Pre-exposure prophylaxis to prevent HIV infection: current status, future opportunities and challenges

Challenges of integrating HIV prevention and treatment in China's border mountain regions: a grounded theory study

BACKGROUND

HIV remains a critical global public health challenge, with 39 million people living with HIV as of 2022 and over 40.4 million lives lost to the epidemic. In China, the burden is similarly significant, with over 1.33 million HIV cases reported as of 2024. The challenges are particularly acute in western regions like Yunnan Province, which face resource limitations, socio-demographic disparities, and a high prevalence of HIV among ethnic minorities.

OBJECTIVES

This study examines the challenges in HIV diagnosis, treatment, and prevention across various institutions in Yunnan Province, including government bodies, hospitals, disease control centers, and primary healthcare institutions. This study aims to identify key challenges in integrating HIV prevention and treatment in China's border mountainous regions to inform targeted strategies for ethnic minority and impoverished communities.

METHODS

This study adopts a grounded theory approach to explore the systemic, socio-demographic, and cultural barriers impeding the integration of HIV prevention and treatment in M City, a resource-constrained border region in Yunnan Province. From May 2024 to January 2025, a comprehensive review of regional HIV prevention and control literature, alongside relevant World Health Organization (WHO) guidelines, was undertaken to contextualize the research. To capture multi-level insights, semi-structured interviews were conducted between August and December 2024 with 23 purposively selected participants, including individuals living with HIV, village doctors, healthcare providers, and local policymakers. The qualitative data were analyzed through a rigorous three-stage coding process-comprising open coding, axial coding, and selective coding-consistent with grounded theory methodology, to systematically construct and refine conceptual categories underpinning the integration challenges.

RESULTS

This study included 23 participants from Yunnan Province. Through three-level coding, three major themes were identified. In HIV prevention, key challenges included patients' inattention to prevention, difficulties for village doctors in home-based screening, and poor enthusiasm for prevention in hospitals. In HIV treatment, difficulties included limited government support, variability in patients' conditions, poor medication adherence, poor quality of village clinic services, challenges for healthcare staff, uncertain effects of Chinese and Western medicine synergy, and unsmooth referral mechanisms. In integration of HIV prevention and treatment, major issues involved low referral rates, loose inter-agency cooperation, and systemic barriers to integration.

CONCLUSION

This study highlights the complex challenges in HIV prevention, treatment, and integration in economically underdeveloped regions, emphasizing the need for improved patient awareness, healthcare system efficiency, and cross-institutional collaboration. Future research should focus on multi-center, longitudinal studies and real-world implementation to refine and scale the integration model for sustainable HIV care in these regions.

Cannabis use is associated with a lower likelihood of presence of HIV drug resistance mutations in a retrospective cohort of adults with HIV

Objectives

A significant clinical concern in the era of Pre-Exposure Prophylaxis (PrEP) is the increased incidence of HIV Anti-Retroviral Drug Resistance Mutations (ARV-DRM). Previous research has indicated that there is an association between substance use and failed viral suppression, which can lead to ARV-DRM. The goal of this retrospective study was to investigate whether substance use as determined by at least one positive urinalysis screen is associated with increased/decreased odds of having a ARV-DRM.

Methods

This study used firth logistic regression analyses of data retrieved from the National NeuroAIDS Tissue Consortium Data Coordinating Center to examine the relationship between substance use and ARV-DRM. The dataset analyzed 614 participants with the following criteria: HIV+ status, at least one paired plasma and cerebrospinal fluid (CSF) viral load measurement, at least one urinalysis of substance use, at least 18 years of age, and analysis of DRM in CSF/Plasma.

Results

Cannabis use was a significant predictor of ARV-DRM and was associated with a lower odds of having ARV-DRM (odds ratio=0.189), after accounting for demographic variables and the interaction between polysubstance use and cannabis use. A significant negative relationship was observed between a cannabis positive test and high viremia (>1,000 copies/mL) but not between a cannabis positive test and CSF Escape (viral load CSF>viral load plasma).

Conclusions

The above results may suggest an immunomodulatory role for cannabis that impacts the propensity for ARV-DRM. These findings could incentivize future research to further investigate effects of cannabis use on the development of HIV ARV-DRM.

Updates on HIV Pre-exposure Prophylaxis in Latin America: Available Drugs and Implementation Status

Latin America has reported a 9% increase in new HIV infections from 2010 to 2023. Pre-exposure prophylaxis (PrEP) is a crucial biomedical intervention for preventing HIV transmission. Currently, several antiretroviral drugs, in various forms of administration, have demonstrated high efficacy and effectiveness to protect against HIV. Among the oral drugs, we have emtricitabine/tenofovir and emtricitabine/tenofovir alafenamide, while alternative options include the dapivirine vaginal ring, injectable drugs such as Cabotegravir, and the most recently studied Lenacapavir. Despite their high efficacy and effectiveness, implementing PrEP in Latin America has been challenging throughout the region. Although some countries such as Brazil, Mexico, and Colombia have shown progress in increasing the number of users, there is a significant gap between these countries and others where PrEP access remains limited or non-existent. Barriers such as lack of awareness, inadequate funding, political instability, and outdated policies contribute to disparities in access, leaving many populations at high risk of HIV infection without this preventative measure. Innovative strategies need to be implemented to address and monitor policies that ensure access for all at-risk populations.

Exploring pre-exposure prophylaxis (PrEP) modality preferences among black cisgender women attending family planning clinics in Chicago via a cross-sectional mixed-methods study

Background

Despite pre-exposure prophylaxis (PrEP) demonstrated effectiveness, black cisgender women continue to be at an elevated risk for HIV acquisition and uptake of daily oral PrEP is low in this population in the USA. As advancements in PrEP delivery options continue, it is important to understand women's acceptability of these additional options, specifically black cisgender women, in order to inform uptake and adherence among this population at increased need of HIV prevention options.

Setting

A cross-sectional survey among black cisgender women ages 13-45 (inclusive) attending women's health clinics in Chicago, Illinois, USA, prior to the approval of cabotegravir long-acting injectable.

Methods

Descriptive statistics were used to describe the sample and bivariate analysis was used to detect differences between categorical and outcome variables using χ2 test. Responses to open-ended questions were thematically coded to explore black cisgender women's attitudes and preferences between the three methods of PrEP delivery including vaginal ring, long-acting injectable and a combined method that would prevent both pregnancy and HIV.

Results

In total, 211 cisgender women and adolescents responded to the survey. Both injections and combination pills were popular among participants, with 64.5% and 67.3% expressing interest in these forms of PrEP, respectively. The least popular method was the vaginal ring option, with 75.4% of respondents indicating that they would not consider using this modality. Overall, responses were not statistically different between the two surveys administered (χ2 p values for injection PrEP method 0.66, combination PrEP method 0.93 and ring PrEP method 0.66) suggesting that the popularity of each method was not dependent on clinic location or the age of participants.

Conclusion

This research provides important insights into the preferences and attitudes of different PrEP modalities among black cisgender women. As different modalities continue to be approved for use among cisgender women, more research is needed to investigate the acceptability and preferences of these different modalities in order to improve uptake and adherence among this population.

HIV status disclosure to male sexual partners and predictors among young women living with HIV in rural Uganda: a cross-sectional study

Background

In 2020 in sub-Saharan Africa, 25% of new human immunodeficiency virus (HIV) infections occurred among young women (15-24 years). In Uganda, the HIV prevalence is three times higher among young women at 2.9% compared to 0.8% among their male counterparts. HIV status disclosure is a gateway to preventive services.

Objectives

We set out to estimate the prevalence of HIV status disclosure to current male partners, and the predictors among the adolescent girls and young women living with HIV (AGYWLHIV) in a semi-rural northern Uganda.

Design

In a cross-sectional study design, a consecutive sample of the AGYWLHIV was recruited from six antiretroviral therapy clinics between November 2022 and April 2023.

Methods

Participants were administered an interviewer-guided questionnaire. They were asked whether they have ever disclosed their HIV status to their current male partners. They were also asked about their socio-demographics, sexual and reproductive health profiles, knowledge and perceptions of dual protection, and safer conception methods for AGYWLHIV. Percentages to estimate prevalence, Chi-square tests to assess associations, simple and multivariate modified Poisson regression to identify predictors at p < 0.05 and 95% confidence intervals (CI) were considered.

Results

Overall, 423 participants with a median age of 22 (IQR 4) years participated in the study. The prevalence of HIV status disclosure to the current male partners was found at 73.3% (95% CI 69.0-77.5). The predictors for HIV status disclosure were found to include the women's knowledge of their HIV status (APR 1.1 (95% CI 1.0-1.2), p 0.032), knowledge of their male partner's HIV status (APR 0.8 (95% CI 0.7-0.9), p 0.003), and the male partners' disclosure of their HIV status to the women (APR 0.7 (95% CI 0.5-0.9), p <0.016).

