Increasing preexposure prophylaxis use and 'net prevention coverage' in behavioural surveillance of Australian gay and bisexual men

Variations in HIV Prevention Coverage in Subpopulations of Australian Gay and Bisexual Men, 2017-2021: Implications for Reducing Inequities in the Combination Prevention Era

Using repeated behavioural surveillance data collected from gay and bisexual men (GBM) across Australia, we assessed trends in HIV prevention coverage (the level of 'safe sex' achieved in the population by the use of effective prevention methods, including condoms, pre-exposure prophylaxis [PrEP] and having an undetectable viral load). We stratified these trends by age, country of birth/recency of arrival, sexual identity, and the proportion of gay residents in the participant's suburb. Among 25,865 participants with casual male partners, HIV prevention coverage increased from 69.8% in 2017 to 75.2% in 2021, lower than the UNAIDS target of 95%. Higher levels of coverage were achieved among older GBM (≥ 45 years), non-recently-arrived migrants, and in suburbs with ≥ 10% gay residents. The lowest levels of prevention coverage (and highest levels of HIV risk) were recorded among younger GBM (< 25 years) and bisexual and other-identified participants. Younger, recently-arrived, and bisexual GBM were the most likely to use condoms, while PrEP use was concentrated among gay men, 25-44-year-olds, and in suburbs with more gay residents. The use of undetectable viral load was most common among participants aged ≥ 45 years. Our analysis shows that high HIV prevention coverage can be achieved through a mixture of condom use, PrEP use, and undetectable viral load, or by emphasising PrEP use. In the Australian context, younger, bisexual and other-identified GBM should be prioritised for enhanced access to effective HIV prevention methods. We encourage other jurisdictions to assess the level of coverage achieved by combination prevention, and variations in uptake.

Collective antiretroviral protection: new dimensions of community HIV prevention practices at the intersection of U=U and PrEP

Collective antiretroviral protection is an evolving sexual health strategy in HIV prevention, used in particular by gay, bisexual, and other men who have sex with men. The strategy involves HIV-negative individuals who engage in condomless sexual activities but, instead of using pre-exposure prophylaxis (PrEP) themselves, choose partners who either have undetectable viral loads or are on PrEP. This biomedical-sorting practice, rooted in the scientific principles of undetectable equals untransmittable (U=U) and PrEP, relies on an indirect protection strategy. Collective antiretroviral protection allows for HIV-negative individuals not on PrEP to benefit from their partner's antiretroviral use, without directly consuming antiretrovirals themselves for HIV prevention, during condomless sex. Empirical research is needed to evaluate the public health implications of this emerging sexual health approach. Research and public health initiatives should adopt a non-stigmatising approach to individuals engaging in collective antiretroviral protection and look beyond individual behaviour to understand the broader community-level effects of this innovative HIV prevention strategy.

Optimising HIV pre-exposure prophylaxis and testing strategies in men who have sex with men in Australia, Thailand, and China: a modelling study and cost-effectiveness analysis

BACKGROUND

Men who have sex with men (MSM) in the Asia-Pacific region have a disproportionately high burden of HIV infection compared with the general population. Although pre-exposure prophylaxis (PrEP) for HIV is highly effective at preventing new HIV infections, the cost-effectiveness of PrEP for MSM in different countries in the Asia-Pacific region with varying PrEP coverage and HIV testing frequencies remains unstudied. We aimed to analyse the economic and health benefits of long-acting injectable cabotegravir (CAB-LA) compared with oral PrEP in high-income countries and low-income and middle-income countries within the Asia-Pacific region.

METHODS

We developed a decision-analytic Markov model to evaluate the population impact and cost-effectiveness of PrEP scale-up among MSM in Australia, Thailand, and China. We assumed a static cohort of 100 000 MSM aged 18 years or older who were at risk of HIV infection, with a monthly cycle length over a 40-year time period. We evaluated hypothetical scenarios with universal PrEP coverage of 80% among 100 000 suitable MSM in each country. We modelled oral PrEP and CAB-LA for MSM with diverse HIV testing frequency strategies. We adopted the health-care system's perspective with a 3% annual discount rate. We calculated the incremental cost-effectiveness ratio (ICER), measured as additional cost per quality-adjusted life-year (QALY) gained, to compare different strategies with the status quo in each country. All costs were reported in 2021 US$. We also performed one-way, two-way, and probabilistic sensitivity analyses to assess the robustness of our findings.

FINDINGS

Compared with the status quo in each country, expanding oral PrEP to 80% of suitable MSM would avert 8·1% of new HIV infections in Australia, 14·5% in Thailand, and 26·4% in China in a 40-year period. Expanding oral PrEP use with 6-monthly HIV testing for both PrEP and non-PrEP users was cost-saving for Australia. Similarly, expanding oral PrEP use remained the most cost-effective strategy in both Thailand and China, but optimal testing frequency varied, with annual testing in Thailand (ICER $4707 per QALY gained) and 3-monthly testing in China (ICER $16 926 per QALY gained) for both PrEP and non-PrEP users. We also found that replacing oral PrEP with CAB-LA for MSM could avert more new HIV infections (12·8% in Australia, 27·6% in Thailand, and 32·8% in China), but implementing CAB-LA was not cost-effective due to its high cost. The cost of CAB-LA would need to be reduced by 50-90% and be used as a complementary strategy to oral PrEP to be cost-effective in these countries.

