescribed PrEP categorized as never-female. Patients of trans experience were 9.6% of the PrEP cohort and 1.5% of the never PrEP cohort (p < .001). Patients identifying as Black/African American made up 19.8% of patients prescribed PrEP and 49.8% of those never prescribed PrEP (p < .001). Patients with the lowest reported income composed 48.4% of those prescribed PrEP compared to 69.3% of patients who were never prescribed PrEP (p < .001). These findings indicate that key demographic categories may not be accessing PrEP as much as would be expected for their level of risk. Barriers to access of PrEP for women and other at-risk, under-represented populations should be further studied.

Pre-exposure prophylaxis awareness and interest among participants in a medications for addiction treatment program in a unified jail and prison setting in Rhode Island

People who are incarcerated are at increased risk for HIV (human immunodeficiency virus) acquisition upon release, and one possible intervention for prevention is the use of pre-exposure prophylaxis (PrEP) upon release. The present study assessed HIV risk perceptions as well as PrEP awareness and interest among 39 people who were incarcerated and enrolled in a structured Medication for Addiction Treatment (MAT) program at the Rhode Island Department of Corrections using semi-structured, qualitative interviews. Analysis was conducted using a generalized, inductive method in NVivo 12. While PrEP awareness was low across the study sample, some participants were interested in PrEP uptake or learning more about PrEP after they were provided with an overview of it. PrEP interest strongly related to current perceived HIV risk. Potential barriers included side effects, adherence, and reluctance to take medications in general. MAT programs for people who are criminal justice (CJ) involved may serve as useful linkage spaces to PrEP information, access, and retention.

Using HIV Risk Prediction Tools to Identify Candidates for Pre-Exposure Prophylaxis: Perspectives from Patients and Primary Care Providers

Clinical guidelines for HIV pre-exposure prophylaxis (PrEP) include risk prediction tools to identify appropriate candidates. We conducted a qualitative interview study to explore the potential acceptability, interpretation, and anticipated impact of such tools from the perspectives of men who have sex with men (MSM) and primary care providers (PCPs). Our purposive sample of English-speaking participants included: (1) MSM reporting HIV risk behaviors (n = 32; median age = 38 years; 53% non-Hispanic white; 22% high school degree or less education); (2) PCPs specializing in health care for MSM (n = 12); and (3) PCPs in general practice (n = 19). MSM participants questioned the ability of risk tools to predict HIV acquisition, and their perceptions of what might constitute a high HIV risk score varied widely. Many MSM participants believed that receiving a high score would prompt them to consider PrEP or other risk reduction strategies. Some believed that the data would be useful, particularly if discussed with their providers, whereas others anticipated feeling fear, anxiety, or mistrust. PCPs expressed more confidence in HIV risk prediction and imagined integrating tools with medical histories and their clinical judgment to assess risk. PCPs were most enthusiastic about adopting HIV risk prediction as a teaching tool to help patients visualize and reduce risk, their concerns about time constraints notwithstanding. In conclusion, our findings suggest that PCPs' views of HIV risk prediction tools are generally positive, whereas MSM participants' are more mixed. Given that both groups emphasized the value of contextualizing risk, shared decision making may be needed to implement HIV risk prediction tools effectively.

Development and validation of an automated HIV prediction algorithm to identify candidates for pre-exposure prophylaxis: a modelling study

BACKGROUND

HIV pre-exposure prophylaxis (PrEP) is effective but underused, in part because clinicians do not have the tools to identify PrEP candidates. We developed and validated an automated prediction algorithm that uses electronic health record (EHR) data to identify individuals at increased risk for HIV acquisition.

METHODS

We used machine learning algorithms to predict incident HIV infections with 180 potential predictors of HIV risk drawn from EHR data from 2007-15 at Atrius Health, an ambulatory group practice in Massachusetts, USA. We included EHRs of all patients aged 15 years or older with at least one clinical encounter during 2007-15. We used ten-fold cross-validated area under the receiver operating characteristic curve (cv-AUC) with 95% CIs to assess the model's performance at identifying individuals with incident HIV and patients independently prescribed PrEP by clinicians. The best-performing model was validated prospectively with 2016 data from Atrius Health and externally with 2011-16 data from Fenway Health, a community health centre specialising in sexual health care in Boston (MA, USA). We calculated HIV risk scores (ie, probability of an incident HIV diagnosis) for every HIV-uninfected patient not on PrEP during 2007-15 at Atrius Health and assessed the distribution of scores for thresholds to determine possible candidates for PrEP in the three study cohorts.