Conclusion

About three-fourths of the AGYWLHIV in semi-rural northern Uganda disclosed their HIV status to their male partners. The predictors of disclosure included the women's knowledge of their HIV status, knowledge of their male partner's HIV status, and the male partner's reciprocal disclosure of their HIV status. To enhance disclosure rates, post-test, and disclosure counseling for both individuals and couples is recommended as part of the routine HIV testing, treatment, and care programs.

A call for change: addressing the implementation strategy using pre exposure Prophylaxis for combating the escalating HIV crisis in Zanzibar's key populations

The Integrated Bio-Behavioural Surveillance Survey of 2022-2023 among key populations report from Zanzibar has been released. The prevalence of HIV is estimated to be 21.1%, 11.4%, and 9.3% among Female Sex Workers, Men who have Sex with Men, and People Who Injected Drugs, respectively. This has prompted a closer examination of the factors contributing to this trend, with a particular focus on the low coverage of Pre-Exposure Prophylaxis in these key populations. The current prevalence reported in December 2023 signals a critical turning point that necessitates a reevaluation of the barriers and facilitators of Pre Exposure Prophylaxis intervention to combat the epidemic. It is imperative to acknowledge the severity of the situation and take decisive action to prevent further spread of the virus in the Isles.

Female-controlled dual protection methods: Prevalence, predictors, experiences and perceptions among young women living with HIV in northern Uganda-A mixed-method study protocol

STUDY BACKGROUND

The use of dual protection methods among young women living with HIV (YWLHIV) aged 15-24 years in sub-Saharan Africa (SSA) is poorly researched despite the double risk of unintended pregnancy and HIV. Even more scanty is literature on the use of female-controlled dual protection methods. We propose to determine the female-controlled dual protection prevalence, and the predictors among YWLHIV in northern Uganda. The study will also explore the YWLHIV's experiences and perceptions regarding the female-controlled dual protection methods.

MATERIALS AND METHODS

This study will employ a mixed-methods design. The study area will be Lira district and Lira city located in northern Uganda. The setting for recruitment of participants will be the public health facility-based anti-retroviral therapy (ART) clinics. These ART clinics serves a total of about 1,771 YWLHIV. A sample of 425 YWLHIV will be selected by stratified random sampling from the ART clinic registers. The three strata of interest will be the YWLHIV attending the ART clinic at referral hospitals, health centers level IV (primary healthcare centers), and health centers level III (dispensaries). The primary outcome will be the use of the female-controlled dual protection methods. The outcome will be measured by asking the YWLHIV 'what methods under their control as YWLHIV do they use to protect against both unintended pregnancy and HIV during sexual intercourse with their male partners.' The questionnaire also has measures for the unintended pregnancy, HIV status, and the potential predictors. Qualitative component of the study will be in-depth interviews of the participants about their experiences and perceptions regarding the female-controlled dual protection methods. Data collection was still ongoing at the time of first submission of this study protocol to the journal (14th March 2023). The Statistical Package for Social Sciences (SPSS) version 23.0 will be used for the statistical analyses. Descriptive statistics, bivariate and multivariate regression analyses will be used to establish the prevalence, associated factors and the predictors of the outcome respectively. The statistical significance level of 5% and 95% confidence interval will be considered. In-depth interviews will be manually analyzed using a thematic analysis approach for codes, themes, and categories.

Oral Pre-Exposure Prophylaxis (PrEP) Awareness and Acceptability Among Persons who Inject Drugs (PWID) in Kenya: A Qualitative Investigation

Background

People who inject drugs (PWID) are disproportionately affected by HIV despite the availability of multiple efficacious biomedical prevention interventions including oral pre-exposure prophylaxis (PrEP). Little is known about the knowledge, acceptability, and uptake of oral PrEP among this population in Kenya. To inform the development of oral PrEP uptake optimization interventions for PWID in Kenya, we conducted a qualitative assessment to establish oral PrEP awareness and willingness to take PrEP by this group in Nairobi City.

Methodology

Guided by the Capability, Opportunity, Motivation, and Behaviour (COM-B) model of health behavior change, we conducted 8 focus group discussions (FGDs) among randomly constituted samples of PWID in four harm reduction drop-in centers (DICs) in Nairobi in January 2022. The domains explored were: perceived risks (behaviour), oral PrEP awareness and knowledge (capability), motivation to use oral PrEP (behaviour), and perceptions on community uptake (motivation and opportunity). Completed FGD transcripts were uploaded to Atlas.ti version 9 and thematic analysis was conducted through an iterative process of review and discussion by two coders.

Findings

There was a low level of oral PrEP awareness with only 4 of the 46 PWID having heard of PrEP; only 3 out of 46 participants had ever used oral PrEP and 2 out of 3 were no longer using it, indicating a low capacity to make decisions on oral PrEP. Most study participants were aware of the risk posed by unsafe drug injection and expressed willingness to take oral PrEP. Nearly all participants demonstrated low understanding of the role oral PrEP plays in complementing condoms in HIV prevention, presenting an opportunity for awareness creation. While the PWID were eager to learn more about oral PrEP, they favored DICs as places where they would like to obtain information and oral PrEP if they chose to use it, identifying an opportunity for oral PrEP programming interventions.

Conclusion

Creation of oral PrEP awareness among PWID in Kenya is likely to improve uptake since the PWID are receptive. Oral PrEP should be offered as part of combination prevention approaches, and effective messaging through DICs, integrated outreaches, and social networks are recommended to mitigate displacement of other prevention and harm reduction practices by this population.

Trial Registration

ClinicalTrials.gov Protocol Record STUDY0001370.

Using a Structural-Ecological Model to Facilitate Adoption of Preexposure Prophylaxis Among Latinx Sexual Minority Men: A Systematic Literature Review

Research has consistently shown that individual, interpersonal, community and structural factors influence the degree to which individuals' access and utilize health care services, and these factors may play a role in explaining racial and ethnic differences in health care outcomes. Differences in HIV prevalence and treatment between Latinx adults and white adults in the U.S. must be considered in the context of these factors. However, much of the existing research connecting these factors and HIV/AIDS outcomes in Latinxs remains disparate, limited in scope, and has yet not been applied to the use of biomedical HIV preventions. The following systematic literature review examined research related to PrEP in Latinx sexual minority men (SMM) to build a structural-ecological framework of the existing research, while identifying gaps in the literature and areas for future research. We searched two electronic databases using a systematic review protocol, screened 71 unique records, and identified 23 articles analyzing data from Latinx SMM and intended and/or actual PrEP-use in the United States. Based on the present review, disparities in PrEP uptake by Latinx SMM could be explained, in part, by examining how all levels of the structural-ecological framework uniquely contributes to how Latinx SMM engage with HIV prevention measures and come to understand PrEP. It is clear from the existing literature base that some of the most prominent barriers deterring Latinx SMM from seeking PrEP services are the lack of information surrounding PrEP and HIV/gay stigmas. However, higher order structural-level risks can facilitate or reduce access to PrEP. We propose a structural-ecological model to help visualize multi-level domains of unique stressors that limit the implementation of PrEP among Latinxs. At this stage, the available literature provides little guidance beyond suggesting that culturally adapted interventions can be effective in this population. The model developed here provides that needed specificity regarding targeted interventions that will fit the needs of this population.

Recent Advances in Surface Plasmon Resonance Sensors for Sensitive Optical Detection of Pathogens

The advancement of science and technology has led to the recent development of highly sensitive pathogen biosensing techniques. The effective treatment of pathogen infections requires sensing technologies to not only be sensitive but also render results in real-time. This review thus summarises the recent advances in optical surface plasmon resonance (SPR) sensor technology, which possesses the aforementioned advantages. Specifically, this technology allows for the detection of specific pathogens by applying nano-sized materials. This review focuses on various nanomaterials that are used to ensure the performance and high selectivity of SPR sensors. This review will undoubtedly accelerate the development of optical biosensing technology, thus allowing for real-time diagnosis and the timely delivery of appropriate treatments as well as preventing the spread of highly contagious pathogens.

Using an Intersectional Framework to Understand the Challenges of Adopting Pre-exposure Prophylaxis (PrEP) Among Young Adult Black Women

Introduction

There is limited functional knowledge and utilization of pre-exposure prophylaxis (PrEP) among young adult Black cisgender women (YBW).

Methods

We conducted four focus groups with YBW using an intersectional framework to explore multiple levels of factors that impede YBW awareness, interest, and utilization of PrEP in conjunction with their sexual and reproductive healthcare needs.

Results

Influences at the cultural-environmental level included a lack of information and resources to access to PrEP and medical mistrust in the healthcare system. At the social normative level, influences included attitudes towards the long-term effects on sexual and reproductive health and self-efficacy to follow the PrEP regimen. At the proximal intrapersonal level, influences included anticipated HIV stigma from family and peers along with the fear of rejection from their main partners.

