Daily and on-demand HIV pre-exposure prophylaxis with emtricitabine and tenofovir disoproxil (ANRS PREVENIR): a prospective observational cohort study

Rectal Douche as HIV Pre-Exposure Prophylaxis for Receptive Anal Intercourse: An End User Tenofovir Powder Sachet Preparation Feasibility Study (DREAM-04)

BACKGROUND

Unprotected receptive anal intercourse carries the highest sexual HIV transmission risk. The need for diverse pre-exposure prophylaxis (PrEP) options has encouraged the development of on-demand, topical PrEP products for those preferring nonsystemic or occasional PrEP. We assessed end users' proficiency in preparing tenofovir douches from sachets containing 2 different powder types, lyophilized and spray dried, and evaluated their experience.

METHODS

Cisgender adult men with a history of RAI-related douching were consented, screened, and randomized 1:1 to the order of the powder type prepared. All participants prepared at least 3 enema bottles of each powder type. Aliquots from each prepared douche bottle were analyzed for tenofovir (TFV) concentration, osmolality, and pH. User experience and likelihood of future product use were assessed by questionnaire.

RESULTS

Twenty-one eligible participants were enrolled. Most participants reported both products as easy or very easy to prepare and likely or very likely to be used. Participants preferred the lyophilized product. The lyophilized and spray-dried douche bottles prepared met the osmolality specifications 89% and 61% of the time and TFV content specifications 81% and 29% of the time, respectively. Questionnaires indicated the most common challenges were tearing open the sachets and transferring the spray-dried product.

CONCLUSIONS

Most participants reported the douches were easy to prepare and indicated likely future use. Although the lyophilized sachets were prepared sufficiently to establish preparation feasibility, the spray-dried sachets often fell outside specifications. Failure analysis provided insights to guide product modifications to improve the proficiency of douche preparation and future product use.

A Competing Risks Duration Model to Study PrEP Discontinuation Among MSM in France: The ERAS 2023 Study

Although PrEP prevents HIV among at-risk populations, high discontinuation rates hinder its effectiveness. We investigated three reasons for PrEP discontinuation in real-life settings in France and associated factors, in order to assess weariness taking PrEP. We used data from the French online survey Enquête Rapport au Sexe 2023 which targeted gay and bisexual men having sex with men (GBMSM). First, we constructed the outcome 'PrEP duration'. Second, we created a three-category 'reason for PrEP discontinuation' variable as follows: changes in sexual behaviors, a desire to discontinue PrEP, and clinical reasons. Third, we calculated PrEP survival probability. We then performed a Weibull accelerated failure time model with competing risks to assess how the duration of time on PrEP influenced discontinuation, and whether specific factors were associated with different discontinuation reasons. The analysis included 4819 GBMSM. Median PrEP duration was 19 months. Discontinuation because of changes in sexual behaviors was less likely among GBMSM who initiated PrEP prescription in a sexual health structure (AF = 0.604 [0.424-0.858]). A desire to stop PrEP was more likely among those living in regions with the lowest reported seropositivity rates (AF = 2.320 [1.054-5.107]). Discontinuing PrEP for clinical reasons was more likely among participants coming from smaller municipalities (AF = 2.312 [1.099-4.868]). PrEP duration dependence was negative for all three reasons, implying that the longer the time taking PrEP, the lower the probability of discontinuation. We found no weariness with PrEP use among GBMSM; this highlights the need to detail specific factors associated with PrEP discontinuation.

Acceptability of public health information and prevention measures by gay men, bisexual men and men who have sex with men during the French Mpox outbreak in 2022: the ANRS-MPX-SHS cross-sectional survey

OBJECTIVES

This study investigated the acceptability by gay men, bisexual men and other men who have sex with men (GBMSM) of French public health information and prevention measures implemented during the 2022 Mpox outbreak.

METHODS

ANRS-MPX-SHS "Mpox: perception of risks, health measures and vaccination" is a cross-sectional survey conducted in GBMSM between July and September 2022. Online questionnaires collected information about Mpox-related awareness, perceptions and prevention behaviours. Multiple correspondence analysis identified participant profiles according to their level of acceptability of the information and prevention measures implemented during the 2022 outbreak. The study outcome was a variable grouping participants into three profiles: 'strong endorsers', 'uninformed hesitant endorsers' and 'indifferent objectors'. Multinomial logistic regression was used to estimate factors associated with each profile.

RESULTS

Of the 5688 participants, 5320 (93.5%) had available data for the outcome. The latter were mostly cisgender men (98%), aged between 35 and 54 years (54.5%), with tertiary education (82%); 44% were living in the Greater Paris region. Strong endorsers, uninformed hesitant endorsers and indifferent objectors accounted for 77.8%, 14.4% and 7.8% of the sample, respectively. Participants with tertiary education, those who had sex exclusively with men, those taking pre-exposure prophylaxis (ie, HIV-negative participants), HIV-positive participants and individuals living in the Greater Paris region, were all less likely to be uninformed hesitant endorsers or indifferent objectors. Participants with no lifetime HIV/sexually transmitted infection (STI) screening and those with infrequent screening were, respectively, more likely to belong to these two profiles.

CONCLUSIONS

Participants' acceptability of the information and prevention measures implemented during the 2022 Mpox outbreak in France depended on the perceived capability of public health authorities to effectively diversify information targets, representations and communication channels. In order to prevent the transmission of Mpox (and other STIs) in the general population in future outbreaks, information and measures adopted must take into account the needs, perceptions and experiences of persons never or not regularly screened for HIV/STIs.

Measurements of tenofovir-diphosphate and emtricitabine-triphosphate concentrations in dried blood spots of people receiving pre-exposure prophylaxis for HIV with co-formulated tenofovir disoproxil fumarate and emtricitabine

BACKGROUND/PURPOSE(S)

Data regarding the concentrations of tenofovir-diphosphate (TFV-DP) and emtricitabine-triphosphate (FTC-TP) in the Asian population receiving pre-exposure prophylaxis (PrEP) for HIV with tenofovir disoproxil fumarate (TDF) and emtricitabine (FTC) (TDF/FTC) are limited, and the associations between the frequency of TDF/FTC administration and drug concentration among people receiving on-demand PrEP remain unclear.

METHODS

Fifty-seven participants receiving daily TDF/FTC and 113 participants receiving on-demand TDF/FTC were enrolled in this study. The concentrations of TFV-DP and FTC-TP were measured in dried blood spots using liquid chromatography‒mass spectrometry.

RESULTS

Thirty-six (62.2 %) daily PrEP users and 38 (33.6 %) on-demand PrEP users achieved TFV-DP concentrations ≥700 fmol/punch. Higher proportions of undetectable FTC-TP were observed in participants whose TFV-DP concentrations were ≤350 fmol/punch, regardless of the frequency of TDF/FTC administration. In participants who used on-demand PrEP, the TFV-DP and FTC-TP concentrations were moderately correlated with the TDF/FTC tablets taken when sampling was performed within 12-24 h after the last dose of TDF/FTC (R = 0.63, p = 0.006 and R = 0.75, p = 0.0005). In addition, on-demand PrEP users who had received 8 tablets within the last 28 days had a median TFV-DP concentration similar to that of those participants who had received 16 tablets (544.6 vs. 556.9 fmol/punch, p > 0.99).

CONCLUSIONS

These results underscore the importance of well-controlled sampling times for obtaining reliable TFV-DP and FTC-TP concentrations to estimate the adherence and effectiveness of on-demand PrEP.

HIV pre-exposure prophylaxis re-initiation among men who have sex with men: a multi-center cohort study in China

Background Data on persistent use of HIV pre-exposure prophylaxis (PrEP) is limited among Chinese men who have sex with men (MSM). This study aimed to explore factors associated with the re-initiation of PrEP among Chinese MSM from a longitudinal PrEP demonstration trial. Methods A multi-center cohort study was conducted in Guangzhou and Wuhan, China (September 2021-2024), providing 1134 MSM participants with a 12-month dosage of tenofovir disoproxil fumarate and emtricitabine (TDF/FTC) as oral PrEP. Following the trial, a subgroup of participants were invited to complete a 3-month post-trial follow-up survey. These participants were categorized on the basis of self-reported PrEP use patterns into (1) continued PrEP use, (2) discontinued without re-initiation, and (3) re-initiated after discontinuation. Log-binomial regression models were used to assess factors associated with PrEP re-initiation. Results Out of 408 participants who completed the 3-month post-trial follow-up survey, 70.1% (n =286/408) reported discontinuing PrEP, and 50.7% (n =145/286) of those who discontinued subsequently re-initiated PrEP. Participants who had concurrent sexual partnerships (adjusted risk ratio [aRR]=1.47, 95% CI: 1.11-1.96), used drugs during sex (aRR=1.34, 95% CI: 1.09-1.65), or lived alone (aRR=1.29, 95% CI: 1.03-1.61) were more likely to re-initiate PrEP. The Likert scale analysis indicated that perceived partner influence, specifically the expectation of condomless sex, played a significant role in re-initiation decisions (P =0.03). Conclusion Individuals engaging in higher-risk behaviors are more likely to re-initiate PrEP, highlighting the dynamic nature of risk perception. Future interventions should focus on promoting both re-initiation and consistent condom use, emphasizing partner-related dynamics and substance use as key factors in PrEP decisions among MSM.

