Equity of PrEP uptake by race, ethnicity, sex and region in the United States in the first decade of PrEP: a population-based analysis

Background

PrEP was approved for HIV prevention in the US in 2012; uptake has been slow. We describe relative equity with the PrEP Equity Ratio (PER), a ratio of PrEP-to-Need Ratios (PnRs).

Methods

We used commercial pharmacy data to enumerate PrEP users by race and ethnicity, sex, and US Census region from 2012 to 2021. We report annual race and ethnicity-, sex-, and region-specific rates of PrEP use and PnR, a metric of PrEP equity, to assess trends.

Findings

PrEP use increased for Black, Hispanic and White Americans from 2012 to 2021. By 2021, the rate of PrEP use per population was similar in Black and White populations but slightly lower among Hispanic populations. PnR increased from 2012 to 2021 for all races and ethnicities and regions; levels of PrEP use were inconsistent across regions and highly inequitable by race, ethnicity, and sex. In all regions, PnR was highest for White and lowest for Black people. Inequity in PrEP use by race and ethnicity, as measured by the PER, grew early after availability of PrEP and persisted at a level substantially below equitable PrEP use.

Interpretation

From 2012 to 2021, PrEP use increased among Americans, but PrEP equity for Black and Hispanic Americans decreased. The US South lagged all regions in equitable PrEP use. Improved equity in PrEP use will be not only just, but also impactful on the US HIV epidemic; persons most at-risk of acquiring HIV should have the highest levels of access to PrEP. Prevention programs should be guided by PrEP equity, not PrEP equality.

Funding

National Institutes of Health, Gilead Sciences.

Prevalence of COVID-19 Mitigation Behaviors in US Adults (August-December 2020): Nationwide Household Probability Survey

BACKGROUND

COVID-19 mitigation behaviors, such as wearing masks, maintaining social distancing, and practicing hand hygiene, have been and will remain vital to slowing the pandemic.

OBJECTIVE

This study aims to describe the period prevalence of consistent mask-wearing, social distancing, and hand hygiene practices during the peak of COVID-19 incidence (August-December 2020) and just before COVID-19 vaccine availability, overall and in demographic subgroups.

METHODS

We used baseline survey data from a nationwide household probability sample to generate weighted estimates of mitigation behaviors: wearing masks, maintaining social distancing, and practicing hand hygiene. Weighted logistic regression explored differences in mitigation behaviors by demographics. Latent class analysis (LCA) identified patterns in mitigation behaviors.

RESULTS

Among 4654 participants, most (n=2727, 58.6%) were female, were non-Hispanic White (n=3063, 65.8%), were aged 55 years or older (n=2099, 45.1%), lived in the South (n=2275, 48.9%), lived in metropolitan areas (n=4186, 89.9%), had at least a bachelor's degree (n=2547, 54.7%), had an income of US $50,000-$99,000 (n=1445, 31%), and were privately insured (n=2734, 58.7%). The period prevalence of consistent mask wearing was 71.1% (sample-weighted 95% CI 68.8-73.3); consistent social distancing, 42.9% (95% CI 40.5-45.3); frequent handwashing, 55.0% (95% CI 52.3-57.7); and frequent hand sanitizing, 21.5% (95% CI 19.4-23.8). Mitigation behaviors were more prevalent among women, older persons, Black or Hispanic persons, those who were not college graduates, and service-oriented workers. LCA identified an optimal-mitigation class that consistently practiced all behaviors (n=2656, 67% of US adults), a low-mitigation class that inconsistently practiced all behaviors (n=771, 20.6%), and a class that had optimal masking and social distancing but a high frequency of hand hygiene (n=463, 12.4%).

CONCLUSIONS

Despite a high prevalence of COVID-19 mitigation behaviors, there were likely millions who did not consistently practice these behaviors during the time of the highest COVID-19 incidence. In future infectious disease outbreak responses, public health authorities should also consider addressing disparities in mitigation practices through more targeted prevention messaging.

Comparing open-ended question methods to vignette methods to explore willingness to obtain pre-exposure prophylaxis access in pharmacies among black men who have sex with men

Black men who have sex with men (BMSM) are at higher risk of HIV transmission than any other group; however, their uptake of the highly effective HIV prevention medication, pre-exposure prophylaxis (PrEP), is low. In collaboration with a communitybased organization in Atlanta, Georgia, we explored ten HIV-negative BMSM's willingness to obtain PrEP in pharmacies using standard open-ended and vignette qualitative methods. Three overarching themes were identified: privacy, patient-pharmacist interactions, and HIV/STI screening. While open-ended questions allowed participants to provide broad answers on their willingness to receive prevention services at a pharmacy, the vignette drew out specific responses to facilitate in-pharmacy PrEP delivery. Using both openended questions and vignette data collection strategies, BMSM reported high willingness to screen for and uptake PrEP in pharmacies. However, the vignette method allowed for greater depth. Open-ended questions elicited responses that highlighted general barriers and facilitators of PrEP dispensing in pharmacies. However, the vignette allowed participants to customize a plan of action that would best fit their needs. Vignette methods are underutilized in HIV research and may be helpful in supplementing standard open-ended interview questions to uncovering unknown challenges about health behaviors and obtain more robust data on highly sensitive research topics in HIV research.

Assessing the association of stigma and HIV service and prevention uptake among men who have sex with men and transgender women in South Africa

HIV prevention for gay, bisexual, and other men who have sex with men (GBMSM) and transgender women (TGW) is critical to reducing health disparities and population HIV prevalence. To understand if different types of stigma impact engagement with HIV prevention services, we assessed associations between stigmas and use of HIV prevention services offered through an HIV prevention intervention. This analysis included 201 GBMSM and TGW enrolled in a prospective cohort offering a package of HIV prevention interventions. Participants completed a baseline survey that included four domains of sexual identity/behavior stigma, HIV-related stigma, and healthcare stigma. Impact of stigma on PrEP uptake and the number of drop-in visits was assessed. No domain of stigma was associated with PrEP uptake. In bivariate analysis, increased enacted sexual identity stigma increased number of drop-in visits. In a logistic regression analysis constrained to sexual identity stigma, enacted stigma was associated with increased drop-in visits (aIRR = 1.30, [95% CI: 1.02, 1.65]). Participants reporting higher enacted stigma were modestly more likely to attend additional services and have contact with the study clinics and staff. GBMSM and TGW with higher levels of enacted stigma may seek out sensitized care after negative experiences in their communities or other healthcare settings.