Conclusions

Translation of these results indicated that interventions to increase PrEP utilization and adherence among YBW will require multi-level strategies to address barriers to integrating HIV prevention into sexual and reproductive healthcare.

Eudragit® L100/chitosan composite thin bilayer films for intravaginal pH-responsive release of Tenofovir

The high rate of HIV new infections and AIDS-related deaths each year make prevention tools still necessary today. Different dosage forms - including films - for vaginal administration of antiretroviral drugs have been developed for this purpose. Six batches of Tenofovir-loaded films were formulated based on Eudragit® L100 (EL100) and chitosan, containing triethyl citrate and glycerol. In all the cases films structured in two layers - the upper layer mainly attributed to EL100 and the lower layer to chitosan - were revealed by SEM. A higher content in EL100 and plasticizers improves the mechanical properties and control over drug release in the vaginal medium without affecting mucoadhesion. The EL100-based layer acts as a structuring agent that controls Tenofovir release for days in the vaginal medium while it occurs in a few hours in the presence of seminal fluid. Bilayer films with the highest tested content of EL100 and plasticizers would be the most suitable as vaginal microbicides as they are easier to administer due to their excellent mechanical properties and they offer more comfortable posology and enhanced protection against HIV during intercourse due to their pH-responsive release of Tenofovir.

Perspectives on Social Support and Stigma in PrEP-related Care among Gay and Bisexual Men: A Qualitative Investigation

Despite its effectiveness at preventing HIV, uptake of PrEP has been slow. PrEP-related stigma is a potential barrier to uptake. Social support has been found to buffer against some PrEP stigma. Unfortunately, little research has investigated the relationship between social support and PrEP-related care. In 2018, we conducted 20 semistructured interviews with MSM who use PrEP (ages 22-70). Interview questions explored social support and PrEP-related stigma, and how these and other psychosocial factors affected PrEP use and continuation. Data were analyzed using grounded theory. Social support was important in PrEP-related care and promoted adaptive behavioral responses, such as adherence to PrEP-related medical care and enhancing resilience to stress. Participants described psychosocial benefits of PrEP, such as reduced HIV-related anxiety, but some also reported that PrEP-related stigma was an additional stressor. Findings suggest that social support has significant impacts within PrEP-related care and may help buffer against stigma.

HBV/HIV Coinfection: Impact on the Development and Clinical Treatment of Liver Diseases

Hepatitis B virus (HBV) infection is a common contributor to chronic hepatitis, liver cirrhosis, and hepatocellular carcinoma. Approximately 10% of people with human immunodeficiency virus (HIV) also have chronic HBV co-infection, owing to shared transmission routes. HIV/HBV coinfection accelerates the progression of chronic HBV to cirrhosis, end-stage liver disease, or hepatocellular carcinoma compared to chronic HBV mono-infection. HBV/HIV coinfection alters the natural history of hepatitis B and renders the antiviral treatment more complex. In this report, we conducted a critical review on the epidemiology, natural history, and pathogenesis of liver diseases related to HBV/HIV coinfection. We summarized the novel therapeutic options for these coinfected patients.

Awareness and acceptability of HIV pre-exposure prophylaxis (PrEP) among students at two historically Black universities (HBCU): a cross-sectional survey

Background

Despite young African American adults (ages 18–24) being among the highest risk groups for HIV infection, little is known about their awareness of HIV pre-exposure prophylaxis (PrEP) – a once daily pill shown to be > 90% effective in preventing HIV. To explore awareness and acceptability of PrEP among college students in this demographic, we conducted a survey of attendees at two large historically Black universities (HBCU) in North Carolina.

Methods

We administered a 14-item questionnaire to students at two HBCUs in North Carolina between February and April 2018. Questions were formatted in a yes/no or multiple choice format. Questionnaire items specifically addressed PrEP awareness and acceptability. Surveys were administered to students at a campus health fair and while transiting the campus student union via iPad. Response to all questions was optional. We fit a logistic regression model to determine association of key demographic determinants with PrEP acceptability and awareness. Statistical analyses were conducted using SAS 9.4 (SAS, Cary, NC).

Results

Overall, 210 students participated in the survey, of which 60 completed all survey items as presented. The survey cohort was 75% female, 89% heterosexual and 39% freshmen. The mean age of respondents was 19.8 years (SD: 1.8). Fifty-two percent of survey respondents reported that they were aware of PrEP prior to the time of survey administration. Only 3% of respondents reported that they were on PrEP. The most common sources of information on PrEP were campus health services (24%) and non-social media advertising (15%). Of respondents who were aware of PrEP, 61% reported that they had heard about in the 6 months prior to survey administration, while only 19% say they were aware of it for more than a year. Regarding acceptability of PrEP, 58% of respondents reported that they would take a once a day pill for HIV if they were at risk. Our logistic regression analysis found no statistically significant associations between key demographic factors and PrEP awareness. However, persons who perceived themselves to be at risk for HIV acquisition were more likely to find once daily oral PrEP (relative risk 2.66 (95% CI 1.31–5.42)) as an acceptable prevention strategy than the rest of the survey cohort.

Conclusions

African American HBCU students are becoming aware of PrEP, and generally perceive the intervention as acceptable and worth consideration.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12889-021-10996-2.

HIV pre-exposure prophylaxis (PrEP) knowledge, familiarity, and attitudes among United States healthcare professional students: A cross-sectional study

The United States' initiative to End the HIV Epidemic by 2030 includes a primary goal to reduce new HIV infections by 90 percent. One key contributor to this plan is HIV pre-exposure prophylaxis (PrEP). While knowledge and acceptance of PrEP among clinicians is growing, few studies have assessed knowledge and awareness among future healthcare professionals in academic training programs. The present study aimed to assess and compare healthcare trainees' awareness, knowledge, and familiarity with PrEP prescribing guidelines to better understand and prevent gaps in academic training regarding PrEP. A cross-sectional web-based survey of medical, nurse practitioner, and pharmacy students enrolled at two universities was conducted between October 2017 and January 2018. The study assessed participants' awareness, knowledge, and familiarity with PrEP prescribing guidelines and willingness to prescribe PrEP and refer to another healthcare provider. The survey was completed by 744 participants (response rate = 36.2%). Overall, PrEP awareness was high though PrEP knowledge was low. There were significant differences among student groups in domains of interest. Pharmacy students had the greatest PrEP knowledge, awareness, and familiarity with prescribing guidelines. However, medical students reported the greatest comfort with performing PrEP-related clinical activities and willingness to refer a candidate to another provider. Study findings enhance our understanding of healthcare professional students' perspectives of PrEP as a biomedical prevention strategy for HIV. The gaps in students' knowledge offer opportunities for the development of educational strategies to support HIV prevention among future healthcare professionals.

Avoiding Drug Resistance in HIV Reverse Transcriptase

HIV reverse transcriptase (RT) is an enzyme that plays a major role in the replication cycle of HIV and has been a key target of anti-HIV drug development efforts. Because of the high genetic diversity of the virus, mutations in RT can impart resistance to various RT inhibitors. As the prevalence of drug resistance mutations is on the rise, it is necessary to design strategies that will lead to drugs less susceptible to resistance. Here we provide an in-depth review of HIV reverse transcriptase, current RT inhibitors, novel RT inhibitors, and mechanisms of drug resistance. We also present novel strategies that can be useful to overcome RT's ability to escape therapies through drug resistance. While resistance may not be completely avoidable, designing drugs based on the strategies and principles discussed in this review could decrease the prevalence of drug resistance.

Understanding the role of nurse practitioners, physician assistants and other nursing staff in HIV pre-exposure prophylaxis care in the United States: a systematic review and meta-analysis

BACKGROUND

Although pre-exposure prophylaxis (PrEP) was approved for primary HIV prevention by the Federal Drug Administration in 2012, PrEP utilization has been suboptimal. A body of literature and programs has emerged to examine the role of nurse practitioners (NPs), physician assistants and nursing staff in PrEP care. This review aims to understand the current status of non-physician health providers in PrEP care implementation in the United States.

METHODS

Following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidance, we conducted a comprehensive literature search using multiple databases to identify peer-reviewed articles that examined the role of non-physician health providers in the implementation of PrEP. Four major databases of studies using observational study design, randomized control trials and mixed-method study design were screened from November 2019 to January 2020 were searched. Two independent reviewers examined eligibility and conducted data extraction. We employed random-effects model aims to capture variances of estimates across studies.