Pre-exposure prophylaxis program in the Community of Madrid: Two years of experience

INTRODUCTION

Pre-exposure prophylaxis (PrEP) against the human immunodeficiency virus (HIV) is an effective and safe preventive measure. However, it has not reached all target users who could benefit from it. The study aimed to understand the sociodemographic, clinical and behavioral baseline characteristics of PrEP users. As a secondary objective, the use of concomitant medication and drug consumption were described.

METHODOLOGY

Observational, retrospective and descriptive study of the sociodemographic, clinical and behavioral characteristics of the users who were included in the PrEP program of the Community of Madrid during the first two years of experience.

RESULTS

Two thousand two hundred fifty-six PrEP users were included, 99.0% men, with a mean age of 36.9 years (SD 8.68). 33.1% presented a sexually transmitted infection (STI) on the first visit, highlighting chlamydiasis and rectal gonococci. 70.4% reported using drugs associated with sex, and 42.4% participated in chemsex sessions in the last 3 months. A high percentage of users with concomitant medication was observed (37.6%), highlighting drugs related to mental health and alopecia.

CONCLUSIONS

A multidisciplinary approach is required to cover all the needs of PrEP users, including mental health evaluation measures and addiction treatment with the clinical approach.

Rapid HIV pre-exposure prophylaxis (PrEP) initiation is safe and feasible: Experience from Wroclaw All Saints cohort in Poland 2017-2021

INTRODUCTION

HIV pre-exposure prophylaxis (PrEP) still faces many barriers around the world. Additional barriers such as retesting or rescheduling for result analysis and prescription might lead to abandoning PrEP initiation altogether. We wanted to explore whether there would be a significant number of alert issues among people starting PrEP that would warrant more in-depth clinical analysis before commencing PrEP safely.

METHODS

A retrospective medical data analysis of people who started PrEP at All Saints Clinic in Wroclaw, Poland between October 2017 and January 2021 was performed. Rapid (during the first visit) or delayed PrEP initiation was chosen at the discretion of the attending physician.

RESULTS

A total of 308 people started PrEP in the analysed period and were included in the analysis. The median age was 33 years with 96.75% being men who have sex with men (MSM) and 68.5% opting for daily dosing at PrEP initiation. Most (n=233) started PrEP rapidly (i.e., during the first visit), whereas for 75 individuals the initiation was delayed by a median of 7 days. Logistic regression analysis showed that lack of test laboratory results, recent exposure or age over 50 years were reasons for delaying PrEP initiation. Median creatinine values increased from 0.93 mg/mL to 0.95 mg/mL 1 month after PrEP initiation. Despite being statistically significant (p = 0.0282, 95% CI 0.0015-0.027), the difference was not significant clinically.

CONCLUSIONS

Rapid PrEP initiation was feasible and safe while contraindications were rare. HIV infection exclusion before PrEP initiation can be streamlined by utilizing remote consultations and patient self-interpretation of the results. Renal complications are either not clinically significant or occur rarely.

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.

Effectiveness of MenB-4C Vaccine Against Gonorrhea: A Systematic Review and Meta-analysis

BACKGROUND

There is no licensed vaccine against gonorrhea, but Neisseria meningitidis serogroup B outer membrane vesicle-based vaccines, such as MenB-4C, may offer cross-protection against gonorrhea. This systematic review and meta-analysis synthesized the published literature on MenB-4C vaccine effectiveness against gonorrhea.

METHODS

We conducted a literature search of electronic databases (PubMed, Medline, Embase, Global Health, Scopus, Google Scholar, CINAHL, and Cochrane Library) to identify peer-reviewed articles published in English from 1 January 2013 to 11 September 2024 that reported MenB-4C vaccine effectiveness estimates against gonorrhea and gonorrhea/chlamydia coinfection and the duration of MenB-4C vaccine-induced protection. We estimated pooled MenB-4C vaccine effectiveness (≥1 dose) against gonorrhea using the DerSimonian-Laird random effects model.

RESULTS

Eight articles met our eligibility criteria. Receipt of ≥1 dose of MenB-4C vaccine was 23% to 47% effective against gonorrhea. Two doses of MenB-4C vaccine were 33% to 40% effective against gonorrhea, and 1 dose of MenB-4C vaccine was 26% effective. MenB-4C vaccine effectiveness against gonorrhea/chlamydia coinfection was mixed, with 2 studies reporting effectiveness estimates of 32% and 44% and 2 other studies showing no protective effect. MenB-4C vaccine effectiveness against gonorrhea was comparable in people with HIV (44%) and people without HIV (23%-47%). Pooled MenB-4C vaccine effectiveness (≥1 dose) against gonorrhea was 32.4%. One study concluded that MenB-4C vaccine effectiveness against gonorrhea may wane approximately 36 months postvaccination.

CONCLUSIONS

MenB-4C vaccine is moderately effective against gonorrhea in various populations. Prospective clinical trials that assess the efficacy of MenB-4C against gonorrhea, gonorrhea/chlamydia coinfection, and duration of protection are warranted to strengthen this evidence.

Benefits of HIV-1 transmission cluster surveillance: a French retrospective observational study of the molecular and epidemiological co-evolution of recent circulating recombinant forms 94 and 132

INTRODUCTION

Molecular surveillance is an important tool for detecting chains of transmission and controlling the HIV epidemic. This can also improve our knowledge of molecular and epidemiological factors for the optimization of prevention. Our objective was to illustrate this by studying the molecular and epidemiological evolution of the cluster including the new circulating recombinant form (CRF) 94_cpx of HIV-1, detected in 2017 and targeted by preventive actions in 2018.

METHODS

In June 2022, 32 HIV-1 sequence databases from French laboratories were screened to identify all individuals who had acquired CRF94_cpx or a similar strain, whatever the date of diagnosis. Phylogenetic analyses were performed with the sequences identified, and biological parameters were collected at the time of diagnosis and after the start of treatment to analyse the evolution of the cluster. Full genomes were sequenced to characterize the new strains.

RESULTS

We analysed 98 HIV-1 isolates: 63 were CRF94, three were unclassifiable, and the other 32 formed a new cluster containing a new recombinant, CRF132_94B, derived from CRF94 and a subtype B strain. At least 95% of the individuals in both the CRF94 and CRF132 clusters were men who have sex with men (MSM), most of whom had acquired HIV less than 12 months before diagnosis. The number of CRF94 diagnoses declined drastically after 2018, but CRF132 strains spread widely between 2020 and 2022, into a different area of Ile-de-France region and within a younger population nevertheless aware of pre-exposure prophylaxis. Higher viraemia, lower CD4 cell counts and delayed treatment efficacy suggested that CRF94 was more virulent than CRF132, possibly due to the F subtype fragment of the vif gene.

CONCLUSIONS

These findings highlight the role of the MSM transmission cluster in spreading HIV and new variants. They show also the benefits of cluster surveillance for improving the targeting of preventive interventions, detecting the emergence of new strains and enriching our knowledge on virulence mechanisms. However, these investigations require support with sufficient resources dedicated to a regional or national programme to be responsive and effective.

Event-driven PrEP beyond cisgender men who have sex with men

Despite advancements in existing antiretroviral-based prevention strategies, including daily oral, locally acting, and injectable options, there is a pressing need for more inclusive and flexible event-driven pre-exposure prophylaxis (PrEP) strategies for all. Event-driven or intermittent dosing of PrEP in populations beyond cisgender men who have sex with men would offer a promising alternative by fitting prevention into the diverse lifestyles of affected populations and thereby advancing health equity. Evidence from PrEP clinical trials, pharmacokinetic studies, modelling studies, and real-world observational research suggests that event-driven PrEP could be a flexible and inclusive option, yet optimal dosing has not been established across sex and gender spectrums. To advance PrEP equity through inclusivity, studies on event-driven PrEP should include people across the gender spectrum. Real-world demonstration studies and simulation studies of optimal dosing strategies are needed. While awaiting further evidence, clinical providers can offer shared decision making and counselling on available data to include event-driven dosing as an option, especially when daily oral, locally acting, or injectable PrEP are not acceptable or preferred methods. Wider access to diverse PrEP options for all populations fosters a more inclusive and effective global HIV prevention strategy.

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.

Brief Report: Gaps in HIV Preexposure Prophylaxis Acceptance: Findings From an Outpatient HIV Testing Service in Italy

BACKGROUND

The aim of this study is to assess the acceptability of HIV preexposure prophylaxis (PrEP) among individuals eligible for prophylaxis.

SETTING

Retrospective study of individuals receiving their first HIV test at the Infectious Diseases Unit of IRCCS San Raffaele Scientific Institute, Milan, Italy.

METHODS

People (1) who received their first HIV test (baseline date) between January 2018 (availability of PrEP in Italy) and December 2023 (data lock) and (2) with an indication for PrEP based on condomless sex were included; those already on PrEP were excluded. Individuals with a negative HIV test result were offered PrEP counseling and prescription according to guidelines. Characteristics of people who accepted or declined HIV PrEP were compared using Mann-Whitney or χ 2 tests, as appropriate.

