Use of non-occupational post-exposure prophylaxis does not lead to an increase in high risk sex behaviors in men who have sex with men participating in the EXPLORE trial

Can HIV Post-Exposure Prophylaxis Services Change the Sexual Behavior Characteristics of Men Who Have Sex with Men? A Cohort Study in Guangzhou, China

This study examines the impact of HIV post-exposure prophylaxis (PEP) on sexual behavior changes in men who have sex with men (MSM), aiming to assess a comprehensive HIV prevention strategy integrating biomedical and behavioral interventions to maximize PEP service effectiveness. From a Guangzhou MSM cohort, participants without prior PEP experience were included. The exposed group received PEP services during follow-up (June 2019-April 2022), while controls did not. Cox proportional hazard regression models assessed PEP's effects on sexual behavior changes. Of 411 participants (mean age: 30.72), 14.1% received PEP during follow-up. The exposed group showed a higher likelihood of reducing Internet partner-seeking (aHR: 3.58, 95%CI: 1.80-7.10, P < 0.001), decreasing anal intercourse partners (aHR: 3.81, 95%CI: 2.14-6.82, P < 0.001) in the past 6 months, lowering last week's anal intercourse occurrences (aHR: 3.95, 95%CI: 2.33-6.68, P < 0.001), and improving condom use during past 6 months' anal intercourse (aHR: 3.94, 95%CI: 1.75-8.90, P = 0.001) and the most recent anal intercourse (aHR: 4.96, 95%CI: 1.77-13.88, P = 0.002) compared to controls. To sum up, PEP services contribute significantly to positive sexual behavior changes in MSM. Strengthening behavioral interventions at PEP's baseline and follow-up stages is crucial for maximizing comprehensive preventive impact on both biomedical and behavioral aspects in MSM.

Missed Opportunities: A Narrative Review on Why Nonoccupational Postexposure Prophylaxis for HIV Is Underutilized

Postexposure prophylaxis (PEP) is an important tool for preventing HIV infection but remains underutilized. In this narrative review, we aim to summarize the frequency of missed opportunities for prescribing PEP among studies from around the world, discuss the complexities of the challenges facing PEP provision, and describe possible solutions. We identified 20 studies published in the last 10 years among 43 832 individuals, of whom an estimated 41 477 were eligible for PEP. Of those eligible for PEP, PEP was prescribed among 27 705 (66.8%). There was a significant difference in PEP prescriptions in acute compared with non-acute care settings (63.5% vs 94.5%; P < .001). Emergent themes contributing to PEP underutilization included lack of provider and patient awareness, reduced PEP acceptability, HIV stigma and homophobia, lack of access (either to care or to medication), and stigmatizing policies. Each of those issues should be the focus of future PEP implementation efforts.

Risk perception and usage of non-occupational post-exposure prophylaxis among fisherfolk in Ggulwe parish on the shores of Lake Victoria in central Uganda

Background

The use of non-occupational post-exposure prophylaxis (nPEP) to prevent HIV acquisition among those exposed as an approach to HIV prevention has expanded in Uganda. Although there are increased efforts to avail nPEP services among most at-risk populations, the usage of nPEP medicines remains low. Therefore, this study examined the risk perception and usage of non-occupational post-exposure prophylaxis (nPEP) among fisherfolk in the Ggulwe fishing parish, Bussi sub-county, Wakiso district.

Methods

A cross-sectional study among adults was carried out from October 2020 to January 2021 in Ggulwe parish, Bussi sub-county, Wakiso district, to examine the usage of nPEP and factors influencing the usage. Data were collected using semi-structured questionnaires, and key informants' interviews were conducted among healthcare providers and the local leadership. The quantitative data were summarized using bivariate and multivariate logistic regression, while the qualitative data were analyzed thematically to enrich the quantitative results.

Results

Overall, 248 fisherfolk encountered an event that required the use of nPEP, and of these, 55/248 (22.2%) were able to use nPEP to prevent them from acquiring HIV. The usage of nPEP among adults in the Bussi sub-county, Wakiso district, was associated with not knowing that HIV can be prevented using nPEP medicines (AOR:0.1, 95% CI 0.03-0.36, p < 0.001), lack of knowledge of the existence of nPEP (AOR: 0.3, 95% CI 0.13-0.76, p = 0.01), the perception that nPEP can effectively prevent HIV infection after exposure (AOR 0.0586, 95% CI: 0.0177-0.1944, p < 0.001), and the community's opinion affecting the willingness to take nPEP (AOR 0.1924, 95% CI: 0.0380-0.9727, p = 0.0462).

Conclusion

The usage of nPEP among fisherfolk was low (22.2%). The low usage of nPEP was associated with a lack of knowledge and awareness about nPEP. This effort to improve the usage of nPEP should include community sensitization and HIV infection prevention using nPEP to raise awareness about HIV infection exposures and the risk of HIV infection during non-occupational exposures.

The Use of HIV Pre- and Postexposure Prophylaxis Among a Web-Based Sample of HIV-Negative and Unknown Status Cisgender and Transgender Sexual Minority Men: Cross-sectional Study

BACKGROUND

HIV disproportionately affects sexual minority men (SMM) in the United States.

OBJECTIVE

We sought to determine past HIV postexposure prophylaxis (PEP) use and current and prior pre-exposure prophylaxis (PrEP) use among a web-based sample of cisgender and transgender men who have sex with men.

METHODS

In 2019, HIV-negative and unknown status SMM (n=63,015) were recruited via geosocial networking apps, social media, and other web-based venues to participate in a brief eligibility screening survey. Individuals were asked about past PEP use and current and prior PrEP use. We examined associations of demographics, socioeconomic indicators, and recent club drug use with PEP and PrEP use, as well as the association between past PEP use and current and prior PrEP use using generalized linear models and multinomial logistic regression. Statistical significance was considered at P<.001, given the large sample size; 99.9% CIs are reported.

RESULTS

Prior PEP use was reported by 11.28% (7108/63,015) of the participants, with current or prior PrEP use reported by 21.95% (13,832/63,015) and 8.12% (5118/63,015), respectively. Nearly half (3268/7108, 46%) of the past PEP users were current PrEP users, and another 39.9% (2836/7108) of the participants who reported past PEP use also reported prior PrEP use. In multivariable analysis, past PEP use was associated with current (relative risk ratio [RRR] 23.53, 99.9% CI 14.03-39.46) and prior PrEP use (RRR 52.14, 99.9% CI 29.39-92.50). Compared with White men, Black men had higher prevalence of past PEP use and current PrEP use, Latino men had higher prevalence of PEP use but no significant difference in PrEP use, and those identifying as another race or ethnicity reported higher prevalence of past PEP use and lower current PrEP use. Past PEP use and current PrEP use were highest in the Northeast, with participants in the Midwest and South reporting significantly lower PEP and PrEP use. A significant interaction of Black race by past PEP use with current PrEP use was found (RRR 0.57, 99.9% CI 0.37-0.87), indicating that Black men who previously used PEP were less likely to report current PrEP use. Participants who reported recent club drug use were significantly more likely to report past PEP use and current or prior PrEP use than those without recent club drug use.

CONCLUSIONS

PrEP use continues to be the predominant HIV prevention strategy for SMM compared with PEP use. Higher rates of past PEP use and current PrEP use among Black SMM are noteworthy, given the disproportionate burden of HIV. Nonetheless, understanding why Black men who previously used PEP are less likely to report current PrEP use is an important avenue for future research.

