Low incidence of HIV infection and decreasing incidence of sexually transmitted infections among PrEP users in 2020 in Germany

Four-Year Experience of HIV Pre-exposure Prophylaxis (PrEP) from an Italian Multicentre Cohort: Incidence of Sexually Transmitted Infections and Renal Toxicity

Pre-Exposure Prophylaxis (PrEP) with Tenofovir-Disoproxil/Emtricitabine (TDF/FTC) is efficacious for HIV prevention. PrEP users might be more exposed to other sexually transmitted infections (STIs) and toxicities. Our aim was to evaluate the trend of STIs and toxicities in an Italian PrEP cohort. A retrospective multicentre cohort study (Modena, Genova and Padova) including TDF/FTC-PrEP users followed from Jan-2019 to Jul-2022. Data collection included demographics, toxicities and STIs detection: N.gonorrhoeae (NG), C.trachomatis (CT), M.genitalium (MG), T.vaginalis (TV), T.pallidum (TP), HAV, HBV and HCV. Two-hundred-forty-four persons included: 97% males; median age 39 years (IQR 33-47). A nearly incremental trend was recorded in NG and MG incidences, especially after 2020: from 5.7% to 2.3% in 2020, to 10.3% and 6.5% in 2021 and to 9.6% and 4.8% in the first 7 months of 2022. CT and TP presented a variable trend, while only two TV diagnoses were done. The test for trend for ordered groups across years showed no statistical significance for all the STIs and the annual proportions of subjects with multiple STIs varied. At logistic regression, only history of STIs was associated to risk of new STIs. Twenty cases of nephrotoxicity were recorded, leading to PrEP interruption in 1 case only. Concluding, STIs incidence and nephrotoxicity in our cohort were consistent with other data from literature. In 2020 we observed a lower STIs incidence, probably as consequence of COVID-19 restrictions. An incremental trend could be hypothesized regarding NG, MG and CT incidence. Thus, we suggest STIs monitoring, prophylaxis and treatment to contain their spread among PrEP users.

Outcomes of a policy to prioritize populations with expected healthcare barriers for subsidized preexposure prophylaxis care in Amsterdam, the Netherlands

OBJECTIVE

The Dutch HIV preexposure prophylaxis (PrEP) pilot provided subsidized PrEP care to maximum 2900 individuals at a time in Amsterdam. Populations with expected barriers to accessing PrEP elsewhere were prioritized for program inclusion. We evaluated their prior sexual health service engagement and PrEP need.

DESIGN

Cross-sectional analysis using enrolment data.

METHODS

We included individuals ever enrolled in the PrEP program at the Center for Sexual Health (CSH) Amsterdam between 2019 and 2023. We calculated the proportion belonging to higher-priority groups (i.e., <25 years old, transgender, sex worker, uninsured or migrant). We defined classes of sexual health service engagement in the 12 months preceding enrolment using latent class analysis (LCA). We compared engagement classes, sexual behavior and positivity of HIV and sexually transmitted infections (STI) between higher- and lower-priority groups.

RESULTS

2004/4075 (49%) individuals enrolled belonged to higher-priority groups. LCA showed three classes of prior engagement: "newly engaged" (14%, n  = 551) were new to the CSH-Amsterdam; "PrEP initiators" (40%, n  = 1642) previously visited the CSH-Amsterdam but had not used PrEP; "PrEP experienced" individuals (46%, n  = 1882) previously accessed PrEP. Higher-priority groups were more often "newly engaged" or "PrEP-initiators" than "PrEP-experienced". Higher-priority groups less often had condomless anal sex with casual partners or chemsex in the prior 6 months. Positivity of bacterial STI was similar between higher-priority ( n  = 300/2004, 15.0%) and lower-priority ( n  = 315/2071, 15.2%) groups. 13/14 HIV diagnoses at enrolment were in higher-priority groups.

CONCLUSION

Higher-priority populations had less often previously used sexual health services and accounted for most new HIV diagnoses at enrolment. Engaging these populations in sexual healthcare, including PrEP, should be stressed.