RESULTS

A total of 2627 people were tested for HIV: 175 (6.6%) were diagnosed with HIV. Of the 2452 people with negative HIV test results, 2165 (88.3%) were men; median age was 34.3 years (interquartile range = 28.7-42.4). Sexually transmitted infections were detected in 478 of 2452 (19.5%) people, most commonly gonorrhea (206/2452, 8.4%). Overall, 982 of 2452 (40.0%) people accepted PrEP, including only 3 women. Nonacceptance was higher among women ( P < 0.001) and non-White ( P < 0.001). Of those who did not accept PrEP, 260 (17.7%) were diagnosed with at least 1 sexually transmitted infection at the time of HIV testing.

CONCLUSIONS

Low PrEP acceptance was observed, particularly among women and people of non-White origin. Nonacceptance of PrEP was also observed among individuals diagnosed with an sexually transmitted infection.

Update on HIV Chemoprevention

Despite rapid advances in the field of HIV prevention and treatment, unacceptably high global HIV incidence rates highlight the ongoing need for effective HIV prevention interventions for populations at risk for HIV acquisition. This article provides an updated review of the current data surrounding HIV prevention strategies, including treatment as prevention (TasP), preexposure prophylaxis (PrEP), and postexposure prophylaxis (PEP), as well as advances in sexually transmitted infection biomedical prevention. This review provides an overview of the multiple PrEP modalities that are available globally, such as oral PrEP, injectable cabotegravir, and the dapivirine vaginal ring, and describes their respective clinical trials, efficacies, and regulatory approvals. We also discuss ongoing research into novel PrEP agents, such as broadly neutralizing antibodies, and efforts toward HIV vaccine development.

PrEP Use in a US National Sample of Trans Men and Other Transmasculine People Who Have Sex With Men: A Longitudinal Analysis

INTRODUCTION

Efforts to improve pre-exposure prophylaxis (PrEP) uptake among gay men, transgender women, and Black cisgender women are evident across the United States, responding to epidemiologic data showing a disproportionate HIV burden in these communities. However, transgender men and other transmasculine people who have sex with men (TMSM)-those assigned female at birth who identify otherwise and have sex with cisgender men-are often excluded from these statistics. This community has unique vulnerabilities and prevention needs. National HIV prevention and planning has yet to include transgender men as a group with increased vulnerability to HIV seroconversion. This study follows a cohort of TMSM to characterize PrEP use longitudinally.

METHODS

Using data from a prospective US national cohort of TMSM not on PrEP, we analyzed annual PrEP uptake, discontinuation, and other HIV prevention measures over 24 months. We also used generalized estimating equations modeling to assess demographic, healthcare access, gender-affirming, and behavioral factors associated with PrEP uptake over time.

RESULTS

Our cohort of 196 TMSM was demographic and regionally diverse. 29% of our sample reported uptake of PrEP in 24 months, with about one-third of users discontinuing within 1 year. Health insurance, having had lower surgery, used post-exposure prophylaxis, or recently having a sexually transmitted infection were associated with increased odds of PrEP use.

CONCLUSION

We found low uptake of PrEP and high discontinuation rates in a US national sample of TMSM over 24 months, despite significant need for HIV prevention. It is vital to increase efforts and investments to support this neglected community.

Increasing event-driven HIV pre-exposure prophylaxis use among gay, bisexual and other men who have sex with men in Australia: results from behavioural surveillance 2019-2023

INTRODUCTION

HIV pre-exposure prophylaxis (PrEP) has been publicly available since 2018 in Australia as a daily regimen. In 2019, clinical guidelines were updated to support guidance on event-driven PrEP (ED-PrEP) use. We assessed trends in the PrEP dosing regimen by comparing daily PrEP use to ED-PrEP among cisgender gay, bisexual and other men who have sex with men (GBMSM).

METHODS

Data from repeated, cross-sectional, national behavioural surveillance surveys were analysed from 2019 to 2023 among participants not living with HIV. Logistic regression models were conducted to assess trends and compared ED-PrEP users to non-PrEP users and daily PrEP.

RESULTS

Among 38,880 participants, overall PrEP use with any regimen increased from 27.6% in 2019 to 42.7% in 2023 (OR = 1.16, 95% CI = 1.15-1.18, p < 0.001). Among 12,922 participants who reported PrEP use in the last 6 months, the proportion reporting ED-PrEP use increased from 7.6% in 2019 to 27.8% in 2023 (OR = 1.41, 95% CI = 1.37-1.46, p < 0.001) with those who reported daily PrEP decreasing from 92.4% to 63.3% (OR = 0.64, 95% CI = 0.62-0.66, p < 0.001). In a cross-sectional sub-sample in 2022-2023 (n = 8840), compared to ED-PrEP users, non-PrEP users were less likely to have received three or more HIV tests in the last 12 months (aRRR = 0.26, 95% CI = 0.22-0.31, p < 0.001), have 2-10 male sexual partners in the last 6 months (aRRR = 0.24, 95% CI = 0.14-0.41, p < 0.001) or 11 or more (aRRR = 0.26, 95% CI = 0.15-0.45, p < 0.001) compared to none, or to report condomless anal intercourse with casual partners (aRRR = 0.38, 95% CI = 0.32-0.46, p < 0.001). Compared to ED-PrEP users, daily PrEP users were more likely to have received three of more HIV tests in the last year (aRRR = 3.73, 95% CI = 3.15-4.40, p < 0.001) and less likely to be born overseas and lived in Australia for less than 5 years compared to being born in Australia (aRRR = 0.64, 95% CI = 0.49-0.83, p = 0.001).

CONCLUSIONS

While daily PrEP remains the most common PrEP dosing regimen among GBMSM in Australia, there has been a steep increase in the proportion of PrEP users who are taking ED-PrEP. Monitoring of PrEP use should continue to adapt to new dosing methods and future PrEP options. As ED-PrEP use increases, further work is needed to ensure those taking ED-PrEP are taking it effectively to prevent HIV.

Interest in event-driven PrEP among men who have sex with men using daily PrEP in Mexico in 2019-2020: a cross-sectional assessment in a large-scale demonstration project

This study aimed to evaluate the interest in event-driven PrEP (ED-PrEP) among men who have sex with men (MSM) using daily PrEP in Mexico's PrEP demonstration project between 2019 and 2020. We compared participants interested or not in ED-PrEP during their first-month visit and identified associated factors. Of 1,021 MSM attending their first-month visit, 7% had previous knowledge of ED-PrEP, but 40% were interested in ED-PrEP. However, over 50% perceived the scheme as less protective than daily PrEP. Having doubts about ED-PrEP's level of protection was related to less interest in the scheme (aOR = 0.11; CI = 0.07-0.18), just like reporting perceived barriers such as having frequent sex (aOR = 0.06; CI = 0.03-0.14), unplanned sex (aOR = 0.17; CI = 0.11-0.27), forgetting the medicine (aOR = 0.06; CI = 0.03-0.12), or difficulty carrying the medicine (aOR =   0.13; CI = 0.07-0.25). Finally, reporting not taking PrEP for >20 days in the last month (aOR = 0.05; CI = 0.01-0.27) diminished interest in ED-PrEP. In conclusion, few MSM daily PrEP users knew about ED-PrEP yet many were interested in it, suggesting the importance of awareness campaigns regarding ED-PrEP's effectiveness. The lack of interest in ED-PrEP among participants with poor adherence to daily PrEP indicates that they might prefer long-acting PrEP or HIV prevention strategies without medication.

Dynamic choice HIV prevention with cabotegravir long-acting injectable in rural Uganda and Kenya: a randomised trial extension

BACKGROUND

HIV infections are ongoing globally despite efficacious biomedical prevention options. We sought to determine whether an HIV prevention package providing choice of daily pills or long-acting injectable cabotegravir and opportunities to change prevention options could increase biomedical prevention coverage and reduce new HIV infections.

METHODS

This study was an extension of three randomised trials that used SEARCH dynamic choice HIV prevention to recruit adults (aged ≥15 years) at risk for HIV from antenatal, outpatient, and community settings in rural Uganda and Kenya. In this 48-week open-label extension, participants maintained their original (1:1) randomisation group; the option to choose cabotegravir long-acting injectable was added for intervention participants. Inclusion criteria for the extension were previous enrolment in a SEARCH dynamic choice HIV prevention trial, negative HIV rapid test, and residence in study region. The intervention provided person-centred choice of oral pre-exposure prophylaxis (PrEP) or post-exposure HIV prophylaxis (PEP) or cabotegravir long-acting injectable, with the option to switch according to participant preference. The control provided standard-of-care access to oral PrEP and PEP, but not cabotegravir long-acting injectable. Biomedical prevention coverage (proportion of follow-up covered by oral PrEP, PEP, or cabotegravir long-acting injectable; primary outcome) and HIV incidence (secondary outcome) were compared between groups using targeted minimum loss-based estimation. The trial (NCT05549726) is closed to recruitment.