UK guideline for the use of HIV post-exposure prophylaxis 2021

We present the updated British Association for Sexual Health and HIV (BASHH) guidelines for post-exposure prophylaxis (PEP) to HIV following sexual exposures, occupational exposures and other nonoccupational exposures in the community. This serves as an update to the 2015 BASHH guideline on PEP following sexual exposures and the 2008 Expert Advisory Group on AIDS guidelines on HIV PEP. We aim to provide evidence-based guidance on best clinical practice in the provision, monitoring and support of PEP for the prevention of HIV acquisition following sexual, occupational and other nonoccupational exposures in the community. The guideline covers when to prescribe PEP, what antiretroviral agents to use and how to manage PEP. This includes (i) evidence of PEP efficacy; (ii) evidence relating to individual-level efficacy of antiretroviral therapy to prevent the sexual transmission of HIV; (iii) data on the detectable (transmissible) prevalence of HIV in specific populations; (iv) risk of HIV transmission following different types of sexual and occupational exposure; (v) baseline risk assessment; (vi) drug regimens and dosing schedules; (vii) monitoring PEP; (viii) baseline and follow-up blood-borne virus testing; (ix) the role of PEP within broader HIV prevention strategies, for example, HIV pre-exposure prophylaxis (PrEP). The guideline also covers special scenarios such as PEP in pregnancy, breastfeeding and chronic hepatitis B virus infection, and when PEP should be considered in people using HIV PrEP. The guidelines are aimed at clinical professionals directly involved in PEP provision and other stakeholders in the field. A proforma to assist PEP consultations is included. A public consultation process was undertaken prior to finalizing the recommendations.

Implementation of HIV non-occupational post-exposure prophylaxis for men who have sex with men in 2 cities of Southwestern China

ABSTRACT

Non-occupational post-exposure prophylaxis (nPEP) has often relied on the joint work of emergency physicians and infectious disease specialists in busy emergency departments and human immunodeficiency virus (HIV)/sexually transmitted infections clinics abroad, where adherence education and follow-up are invariably reactive. In our pilot study, community-based organizations (CBOs) were invited to together implement the nPEP tailored to men who have sex with men (MSM) in 2 cities of Guangxi in Southwestern China, of which experiences and lessons drawn from would be provided to the promotion of nPEP in China.The study population enrolled MSM individuals prescribed nPEP from September 2017 to December 2019. One-to-one follow-ups by CBOs were applied through the treatment. Predictors of treatment completion were assessed by logistic regression.Of 271 individuals presented for nPEP, 266 MSM with documented treatment completion or non-completion, 93.6% completed the 28-day course of medication. Completion was associated with reporting side effects (aOR = .10; 95% CI: 0.02-0.38; P = .001). The follow-up rate of 91.9% was achieved based on the definition of loss to follow-up. No documented nPEP failures were found, although 1 MSM subsequently seroconverted to HIV due to ongoing high-risk behavior.CBOs' engagement in HIV nPEP, especially the "one-to-one" follow-up supports by peer educators partly ensure adherence and retention to nPEP. Tailored interventions are needed to address the subsequent high-risk behaviors among the MSM population.

Awareness and use of nonoccupational HIV post-exposure prophylaxis and factors associated with awareness among MSM in Beijing, China

Background

Human immunodeficiency virus (HIV) sexual transmission among men who have sex with men (MSM) has increased markedly in Beijing, China, during the past decade. Nonoccupational HIV post-exposure prophylaxis (nPEP) is a highly efficacious biomedical prevention strategy that significantly reduces HIV-transmission risk. This study examined nPEP awareness among MSM and the factors influencing it.

Methods

Consecutive, cross-sectional MSM surveys were conducted from April to August of 2018 and 2019. Demographic data as well as that on behavior and awareness regarding nPEP was collected. Factors influencing nPEP awareness were assessed using univariate and multivariable logistic regression.

Results

There were 1,202 eligible responders recruited. Of the responders, 42.5% had nPEP awareness, and 59.9% expressed interest in receiving nPEP in the future, if required. Greater odds of nPEP awareness were associated with younger age, higher education level (adjusted odds ratio [aOR]: 4.011, 95% confidence interval [CI]: 2.834–5.678, P<0.001), higher income, use of the Internet to meet sexual partners (aOR: 2.016, 95% CI: 1.481–2.744, P<0.001), greater HIV-related knowledge (aOR: 3.817, 95% CI: 1.845–7.899, p<0.001), HIV testing (aOR: 2.584, 95% CI: 1.874–3.563, p<0.001), and sexually transmitted infections (aOR: 1.736, 95% CI: 1.174–2.569, P = 0.006). Lower odds of nPEP awareness were associated with greater stigma score (aOR: 0.804, 95% CI: 0.713–0.906, P<0.001).

Conclusions

The findings indicate suboptimal awareness and low utilization of nPEP in Beijing and highlight nPEP inequities among MSM with stigma. Strengthening the training of health service providers and peer educators in reducing stigma and disseminating nPEP knowledge is imperative.

Service acceptance of HIV non-occupational post-exposure prophylaxis(nPEP) among college students: a cross-sectional study in China

Background

College students were the key group we should pay more attention for acquired immune deficiency syndrome (AIDS) prevention and control in recent years in China. Few studies of HIV non-occupational post-exposure prophylaxis (nPEP) knowledge and service acceptance had been conducted among them in China. This study conducted a cross-sectional survey to understand the service acceptance of nPEP and its influencing factors among college students in the three cities of China.

Methods

A questionnaire survey was conducted to collect information on socio-demographic, behavioral characteristic, HIV/AIDS knowledge, nPEP knowledge, acceptance of nPEP services among the college students in Beijing, Shenzhen, and Kunming of China from March to April of 2019. Each participant completed an anonymous questionnaire on line by computer-assisted or mobile phone-assisted self-interview with informed consent. Multivariable logistic regression analyses identified predictors for service acceptance of nPEP.

Results

A total of 4698 students were surveyed with the average age of 20 years old. 98.0% (4605/4698) of them were undergraduates, 21.8%(1022/4698) had sexual intercourse; 48.6% (2282/4698) heard of nPEP, among which 4.95%(113/2282) received nPEP services. The awareness rate of HIV/AIDS knowledge was 85.6% (5495/4698) with the differences statistically significant between the three cities. The awareness rate of nPEP knowledge was 16.5% (774/4698). There were significant differences in receiving nPEP services among students of different ages, genders, sexual behaviors, and knowledge of HIV/AIDS by univariate analysis. Multivariable analyses indicated that age group of 18 and under (OR = 2.551, 95% CI = 1.153–5.646), male (OR = 3.131, 95% CI = 1.866–5.253), homosexual behavior (OR = 4.661,95%CI = 2.658–8.172), heterosexual behavior (OR = 1.676, 95% CI = 1.040–2.947), no awareness of AIDS knowledge (OR = 3.882, 95% CI = 2.371–6.356) and nPEP (OR = 4.788, 95% CI = 2.50–9.169) knowledge, were associated with the service acceptance of nPEP among the college students.

Conclusion

The low acceptance of nPEP services was mainly affected by low level of nPEP knowledge among the college students. Further publicity and education of nPEP knowledge were necessary, as well as promotion of knowledge of HIV/AIDS prevention and treatment. More attention should be paid to the factors associated with acceptance of nPEP services.

Applying a Nursing Perspective to Address the Challenges Experienced by Cisgender Women in the HIV Status Neutral Care Continuum: A Review of the Literature

ABSTRACT

The field of HIV research has grown over the past 40 years, but there remains an urgent need to address challenges that cisgender women living in the United States experience in the HIV neutral status care continuum, particularly among women such as Black women, who continue to be disproportionately burdened by HIV due to multiple levels of systemic oppression. We used a social ecological framework to provide a detailed review of the risk factors that drive the women's HIV epidemic. By presenting examples of effective approaches, best clinical practices, and identifying existing research gaps in three major categories (behavioral, biomedical, and structural), we provide an overview of the current state of research on HIV prevention among women. To illustrate a nursing viewpoint and take into account the diverse life experiences of women, we provide guidance to strengthen current HIV prevention programs. Future research should examine combined approaches for HIV prevention, and policies should be tailored to ensure that women receive effective services that are evidence-based and which they perceive as important to their lives.