Factors associated with bacterial sexually transmitted infection screening uptake and diagnosis among men who have sex with men in France

BACKGROUND

The prevalence of syphilis, Chlamydia trachomatis (CT), and Neisseria gonorrhoeae (NG) in men who have sex with men (MSM) is very high. As these bacterial sexually transmitted infections (bSTIs) are frequently asymptomatic, they are often undiagnosed and therefore untreated. We aimed to characterize the profile of MSM who reported bSTI screening and diagnosis in the previous 12 months, and to identify the factors associated with a diagnosis of a bSTI among MSM in France.

METHODS

We used data from Enquête Rapport au Sexe (ERAS), a large French national anonymous cross-sectional online survey among MSM conducted from 26 February to 11 April 2021. After comparing MSM screened and diagnosed in the previous year with those who were not, a binary logistic regression model was used to compare MSM diagnosed with at least one bSTI with those who were not.

RESULTS

Of the 13 300 survey respondents, 6 263 (47.1%) MSM reported screening for at least one bSTI in the previous 12 months. Of these, 1 060 (16.9%) were diagnosed for at least one bSTI during their most recent screening. Specifically, 446 (7.1%) MSM were diagnosed with NG, 427 (6.8%) with CT, and 402 (6.4%) for syphilis. The following self-reported factors were associated with a greater likelihood of bSTI diagnosis: younger age, a lower educational level, frequenting MSM meeting places, not currently using pre-exposure prophylaxis (PrEP) but willing to take preventive treatment against bSTIs (reference group: not using PrEP and not willing to take preventive treatment against bSTIs), low health literacy, more than one sexual male partner, practicing chemsex, and condomless anal intercourse with casual male partners (the latter three factors concerning the previous six months).

CONCLUSIONS

A large proportion of MSM were diagnosed for at least one bSTI. This result provides an insight into bSTI screening uptake and diagnosis among MSM in France, and could inform future decisions about how to plan effective bSTI screening and diagnosis programs for this population.

Incidence of sexually transmitted infections and screening models among pre-exposure prophylaxis users

INTRODUCTION

There is discussion about the frequency of STI screening among pre-exposure prophylaxis (PrEP) users. The aim of this study was to analyse the incidence of STIs and to evaluate different screening models in order to optimise the follow-up.

METHODOLOGY

A prospective study was conducted between 2017 and 2023, including 138 PrEP users in a STI clinic. Participants were tested for STIs every three months. Unscheduled visits were performed for those with STI-related symptoms or for people who were notified for an STI by a sexual partner. We performed a survival analysis of repeated events, estimating the cumulative incidence (CI) and incidence rate (IR).

RESULTS

The overall CI by quarterly screening was 8.3 (95% CI: 7.6-9.1) infections per person over six years, with a decreasing trend. The most frequently diagnosed pathogen was Neisseria gonorrhoeae, with a IR of 0.76 (95% CI: 0.68-0.84). If the frequency of screening is reduced to every six months, the IR of STIs is reduced by (95% CI: 0.5-0.66) infections per user per year, and at 12 months by 0.82 (95% CI: 0.73-0.89). In the case of no pharyngeal or urethral screening, IR is reduced by 0.37 (95% CI: 0.32-0.42) infections per person per year and in those over 35 years of age by 0.33 (95% CI: 0.25-0.4). Eliminating unscheduled visits, the reduction in IR is 0.33 (95% CI: 0.24-0.42).

CONCLUSIONS

The incidence of STIs among PrEP users is high, especially in the rectum, but it does not increase over time. STI screening could be optimised reducing the frequency of pharyngeal and urethral testing, particularly in those over 35 years of age. It is essential to redistribute health resources for unscheduled visits, which have been shown to be the most cost-effective screening.

Incidence and risk factors associated with acquired syphilis in HIV pre-exposure prophylaxis users

BACKGROUND

Acquired syphilis continues to affect millions of people around the world. It is crucial to study it in the context of HIV Pre-Exposure Prophylaxis (PrEP) to achieve the goals set out in the 2030 Agenda since the literature suggests increased risk behaviors for sexually transmitted infections. This study aimed to investigate the incidence and factors associated with acquired syphilis among PrEP users.