RESULTS

A total of 26 studies with 15,789 health professionals, including NPs (18, 95% CI = 14,24%), physician assistants (6, 95% CI = 2, 10%), nursing staff (26, 95% CI = 18-34%), and physicians (62,95% CI = 45, 75%), were included in the analysis. The odds of prescribing PrEP to patients among NPs were 40% (OR = 1.40, 95% CI = 1.02,1.92) higher than that among physicians, while the likelihood of being willing to prescribe PrEP was similar. On the other hand, the odds of being aware of PrEP (OR = 0.63, 95% CI = 0.46, 0.87) was 37% less in nursing professionals than that among physicians.

CONCLUSIONS

Although the limited number and scope of existing studies constrained the generalizability of our findings, the pattern of PrEP care implementation among non-physician health providers was described. To achieve wider PrEP care implementation in the U.S., increasing awareness of PrEP among all health providers including both physicians and non-physicians is a key step.

Human immunodeficiency virus prevention strategies in China

This paper reviews the current epidemics of human immunodeficiency virus (HIV) infection in China, particularly the globally available prevention strategies developed and implemented. This review focuses on HIV prevention measures in general, such as education, testing, and counseling and in specific responses to transmission modes, such as blood safety, harm reduction for people who inject drugs, and condom promotion to reduce sexual transmission. We also assess newly developed prevention measures, such as prevention treatment, pre-exposure prophylaxis, post-exposure prophylaxis, male circumcision, and promising potential future preventions, including microbicides and vaccines. Based on this assessment, we provide recommendations for their implementation in China. We conclude that there is no magic bullet for HIV prevention, particularly sexual transmission of the disease, but only a combination of these prevention strategies can control the HIV epidemic.

Willingness to use HIV prevention methods among vaccine efficacy trial participants in Soweto, South Africa: discretion is important

BACKGROUND

Despite multiple available HIV prevention methods, the HIV epidemic continues to affect South Africa the most. We sought to understand willingness to use actual and hypothetical HIV prevention methods among participants enrolled in a preventative HIV vaccine efficacy trial in Soweto, South Africa.

METHODS

We conducted a qualitative study with 38 self-reporting HIV-uninfected and consenting 18-35 year olds participating in the HVTN 702 vaccine efficacy trial in Soweto. Using a semi-structured interview guide, five focus group discussions (FGDs) were held, stratified by age, gender and sexual orientation. The FGDs were composed of: (i) 10 heterosexual women aged 18-24 years; (ii) 9 heterosexual and bisexual women aged 25-35 years; (iii & iv) heterosexual men aged 25-35 years with 7 in both groups; and (v) 5 men aged 18-35 years who have sex with men. FGDs were audio-recorded, transcribed verbatim, translated into English and analysed using thematic analysis.

RESULTS

We present five main themes: (i) long-lasting methods are preferable; (ii) condoms are well-known but not preferred for use; (iii) administration route of HIV prevention method is a consideration for the user; (iv) ideal HIV prevention methods should blend into the lifestyle of the user; and the perception that (v) visible prevention methods indicate sexual indiscretion.

CONCLUSIONS

The participants' candour about barriers to condom and daily oral pre-exposure prophylaxis (PrEP) use, and expressed preferences for long-lasting, discreet, lifestyle-friendly methods reveal a gap in the biomedical prevention market aiming to reduce sexually acquired HIV in South Africa. Product developers should consider long-acting injectable formulations, such as vaccines, passive antibodies and chemoprophylaxis, for HIV prevention technologies. Future innovations in HIV prevention products may need to address the desire for the method to blend easily into lifestyles, such as food-medication formulations.

Improving the HIV PrEP continuum of care using an intervention for healthcare providers: a stepped-wedge study protocol

INTRODUCTION

Pre-exposure prophylaxis (PrEP) has demonstrated to be a highly effective method for preventing HIV; however, many individuals with PrEP indications are not receiving PrEP. Primary care settings provide an opportunity to offer PrEP to a wide range of patients. In this paper, we describe the PrEP Optimisation Intervention (PrEP-OI), which includes a PrEP Coordinator and a web-based panel management tool (called PrEP-Rx), and is targeted at healthcare providers (HCPs) to increase PrEP uptake and persistence among those at risk for acquiring HIV.

METHODS AND ANALYSIS

The PrEP-OI study evaluates the efficacy of the PrEP intervention (PrEP Coordinator + PrEP-Rx) to increase PrEP prescriptions through a stepped-wedge design among 10 primary care clinical sites in the San Francisco Department of Public Health. The number of PrEP initiation prescriptions constitute the primary outcome, and we hypothesise that the mean number of PrEP prescriptions written will significantly increase after the clinics initiate PrEP-OI versus before this intervention. Secondary objectives include: 1-differences in PrEP initiation, duration of use and reasons for discontinuation based on patient's age, race/ethnicity and sex/gender, and by clinic and HCP characteristics, 2-sustainability of the intervention during a 12-month follow-up after the stepped-wedge phase, and 3-facilitators and barriers of PrEP delivery and experiences with the proposed PrEP intervention through qualitative interviews with HCPs. The results of this study can provide valuable insight into methods to reduce the burden of PrEP care on HCPs and improve PrEP continuum of care.

ETHICS AND DISSEMINATION

This study and its protocols have been approved by the University of California, San Francisco (UCSF) Institutional Review Board. Study staff will disseminate findings locally (eg, the UCSF Centre for AIDS Prevention Studies' Community Engagement Core), statewide (eg, the California Department of Public Health's Office of AIDS) and nationally and internationally at conferences related to HIV.

TRIAL REGISTRATION NUMBER

NCT03532191.

Cabotegravir and rilpivirine for the treatment of HIV

Introduction: Antiretroviral treatment (ART) has led to improved control of HIV infection, giving the opportunity of exploring therapeutic alternatives as new long-acting (LA) regimens, that might improve the quality of life of people living with HIV (PLWH).Areas covered: This article overviews the pharmacokinetic and pharmacodynamic properties of LA cabotegravir and rilpivirine (CR), two nanoformulated drugs of intramuscular administration and focuses on assessing its role on the treatment of HIV infection.Expert opinion: In addition to the advantage of treatment simplification, which could be especially beneficial for population subgroups with significant HIV-related stigma, it also reduces the number of drugs, and probably, the risk of treatment-related toxicity. The similar efficacy when compared to oral triple therapies in clinical trials and the high satisfaction rates among both professionals and patients make LA CR a suitable alternative for the control of HIV infection in the modern era.

Prescribing HIV pre-exposure prophylaxis: A qualitative analysis of health care provider training needs

Increasing the number of pre-exposure prophylaxis (PrEP) prescriptions will require more health care providers to be willing and trained to prescribe the medication. The purpose of our study was to understand the training needs of clinicians who do not prescribe PrEP. From September 2017 to January 2018, qualitative interviews were conducted with providers who had no experience prescribing PrEP (N = 20). Thematic analysis revealed four themes: three emphasized the temporal nature of training requirements and one identified training preferences of providers. Study findings suggest that clinicians require specific information in order to integrate PrEP into their practices successfully.

Concomitant Utilization of Pre-Exposure Prophylaxis (PrEP) and Meningococcal Vaccine (MenACWY) Among Gay, Bisexual, and Other Men Who Have Sex with Men in Los Angeles County, California

Recent outbreaks of serogroup C meningococcal disease in Southern California have led the California Department of Public Health to recommend the quadrivalent meningococcal vaccine (MenACWY) for gay, bisexual, and other men who have sex with men (GBMSM) in Southern California. High-risk GBMSM have also been advised to utilize pre-exposure prophylaxis (PrEP) for HIV prevention. Data collected from a community-based sample of HIV-negative GBMSM in Los Angeles County (N = 476) were used in a multinomial logit regression analysis to identify patterns in MenACWY and PrEP usage and evaluate factors associated with use of both, one, or neither of these prevention methods. More than half (56%) of participants had neither been vaccinated nor used PrEP. A smaller percentage (34%) had either been vaccinated or were PrEP users, leaving 10% who had concomitant PrEP and MenACWY use. Higher education, more recent sex partners, illicit drug use, and recent receptive condomless anal sex (CAS) were significantly associated with greater odds of using both prevention methods relative to neither. Higher education, prior sexually transmitted infection diagnosis, more recent sex partners, and recent receptive CAS were significantly associated with greater odds of just PrEP use relative to neither. Higher education was the only factor significantly associated with greater odds of just MenACWY immunization relative to neither. Findings highlight important gaps in immunization among PrEP users and opportunities to screen for PrEP eligibility among GBMSM in conjunction with immunization. Public health practitioners should consider the ways in which strategies to increase PrEP and vaccine-preventable illnesses among GBMSM may complement one another.

Getting youth PrEPared: adolescent consent laws and implications for the availability of PrEP among youth in countries outside of the United States

INTRODUCTION

Youth under the age of 25 are at high risk for HIV infection. While pre-exposure prophylaxis (PrEP) has the potential to curb new infections within this population, it is unclear how country-specific laws and policies that govern youth access to sexual and reproductive health (SRH) services impact access to PrEP. The purpose of this review was to analyse laws and policies concerning PrEP implementation and SRH services available to youth in countries with a high HIV incidence. To the best of our knowledge this is the first systematic assessment of country-level policies that impact the availability of PrEP to adolescent populations.

