Roll-out of HIV pre-exposure prophylaxis use in France: A nationwide observational study from 2016 to 2021

Evolving impact of the COVID-19 pandemic in chronic dialysis recipients in France

BACKGROUND

This observational study aimed to assess the impact of the pandemic on the way kidney transplantation, survival, and vaccination evolved in chronic dialysis recipients (CDR) over the course of the COVID-19 pandemic waves and inter-waves.

METHODS

Using the French national health claims database, incident persons with end-stage kidney disease in the years 2015 to 2021 treated with dialysis were followed up until 31 December, 2022. Kidney transplantation and survival in the pandemic sub-periods compared to the pre-pandemic period were investigated using longitudinal models with time-dependent covariates. In addition, the impact of cumulative doses of COVID-19 vaccine on hospitalization and survival was studied, comparing CDR and matched controls.

RESULTS

Here, we show that the follow-ups of the 71,583 CDR and the 143,166 controls totalize 639,341 person-years (CDR: 184,909; controls: 454,432). The likelihood of receiving a kidney transplant is lower in all pandemic sub-periods. The 3 waves are associated with a higher risk of death (hazard ratio (HR [95% confidence interval]): 1.19 [1.13-1.27], 1.19 [1.15-1.23], and 1.12 [1.07-1.17], respectively). While vaccine coverage declines with each booster dose, receiving these doses is associated with a lower risk of COVID-19-related hospitalization (0.66 [0.56-0.77], 0.83 [0.72-0.94] for 1st booster versus 2nd dose and 2nd booster versus 1st booster, respectively) and death (corresponding HR: 0.55 [0.51-0.59], 0.88 [0.83-0.95]).

CONCLUSIONS

The evolving patterns in mortality and vaccination outcomes are similar in CDR and controls, suggesting that the impact of the pandemic on CDR is not specific to kidney disease per se.

HIV incident infections during pre-exposure prophylaxis (PrEP) use in Wroclaw, Poland, 2017-2023: a real-life experience

OBJECTIVES

The efficacy of pre-exposure prophylaxis (PrEP) relies on adherence to effective regimens. As data on real-life PrEP roll-out and efficacy from Central and Eastern Europe are scarce, we explored the HIV incident infections among PrEP users in an observational cohort in Poland.

METHODS

A cohort of 887 men having sex with men (MSM) on generic emtricitabine/tenofovir disoproxil (FTC/TDF) were followed for a cumulative 2587 person years (PY). HIV infection was confirmed using molecular and immunoassays, with subtype and genotyping performed at diagnosis. For phylogenetic analysis, we used 2087 HIV-1 A6 partial pol sequences from Poland as background.

RESULTS

Nine (1%) PrEP users acquired HIV during the follow-up period. The estimated HIV incidence was 0.347 per 100 PY, with a relative risk reduction of 90.9%. All users who acquired HIV were cisgender white MSM of European origin (median age: 35.5 years). The majority (eight out of nine) used PrEP on demand (ie, 2-1-1 schedule), with one using PrEP only before receptive and not insertive sexual contacts and seven skipping the double dose. Infections occurred due to inadequate PrEP dosing. In five (55.6%) and four (44.4%) users, subtypes B and A6 were acquired, respectively, with no drug resistance. Each of the four A6 sub-subtypes belonged to distinct clusters. Three of them had distinct regional origins within Poland and one in Ukraine. Users were started on tenofovir alafenamide/emtricitabine/bictegravir at a median of 10.5 days from diagnosis and reached undetectable viral load (<50 copies/mL) at a median of 63 days.

CONCLUSIONS

Overall, FTC/TDF PrEP was very effective, with failures occurring due to suboptimal adherence to on-demand dosing. Effective communication of HIV-related risks and clear instructions on how to use on-demand PrEP without missing doses should be provided to PrEP users. Despite the lack of transmitted drug resistance, we noted a higher number of infections with the A6 subtype and independent lineage introductions.