Examining potential effects of non-occupational post-exposure prophylaxis (nPEP) on sexual behaviors of Chinese men who have sex with men: a cross-sectional study

BACKGROUND

In China, non-occupational post-exposure prophylaxis (nPEP) is not a conventional service yet and nPEP related studies are very few. Recently, China's 13th Five Year Action Plan for HIV/AIDS Containment and Prevention examines the feasibility of including nPEP as one of the national strategies for HIV prevention. However, there is a concern that nPEP use might exacerbate high-risk sexual activities. In order to facilitate a research-based policy making of routinizing nPEP services, the current study examined potential effects of nPEP use on condom use and number of sexual partners among Chinese men who have sex with men (MSM) .

METHODS

A cross-sectional survey was conducted in two cities of China in November and December 2018. Descriptive analyses of participants' sociodemographic and behavioral characteristics were conducted using SPSS 24.0. Mplus 7.4 was used to conduct confirmatory factor analysis and structural equation modeling.

RESULTS

The sample included 419 Chinese MSM with a mean age of 28.04 (SD = 9.71). Participants reported more positive anticipation of their own behaviors than other MSM's behaviors regarding condom use and number of sexual partners if nPEP were to be routinized in China. About 60% of participants reported discrepancies between anticipated individual and population behaviors as a potential result of routinization of nPEP services. Anticipated individual behavioral change was positively related to age and duration of residence in the current city, and negatively related to education. Anticipated population behavioral change was positively related to age. Anticipated behavioral discrepancy was positively related to being ethnic minority and never married.

CONCLUSIONS

These findings identify a high-risk subgroup of MSM, who reported they would use condoms less and/or have more sexual partners when nPEP becomes available. This subgroup of MSM might benefit from targeted health interventions. Moreover, there is a clear discrepancy between anticipated individual and population behavioral changes regarding future routinization of nPEP services, suggesting incorporating nPEP services as a means of community development for MSM.

Awareness of and barriers to using non-occupational post-exposure prophylaxis among male clients of female sex workers in two cities of China: a qualitative study

Background Male clients of female sex workers ('clients' hereafter) are considered high-risk and potentially a bridge population in the HIV epidemic. Non-occupational post-exposure prophylaxis (nPEP) is a safe and effective but under-utilised public health intervention to prevent HIV transmission. This study aims to explore clients' awareness of nPEP, intention of uptake, potential barriers to nPEP uptake and adherence, and suggestions for nPEP promotion in China.

METHODS

We conducted semi-structured in-depth interviews with 20 clients in two Chinese cities in 2018. Participants were recruited through purposive sampling. The content of the interviews was analysed using thematic content analysis in ATLAS.ti.

RESULTS

Overall, just a minority of participants were aware of nPEP. A majority expressed willingness to use nPEP. Potential barriers to nPEP uptake and adherence included adverse drug reactions, price, concerns of drug efficacy, privacy issues, and forgetting to take the drugs. Almost all participants expressed the need to promote nPEP among clients. Participants suggested that the promotion of nPEP should be at hospitals, online, and be integrated with HIV/AIDS health education.

CONCLUSIONS

Our findings suggested that nPEP guidelines should be formulated and implementation strategies should be developed to address barriers to uptake and adherence in order to successfully tap into the potential of nPEP as an effective HIV prevention tool.

"It's Like Plan B but for HIV!" Design and Evaluation of a Media Campaign to Drive Demand for PEP

Post-exposure Prophylaxis (PEP) is an effective yet underutilized HIV prevention tool. PEPTALK developed and evaluated a media campaign to drive demand for PEP among men who have sex with men (MSM) and transgender women (TW) living in high HIV prevalence areas in New York City. Formative qualitative research (38 in-depth interviews and five focus groups [N = 48]) with Black or African-American MSM or TW who reported condomless sex with a HIV-positive/unknown status man was conducted to inform campaign design. We assessed the impact of the campaign, 15 bus shelter ads and low or no-cost social media, by assessing change in the proportions of new PEP patient visits, to the clinical site where the campaign directed consumers, using one-sided z-test for proportions, before and after the media campaign. The proportion of new PEP patients increased significantly after the media campaign in the periods examined, suggesting that such campaigns may increase PEP demand.

HIV Post-Exposure Prophylaxis (PEP) Awareness and Non-Occupational PEP (nPEP) Prescribing History Among U.S. Healthcare Providers

Non-occupational post-exposure prophylaxis (nPEP) has been clinically recommended since 2005. HIV providers and non-HIV providers (n = 480) practicing within above-average HIV prevalence ZIP codes of the 10 U.S. cities with greatest overall HIV prevalence participated in a cross-sectional survey between July 2014 and May 2015. Providers were asked about their awareness of post-exposure prophylaxis (PEP) and nPEP prescribing experience for patients with potential sexual exposures to HIV, which we coded into a PEP prescribing cascade with three categories: (1) PEP unaware, (2) PEP aware, no nPEP prescribing experience, and (3) nPEP prescribing experience. Overall, 12.5% were unaware of PEP, 43.5% were aware but hadn't prescribed nPEP, and 44.0% had prescribed nPEP for potential sexual exposures to HIV. Fewer providers practicing in the U.S. South had ever prescribed nPEP compared to providers in other regions (χ2= 39.91, p < 0.001). HIV providers, compared to non-HIV providers, were more likely to be classified in the nPEP prescription group compared to the PEP aware without nPEP prescription group (RRR = 2.96, p < 0.001). PrEP prescribers, compared to those PrEP unaware, were more likely to be classified in the nPEP prescription group compared to PEP aware without nPEP prescription group (RRR = 12.49, p < 0.001).

Pharmacy PEP Access Intervention Among Persons Who Use Drugs in New York City: iPEPcare Study-Rethinking Biomedical HIV Prevention Strategies

Biomedical HIV prevention uptake has not taken hold among Black and Latinx populations who use street-marketed drugs. A pilot intervention providing a PEP informational video and direct pharmacy access to a PEP starter dose was conducted among this population. Four study pharmacies were selected to help facilitate syringe customer recruitment (2012-2016). Baseline, post-video, and 3-month ACASI captured demographic, risk behavior, and psychosocial factors associated with PEP willingness, and willingness to access PEP in a pharmacy. A non-experimental study design revealed baseline PEP willingness to be associated with PEP awareness, health insurance, being female, and having a high-risk partner (n = 454). Three-month PEP willingness was associated with lower HIV stigma (APR = 0.95). Using a pre-post approach, PEP knowledge (p < 0.001) and willingness (p < 0.001) increased overtime; however, only three participants requested PEP during the study. In-depth interviews (n = 15) identified lack of a deeper understanding of PEP, and contextualized perceptions of HIV risk as PEP access barriers. Pharmacy PEP access shows promise but further research on perceived risk and HIV stigma is warranted.