INTERPRETATION

Expanding oral PrEP use for MSM, with country-specific testing frequency, is cost-effective in Australia, Thailand, and China. Due to the high cost, CAB-LA is currently not affordable as a single-use strategy but might be offered as an additional option to oral PrEP.

FUNDING

Ministry of Science and Technology of the People's Republic of China, the Australian National Health and Medical Research Council, National Key Research and Development Program of China, and National Natural Science Foundation of China.

Trends in illicit drug use and their association with HIV transmission risks from behavioural surveillance of Australian gay and bisexual men

INTRODUCTION

Investigating drug trends among Australian gay and bisexual men (GBM) is crucial for understanding levels of use and the potential for harm, including HIV transmission risk.

METHOD

Using repeated, national, cross-sectional survey data collected between 2012 and 2021 (69,567 surveys), trends of recent (previous 6 months) and frequent (weekly) drug use were analysed, using logistic regression models. The last round of data from each jurisdiction (6709 surveys) was used to compare GBM who reported no use, infrequent (less than weekly) use and frequent (at least weekly) use of party drugs to investigate the association between party drug use and HIV transmission risk, using multinomial logistic regression models.

RESULTS

There was a significant upward trend in any recent drug use (from 58.4% in 2012 to 64.1% in 2021; p < 0.001). Frequent party drug use remained a minority practice over the period (consistently less than 3%). In cross-sectional analysis, frequent party drug users were more likely to report behaviours with HIV transmission risks, such as condomless anal intercourse without biomedical prevention strategies (30.0% vs. 13.1%; adjusted relative risk ratio [aRRR], 2.08; 95% CI, 1.24-3.47), weekly group sex (16.3% vs. 0.6%; aRRR, 12.36; 95% CI, 5.75-26.56) and more than 20 recent sexual partners (42.5% vs. 5.0%; aRRR, 21.44; 95% CI, 5.82-78.89), compared with GBM who did not use party drugs.

DISCUSSION AND CONCLUSION

Our findings suggest that the frequent use of party drugs remains a marker of HIV transmission risk among Australian GBM, despite the increased adoption of biomedical HIV prevention strategies over the past few years.

The Potential Role of Undetectable = Untransmittable (U = U) in Reducing HIV Stigma among Sexual Minority Men in the US

The Undetectable = Untransmittable (U = U) message and its scientific underpinnings have been widely suggested to reduce HIV stigma. However, misunderstanding and skepticism about U = U may prevent this destigmatizing potential from being fully realized. This cross-sectional study examined associations between U = U belief (belief that someone with a sustained undetectable viral load has zero risk of sexually transmitting HIV) and HIV stigma among US sexual minority men. Differences by serostatus and effects of brief informational messaging were also explored. The survey was completed online by 106 men living with HIV and 351 HIV-negative/status-unknown men (2019-2020). Participants were 18-83 years old (M[SD] = 41[13.0]). Most were non-Hispanic White (70.0%) and gay (82.9%). Although nearly all participants (95.6%) were aware of U = U, only 41.1% believed U = U. A greater percentage of participants living with HIV (66.0%) believed U = U compared with HIV-negative/status-unknown participants (33.6%). Among participants living with HIV, U = U belief was not significantly associated with perceived, internalized, or experienced HIV stigma or with viral load prejudice (prejudice against people who have a detectable HIV viral load). Among HIV-negative/status-unknown participants, U = U belief was associated with less frequently enacted HIV discrimination, more positive feelings toward people with an undetectable viral load, and lower personal endorsement of stigmatizing beliefs. Brief informational messaging about U = U did not affect most stigma dimensions and did not favorably affect any. Interventions are needed to correct commonly held, outdated misconceptions about HIV transmission risk. Such initiatives must not only engage people living with HIV but also engage HIV-negative/status-unknown people to maximize the destigmatizing potential of U = U.

Assessing HIV risk and the social and behavioural characteristics of gay and bisexual men who have recently migrated to Australia: an analysis of national, behavioural surveillance data 2019-2021

INTRODUCTION

Overseas-born gay and bisexual men (GBM) are overrepresented in HIV diagnoses in Australia. We assessed social and sexual behaviours, and the use of HIV prevention and testing, by region of birth and length of residence in Australia. We sought to identify similarities and differences between recently arrived and non-recently arrived GBM from non-English-speaking countries to improve targeting and engagement with HIV testing and prevention.

METHODS

Data were collected in national repeated, behavioural surveillance surveys conducted across Australia during 2019-2021. Logistic regression was used to identify factors that differentiated between recently arrived (<2 years) and non-recently arrived (≥2 years in Australia) GBM from non-English-speaking countries.