METHODS

We conducted a review of national policies published on or before 12 June 2018 that could impact adolescents' access to PrEP, SRH services and ability to consent to medical intervention. Countries were included if: (1) there was a high incidence of HIV; (2) they had active PrEP trials or PrEP was available for distribution; (3) information regarding PrEP guidelines were publicly available. We also included a selected number of countries with lower adolescent HIV incidence. Internet and legal database searches were used to identify policies relevant to adolescent PrEP (e.g. age of consent to HIV testing).

RESULTS AND DISCUSSION

Fifteen countries were selected for inclusion in this review. Countries varied considerably in their respective laws and policies governing adolescents' access to PrEP, HIV testing and SRH services. Six countries had specific polices around the provision of PrEP to youth under the age of 18. Five countries required people to be 18 years or older to access HIV testing, and six countries had specific laws addressing adolescent consent for- and access to- contraceptives.

CONCLUSIONS

Adolescents' access to PrEP without parental consent remains limited or uncertain in many countries where this biomedical intervention is needed. Observational and qualitative studies are needed to determine if and how adolescent consent laws are followed in relation to adolescent PrEP provisions. Intensified efforts to amend laws that limit adolescent access to PrEP and restrict the establishment of national guidelines supporting adolescent PrEP are also needed to address the epidemic in this group.

Owens DK, Davidson KW, Krist AH, Barry MJ, Cabana M, Caughey AB, Curry SJ, Doubeni CA, Epling JW, Kubik M, Landefeld CS, Mangione CM, Pbert L, Silverstein M, Simon MA, Tseng CW, Wong JB. Preexposure Prophylaxis for the Prevention of HIV Infection: US Preventive Services Task Force Recommendation Statement

IMPORTANCE

An estimated 1.1 million individuals in the United States are currently living with HIV, and more than 700 000 persons have died of AIDS since the first cases were reported in 1981. In 2017, there were 38 281 new diagnoses of HIV infection reported in the United States; 81% of these new diagnoses were among males and 19% were among females. Although treatable, HIV infection has no cure and has significant health consequences.

OBJECTIVE

To issue a new US Preventive Services Task Force (USPSTF) recommendation on preexposure prophylaxis (PrEP) for the prevention of HIV infection.

EVIDENCE REVIEW

The USPSTF reviewed the evidence on the benefits of PrEP for the prevention of HIV infection with oral tenofovir disoproxil fumarate monotherapy or combined tenofovir disoproxil fumarate and emtricitabine and whether the benefits vary by risk group, population subgroup, or regimen or dosing strategy; the diagnostic accuracy of risk assessment tools to identify persons at high risk of HIV acquisition; the rates of adherence to PrEP in primary care settings; the association between adherence and effectiveness of PrEP; and the harms of PrEP when used for HIV prevention.

FINDINGS

The USPSTF found convincing evidence that PrEP is of substantial benefit in decreasing the risk of HIV infection in persons at high risk of HIV acquisition. The USPSTF also found convincing evidence that adherence to PrEP is highly associated with its efficacy in preventing the acquisition of HIV infection; thus, adherence to PrEP is central to realizing its benefit. The USPSTF found adequate evidence that PrEP is associated with small harms, including kidney and gastrointestinal adverse effects. The USPSTF concludes with high certainty that the magnitude of benefit of PrEP with oral tenofovir disoproxil fumarate-based therapy to reduce the risk of acquisition of HIV infection in persons at high risk is substantial.

CONCLUSIONS AND RECOMMENDATION

The USPSTF recommends offering PrEP with effective antiretroviral therapy to persons at high risk of HIV acquisition. (A recommendation).

Antiretroviral agents in pre-exposure prophylaxis: emerging and advanced trends in HIV prevention

OBJECTIVES

Antiretroviral agents (ARVs) have been the most promising line of therapy in the management of human immunodeficiency virus (HIV) infections. Some of these ARVs are used in the pre-exposure prophylaxis (PrEP) to suppress the transmission of HIV. Prophylaxis is primarily used in uninfected people, before exposure, to effectively prevent HIV infection. Several studies have shown that ART PrEP prevents HIV acquisition from sexual, blood and mother-to-child transmissions. However, there are also several challenges and limitations to PrEP. This review focuses on the current antiretroviral therapies used in PrEP.

KEY FINDINGS

Among ARVs, the most common drugs employed from the class of entry inhibitors are maraviroc (MVC), which is a CCR5 receptor antagonist. Other entry inhibitors like emtricitabine (FTC) and tenofovir (TFV) are also used. Rilpivirine (RPV) and dapivirine (DPV) are the most common drugs employed from the Non-nucleoside reverse transcriptase inhibitor (NNRTIs) class, whereas, tenofovir disoproxil fumarate (TDF) is primarily used in the Nucleoside Reverse Transcriptase Inhibitor (NRTIs) class. Cabotegravir (CAB) is an analog of dolutegravir, and it is an integrase inhibitor. Some of these drugs are also used in combination with other drugs from the same class.

SUMMARY

Some of the most common pre-exposure prophylactic strategies employed currently are the use of inhibitors, namely entry inhibitors, non-nucleoside reverse transcriptase inhibitors, nucleoside reverse transcriptase inhibitors, integrase and protease inhibitors. In addition, we have also discussed on the adverse effects caused by ART in PrEP, pharmacoeconomics factors and the use of antiretroviral prophylaxis in serodiscordant couples.

Misclassification of sexual health risks in a self-identified low risk cohort of men who have sex with men (MSM) enrolled in a community based PrEP program

The CDC recommends PrEP for MSM at substantial risk of HIV acquisition, leaving clinicians unsure whether to prescribe PrEP to MSM who do not disclose HIV risk factors. A longitudinal cohort of MSM requesting PrEP despite reporting during a clinical visit either 100% condom use or participation in oral sex only and no other risk factors was followed over 13 months at a community clinic in San Francisco to assess the accuracy of their HIV risk perception. Participants completed a sexual and substance use behavior questionnaire at baseline, outside of the clinical visit and were followed by quarterly HIV/STI testing and condom use change questionnaires. Condomless sex increased from 0% at baseline to 12% at month 1, peaked at 34% at month 7, and then decreased again to 8% at month 13. Rates of pharyngeal GC/CT varied from 7% at baseline to 12% at month 13, while rectal GC/CT decreased from 6% at baseline to 0% at month 13. The rate of syphilis was 1% both at baseline and at month 13, however, 11% and 15% of clients tested positive for syphilis at months 1 and 7 respectively.

Smart Freeze-Dried Bigels for the Prevention of the Sexual Transmission of HIV by Accelerating the Vaginal Release of Tenofovir during Intercourse

Sub-Saharan African women are still at risk from the human immunodeficiency virus (HIV), and sex with men is the main route of transmission. Vaginal formulations containing antiretroviral drugs are promising tools to give women the power to protect themselves. The aim of this work was to obtain freeze-dried bigels containing pectin, chitosan, or hypromellose for the vaginal controlled release of Tenofovir, which is accelerated in the presence of semen. Nine batches of bigels were formulated using different proportions of these polymers in the hydrogel (1, 2, and 3% w/w). The bigels obtained were freeze-dried and then underwent hardness and deformability, mucoadhesion, swelling, and drug release tests, the last two in simulated vaginal fluid (SVF) and SVF/simulated seminal fluid (SSF) mixture. The formulation containing 3% pectin (fd3P) has the highest values for hardness, resistance to deformation, and good mucoadhesivity. Its swelling is conditioned by the pH of the medium, which is responsive to the controlled release of Tenofovir in SVF, with the fastest release in the SVF/SSF mixture. fd3P would be an interesting smart microbicidal system to allow faster release of Tenofovir in the presence of semen, and thus increase women’s ability to protect themselves from the sexual transmission of HIV.

Structural Barriers to Pre-exposure Prophylaxis Use Among Young Sexual Minority Men: The P18 Cohort Study

BACKGROUND

Despite decreasing rates of HIV among many populations, HIV-related health disparities among gay, bisexual and other men who have sex with men persist, with disproportional percentages of new HIV diagnoses among racial and ethnic minority men. Despite increasing awareness of HIV pre-exposure prophylaxis (PrEP), PrEP use remains low. In addition to exploring individual-level factors for this slow uptake, structural drivers of PrEP use must also be identified in order to maximize the effectiveness of biomedical HIV prevention strategies.

METHOD

Using cross-sectional data from an ongoing cohort study of young sexual minority men (N=492), we examine the extent to which structural-level barriers, including access to health care, medication logistics, counseling support, and stigma are related to PrEP use.