MATERIALS AND METHODS

This retrospective cohort included data on PrEP users from all over Brazil from 2018 to 2020, retrieved from the national antiretroviral logistics system. We calculated the proportion of syphilis before PrEP, the incidence during the user's follow-up, reinfections, and their possible associated factors. We conducted descriptive, bivariate, and multivariate analysis, estimating the crude Relative Risk, adjusted Odds Ratio (aOR), and their respective confidence intervals (95%CI).

RESULTS

Most of the 34,000 individuals who started PrEP were male (89.0%), white (53.7%), self-identified as male (85.2%), homosexual, gay, or lesbian (72.2%), and had 12 schooling years or more (67.8%). Of these, 8.3% had syphilis in the six months before starting PrEP, and 4% had it in the first 30 days of using the prophylaxis. We identified a loss-to-follow-up rate of 41.7%, although the loss and the cohort shared similar characteristics. The proportion of missed syphilis tests was high: 33.4% in the 30 days and 38.8% in the follow-up period. In the 19,820 individuals effectively monitored, the incidence of acquired syphilis was 19.1 cases per 100 person-years, and 1.9% of users had reinfection. The rate of missed syphilis tests at the 30-day follow-up was 33.4%, and the total follow-up test period was 38.8%. The multivariate analysis identified female gender (aOR 0.3; 95%CI 0.2-0.5), being white or Black (aOR 0.9; 95%CI 0.7-0.9 and aOR 0.7; 95%CI 0.7-0.99, respectively) as protective factors for syphilis. Being homosexual, gay, lesbian (aOR 2.7; 95%CI 2.0-3.7), or having a history of syphilis in the six months before PrEP (aOR 2.2; 95%CI 1.9-2.5) were risk factors for syphilis during PrEP use. Behaviors related to the risk of syphilis included accepting something in exchange for sex (aOR 1.6; 95%CI 1.3-1.9), irregular condom use (use in less than half of sexual intercourse sessions; aOR 1.7; 95%CI 1.53-2.1) and recreational drug use (poppers; aOR 1.5; 95%CI 1.53-2.1).

CONCLUSION

Syphilis in the context of PrEP has high rates and is associated with sociodemographic and behavioral factors. We recommend additional studies targeting prevention in this population to curb these figures.

Dynamics of HIV PrEP use and coverage during and after COVID-19 in Germany

BACKGROUND

Pre-exposure prophylaxis (PrEP) with oral emtricitabine/tenofovir disoproxil (FTC/TDF) proved highly efficient in preventing HIV. Since 09/2019, FTC/TDF-PrEP is covered by health insurances in Germany, if prescribed by licensed specialists. However, methods to longitudinally monitor progress in PrEP implementation in Germany are lacking.

METHODS

Utilizing anonymous FTC/TDF prescription data from 2017-2021, we developed a mathematical model to disentangle HIV-treatment from PrEP prescriptions, as well as to translate PrEP prescriptions into number of PrEP users. We used the model to estimate past- and future PrEP uptake dynamics, to predict coverage of PrEP needs and to quantify the impact of COVID-19 on PrEP uptake on a national and regional level.

RESULTS

We identified significant (p<0.01) decelerating effects of the first- and second COVID-19-lockdown on PrEP uptake in 04/2020 and 12/2020. We estimated 26,159 (CI: 25,751-26,571) PrEP users by 12/2021, corresponding to 33% PrEP coverage of people in need. We projected 64,794 (CI: 62,956-66,557) PrEP users by 12/2030, corresponding to 81% PrEP coverage. We identified profound regional differences, with high PrEP coverage and uptake in metropoles and low coverage in more rural regions.

CONCLUSIONS

Our approach presents a comprehensive solution to monitor and forecast PrEP implementation from anonymous data and highlighted that the COVID-19 pandemic significantly decelerated PrEP uptake in Germany. Moreover, slow PrEP uptake in rural areas indicate that structural barriers in PrEP care, education or information exist that may hamper the goal of ending the AIDS epidemic by 2030.