RESULTS

Among 24,707 participants in 2019-21, 2811 (11.4%) were from high-income English-speaking countries, 714 (2.9%) were recently arrived overseas-born GBM and 3833 (15.5%) were non-recently arrived migrants. Recently arrived GBM were most likely to be born in Asia (36.1%) and Europe (21.1%). Compared with non-recently arrived GBM, recently arrived GBM from non-English-speaking countries were younger (aOR = 0.95, 95% CI = 0.94-0.96, p<0.001), more likely to be students (aOR = 1.43, 95% CI = 1.11-1.85, p = 0.005), less likely to be in full-time employment (aOR = 0.56, 95% CI = 0.46-0.69, p <0.001), more likely to report consistent condom use (aOR = 1.30, 95% CI = 1.01-1.66, p = 0.039), but had lower awareness (aOR = 0.62, 95% CI = 0.48-0.80, p<0.001) and use of pre-exposure prophylaxis (PrEP) (22.8%, vs. 32.3%, χ2 (1, 4185) = 23.78, p<0.001), and similar levels of casual sex with a risk of HIV acquisition or transmission (aOR = 1.29, 95% CI = 0.98-1.69, p = 0.066). Recently arrived GBM reported similar levels of lifetime HIV testing (aOR = 0.97, 95% CI = 0.54-1.74, p = 0.915) and recent HIV testing (OR = 1.03, 95% CI = 0.86-1.22, p = 0.779), but were much less likely to have tested at general practitioners (aOR = 0.53, 95% CI = 0.41-0.68, p<0.001) and more likely to report testing at hospitals (aOR = 3.35, 95% CI = 2.53-4.43, p<0.001), at home (aOR = 2.85, 95% CI = 1.63-4.99, p<0.001), or community-based services (aOR = 1.36, 95% CI = 1.01-1.84, p = 0.043).

CONCLUSIONS

Recently arrived GBM from non-English-speaking countries reported similar levels of risk of HIV acquisition to longer-term residents in Australia, but lower levels of PrEP awareness and use, and more reliance on HIV testing services which are free or low cost. It is necessary to enhance access to HIV testing and prevention among recently arrived GBM in Australia.

Trends in Testing and Self-Reported Diagnoses of Sexually Transmitted Infections in Gay and Bisexual Men in Australia, 2017 to 2021: Analysis of National Behavioral Surveillance Surveys

BACKGROUND

Gay, bisexual, and other men who have sex with men (GBM) are overrepresented in diagnoses of sexually transmitted infections (STIs) relative to their population size. This study assessed trends in STI testing and diagnoses among GBM in Australia.

METHODS

The Gay Community Periodic Surveys are repeated cross-sectional behavioral surveillance surveys of GBM. Participants reported the number of anal swabs, throat swabs, urine samples, and blood tests for syphilis they undertook in the last year. "Frequent comprehensive testing" was defined as ≥3 of each test in the previous year. Participants reported STI diagnoses of chlamydia, gonorrhea, syphilis, and other STIs in the last year. Trends in testing and diagnoses from 2017 to 2020 and 2020 to 2021 were assessed with logistic regression models.

RESULTS

We analyzed 24,488 survey responses from participants reporting casual sex in the last 6 months. Between 2017 and 2020, frequent comprehensive STI testing decreased among HIV-negative GBM on preexposure prophylaxis (PrEP) from 71.7% to 68.9% and declined further to 58.6% in 2021. Frequent comprehensive STI testing was stable during 2017-2020 among HIV-negative/untested GBM not on PrEP (17.4%-14.6%) and HIV-positive GBM (30.4%-35.1%) but declined in 2021 to 7.5% among non-PrEP-users and 25.7% among HIV-positive participants. There were minimal changes in STI diagnoses during 2017-2020, but diagnoses declined in 2021.

CONCLUSIONS

Many GBM do not meet Australian STI testing guidelines that recommend quarterly testing. Further evaluation of whether this recommendation is realistic or necessary to reduce STIs among GBM is recommended.

The impact of social connections and discrimination to HIV risk among Asian gay and bisexual men in Australia

BACKGROUND

Asian gay, bisexual, and other men who have sex with men (GBMSM) are overrepresented in new HIV diagnoses in Australia. Social engagement with other GBMSM has been associated with HIV testing and pre-exposure prophylaxis (PrEP) uptake. Asian GBMSM may be socially disconnected from LGBTQ+ people, which may increase their HIV risk. This analysis assessed the contribution of social connection on HIV risk among Asian GBMSM.

METHODS

Using an online cross-sectional survey of Asian GBMSM in Australia, we measured condomless anal intercourse (CLAI) in the last 6months without PrEP or an undetectable viral load (UVL), i.e. CLAI with a risk of HIV transmission. Bivariable and multivariable logistic regression models were performed to compare demographic characteristics and social engagement of participants who had CLAI without PrEP or UVL to those who had not. Analyses were restricted to participants who reported sex with casual partners in the last 6months.

RESULTS

Among 509 participants who had casual partners in the last 6months, 151 (29.7%) reported CLAI without PrEP or UVL. CLAI without PrEP or UVL was negatively associated with full-time employment, and recently being tested for HIV and was positively associated with experiencing discrimination based on sexual orientation. Social engagement with LGBTQ+ people was not associated with CLAI without PrEP or UVL.

CONCLUSIONS

CLAI without PrEP or UVL was not related to social connections with LGBTQ+ people but was more likely among Asian men who had experienced sexuality-related discrimination, suggesting that mitigating homophobia and biphobia may assist in improving HIV prevention among Asian GBMSM who live in Australia.

