Individual and structural-level Correlates of Pre-exposure Prophylaxis (PrEP) lifetime and current use in a nationwide sample of young sexual and gender minorities

HIV Pre-Exposure Prophylaxis Among Sexual and Gender Minority Homeless Youth

OBJECTIVE

Sexual and gender minority (SGM) people account for up to 40% of youth experiencing homelessness. SGM youth experiencing homelessness report a higher likelihood of engaging in behavior that puts them at risk of acquiring HIV. To address this increased risk, it is necessary to identify difference in awareness and use of HIV pre-exposure prophylaxis (PrEP) among SGM youth experiencing homelessness.

METHODS

Using intake forms from a single service provider in New York City, New York, that specializes in providing shelter and health care for SGM youth experiencing homelessness, we conducted a retrospective, cross-sectional study examining associations between access to care and engaging in transactional sexual exchanges (TSEs) with awareness and use of HIV PrEP.

RESULTS

Of 1312 SGM youth, 63.1% (n = 828) reported being aware of HIV PrEP, but only 11.7% (n = 153) had ever taken HIV PrEP. Access to care was associated with being aware of HIV PrEP (odds ratio [OR] 1.57, 95% CI [1.20-2.07]) but not ever using it (OR 1.47, 95% CI [0.94-2.29]). Notably, previous use of HIV PrEP was higher among SGM youth who had engaged in TSE than among those who had not (OR 3.55, 95% CI [2.47-5.08]).

CONCLUSIONS

Access to medical care is associated with awareness but not utilization of HIV PrEP. Providing HIV preventive care for SGM youth experiencing homelessness requires more than access to care. Further research is needed to assess facilitators and barriers to HIV PrEP utilization in this population.

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

BackgroundAlthough PrEP is a highly effective HIV prevention method, some groups are underrepresented in PrEP uptake. Much HIV prevention research groups gay, bisexual and other men who have sex with men together; however, men who have sex with both men and women (MSWM) may have needs distinct from those who identify as exclusively gay. This scoping review aims to explore documented barriers to PrEP use among MSWM.MethodsLiterature was searched using four databases. Studies were included if data referring to MSWM were reported as a distinct category. Data were extracted using a standardised form, and findings were stratified into relevant categories of the social ecological framework.ResultsAlongside intersectional barriers, MSWM were found to have lower awareness of PrEP, and access sexual health services less than men who have sex only with men. Those who did not identify with the LGBT community often missed out on health promotion messages for this group and were less likely to be offered HIV prevention interventions. MSWM identified more stigmatisation around PrEP use than gay men. However, when aware of PrEP, MSWM were very motivated to use this intervention.ConclusionsNot all MSM will identify within the LGBTQ + community and may miss out on valuable opportunities for HIV prevention. PrEP information should be widely available in a variety of health and community settings. Health care professionals should avoid assumptions when assessing patients and provide information about HIV and STI prevention to all attending sexual health services.

HIV Testing and PrEP Use Among Trans and/or Non-binary Participants in the TASG Study, a Participatory Study in Germany

HIV testing and pre-exposure prophylaxis (PrEP) are recommended in Germany for individuals at increased HIV risk. However, data on HIV testing, PrEP use, and PrEP knowledge among trans and non-binary people are limited. We analysed data from the 'Sexuelle Gesundheit in trans und nicht-binären Communitys' (TASG) study, a participatory study on HIV/STI and sexual health among trans and non-binary people in Germany. The study was designed, promoted, and analysed with active involvement of community members. Participants were invited to complete an anonymous online survey between 1 March and 1 July 2022. The outcomes included HIV testing within the last 5 years, PrEP use, and PrEP-specific knowledge. Predictors for HIV testing were identified using a bootstrap stepwise selection procedure. Among 2468 HIV-negative participants with information on potential HIV risks, 21.5% had potential needs for HIV testing and PrEP. Of these, only 44.3% (208/470, missing: 60) reported testing for HIV within the last 5 years. Older participants, those living in larger cities, and those with higher education levels were more likely to have tested for HIV. Additionally, only 8.3% (38/459, missing: 71) reported ever using PrEP. Among 451 participants with potential PrEP needs (missing: 79), only 57.4% knew at least one of three key PrEP-related facts at the time of the survey. Our findings highlight substantial gaps in HIV testing and prevention among trans and non-binary individuals in Germany with potential needs for these services. Reducing barriers to testing and prevention is essential to enable broader access to these critical services.