FINDINGS

We included 1 155 966 Atrius Health patients from 2007-15 (150 [<0·1%] patients with incident HIV) in our development cohort, 537 257 Atrius Health patients in 2016 (16 [<0·1%] with incident HIV) in our prospective validation cohort, and 33 404 Fenway Health patients from 2011-16 (423 [1·3%] with incident HIV) in our external validation cohort. The best-performing algorithm was obtained with least absolute shrinkage and selection operator (LASSO) and had a cv-AUC of 0·86 (95% CI 0·82-0·90) for identification of incident HIV infections in the development cohort, 0·91 (0·81-1·00) on prospective validation, and 0·77 (0·74-0·79) on external validation. The LASSO model successfully identified patients independently prescribed PrEP by clinicians at Atrius Health in 2016 (cv-AUC 0·93, 95% CI 0·90-0·96) or Fenway Health (0·79, 0·78-0·80). HIV risk scores increased steeply at the 98th percentile. Using this score as a threshold, we prospectively identified 9515 (1·8%) of 536 384 patients at Atrius Health in 2016 and 4385 (15·3%) of 28 702 Fenway Health patients as potential PrEP candidates.

INTERPRETATION

Automated algorithms can efficiently identify patients at increased risk for HIV acquisition. Integrating these models into EHRs to alert providers about patients who might benefit from PrEP could improve prescribing and prevent new HIV infections.

FUNDING

Harvard University Center for AIDS Research, Providence/Boston Center for AIDS Research, Rhode Island IDeA-CTR, the National Institute of Mental Health, and the US Centers for Disease Control and Prevention.

Use of electronic health record data and machine learning to identify candidates for HIV pre-exposure prophylaxis: a modelling study

BACKGROUND

The limitations of existing HIV risk prediction tools are a barrier to implementation of pre-exposure prophylaxis (PrEP). We developed and validated an HIV prediction model to identify potential PrEP candidates in a large health-care system.

METHODS

Our study population was HIV-uninfected adult members of Kaiser Permanente Northern California, a large integrated health-care system, who were not yet using PrEP and had at least 2 years of previous health plan enrolment with at least one outpatient visit from Jan 1, 2007, to Dec 31, 2017. Using 81 electronic health record (EHR) variables, we applied least absolute shrinkage and selection operator (LASSO) regression to predict incident HIV diagnosis within 3 years on a subset of patients who entered the cohort in 2007-14 (development dataset), assessing ten-fold cross-validated area under the receiver operating characteristic curve (AUC) and 95% CIs. We compared the full model to simpler models including only men who have sex with men (MSM) status and sexually transmitted infection (STI) positivity, testing, and treatment. Models were validated prospectively with data from an independent set of patients who entered the cohort in 2015-17. We computed predicted probabilities of incident HIV diagnosis within 3 years (risk scores), categorised as low risk (<0·05%), moderate risk (0·05% to <0·20%), high risk (0·20% to <1·0%), and very high risk (≥1·0%), for all patients in the validation dataset.

FINDINGS

Of 3 750 664 patients in 2007-17 (3 143 963 in the development dataset and 606 701 in the validation dataset), there were 784 incident HIV cases within 3 years of baseline. The LASSO procedure retained 44 predictors in the full model, with an AUC of 0·86 (95% CI 0·85-0·87) for incident HIV cases in 2007-14. Model performance remained high in the validation dataset (AUC 0·84, 0·80-0·89). The full model outperformed simpler models including only MSM status and STI positivity. For the full model, flagging 13 463 (2·2%) patients with high or very high HIV risk scores in the validation dataset identified 32 (38·6%) of the 83 incident HIV cases, including 32 (46·4%) of 69 male cases and none of the 14 female cases. The full model had equivalent sensitivity by race whereas simpler models identified fewer black than white HIV cases.

INTERPRETATION

Prediction models using EHR data can identify patients at high risk of HIV acquisition who could benefit from PrEP. Future studies should optimise EHR-based HIV risk prediction tools and evaluate their effect on prescription of PrEP.

FUNDING

Kaiser Permanente Community Benefit Research Program and the US National Institutes of Health.