Changing Characteristics of HIV-Positive Gay and Bisexual Men's Relationships in the Era of Biomedical Prevention

OBJECTIVE

To assess changes in personal and relationship characteristics among HIV-positive Australian gay and bisexual men (GBM) as rates of antiretroviral therapy and knowledge and confidence regarding the effectiveness of viral suppression in preventing HIV transmission have increased.

DESIGN

Repeated behavioral surveillance of GBM recruited from venues, events, and online in 7 Australian states and territories.

METHODS

HIV-positive participants were included. Trends in demographics, HIV treatment, and relationship characteristics were assessed with binary and multivariable logistic regression.

RESULTS

A total of 3643 survey responses (2016-2020) were included. Over time, HIV-positive GBM became less likely to identify as gay or report an Anglo-Australian ethnicity. The average length of time since HIV diagnosis increased and the frequency of attending HIV-related clinical appointments decreased. There were no changes in the reported number of recent sex partners or proportion reporting regular male partners over time. Among HIV-positive GBM in relationships, the proportion reporting HIV-positive partners decreased and the proportion reporting HIV-negative partners increased. Levels of condomless sex with regular partners increased over time; however, this was concentrated among HIV-positive GBM in serodiscordant relationships.

CONCLUSION

Findings suggest that increased accessibility and trust in biomedical prevention strategies have contributed to broader relationship and sexual opportunities for HIV-positive GBM in Australia. Our findings suggest that future health promotion activities could highlight the social and relationship benefits of treatment as prevention to further increase trust in it as an HIV prevention strategy among GBM.

Explicit Relationship Agreements and HIV Pre-exposure Prophylaxis Use by Gay and Bisexual Men in Relationships

Relationship agreements are important for HIV prevention among gay and bisexual men (GBM) in relationships, with research earlier in the HIV epidemic often finding that agreements specified monogamy or condom use with casual partners. There is evidence that HIV pre-exposure prophylaxis (PrEP) has shifted sexual practices among some men in relationships, such as allowing condomless sex with casual partners, but there has been little attention paid to relationship agreements among GBM who use PrEP. In this paper, we analyzed national, Australian, cross-sectional data from an online survey completed by non-HIV-positive GBM in 2021 (N = 1,185). Using logistic regression, we identified demographic characteristics, sexual practices and the types of relationship agreement that were associated with PrEP use among GBM in relationships. Using Pearson's chi-squared tests, we explored whether PrEP users in relationships reported similar sexual practices to PrEP users not in relationships. PrEP use among GBM in relationships was independently associated with older age, identifying as gay, being in a non-monogamous relationship, having a spoken (explicit) relationship agreement, having a primary HIV-negative partner taking PrEP or a primary partner living with HIV, reporting recent condomless casual sex, reporting an STI diagnosis in the past year, and knowing at least one other PrEP user. We found that PrEP users in relationships had similar sexual practices to PrEP users not in relationships. GBM in relationships who have casual sex and who meet PrEP suitability criteria may be good candidates for PrEP. Our findings suggest that explicit relationship agreements remain important for HIV prevention, and they support PrEP use among GBM in relationships.

Incidence and Risk Factors for Early Syphilis Among Men Who Have Sex With Men in Australia, 2013-2019: A Retrospective Cohort Study

Background

We aimed to examine the incidence of syphilis in men who have sex with men (MSM) and identify subgroups of MSM at a higher risk of syphilis infection.

Methods

We conducted a retrospective cohort study of MSM attending a sexual health clinic in Australia, during 2013-2019, who had at least 2 syphilis serological tests during the study period. The incidence of syphilis was expressed as per 100 person-years. A cox regression analysis was conducted to identify risk factors for syphilis.

Results

A total of 24 391 individual MSM (75 086 consultations) were included. A total of 1404 new syphilis cases were diagnosed with an incidence of 3.7/100 person-years (95% confidence interval, 3.5-3.9). Syphilis incidence was higher in MSM with human immunodeficiency virus ([HIV] 9.3/100 person-years) than in MSM taking HIV pre-exposure prophylaxis (PrEP) (6.9/100 person-years) or HIV-negative MSM not taking PrEP (2.2/100 person-years). Risk factors associated with high incidence of syphilis included the following: MSM with HIV (adjusted hazard ratio [aHR] 2.7), MSM taking HIV PrEP (aHR 2.1), past history of syphilis infection (aHR 2.4), injecting drug use (aHR 2.7), condomless anal sex (aHR 1.7), >4 sexual partners in the last 12 months (aHR 1.2), and concurrent sexually transmitted infection (chlamydia and gonorrhoea) (aHR 1.6).

Conclusions

The incidence of syphilis remains high among MSM, particularly in subgroups with associated risk factors for syphilis infections. These data highlight the need for biomedical and behavioral interventions to be targeted to subgroups of MSM at the highest risk of syphilis infection.

Inconsistent condom use with casual partners among men who have sex with men in Brazil: a cross-sectional study

OBJECTIVE

This study aimed to evaluate factors associated with inconsistent condom use with casual partners in a population of men who have sex with men (MSM) in Brazil.