HIV Nonoccupational Postexposure Prophylaxis Among Men Who Have Sex with Men: A Systematic Review and Meta-Analysis of Global Data

HIV nonoccupational postexposure prophylaxis (nPEP) has been prescribed to men who have sex with men (MSM) for decades, but the global situation of nPEP implementation among this population remains unclear. To understand nPEP awareness, uptake, and factors associated with uptake among MSM, we searched PubMed, Scopus, Embase, the Cochrane Library, and Web of Science for studies reporting nPEP implementation among MSM published before May 19, 2019. We estimated pooled rates and their 95% confidence intervals (CIs) of awareness, uptake using a random-effects model. We identified 74 studies: 3 studies (4.1%) from upper-middle-income regions and 71 (95.9%) from high-income regions. The pooled rate of nPEP awareness and uptake was 51.6% (95% CI 40.6-62.5%) and 6.0% (5.0-7.1%), respectively. Pooled uptake rate was higher in upper-middle-income regions [8.9% (7.8-10.0%)] than in high-income regions [5.8% (4.8-6.9%)]. Unprotected anal sex was the most common exposure (range: 55.0-98.6%, median: 62.9%). Pooled completion of nPEP was 86.9% (79.5-92.8%). Of 19,546 MSM prescribed nPEP, 500 HIV seroconversions (2.6%) were observed. Having risky sexual behaviors and history of sexually transmitted infections were associated with higher nPEP uptake, whereas insufficient knowledge, underestimated risk of exposure to HIV, lack of accessibility, and social stigma might hinder nPEP uptake. Awareness and uptake of nPEP among MSM worldwide are low. Further efforts are needed to combat barriers to access nPEP, including improving accessibility and reducing stigma. Seroconversions post-nPEP uptake suggest that joint prevention precautions aside from nPEP are needed for high-risk MSM. More evidence from low-income and middle-income regions is needed.

Sexual goals and perceptions of goal congruence in individuals' PrEP adoption decisions: A mixed-methods study of gay and bisexual men who are in primary relationships

BACKGROUND

Although health goals are recognized as a central feature of health behavior theories, the relational context through which goals are conceptualized is often overlooked. Interdependence theory represents a valuable framework for understanding goals in the adoption of health behaviors, such as pre-exposure prophylaxis (PrEP), among gay and bisexual men in primary relationships.

PURPOSE

We examined the content and focus of men's sexual health goals, as well as whether goal content, goal focus, or perceptions of goal congruence with a primary partner were related to PrEP adoption among gay and bisexual men in primary relationships.

METHODS

Mixed-methods data were collected from a PrEP demonstration project from 145 HIV-negative gay and bisexual men in primary relationships. Participants reported their sexual health goals and completed measures of perceptions of goal congruence, relationship factors, and sociodemographic factors.

RESULTS

Three main goal content categories were identified: prevention, satisfaction, and intimacy. In expressing these goals, participants framed them with either a self-focus or a relationship-focus. Men in serodiscordant relationships reported more intimacy goals and greater perceptions of goal congruence. There were no differences in goal content or focus by sexual agreement. In the multivariable logistic regression model, perceived goal congruence was associated with PrEP adoption, over and above covariates.

CONCLUSIONS

Intimate relationships play a significant role in the formation of health-related goals. Goal content, focus, and perceived congruence with partners may represent important targets for HIV prevention interventions for gay and bisexual men in primary relationships, especially in the context of PrEP.

Composite Risk for HIV: A New Approach Towards Integrating Biomedical and Behavioral Strategies in Couples-Based HIV Prevention Research

A substantial number of new HIV infections among gay, bisexual, and other men who have sex with men and transgender women occurs in the context of primary partnerships. Given the diversity of risk reduction needs and various approaches available for reducing risk within couples, condomless sex is no longer the gold standard HIV outcome. We present a novel, comprehensive, and flexible Composite Risk for HIV (CR-HIV) approach for integrating evolving biomedical and behavioral HIV prevention strategies into couples-based HIV prevention intervention and survey research. We provide illustrative examples of the utility of the CR-HIV approach based on couples' HIV status.

Characteristics, sexual practices and sexually transmissible infections diagnoses of men who have sex with men and use non-occupational HIV post-exposure prophylaxis in Victoria, Australia

Background Non-occupational post-exposure prophylaxis (NPEP) is available to people with a potential risk for HIV exposure within the preceding 72h. We sought to determine if men who have sex with men (MSM) and receive NPEP had a significantly different risk profile (before the preceding 72h) from MSM not receiving NPEP. If this is the case, NPEP consultations may act as a cue for also discussing pre-exposure prophylaxis.

METHODS

We conducted a retrospective analysis to compare the demographic characteristics, sexual practices and clinical diagnoses of MSM who were NPEP users and those who were non-NPEP users attending Melbourne Sexual Health Centre from January 2008 to December 2014. Univariate and multivariate logistic regression models were used to examine the association between NPEP use and risk practices. Generalised estimating equations were used to adjust for within-individual correlations related to multiple visits of the same individual.

RESULTS

Of the 40395 MSM consultations included in the study, 1776 consultations (4%) were related to NPEP prescription. NPEP prescribing was associated with ever having injected drugs (adjusted odds ratio (AOR) 1.8, 95% confidence interval (CI): 1.4-2.3), sex with males only (AOR 1.9, 95% CI: 1.6-2.3), more than three male partners in the past 3 months (AOR 1.5, 95% CI: 1.4-1.7) and inconsistent condom use with these partners within the past 3 months (AOR 2.1, 95% CI: 1.9-2.4). Sex workers (AOR 0.6, 95% CI: 0.3-0.9), and men reporting sex overseas within the past 12 months (AOR 0.7, 95% CI: 0.6-0.8) were less likely to receive NPEP. MSM who used NPEP were more likely to test positive for any sexually transmissible infection (AOR 1.2, 95% CI: 1.0-1.4).

CONCLUSIONS

MSM receiving NPEP generally had a higher risk profile than MSM not requesting NPEP, indicating that NPEP was used by MSM at higher risk for HIV. Therefore, consultations for NPEP may be an opportune time for also discussing pre-exposure prophylaxis for HIV.

What is the extent of repeat prescriptions for post-exposure prophylaxis for HIV after sexual exposure among men who have sex with men in the UK?

People who repeatedly present for post-exposure prophylaxis (PEP) for prevention of HIV following a high-risk sexual exposure are of concern according to the British HIV Association PEP guidelines. The aim of this audit was to determine the extent of repeat PEP prescriptions for men who have sex with men (MSM) by conducting a retrospective review of patient notes from a 5-year period at one genitourinary medicine clinic. Over the 5 years, 107 of 929 MSM (11.5%; 95% confidence interval: 9.45-13.55) received more than one PEP prescription (repeat range 1-8; mean=3.3, s.d.=1.44). Forty percent of these had received three or more PEP prescriptions. Seven of the 107 became HIV positive. Patients need to be offered and encouraged to take up behavioural risk reduction interventions at the time of each PEP prescription.

A mixed methods study of non-occupational post-exposure prophylaxis at an STI clinic in Singapore: Five-year retrospective analysis and providers' perspectives

BACKGROUND

This mixed methods study aims to describe 1) characteristics of the population treated with non-occupational post-exposure prophylaxis (nPEP), 2) predictors of loss to follow-up (LTFU) and nPEP adherence, and 3) to evaluate the nPEP prescribing practices against current management guideline.

METHODS

This study was conducted at the Department of Sexually Transmitted Infections Control Clinic in Singapore using clinical data from 2010 to 2016. Explanatory sequential mixed method design was adopted. Predictors of LTFU and nPEP adherence were assessed using modified Poisson regression with robust sandwich variance. Subsequently, nine in-depth interviews with healthcare providers were conducted to gain their insights into barriers and facilitators to nPEP implementation. Transcripts were coded and themes were explored using applied thematic analysis.

RESULTS

Of 502 nPEP cases reviewed, 46% were LTFU, 42% were adherent to nPEP and 431 prescription decisions were made in accordance with the guideline. Tourists (aRR, 2.29 [1.90-2.74]; p<0.001) and men who have sex with men/bisexual men (aRR, 1.32 [1.09-1.59]; p = 0.004) were significant predictors of LTFU. Absence of side effects (aRR, 1.14 [1.02-1.27]; p = 0.024) and nPEP treatment with TDF/FTC/ATV/r (aRR, 1.15 [1.03-1.29]; p = 0.017) were positively associated with nPEP adherence. Stigma, types of antiretroviral regimen, side effects, and patients' perception of risk and treatment benefits derived qualitatively further reinforced corresponding quantitative findings.

