Who is using PrEP on-demand? Factors associated with PrEP use modality among Black and Hispanic/Latino emerging adults

Differences Among Current Pre-exposure Prophylaxis (PrEP) Users, Former Users, and Nonusers in a Community Sample in Two Midwestern U.S. Cities: Implications for Interventions to Promote PrEP Uptake and Adherence

Disparate rates of HIV infection among Black MSM and TGW emphasize the need for interventions designed to overcome obstacles to increasing PrEP adoption within these populations. This study compared PrEP-use groups on a variety of attitudinal and behavioral factors related to PrEP adoption. Regression analysis confirmed that current and former users demonstrated greater PrEP knowledge and communicated more frequently to friends about PrEP and its benefits than nonusers. Former users exhibited more positive attitudes and perceived less stigma regarding PrEP use than other groups. Current users reported the highest prevalence of condomless anal sex and multiple partners; conversely, former users were most often in stable monogamous relationships. Our findings are consistent with the notion of prevention-effective adherence and advance our understanding of attitudinal supports for that paradigm. This research also suggests that recruitment of former PrEP users could increase the pool of effective peer behavior-change agents in future intervention efforts.

Strengthening PrEP services at community-based organizations for Latinx men who have sex with men: an implementation science approach

BACKGROUND

In Miami-Dade County Florida (Miami), the rate of newly diagnosed HIV per 100,000 population is four times the national rate with a large majority of transmission due to male-to-male sex. Latinx men are prescribed HIV preventative medication (PrEP) at a lower rate than White individuals; as such, efforts are being made by community health organizations to engage Latinx men who have sex with men (LMSM) in PrEP promotion programs. The objective of this study is to characterize the features, strengths, and weaknesses of the implementation of a PrEP promotion program (DiversiPrEP) at three community based organization (CBO) locations across Miami-Dade and Broward Counties.

METHODS

All 30 staff members were invited via e-mail to participate; 11 staff participated in semi-structured interviews were conducted by two authors to assess implementation of the DiversiPrEP program with questions mapped to the Consolidated Framework for Implementation Research (CFIR). We used directed content analysis to analyze qualitative data.

RESULTS

All staff members self-identified as male and 82% (9 of the 11) identified as Hispanic/Latino. Facilitators to providing PrEP services included: 1) individualized counseling for the PrEP process; 2) providing inviting community-focused spaces with staff who reflect the demographics of the priority population; and 3) hiring non-medical staff that bridge the gap as a translator of both medical and administrative issues. Negative influences on implementation included: 1) federal funding restrictions on lab and testing costs that hinder the ability of the CBO to provide no-cost testing to clients; and 2) finding ways to advertise services to LMSM that may not already be familiar with the CBO.

CONCLUSIONS

CBO administrative staff provide actionable policy and implementation recommendations for offering culturally tailored PrEP services in other LMSM communities. CBO can reduce PrEP service barriers by acting as intermediaries for navigation of the healthcare system and deferring costs to the clients through federal and state funding programs.

PrEP demand creation strategies for adolescents at increased risk of HIV infection in São Paulo, Brazil: a cost-consequence analysis

BACKGROUND

The extension of PrEP coverage for vulnerable populations depends on demand creation strategies that aim to inform, encourage usage, and facilitate access to health services. However, there are no cost estimates for Brazil or Latin America regarding demand creation strategies focused on populations with higher vulnerability and risk of HIV infection. This analysis aims to assess the costs and health outcomes of different strategies used to create demand for PrEP for individuals aged 15 to 19 who identify as men who have sex with men (MSM), transgender women (TGW), or non-binary people assigned male at birth.

METHODS

Cost-consequence analysis of six demand creation strategies used in the "PrEP1519 Study" (chatbot strategy; dating apps strategy; social media strategy; socialization places strategy; NGOs strategy; direct referrals strategy). The analysis was conducted using data from January 2019 to December 2021. The evaluated outcome was the "PrEP initiation ratio" (PrEPIR), which represents the percentage of approached individuals who started PrEP. The cost analysis included direct costs related to personnel, promotional materials, testing, equipment, and services.

RESULTS

The strategy with the highest PrEPIR was the social media strategy (2.97% [95% CI 2.29-3.84]), followed by the socialization places strategy (2.05% [1.45-2.89]). The direct referrals strategy, which served as the baseline, had one of the lowest PrEPIR (0.36% [0.30-0.43]). The average cost per participant included ranged from $100.74 for the direct referrals strategy to $5,572.00 for the chatbot strategy. The strategy with the highest total cost was the chatbot strategy ($55,719.98), whereas the strategy with the lowest total cost was the NGOs strategy ($10,809.80).