Insights into invasive fungal infection diagnostic and treatment capacities in tertiary care centres of Germany

Introduction

In Germany, the growing incidence of invasive fungal infections (IFIs) is a significant health concern, particularly impacting individuals with compromised immune systems due to factors like increasing transplant recipients, an ageing population, and heightened use of immunosuppressive medications. Diagnosing IFI remains challenging, and the integration of biomarker assays into clinical practice is difficult. Antifungal resistance, exemplified by pan-antifungal-resistant Candida auris cases, adds complexity to treatment. This study aims to provide a concise overview of the diagnostic and treatment landscape for IFI in Germany, identifying areas for improvement and paving the way for targeted interventions.

Methods

Data were collected using an online electronic case report form from October 2021 to February 2023. The survey included questions about institutional practices related to fungal infection diagnosis and treatment, with invitations extended to researchers nationwide.

Results

The study surveyed 58 hospitals across Germany. Notably, 77.6% managed high-risk patients for IFI. While 86% had onsite microbiology labs, a significant difference was noted for high-risk patients (93% in specialized hospitals versus 62% in others). Microscopy services had 96% coverage, while overall access to culture was 96%. Antigen tests had 96% coverage, and antibody access was reported at 98%. PCR testing was available at 98%. Imaging access showed no significant access differences. Variability existed in amphotericin B formulations based on patient profiles. Therapeutic drug monitoring was more common in high-risk patient institutions (89.5% versus 50.0%). All analysed institutions reported access to surgery (100%).

Conclusions

Addressing identified disparities in diagnostic and therapeutic resources for IFI is crucial to improving patient outcomes. The study calls for ongoing research and collaboration to optimize strategies for the prevention and treatment of IFI, emphasizing the importance of equitable access to resources, especially in high-risk patient populations.

Increasing hepatitis B vaccination coverage and decreasing hepatitis B co-infection prevalence among people with HIV-1 in Germany, 1996-2019. Results from a cohort study primarily in men who have sex with men

OBJECTIVES

Viral hepatitis co-infection among people living with HIV is known to accelerate the progression of liver disease and AIDS. An increased prevalence and incidence of hepatitis B virus (HBV) infection among people living with HIV demands continuous monitoring to adapt targeted prevention strategies to reach the global goals of eliminating viral hepatitis as a public health threat.

METHODS

We determined the prevalence and incidence of HBV for the years 1996-2019 from yearly blood sample testing and questionnaire reports among people living with HIV belonging to a nationwide, multicentre observational, prospective cohort study.

RESULTS

Among this study population of 3479 participants, the majority (87%) indicated that being men who have sex with men (MSM) was their likely HIV transmission route; 51% were recruited from Berlin. HBV prevalence for acute/chronic and resolved infections decreased from 4.1% and 45% in 1996-1999 to 1.3% and 16% in 2019, respectively. Simultaneously, participants with a serological status indicating HBV vaccination increased from 25% in 1996-1999 to 69% in 2019. Among vaccinated participants with relevant information (n = 1135), 38% received their first HBV vaccination after HIV infection. The HBV incidence rate in 565 eligible participants decreased from 6.9/100 person-years in 2004-2007 to 0.45/100 person-years in 2015.

CONCLUSION

Increasing vaccination coverage because of a general HBV vaccination recommendation and catch-up vaccination efforts among risk groups decreased HBV infection prevalence over time among this study population of people living with HIV, primarily MSM and from Berlin. Despite this success, the prevalence and incidence of HBV remains higher than in the general population in Germany. This emphasizes the need for continued HBV prevention by promoting HBV vaccination and HBV screening at regular intervals based on the individual risk behaviour.