CONCLUSION

Tailored socio-behavioral interventions are needed to address inherent differences within heterogeneous populations requesting nPEP, stigma, and patients' perceptions of nPEP in order to improve follow-up and its adherence.

To prescribe, or not to prescribe: decision making in HIV-1 post-exposure prophylaxis

OBJECTIVES

We investigated the trend in usage of post-exposure prophylaxis (PEP) after HIV-1 risk exposure and evaluated PEP prescription decision making of physicians according to guidelines.

METHODS

All PEP consultations from January 2014 to December 2016 in patients presenting at the University Hospital of Cologne (Germany) were retrospectively analysed. HIV risk contacts included sexual and occupational exposure. The European AIDS Clinical Society (EACS) Guidelines for HIV PEP (version 9.0, 2017) were used for assessment.

RESULTS

A total of 649 patients presented at the emergency department (ED) or the clinic for infectious diseases (IDC) for PEP consultations. A continuous increase in the number of PEP requests was recorded: 189 in 2014, 208 in 2015 and 252 in 2016. PEP consultations in men who have sex with men (MSM) showed a remarkable increase in 2016 (2014, n = 96; 2015, n = 101; 2016, n = 152). Decisions taken by physicians with a specialization in infectious diseases (n = 547) included 61 (11%) guideline-discordant prescriptions [2014: 14% (n = 22); 2015: 9% (n = 16); 2016: 11% (n = 23)]. Among these, sexual exposure accounted for 45 (74%) cases, including 15 cases of nonconsensual sex, while occupational exposure accounted for 14 (23%) cases and other exposure two cases (3%). The main reason for guideline-discordant PEP prescriptions was emotional stress of the patient (n = 37/61).

CONCLUSIONS

PEP prescriptions are increasing and decision making is influenced by patients' emotional stress, but PEP prescriptions should be strictly administered according to risk assessment.

Expert consensus statement on the science of HIV in the context of criminal law

INTRODUCTION

Globally, prosecutions for non-disclosure, exposure or transmission of HIV frequently relate to sexual activity, biting, or spitting. This includes instances in which no harm was intended, HIV transmission did not occur, and HIV transmission was extremely unlikely or not possible. This suggests prosecutions are not always guided by the best available scientific and medical evidence.

DISCUSSION

Twenty scientists from regions across the world developed this Expert Consensus Statement to address the use of HIV science by the criminal justice system. A detailed analysis of the best available scientific and medical research data on HIV transmission, treatment effectiveness and forensic phylogenetic evidence was performed and described so it may be better understood in criminal law contexts. Description of the possibility of HIV transmission was limited to acts most often at issue in criminal cases. The possibility of HIV transmission during a single, specific act was positioned along a continuum of risk, noting that the possibility of HIV transmission varies according to a range of intersecting factors including viral load, condom use, and other risk reduction practices. Current evidence suggests the possibility of HIV transmission during a single episode of sex, biting or spitting ranges from no possibility to low possibility. Further research considered the positive health impact of modern antiretroviral therapies that have improved the life expectancy of most people living with HIV to a point similar to their HIV-negative counterparts, transforming HIV infection into a chronic, manageable health condition. Lastly, consideration of the use of scientific evidence in court found that phylogenetic analysis alone cannot prove beyond reasonable doubt that one person infected another although it can be used to exonerate a defendant.

CONCLUSIONS

The application of up-to-date scientific evidence in criminal cases has the potential to limit unjust prosecutions and convictions. The authors recommend that caution be exercised when considering prosecution, and encourage governments and those working in legal and judicial systems to pay close attention to the significant advances in HIV science that have occurred over the last three decades to ensure current scientific knowledge informs application of the law in cases related to HIV.

Suspected unexpected and other adverse reactions to antiretroviral drugs used as post-exposure prophylaxis of HIV infection - five-year experience from clinical practice

INTRODUCTION

With increased use of antiretroviral drugs (ARVs) in HIV uninfected persons, proper reporting on suspected unexpected serious adverse reactions (SUSARs) and continued insight into adverse drug reactions (ADRs) are needed for adequate information on safety of ARVs in such populations.

MATERIAL AND METHODS

Medical documentation of persons receiving ARVs after non-occupational HIV exposure (non-occupational post-exposure prophylaxis - nPEP) during 5 successive years (2009-2013) was evaluated by two HIV physicians. Adverse drug reactions s and SUSARs were defined according to international standards. In statistical analyses Cox proportional hazard models were used to identify independent predictors of developing a first ADR.

RESULTS

In total 375 persons received nPEP with the following indications: needle stick (43%), unprotected sexual intercourse (17%), rape (10%) and first aid (10%). In 84 (22%) cases the source patient was HIV positive or an active injecting drug user. In total 170 ADRs were reported. One hundred thirty-nine persons had only 1 ADR. The most frequent first ADRs were gastrointestinal disorders (22%), followed by general symptoms (9%), hypersensitivity reactions (1.6%) and CNS symptoms (1.3%). The remaining events represented less than 1% of all patients. Eight (2.1%) patients developed a SUSAR. In multivariate analyses only age at first visit to the clinic was an independent predictor of developing an ADR (HR = 1.17, 95% CI: 1.03-1.34; p = 0.02).

CONCLUSIONS

In our observations ADRs in reaction to nPEP were frequent yet usually mild events, mostly occurring in the first 2 weeks and rarely causing discontinuation. The only significant factor increasing the risk of ADR was age. SUSARs were rare, transient and clinically insignificant.

Brief Report: Rethinking Data Collection for HIV Prevention Trials

There is a strong push to conduct large-scale randomized controlled study designs in HIV prevention studies. In these randomized controlled studies, the primary research objective is typically to determine the treatment effect based on some biological outcome (eg, HIV infection). But many unused self-reported outcomes are also being collected. We illustrate the extent of this problem using the EXPLORE data as an example.

Experiences of HIV postexposure prophylaxis (PEP) among highly exposed men who have sex with men (MSM)

OBJECTIVES

HIV postexposure prophylaxis (PEP) is indicated after sexual exposure with high risk of transmission. Men who have sex with men (MSM) are the main target of PEP. The aim of our study was to investigate the experience and shortcomings of PEP among people with a high risk of HIV exposure.

DESIGN AND METHODS

Subjects with ongoing follow-up for HIV infection and PEP history were selected for the qualitative study. Semistructured interviews were conducted at the patients' homes. They were audio-recorded, transcribed and deidentified before data analysis, double coding and thematic analysis with an inductive approach.

RESULTS

Twenty-three patients were eligible for the qualitative study. Thirteen interviews were carried out. All patients were 20-60-year-old MSM. The median time between PEP and HIV diagnosis was 3.3 years (interquartile range (IQR)_25-75=0.9-4.9). Many participants reported negative PEP experiences: awkward access to the PEP clinic, uneasiness and shame in the hospital setting, unpleasant interaction and moral disapprobation from the medical staff, treatment intolerance and prevention messages that were 'inconsistent with real life' CONCLUSION: Our data highlight PEP management failures among its target population that may have compromised any subsequent attempts to seek out PEP. Practitioners should be more aware of MSM sexual contexts and practices. PEP consultations should provide the opportunity to discuss prevention strategies with highly exposed HIV-negative subjects, which may include pre-exposure prophylaxis.