CONCLUSION

Despite incurring higher costs, the implementation of more successful demand creation strategies (such as socialization places, social media, and dating apps) has the potential to increase PrEP usage and, consequently, reduce HIV infection in populations facing greater vulnerability. These findings can contribute to more effective planning and organization of prevention programs by healthcare services to reach these populations.

TRIAL REGISTRATION

This analysis is part of the "PrEP1519 Study" (protocol number 89993018.9.0000.0065).

Latino Sexual Minority Men's Pre-Exposure Prophylaxis Modality Preferences: A Latent Class Analysis

Pre-exposure prophylaxis (PrEP) is an effective HIV prevention tool available in several modalities (e.g., daily oral, injectable, implants, rectal douching). The Ending the HIV Epidemic (EHE) initiative, a national initiative that began in 2019 as a partnership among the Department of Health and Human Services and other federal agencies (e.g., the Centers for Disease Control and Prevention, National Institute of Health), seeks to increase PrEP engagement for groups experiencing HIV inequities, including Latino sexual minority men (LSMM). Given the limited research on PrEP modality preferences among LSMM, this study aimed to explore and characterize these preferences. LSMM (n = 214) not using PrEP and living in South Florida participated in the DÍMELO study, which examined PrEP engagement among LSMM in South Florida. Authors employed latent class analysis (LCA) to identify groups of LSMM based on their PrEP modality preferences and examined predictors of class membership. LCA results led to a three-class solution with participants who were: (1) reluctant to use most PrEP modalities (30.5%), (2) PrEP willing, with constraints (36.0%), and (3) enthusiastically accepting of all PrEP modalities (33.5%). LSMM in the reluctant class (Class 1) showed minimal interest in most PrEP modalities. The constrained class (Class 2) displayed interest in daily oral, on-demand, and quarterly injectable PrEP while the enthusiastic class (Class 3) demonstrated high interest in all modalities except rectal douching. Key predictors of PrEP modality preferences were altruism, community normalization of PrEP, and migration history. Understanding LSMM's PrEP modality preferences can enhance the reach of PrEP to LSMM, a group the EHE initiative prioritizes. The current findings suggest the need to tailor PrEP outreach efforts to promote various PrEP modalities based on LSMM's preferences.

Preferences for Starting Daily, On-Demand, and Long-Acting Injectable HIV Preexposure Prophylaxis Among Men Who Have Sex With Men in the United States (2021-2022): Nationwide Online Cross-Sectional Study

BACKGROUND

Long-acting (LA) injectable preexposure prophylaxis (PrEP) and on-demand PrEP may improve overall PrEP uptake among men who have sex with men (MSM), but little is understood about the PrEP option preferences of MSM in practical scenarios where they may choose between various PrEP options.

OBJECTIVE

This study aims to examine the preferences for starting various PrEP options among a US nationwide online convenience sample of MSM from September 2021 to February 2022.

METHODS

Participants reporting no prior HIV diagnosis were provided brief descriptions of each PrEP option and were asked, "If [PrEP option] were available from your local doctor and you could access it for free, would you go to your doctor in the next month to start [PrEP option]?" Those who said "yes" to multiple options were asked to rank them in order of preference. MSM currently taking daily oral (DO) PrEP were asked whether they would switch to on-demand or LA PrEP options. Log binomial models were created to examine the association between willingness to start or switch to on-demand and LA PrEP with various sociodemographic and behavioral factors.

RESULTS

In the analytic sample (N=7760), among the participants who did not use any PrEP in the past 12 months (n=5108, 66%), 54% (n=2445) reported willingness to start at least 1 PrEP option and 41% (n=1845) of participants showed interest in starting multiple PrEP options. Overall, the highest willingness was reported for on-demand PrEP (n=2235, 44%), followed by DO PrEP (n=2174, 43%) and LA PrEP (n=1482, 29%). LA PrEP was ranked first among those interested in multiple options. Characteristics associated with ranking LA PrEP as a first option to start PrEP versus DO or on-demand PrEP were region of residence (residing in the West vs Northeast), report of sexually transmitted infection diagnosis in the past year, report of illicit drug use other than marijuana in the past year, and prior awareness of LA PrEP. Among current DO PrEP users (n=2379, 31%), 58% (n=1386) were willing to switch to on-demand or LA PrEP, and LA PrEP was ranked first among participants who were open to switching to both options. Willingness to switch to LA PrEP was higher among those who used illicit drugs other than marijuana in the past year, who heard of LA PrEP prior to the survey, and those who took 15 or less doses of oral PrEP in the last 30 days.