FINDINGS

Of 1534 participants initially randomly assigned (from April 15, 2021 to Sept 29, 2022), 984 (487 in the intervention group and 497 in the standard-of-care group) reconsented to the extension (from Jan 2 to March 3, 2023). The mean proportion of follow-up covered by biomedical HIV prevention was 69·7% (95% CI 64·9-74·5) in the intervention group versus 13·3% (10·2-16·3) in the standard-of-care group, corresponding to an absolute difference of 56·4 percentage points (95% CI 50·8-62·1; p<0·0001). The intervention significantly improved coverage across prespecified subgroups (sex and age groups). During the study, 274 (56%) of 485 intervention participants used cabotegravir long-acting injectable, 255 (53%) used oral PrEP, and ten (2%) used PEP. Among cabotegravir long-acting injectable initiators, 118 (43%) of 274 were not previously using oral PrEP or PEP. There were seven incident HIV infections in 390 person-years of follow-up in the standard-of-care group and no infections in 400 person-years of follow-up in the intervention group (incidence rate difference per 100 person-years 1·8, 95% CI 0·4-3·2; p=0·014).

INTERPRETATION

Offering people the choice of HIV biomedical prevention options including cabotegravir long-acting injectable in a flexible model can increase prevention coverage and reduce incident HIV infections. HIV programmes should support dynamic choice HIV prevention programmes that include effective oral and injectable long-acting products.

FUNDING

National Institutes of Health.

Modeling of HIV-1 prophylactic efficacy and toxicity with islatravir shows non-superiority for oral dosing, but promise as a subcutaneous implant

HIV prevention with pre-exposure prophylaxis (PrEP) constitutes a major pillar in fighting the ongoing epidemic. While daily oral PrEP adherence may be challenging, long-acting (LA-)PrEP in oral or implant formulations could overcome frequent dosing with convenient administration. The novel drug islatravir (ISL) may be suitable for LA-PrEP, but dose-dependent reductions inCD 4 + T cell and lymphocyte counts were observed at high doses. We developed a mathematical model to predict ISL pro-drug levels in plasma and active intracellular ISL-triphosphate concentrations after oral vs. subcutaneous implant dosing. Using phase II trial data, we simulated antiviral effects and estimated HIV risk reduction for multiple dosages and dosing frequencies. We then established exposure thresholds where no adverse effects on immune cells were observed. Our findings suggest that implants with 56-62 mg ISL offer effective HIV risk reduction without reducing lymphocyte counts. Oral 0.1 mg daily, 3-5 mg weekly, and 10 mg biweekly ISL provide comparable efficacy, but weekly and biweekly doses may affect lymphocyte counts, while daily dosing regimen offered no advantage over existing oral PrEP. Oral 0.5-1 mg on demand provided> 90 % protection, while not being suitable for post-exposure prophylaxis. These findings suggest ISL could be considered for further development as a promising and safe agent for implantable PrEP.

Doxycycline prophylaxis and meningococcal group B vaccine to prevent bacterial sexually transmitted infections in France (ANRS 174 DOXYVAC): a multicentre, open-label, randomised trial with a 2 × 2 factorial design

BACKGROUND

Increased rates of sexually transmitted infections (STIs) are reported among men who have sex with men (MSM) and new interventions are needed. We aimed to assess whether post-exposure prophylaxis (PEP) with doxycycline could reduce the incidence of chlamydia or syphilis (or both) and whether the meningococcal group B vaccine (4CMenB) could reduce the incidence of gonorrhoea in this population.

METHODS

ANRS 174 DOXYVAC is a multicentre, open-label, randomised trial with a 2 × 2 factorial design conducted at ten hospital sites in Paris, France. Eligible participants were MSM aged 18 years or older, HIV negative, had a history of bacterial STIs within the 12 months before enrolment, and who were already included in the ANRS PREVENIR study (a cohort of MSM using pre-exposure prophylaxis with tenofovir and emtricitabine for HIV prevention). Participants were randomly assigned (2:1) to doxycycline PEP (two pills of 100 mg each orally within 72 h after condomless sex, with no more than three doses of 200 mg per week) or no PEP groups and were also randomly assigned (1:1) to the 4CMenB vaccine (GlaxoSmithKline, Paris, France; two intramuscular injections at enrolment and at 2 months) or no vaccine groups, using a computer-generated randomisation list with a permuted fixed block size of four. Follow-up occurred for at least 12 months (with visits every 3 months) up to 24 months. The coprimary outcomes were the risk of a first episode of chlamydia or syphilis (or both) after the enrolment visit at baseline for the doxycycline intervention and the risk of a first episode of gonorrhoea starting at month 3 (ie, 1 month after the second vaccine dose) for the vaccine intervention, analysed in the modified intention-to-treat population (defined as all randomly assigned participants who had at least one follow-up visit). This trial is registered with ClinicalTrials.gov, NCT04597424 (ongoing).

FINDINGS

Between Jan 19, 2021, and Sept 19, 2022, 556 participants were randomly assigned. 545 (98%) participants were included in the modified intention-to-treat analysis for the doxycycline PEP and no PEP groups and 544 (98%) were included for the 4CMenB vaccine and no vaccine groups. The median follow-up was 14 months (IQR 9-18). The median age was 40 years (34-48) and all 545 participants were male. There was no interaction between the two interventions (p≥0·1) for the primary outcome. The incidence of a first episode of chlamydia or syphilis (or both) was 8·8 per 100 person-years (35 events in 362 participants) in the doxycycline PEP group and 53·2 per 100 person-years (80 events in 183 participants) in the no PEP group (adjusted hazard ratio [aHR] 0·17 [95% CI 0·12-0·26]; p<0·0001). The incidence of a first episode of gonorrhoea, starting from month 3 was 58·3 per 100 person-years (103 events in 274 participants) in the 4CmenB vaccine group and 77·1 per 100 person-years (122 events in 270 participants) in the no vaccine group (aHR 0·78 [95% CI 0·60-1·01]; p=0·061). There were no deaths during the study. One drug-related serious adverse event (fixed-drug eruption) occurred in the doxycycline PEP group. Six (2%) participants in the doxycycline group discontinued doxycycline PEP because of gastrointestinal adverse events.

INTERPRETATION

Doxycycline PEP strongly reduced the incidence of chlamydia and syphilis in MSM, but we did not show efficacy of the 4CmenB vaccine for gonorrhoea. Doxycycline PEP should be assessed in other populations, such as heterosexual men and women, and its effect on antimicrobial resistance carefully monitored.

FUNDING

ANRS Maladies Infectieuses Emergentes.

TRANSLATION

For the French translation of the abstract see Supplementary Materials section.

Impact of vaccination with third generation modified vaccinia Ankara and sexual behaviour on mpox incidence in men who have sex with men: analysis among participants of the ANRS-174 DOXYVAC trial

Background

Mpox was first reported in France on May 19 and third-generation live Modified Vaccinia Ankara (MVA-BN) vaccination of multiple-partner men who have sex with men (MSM) was recommended as of July 11, 2022. We assessed the impact of vaccination and of sexual behavior adopted during the epidemic period on mpox incidence in the ANRS-174-DOXYVAC trial enrolling MSM on HIV pre-exposure prophylaxis (PrEP) with history of sexually-transmitted infections (STI) in the previous year.

Methods

We compared pre-epidemic socio-behavioral characteristics and change in sexual behaviors after the onset of the epidemic of participants with mpox and mpox-free. Then we compared incidence rates of mpox per 1000 person-months (p-m) between May 9-July 10 (before vaccination of MSM, period-1) and July 11-September 20 2022 (after vaccination launch, period-2) and explored factors explaining the period effect using Poisson regression model.

Findings

472 MSM had data before and after May 9, 2022. Twenty percent had received smallpox vaccine during childhood. Mpox occurred in 77/472 participants (incidence 49.3 per 1000 p-m (95% CI 38.9-61.6)). MVA-BN vaccination roll-out was rapid, with 86% (341/398) of eligible participants having received at least one dose by September 20, 2022. Sexual behavior significantly changed before and after May 9, with a decrease in the proportion of mpox-free participants with >10 partners during last 3 months (45% vs 38%, p = 0.0035). Mpox incidence was 67.4 per 1000 p-m (95% CI 51.6-86.6) in period-1, and 24.4 per 1000 p-m (95% CI 13.9-39.6) in period-2, with an incidence rate ratio of 0.36 (95% CI 0.21-0.63). In multivariable Poisson regression model, only MVA-BN vaccination in 2022 remained significantly associated with mpox incidence, with a 99% risk reduction (95% CI 96.6-99.7).

Interpretation

In MSM on PrEP enrolled in the ANRS-174-DOXYVAC trial, rapid roll-out of MVA-BN vaccination was associated with a strong reduction in mpox incidence.

Funding

ANRS Maladies Infectieuses Emergentes (ANRS/MIE).