Exploring Stigma, Resilience, and Alternative HIV Preventive Service Delivery Among Young Men who Have Sex with Men of Color

Stigmatization on the basis of race, sexuality, gender identity, and/or use of pre-exposure prophylaxis (PrEP) exacerbates HIV disparities for young men who have sex with men of color (YMSM). We explored resilience, healthcare experiences, stigma, and impact of coronavirus disease 2019 (COVID-19) on PrEP care needs among YMSM of color through virtual in-depth interviews. Analyses used adapted grounded theory/constant comparison. Regarding healthcare-based stigma, participants enacted multilevel resilience which was critical to their care retention during COVID-19 (Themes 1 and 2). Some participants noted that remote care could minimize healthcare stigma and promote retention in care and/or on PrEP (Theme 3). Participants were interested in long-acting injectable (LAI) PrEP but expressed concerns about cost, effectiveness, and side effects (Theme 4). Community-based venues like pharmacies were preferred spaces for getting LAI PrEP injections (Theme 4). Although expansion of telehealth that helped mitigate care retention challenges during COVID-19 was temporary, continued telehealth use may reduce stigmatization and promote long-term retention and PrEP persistence.

Effects of mode of transportation on PrEP persistence among urban men who have sex with men

Little is known about the effect of travel-related factors, such as mode of transportation, on retention in PrEP care, or PrEP persistence. We used data from the 2020 American Men's Internet Survey and conducted multilevel logistic regression to estimate the association between mode of transportation used for healthcare access and PrEP persistence among urban gay, bisexual, and other men who have sex with men (MSM) in the U.S. MSM using public transportation were less likely to report PrEP persistence (aOR: 0.51; 95% CI: 0.28-0.95) than MSM using private transportation. There were no significant associations between PrEP persistence and using active transportation (aOR: 0.67; 95% CI: 0.35-1.29) or multimodal transportation (aOR: 0.85; 95% CI: 0.51-1.43) compared to using private transportation. Transportation-related interventions and policies are needed to address structural barriers to accessing PrEP services and to improve PrEP persistence in urban areas.

Examination of HIV Preexposure Prophylaxis Need, Availability, and Potential Pharmacy Integration in the Southeastern US

Importance

Daily preexposure prophylaxis (PrEP) use can prevent up to 99% of HIV infections; however, PrEP uptake is low due to poor access to PrEP-prescribing locations for populations at increased risk for HIV, especially in the southeastern US. Pharmacies are a feasible option to increase PrEP access, but little is known about how they could complement current PrEP-prescribing locations.

Objective

To examine geographic distributions of current PrEP-prescribing locations compared with pharmacies and the facility to need ratios (PFNRs) according to HIV risk in the Southeast and describe the potential reach of pharmacies to expand PrEP access.

Design, Setting, and Participants

Data for this cross-sectional study of PrEP-prescribing locations and pharmacies were compiled from January 1 to December 31, 2021. States or specific counties in the Southeast included in this study were jurisdictions identified as high-priority areas for the Ending the HIV Epidemic in the US (EHE) initiative.

Exposure

Expansion of HIV prevention services to pharmacies.

Main Outcomes and Measures

Choropleth maps of 5-year HIV risk per 100 000 persons were developed for EHE jurisdictions in the southeastern US. PrEP-prescribing locations (obtained from a national database of PrEP prescribers) and pharmacies (obtained from state pharmacy boards) were overlayed on HIV risk maps. The PFNRs by state were calculated as number of facilities (PrEP-prescribing locations or pharmacies) divided by 5-year HIV risk per 100 000 persons. Lower PFNRs indicated lower geographic availability of locations to meet the needs of the population at risk for HIV. The PFNRs for current PrEP-prescribing locations vs pharmacies were compared.

Results

Among the 2 southeastern states and 13 counties in 4 southeastern states included, PrEP-prescribing locations were unequally distributed across EHE areas, with substantially fewer in areas at high risk for HIV. Pharmacies were evenly dispersed across areas regardless of HIV risk. The mean PFNR across all states for current PrEP-prescribing locations was 0.008 (median, 0.000 [IQR, 0.000-0.003]); for pharmacies, it was 0.7 (median, 0.3 [IQR, 0.01-0.1]). The PFNRs were at least 20.3 times higher for pharmacies compared with PrEP-prescribing locations. States with the greatest potential increase in PFNRs with expansion to pharmacies included Kentucky, South Carolina, and Tennessee.

Conclusions and Relevance

The findings of this cross-sectional study suggest that expanding HIV prevention services to pharmacies in EHE areas in the Southeast could significantly increase capacity to reach individuals at increased risk of HIV transmission. Legislation aimed at allowing pharmacists to prescribe PrEP and provide HIV prevention services may be an important next step in ending the HIV epidemic.

Use of COVIDTests.gov At-Home Test Kits Among Adults in a National Household Probability Sample - United States, 2022

At-home rapid antigen COVID-19 tests were first authorized by the Food and Drug Administration in late 2020 (1-3). In January 2022, the White House launched COVIDTests.gov, which made all U.S. households eligible to receive free-to-the-user at-home test kits distributed by the U.S. Postal Service (2). By May 2022, more than 70 million test kit packages had been shipped to households across the United States (2); however, how these kits were used, and which groups were using them, has not been reported. Data from a national probability survey of U.S. households (COVIDVu), collected during April-May 2022, were used to evaluate awareness about and use of these test kits (4). Most respondent households (93.8%) were aware of the program, and more than one half (59.9%) had ordered kits. Among persons who received testing for COVID-19 during the preceding 6 months, 38.3% used a COVIDTests.gov kit. Among kit users, 95.5% rated the experience as acceptable, and 23.6% reported being unlikely to have tested without the COVIDTests.gov program. Use of COVIDTests.gov kits was similar among racial and ethnic groups (42.1% non-Hispanic Black or African American [Black]; 41.5% Hispanic or Latino [Hispanic]; 34.8% non-Hispanic White [White]; and 53.7% non-Hispanic other races [other races]). Use of other home COVID-19 tests differed by race and ethnicity (11.8% Black, 44.4% Hispanic, 45.8% White, 43.8% other races). Compared with White persons, Black persons were 72% less likely to use other home test kits (adjusted relative risk [aRR] = 0.28; 95% CI = 0.16-0.50). Provision of tests through this well-publicized program likely improved use of COVID-19 home testing and health equity in the United States, particularly among Black persons. National programs to address availability and accessibility of critical health services in a pandemic response have substantial health value.