PrEP Disparities Among Transgender Feminine, Transgender Masculine, Nonbinary, and Gender Expansive Youth and Young Adults in the United States

This study assessed disparities in pre-exposure prophylaxis (PrEP) use among transgender and gender expansive youth and young adults (N = 477) between 15 and 24 years old in the CARES (ATN 149) and TechStep (ATN 160) study protocols within the National Adolescent Medicine Trials Network for HIV/AIDS Interventions (ATN). Structural equation modeling was used to test mediation pathways between gender identity and PrEP uptake among the full sample and stratified by sex assigned at birth. Lifetime PrEP uptake was higher among those assigned male at birth (26%) versus assigned female at birth (9%), explained by greater structural and behavioral risks and perceived need for PrEP, especially among trans women. Among those assigned female at birth, PrEP uptake was higher among trans men (12%) than nonbinary participants (6%). Our findings characterize key structural and behavioral drivers of PrEP use and highlight the need to reduce barriers to healthcare for trans youth, particularly in the South.

Knowledge and Barriers to HIV Pre-exposure Prophylaxis in Southern California

Despite the proven effectiveness of human immunodeficiency virus (HIV) pre-exposure prophylaxis (PrEP), its use remains low in high-incidence areas. This study examined knowledge and barriers to PrEP among individuals at risk in Southern California. From September 2022 to April 2023, we recruited adult men who have sex with men, residing in San Bernardino and Riverside counties, who were not living with HIV and not using PrEP. Recruitment occurred through targeted online advertisements and clinic-distributed materials. Statistical analyses explored associations between demographic factors and barriers to PrEP. While 81% had heard of PrEP, nearly half were unaware of HIV testing requirements or of its availability for uninsured individuals. Uninsured participants were significantly less comfortable discussing sexual health with providers (OR: 0.19, 95% CI [0.05, 0.68]). Addressing misinformation, reducing provider stigma, and expanding access for uninsured individuals are essential for increasing PrEP use.

The Impacts of Substance Use and Depression on HIV Pre-Exposure Prophylaxis Use and Adherence Among Sexual and Gender Minority Adolescents and Young Adults in the Keeping it LITE Cohort

Substance use and depression are prevalent in sexual and gender minorities (SGM), but evidence about their impacts on HIV pre-exposure prophylaxis (PrEP) use is mixed. We assessed these impacts in a US-based cohort of 3,330 young SGM who tested negative for HIV and completed baseline and semiannual assessments on substance use (cocaine, methamphetamine, or heroin), depression, and PrEP use and adherence. We estimated prevalence differences (PDs) to compare baseline and 12-month PrEP use and adherence between participants with and without substance use and depression, separately and jointly. At baseline, 8% of participants reported substance use and depression, 7% reported substance use only, 38% reported depression only, and 47% reported neither. PrEP use was reported by 22%, with 78% reporting prior-day adherence. Compared to participants without depression or substance use, participants with substance use alone were more likely to report PrEP use at baseline (PD = 18.9; 95% CI: 7.6, 30.2) and 12 months (PD = 15.9, 95% CI: 5.1, 26.7), without adherence differences. Depression alone was associated with lower baseline PrEP use (PD=-3.6, 95% CI: -6.7, -0.4) and adherence (PD=-10.0, 95% CI: -18.4, -1.6), but associations attenuated over 12 months. Those with both substance use and depression (vs. neither) reported higher baseline PrEP use (PD = 6.5, 95% CI: -0.6, 13.5) and lower adherence (PD=-12.9, 95% CI: -26.2, 0.5), with associations weakening over 12 months. Substance use and depression had opposing relationships with PrEP use and adherence. In addition to its mental health benefits, depression treatment may improve PrEP uptake and adherence in young SGM.

Barriers and Facilitators Along the PrEP Continuum of Care Among Latinx Sexual Minoritized Men and Transgender Women: A Systematic Review

Latinx cisgender sexually minoritized men (SMM) and transgender women (TW) in the U.S. are disproportionately affected by HIV. Although pre-exposure prophylaxis (PrEP) is a highly effective strategy for HIV prevention, rates of PrEP use among Latinx SMM and TW remain suboptimal. The main purpose of this systematic review was to (1) describe engagement in the various stages of the PrEP care continuum among Latinx SMM and TW, and (2) identify multilevel determinants that function as barriers or facilitators to engagement in the PrEP continuum of care for Latinx SMM and TW. This review was conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-Analysis Statement (PRISMA). Five databases (MEDLINE, CINAHL, PsycINFO, Embase, Scopus) were searched to examine the available qualitative, quantitative, and mixed method studies relevant to the research question. A total of 56 studies were included, with the majority focusing on SMM and being cross-sectional in design. Barriers included PrEP knowledge, risk perception, intersecting stigma, and structural conditions. Community resources, social support, and PrEP navigation services facilitated engagement in the PrEP continuum of care. This review highlights the complex factors that influence PrEP care engagement among Latinx SMM and TW. These findings call for comprehensive, multilevel approaches to address inequities disparities in PrEP care engagement among these groups.