Perceived Access to HIV Prevention Services Amidst the COVID-19 Pandemic Among Men Who Have Sex with Men (MSM) and MSM Sex Workers in France, Russia, and Türkiye

This study examined the association between self-identification as a sex worker (SW) and perceived access to pharmacologic and non-pharmacologic HIV prevention methods among MSM in France, Russia, and Türkiye amidst the COVID-19 pandemic. Globally, 17,250 MSM recruited through a geosocial networking smartphone application completed the COVID-19 disparities survey, which was administered between October and November 2020. Approximately 38% of survey respondents were identified as living in France (n = 1269), Russia (n = 3882), and Türkiye (n = 3141) at the time of survey completion. Given the diverse sociodemographic factors and attitudes toward both MSM behavior and commercial sex work in these countries, we conducted a secondary analysis of survey data exploring the relationship between SW status and perceived access to pharmacologic and non-pharmacologic HIV prevention methods during the COVID-19 pandemic. Among respondents in Russia and France, MSM SW status was associated with a reduction in perceived access to condoms/lubricants (p = .001 in Russia, p < .001 in France). MSM SW in France were less likely to report never using PrEP as compared to non-SW peers (RR = 0.40, p = .005). Our findings highlight the disparities in access to HIV prevention for MSM SW living in these three countries during the COVID-19 pandemic. Based on our findings, COVID-19 may have exacerbated pre-existing inequities in HIV prevention among populations experiencing intersecting stigmas.

Engagement in Preexposure Prophylaxis Care at 1 Year Among Men Who Have Sex With Men Enrolled in the French ANRS PREVENIR Cohort Study

Background

We evaluated 1-year engagement in pre-exposure prophylaxis (PrEP) care and associated factors among gay, bisexual, and other men who have sex with men (GBMSM) in a large cohort of oral PrEP users in the Paris region, France.

Methods

We included in this analysis cisgender GBMSM enrolled in the ANRS PREVENIR cohort study from 3 May 2017 to 28 February 2019. We categorized 1-year PrEP engagement into 4 categories: high (consistent visits, attendance, and prescription refills at months 3, 6, 9, and 12), low (missed visits or no prescription refills), disengagement (PrEP discontinuation), and lost to follow-up. We used a logistic regression model to identify sociodemographic and behavioral factors associated with high engagement in PrEP care.

Results

Of 3211 participants, 2685 GBMSM were included in the analysis. At enrollment, participants had a median age of 36 years, with 88% born in Europe and 52.4% already undergoing PrEP. At month 12, 1612 (60.0%) participants met the high engagement definition, 438 (16.3%) exhibited low engagement, 459 (17.1%) disengaged from PrEP care, and 176 (6.6%) were lost to follow-up. In multivariable analysis, high engagement in PrEP care at 1 year was associated with older age (P < .001), being born in Europe (P = .01), having a higher education level (P = .05), already undergoing PrEP at enrollment (P < .001), having a bacterial sexually transmitted infection in the prior year (P = .01), earlier enrollment in the study (P = .04), and using PrEP daily or switching between PrEP regimens within the first year (P < .001).

Conclusions

Younger GBMSM, those born outside Europe, and those who were PrEP naive had lower engagement rates in the cohort, requiring tailored support.

Knowledge, Attitudes, and Perspectives of Women Who Have Migrated from Sub-Saharan Africa to France Toward HIV Pre-Exposure Prophylaxis in a Family Planning Center

Women who have migrated from sub-Saharan Africa (SSA) are underrepresented among HIV pre-exposure prophylaxis (PrEP) users in France (∼2%), yet they account for around 20% of new HIV infections annually. We conducted focus groups to explore the knowledge, attitudes, and perspectives of these women toward PrEP in a French family planning center (FPC). Focus groups occurred from November 2023 to February 2024 within the Lariboisière Hospital FPC in Paris. The social ecological model informed the discussion guide, which explored women's PrEP experiences and determinants for uptake on various levels. Five focus groups were conducted (N = 19). The median age of participants was 29 [interquartile range (IQR) 28-37]. Eight African countries were represented. The average time in France since migration was 3 (IQR 1-6) years. The majority of women had never heard of PrEP but expressed strong interest in learning more about it. Women underscored the difficulty of negotiating HIV prevention tools with their partners, risks from transactional sex, and barriers to PrEP use such as adherence challenges to daily pills and misconceptions about HIV transmission. There was strong interest in long-acting injectable PrEP. Women reported high trust in FPC providers and viewed the FPC as an ideal location to access PrEP. Conspiracy theories, cultural beliefs, and anticipated stigma were also identified as barriers to PrEP uptake. Most women advocated for disseminating PrEP information to their peers using diverse community outreach strategies. Despite a strong interest, increasing PrEP uptake in women from SSA will remain challenging without multi-faceted and adapted implementation strategies.