Development of a Mobile App to Increase the Uptake of HIV Pre-exposure Prophylaxis Among Latino Sexual Minority Men: Qualitative Needs Assessment

BACKGROUND

HIV disproportionally impacts Latino sexual minority men (SMM). Uptake of pre-exposure prophylaxis (PrEP), an effective biomedical intervention to prevent HIV, is low in this group compared with White SMM. Mobile health technology represents an innovative strategy to increase PrEP uptake among Latino SMM.

OBJECTIVE

We aimed to describe the qualitative process leading to the development of SaludFindr, a comprehensive HIV prevention mobile app aiming to increase PrEP uptake, HIV testing, and condom use by Latino SMM.

METHODS

We conducted 13 in-depth interviews with Latino SMM living in the Atlanta area to explore their main barriers and facilitators to PrEP uptake and to analyze their opinions of potential SaludFindr app functionalities. To explore potential app functions, we used HealthMindr, an existing HIV prevention app, as a template and added new proposed features intended to address the specific community needs.

RESULTS

We identified general PrEP uptake barriers that, although common among non-Latino groups, had added complexities such as the influence of religion and family on stigma. Low perceived PrEP eligibility, intersectional stigma, lack of insurance, cost concerns, and misconceptions about PrEP side effects were described as general barriers. We also identified Latino-specific barriers that predominantly hinder access to existing services, including a scarcity of PrEP clinics that are prepared to provide culturally concordant services, limited availability of Spanish language information related to PrEP access, distrust of peers as credible sources of information, perceived ineligibility for low-cost services owing to undocumented status, fear of immigration authorities, and competing work obligations that prevent PrEP clinic attendance. Health care providers represented a trusted source of information, and 3 provider characteristics were identified as PrEP facilitators: familiarity with prescribing PrEP; being Latino; and being part of lesbian, gay, bisexual, transgender, queer, intersex, and asexual (LGBTQIA+) group or ally. The proposed app was very well accepted, with a particularly high interest in features that facilitate PrEP access, including a tailored list of clinics that meet the community needs and a private platform to seek PrEP information. Spanish language availability and free or low-cost PrEP care represented the 2 main clinic criteria that would facilitate PrEP uptake. Latino representation in clinic staff and providers; clinic perception as a safe space for undocumented patients; and LGBTQIA+ representation was listed as additional criteria. Only 8 of 47 clinics listed on the Centers for Diseases Control and Prevention PrEP locator website for the Atlanta area fulfilled at least 2 main criteria.

CONCLUSIONS

This study provides further evidence of the substantial PrEP uptake barriers that Latino SMM face; exposes the urgent need to increase the number of accessible PrEP-providing clinics for Latino SMM; and proposes an innovative, community-driven, and mobile technology-based tool as a future intervention to overcome some of these barriers.

COVID-19 vaccine attitudes among a majority black sample in the Southern US: public health implications from a qualitative study

BACKGROUND

The COVID-19 pandemic continues to have high caseloads in the US, with vaccines a critical component of the response. Disparities in COVID-19 morbidity and mortality have been identified across states and racial/ethnic groups, which are likely in part due to disparities in COVID-19 vaccine uptake. This study aims to better understand and contextualize COVID-19 vaccine hesitancy among persons from under-represented racial/ethnic populations in the Southern US.

METHODS

We conducted 29 in-depth interviews with a sample of households in Atlanta, GA that were selected from an address-based sampling frame. We purposively approached households, from February 6 to June 27, 2021, that declined participation in a national COVID-19 serosurvey to gain perspectives of people who are often under-represented in research. Interviews were conducted in-person or over phone calls for participants with that preference. Thematic analysis was used to identify barriers and facilitators of COVID-19 vaccination, and to contextualize drivers of vaccine hesitancy.

RESULTS

Decision-making about vaccination was described as dynamic, and was compared to the feeling of being on a roller coaster. The predominant reported sources of information were mass media and social media. Facilitators of vaccination included altruism, positive communication from trusted community members and workplace colleagues, and local vaccine provision sites. Driving reasons for vaccine hesitancy included limited trust in the government and concerns about COVID-19 vaccine safety, which one participant compared to jumping off a cliff without a tested rope. Among a subset of participants, beliefs regarding perceived intent to harm the Black community were prevalent. Opportunities to optimally address vaccine hesitancy included countering negative social media messages with positive messaging that matches the community's vivid ways of discussing vaccines, collaborating with community stakeholders on vaccine promotion efforts, and offering workplace-based vaccine promotion efforts.

CONCLUSIONS

This study presents data that indicate it may be optimal to more broadly define 'community' in COVID-19 vaccine promotion efforts to include social media and workplace venues. To optimize vaccine and vaccine booster uptake and equity, public health must address historic racism and other concerns by using outreach that is grounded in communities.

Randomized Controlled Trial of Automated Directly Observed Therapy for Measurement and Support of PrEP Adherence Among Young Men Who have Sex with Men

Measurement of adherence to oral pre-exposure prophylaxis (PrEP) in real-time has been challenging. We developed DOT Diary, a smartphone application that combines automated directly observed therapy with a PrEP adherence visualization toolkit, and tested its ability to measure PrEP adherence and to increase adherence among a diverse cohort of young men who have sex with men (MSM). We enrolled 100 MSM in San Francisco and Atlanta and randomly assigned them 2:1 to DOT Diary versus standard of care. Concordance between DOT Diary measurement and drug levels in dried blood spots was substantial, with 91.0% and 85.3% concordance between DOT Diary and emtricitabine-triphosphate and tenofovir-diphosphate, respectively. There was no significant difference in the proportion of participants with detectable PrEP drug levels at 24 weeks between study arms. These results suggest DOT Diary is substantially better than self-reported measures of adherence, but additional interventions are needed to improve PrEP adherence over time.

Video selection and assessment for an app-based HIV prevention messaging intervention: formative research

BACKGROUND

Gay, bisexual, and other men who have sex with men (GBMSM) continue to be overrepresented in human immunodeficiency virus (HIV) infection in the United States. HIV prevention and care interventions that are tailored to an individual's serostatus have the potential to lower the rate of new infections among GBMSM. Mobile technology is a critical tool for disseminating targeted messaging and increasing uptake of basic prevention services including HIV testing, sexually transmitted infection (STI) testing, and pre-exposure prophylaxis (PrEP). Mobile Messaging for Men (M-Cubed) is a mobile health HIV prevention intervention designed to deliver video- and text-based prevention messages, provide STI and HIV information, and link GBMSM to prevention and healthcare resources. The current report describes an iterative process of identifying and selecting publicly available videos to be used as part of the M-Cubed intervention. We also conducted interviews with GBMSM to assess the acceptability, comprehension, and potential audience reach of the selected video messages.