METHODS

In 2016, 4,176 MSM >18 years were enrolled in 12 capitals of Brazil using a Respondent Driven Sampling (RDS) method. For the construction of the outcome, we evaluated questions about condom use in all anal intercourse (receptive and insertive) in the previous six months and the last sexual intercourse. Estimates were calculated using a weighted complex sample design. We performed a logistic regression analysis to determine the associations between sociodemographic and behavioral factors and inconsistent condom use in sexual relationships with casual male partners.

RESULTS

More than half of our sample (50.8%) had not used condoms consistently with casual partners in the previous six months. Inconsistent condom use was significantly associated with: low education (weighted odds ratio - wOR: 1.55; 95% confidence interval - CI 0.99-2.40), lack of counseling on sexually transmitted infections STI (wOR: 1.51; 95%CI 1.05-2.17), non-use of condoms at sexual debut (wOR: 3.05; 95%CI 2.12-4.40) and moderate and high perceived risk for HIV (wOR: 1.51; 95%CI 1.07-2.14). Higher age was negatively associated with inconsistent condom use (wOR=0.97, 95%CI 0.89-0.99).

CONCLUSION

Despite being an individual behavior, condom use is related to factors beyond the individual scope. HIV/Aids prevention policies should focus on younger MSM, providing qualified information about condom use, preferably before the beginning of their sexual life.

Adjusting Behavioural Surveillance and Assessing Disparities in the Impact of COVID-19 on Gay and Bisexual Men's HIV-Related Behaviour in Australia

COVID-19 has disrupted sexual behaviour and access to health systems. We adapted regular HIV behavioural surveillance of gay and bisexual men (GBM) in Australia in response to COVID-19, assessed the impact on the profile of the sample, the participants' HIV-related behaviour, and whether COVID-19 may have accentuated existing disparities in the Australian HIV epidemic. Data collected from five states during July 2017-June 2021 were included (N = 31,460). The emphasis on online recruitment after COVID-19 led to smaller sample sizes, greater geographic reach, and a higher proportion of bisexual-identifying participants. Most participants (88.1%) reported physical distancing and 52.1% had fewer sex partners due to COVID-19. In the COVID-19-affected rounds (July 2020-June 2021), the number of male partners, recent HIV testing and pre-exposure prophylaxis (PrEP) use all fell, and HIV risk among the smaller group of participants who reported casual sex increased. COVID-related changes were generally more pronounced among GBM aged under 25 years, participants from suburbs with fewer gay residents, and bisexual men. These groups should be prioritised when encouraging GBM to reengage with HIV testing services and effective prevention methods, like condoms and PrEP.

An overview of programmatic indicators to monitor the roll-out of HIV preexposure prophylaxis

Preexposure prophylaxis (PrEP) is increasingly implemented in national HIV prevention programmes through routine care. Monitoring will be vital to understand whether programmes succeed in engaging people into using PrEP appropriately, and in reducing the HIV epidemic. Yet, it is currently unclear which indicators are most suited to monitor PrEP programmes' performance. We therefore aimed to identify and map indicators that are currently used or suggested for monitoring PrEP programmes. We conducted a scoping review based on the framework by Arksey and O'Malley. We combined a systematic search in the peer-reviewed literature with hand-searching grey literature documents describing indicators and strategies that are used or suggested for PrEP monitoring. Only literature published after 2012 was included. No geographical restrictions were set. We charted data on indicator definitions, data sources used, reported experiences with monitoring and any relevant contextual factors. Ultimately, 35 peer-reviewed and 14 grey literature records were included. We identified indicators related to preuptake stages of PrEP, uptake and coverage, and programme impact. The indicators most commonly suggested for national-level monitoring were the number of new and current PrEP users, the number of HIV seroconversions among PrEP users and some variably defined indicators related to continuation and discontinuation of PrEP. Despite its perceived high relevance, studies reported several challenges to routinely monitor the population in need of PrEP and track prevention-effective PrEP use. In conclusion, a variety of indicators is currently used or suggested for monitoring PrEP programmes. Implementing proxy measures that track different aspects of PrEP use over time, and making synergies with research more explicit, could be used as strategies to obtain more granular insights into trends revealed by routine monitoring.

Changing Attitudes Towards Condoms Among Australian Gay and Bisexual Men in the PrEP Era: An Analysis of Repeated National Online Surveys 2011-2019

Condoms have been the primary form of HIV prevention for gay and bisexual men (GBM) for most of the HIV epidemic. The introduction of biomedical HIV prevention may have changed attitudes towards condoms. Data from repeated national online surveys of GBM in Australia were used to examine how attitudes towards condoms and confidence discussing condoms with partners changed in the period 2011-2019. The proportion of all participants who reported a positive experience in using condoms remained low and unchanged (9.6% in 2011 to 6.0% in 2019). Confidence in discussing condoms with partners decreased over time (from 72.2% in 2011 to 56.6% in 2019). Confidence in discussing condoms was associated with concern about sexually transmitted infections, and more consistent condom use. Sustaining confidence in using condoms may be more challenging as biomedical prevention methods become more commonly used.

Correlations between community-level HIV preexposure prophylaxis coverage and individual-level sexual behaviors among United States MSM

OBJECTIVE

To evaluate if community-level HIV PrEP coverage is correlated with individual sexual behaviors.