CONCLUSIONS

LA PrEP was the highest-ranked option among most MSM who were willing to try multiple options or switch from DO PrEP. These findings highlight that LA PrEP might fill coverage gaps among MSM who use illicit drugs, have had a recent sexually transmitted infection diagnosis, and have less than optimal DO PrEP adherence.

Perspectives and Factors Related to Pre-exposure Prophylaxis Use Among Young Men Who Have Sex With Men in the United States: A Mixed-Methods Study on the Role of History of PrEP Use

ABSTRACT

This study quantitatively examined factors related to young men who have sex with men (YMSM)'s decisions to use pre-exposure prophylaxis (PrEP) by their history of PrEP use and qualitatively elicited their perspectives on PrEP options. Higher proportions of YMSM who had never used (vs. ever used) PrEP considered the following factors as important in their decisions to use PrEP: (a) Returning to PrEP follow-up visits ( p = .02), (b) having to talk about sex/PrEP with providers ( p = .013), (c) people assuming they are infected with HIV ( p = .021), (d) family finding out about their PrEP use ( p = .001), and (e) friends finding out about their PrEP use ( p = .008). Through inductive content analysis, qualitative data showed that a higher proportion of YMSM who had never used PrEP (vs. ever used) expressed concerns about HIV stigma from nonaffirming health care providers and the potential risk of inadvertently revealing their LGBTQ+ identity to others, which were described as potential barriers to PrEP use. Overall, our findings suggest that future interventions may consider tailoring PrEP messaging to YMSM's history of PrEP use, which may ultimately increase PrEP uptake and adherence.

Identification of Determinants and Implementation Strategies to Increase Long-Acting Injectable PrEP for HIV Prevention Among Latino Men Who Have Sex with Men (MSM)

BACKGROUND

Latino men who have sex with men (LMSM) are disproportionally affected by HIV infections in the USA. The uptake rate of pre-exposure prophylaxis (PrEP) for HIV prevention has remained low among LMSM. Long-acting injectable PrEP (LAI-PrEP) may have the potential to improve structural, behavioral, and cognitive barriers to adherence. Given the potential benefits of LAI-PrEP and the limited data with this population, the aim of our study was to explore experiences and attitudes of LAI-PrEP among LMSM and identify implementation barriers compared to the standard oral presentation, align proposed implementation strategies, and propose outcomes to monitor and assess impact.

METHODS

In this qualitative study, guided by the Consolidated Framework for Implementation Research, we explored health care providers perspectives on facilitators and barriers to LAI-PrEP implementation strategies for LMSM. Interviews were recorded, transcribed, and analyzed using thematic content analysis.

RESULTS

Fear of immigration policies, ability to conceal PrEP medication, health insurance coverage, health information fatigue, lack of culturally adapted information, and provider's lack of knowledge were among the main barriers to LAI-PrEP. Most providers discussed the need for adapted and/or tailored training materials for and suggested designing marketing materials and specific clinical recommendations for LAI-PrEP.

CONCLUSION

In order to ensure an effective adaptation process that encompasses local and national goals of HIV prevention, future interventions should be designed in a way that incorporates culturally relevant information for LMSM. This study provides an implementation research logic model to guide future studies.

PrEP to Party: Exploring MSM's PrEP Use and Interest in the Context of Sexually Themed Events

Sexually themed events present a unique opportunity for scaling up pre-exposure prophylaxis (PrEP) to men who have sex with men (MSM). This study descriptively explored PrEP uptake among MSM who anticipated attending a week-long major South Florida sexually themed event and examined potential facilitators and barriers to PrEP engagement among potential attendees. Of the participating HIV-negative MSM (n = 96), 66.7% were currently taking PrEP. Prior attendance at sexually themed events was significantly associated with current PrEP engagement and almost 75% of HIV-negative MSM not on PrEP reported high interest in taking PrEP if offered for free at future events.

Changes in Glomerular Filtration Rate After Switching From Tenofovir Disoproxil Fumarate to Tenofovir Alafenamide Fumarate for Human Immunodeficiency Virus Preexposure Prophylaxis

Background

Tenofovir alafenamide fumarate (TAF) was promoted as a safer alternative to tenofovir disoproxil fumarate (TDF) for human immunodeficiency virus oral preexposure prophylaxis (PrEP). It is unknown if switching from TDF to TAF translates to improved renal function. We used electronic health record (EHR) data to assess changes in creatinine-estimated glomerular filtration rate (eGFR) after switching from TDF to TAF.