METHODS

The selection of videos included balancing of specific criteria [e.g., accuracy of scientific information, video length, prevention domains: HIV/STI testing, antiretroviral therapy (ART), PrEP, engagement in care, and condom use] to ensure that they were intended for our GBMSM audiences: HIV-negative men who engage in condomless anal sex, HIV-negative men who do not engage in condomless anal sex, and men living with HIV. This formative study included in-person interviews with 26 GBMSM from three U.S. cities heavily impacted by the HIV epidemic-New York City, Detroit, and Atlanta.

RESULTS

Following a qualitative content analysis, the study team identified five themes across the interviews: participant reactions to the video messages, message comprehension, PrEP concerns, targeting of video messaging, and prompted action.

CONCLUSIONS

Study results informed a final selection of 12 video messages for inclusion in a randomized controlled trial of M-Cubed. Findings may serve as a guide for researchers who plan to develop HIV prevention interventions that utilize publicly available videos to promote behavioral change. Further, the findings presented here suggest the importance of developing videos with broad age and gender diversity for use in interventions such as M-Cubed, and in other health promotion settings.

Demographic and behavioral characteristics of urban and non-urban PrEP-using MSM in the South

Pre-exposure prophylaxis (PrEP) is a highly effective HIV prevention intervention; however, most studies of PrEP adherence and persistence among men who have sex with men (MSM) have been conducted with MSM who live in urban areas. The experiences of PrEP-using MSM in non-urban areas might differ due to increased barriers to culturally competent care. We examined similarities and differences among urban and non-urban PrEP-using MSM in the southern United States, the region with the highest number of annual HIV diagnoses. We surveyed a total of 78 (n = 25 non-urban, n = 53 urban) PrEP-using MSM. Self-reported adherence was high across all participants. No differences were observed with respect to PrEP persistence, source of PrEP, or reasons for PrEP initiation. Fewer non-urban than urban men reported STI testing in the past 12 months. Overall, we observed few differences comparing urban and non-urban PrEP-using MSM. Additional studies are needed to describe differences in PrEP initiation comparing urban and non-urban MSM.

Association of Guideline Complexity With Individuals' Ability to Determine Eligibility for COVID-19 Vaccination

This cross-sectional study examines the association between the complexity of consumer guidelines for COVID-19 vaccination and identification of eligibility.

Association between the geographic accessibility of PrEP and PrEP use among MSM in nonurban areas

PURPOSE

The US HIV epidemic has become a public health issue that increasingly affects men who have sex with men (MSM), including those residing in nonurban areas. Increasing access to pre-exposure prophylaxis (PrEP) in nonurban areas will prevent HIV acquisition and could address the growing HIV epidemic. No studies have quantified the associations between PrEP access and PrEP use among nonurban MSM.

METHODS

Using 2020 PrEP Locator data and American Men's Internet Survey data, we conducted multilevel log-binomial regression to examine the association between area-level geographic accessibility of PrEP-providing clinics and individual-level PrEP use among MSM residing in nonurban areas in the United States.

FINDINGS

Of 4,792 PrEP-eligible nonurban MSM, 20.1% resided in a PrEP desert (defined as more than a 30-minute drive to access PrEP), and 15.2% used PrEP in the past 12 months. In adjusted models, suburban MSM residing in PrEP deserts were less likely to use PrEP in the past year (adjusted prevalence ratio [aPR] = 0.35; 95% confidence interval [CI] = 0.15, 0.80) than suburban MSM not residing in PrEP deserts, and other nonurban MSM residing in PrEP deserts were less likely to use PrEP in the past year (aPR = 0.75; 95% CI = 0.60, 0.95) than other nonurban MSM not residing in PrEP deserts.

CONCLUSIONS

Structural interventions designed to decrease barriers to PrEP access that are unique to nonurban areas in the United States are needed to address the growing HIV epidemic in these communities.

Nationally representative social contact patterns among U.S. adults, August 2020-April 2021

The response to the COVID-19 pandemic in the U.S prompted abrupt and dramatic changes to social contact patterns. Monitoring changing social behavior is essential to provide reliable input data for mechanistic models of infectious disease, which have been increasingly used to support public health policy to mitigate the impacts of the pandemic. While some studies have reported on changing contact patterns throughout the pandemic, few have reported differences in contact patterns among key demographic groups and none have reported nationally representative estimates. We conducted a national probability survey of US households and collected information on social contact patterns during two time periods: August-December 2020 (before widespread vaccine availability) and March-April 2021 (during national vaccine rollout). Overall, contact rates in Spring 2021 were similar to those in Fall 2020, with most contacts reported at work. Persons identifying as non-White, non-Black, non-Asian, and non-Hispanic reported high numbers of contacts relative to other racial and ethnic groups. Contact rates were highest in those reporting occupations in retail, hospitality and food service, and transportation. Those testing positive for SARS-CoV-2 antibodies reported a higher number of daily contacts than those who were seronegative. Our findings provide evidence for differences in social behavior among demographic groups, highlighting the profound disparities that have become the hallmark of the COVID-19 pandemic.

Severe Acute Respiratory Syndrome Coronavirus 2 Cumulative Incidence, United States, August 2020-December 2020

BACKGROUND

Reported coronavirus disease 2019 (COVID-19) cases underestimate severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infections. We conducted a national probability survey of US households to estimate cumulative incidence adjusted for antibody waning.

METHODS

From August-December 2020 a random sample of US addresses were mailed a survey and self-collected nasal swabs and dried blood spot cards. One adult household member completed the survey and mail specimens for viral detection and total (immunoglobulin [Ig] A, IgM, IgG) nucleocapsid antibody by a commercial, emergency use authorization-approved antigen capture assay. We estimated cumulative incidence of SARS-CoV-2 adjusted for waning antibodies and calculated reported fraction (RF) and infection fatality ratio (IFR). Differences in seropositivity among demographic, geographic, and clinical subgroups were explored.

RESULTS

Among 39 500 sampled households, 4654 respondents provided responses. Cumulative incidence adjusted for waning was 11.9% (95% credible interval [CrI], 10.5%-13.5%) as of 30 October 2020. We estimated 30 332 842 (CrI, 26 703 753-34 335 338) total infections in the US adult population by 30 October 2020. RF was 22.3% and IFR was 0.85% among adults. Black non-Hispanics (Prevalence ratio (PR) 2.2) and Hispanics (PR, 3.1) were more likely than White non-Hispanics to be seropositive.

CONCLUSIONS

One in 8 US adults had been infected with SARS-CoV-2 by October 2020; however, few had been accounted for in public health reporting. The COVID-19 pandemic is likely substantially underestimated by reported cases. Disparities in COVID-19 by race observed among reported cases cannot be attributed to differential diagnosis or reporting of infections in population subgroups.