Pre-Exposure Prophylaxis for the Prevention of HIV-1: An Assessment of Oral Pre-Exposure Prophylaxis Usage Patterns, First Evidence of HIV-1, and HIV-1 Risk Factors in the United States

In clinical trials, once-daily oral tenofovir-based pre-exposure prophylaxis (PrEP) significantly reduced HIV-1 acquisition risk; however, this was highly dependent on medication adherence and persistence. We report clinical characteristics, PrEP usage patterns, first evidence of HIV-1, and associated risk factors among adults with commercial insurance using oral PrEP in the United States using health plan claims from the IQVIA PharMetrics® Plus database between January 1, 2015, and March 31, 2020, from individuals who newly initiated emtricitabine/tenofovir disoproxil fumarate (FTC/TDF) or FTC/tenofovir alafenamide (TAF) for daily PrEP. Overall, 25,419 individuals were included (FTC/TDF, n = 24,232; FTC/TAF, n = 1187), with generally similar characteristics reported during the 6-month baseline period across cohorts. Mean follow-up length was 504 and 77 days for FTC/TDF and FTC/TAF, respectively, corresponding with the 2019 approval of FTC/TAF for PrEP. Similarly, mean PrEP use duration was 354 and 68 days for FTC/TDF and FTC/TAF, respectively. PrEP breaks (>90-day gap) were observed in 11.1% of individuals using FTC/TDF, with a mean break duration of 249 days; 20.0% of individuals using FTC/TDF and 7.3% using FTC/TAF had ≥1 sexually transmitted infection diagnosis during follow-up. From 6 to 12 months of follow-up, mean FTC/TDF proportion of days covered (PDC; 0.74 vs. 0.67) and persistence (70.2% vs. 57.4%) decreased; real-world PDC and persistence were lower than reported in globally conducted clinical trials. First evidence of HIV-1 was infrequent among individuals using FTC/TDF (0.6%), though 60.3% had PrEP on hand when HIV-1 definition was met; high-risk sexual behavior, syphilis, and gonorrhea were the most important risk factors.

Mortality and comorbidities in a Nationwide cohort of HIV-infected adults: comparison to a matched non-HIV adults' cohort, France, 2006-18

BACKGROUND

Human immunodeficiency virus (HIV) remains a significant cause of morbidity and mortality worldwide. The aim of this study was to describe the mortality rate and associated comorbidities in a nationwide population-based cohort of persons living with HIV (PLWHIV) and to compare it with mortality in an age and gender-matched cohort of non-HIV individuals in France.

METHODS

Using data from the French national health data system, we identified and included 173 712 PLWHIV (66.5% men) and 173 712 non-HIV participants (66.5% men) matched for age and gender. PLHIV were identified based on ICD-10 HIV diagnoses, HIV-specific laboratory tests, and/or prescriptions for antiretroviral therapy specific to HIV. Hazard ratios (HRs) of mortality were assessed using multiple Cox regression models.

RESULTS

During the 13 years of follow-up (2006-18), we observed 20 018 deaths among PLWHIV compared with 6262 deaths among non-HIV participants (11.52% vs. 3.60%, P < 0.001). The over-mortality of PLWHIV was expressed by univariable HR = 2.135 (2.072-2.199), which remained significant after adjustment for region, Complementary Universal Health Insurance and AME, with multivariable HR = 2.182 (2.118-2.248). The results remained significant after adjusting for comorbidities, including infectious diseases [HR = 1.587 (1.538-1.638)]. Notably, PLWHIV were more importantly associated with mortality in women [HR = 2.966 (2.767-3.180)], compared in men [HR = 1.961 (1.898-2.027)].

CONCLUSION

Although the life expectancy of PLWHIV has globally increased, the causes of death should be prioritized in prevention policies and care management. Gender-specific policies should be highlighted, as we observed a higher impact of HIV mortality in women.