DESIGN

We used demographic, behavioral, and sexual network data from ARTnet, a 2017-2019 study of United States MSM.

METHODS

Multivariable regression models with a Bayesian modeling framework were used to estimate associations between area-level PrEP coverage and seven sexual behavior outcomes [number of total, main, and casual male partners (network degree); count of one-time partnerships; consistent condom use in one-time partnerships; and frequency of casual partnership anal sex (total and condomless)], controlling for individual PrEP use.

RESULTS

PrEP coverage ranged from 10.3% (Philadelphia) to 38.9% (San Francisco). Total degree was highest in Miami (1.35) and lowest in Denver (0.78), while the count of one-time partners was highest in San Francisco (11.7/year) and lowest in Detroit (1.5/year). Adjusting for individual PrEP use and demographics, community PrEP coverage correlated with total degree [adjusted incidence rate ratio (aIRR) = 1.73; 95% credible interval (CrI), 0.92-3.44], casual degree (aIRR = 2.05; 95% CrI, 0.90-5.07), and count of one-time partnerships (aIRR = 1.90; 95% CrI, 0.46-8.54). Without adjustment for individual PrEP use, these associations strengthened. There were weaker or no associations with consistent condom use in one-time partnerships (aIRR = 1.68; 95% CrI, 0.86-3.35), main degree (aIRR = 1.21; 95% CrI, 0.48-3.20), and frequency of casual partnership condomless anal sex (aIRR = 0.23; 95% CrI, 0.01-3.60).

CONCLUSION

Most correlations between community PrEP coverage and sexual behavior were explained by individual PrEP use. However, some residual associations remained after controlling for individual PrEP use, suggesting that PrEP coverage may partially drive community-level differences in sexual behaviors.

Clinician imaginaries of HIV PrEP users in and beyond the gay community in Australia

Through the development and implementation of HIV pre-exposure prophylaxis (PrEP), the characteristics of PrEP users have been configured in a range of ways. Drawing on the concept of 'imaginaries', we consider how clinicians imagine PrEP users and related communities. We conducted 28 semi-structured interviews in 2019-2020 with PrEP-providing clinicians based in New South Wales and Western Australia. Participants included general practitioners, sexual health nurses and sexual health doctors. We inductively developed three themes through a reflexive thematic analysis: 'PrEP users as 99% gay men/MSM', 'The informed and connected PrEP user', and 'Condom users in the PrEP era'. Participants imagined PrEP users primarily as gay men, and so we focused on how gay community was imagined in relation to PrEP users. Users were imagined as supporting one another to use PrEP effectively, but some were imagined as threatening norms of condom use amongst gay community. Analysing clinician imaginaries of PrEP users reveals insight into how clinicians speculate about and engage with changing community norms related to condom use and accessing PrEP. These imaginaries reveal ongoing tensions about who is believed to be best suited to PrEP, and PrEP's impact on norms of conduct in imagined biosocial communities like gay men.

HIV prevention for the next decade: Appropriate, person-centred, prioritised, effective, combination prevention

UNAIDS and a broad range of partners have collaborated to establish a new set of HIV prevention targets to be achieved by 2025 as an intermediate step towards the sustainable development target for 2030.The number of new HIV infections in the world continues to decline, in part due to the extraordinary expansion of effective HIV treatment. However, the decline is geographically heterogeneous, with some regions reporting a rise in incidence. The incidence target that was agreed for 2020 has been missed.A range of exciting new HIV prevention technologies have become available or are in the pipeline but will only have an impact if they are accessible and affordable and delivered within systems that take full account of the social and political context in which most infections occur. Most new infections occur in populations that are marginalised or discriminated against due to structural, legal, and cultural barriers.The new targets imply a new approach to HIV prevention that emphasises appropriate, person-centred, prioritised, effective, combination HIV prevention within a framework that reduces existing barriers to services and acknowledges heterogeneity, autonomy, and choice.These targets have consequences for people working in HIV programmes both for delivery and for monitoring and evaluation, for health planners setting local and national priorities, and for funders both domestic and global. Most importantly, they have consequences for people who are at risk of HIV exposure and infection.Achieving these targets will have a huge impact on the future of the HIV epidemic and put us back on track towards ending AIDS as a public health threat by 2030.

Scaling up preexposure prophylaxis to maximize HIV prevention impact

PURPOSE OF REVIEW

Ten years since the first regulatory approval of oral HIV preexposure prophylaxis (PrEP), this review summarizes PrEP uptake, the role of ambitious PrEP targets, emerging evidence of impact on the HIV epidemic and innovative approaches to increasing PrEP uptake.

RECENT FINDINGS

PrEP uptake among people at risk of HIV has been slow, but has accelerated in recent years, particularly in gay and bisexual men in a limited number of high-income settings and recently in heterosexuals at risk of HIV in sub-Saharan Africa. However, UNAIDS 2020 PrEP targets and HIV prevention targets were missed by large margins. Although UNAIDS testing and treatment targets have galvanised public health action, in contras, PrEP targets have been lower profile and insufficiently ambitious. Parts of the USA, Australia and the UK with high PrEP coverage have demonstrated striking reductions in HIV infection at the population level, as PrEP is introduced at scale. Scaling up PrEP uptake will require innovations in PrEP promotion, simplified models of care, improved adherence interventions, improved choice in the form of longer-acting PrEP and interventions to ensure that all those who can benefit from PrEP can access it.