Nationally Representative Social Contact Patterns among U.S. adults, August 2020-April 2021

The response to the COVID-19 pandemic in the U.S prompted abrupt and dramatic changes to social contact patterns. Monitoring changing social behavior is essential to provide reliable input data for mechanistic models of infectious disease, which have been increasingly used to support public health policy to mitigate the impacts of the pandemic. While some studies have reported on changing contact patterns throughout the pandemic., few have reported on differences in contact patterns among key demographic groups and none have reported nationally representative estimates. We conducted a national probability survey of US households and collected information on social contact patterns during two time periods: August-December 2020 (before widespread vaccine availability) and March-April 2021 (during national vaccine rollout). Overall, contact rates in Spring 2021 were similar to those in Fall 2020, with most contacts reported at work. Persons identifying as non-White, non-Black, non-Asian, and non-Hispanic reported high numbers of contacts relative to other racial and ethnic groups. Contact rates were highest in those reporting occupations in retail, hospitality and food service, and transportation. Those testing positive for SARS-CoV-2 antibodies reported a higher number of daily contacts than those who were seronegative. Our findings provide evidence for differences in social behavior among demographic groups, highlighting the profound disparities that have become the hallmark of the COVID-19 pandemic.

Differences in Sexual Behaviors, HIV Testing, and Willingness to Use PrEP between Gay and Bisexual Men Who Have Sex with Men in China

Objectives: Accumulating evidence suggests that there may be differences in sexual behaviors, condom use, and HIV prevention service utilization (e.g., HIV testing, PrEP use) between gay and bisexual men, but this remains under-explored, especially among gay and bisexual men in China. Methods: We surveyed 4,142 gay and bisexual men on a geosocial networking app in China. Results: In adjusted model, bisexual men were less likely to have received HIV testing in their lifetime (AOR = .62, 95% CI [.53, .72]) or to have received a recent HIV test (AOR = .78, 95% CI [.68, .90]). Conversely, among those who reported having had anal sex in the past six months, bisexual men were more likely to report consistent condom use than gay men (OR = 1.38, 95% CI [1.17, 1.62]). Compared with gay men, bisexual men were significantly less likely to be aware of PrEP (AOR = .62, 95% CI [.52, .74]) and significantly less willing to use PrEP (AOR = .58, 95% CI [.46, .73]). Conclusions: Tailored HIV prevention interventions are needed to address bisexual men's needs in the context of the unique sociocultural influences on sexual behavior in China.

From declining PrEP to PrEP initiation as "first nature" - what changes PrEP initiation decisions among young, Black MSM

Young Black men who have sex with men (YBMSM) bear a disproportionate burden of HIV, and HIV pre-exposure prophylaxis (PrEP) uptake has been slow. Decisions regarding PrEP initiation change in different life contexts over time. Our YBMSM cohort study found about 1/3 of those who initially declined PrEP subsequently changed and initiated PrEP care. This study explores the process of their PrEP decision changes. The study interviewed participants who initially voiced strong and clear reservations about PrEP, but subsequently started PrEP 1-14 months later. In "review/renew" follow-up interviews, participants reviewed their past statements from a time they declined PrEP, and renew their understanding regarding perspective and behavioral change. Analyzing the data with a positive deviance framework, we found that shifting the decisional balance in favor of PrEP initiation only required change in some areas. There were not consistent factors that prevented or facilitated PrEP uptake. Instead, YBMSM initiated PrEP while maintaining an array of substantial reservations. PrEP initiation discussions should be viewed by health practitioners as a longitudinal process, and routine PrEP offers should be made over time. To optimally facilitate PrEP use among YBMSM, the diverse benefits of PrEP should be emphasized rather than focusing on allaying all concerns.

Integrating and Disseminating Pre-Exposure Prophylaxis (PrEP) Screening and Dispensing for Black Men Who Have Sex With Men in Atlanta, Georgia: Protocol for Community Pharmacies

BACKGROUND

Black men who have sex with men (BMSM) suffer from alarmingly high rates of HIV in the United States. Pre-exposure prophylaxis (PrEP) can reduce the risk of HIV infection by 99% among men who have sex with men, yet profound racial disparities in the uptake of PrEP persist. Low PrEP uptake in BMSM is driven by poor access to PrEP, including inconvenient locations of PrEP-prescribing physicians, distrust of physicians, and stigma, which limit communication about PrEP and its side effects. Previous work indicates that offering HIV prevention services in pharmacies located in low-income, underserved neighborhoods is feasible and can reduce stigma because pharmacies offer a host of less stigmatized health services (eg, vaccinations). We present a protocol for a pharmacy PrEP model that seeks to address challenges and barriers to pharmacy-based PrEP specifically for BMSM.

OBJECTIVE

We aim to develop a sustainable pharmacy PrEP delivery model for BMSM that can be implemented to increase PrEP access in low-income, underserved neighborhoods.

METHODS

This study design is a pilot intervention to test a pharmacy PrEP delivery model among pharmacy staff and BMSM. We will examine the PrEP delivery model's feasibility, acceptability, and safety and gather early evidence of its impact and cost with respect to PrEP uptake. A mixed-methods approach will be performed, including three study phases: (1) a completed formative phase with qualitative interviews from key stakeholders; (2) a completed transitional pilot phase to assess customer eligibility and willingness to receive PrEP in pharmacies during COVID-19; and (3) a planned pilot intervention phase which will test the delivery model in 2 Atlanta pharmacies in low-income, underserved neighborhoods.

RESULTS

Data from the formative phase showed strong support of pharmacy-based PrEP delivery among BMSM, pharmacists, and pharmacy staff. Important factors were identified to facilitate the implementation of PrEP screening and dissemination in pharmacies. During the transitional pilot phase, we identified 81 individuals who would have been eligible for the pilot phase.

CONCLUSIONS

Pharmacies have proven to be a feasible source for offering PrEP for White men who have sex with men but have failed to reach the most at-risk, vulnerable population (ie, BMSM). Increasing PrEP access and uptake will reduce HIV incidence and racial inequities in HIV. Translational studies are required to build further evidence and scale pharmacy-based PrEP services specifically for populations that are disconnected from HIV prevention resources.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

DERR1-10.2196/35590.

Behavioral Efficacy of a Sexual Health Mobile App for Men Who Have Sex With Men: Randomized Controlled Trial of Mobile Messaging for Men

BACKGROUND

Gay, bisexual, and other men who have sex with men (GBMSM) face the highest burden of HIV in the United States, and there is a paucity of efficacious mobile health (mHealth) HIV prevention and care interventions tailored specifically for GBMSM. We tested a mobile app combining prevention messages and access to core prevention services for GBMSM.