Pre-exposure prophylaxis (PrEP) use trajectories and incidence of HIV and other sexually transmitted infections among PrEP users in Belgium: a cohort analysis of insurance claims data from 2017 to 2019

BACKGROUND

Since June 2017, oral pre-exposure prophylaxis (PrEP) has been reimbursed in Belgium for people at substantial risk of HIV. To inform the national PrEP programme, we described sociodemographic characteristics of PrEP users, PrEP dispensing practices, testing for HIV and sexually transmitted infections (STIs; gonorrhoea, chlamydia and syphilis), and incidence of HIV and STIs.

METHODS

Analysis of routinely collected social health insurance claims data from all individuals who were dispensed at least one PrEP prescription between June 2017 and December 2019. Using logistic regression adjusted for age, we examined associations between sociodemographic characteristics and having been dispensed PrEP only once in the first six months of PrEP use.

RESULTS

Overall, 4559 individuals were dispensed PrEP. Almost all PrEP users were male (99.2%, 4522/4559), with a median age of 37 years (IQR 30-45). A minority were entitled to an increased healthcare allowance (11.4%, 514/4559). 18% (657/3636) were dispensed PrEP only once in the first six months of PrEP use. PrEP users younger than 25 years, unemployed, entitled to an increased healthcare allowance, and who initiated PrEP between January 2019 and June 2019 were more likely to have had no PrEP dispensing after initiation compared to their counterparts. The testing rates for bacterial STIs and HIV were 4.2 tests per person-year (95% CI 4.1-4.2) and 3.6 tests per person-year (95% CI 3.5-3.6), respectively. Twelve individuals were identified to have seroconverted during the study period, resulting in an HIV incidence rate of 0.21/100 person-years (95% CI 0.12-0.36). The incidence of bacterial STIs was 81.2/100 person-years (95% CI 78.7-83.8).

CONCLUSIONS

The study highlights challenges in PrEP persistence and a high incidence of bacterial STIs among individuals receiving PrEP. Tailored prevention support is crucial for individuals with ongoing HIV risk to optimise PrEP effectiveness. Integrated STI testing and prevention interventions within PrEP care are necessary to mitigate STI acquisition and transmission among PrEP users.

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.

Sexual behaviour and STIs among MSM living with HIV in the PrEP era: the French ANRS PRIMO cohort study

INTRODUCTION

In a context of declining condom use and high sexually transmitted infection (STI) incidence, the diffusion of "treatment as prevention" (Tasp) and more recently pre-exposure prophylaxis (PrEP) may have changed the sexual behaviour of newly diagnosed men who have sex with men (MSM) with HIV.

METHODS

Six hundred and nine MSM were enrolled and followed annually between 2014 and 2021 in the ANRS PRIMO Cohort (ClinicalTrials.gov:NCT03148964) from the time of HIV seroconversion. We studied changes over calendar time in sexual behaviour before and after HIV diagnosis. Factors associated with inconsistent condom use (ICU) after HIV diagnosis, PrEP use by partner(s) and bacterial STI acquisition were studied in random-effects models.

RESULTS

In the 6 months preceding HIV diagnosis, the number of sexual partners decreased from a median of 10 (IQR: 4-19) in 2014 to 6 (3-11) in 2021. After HIV diagnosis, ICU increased from 57.1% (16/28) of visits in 2014 up to 84.2% (229/272) in 2020-2021. Up to 25% (63/229) of MSM with HIV in recent years reported the use of PrEP by their partner(s) as the reason for ICU; these MSM were less frequently in a stable relationship, had a higher number of sexual partners and higher education level than those who did not report the use of PrEP by their partner(s). STI incidence after HIV diagnosis increased between 2014 and 2016 and remained high afterwards. STI risk was no longer associated with PrEP use by partners after adjustment for the number of partners and calendar period. ICU, age below 35 years, not being in a stable relationship, higher number of sexual partners were independently associated with an increased risk of STI.

CONCLUSIONS

Implementation of TasP and more recently PrEP has led to major changes in the sexual behaviour of MSM with HIV. ICU has become overwhelmingly prevalent, PrEP use by the partner increasingly being the reported reason for ICU, behind TasP, which remains the main reason. Characteristics of MSM at the time of diagnosis of HIV have changed, with fewer number of sexual partners today than in 2014, which must lead to broaden the indications for PrEP prescription. STIs incidence remains high in MSM with HIV and requires improvements in screening and prevention methods such as pre- or post-exposition antibiotics or vaccines.