Genotypic cluster analysis of Neisseria gonorrhoeae reveals a spectrum of sexual mixing including among HIV-serodiscordant men who have sex with men

BACKGROUND

Men who have sex with men (MSM) are more vulnerable to acquiring sexually transmitted infections (STIs). In 2019, for instance, 74% of European Neisseria gonorrhoeae (Ng) cases among males affected MSM. A recent report by the World Health Organization showed that most of the 2020' interim targets to end STIs by 2030 had not been met. A broadened understanding of STI transmission networks could guide future elimination strategies and reduce the STI burden. Therefore, we used whole-genome sequencing (WGS) to determine Ng-clusters and assess sexual mixing.

METHODS

WGS was performed on Ng-isolates collected at the Medical University of Vienna, Austria and was used for core genome multi-locus sequencing typing cluster analysis. Epidemiologic and infection-specific details were extracted from medical records.

RESULTS

Genomic analysis and demographic data were available for 415 isolates, and 43.9% (182/415) were allocated to 31 Ng-clusters. Nine clusters comprised samples from heterosexual individuals only (women N = 4, human immunodeficiency virus (HIV)-negative men N = 49, HIV-positive man N = 1), nine clusters included MSM only (HIV-negative N = 22, HIV-positive N = 13) and 13 clusters included both heterosexuals and MSM (HIV-negative N = 75, HIV-positive N = 18). Current use of HIV pre-exposure prophylaxis (PrEP) was reported by 22.8% of MSM. In multivariate analysis, only 'MSM' predicted clustering with isolates from HIV-positive individuals (adjusted odds ratio 10.24 (95% CI 5.02-20.90)).

CONCLUSIONS

Sexual mixing of HIV-positive, HIV-negative MSM and non-MSM was frequently observed. Furthermore, HIV-serodiscordant clustering highlights the importance of PrEP rollout to avert HIV transmission. Our findings can inform future STI prevention strategies and continuous surveillance efforts are required to keep up with transmission dynamics.

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.

HIV preexposure prophylaxis in adolescents and young adults: an update

PURPOSE OF REVIEW

This review provides an update of evidence for HIV preexposure prophylaxis (PrEP), including efficacy and safety of newly available medications. It discusses barriers to care that are unique to adolescents and young adults as well as interventions that may help increase uptake, adherence, and retention in care.

RECENT FINDINGS

Tenofovir alafenamide-emtricitabine and cabotegravir are both newly approved medications for the prevention of HIV and are well tolerated and effective for adolescents. These medications, along with tenofovir disoproxil-emtricitabine, offer a variety of PrEP options to choose from.

SUMMARY

Adolescents and young adults have many options when it comes to HIV prevention, but barriers persist in terms of uptake and adherence to PrEP and retention in care. Technology-based interventions, provider education, navigation support, and multiple access options are all tools to help increase PrEP use in young people.

Breaking barriers: Assessing pre-exposure prophylaxis awareness and willingness to use in the Lebanese community

BACKGROUND

In the evolving HIV landscape, the Middle East and Northern Africa (MENA) grapples with data gaps, hindering the 95-95-95 targets. Lebanon, despite progress, falls short. Our study addresses Pre-exposure Prophylaxis (PrEP) gaps for effective HIV prevention.

METHODS

Surveying 410 participants via snowball sampling and an online questionnaire, we analyzed data with chi-square and regression over 5 months for insights into PrEP awareness and readiness.

RESULTS

Summarizing the pivotal statistical outcomes of the study, 22.2% reported awareness of PrEP, showcasing diverse knowledge levels about its purpose and usage. Out of them, 57.1% expressed a willingness to use it; while a mere 5.5% have utilized it. The study reveals diverse demographic profiles, with age influencing PrEP awareness and willingness to use. Positive correlations exist between PrEP discussions within social circles, increased information availability, and elevated willingness. Financial considerations and accessibility at pharmacies emerge as critical determinants, guiding the development of targeted interventions.

CONCLUSIONS

This analysis emphasizes tailored education, community initiatives, and policy enhancements to address PrEP challenges in Lebanon. Guiding public health initiatives, our study considers age, social dynamics, education, and accessibility in HIV prevention.

Concordance between daily diary reported pre-exposure prophylaxis intake and intraerythrocytic tenofovir diphosphate in the Amsterdam Pre-exposure Prophylaxis demonstration project

OBJECTIVE

We assessed the association and concordance between self-reported oral pre-exposure prophylaxis (PrEP) intake in a diary app and intraerythrocytic drug metabolite concentrations.

DESIGN

AMPrEP was a prospective demonstration study providing daily and event-driven PrEP to MSM in Amsterdam, the Netherlands (2015-2020).

METHODS

Participants could record their PrEP intake in a diary app. Dried blood spots (DBS) were taken at 6, 12, 24, and 48 months and analysed for tenofovir diphosphate (TFV-DP) and emtricitabine triphosphate (FTC-TP) concentrations. We included TFV-DP measurements preceded by diary completion on at least 90% of days in the 6 weeks prior. We examined the association between self-reported PrEP intake (i.e. number of pills) and TFV-DP concentrations using tobit regression with a random intercept per participant. We also calculated concordance between categorized PrEP intake (i.e. <2, 2-3, 4-6 or 7 pills per week) and categorized TFV-DP concentrations (i.e. <350, 350-699,700-1249 or ≥1250 fmol/punch) using weighted Cohen's kappa. Last, we calculated concordance between self-reported recent PrEP intake (yes/no, in past 2 days) and quantifiability of FTC-TP (yes/no) using Cohen's kappa.

RESULTS

Seven hundred and fifty-nine DBS measurements from 282 MSM were included. Self-reported PrEP intake was strongly and positively associated with TFV-DP concentration ( β  = 0.77, 95% CI = 0.70-0.84, P  < 0.0001). Concordance between categorized PrEP intake and TFV-DP concentration was moderate ( κ  = 0.44, 95% CI = 0.39-0.50). Concordance between self-reported recent PrEP intake and FTC-TP quantifiability was perfect ( κ  = 0.83, 95% CI 0.76-0.90).

CONCLUSION

Self-reported PrEP intake in a diary app is strongly correlated with actual use, and therefore reliable for comparing PrEP adherence between groups. Still, suboptimal criterion validity according to clinically relevant categories warrants caution when assessing 6-week reported adherence for individuals.

Incidence and factors associated with PrEP discontinuation in France

OBJECTIVES

HIV pre-exposure prophylaxis (PrEP) is effective in preventing HIV, but some seroconversions occur due to poor adherence or PrEP discontinuation. Our objective was to estimate the incidence of PrEP discontinuation and describe the reasons and factors associated with discontinuations.

METHODS

A retrospective cohort was conducted in three French hospitals between January 2016 and June 2022. PrEP users who attended at least twice within 6 months during study period were included and followed up until December 2022. The incidence rate of PrEP discontinuation was estimated by censoring lost to follow up individuals. Factors associated with PrEP discontinuations were identified using a multivariate Cox model.

RESULTS

A total of 2785 PrEP users were included, with 94% men and 5% transgender people. Median age was 35 years. By December 2022, 653 users had stopped PrEP (24%). The incidence rate was 10.8 PrEP discontinuations for 100 person-years (PY). The main causes of discontinuation were being in a stable relationship (32%), and not judging the treatment useful anymore (12%). Individuals who discontinued PrEP were younger [<29, HR = 1.45 (1.17-1.80)], and more likely to be women [HR = 2.44 (1.50-3.96)] or sex workers [HR = 1.53 (0.96-2.44)]. They were more likely to report PrEP side effects [HR = 2.25 (1.83-2.77)] or ≥2 sexually transmitted infections [HR = 1.87 (1.53-2.27)] during the last year.

CONCLUSION

The incidence of PrEP discontinuations was quite low compared to rates observed in other cohorts. Users who stopped PrEP were sometimes still exposed to HIV, emphasizing the need for targeted interventions to prepare and support PrEP discontinuations and limit seroconversion risk.

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.

Breakthrough Acute HIV Infections among Pre-Exposure Prophylaxis Users with High Adherence: A Narrative Review

Pre-exposure prophylaxis (PrEP) is a pivotal intervention among HIV prevention strategies. We aimed to narratively revise the topic of HIV acute infection in the setting of PrEP exposure with a focus on diagnostic options, clinical features, and future PrEP perspectives, with a particular focus on users with high adherence to PrEP. We searched the main databases (PubMed, Embase, and Scopus) with the keywords "PrEP" or "Pre-Exposure Prophylaxis" and "HIV" or "PLWH" and "breakthrough" or "acute infection" or "primary infection". We included all randomized clinical trials and non-experimental studies (both case reports and observational studies) ever published. In the present narrative review, we revise the diagnostic challenges related to HIV diagnosis in the setting of PrEP and the clinical characteristics and symptoms of breakthrough infections. We discuss the management of acute HIV infection during PrEP and the new challenges that arise from the use of long-acting drugs for PrEP. Our review underlines that although extremely rare, HIV seroconversions are still possible during PrEP, even in a context of high adherence. Efforts to promptly identify these events must be included in the PrEP follow-up in order to minimize the chance of overlooked HIV breakthrough infections and thus exposure to suboptimal concentrations of antiretrovirals.

Effect of mass treatment on the long-term prevalence of gonorrhoea, chlamydia and syphilis-a systematic review

BACKGROUND

Selective mass treatment of STIs may lead to a durable reduction in the prevalence of STIs or a temporary reduction associated with an increased probability of antimicrobial resistance emerging.