OBJECTIVE

This study aims to measure the efficacy of the Mobile Messaging for Men (M-cubed) app and related services to increase HIV prevention and care behaviors in diverse US GBMSM.

METHODS

We conducted a randomized open-label study with a waitlist control group among GBMSM in 3 groups (low-risk HIV-negative group, high-risk HIV-negative group, and living-with-HIV [LWH] group) recruited online and in venues in Atlanta, Detroit, and New York City. Participants were randomly assigned to receive access to the app immediately or at 9 months after randomization. The app provided prevention messages in 6 domains of sexual health and offered ordering of at-home HIV and sexually transmitted infection test kits, receiving preexposure prophylaxis (PrEP) evaluations and navigation, and service locators. Serostatus- and risk-specific prevention outcomes were evaluated at baseline, at the end of the intervention period, and at 3, 6, and 9 months after the intervention period.

RESULTS

In total, 1226 GBMSM were enrolled and randomized; of these 611 (49.84%) were assigned to the intervention group and 608 (99.51%) were analyzed, while 615 (50.16%) were assigned to the control group and 612 (99.51%) were analyzed. For high-risk GBMSM, allocation to the intervention arm was associated with higher odds of HIV testing during the intervention period (adjusted odds ratio [aOR] 2.02, 95% CI 1.11-3.66) and with higher odds of using PrEP in the 3 months after the intervention period (aOR 2.41, 95% CI 1.00-5.76, P<.05). No changes in HIV prevention or care were associated with allocation to the intervention arm for the low-risk HIV-negative and LWH groups.

CONCLUSIONS

Access to the M-cubed app was associated with increased HIV testing and PrEP use among high-risk HIV-negative GBMSM in 3 US cities. The app could be made available through funded HIV prevention providers; additional efforts are needed to understand optimal strategies to implement the app outside of the research setting.

TRIAL REGISTRATION

ClinicalTrials.gov NCT03666247; https://clinicaltrials.gov/ct2/show/NCT03666247.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

RR2-10.2196/16439.

Alignment of PrEP use and sexual behavior over four months among men who have sex with men in the southern United States

Unlike antiretrovirals for HIV treatment, pre-exposure prophylaxis (PrEP) does not require continual adherence to be fully effective; rather, PrEP adherence is important only in the context of episodes of sexual risk. Therefore, studies of PrEP adherence and persistence must incorporate contemporaneous measurement of sexual behavior. Short, frequent surveys of PrEP use and sexual behavior allow for the measurement of the alignment between PrEP use and sexual behavior. We assessed the feasibility of using biweekly PrEP use and sexual behavior questionnaires to measure adherence and persistence on PrEP over a period of four months. We also measured the alignment of PrEP use and condomless anal sex. PrEP-using MSM in the southern US were recruited using online advertisements. Participants completed a baseline survey followed by brief surveys every two weeks for 16 weeks to report their PrEP use and sexual behavior over the preceding two-week period. Study retention was high: 91% of participants completed the baseline and final survey and, overall, 86% of study surveys were completed. Self-reported PrEP adherence and persistence were high, but instances of PrEP non-adherence were observed to frequently overlap with episodes of condomless anal sex. The most prominent reasons cited for missing PrEP doses were being too busy, not having PrEP on hand, and not being sexually active. Completing short, biweekly surveys of PrEP use and sexual behavior is feasible and acceptable to MSM in the southern US. Future studies should investigate incorporating biomarker measurements to validate self-reported adherence.

Seroadaptive Strategy Patterns of Young Black Gay, Bisexual, and Other Men Who Have Sex With Men in Atlanta, Georgia

BACKGROUND

Young Black gay, bisexual, and other men who have sex with men (YBMSM) are disproportionally affected by HIV. Seroadaptive strategies-modification of sexual behavior based on an individual's perceived serostatus, the perceived status of the partner, and/or HIV transmission risk by the type of sex act-are often used to reduce the risk of HIV transmission or acquisition.

METHODS

We used demographic, behavioral, and clinical data from Ele[MEN]t, a prospective cohort study of YBMSM aged 18-29 years in Atlanta, GA, conducted during 2015-2019. The prevalence of seroadaptive strategies at baseline was reported, and latent class analysis was used to identify the latent classes of strategies for both YBMSM known and not known to be living with HIV. Latent classes were compared by key behavioral and clinical characteristics to validate our findings.

RESULTS

In a 4-class model, the most common latent class of YBMSM not known to be living with HIV (32.4%) was characterized by all individuals reporting only having sex with men not perceived to be living with HIV. The most common latent class of YBMSM known to be living with HIV (48.2%) was characterized by a combination of serosorting strategies, including using condoms for anal sex with partners not known to be living with HIV and avoiding sex with men not known to be living with HIV.

CONCLUSIONS

YBMSM use various patterns of strategies to reduce their HIV transmission or acquisition risk. Our study highlights the need for targeted HIV prevention recommendations based on individual behaviors.

HIV incidence among men who have sex with men in mainland China: a systematic review protocol

BACKGROUND

Men who have sex with men (MSM) are disproportionately affected by HIV in China. Globally, younger MSM are at higher risk for incident HIV infections, but there has been substantial variation in the estimates of age-stratified HIV incidence among MSM in mainland China, potentially due to regional differences in the nature of the epidemic. Given the need for quality epidemiological data to meet the global goal of ending new HIV infections by 2030, this systematic review and meta-analysis aims to determine age-stratified HIV incidence in mainland China, including consideration by geographic region and time.

METHODS

This review will include longitudinal studies, cross-sectional surveys, and surveillance reports among MSM in mainland China that have reported HIV incidence. We will search studies and reports published from January 1, 2003, to April 30, 2020, in both English and Chinese language literature databases. For each study considered, two reviewers will independently screen, determine eligibility, and extract relevant data, with discrepancies resolved by consensus of a third reviewer. The methodological quality of included studies will be assessed by the Quality Assessment Tool for Systematic Reviews of Observational Studies Score (QATSO). We will develop age-stratified estimates of HIV incidence with geographic variations and temporal trends. Heterogeneity will be examined using statistical techniques appropriate to the dataset. For subgroup analyses, we will conduct mixed-effects meta-analysis models.

DISCUSSION

This review will contribute to a better understanding of the HIV epidemic among MSM in mainland China by providing age-stratified estimates of HIV incidence with a portrayal of geographic and temporal variations. Findings will reflect epidemic dynamics, informing local and national intervention programs and policies for HIV prevention, and providing estimation data to inform future research among MSM in China.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO ID 154834.