RESULTS

While almost all participants indicated awareness of PrEP, only 14% had ever used PrEP. PrEP use was associated with lower concerns about health care access, particularly paying for PrEP. Those with greater concerns talking with their provider about their sexual behaviors were less likely to use PrEP.

CONCLUSION

Paying for PrEP and talking to one's provider about sexual behaviors are concerns for young sexual minority men. In particular, stigma from healthcare providers poses a significant barrier to PrEP use in this population. Providers need not only to increase their own awareness of and advocacy for PrEP as an effective risk-management strategy for HIV prevention, but also must work to create open and non-judgmental spaces in which patients can discuss sexual behaviors without the fear of stigma.

The Anti-Human Immunodeficiency Virus Drug Tenofovir, a Reverse Transcriptase Inhibitor, Also Targets the Herpes Simplex Virus DNA Polymerase

Background

Genital herpes is an important cofactor for acquisition of human immunodeficiency virus (HIV) infection, and effective prophylaxis is a helpful strategy to halt both HIV and herpes simplex virus (HSV) transmission. The antiretroviral agent tenofovir, formulated as a vaginal microbicide gel, was shown to reduce the risk of HIV and HSV type 2 (HSV-2) acquisition.

Methods

HSV type 1 (HSV-1) and HSV-2 mutants were selected for resistance to tenofovir and PMEO-DAPy (6-phosphonylmethoxyethoxy-2,4-diaminopyrimidine, an acyclic nucleoside phosphonate with dual anti-HSV and anti-HIV activity) by stepwise dose escalation. Several plaque-purified viruses were characterized phenotypically (drug resistance profiling) and genotypically (sequencing of the viral DNA polymerase gene).

Results

Tenofovir resistant and PMEO-DAPy-resistant viruses harbored specific amino acid substitutions associated with resistance not only to tenofovir and PMEO-DAPy but also to acyclovir and foscarnet. These amino acid changes (A719V, S724N, and L802F [HSV-1] and M789T and A724V [HSV-2]) were also found in clinical isolates recovered from patients refractory to acyclovir and/or foscarnet therapy or in laboratory-derived strains. A total of 10 (HSV-1) and 18 (HSV-2) well-characterized DNA polymerase mutants had decreased susceptibility to tenofovir and PMEO-DAPy.

Conclusions

Tenofovir and PMEO-DAPy target the HSV DNA polymerase, and clinical isolates with DNA polymerase mutations emerging under acyclovir and/or foscarnet therapy showed cross-resistance to tenofovir and PMEO-DAPy.

Awareness, knowledge, and attitudes towards human immunodeficiency virus (HIV) pre-exposure prophylaxis (PrEP) among pharmacy students

INTRODUCTION

The purpose of this study was to assess pharmacy students' awareness, knowledge, and perceptions towards human immunodeficiency virus (HIV) pre-exposure prophylaxis (PrEP), confidence and intentions to counsel patients on PrEP, and preferred PrEP training.

METHODS

A web-based cross-sectional survey was conducted with pharmacy students. Descriptive statistics and multivariate logistic regressions were performed.

RESULTS

Ninety-one percent of participants were aware of PrEP and 61% were familiar with PrEP prescription guidelines. In multivariate analysis, greater PrEP knowledge, attitudes towards PrEP, and familiarity with prescribing guidelines were significantly associated with confidence in PrEP counseling (p < 0.01 for all). Males had significantly higher odds of reporting confidence in PrEP counseling relative to their female counterparts (p < 0.01). Relative to fourth year students, second year students were less likely to report confidence in PrEP counseling (p < 0.01). Participants who were familiar with prescribing guidelines had significantly higher odds of PrEP counseling intentions (p < 0.05). Preferred educational topics regarding PrEP included training on side effects and adherence monitoring (65% and 51%, respectively). The most preferred modalities for receiving PrEP education were online education (47%), educational seminars in required courses (43%), and self-study modules (39%).

CONCLUSIONS

Given the key role played by pharmacists in patient engagement, they may be presented with opportunities to provide PrEP counseling and education. The development of educational modules for pharmacy students in an effort to increase PrEP uptake should consider addressing gaps in knowledge and preferred training modalities.

Improving PrEP Implementation Through Multilevel Interventions: A Synthesis of the Literature

There are many challenges to accessing PrEP and thus low uptake in the United States. This review (2007–2017) of PrEP implementation identified barriers to PrEP and interventions to match those barriers. The final set of articles (n = 47) included content on cognitive aspects of HIV service providers and individuals at risk for infection, reviews, and case studies. Cognitive barriers and interventions regarding patients and providers included knowledge, attitudes, and beliefs about PrEP. The “purview paradox” was identified as a key barrier—HIV specialists often do not see HIV-negative patients, while primary care physicians, who often see uninfected patients, are not trained to provide PrEP. Healthcare systems barriers included lack of communication about, funding for, and access to PrEP. The intersection between PrEP-stigma, HIV-stigma, transphobia, homophobia, and disparities across gender, racial, and ethnic groups were identified; but few interventions addressed these barriers. We recommend multilevel interventions targeting barriers at multiple socioecological domains.

Ranpirnase Reduces HIV-1 Infection and Associated Inflammatory Changes in a Human Colorectal Explant Model

Ranpirnase (RNP) is a low molecular weight type III endoribonuclease, which demonstrates broad antiviral and antitumor properties. We sought to characterize the antiviral activity of RNP against HIV-1 and to determine whether RNP modulates local inflammatory changes associated with HIV infection in the colorectal explant model. Colorectal explants were incubated for 2 h with HIV-1_BaL, in the presence of increasing concentrations of RNP (0-60 μg/mL). After washing, explants were cultured for 14 days, with supernatant collected at days 3, 7, 10, and 14. All samples were assayed for HIV-1 p24. Additionally, 30 soluble inflammatory biomarkers were assayed in the day 3 supernatant sample. Other biopsies were stimulated with lipopolysaccharides (LPS) (10 μg/mL) in the presence of RNP and soluble biomarkers assayed at day 3. RNP inhibited productive infection of the colorectal explants with HIV-1_BaL and induced a dose-dependent decrease in 15/30 biomarkers. Affected biomarkers included IP-10, MDC, MIP-1α, MIP-1β, TARC, IL12-p40, IL-15, IL-17, IL-1α, IL-7, IFNγ, IL12-p70, IL-1β, IL-4, IL-5, and TNF-β. Similarly, RNP dose-dependent inhibition was demonstrated in 7/30 biomarkers after LPS stimulation, all of which overlapped with HIV-1_BaL-induced biomarker changes. The ability of RNP to inhibit both colorectal explant HIV-1_BaL infection and inflammatory changes associated with HIV-1 infection makes RPN a promising agent for topical rectal pre-exposure prophylaxis.

Transcutaneously refillable nanofluidic implant achieves sustained level of tenofovir diphosphate for HIV pre-exposure prophylaxis

Pre-exposure prophylaxis (PrEP) with antiretroviral (ARV) drugs are effective at preventing human immunodeficiency virus (HIV) transmission. However, implementation of PrEP presents significant challenges due to poor user adherence, low accessibility to ARVs and multiple routes of HIV exposure. To address these challenges, we developed the nanochannel delivery implant (NDI), a subcutaneously implantable device for sustained and constant delivery of tenofovir alafenamide (TAF) and emtricitabine (FTC) for HIV PrEP. Unlike existing drug delivery platforms with finite depots, the NDI incorporates ports allowing for transcutaneous refilling upon drug exhaustion. NDI-mediated drug delivery in rhesus macaques resulted in sustained release of both TAF and FTC for 83 days, as indicated by concentrations of TAF, FTC and their respectively metabolites in plasma, PBMCs, rectal mononuclear cells and tissues associated with HIV transmission. Notably, clinically relevant preventative levels of tenofovir diphosphate were achieved as early as 3 days after NDI implantation. We also demonstrated the feasibility of transcutaneous drug refilling to extend the duration of PrEP drug delivery in NHPs. Overall, the NDI represents an innovative strategy for long-term HIV PrEP administration in both developed and developing countries.

HIV Prevention in Adolescents and Young People in the Eastern and Southern African Region: A Review of Key Challenges Impeding Actions for an Effective Response

The global commitment to ending the AIDS epidemic by 2030 places HIV prevention at the centre of the response. With the disease continuing to disproportionately affect young populations in the Eastern and Southern African Region (ESAR), particularly adolescent girls and young women, reducing HIV infections in this group is integral to achieving this ambitious target. This paper examines epidemiological patterns of the HIV epidemic among adolescents and young people, indicating where HIV prevention efforts need to be focused (i.e., adolescent girls and young women, adolescent boys and young men and young key populations).