Post-exposure prophylaxis awareness and use among men who have sex with men in London who use geosocial-networking smartphone applications

The number of new HIV infections continues to be on the rise in many high-income countries, most notably among men who have sex with men (MSM). Despite recent attention to the use of antiretroviral medications as pre-exposure prophylaxis (PrEP) among MSM, considerably less research has been devoted to examining the awareness and use of post-exposure prophylaxis (PEP). Based on a convenience sample of 179 self-reported HIV-uninfected MSM using a geosocial-networking smartphone application, this study is among the first to examine the awareness and use of PEP and their demographic and behavioral correlates among MSM in London. Most respondents (88.3%) had heard of PEP, where 27.4% reported having used it. In multivariable models, the disclosure of one's sexual orientation to their general practitioner (Prevalence ratio [PR]: 3.49; 95% confidence interval (CI): 1.14, 10.70; p = .029) and reporting one's HIV status as negative (rather than unknown) (PR: 11.49; 95% CI: 1.68, 76.92; p = .013) were associated with having heard of PEP; while the recent use of club drugs (PR: 3.02; 95% CI: 1.42, 6.43; p = .004) was associated with having ever used PEP. High awareness and use in this sample suggest that PEP is a valuable risk-reduction strategy that should be capitalized on, be it in addition to or in the absence of PrEP.

Beyond Condoms: Risk Reduction Strategies Among Gay, Bisexual, and Other Men Who Have Sex With Men Receiving Rapid HIV Testing in Montreal, Canada

Gay, bisexual, and other men who have sex with men (MSM) have adapted their sexual practices over the course of the HIV/AIDS epidemic based on available data and knowledge about HIV. This study sought to identify and compare patterns in condom use among gay, bisexual, and other MSM who were tested for HIV at a community-based testing site in Montreal, Canada. Results showed that while study participants use condoms to a certain extent with HIV-positive partners and partners of unknown HIV status, they also make use of various other strategies such as adjusting to a partner's presumed or known HIV status and viral load, avoiding certain types of partners, taking PEP, and getting tested for HIV. These findings suggest that MSM who use condoms less systematically are not necessarily taking fewer precautions but may instead be combining or replacing condom use with other approaches to risk reduction.

What are the characteristics of, and clinical outcomes in men who have sex with men prescribed HIV postexposure prophylaxis following sexual exposure (PEPSE) at sexual health clinics in England?

OBJECTIVES

To explore the risk factors for, and clinical outcomes in men who have sex with men (MSM) prescribed HIV postexposure prophylaxis following sexual exposure (PEPSE) at sexual health clinics (SHCs) in England.

METHODS

National STI surveillance data were extracted from the genitourinary medicine clinic activity dataset (GUMCADv2) for 2011-2014. Quarterly and annual trends in the number of episodes where PEPSE was prescribed were analysed by gender and sexual risk. Risk factors associated with being prescribed PEPSE among MSM attendees were explored using univariable and multivariable logistic regression. Subsequent HIV acquisition from 4 months after initiating PEPSE was assessed using multivariable Cox proportional hazards models, stratified by clinical risk profiles.

RESULTS

During 2011-2014, there were 24 004 episodes where PEPSE was prescribed at SHCs, of which 69% were to MSM. The number of episodes where PEPSE was prescribed to MSM increased from 2383 in 2011 to 5944 in 2014, and from 1384 to 2226 for heterosexual men and women. 15% of MSM attendees received two or more courses of PEPSE. Compared with MSM attendees not prescribed PEPSE, MSM prescribed PEPSE were significantly more likely to have been diagnosed with a bacterial STI in the previous 12 months (adjusted OR (95% CI)-gonorrhoea: 11.6 (10.5 to 12.8); chlamydia: 5.02 (4.46 to 5.67); syphilis: 2.25 (1.73 to 2.93)), and were more likely to subsequently acquire HIV (adjusted HR (aHR) (95% CI)-single PEPSE course: 2.54 (2.19 to 2.96); two or more PEPSE courses: aHR (95% CI) 4.80 (3.69 to 6.25)). The probability of HIV diagnosis was highest in MSM prescribed PEPSE who had also been diagnosed with a bacterial STI in the previous 12 months (aHR (95% CI): 6.61 (5.19 to 8.42)).

CONCLUSIONS

MSM prescribed PEPSE are at high risk of subsequent HIV acquisition and our data show further risk stratification by clinical and PEPSE prescribing history is possible, which might inform clinical practice and HIV prevention initiatives in MSM.

Predictive Factors for HIV Seroconversion Among Individuals Attending a Specialized Center After an HIV Risk Exposure: A Case-Control Study

OBJECTIVE

To better target our current prevention strategies, we assessed factors associated with HIV seroconversion in individuals attending a specialized center after a risk exposure.

MATERIALS AND METHODS

We studied individuals from an HIV Unit's contact risk cohort at a tertiary care hospital in Barcelona, Spain, between 2003 and 2013 and performed a retrospective matched case-control study. Cases were individuals who seroconverted to HIV after at least 3 months since first follow-up visit for a contracting risk. Controls were HIV-negative individuals from the same cohort. Demographics and behavior variables were studied and compared using a McNemar test assessing factors associated with seroconversion. Univariate analysis and binary logistic regression were performed to develop a model for predicting probability of HIV seroconversion. We also evaluated sensitivity and specificity of our model and an area under Receiver Operating Characteristic (ROC) curve was estimated.

RESULTS

Sixty-nine (2.2%) individuals seroconverted after a median (interquartile range) of 24 (9-34) months since last follow-up. Seroconverters were predominantly male (96%) and men who have sex with men (MSM) (94%). No differences were observed regarding risk of exposure. Being MSM [odds ratio (OR) 5.2 (1.4-20.2), p = .01], having a known HIV-positive partner [OR 2.7 (1.2-6.2), p = .02], previous postexposure prophylaxis (PEP) [OR 3.9 (1.0-15.6), p = .05], and having previous sexually transmitted infections (STIs) [OR 4.6 (1.9-10.9), p = .001] were the factors independently associated with HIV seroconversion. The sensitivity and specificity of our model were 64.06% and 73.53%, respectively, and the area under ROC curve was 0.777.

DISCUSSION

HIV seroconversions were observed frequently between individuals attending a specialized center because of a risk exposure. Being MSM, having had previous PEP, an HIV-positive sexual partner, and previous STI were predictive factors for HIV seroconversion. Closer and longer follow-up and/or pre-exposure prophylaxis should be considered to prevent HIV infections in this high-risk population.

Awareness and use of nonoccupational post-exposure prophylaxis among men who have sex with men in Vancouver, Canada

OBJECTIVES

Nonoccupational post-exposure prophylaxis (nPEP) is a strategy to reduce the risk of HIV infection in those with high-risk exposure. This study characterized nPEP awareness among gay, bisexual and other men who have sex with men (MSM) in Metro Vancouver, British Columbia, Canada after a pilot nPEP programme established in 2012.

METHODS

Momentum Health Study participants were MSM aged ≥16 years recruited via respondent-driven sampling (RDS) who completed a computer-assisted self-interview. Stratifying patients by HIV status, we used multivariable logistic regression with backward selection to identify factors associated with nPEP awareness. All analyses were RDS-adjusted.

RESULTS

A total of 51.9% (112 of 173) of HIV-positive and 48.5% (272 of 500) of HIV-negative participants had heard of nPEP. Only 3% (five of 106) of HIV-negative participants who reported recent high-risk sex used nPEP. Generally, nPEP awareness was higher for participants who engaged in sexual activities with increased HIV transmission potential. Factors associated with greater awareness among HIV-negative participants included recent alcohol use, higher communal sexual altruism, previous sexually transmitted infection diagnosis, and greater perceived condom use self-efficacy. Other factors associated with greater awareness among HIV-negative participants included white race/ethnicity, gay sexual identity, more formal education, lower personal sexual altruism, and Vancouver residence. Greater nPEP awareness among HIV-positive participants was associated with greater perceived agency to ask sexual partners' HIV status and more frequently reporting doing so, a higher number of lifetime receptive sex partners, and greater access to condoms.