METHODS

We searched PubMed and Google Scholar for studies evaluating the impact of mass STI treatment on the long-term prevalence of chlamydia, gonorrhoea, syphilis and chancroid. The primary outcomes were the long term (≥3 months post the intervention) impact of the intervention on prevalence/incidence of the STI and on antimicrobial resistance.

RESULTS

Our search yielded 269 studies, of which 4 met the inclusion criteria. With the exception of the Carletonville study, where this was not assessed, three of the four studies found that intensive STI treatment was associated with a reduced prevalence of the targeted STI during or immediately after the intervention. In all four studies, there was no evidence that the intense treatment had a long-term effect on prevalence. In the only study where this was assessed, the intensive use of penicillin to reduce gonococcal prevalence was associated with the emergence of reduced susceptibility to penicillin in N. gonorrhoeae.

CONCLUSION

The available evidence suggests that mass treatment of chlamydia, gonorrhoea and syphilis in high prevalence populations is only associated with a temporary reduction in the prevalence of these infections and may select for antimicrobial resistance.

Pre-exposure prophylaxis against HIV infection

Pre-exposure prophylaxis (PrEP) decreases the risk for HIV transmission in high-risk populations. PrEP has been available in Denmark since 2019 and consists of antiretroviral drugs in a combination tablet taken daily or on demand. The effect of this prophylaxis in Denmark is summarized in the review. PrEP is indicated in men and transgender persons with unprotected anal intercourse with multiple male partners in the latest 12 weeks or recent diagnoses of syphilis, chlamydia, or gonorrhoea. PrEP is provided by infectious disease specialists. Continued implementation could significantly reduce HIV transmission and potentially end the epidemic in Denmark.

Sexual behaviour and incidence of sexually transmitted infections among men who have sex with men (MSM) using daily and event-driven pre-exposure prophylaxis (PrEP): Four-year follow-up of the Amsterdam PrEP (AMPrEP) demonstration project cohort

BACKGROUND

An increasing number of countries are currently implementing or scaling-up HIV pre-exposure prophylaxis (PrEP) care. With the introduction of PrEP, there was apprehension that condom use would decline and sexually transmitted infections (STIs) would increase. To inform sexual health counselling and STI screening programmes, we aimed to study sexual behaviour and STI incidence among men who have sex with men (MSM) and transgender women who use long-term daily or event-driven PrEP.

METHODS AND FINDINGS

The Amsterdam PrEP demonstration project (AMPrEP) was a prospective, closed cohort study, providing oral daily PrEP and event-driven PrEP to MSM and transgender women from 2015 to 2020. Participants could choose their PrEP regimen and could switch at each three-monthly visit. STI testing occurred at and, upon request, in-between 3-monthly study visits. We assessed changes in numbers of sex partners and condomless anal sex (CAS) acts with casual partners over time using negative binomial regression, adjusted for age. We assessed HIV incidence and changes in incidence rates (IRs) of any STI (i.e., chlamydia, gonorrhoea, or infectious syphilis) and individual STIs over time using Poisson regression, adjusted for age and testing frequency. A total of 367 participants (365 MSM) commenced PrEP and were followed for a median 3.9 years (interquartile range [IQR] = 3.4-4.0). Median age was 40 years (IQR = 32-48), 315 participants (85.8%) self-declared ethnicity as white and 280 (76.3%) had a university or university of applied sciences degree. Overall median number of sex partners (past 3 months) was 13 (IQR = 6-26) and decreased per additional year on PrEP (adjusted rate ratio [aRR] = 0.86/year, 95% confidence interval [CI] = 0.83-0.88). Overall median number of CAS acts with casual partners (past 3 months) was 10 (IQR = 3-20.5) and also decreased (aRR = 0.92/year, 95% CI = 0.88-0.97). We diagnosed any STI in 1,092 consultations during 1,258 person years, resulting in an IR of 87/100 person years (95% CI = 82-92). IRs of any STI did not increase over time for daily PrEP or event-driven PrEP users. Two daily PrEP users, and no event-driven PrEP users, were diagnosed with HIV during their first year on PrEP. Study limitations include censoring follow-up due to COVID-19 measures and an underrepresentation of younger, non-white, practically educated, and transgender individuals.

CONCLUSIONS

In this prospective cohort with a comparatively long follow-up period of 4 years, we observed very low HIV incidence and decreases in the numbers of casual sex partners and CAS acts over time. Although the STI incidence was high, it did not increase over time.

TRIAL REGISTRATION

The study was registered at the Netherlands Trial Register (NL5413) https://www.onderzoekmetmensen.nl/en/trial/22706.

Appropriate usage of post-exposure prophylaxis-in-pocket for HIV prevention by individuals with low-frequency exposures

PEP-In-Pocket (Post-Exposure Prophylaxis-In-Pocket, or "PIP") is a biobehavioural HIV prevention strategy wherein patients are proactively identified and given a prescription for HIV post-exposure prophylaxis (PEP) medications to self-initiate in case of high-risk exposures. We evaluated this strategy in a prospective observational study at two hospital-based clinics in Toronto, Canada. HIV-negative adults using PIP underwent chart review and completed quarterly electronic questionnaires over 12 months. The primary objective was to quantify appropriate PIP initiation, defined as starting PIP within 72 h of a high-risk exposure. Secondary objectives were to quantify HIV seroconversions, changes in sexual risk behaviour, sexual satisfaction, and satisfaction with the PIP strategy. From 11/2017 to 02/2020, 43 participants enrolled and completed ≥1 questionnaire. PIP was self-initiated on 27 occasions by 15 participants, of which 24 uses (89%) were appropriate, 2 were unnecessary, and 1 was for an unknown exposure. Chart review identified no inappropriate non-use. Over 32 person-years of testing follow-up, we observed zero HIV seroconversions. Sexual risk declined modestly over follow-up, with a HIRI-MSM (HIV Incidence Risk Index for MSM) change of -0.39 (95% CI = -0.58, -0.21 per 3 months, p < .001). Sexual satisfaction was stable over time. At 12 months, 31 (72%) remained on PIP, 8 (19%) had transitioned to pre-exposure prophylaxis and 4 (9%) were lost-to-follow-up. Among participants who remained on PIP and completed questionnaires at 12 months, 24/25 (96%) strongly/somewhat agreed that PIP decreased their anxiety about contracting HIV and 25/25 (100%) strongly/somewhat agreed that they would recommend PIP to a friend. PIP is a feasible HIV prevention strategy in carefully selected individuals at modest HIV risk.

Tenofovir Douche as HIV Preexposure Prophylaxis for Receptive Anal Intercourse: Safety, Acceptability, Pharmacokinetics, and Pharmacodynamics (DREAM 01)

BACKGROUND

Despite highly effective HIV preexposure prophylaxis (PrEP) options, no options provide on-demand, nonsystemic, behaviorally congruent PrEP that many desire. A tenofovir-medicated rectal douche before receptive anal intercourse may provide this option.

METHODS

Three tenofovir rectal douches-220 mg iso-osmolar product A, 660 mg iso-osmolar product B, and 660 mg hypo-osmolar product C-were studied in 21 HIV-negative men who have sex with men. We sampled blood and colorectal tissue to assess safety, acceptability, pharmacokinetics, and pharmacodynamics.

RESULTS

The douches had high acceptability without toxicity. Median plasma tenofovir peak concentrations for all products were several-fold below trough concentrations associated with oral tenofovir disoproxil fumarate (TDF). Median colon tissue mucosal mononuclear cell (MMC) tenofovir-diphosphate concentrations exceeded target concentrations from 1 hour through 3 to 7 days after dosing. For 6-7 days after a single product C dose, MMC tenofovir-diphosphate exceeded concentrations expected with steady-state oral TDF 300 mg on-demand 2-1-1 dosing. Compared to predrug baseline, HIV replication after ex vivo colon tissue HIV challenge demonstrated a concentration-response relationship with 1.9 log10 maximal effect.

CONCLUSIONS

All 3 tenofovir douches achieved tissue tenofovir-diphosphate concentrations and colorectal antiviral effect exceeding oral TDF and with lower systemic tenofovir. Tenofovir douches may provide a single-dose, on-demand, behaviorally congruent PrEP option, and warrant continued development. Clinical Trials Registration . NCT02750540.

Ex-vivo rectal tissue infection with HIV-1 to assess time to protection following oral preexposure prophylaxis with tenofovir disoproxil/emtricitabine

OBJECTIVES

We wished to assess time to protection from HIV-1 infection following oral tenofovir disoproxil and emtricitabine (TDF/FTC) as preexposure prophylaxis (PrEP), using ex-vivo rectal tissue infections and drug concentration measures in blood and rectal tissue.

DESIGN/METHODS

Participants from the ANRS PREVENIR study (NCT03113123) were offered this sub-study after a 14-day wash-out. We used an ex-vivo model to evaluate rectal tissue HIV-1 susceptibility before and after PrEP, 2 h after two pills or 7 days of a daily pill of TDF/FTC. PrEP efficacy was expressed by the difference (after-before) of 14-day cumulative p24 antigen levels. TFV-DP and FTC-TP levels were measured in rectal tissue and PBMCs and correlated with HIV-1 infection.