Cumulative incidence of SARS-CoV-2 infections among adults in Georgia, USA, August-December 2020

BACKGROUND

Reported COVID-19 cases underestimate true SARS-CoV-2 infections. Data on all infections, including asymptomatic infections, are needed to guide programs. To minimize biases in estimates from reported cases and seroprevalence surveys, we conducted a household-based probability survey in Georgia and estimated cumulative incidence of SARS-CoV-2 infections adjusted for antibody waning.

METHODS

From August to December 2020, we mailed specimen collection kits (nasal swabs and blood spots) to a random sample of Georgia addresses. One household adult completed a survey and returned specimens for virus and antibody testing. We estimated cumulative incidence of SARS-CoV-2 infections adjusted for waning antibodies, reported fraction, and infection fatality ratio (IFR). Differences in seropositivity among demographic, geographic and clinical subgroups were explored with weighted prevalence ratios (PR).

RESULTS

Among 1,370 participants, adjusted cumulative incidence of SARS-CoV-2 was 16.1% (95% credible interval (CrI): 13.5-19.2%) as of November 16, 2020. The reported fraction was 26.6% and IFR was 0.78%. Non-Hispanic Black (PR: 2.03, CI 1.0, 4.1) and Hispanic adults (PR: 1.98, CI 0.74, 5.31) were more likely than non-Hispanic White adults to be seropositive.

CONCLUSIONS

As of mid-November 2020, one in 6 adults in Georgia had been infected with SARS-CoV-2. The COVID-19 epidemic in Georgia is likely substantially underestimated by reported cases.

The spatiotemporal distribution of pre-exposure prophylaxis accessibility in the United States, 2016-2020

PURPOSE

Residing in areas with little spatial accessibility to HIV pre-exposure prophylaxis (PrEP) providers, or PrEP deserts, contributes to low PrEP uptake. This study examines and characterizes the spatial distribution of PrEP accessibility in the United States over time.

METHODS

We conducted spatial network analyses and geographic mapping to explore the spatiotemporal distribution of persistent PrEP deserts (census tracts with suboptimal accessibility in 2016 and 2020), new PrEP deserts (tracts with suboptimal accessibility in 2020 but not 2016), new PrEP oases (tracts with suboptimal accessibility in 2016 but not 2020), and persistent PrEP oases (tracts with optimal accessibility in 2016 and 2020). We used polytomous logistic regression to determine area-level factors associated with these four spatiotemporal PrEP accessibility types.

RESULTS

There was a reduction of 52.8% in the prevalence of 30-minute PrEP deserts from 2016 (28,055 tracts) to 2020 (13,240 tracts) and an increase of 33.5% in 30-minute PrEP oases from 2016 (44,259 tracts) to 2020 (59,074 tracts). Of all tracts, 12,487 (17.3%) were persistent PrEP deserts, 753 (1.0%) were new PrEP deserts, 15,568 (21.5%) were new PrEP oases, and 43,506 (60.1%) were persistent PrEP oases. Overall, persistent PrEP oases were more likely to be of higher socioeconomic status, racially/ethnically diverse, located in urban areas, and located in the Northeast compared with other spatiotemporal PrEP accessibility types, with variation by urbanicity and U.S. Census region.

CONCLUSIONS

Efforts to improve PrEP accessibility should be especially focused in disadvantaged communities in nonurban areas and the South, Midwest, and West. Monitoring changes in the spatial accessibility of PrEP over time and determining the factors associated with such changes can help to evaluate progress made towards improving PrEP accessibility.

Trajectory of COVID-19 Vaccine Hesitancy Over Time and Association of Initial Vaccine Hesitancy With Subsequent Vaccination

This cohort study assesses the association between baseline vaccine hesitancy and vaccine receipt at study follow-up and explores the validity of vaccine self-report.

A framework for monitoring population immunity to SARS-CoV-2

In the effort to control SARS-CoV-2 transmission, public health agencies in the United States and globally are aiming to increase population immunity. Immunity through vaccination and acquired following recovery from natural infection are the two means to build up population immunity, with vaccination being the safe pathway. However, measuring the contribution to population immunity from vaccination or natural infection is non-trivial. Historical COVID-19 case counts and vaccine coverage are necessary information but are not sufficient to approximate population immunity. Here, we consider the nuances of measuring each and propose an analytical framework for integrating the necessary data on cumulative vaccinations and natural infections at the state and national level. To guide vaccine roll-out and other aspects of control over the coming months, we recommend analytics that combine vaccine coverage with local (e.g. county-level) history of case reports and adjustment for waning antibodies to establish local estimates of population immunity. To do so, the strategic use of minimally-biased serology surveys integrated with vaccine administration data can improve estimates of the aggregate level of immunity to guide data-driven decisions to re-open safely and prioritize vaccination efforts.

Mixed-Methods Evaluation of the Incorporation of Home Specimen Self-Collection Kits for Laboratory Testing in a Telehealth Program for HIV Pre-exposure Prophylaxis

Home specimen self-collection kits with central laboratory testing may improve persistence with PrEP and enhance telehealth programs. We offered Iowa TelePrEP clients the choice of using a home kit or visiting a laboratory site for routine monitoring. Mixed-methods evaluation determined the proportion of clients who chose a kit, factors influencing choice, associations between kit use and completion of indicated laboratory monitoring, and user experience. About 46% (35/77) chose to use a kit. Compared to laboratory site use, kit use was associated with higher completion of extra-genital swabs (OR 6.33, 95% CI 1.20-33.51, for anorectal swabs), but lower completion of blood tests (OR 0.21, 95% CI 0.06-0.73 for creatinine). Factors influencing choice included self-efficacy to use kits, time/convenience, and privacy/confidentiality. Clients reported kit use was straight-forward but described challenges with finger prick blood collection. Telehealth PrEP programs should offer clients home kits and support clients with blood collection and kit completion.

SARS-CoV-2 Cumulative Incidence and Period Seroprevalence: Results From a Statewide Population-Based Serosurvey in California

Background

California has reported the largest number of coronavirus disease 2019 (COVID-19) cases of any US state, with more than 3.5 million confirmed as of March 2021. However, the full breadth of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) transmission in California is unknown as reported cases only represent a fraction of all infections.

Methods

We conducted a population-based serosurvey, utilizing mailed, home-based SARS-CoV-2 antibody testing along with a demographic and behavioral survey. We weighted data from a random sample to represent the adult California population and estimated period seroprevalence overall and by participant characteristics. Seroprevalence estimates were adjusted for waning antibodies to produce statewide estimates of cumulative incidence, the infection fatality ratio (IFR), and the reported fraction.