CONCLUSIONS

Following implementation of an nPEP pilot programme, nPEP awareness among HIV-negative MSM was 51% and use was 3%. These data support the need to expand access to and actively promote nPEP services.

HIV-Negative Partnered Men's Willingness to Use Non-Occupational Post-Exposure Prophylaxis and Associated Factors in a U.S. Sample of HIV-Negative and HIV-Discordant Male Couples

PURPOSE

Non-occupational post-exposure prophylaxis (nPEP) is an underutilized biomedical option for HIV prevention. Few studies have assessed male couples' knowledge of and willingness to use nPEP.

METHODS

Cross-sectional dyadic data from 275 HIV-negative and 58 HIV-discordant male couples were used to describe HIV-negative, partnered men's awareness and willingness to use nPEP, and factors associated with their willingness to use nPEP. Data were analyzed with the use of multivariate multilevel modeling.

RESULTS

Less than a third of the men were aware of nPEP, yet 73% were very-to-extremely likely to use nPEP. Partnered men's willingness to use nPEP was positively associated with having an individual income less than $30,000 USD and serosorting within the relationship. Willingness to use nPEP was negatively associated with greater age difference between primary partners and with higher scores on measures of couples' investment in their relationship.

CONCLUSION

Efforts should be made to increase male couples' awareness of nPEP and how to access nPEP. Uptake of nPEP has the potential to help avert new HIV infections among male couples.

Longitudinal trends in HIV nonoccupational postexposure prophylaxis use at a Boston community health center between 1997 and 2013

Secular trends in nonoccupational postexposure prophylaxis (NPEP) use have not been well characterized. We performed a retrospective longitudinal study of 894 electronic medical records of NPEP users, mostly men who have sex with men, at a Boston community health center who presented between July 1997 and August 2013. NPEP use and condomless sexual exposures increased over time; 19.4% had multiple NPEP courses. Having an HIV-infected partner was associated with increased odds of regimen completion, and 3-drug regimens were associated with decreased odds of completion. Targeted adherence and risk-reduction counseling are warranted for select NPEP users at this center.

Subsequent HIV infection among men who have sex with men who used non-occupational post-exposure prophylaxis at a Boston community health center: 1997-2013

Non-occupational post-exposure prophylaxis (NPEP) has been recommended to prevent HIV acquisition for nearly 20 years. However, limited behavioral and clinical outcome data exist after men who have sex with men (MSM) present for NPEP. We reviewed the electronic medical records of HIV-uninfected adults who presented for NPEP at a large community health center in Boston between July, 1997 and August, 2013. Data from 894 patients were analyzed, 88.1% of whom were MSM. Consensual unprotected sex was the most common reason for NPEP visits among MSM (64.2%), followed by condom failure (30.6%). The HIV serostatus of the partner was unknown for 64.4% of the MSM, positive with unknown treatment status for 18.1%, positive and not on treatment for 4.1%, and positive and on treatment for 13.4%. Thirty-nine patients subsequently became HIV-infected (4.4%), all of whom were MSM. The MSM-specific HIV incidence after NPEP use was 2.2 cases per 100 person-years. Incident HIV infection was associated with younger age (AHR=0.94; p=0.003), being Latino (AHR=2.44; p=0.044), and/or being African American (AHR=3.43; p=0.046). Repeated NPEP use was not associated with incident HIV infection (AHR=0.67; p=0.26). Younger MSM of color who access NPEP, in particular, may benefit from early HIV risk-reduction and pre-exposure prophylaxis counseling.

Current perspectives in HIV post-exposure prophylaxis

The incidence of human immunodeficiency virus (HIV) infection continues to rise among core groups and efforts to reduce the numbers of new infections are being redoubled. Post-exposure prophylaxis (PEP) is the use of short-term antiretroviral therapy (ART) to reduce the risk of acquisition of HIV infection following exposure. Current guidelines recommend a 28-day course of ART within 36-72 hours of exposure to HIV. As long as individuals continue to be exposed to HIV there will be a role for PEP in the foreseeable future. Nonoccupational PEP, the vast majority of which is for sexual exposure (PEPSE), has a significant role to play in HIV prevention efforts. Awareness of PEP and its availability for both clinicians and those who are eligible to receive it are crucial to ensure that PEP is used to its full potential in any HIV prevention strategy. In this review, we provide current evidence for the use of PEPSE, assessment of the risk of HIV transmission, indications for PEP, drug regimens, and management of patients started on PEP. We summarize national and international guidelines for the use of PEPSE. We explore the place of PEP within the wider strategy of reducing HIV incidence rates in the era of treatment as prevention and pre-exposure prophylaxis. We also consider the implications of recent data from interventional and observational studies demonstrating significant reductions in the risk of HIV transmission within a serodiscordant relationship if the HIV-positive partner is taking effective ART upon PEP guidelines.

Trends in condom use and risk behaviours after sexual exposure to HIV: a seven-year observational study

OBJECTIVE

We aimed to determine the trends in numbers and percentages of sexually exposed persons to HIV (SE) consulting an ED for post-exposure prophylaxis (PEP), as well as predictors of condom use.

STUDY DESIGN

We conducted a prospective-observational study.

METHODS

We included all SE attendances in our Emergency Department (ED) during a seven-year study-period (2006-2012). Trends were analyzed using time-series analysis. Logistic Regression was used to define indicators of condom use.

RESULTS

We enrolled 1851 SE: 45.7% reported intercourse without condom-use and 12.2% with an HIV-infected partner. Significant (p<0.01) rising trends were observed in the overall number of SE visits (+75%), notably among men having sex with men (MSM) (+126%). There were rising trends in the number and percentage of those reporting intercourse without condom-use in the entire population +91% (p<0.001) and +1% (p>0.05), in MSM +228% (p<0.001) and +49% (p<0.001), in Heterosexuals +68% (p<0.001) and +10% (p = 0.08). Among MSM, significant rising trends were found in those reporting high-risk behaviours: anal receptive (+450% and +76%) and anal insertive (+l33% and +70%) intercourses. In a multivariate logistic regression analysis, heterosexuals, vaginal intercourse, visit during the night-shift and short time delay between SE and ED visit, were significantly associated with condom-use.

CONCLUSION

We report an increasing trend in the number of SE, mainly among MSM, and rising trends in high-risk behaviours and unprotected sexual intercourses among MSM. Our results indicate that SE should be considered as a high-risk population for HIV and sexually transmitted diseases.

Overviewing a Nurse-Led, Community-Based HIV PEP Program: Applying the Extant Literature in Frontline Practice

This clinical concept paper overviews a program to facilitate access to postexposure prophylaxis (PEP) for gay, bisexual, and other men who have sex with men. The project, which was a collaborative initiative involving the local School of Nursing, public health unit, AIDS service organization, hospital-based HIV clinic, and an outpatient pharmacy, was implemented to circumvent common barriers to care identified in the literature. In this project, persons who present to one of the two participating clinics after having come, or likely having come, into contact with HIV within the previous 72 hr, are offered rapid HIV testing, also known as point-of-care (POC) testing, to rule out existing HIV infection, and provided with a follow-up appointment booked at the HIV clinic. Clients are also offered comprehensive STI testing, and HIV prevention counseling. The implementation of this collaborative community-based access-to-PEP project demonstrates the application of research to a real-world health care setting, and it is hoped that others will adapt this model to their local setting, enabling ease of access to PEP for members of groups that are disproportionately affected by HIV.

HIV medical providers' perceptions of the use of antiretroviral therapy as nonoccupational postexposure prophylaxis in 2 major metropolitan areas

INTRODUCTION

In 2005, the Centers for Disease Control and Prevention expanded its recommendation of postexposure prophylaxis (PEP) use in the workplace to include nonoccupational exposures (nPEP). The availability and extensive use of nPEP have not achieved widespread acceptance among health-care providers of high-risk populations, and public health and primary care agencies have been sparse in their implementation of nPEP promotion, protocols, and practices.