SUMMARY

PrEP is a revolutionary HIV prevention tool, which if ambitiously scaled up could drive HIV transmission towards elimination. Highly publicized and ambitious PrEP targets could help drive this.

Prescribing as affective clinical practice: Transformations in sexual health consultations through HIV pre-exposure prophylaxis

New medicines can transform routines and priorities in clinical practice, but how do clinicians think and feel about these changes, and how does it affect their work? In Australia, the HIV prevention regimen pre-exposure prophylaxis (PrEP) has been rapidly rolled out, transforming the sexual cultures and practices of users, but less attention has been given to the ways PrEP has reconfigured clinical practice. This paper draws on 28 qualitative semi-structured interviews conducted between 2019 and 2020 with PrEP-providing doctors and nurses in Australia to consider how they have affectively engaged with PrEP and put it into practice. Through a reflexive thematic analysis, we explore how clinicians adapted to PrEP, how the field of HIV prevention has been transformed, and how these developments have changed how clinicians approach patients. While the introduction of PrEP was initially received with uncertainty and shock, clinicians described PrEP as enjoyable to prescribe, and better aligned with the moral duties of sexual health consultations than existing HIV prevention strategies like condoms. Through approaching clinical work as an 'affective practice', we argue for attending not only to how new interventions change expectations and practices, but also how these changes are felt and valued by clinicians.

Structural Stigma and Sexual Health Disparities Among Gay, Bisexual, and Other Men Who Have Sex With Men in Australia

BACKGROUND

Discrimination and stigmatization at the institutional and sociocultural level (conceptualized as "structural stigma") has been associated with adverse health outcomes among sexual and gender minorities. However, few studies explore whether structural stigma is associated with sexual health outcomes. Addressing this gap, here, we explore this relationship among Australian gay, bisexual, and other men who have sex with men (GBM)-a population disproportionately affected by HIV.

SETTING AND METHODS

Using responses from the 2017 Australian Marriage Law Postal Survey, we operationalized structural stigma related to sexual minority status as the regional percentage of votes against legalizing same-sex marriage. These responses were then linked to national HIV behavioral surveillance data from Australian GBM (43,811 responses between 2015 and 2019). Controlling for a rich set of individual and regional level confounders, regression analyses were used to estimate the extent to which structural stigma was associated with testing for, and diagnoses of, HIV and sexually transmitted infections (STIs), and awareness and use of HIV prevention and treatment interventions (pre-exposure and postexposure prophylaxis, combination therapy, and HIV-related clinical care).

RESULTS

Australian GBM living in regions with higher levels of structural stigma were less likely to undergo HIV/STI testing, receive HIV/STI diagnoses, and be taking, or aware of, biomedical prevention strategies. Among GBM living with HIV, structural stigma was associated with a reduced likelihood of being on combination therapy and fewer HIV-related clinical visits.

CONCLUSIONS

Altogether, these results suggest that structural stigma may undermine HIV prevention strategies as well as adequate management of HIV infection among GBM.

COVID-19 Vaccination Uptake and Hesitancy in a National Sample of Australian Gay and Bisexual Men

Minority groups may face additional barriers to vaccination. In April-June 2021, we assessed the level of COVID-19 vaccination and willingness to be vaccinated in a national, online survey of 1280 gay and bisexual men in Australia. Over a quarter of the sample (28.0%) had been partially or fully vaccinated, and 80.0% of the unvaccinated were willing to be vaccinated. Vaccination was independently associated with older age, being university educated, and HIV status (with HIV-positive participants being more likely and untested participants less likely to be vaccinated). Willingness to be vaccinated was independently associated with living in a capital city and being university educated. Those who had lost income or their job due to COVID-19 were less willing to be vaccinated. Our results suggest encouraging COVID-19 vaccination among those with lower levels of health literacy and supporting those who have experienced financial stress because of the pandemic.

Sexual experience, relationships, and factors associated with sexual and romantic satisfaction in the first Australian Trans & Gender Diverse Sexual Health Survey

Background: Sexual and romantic satisfaction are important aspects of sexual health and wellbeing, but they have not been thoroughly investigated among transgender and gender diverse ('trans') people in Australia. Aims: To address this gap and improve sexual health and wellbeing, we assessed the sexual behavior and relationships of a national sample of trans people in Australia, and factors associated with sexual and romantic satisfaction. Methods: We conducted a national survey of trans people from Australia in October-November 2018. Results: The sample included 1,613 trans participants, of whom 353 (21.9%) were men, 397 (24.6%) were women and 863 (53.5%) were non-binary. Over 70% of the sample had been sexually active in the previous year, and 56.9% were in a relationship, but only 32.4% were satisfied with the sexual aspects and 47.1% with the romantic aspects of their lives. Sexual satisfaction was associated with younger age, being asexual, having more trans friends, more frequent sex, and using illicit drugs in the context of sexual activity. Anxiety or fear about sex was associated with less sexual satisfaction, as was being in an open relationship. Romantic satisfaction was associated with younger age, having non-binary partners, and being in a current relationship (particularly a monogamous one). Recent distress, anxiety, or fear about sex were associated with less romantic satisfaction. Conclusion: Participants reported a broad range of sexual relationships, but low levels of satisfaction with the sexual and romantic aspects of their lives. The findings underscore the importance of supportive partners, access to social support and peer networks of trans people, as well as access to mental health support and sex-positive, trans affirming counseling in sexual health services.