Update on HIV Preexposure Prophylaxis: Effectiveness, Drug Resistance, and Risk Compensation

PURPOSE OF REVIEW

In 2019, the US government launched an initiative to decrease new HIV infections by 90% over the next decade. Studies have demonstrated the efficacy of HIV preexposure prophylaxis (PrEP) for high-risk populations, and the United States Preventative Services Task Force has issued a grade A recommendation for PrEP, indicating substantial net benefit. However, questions have been raised about the effectiveness of PrEP in clinical settings and whether PrEP use might promote antiretroviral drug resistance and increased sexual risk behaviors, which could increase transmission of bacterial sexually transmitted infections. In this narrative review, we summarize recent evidence of the effectiveness of PrEP when provided in clinical and community settings, the emergence of antiretroviral drug resistance during PrEP use, and associations between PrEP use and increased sexual risk behaviors. We also review novel PrEP modalities that are being developed to optimize PrEP acceptability, adherence, and effectiveness.

RECENT FINDINGS

Studies suggest that PrEP is effective when provided in clinical settings. However, PrEP uptake and impact have been limited in the USA thus far, and major disparities in access to PrEP exist. In addition, there is evidence that drug resistance can occur with PrEP use, particularly with inadvertent PrEP use during undiagnosed acute HIV infection. Risk compensation can also occur with PrEP use and has been associated with increased sexually transmitted infections. Promising new modalities for PrEP could expand options. PrEP has strong potential to decrease HIV incidence. However, disparities in access must be addressed to ensure equity and impact for PrEP. While drug resistance and risk compensation can occur with PrEP use, these are not valid reasons to withhold PrEP from patients given its substantial protective benefits.

Next-Wave HIV Pre-Exposure Prophylaxis Implementation for Gay and Bisexual Men

Data indicate that diffusion of pre-exposure prophylaxis (PrEP) programs for HIV prevention is increasing in the United States; however, persistent disparities in PrEP access remain. Earlier waves of PrEP implementation focused on development (2012-2015) and diffusion (2016-2018). To reduce disparities, the next wave of PrEP implementation should focus on integration; that is, the assimilation of PrEP service as an integral part of HIV prevention, sexual health, and primary care. This review analyzes PrEP implementation literature in the context of three "next-wave" challenges: increasing patient demand, enhancing provider investment and competency, and improving health systems capacity. Our review revealed five activities we consider critical to successful next-wave PrEP implementation efforts: (1) redefining PrEP eligibility assessment, (2) de-emphasizing risk perception as a strategy to increase demand, (3) rejecting risk compensation arguments, (4) altering guidelines to make PrEP follow-up less onerous, and (5) focusing directly on strategies to reduce the cost of PrEP medication. This article ends with a case study of a research-practice partnership designed to instantiate new approaches to integrative implementation efforts.

Estimated Impact of Targeted Pre-Exposure Prophylaxis: Strategies for Men Who Have Sex with Men in the United States

Pre-exposure prophylaxis (PrEP) effectively reduces human immunodeficiency virus (HIV) transmission. We aimed to estimate the impact of different PrEP prioritization strategies among Black and Latino men who have sex with men (MSM) in the United States, populations most disproportionately affected by HIV. We developed an agent-based simulation to model the HIV epidemic among MSM. Individuals were assigned an HIV incidence risk index (HIRI-MSM) based on their sexual behavior. Prioritization strategies included PrEP use for individuals with HIRI-MSM ≥10 among all MSM, all Black MSM, young (≤25 years) Black MSM, Latino MSM, and young Latino MSM. We estimated the number needed to treat (NNT) to prevent one HIV infection, reductions in prevalence and incidence, and subsequent infections in non-PrEP users avoided under these strategies over 5 years (2016-2020). Young Black MSM eligible for PrEP had the lowest NNT (NNT = 10) followed by all Black MSM (NNT = 33) and young Latino MSM (NNT = 35). All Latino MSM and all MSM had NNT values of 63 and 70, respectively. Secondary infection reduction with PrEP was the highest among young Latino MSM (53.2%) followed by young Black MSM (37.8%). Targeting all MSM had the greatest reduction in prevalence (14.7% versus 2.9%-3.9% in other strategies) and incidence (49.4% versus 9.4%-13.9% in other groups). Using data representative of the United States MSM population, we found that a strategy of universal PrEP use by MSM was most effective in reducing HIV prevalence and incidence of MSM. Targeted use of PrEP by Black and Latino MSM, however, especially those ≤25 years, had the greatest impact on HIV prevention.