METHODS

We conducted a survey of HIV providers (n = 142, response rate = 61%) in Miami-Dade County (Florida) and the District of Columbia that focused on their knowledge, attitudes, beliefs, and practices related to the delivery of nPEP. We then analyzed differences in survey responses by site and by history of prescribing nPEP using bivariate and multivariate logistic regression.

RESULTS

More District of Columbia providers (59.7%) reported ever prescribing nPEP than in Miami (39.5%, P < 0.048). The majority of practices in both cities did not have a written nPEP protocol and rarely or never had patients request nPEP. Multivariable analysis for history of prescribing nPEP was dominated by having patients request nPEP [odds ratio (OR) = 21.53] and the belief that nPEP would lead to antiretroviral resistance (OR = 0.14) and having a written nPEP protocol (OR = 7.49).

DISCUSSION

Our findings are consistent with earlier studies showing the underuse of nPEP as a prevention strategy. The significance of having a written nPEP protocol and of patient requests for nPEP speaks to the importance of using targeted strategies to promote widespread awareness of the use of HIV antiretroviral medications as a prevention intervention.

Attitudes toward Web application supporting pharmacist-clinician comanagement of postexposure prophylaxis patients

OBJECTIVES

To qualitatively explore clinician and pharmacist attitudes toward using a Web application virtual pharmacist-clinician partnership (VPCP) to assist with comanaged care of illicit drug-using patients prescribed postexposure prophylaxis (PEP).

DESIGN

Qualitative, descriptive, nonexperimental study.

SETTING

New York City (NYC) from February 2011 to March 2012.

PARTICIPANTS

Four pharmacists and nine clinicians.

INTERVENTION

In-depth interviews.

MAIN OUTCOME MEASURES

Potential impact of the VPCP on pharmacist-clinician communication and potential barriers to use of the VPCP when comanaging PEP patients among pharmacists and clinicians.

RESULTS

Pharmacists and clinicians were supportive of an interactive Web application that would expand the role of pharmacists to include assistance with PEP access and patient management. Participants noted that the VPCP would facilitate communication between pharmacists and clinicians and have potential to support adherence among patients. Pharmacists and clinicians were concerned about not having time to use the VPCP and security of patient information on the site. Pharmacist and clinician concerns informed final development of the VPCP, including creation of a user-friendly interface, linkage to users' e-mail accounts for timeline notification, and attention to security.

CONCLUSION

Use of Web-based technology to support communication between pharmacists and clinicians was seen as being a potentially feasible method for improving patient care, particularly in the delivery of PEP to drug users and other high-risk groups. These findings highlight the need for further study of a technology-supported partnership, particularly for comanagement of patients who face challenges with adherence.

Awareness and use of nonoccupational HIV post-exposure prophylaxis among people receiving rapid HIV testing in Spain

OBJECTIVES

This paper examines the awareness and use of nonoccupational HIV post-exposure prophylaxis (nPEP) in Spain, and the factors that influence this awareness.

METHODS

Between June 2009 and July 2010, a mobile unit offered free, rapid HIV tests in a number of Spanish cities. A total of 2545 people were passively recruited and tested, and answered a self-administered questionnaire containing sociodemographic, behavioural and nPEP-related questions. Bivariate and multivariate analyses were performed, stratifying by gender/sexual behaviour.

RESULTS

Some 34% of the responders were men who have sex with men (MSM), 30% were men who have sex exclusively with women (MSW), and 35% were women. Approximately 26% were foreigners, 46% had a university degree, and 51% had previously taken an HIV test. Overall, 22% were aware of nPEP. Only 2% had ever used it; 70% of these after high-risk sexual intercourse. Awareness was higher among MSM (34%) than women (16%) and MSW (15%). Multivariate analysis showed a lack of nPEP awareness to be associated with being born in Latin America, while awareness increased with the number of previous HIV tests among women and MSW. In MSM, awareness was also associated with having a university degree, the degree of interaction with gay culture, number of partners, and use of the internet as the main way of meeting partners.

CONCLUSIONS

nPEP awareness in the studied population was unacceptably low. The promotion of its availability should be made a major objective of prevention programmes, as a complementary measure to condom use.

A novel combination HIV prevention strategy: post-exposure prophylaxis with contingency management for substance abuse treatment among methamphetamine-using men who have sex with men

Methamphetamine use has been associated with HIV transmission among men who have sex with men (MSM). However, providers have been hesitant to utilize post-exposure prophylaxis (PEP) in populations of stimulant users. This single-arm, open label pilot study sought to demonstrate the safety, feasibility, and acceptability of PEP combined with the drug abstinence intervention of contingency management (CM) in methamphetamine-using MSM. HIV-uninfected MSM reporting recent methamphetamine use were recruited to a CM intervention. Those who reported a recent high-risk sexual or injection drug exposure to an HIV-infected or serostatus unknown source were initiated on tenofovir/emtricitabine (Truvada)-based PEP. Participants were followed over 3 months for infectious/biologic, behavioral, and drug use outcomes. Fifty-three participants enrolled in the study; 35 participants (66%) initiated PEP after a high-risk exposure. The median time from exposure to medication administration was 37.8 h (range 12.5-68.0 h). Twenty-five (71.4%) PEP initiators successfully completed the treatment course. Median medication adherence was 96% (IQR 57-100%), and medication was generally well tolerated. Methamphetamine abstinence during CM treatment increased PEP adherence (2% [95% CI +1-+3%]) per clean urine toxicology sample provided), and increased the odds of PEP course completion (OR 1.17, 95% CI 1.04-1.31). One incident of HIV seroconversion was observed in a participant who did not complete PEP treatment, and reported multiple subsequent exposures. Findings demonstrate that PEP, when combined with CM, is safe, feasible, and acceptable as an HIV prevention strategy in methamphetamine-using MSM.

High HIV incidence among MSM prescribed postexposure prophylaxis, 2000-2009: indications for ongoing sexual risk behaviour

OBJECTIVE

To determine (trends in) HIV incidence among MSM\ who have recently had postexposure prophylaxis (PEP) prescribed in Amsterdam, compared with MSM participating in the Amsterdam Cohort Studies (ACS).

DESIGN AND METHODS

We used data from MSM who were prescribed PEP in Amsterdam between 2000 and 2009, who were HIV-negative at the time of PEP prescription and had follow-up HIV testing 3 and/or 6 months after PEP prescription (n = 395). For comparison, cohort data from MSM participating in the ACS in the same period were used (n = 782). Poisson log-linear regression analyses were performed to model trends in HIV incidence and identify differences in HIV incidence between both cohorts at different time points.

RESULTS

Between 2000 and 2009, among MSM who were prescribed PEP, an overall HIV incidence of 6.4 [95% confidence interval (CI) 3.4-11.2] per 100 person-years was found, compared with an HIV incidence of 1.6 (95% CI 1.3-2.1) per 100 person-years among MSM participating in the ACS (P < 0.01). In both cohorts, an increasing trend in HIV incidence over time was observed [incidence rate ratio (IRR(per calendar year)) 1.3 (95% CI 0.9-1.7) and 1.1 (95% CI 1.0-1.2) among MSM prescribed PEP and MSM of the ACS, respectively]. The difference in HIV incidence between both cohorts was most evident in more recent years [IRR(PEP versus ACS in 2009) 4.8 (95% CI 2.0-11.5)].

CONCLUSION

Particularly in more recent years, MSM recently prescribed PEP had a higher HIV incidence compared with MSM participating in the ACS, indicating ongoing sexual risk behaviour.