Changes in Sexual Behaviour Following PrEP Initiation Among Australian Gay and Bisexual Men in Relationships: Results from a Prospective Observational Study

Few studies have examined changes in sexual behaviour following HIV pre-exposure prophylaxis (PrEP) initiation among gay, bisexual and other men who have sex with men (GBM) in relationships. In a national, online, prospective study of GBM in Australia, we compared sexual behaviours prior to and after PrEP initiation among HIV-negative and unknown-HIV-status men (recruited 2014-2017) not taking PrEP at baseline and who completed at least one six-monthly follow-up by July 2018. Among men in relationships who did not initiate PrEP (n = 339), we compared their most recent survey to their prior one, while among men in relationships who initiated PrEP (n = 81), we compared follow-ups before and after PrEP initiation. Among the 81 PrEP-initiators who were in a relationship both before and after initiation, the proportion reporting their regular partner was on PrEP increased from 8.3 to 44.4% (p < 0.001) and the proportion reporting receptive CLAIC increased from 27.2 to 44.4% (p = 0.009). Overall, men who initiated PrEP were more likely to be in a relationship with a partner on PrEP, and it appeared they started PrEP around the same time. Receptive CLAIC also became more common.

Estimation of Potential HIV Transmission Risk in Recent Anal Intercourse Events among Men Who Have Sex with Men and Transgender Women in Bali, Indonesia

In recent years, prevalence of Human Immunodeficiency Virus (HIV) has increased substantially in Bali, Indonesia, in men who have sex with men (MSM) and transgender women, known locally as ‘waria’. There are limited behavioural data in this population. We conducted a behavioural survey of MSM/waria in Bali in March–April 2018. Respondents were primarily recruited by HIV outreach workers. Respondents reported details about anal intercourse events with their last male/waria romantic partner and/or last male/waria casual partner (respondents could report on both if relevant). Statistical significance was tested with generalised estimating equations. Among 709 participants, median age was 27 (interquartile range = 24–31), and 92.1% were male and 7.9% were waria. One-third were born in Bali. Overall, 85.9% had ever had an HIV test; 55.1% reported being HIV-negative, 15.0% HIV-positive, and 30.0% had unknown serostatus. Most (86.5%) reported sex with men, 9.5% with waria, and 20.0% with women in the previous 6 months. Respondents described 703 anal intercourse events (397/306 with romantic/casual partners, respectively; 191 reported on both). Over half (56.5%) of the events were protected by condoms and 7.3% by biomedical prevention (2.6% by PrEP in either partner, 4.7% by HIV treatments in either partner). Thus, 36.3% of events involved unprotected condomless anal intercourse (40.8%/30.4% in romantic/casual partners, respectively). In multivariate analysis, unprotected condomless anal intercourse events were associated with romantic partners (p < 0.001), being born in Bali (p = 0.002), lower education (p = 0.013), believing that withdrawal before ejaculation is effective (p < 0.001), liking to use withdrawal (p = 0.021), and not liking condoms (p < 0.001). One-quarter of events had potentially reduced HIV transmission risk through non-condom-based risk reduction strategies, while 11.1% had no potential risk reduction. Events presenting the highest potential risk of HIV transmission were more commonly reported by respondents born in Bali.

HIV pre-exposure prophylaxis: scaling up for impact now and in the future

More than a decade after the first efficacy evidence for oral HIV pre-exposure prophylaxis (PrEP) was reported, PrEP uptake globally has been inadequate and global HIV prevention targets have been missed. Access to PrEP is still highly concentrated in a fairly small number of countries and, even within countries with widespread PrEP access, inequalities have emerged. More ambitious, high-priority global targets for PrEP uptake are required and could accelerate the HIV prevention response in a similar way to the success of the 90-90-90 testing and treatment targets. Health systems must be PrEP-friendly and allow PrEP to be prescribed in settings already attended by large numbers of HIV-negative individuals who are at risk. Several models have been advanced for the greater demedicalisation of PrEP. Individual-level barriers to PrEP uptake and persistence have been characterised, such as low awareness, low willingness to use PrEP, and the gap between self-perceived and actual HIV risk. Overcoming these barriers will require further efforts to understand and address them first. New PrEP modalities are emerging; as more options become available, we need to develop a greater understanding of the long-term patterns of PrEP use in different populations and to develop models of such use that can accommodate people alternating through periods of use and non-use, as well as switching between dosing regimens or modalities as they become available. Scaling up PrEP is crucial to achieving the UNAIDS prevention targets for 2030. Simply getting more people onto PrEP cannot be the only goal: the big-picture definition of success for PrEP programmes must be their impact on the HIV epidemic.