[Daily use of HIV pre-exposure prophylaxis among gay, bisexual and other men who have sex with men in Spain: Prevalence and associated factors]

OBJECTIVE

We aim to estimate the prevalence of daily HIV pre-exposure prophylaxis (PrEP) use 6 months after public funding approval in Spain and identify associated factors in a national sample of gay, bisexual and other men who have sex with men (GBMSM).

MATERIAL AND METHODS

We analysed 4692 HIV-undiagnosed GBMSM men recruited via an online questionnaire distributed nationally via gay contact apps and websites between May and July 2020. We estimated the proportion of participants using daily PrEP and identified associated factors using Poisson regression with robust variance.

RESULTS

Daily PrEP use was reported by 2.8% (95% CI 2.3-3.3) of all participants. Daily PrEP use was independently associated with being recruited into community programmes, being older than 30 years, living in a large city, living with men, having condomless anal intercourse with more than 10 sexual partners, using drugs for sex, especially chemsex drugs, and being diagnosed with a sexually transmitted infection.

CONCLUSION

Six months after PrEP was approved in Spain, the prevalence of daily use is low in a national sample of GBMSM men. There is a need to promote access, demand and interest in PrEP, especially among young GBMSM men, those living in small and medium-sized cities, and those who hide their relationships with other men.

Time to Treatment Initiation and HIV Viral Suppression in People Diagnosed With HIV-1 During COVID-19 Pandemic in Ex-Aquitaine, France (ANRS CO3 AQUIVIH-NA Cohort-QuAliCOV Study)

OBJECTIVES

The COVID-19 pandemic's impact on initiation and effectiveness of antiretroviral therapy (ART) in people diagnosed with HIV remains unclear. We evaluated critical delays in HIV care in people diagnosed before and during the pandemic in ex-Aquitaine, France.

METHODS

We considered adults diagnosed with HIV-1 in 2018-2021 and enrolled in the ANRS CO3 AQUIVIH-NA and followed them until October 10, 2022 for those diagnosed during the pandemic (April 01, 2020-December 31, 2021) and until March 31, 2020 for historical controls. We compared their characteristics at inclusion and the median time between diagnosis and ART initiation, ART initiation and viral suppression, and diagnosis and virologic, suppression (effective management).

RESULTS

Eighty-three individuals were diagnosed during the pandemic versus 188 during the prepandemic period. Median follow-up was 549 (interquartile range: 329-713) days. Populations were similar in sex, age, HIV acquisition mode, hospital type, and clinical characteristics at diagnosis; however, fewer were foreign-born during the pandemic (15.7% versus 33.5%, P = 0.003). The probability of ART initiation, therapeutic success, and effective management was higher in people living with HIV (PLWH) diagnosed during the pandemic in adjusted analyses (hazard ratio [HR]: 2.0; 95% CI: 1.5 to 2.7; HR: 1.7; 95% CI: 1.2 to 2.3; HR: 1.8; 95% CI: 1.3 to 2.6, respectively). Those diagnosed during the pandemic were 2.3 (95% CI: 1.2 to 4.1) times more likely to be virologically suppressed within six months of diagnosis compared with historical controls.

CONCLUSIONS

Pandemic-related reorganizations may have resulted in newly diagnosed PLWH being prioritized; however, the lower proportion of foreign-born PLWH diagnosed during the pandemic period, likely because of reduced migration and potential delays in diagnosis, may contribute to these preliminary findings.

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.

Roll-out and effectiveness of HIV pre-exposure prophylaxis in France: An overview

CONTEXT

Oral HIV pre-exposure prophylaxis (PrEP) has been available and fully reimbursed for people at high risk of sexually acquired HIV infection in France since January 2016.

OBJECTIVE

To evaluate the roll-out of PrEP use in France and its real-life effectiveness. The main results of two previously published studies were presented at the second e-congress of the EPI-PHARE scientific interest group on pharmacoepidemiology and public decision support held in June 2022, and are reported in this article.