Protocol for a systematic search and critical discourse analysis of research on national HIV pre-exposure prophylaxis programmes among gay, bisexual, and other men who have sex with men

Background

HIV pre-exposure prophylaxis (PrEP) is a medication that prevents the acquisition of HIV, most commonly taken in the form of a pill. PrEP is an efficacious tool for HIV prevention, including among gay, bisexual, and other men who have sex with men (gbMSM). PrEP is often provided through formal PrEP programmes. Research on these programmes may employ discourses shaped by heteronormativity and homophobia. Given that expert language influences how HIV prevention is understood and delivered, problematic discourses in research likely extend into PrEP implementation. This study will use critical discourse analysis (CDA) to explore research on PrEP programme implementation for gbMSM. Within this literature, we will identify interpretive repertoires used to discuss gbMSM; the subject positions afforded to gbMSM; and the implications of these interpretive repertoires and subject positions for gbMSM engaging with HIV PrEP programmes.

Methods

Systematic search methods identified relevant articles through timebound searching (2012-2023) in ProQuest ASSIA, EBSCOhost PsycInfo, OVID Medline, OVID Embase, and EBSCOhost CINAHL, with forward and backward citation searching of included studies. Grey literature will be identified through ProQuest and Google Scholar. Screening will be conducted by two independent reviewers, who will conduct random partial double screening for titles and abstracts and for all full text articles. Data will be analysed and synthesised using CDA informed by critical realism (CR). CDA focuses on relationships between language and power, including how language enables inequality. The analytic process will explore the background of included studies, identify themes, and analyse external and internal relations in included studies.

Conclusions

Highlighting issues with discourses in PrEP implementation may enhance reflective engagement with assumptions underlying this research, preventing further stigmatisation of gbMSM's sexual and protective practices. As PrEP programmes become more common, diverse and inclusive perspectives in PrEP programme research may inform interventions that enhance their acceptability and implementation.

Changes in Sexual Behaviors Due to Mpox: a Cross-Sectional Study of Sexual and Gender Minority Individuals in Illinois

The spread of the monkeypox virus (mpox) in 2022 primarily within the sexual networks of men who have sex with men (MSM) triggered a potentially stigmatizing public health response in the USA. Despite mpox being primarily spread through skin-to-skin contact, most messaging has promoted abstinence and/or reduction in sexual risk behaviors. More research is needed on decreases in sexual risk behaviors among sexual and gender minority (SGM) youth and young adults (YYA) related to the most recent mpox epidemic and whether there are factors associated with these decreases in sexual risk behavior. Participants within an ongoing cohort study of SGM YYA who reside in Illinois were offered the opportunity to participate in an mpox survey between September 10th and September 20th, 2022. Analyses looked at demographic factors associated with sexual activity since the start of the outbreak, as well as associations with two sexual risk reduction factors. Survey participation was 68.7% (322/469). Three-quarters of participants (82.6%) reported sexual activity since June 1st. Most sexually active participants (83.5%) adopted at least one sexual risk reduction behavior due to mpox. Black and Latinx individuals were less likely to be sexually active but more likely to report risk reduction behaviors (31.3% and 22.6%, respectively). Participants who received the mpox vaccine were more likely to report sexual activity. SGM YYA in Illinois reported that their sexual behaviors were impacted by the mpox outbreak. However, associations between vaccination and sexual behavior demonstrate that those who are vaccinated do adopt protective methods despite not decreasing sexual activity. Therefore, sex-positive communications and harm reduction messaging may be more appropriate as opposed to abstinence-only prevention, which can further stigmatize an already marginalized group.

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

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

Opportunities to Increase Access to HIV Prevention: Evaluating the Implementation of Pharmacist-Initiated Pre-exposure Prophylaxis in California

Background

Pharmacies are a promising setting through which to expand access to human immunodeficiency virus (HIV) prevention, including pre-exposure and post-exposure prophylaxis (PrEP and PEP, respectively). We aimed to evaluate and inform the implementation of California's Senate Bill 159 (2019), allowing pharmacists to independently prescribe PrEP and PEP.

Methods

From October through December 2022, we conducted a cross-sectional study of 919 California pharmacists and pharmacy students, primarily recruited via the email listservs of professional organizations. Participants completed an online survey assessing the implementation of pharmacist-initiated PrEP/PEP, including knowledge, attitudes, practices, perceived barriers, and implementation preferences elicited through a discrete choice experiment.

Results

Among 919 participants (84% practicing pharmacists, 43% in community pharmacies), 11% and 13% reported that pharmacists at their pharmacy initiate PrEP and PEP, respectively. Most believed that pharmacist-initiated PrEP/PEP is important (96%) and were willing to provide PrEP (81%); fewer (27%) had PrEP/PEP training. Common implementation barriers were lack of staff/time and payment for pharmacist services. Participants preferred PrEP implementation models with in-pharmacy rapid oral HIV testing and pharmacists specifically hired to provide PrEP services.

Conclusions

Despite pharmacists' supportive attitudes, Senate Bill 159 implementation in California pharmacies remains limited, in part due to policy-level and organizational-level barriers. Ensuring PrEP/PEP-related payment for services and sufficient workforce capacity is key to leveraging pharmacists' role in HIV prevention.