Statutory health insurance-covered pre-exposure prophylaxis in Germany: changing trends in nationwide tenofovir disoproxil/emtricitabine prescriptions during the COVID-19 pandemic

Background: In 2019, Germany introduced a law to reimburse high-incidence populations for pre-exposure prophylaxis (PrEP), prescribed as tenofovir-disoproxil/emtricitabine (TDF/FTC), via statutory health insurance (SHI). We studied changes in TDF/FTC-prescriptions after the implementation of this law and during the COVID-19 pandemic. Methods: We performed an interrupted time series analysis with monthly prescriptions per defined time period as the outcome. We considered the introduction of SHI-covered PrEP (09/2019) as an interruption, and four COVID-19 waves and two national lockdowns (2020-2021) as explanatory variables. We extrapolated prescriptions had the lockdowns not occurred, and compared this to the actual prescriptions. We performed sub-analyses based on stratification by five federal states with the highest proportion of PrEP users. We assessed the models' goodness-of-fit based on the adjusted R-squared using RStudio. Results: The best fitting model included SHI-covered PrEP and the first COVID-19 lockdown (04/2020). The decrease in prescriptions during the first lockdown was significant nationally, and in the five federal states for single-month prescriptions. The first lockdown resulted in reductions of 57.7% (95% prediction interval (PI): 23.0%-92.4%) for single-month prescriptions, while 17.4% (95% PI: 0.28%-34.5%) nationally, and 13.9% (95% PI: -3.67%-31.5%) for 3-month prescriptions. Conclusion: Introduction of SHI-covered PrEP resulted in a doubling of TDF/FTC-prescriptions nationwide in the first month alone. A drop in prescriptions was most apparent after the first lockdown, and particularly affected PrEP initiations, possibly due to reduced healthcare access and behavioural changes. Ongoing monitoring of TDF/FTC-prescriptions is needed to safeguard access to preventative care such as PrEP and particularly PrEP initiation during public health crises like COVID-19.

[Evaluating the introduction of HIV pre-exposure prophylaxis as a benefit of statutory health insurance (EvE-PrEP) : Highly effective protection against HIV without an increase in sexually transmitted infections]

BACKGROUND

We investigated the impact of HIV pre-exposure prophylaxis (PrEP) as a new service of the statutory health insurance (SHI) on the incidence of HIV and other sexually transmitted infections (STIs) in Germany. In addition, PrEP needs and access barriers were analyzed.

METHODS

The following data were evaluated as part of the evaluation project: HIV and syphilis notification data and extended surveillance by the Robert Koch Institute (RKI), pharmacy prescription data, SHI routine data, PrEP use in HIV-specialty care centers, Checkpoint, the BRAHMS and PrApp studies, as well as a community board.

RESULTS

The majority of PrEP users were male (98-99%), primarily aged between 25-45 years, and predominantly of German nationality or origin (67-82%). The majority were men who have sex with men (99%). With regard to HIV infections, PrEP proved to be highly effective. There were only isolated cases of HIV infections (HIV incidence rate 0.08/100 person years); in most cases the suspected reason was low adherence. The incidences of chlamydia, gonorrhea, and syphilis did not increase but remained almost the same or even decreased. A need for information on PrEP for people in trans*/non-binary communities, sex workers, migrants, and drug users emerged. Needs-based services for target groups at increased risk of HIV are necessary.

DISCUSSION

PrEP proved to be a very effective HIV prevention method. The partly feared indirect negative influences on STI rates were not confirmed in this study. Due to the temporal overlap with the containment measures during the COVID-19 pandemic, a longer observation period would be desirable for a conclusive assessment.

The future of HIV pre-exposure prophylaxis adherence: reducing barriers and increasing opportunities

The effectiveness of HIV pre-exposure prophylaxis (PrEP) hinges on adherence, which has been restricted by multifaceted barriers. Uptake of PrEP has been impeded by poor access resulting from high costs, provider uncertainty, discrimination, stigma, and poor understanding within the health-care community and the public of who can benefit from PrEP. Other important barriers to adherence and persistence over time relate to individuals (eg, depression) and their community, partners, and family (eg, poor support), and their effects vary substantially with each person, population, and setting. Despite these challenges, key opportunities for improving PrEP adherence exist, including novel delivery systems, tailored individual interventions, mobile health and digital health interventions, and long-acting formulations. Objective monitoring strategies will help to improve adherence interventions and alignment of PrEP use with the need for HIV prevention (ie, prevention-effective adherence). The future of PrEP adherence lies in person-centred approaches to service delivery that meet the needs of individuals while creating supportive environments and facilitating health-care access and delivery.