Methods

We conducted a retrospective cohort study using EHR data from Kaiser Permanente Southern California. We identified individuals who switched from TDF to TAF between October 2019 and May 2022 and used time-varying propensity score matching to identify controls who were on TDF ("nonswitchers"). We then used Bayesian longitudinal modeling to compare differences in eGFR between switching and nonswitching scenarios.

Results

Among 5246 eligible individuals, we included 118 TDF to TAF switchers and 114 nonswitchers. Compared to nonswitchers, switchers had older age of starting TDF but similar body weights at index date. A higher proportion of switchers were White, on Medicare or Medicaid, and had dyslipidemia at index date. Switching to TAF was associated with a higher eGFR compared to staying on TDF in 3-15 months post-switch, but the differences were not statistically significant (eg, month 9 difference: 1.27 [95% credible interval, -1.35 to 3.89]). While most of the estimated changes showed eGFR increase associated with switching, most were <2 eGFR units. Sensitivity analyses to address missingness or nonadherence showed similar results.

Conclusions

Switching from TDF to TAF for PrEP was associated with a nonsignificant increase in eGFR. Findings need to be confirmed using larger cohorts.

Prediction of Sex and the Potential Use of On-Demand PrEP Among Young Men Who Have Sex With Men in the United States

BACKGROUND

On-demand dosing of preexposure prophylaxis (PrEP) requires accurate prediction of sex; however, prediction abilities among young men who have sex with men (YMSM) have not been characterized.

SETTING

A nationally recruited prospective cohort of YMSM ages 16-24 years.

METHODS

We followed 120 YMSM for 8 weeks using digital daily surveys (DDSs) to measure engagement in and prediction of anal sex over 24 hours, along with condom use and other encounter-level circumstances. Our main outcome, an "unpredicted spontaneous encounter," was defined as an anal sex encounter that occurred without sufficient prior knowledge to (hypothetically) enable protective on-demand PrEP use according to dosing guidelines. We operationalized this outcome as an anal sex encounter for which a participant indicated: (1) on the prior day's DDS that there was a low likelihood of sex occurring in the subsequent 24 hours (unpredicted) and (2) on the current day's DDS that he knew ≤2 hours in advance that the encounter would occur (spontaneous).

RESULTS

Approximately one-third of all anal sex encounters during the study period were unpredicted and spontaneous and would not have been protected (hypothetically) by on-demand dosing. More than two-thirds of participants experienced such an encounter and almost three-quarters of all acts were condomless.

CONCLUSIONS

On-demand PrEP to prevent HIV acquisition may be challenging for many YMSM. Clinical and public health approaches that account for patients' predictive abilities alongside their dosing preferences may help to optimize selection of and adherence to PrEP dosing strategies.

Pre-exposure prophylaxis in the era of emerging methods for men who have sex with men in the USA: the HIV Prevention Cycle of Care model

Expanding on previous work, we present an HIV Prevention Cycle of Care model to facilitate understanding of the complexity of issues involved in pre-exposure prophylaxis implementation for gay, bisexual, and other men who have sex with men (MSM) in the USA, including individual, client-provider, and overarching issues such as health equity, stigma, and prevention nomenclature. The HIV prevention cycle of care applies to MSM who test negative for HIV. The Prevention Cycle of Care model includes seven steps: prevention knowledge, prevention self-awareness and preferences, prevention motivation, health-care access and cost, provider issues, adherence and persistence, and periodic reassessment and adjustment. HIV prevention is complex in an era of emerging multiple modalities, and more research is needed to successfully implement pre-exposure prophylaxis options over time and across diverse communities of MSM who are sexually active.

Factors Associated with Disclosure of Sexual Orientation Among Black Sexual Minority Men

Purpose: This study evaluated the characteristics associated with sexual orientation disclosure among HIV-negative Black sexual minority men (BSMM) in the greater Atlanta, Georgia area. Survey data were collected from 475 HIV-negative BSMM from 2017 to 2019 as part of a larger behavioral intervention study focused on stigma, prejudice, and HIV-testing uptake. Methods: Participants reported their levels of sexual orientation disclosure globally, to their community, and to their family. Data were analyzed using one-way analysis of variance and multinomial logistic regression to determine whether demographic, minority stress, substance use, and mental health were associated with sexual orientation disclosure globally, to community members, and to family members. Results: Findings revealed that participants with older age, bisexual identity, and higher levels of internalized homophobia had higher odds of global, community, and family sexual orientation nondisclosure. Furthermore, participants with higher levels of resilience had lower odds of partial sexual orientation disclosure compared with their fully disclosed counterparts. Conclusions: These findings reveal variations associated with sexual orientation disclosure across varying contexts among HIV-negative BSMM, particularly among family member disclosure.