Pre-Exposure Prophylaxis Integration into Family Planning Services at Title X Clinics in the Southeastern United States: A Geographically-Targeted Mixed Methods Study (Phase 1 ATN 155)

BACKGROUND

Black adolescent and young adult women (AYAW) in the Southern United States are disproportionately affected by HIV. Pre-exposure prophylaxis (PrEP) is an effective, scalable, individual-controlled HIV prevention strategy that is grossly underutilized among women of all ages and requires innovative delivery approaches to optimize its benefit. Anchoring PrEP delivery to health services that AYAW already trust, access routinely, and deem useful for their sexual health may offer an ideal opportunity to reach women at risk for HIV and to enhance their PrEP uptake and adherence. These services include those of family planning (FP) providers in high HIV incidence settings. However, PrEP has not been widely integrated into FP services, including Title X-funded FP clinics that provide safety net sources of care for AYAW. To overcome potential implementation challenges for AYAW, Title X clinics in the Southern United States are uniquely positioned to be focal sites for conceptually informed and thoroughly evaluated PrEP implementation science studies.

OBJECTIVE

The aim of this study is to assess inner and outer context factors (barriers and facilitators) that may influence the adoption of PrEP prescription and treatment services in Title X clinics serving AYAW in the Southern United States.

METHODS

Phase 1 of Planning4PrEP is an explanatory sequential, mixed methods study consisting of a geographically-targeted Web-based survey of Title X clinic administrators and providers in the Southern United States, followed by key informant interviews among a purposively selected subset of responders to more comprehensively assess inner and outer context factors that may influence adoption and implementation of PrEP in Title X FP clinics in the South.

RESULTS

Phase 1 of Planning4PrEP research activities began in October 2017 and are ongoing. To date, survey and key informant interview administration is near completion, with quantitative and qualitative data analysis scheduled to begin soon after data collection completion.

CONCLUSIONS

This study seeks to assess inner and outer contextual factors (barriers and facilitators) that may influence the adoption and integration of PrEP prescription and treatment services in Title X clinics serving AYAW in the Southern United States. Data gained from this study will inform a type 1 hybrid effectiveness implementation study, which will evaluate the multilevel factors associated with successful PrEP implementation while evaluating the degree of PrEP uptake, continuation, and adherence among women seen in Title X clinics.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

DERR1-10.2196/12774.

Acute Retroviral Syndrome Presenting as Acute Hepatitis

Acute retroviral syndrome (ARS) can present as a wide array of clinical manifestations. Establishing a diagnosis early in the disease course can provide an opportunity to minimize immunosuppression and limit further transmission of human immunodeficiency virus (HIV). We present a case of a previously healthy young male who presented with acute hepatitis, as a manifestation of ARS. Initial HIV antigen/antibody testing was negative; however, a high index of suspicion prompted HIV ribonucleic acid (RNA) virologic testing revealing >10 million RNA copies/mL. Anti-retroviral treatment was initiated, along with supportive measures, accomplishing resolution of the transaminitis and the restoration of CD4 counts within normal at one month. Early in the disease course, HIV screening immunoassay could still be negative; hence, confirmatory testing with HIV RNA virologic testing should be pursued when clinical suspicion is high. Prompt diagnosis and treatment can improve outcome and curtail viral transmission.

Faith leaders' messaging is essential to enhance HIV prevention among black Americans: results from the 2016 National Survey on HIV in the black community (NSHBC)

Background

To investigate whether religious service attendance and faith leaders’ messages about HIV and same-sex relationships are associated with acceptance of HIV prevention strategies.

Methods

Multivariable Poisson regression assessed whether attending religious services, faith leaders’ messages about HIV and same-sex relationships, and supportiveness of those messages were associated with HIV testing, as well as knowledge of and willingness to use pre-exposure prophylaxis (PrEP) among 868 Black Americans [45% men; M (SD) = 34 (9) years-old] in the 2016 National Survey on HIV in the Black Community, USA.

Results

Participants who reported attending services monthly and/or hearing faith leaders’ messages that were supportive of same-sex relationships had a significantly higher likelihood of willingness to use PrEP (adjusted Rate Ratio[ARR] = 1.76; 95% confidence interval [CI] = 1.09, 2.48) and aRR = 2.19; 95% CI = 1.35, 3.55, respectively), independent of HIV risk. Homophobia was significantly associated with higher likelihood of being aware of PrEP and testing for HIV testing in the past 12 months.

Conclusions

Faith leaders’ messaging can influence Black Americans’ perceptions and uptake of HIV prevention strategies. Faith institutions and faith leaders should be involved in designing and disseminating HIV prevention strategies.