Key innovations in the science of HIV prevention and strategies for dealing with programme implementation are reviewed. The paper also discusses the value of processes to mitigate HIV vulnerability and recommends actions needed to sustain the HIV prevention response. Stemming the tide of new HIV infections among young people in the ESAR requires an amplification of efforts across all sectors, which will safeguard past achievements and advance actions towards eliminating AIDS as a public health threat.

Vaginal microbiome modulates topical antiretroviral drug pharmacokinetics

Tenofovir gel and dapivirine ring provided variable HIV protection in clinical trials, reflecting poor adherence and possibly biological factors. We hypothesized that vaginal microbiota modulates pharmacokinetics and tested the effects of pH, individual bacteria, and vaginal swabs from women on pharmacokinetics and antiviral activity. Tenofovir, but not dapivirine, uptake by human cells was reduced as pH increased. Lactobacillus crispatus actively transported tenofovir leading to a loss in drug bioavailability and culture supernatants from Gardnerella vaginalis, but not Atopobium vaginae, blocked tenofovir endocytosis. The inhibition of endocytosis mapped to adenine. Adenine increased from 65.5 μM in broth to 246 μM in Gardnerella, but decreased to 9.5 μM in Atopobium supernatants. This translated into a decrease in anti-HIV activity when Gardnerella supernatants or adenine were added to cultures. Dapivirine was also impacted by microbiota, as drug bound irreversibly to bacteria, resulting in decreased antiviral activity. When drugs were incubated with vaginal swabs, 30.7% ± 5.7% of dapivirine and 63.9% ± 8.8% of tenofovir were recovered in supernatants after centrifugation of the bacterial cell pellet. In contrast, no impact of microbiota on the pharmacokinetics of the prodrugs, tenofovir disoproxil fumarate or tenofovir alafenamide, was observed. Together, these results demonstrate that microbiota may impact pharmacokinetics and contribute to inconsistent efficacy.

Assessing Mozambicans' willingness and determinants to use pre-exposure prophylactic HIV medication

In anticipation of the introduction of the pre-exposure prophylaxis drugs as an additional HIV prevention tool, we mapped the different positions of Mozambicans' willingness to use it. Overall, 507 adults indicated willingness to use under different conditions varying as a function of perceived susceptibility to and severity of infection, side effects, administration protocol, and cost. Three qualitatively different positions were found: Unwillingness irrespective of conditions (4%), depend on circumstances (76%), and unconditional willingness (8%). A large majority of participants were willing to use pre-exposure prophylaxis drugs, provided that the administration is not too constraining, and the adverse side effects can be minimized.

Long acting systemic HIV pre-exposure prophylaxis: an examination of the field

Oral pre-exposure prophylaxis for the prevention of HIV-1 transmission (HIV PrEP) has been widely successful as demonstrated by a number of clinical trials. However, studies have also demonstrated the need for patients to tightly adhere to oral dosing regimens in order to maintain protective plasma and tissue concentrations. This is especially true for women, who experience less forgiveness from dose skipping than men in clinical trials of HIV PrEP. There is increasing interest in long-acting (LA), user-independent forms of HIV PrEP that could overcome this adherence challenge. These technologies have taken multiple forms including LA injectables and implantables. Phase III efficacy trials are ongoing for a LA injectable candidate for HIV PrEP. This review will focus on the design considerations for both LA injectable and implantable platforms for HIV PrEP. Additionally, we have summarized the existing LA technologies currently in clinical and pre-clinical studies for HIV PrEP as well as other technologies that have been applied to HIV PrEP and contraceptives. Our discussion will focus on the potential application of these technologies in low resource areas, and their use in global women's health.

Incidence of sexually transmitted infections before and after preexposure prophylaxis for HIV

Objective:

Use of preexposure prophylaxis (PrEP) for HIV raises concerns about sexually transmitted infection (STI) incidence because of decreased condom use among MSM. This study examines whether PrEP is associated with STIs in the 12 months following PrEP prescription relative to the 12 months prior to PrEP and if STI rates are higher among PrEP users relative to individuals receiving postexposure prophylaxis (PEP).

Design:

Retrospective cohort study including PrEP users with more than 12 months of follow-up before PrEP prescription and individuals receiving PEP from 2010 to 2015 at Clinique l’Actuel (Montréal, Canada).

Methods:

Incidence of chlamydia, gonorrhoea, syphilis and hepatitis C virus over 12 months was compared before and after PrEP; and for PrEP versus PEP users using Poisson models to generate incidence rate ratios (IRRs) with 95% confidence intervals (CIs) and adjusted IRRs (aIRRs) controlling for frequency of STI-screening visits. Models comparing PrEP and PEP users were further adjusted for age and education.

Results:

One hundred and nine PrEP and 86 PEP users were included. Increased rates of STIs were observed in the 12 months after PrEP relative to the 12 months prior (IRR: 1.72, CI: 1.22–2.41; aIRR: 1.39, CI 0.98–1.96). PrEP users were also at higher STI risk relative to PEP users (IRR: 2.18, CI: 1.46–3.24; aIRR: 1.76, CI: 1.14–2.71).

Conclusion:

Increased rates of STIs among individuals after initiation of PrEP may suggest greater risk behaviours during the first year on PrEP. Further studies are needed to measure long-term trends in STI acquisition following PrEP initiation.

HIV Testing in Men who have Sex with Men: A Follow-up Review of the Qualitative Literature since 2010

The landscape of HIV testing has changed significantly in recent years following the rise in importance of the 'treatment as prevention' strategy and advancements in new HIV testing and prevention technologies. This review provides a synthesis of qualitative research findings published since 2010 on preferences and practices of men who have sex with men (MSM) surrounding HIV testing in high-income settings. MSM are one of the hardest groups to reach with standard or conventional HIV testing approaches. To develop innovative testing strategies for this particular group, a good understanding of their concerns, barriers and facilitators of accessing HIV testing is needed. This updated review provides valuable information for improving existing programs and designing new testing services for MSM.

A Simple Pre-Exposure Prophylaxis (PrEP) Optimization Intervention for Health Care Providers Prescribing PrEP: Pilot Study

Background

Pre-exposure prophylaxis (PrEP) has been shown to be highly effective for the prevention of HIV in clinical trials and demonstration projects, but PrEP uptake and adherence outside of these settings in the United States has been limited. Lack of knowledge and willingness of health care providers (HCPs) to prescribe PrEP is an important barrier to implementation.

Objective

The objective of this study was to describe and examine the feasibility and acceptability of a PrEP Optimization Intervention (PrEP-OI) targeted at HCPs. The ultimate purpose of this intervention was to increase PrEP uptake, adherence, and persistence among those at risk for HIV acquisition.

Methods

This intervention included the following: (1) a Web-based panel management tool called PrEP-Rx, which provides comprehensive HIV risk assessment, automates reminders for follow-up, and reports patients' history of PrEP use; and (2) centralized PrEP coordination by a clinical support staff member (ie, the PrEP coordinator) who can identify individuals at risk for HIV, provide medical insurance navigation, and support multiple HCPs. Feasibility was evaluated based on HCPs' ability to log in to PrEP-Rx and use it as needed. Acceptability was assessed via individual formative qualitative interviews with HCPs after 1 month of the intervention.

Results

The intervention was feasible and acceptable among HCPs (N=6). HCPs identified system-level barriers to PrEP provision, many of which can be addressed by this intervention. HCPs noted that the intervention improved their PrEP knowledge; increased ease of PrEP prescription; and was likely to improve patient engagement and retention in care, enhance communication with patients, and improve patient monitoring and follow-up.

Conclusions

Given the critical role HCPs serve in disseminating PrEP, we created an easy-to-use PrEP optimization intervention deemed feasible and acceptable to providers. Further research on this tool and its ability to impact the PrEP continuum of care is needed.

Awareness and willingness to use HIV pre-exposure prophylaxis among men who have sex with men in low- and middle-income countries: a systematic review and meta-analysis

Introduction: To facilitate provision of pre-exposure prophylaxis (PrEP) in low- and middle-income countries (LMIC), a better understanding of potential demand and user preferences is required. This review assessed awareness and willingness to use oral PrEP among men who have sex with men (MSM) in LMIC.

Methods: Electronic literature search of Cochrane library, Embase, PubMed, PsychINFO, CINHAL, Web of Science, and Google Scholar was conducted between July and September 2016. Reference lists of relevant studies were searched, and three authors contacted for additional data. Non-peer reviewed publications were excluded. Studies were screened for inclusion, and relevant data abstracted, assessed for bias, and synthesized.