METHODS

Two studies were carried out using the French National Health Data System (SNDS) covering 99% of the French population. A first study aimed to evaluate the roll-out of PrEP use in France from its implementation until June 2021, globally over the entire study period, including an assessment of the impact of the coronavirus disease 2019 (COVID-19) pandemic that started in February 2020 in France. A second study using a nested case-control design was conducted in a cohort of men at high risk of HIV acquisition included between January 2016 and June 2020 to assess the effectiveness of PrEP in the real world.

RESULTS

As of 30 June 2021, a total of 42 159 people had initiated PrEP in France. Initiations increased steadily until February 2020, then slowed down sharply from the start of the COVID-19 pandemic and resumed from the first half of 2021. PrEP users were overwhelmingly men (98%), with an average age of 36 years, living in a large urban area (74%), and of whom a minority (7%) were socioeconomically disadvantaged. Throughout the study period, the level of PrEP maintenance from one semester to the next was high (80-90%). However, for 20% of PrEP initiators, no prescription renewals were recorded during the first six months, suggesting a substantial proportion of early treatment discontinuation. A minority (21%) of PrEP renewal prescriptions were made by private practitioners. Among 46 706 men at high risk of HIV infection, 256 patients identified with HIV infection were matched with 1213 controls. PrEP was used by 29% of cases and 49% of controls. Overall, PrEP effectiveness reached 60% (95% confidence interval 46% to 71%), and was increased in people with high PrEP use (93% (84% to 97%)), or after excluding periods of treatment discontinuation (86% (79% to 92%)). PrEP effectiveness was significantly reduced in people under 30 years of age (26% (-21% to 54%)) and in socioeconomically disadvantaged people (-64% (-392% to 45%)), for whom low PrEP uptake rates or high PrEP discontinuation rates were frequently observed.

CONCLUSION

PrEP roll-out has been strongly impacted by the COVID-19 pandemic in France. Although it has been substantial among men who have sex with men, additional measures are needed to expand access to PrEP to all other population groups that could benefit from it. Promoting adherence to PrEP (especially among young people and the socioeconomically disadvantaged) will be essential to ensure a higher level of PrEP effectiveness, which has been shown to be lower in real-life settings than in clinical trials.

Spatio-temporal changes in pre-exposure prophylaxis uptake among MSM in mainland France between 2016 and 2021: a Bayesian small area approach with MSM population estimation

INTRODUCTION

In France, oral pre-exposure prophylaxis (PrEP) for HIV prevention has been publicly available since 2016, mainly targeting at men who have sex with men (MSM). Reliable and robust estimations of the actual PrEP uptake among MSM on a localized level can provide additional insights to identify and better reach marginalized MSM within current HIV prevention service provision. This study used national pharmaco-epidemiology surveillance data and regional MSM population estimations to model the spatio-temporal distribution of PrEP uptake among MSM in France 2016-2021 to identify marginalized MSM at risk for HIV and increase their PrEP uptake.

METHODS

We first applied Bayesian spatial analyses with survey-surveillance-based HIV incidence data as a spatial proxy to estimate the size of (1) regional HIV-negative MSM populations and (2) MSM who could be eligible for PrEP use according to French PrEP guidelines. We then applied Bayesian spatio-temporal ecological regression modelling to estimate the regional prevalence and relative probability of the overall- and new-PrEP uptake from 2016 to 2021 across France.

RESULTS

HIV-negative and PrEP-eligible MSM populations vary regionally across France. Île-de-France was estimated to have the highest MSM density compared to other French regions. According to the final spatio-temporal model, the relative probability of overall PrEP uptake was heterogeneous across France but remained stable over time. Urban areas have higher-than-average probabilities of PrEP uptake. The prevalence of PrEP use increased steadily (ranging from 8.8% [95% credible interval 8.5%;9.0%] in Nouvelle-Aquitaine to 38.2% [36.5%;39.9%] in Centre-Val-de-Loire in 2021).

CONCLUSIONS

Our results show that using Bayesian spatial analysis as a novel methodology to estimate the localized HIV-negative MSM population is feasible and applicable. Spatio-temporal models showed that despite the increasing prevalence of PrEP use in all regions, geographical disparities and inequalities of PrEP uptake continued to exist over time. We identified regions that would benefit from greater tailoring and delivery efforts. Based on our findings, public health policies and HIV prevention strategies could be adjusted to better combat HIV infections and to accelerate ending the HIV epidemic.