RESULTS

Twelve and 11 men were analyzed in the 2 h-double dose and 7 days-single dose groups, respectively. Cumulative p24 differences after-before PrEP were -144 pg/ml/mg (IQR[-259;-108]) for the 2 h-double dose group ( P  = 0.0005) and -179 pg/ml/mg (IQR [-253;-86]) for the 7 days-single dose group ( P  = 0.001), with no differences between groups ( P  = 0.93). Rectal TFV-DP was below quantification after a double dose, but FTC-TP levels were similar to levels at 7 days. There was a significant correlation between rectal FTC-TP levels and p24 changes after a double dose ( R  = -0.84; P  = 0.0001).

CONCLUSION

Oral TDF/FTC provided similar protection against HIV-1 infection of rectal tissue 2 h after a double dose or 7 days of a daily dose. At 2 h, this protection seems driven by high FTC-TP concentrations in rectal tissue. This confirms the importance of combining TDF and FTC to achieve early protection.

Strategies to Eliminate Inequity in PrEP Services in the US South and Rural Communities

ABSTRACT

Inequity in preexposure prophylaxis (PrEP) care in the US South and rural communities is likely attributed to Social Determinants of Health and structural issues beyond individuals' control. We describe three approaches to modify PrEP care practice models to make access easier-"normalizing," "digitalizing," and "simplifying." "Normalizing" approaches are defined as practice models where medical providers who have access to PrEP candidates prescribe PrEP routinely (e.g., primary care providers, community pharmacists); these approaches are found to be highly applicable in real-world settings. Telehealth and other dHealth tools are examples of "digitalizing" PrEP, and their use has been increasing rapidly since the COVID-19 pandemic. "Simplifying" PrEP care (e.g., with HIV self-testing, on-demand PrEP) is highlighted in the most recent World Health Organization PrEP guideline. Identifying, implementing, and scaling up these new strategies can allow PrEP candidates to access it, potentially addressing inequities and promoting HIV risk reduction in the US South and rural communities.

Physical and mental health of long-term users of HIV preexposure prophylaxis in Australia

INTRODUCTION

HIV preexposure prophylaxis (PrEP) is highly effective at preventing HIV. We aimed to assess mental and physical health among long-term PrEP users in Australia's X-PLORE cohort.

METHODS

In early 2021, 1485 X-PLORE participants were emailed a survey covering demographics, sexual practices, ongoing PrEP use, physical and psychological diagnoses received since commencing PrEP, substance use, and impacts of the COVID-19 pandemic. Current anxiety and depression were assessed using GAD-7 and PHQ-9 questionnaires.

RESULTS

Of 476 participants (completion rate 32.1%), 99.8% were cis-gender men. Median PrEP use duration was 48 months (2002 person-years), with 81.7% currently using PrEP. PrEP-related toxicity was uncommon: 2.9% reported bone fractures, 1.3% low bone density, and 4.0% reported kidney problems, largely not necessitating PrEP cessation. Most (92.0%) rated their health as 'good' to 'excellent', and 22.6% reported improved health since starting PrEP, often because of improved mental health. Only 6.2% reported deterioration in health since starting PrEP, largely unrelated to PrEP. The most common diagnoses were hypertension (9.9%), depression (13.2%) and anxiety (14.9%); 17% had PHQ-9 scores indicating current moderate-to-severe depression, which was associated with unemployment [adjusted odds ratio (aOR) 3.90], regular cannabis use (aOR 2.49), and having ceased PrEP (aOR 2.13).

CONCLUSION

Among long-term PrEP users, of which over 80% were currently using PrEP, self-reported PrEP toxicity was uncommon. With almost one in five PrEP users categorized as having depression, and with higher risk among those having ceased PrEP, we recommend routine screening for depression and anxiety in PrEP users and corresponding follow-up of patients no longer attending for PrEP.

High Propensity to Switch to Long-acting Injectable HIV PrEP with Cabotegravir in a Cohort of Oral PrEP Experienced Men who Have Sex with Men in Italy

Aim was to investigate the propensity to switch to long-acting injectable HIV pre-exposure prophylaxis (PrEP) with cabotegravir among oral PrEP-experienced men who have sex with men. Out of 377 PrEP users, 325 (86.2%) were interested (would like = 210) or considering (would consider = 115) switch to long-acting PrEP. At multivariable analysis, the odds ratio of interest in long-acting PrEP in non-adherent vs. adherent individuals to oral PrEP was 5.03 (95%CI = 1.73-14.61,p = 0.003) and of consideration 1.63 (95%CI = 0.51-5.23,p = 0.410). We observed very high propensity to switch to long-acting PrEP, particularly among non-adherent users. Rapid availability of long-acting PrEP might address unmet needs of PrEP users in Italy.

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.

"Take services to the people": strategies to optimize uptake of PrEP and harm reduction services among people who inject drugs in Uganda

BACKGROUND

People who inject drugs (PWID) are at increased risk of HIV acquisition and often encounter barriers to accessing healthcare services. Uganda has high HIV prevalence among PWID and lacks integrated pre-exposure prophylaxis (PrEP) and harm reduction services. Understanding PWID experiences accessing and using harm reduction services and PrEP will inform strategies to optimize integration that align with PWID needs and priorities.

METHODS

Between May 2021 and March 2023, we conducted semi-structured interviews with PWID in Kampala, Uganda. We recruited participants with and without previous experience accessing harm reduction services and/or PrEP using purposive and snowball sampling. Interviews were audio recorded, translated, and transcribed. We used thematic analysis to characterize motivations for uptake of harm reduction and HIV prevention services, and strategies to optimize delivery of needle and syringe programs (NSP), medications for opioid use disorder (MOUD), and PrEP.

RESULTS

We conducted interviews with 41 PWID. Most participants were relatively aware of their personal HIV risk and accurately identified situations that increased risk, including sharing needles and engaging in transactional sex. Despite risk awareness, participants described engaging in known HIV risk behaviors to satisfy immediate drug use needs. All reported knowledge of harm reduction services, especially distribution of sterile needles and syringes, and many reported having experience with MOUD. Participants who had accessed MOUD followed two primary trajectories; limited resources and relationships with other PWID caused them to discontinue treatment while desire to regain something they believed was lost to their drug use motivated them to continue. Overall, PrEP knowledge among participants was limited and few reported ever taking PrEP. However, participants supported integrating PrEP into harm reduction service delivery and advocated for changes in how these services are accessed. Stigma experienced in healthcare facilities and challenges acquiring money for transportation presented barriers to accessing current facility-based harm reduction and HIV prevention services.

CONCLUSIONS

Meeting the HIV prevention needs of PWID in Uganda will require lowering barriers to access, including integrated delivery of PrEP and harm reduction services and bringing services directly to communities. Additional training in providing patient-centered care for healthcare providers may improve uptake of facility-based services.

Global HIV Incidence Analysis and Implications for Affordability Using Long-Acting Cabotegravir Versus Continuous and Event-Driven Oral Preexposure Prophylaxis

BACKGROUND

The HIV Prevention Trials Network (HPTN) 083/084 trials showed up to 88% increased efficacy of long-acting cabotegravir (CAB-LA) versus continuous oral tenofovir disoproxil fumarate/emtricitabine (TDF/FTC). However, CAB-LA's high price limits the number of people who can be treated within fixed prevention budgets. Global human immunodeficiency virus (HIV) prevention budgets are highly limited, with TDF/FTC widely available as a low-cost generic. In randomized clinical trials, event-driven TDF/FTC has shown similar preventive efficacy to continuous TDF/FTC.

METHODS

A systematic review of global HIV incidence studies was conducted. Weighted incidence was calculated in each at-risk population. HIV infection rates were evaluated for 5 prevention strategies, with additional HIV testing, education, and service access costs assumed for each ($18 per person per year). Assumed efficacies were 90% (continuous CAB-LA), 60% (continuous TDF/FTC), and 60% (event-driven TDF/FTC). Using weighted incidence and an assumed 100 000 target population, annual HIV infection rates by population were calculated for each prevention strategy.

RESULTS

Ninety-eight studies in 5 230 189 individuals were included. Incidence per 100 person-years ranged from 0.03 (blood donors) to 3.82 (people who inject drugs). Using the number needed to treat to benefit for each strategy, a mean incidence of 2.6 per 100 person-years in at-risk populations, and a 100 000 target population, current-price continuous CAB-LA cost $949 487 per HIV infection successfully prevented, followed by target-price CAB-LA ($11 453), continuous TDF/FTC ($4231), and event-driven TDF/FTC ($1923).

CONCLUSIONS

High prices of CAB-LA limit numbers treatable within fixed budgets. Low-cost event-driven TDF/FTC consistently prevents the most HIV infections within fixed budgets.