Results: In total, 2186 records were identified, of which 23 studies involving 14,040 MSM from LMIC were included. The proportion of MSM who were aware of PrEP was low at 29.7% (95% CI: 16.9–44.3). However, the proportion willing to use PrEP was higher, at 64.4% (95% CI: 53.3–74.8). Proportions of MSM aware of PrEP was <50% in 11 studies and 50–70% in 3 studies, while willingness to use PrEP was <50% in 6 studies, 50–70% in 9 studies, and over 80% in 5 studies. Several factors affected willingness to use PrEP. At the individual domain, poor knowledge of PrEP, doubts about its effectiveness, fear of side effects, low perception of HIV risk, and the need to adhere or take medicines frequently reduced willingness to use PrEP, while PrEP education and motivation to maintain good health were facilitators of potential use. Demographic factors (education, age, and migration) influenced both awareness and willingness to use PrEP, but their effects were not consistent across studies. At the social domain, anticipated stigma from peers, partners, and family members related to sexual orientation, PrEP, or HIV status were barriers to potential use of PrEP, while partner, peer, and family support were facilitators of potential use. At the structural domain, concerns regarding attitudes of healthcare providers, quality assurance, data protection, and cost were determinants of potential use.

Conclusions: This review found that despite low levels of awareness of PrEP, MSM in LMIC are willing to use it if they are supported appropriately to deal with a range of individual, social, and structural barriers.

In Silico and in Vitro Screening for P-Glycoprotein Interaction with Tenofovir, Darunavir, and Dapivirine: An Antiretroviral Drug Combination for Topical Prevention of Colorectal HIV Transmission

The aim of the study was to use in silico and in vitro techniques to evaluate whether a triple formulation of antiretroviral drugs (tenofovir, darunavir, and dapivirine) interacted with P-glycoprotein (P-gp) or exhibited any other permeability-altering drug-drug interactions in the colorectal mucosa. Potential drug interactions with P-gp were screened initially using molecular docking, followed by molecular dynamics simulations to analyze the identified drug-transporter interaction more mechanistically. The transport of tenofovir, darunavir, and dapivirine was investigated in the Caco-2 cell models and colorectal tissue, and their apparent permeability coefficient (P_app), efflux ratio (ER), and the effect of transporter inhibitors were evaluated. In silico, dapivirine and darunavir showed strong affinity for P-gp with similar free energy of binding; dapivirine exhibiting a ΔG_PB value -38.24 kcal/mol, darunavir a ΔG_PB value -36.84 kcal/mol. The rank order of permeability of the compounds in vitro was tenofovir < darunavir < dapivirine. The P_app for tenofovir in Caco-2 cell monolayers was 0.10 ± 0.02 × 10^-6 cm/s, ER = 1. For dapivirine, P_app was 32.2 ± 3.7 × 10^-6 cm/s, but the ER = 1.3 was lower than anticipated based on the in silico findings. Neither tenofovir nor dapivirine transport was influenced by P-gp inhibitors. The absorptive permeability of darunavir (P_app = 6.4 ± 0.9 × 10^-6 cm/s) was concentration dependent with ER = 6.3, which was reduced by verapamil to 1.2. Administration of the drugs in combination did not alter their permeability compared to administration as single agents. In conclusion, in silico modeling, cell culture, and tissue-based assays showed that tenofovir does not interact with P-gp and is poorly permeable, consistent with a paracellular transport mechanism. In silico modeling predicted that darunavir and dapivirine were P-gp substrates, but only darunavir showed P-gp-dependent permeability in the biological models, illustrating that in silico modeling requires experimental validation. When administered in combination, the disposition of the proposed triple-therapy antiretroviral drugs in the colorectal mucosa will depend on their distinctly different permeability, but was not interdependent.

The Importance of Sexual History Taking for PrEP Comprehension Among Young People of Color

Despite demonstrated efficacy, uptake of pre-exposure prophylaxis (PrEP) remains low, especially among highest priority populations. This study examined four PrEP messaging factors hypothesized to impact comprehension of PrEP educational information: (1) modality (video versus in-person message delivery); (2) frame (risk versus health focus); (3) specificity (gist versus verbatim efficacy information); and (4) sexual history (administered either before or after PrEP education). We examined message comprehension among 157 young people of color (YPoC) eligible for PrEP, using a series of multiple choice questions. Overall, 65.6 % (n = 103) got all message comprehension questions correct. In multivariate analyses, engaging in a sexual history before receiving PrEP education was associated with increased odds of message comprehension (aOR 2.23; 95 % CI 1.06-4.72). This effect was even stronger among those who received PrEP education via video (aOR 3.53; 95 % CI 1.16-10.81) compared to via health educator. This research underscores the importance of sexual history-taking as part of PrEP education and clinical practice for YPoC, and suggests that engaging patients in a sexual history prior to providing them with PrEP education may be key to increasing comprehension.

The future of pre-exposure prophylaxis (PrEP) for human immunodeficiency virus (HIV) infection

INTRODUCTION

People at high risk for HIV acquisition should be offered pre-exposure prophylaxis (PrEP). Tenofovir disoproxil fumarate (TDF)/emtricitabine (FTC) is currently the only medication recommended for pre-exposure prophylaxis (PrEP) by the Centers for Disease Control and Prevention (CDC) in people at high risk for HIV acquisition. This article will review medications currently under investigation and the future landscape of PrEP therapy. Areas covered: This article will review clinical trials that have investigated nontraditional regimens of TDF/FTC, antiretroviral agents from different drug classes such as integrase strand transfer inhibitors (INSTI), nucleoside reverse transcriptase inhibitors (NRTI), and non-nucleoside reverse transcriptase inhibitors (NNRTI) as potential PrEP therapies. Expert commentary: Currently, there are several investigational drugs in the pipeline for PrEP against HIV infection. Increased utilization of PrEP therapy depends on provider identification of people at high risk for HIV transmission. Advances in PrEP development will expand options and access for people and reduce the risk of HIV acquisition.

Prevention Strategies Against HIV Transmission: A Proactive Approach

Human immunodeficiency virus (HIV) has now transformed into a manageable chronic condition. Highly active antiretroviral therapy (HAART) has proven efficacious at controlling the disease progression. Based on compelling evidence, the Department of Health and Human Services (DHHS) and the Infectious Disease Society of America (IDSA) developed guidelines for the management of persons infected with HIV. However, there are approximately 50 000 new cases of HIV in the United States each year. In this article, we review proactive methods to reduce the transmission of HIV, which include reinforcing patient education, gel-coated condoms that destroy HIV, HIV vaccinations, and adequately utilizing pre-exposure prophylaxis (PrEP), and post-exposure prophylaxis (PEP). Further development and consistent utilization of innovative prevention tools can significantly reduce the incidence of HIV infections regardless of HIV status.

Are Prophylactic and Therapeutic Target Concentrations Different?: the Case of Lopinavir-Ritonavir or Lamivudine Administered to Infants for Prevention of Mother-to-Child HIV-1 Transmission during Breastfeeding

The ANRS 12174 trial assessed the efficacy and tolerance of lopinavir (LPV)-ritonavir (LPV/r) prophylaxis versus those of lamivudine (3TC) prophylaxis administered to breastfed infants whose HIV-infected mothers were not on antiretroviral therapy. In this substudy, we assessed LPV/r and 3TC pharmacokinetics to evaluate the percentage of infants with therapeutic plasma concentrations and to discuss these data in the context of a prophylactic treatment. Infants from the South African trial site underwent blood sampling for pharmacokinetic study at weeks 6, 26, and 38 of life. We applied a Bayesian approach to derive the 3TC and LPV pharmacokinetic parameters on the basis of previously published pharmacokinetic models for HIV-infected children. We analyzed 114 LPV and 180 3TC plasma concentrations from 69 infants and 92 infants, respectively. A total of 30 LPV and 20 3TC observations were considered missing doses and discarded from the Bayesian analysis. The overall population analysis showed that 30 to 40% of the infants did not reach therapeutic targets, regardless of treatment group. The median LPV trough concentrations at weeks 6, 26, and 38 were 2.8 mg/liter (interquartile range [IQR], 1.7 to 4.4 mg/liter), 5.6 mg/liter (IQR, 3.2 to 7.7 mg/liter), and 3.4 mg/liter (IQR, 2.3 to 7.3 mg/liter), respectively. The median 3TC area under the curve from 0 to 12 h after the last drug intake were 5.6 mg · h/liter (IQR, 4.1 to 7.8 mg · h/liter), 5.9 mg · h/liter (IQR, 5.1 to 7.5 mg · h/liter), and 7.3 mg · h/liter (IQR, 4.9 to 8.5 mg · h/liter) at weeks 6, 26, and 38, respectively. Use of the therapeutic doses recommended by the WHO would have resulted in a higher proportion of infants achieving the targets. However, no HIV-1 infection was reported among these infants. These results suggest that the prophylactic targets for both 3TC and LPV may be lower than the therapeutic ones. For treatment, the WHO dosing guidelines should be suitable to maintain values above the therapeutic pharmacokinetic targets in most infants. (This study has been registered at ClinicalTrials.gov under identifier NCT00640263.).