Identifying Key Factors to PrEP Initiation and Persistence Among YMSM Through Focus Groups and Surveys in Two High-Priority Settings

Cisgender men are diagnosed with HIV at a rate four times greater than cisgender women, with 71% of infections attributed to male-male sexual contact. Despite expanding accessibility, pre-exposure prophylaxis (PrEP) for HIV prevention is initiated by only 30% of people with PrEP indications. Five focus groups with 42 young men who have sex with men from New York and Alabama were conducted to identify key factors to PrEP initiation and persistence. Thirty focus group participants completed a survey on demographics, PrEP choices and health care attitudes. Findings suggest provider competency significantly influences PrEP use due to stigmatization in medical settings. Participants noted benefits of PrEP including HIV protection and sexual empowerment, yet barriers like cost and side effects were prevalent. Our findings outline barriers and facilitators to PrEP use among young men who have sex with men in two high priority settings that will inform PrEP care updates in participating clinics.

Four cases of HIV infection in men taking pre-exposure prophylaxis in Singapore

Pre-exposure prophylaxis (PrEP) with co-formulated tenofovir disoproxil fumarate (TDF) and emtricitabine (FTC) is an effective prevention strategy against sexual transmission of human immunodeficiency virus (HIV) in at-risk populations.1 It can be taken daily, or on-demand for cisgender men who have sex with men (MSM) and transwomen who have sex with men.2 In spite of this, breakthrough infections have still been reported.3,4 Additionally, despite PrEP being available in Singapore for several years, accurate Singapore data on its utilisation is lacking.5 A Singapore study in February 2018 found that only 15% of MSM on a geosocial networking application (Grindr) had used PrEP.6 However, to our knowledge, there are no published Singapore cases on PrEP failures. We present 4 such cases (Table 1).

Gradient of vaccine hesitancy among French men having sex with men: An electronic cross-sectional survey in 2022

In developed countries, vaccinations against hepatitis B (HBV), hepatitis A (HAV), and human papillomavirus (HPV) are often recommended to men who have sex with men (MSM) because of the risky sexual practices in which some engage. Vaccine coverage against these diseases is not optimal in France, probably due in part to vaccine hesitancy (VH). The overall aim of this survey among MSM was to estimate the prevalence of different grades of VH for these vaccines as well as of general VH (toward any vaccine). The specific objectives were to study the sociodemographic correlates of MSM specific and general VH and its association with vaccine uptake. A cross-sectional electronic survey (February-August 2022) collected information from 3,730 French MSM about their perceptions of HBV, HAV, and HPV and their related vaccines, to construct "specific VH" variables. Information about their past vaccination behaviors for any vaccine was used to construct a "general VH" variable, based on the World Health Organization definition. Almost 90% of MSM showed moderate or high specific VH for HBV, HAV, and/or HPV, and 54% general VH. A higher education level and comfortable financial situation were associated with lower grades of specific and general VH. Younger age was associated with less frequent specific VH and more frequent general VH. Specific VH, versus general, was more strongly associated with frequent self-reported non-vaccination against these three disease. Addressing their concerns about vaccines, improving their knowledge of vaccine-preventable sexually transmitted infections, and motivating them to get vaccinated are public health priorities.

Willingness to take long-acting injectable pre-exposure prophylaxis among men who have sex with men who participated in the CROPrEP study: a cross-sectional online study

INTRODUCTION

Evidence on the willingness of men who have sex with men (MSM) with oral pre-exposure prophylaxis (PrEP) experience, especially those with suboptimal adherence, to take long-acting injectable PrEP (LAI-PrEP) is critical to guide future LAI-PrEP implementation.

OBJECTIVE

The objective was to assess the willingness of MSM with oral PrEP experience to take LAI-PrEP.

METHODS

MSM who participated in the China Real-world Study of Oral PrEP (CROPrEP) were enrolled in this study. Information on the willingness of MSM to take LAI-PrEP and potential correlates was collected using a structured online questionnaire. The main outcomes were the willingness of MSM to take LAI-PrEP and its association with HIV-related behaviours, sexually transmitted infections, and oral PrEP history. Logistic regression was used to identify correlates of the willingness of MSM to take LAI-PrEP.

RESULTS

A total of 612 former CROPrEP participants (FCPs) were included in this study. There were 315 (51.5%) daily oral PrEP (D-PrEP) users and 297 (48.5%) event-driven oral PrEP (ED-PrEP) users at the last follow-up. Most FCPs (77.8%) were willing to take free LAI-PrEP. FCPs with no less than two sexual male partners (aOR = 1.54, [95% CI: 1.04, 2.29], P = 0.031), those with male partners with unknown HIV statuses (aOR = 2.04, [95% CI: 1.31, 3.18], P = 0.002), those with recreational drug use (aOR = 1.58, [95% CI: 1.05, 2.40], P = 0.030), and those with HSV-2 positivity (aOR = 2.15, [95% CI: 1.30, 3.57], P = 0.003) were more willing to take LAI-PrEP, while ED-PrEP users (aOR = 0.66, [95% CI: 0.45, 0.98], P = 0.037) and FCPs with suboptimal oral PrEP adherence (aOR = 0.58, [95% CI: 0.36, 0.94], P = 0.026) were less willing to take LAI-PrEP.

CONCLUSION

LAI-PrEP has good prospects for expanding PrEP coverage. However, FCPs with suboptimal oral PrEP adherence are less likely to take LAI-PrEP. Further intervention and implementation efforts are needed to improve the willingness of MSM to use LAI-PrEP, and sexual health should be considered during the discussion about PrEP initiation.

Preexposure Prophylaxis for HIV Prevention in the United States: An Overview and Update

ABSTRACT

There were 36,136 new HIV diagnoses in the United States and dependent areas in 2021, despite a 12% reduction in estimated HIV incidence from 2017 to 2021. The burden of HIV remains disproportionately high among certain populations, including gay and bisexual men, Black/African American individuals, and Hispanic/Latino individuals, and racial and ethnic health care disparities persist. The Ending the HIV Epidemic initiative aims to significantly reduce new infections, with a focus on HIV prevention, particularly the use of preexposure prophylaxis (PrEP). However, challenges remain in achieving equitable PrEP distribution. As frontline health care providers, nurses play a pivotal role in this battle against HIV. This article provides an update on PrEP screening recommendations, the types of PrEP available, dosing, adverse effects, and the role of nurses in patient support and monitoring.

Recent HIV infection and annualized HIV incidence rates among sexual and gender minorities in Brazil and Peru (ImPrEP seroincidence study): a cross-sectional, multicenter study

Background

HIV incidence estimation is critical for monitoring the HIV epidemic dynamics and the effectiveness of public health prevention interventions. We aimed to identify sexual and gender minorities (SGM) with recent HIV infections, factors associated with recent HIV infection, and to estimate annualised HIV incidence rates.

Methods

Cross-sectional multicentre study in HIV testing services in Brazil and Peru (15 cities). Inclusion criteria: 18+ years, SGM assigned male at birth, not using pre-/post-exposure prophylaxis. We identified recent HIV infection using the Maxim HIV-1 LAg-Avidity EIA assay as part of a recent infection testing algorithm (RITA). Annualized HIV incidence was calculated using the UNAIDS/WHO incidence estimator tool. Multivariable logistic regression models were used to estimate factors associated with recent HIV infection. Trial registration: NCT05674682.

Findings

From 31-Jan-2021 to 29-May-2022, 6899 individuals participated [Brazil: 4586 (66.5%); Peru: 2313 (33.5%)]; 5946 (86.2%) cisgender men, 751 (10.9%) transgender women and 202 (2.9%) non-binary/gender diverse. Median age was 27 (IQR: 23-34) years. HIV prevalence was 11.4% (N = 784/6899); 137 (2.0%) SGM were identified with recent HIV infection. The overall annualized HIV incidence rate was 3.88% (95% CI: 2.86-4.87); Brazil: 2.62% (95% CI: 1.78-3.43); Peru: 6.69% (95% CI: 4.62-8.69). Participants aged 18-24 years had higher odds of recent HIV infection compared to those aged 30+ years in both countries.

Interpretation

Our results highlight the significant burden of HIV epidemic among SGM in large urban centres of Brazil and Peru. Public health policies and interventions to increase access to effective HIV prevention methods such as PrEP are urgently needed in Latin America.

Funding

Unitaid, WHO (Switzerland), Ministry of Health from Brazil and Peru.

Management of asymptomatic sexually transmitted infections in Europe: towards a differentiated, evidence-based approach

Most sexually transmitted infections (STIs) can be accurately diagnosed and treated during asymptomatic carriage. Widespread screening for these STIs is therefore assumed to be an effective way to reduce their prevalence and associated disease. In this review, we provide evidence that this is the case for HIV and syphilis. However, for other STIs such as Neisseria gonorrhoeae and Chlamydia trachomatis, our review reveals that the evidence that screening reduces infection prevalence and associated disease is weak. There is also growing evidence of harms from screening that might outweigh any benefits. The harms include the increased consumption of antimicrobials that follows frequent screening and increased detection of asymptomatic STIs in key populations, such as men who have sex with men taking HIV pre-exposure prophylaxis, and associated risk of antimicrobial resistance in target and non-target organisms. There may also be psycho-social harm associated with an STI diagnosis. We conclude that in the absence of symptoms, in high STI prevalence populations frequent STI screening should be limited to HIV and syphilis.