Results

California's SARS-CoV-2 weighted seroprevalence during August-December 2020 was 4.6% (95% CI, 2.8%-7.4%). Estimated cumulative incidence as of November 2, 2020, was 8.7% (95% CrI, 6.4%-11.5%), indicating that 2 660 441 adults (95% CrI, 1 959 218-3 532 380) had been infected. The estimated IFR was 0.8% (95% CrI, 0.6%-1.0%), and the estimated percentage of infections reported to the California Department of Public Health was 31%. Disparately high risk for infection was observed among persons of Hispanic/Latinx ethnicity and people with no health insurance and who reported working outside the home.

Conclusions

We present the first statewide SARS-CoV-2 cumulative incidence estimate among adults in California. As of November 2020, ~1 in 3 SARS-CoV-2 infections in California adults had been identified by public health surveillance. When accounting for unreported SARS-CoV-2 infections, disparities by race/ethnicity seen in case-based surveillance persist.

A decision analytics model to optimize investment in interventions targeting the HIV preexposure prophylaxis cascade of care

OBJECTIVES

Gaps between recommended and actual levels of HIV preexposure prophylaxis (PrEP) use remain among MSM. Interventions can address these gaps but it is unknown how public health initiatives should invest prevention funds into these interventions to maximize their population impact.

DESIGN

We used a stochastic network-based HIV transmission model for MSM in the Atlanta area paired with an economic budget optimization model.

METHODS

The model simulated MSM participating in up to three real-world PrEP cascade interventions designed to improve initiation, adherence, or persistence. The primary outcome was infections averted over 10 years. The budget optimization model identified the investment combination under different budgets that maximized this outcome, given intervention costs from a payer perspective.

RESULTS

From the base 15% PrEP coverage level, the three interventions could increase coverage to 27%, resulting in 12.3% of infections averted over 10 years. Uptake of each intervention was interdependent: maximal use of the adherence and persistence interventions depended on new PrEP users generated by the initiation intervention. As the budget increased, optimal investment involved a mixture of the initiation and persistence interventions but not the adherence intervention. If adherence intervention costs were halved, the optimal investment was roughly equal across interventions.

CONCLUSION

Investments into the PrEP cascade through initiatives should account for the interactions of the interventions as they are collectively deployed. Given current intervention efficacy estimates, the total population impact of each intervention may be improved with greater total budgets or reduced intervention costs.

SARS-CoV-2 cumulative incidence, United States, August-December 2020

Background

Reported coronavirus disease 2019 (COVID-19) cases underestimate severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infections. We conducted a national probability survey of US households to estimate cumulative incidence adjusted for antibody waning.

Methods

From August–December 2020 a random sample of US addresses were mailed a survey and self-collected nasal swabs and dried blood spot cards. One adult household member completed the survey and mail specimens for viral detection and total (immunoglobulin [Ig] A, IgM, IgG) nucleocapsid antibody by a commercial, emergency use authorization–approved antigen capture assay. We estimated cumulative incidence of SARS-CoV-2 adjusted for waning antibodies and calculated reported fraction (RF) and infection fatality ratio (IFR). Differences in seropositivity among demographic, geographic, and clinical subgroups were explored.

Results

Among 39 500 sampled households, 4654 respondents provided responses. Cumulative incidence adjusted for waning was 11.9% (95% credible interval [CrI], 10.5%–13.5%) as of 30 October 2020. We estimated 30 332 842 (CrI, 26 703 753–34 335 338) total infections in the US adult population by 30 October 2020. RF was 22.3% and IFR was 0.85% among adults. Black non-Hispanics (Prevalence ratio (PR) 2.2) and Hispanics (PR, 3.1) were more likely than White non-Hispanics to be seropositive.

Conclusions

One in 8 US adults had been infected with SARS-CoV-2 by October 2020; however, few had been accounted for in public health reporting. The COVID-19 pandemic is likely substantially underestimated by reported cases. Disparities in COVID-19 by race observed among reported cases cannot be attributed to differential diagnosis or reporting of infections in population subgroups.

Estimating the Cumulative Incidence of SARS-CoV-2 Infection and the Infection Fatality Ratio in Light of Waning Antibodies

BACKGROUND

Serology tests can identify previous infections and facilitate estimation of the number of total infections. However, immunoglobulins targeting severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) have been reported to wane below the detectable level of serologic assays (which is not necessarily equivalent to the duration of protective immunity). We estimate the cumulative incidence of SARS-CoV-2 infection from serology studies, accounting for expected levels of antibody acquisition (seroconversion) and waning (seroreversion), and apply this framework using data from New York City and Connecticut.

METHODS

We estimated time from seroconversion to seroreversion and infection fatality ratio (IFR) using mortality data from March to October 2020 and population-level cross-sectional seroprevalence data from April to August 2020 in New York City and Connecticut. We then estimated the daily seroprevalence and cumulative incidence of SARS-CoV-2 infection.

RESULTS

The estimated average time from seroconversion to seroreversion was 3-4 months. The estimated IFR was 1.1% (95% credible interval, 1.0%, 1.2%) in New York City and 1.4% (1.1, 1.7%) in Connecticut. The estimated daily seroprevalence declined after a peak in the spring. The estimated cumulative incidence reached 26.8% (24.2%, 29.7%) at the end of September in New York City and 8.8% (7.1%, 11.3%) in Connecticut, higher than maximum seroprevalence measures (22.1% and 6.1%), respectively.

CONCLUSIONS

The cumulative incidence of SARS-CoV-2 infection is underestimated using cross-sectional serology data without adjustment for waning antibodies. Our approach can help quantify the magnitude of underestimation and adjust estimates for waning antibodies.

PrEParing for long-acting injectable PrEP in the South: perspectives from healthcare providers in Georgia

New modalities of Pre-exposure Prophylaxis (PrEP) such as long-acting injectable PrEP (LAI-PrEP) promise increased prevention of HIV transmission; however, similar biomedical interventions have not been met with universal adoption by healthcare providers or populations most affected by HIV. This qualitative study explores healthcare provider considerations for the rollout of LAI-PrEP. Eleven key-informant in-depth interviews were conducted with clinicians who prescribe daily oral PrEP. Participants reviewed a currently proposed LAI regimen and were asked to reflect on its implications for their clinical practice. Interviews were transcribed verbatim and thematically coded, with results organized using the Consolidated Framework for Implementation Research (CFIR). All participants expressed interest in prescribing LAI-PrEP and anticipated that at least some patients would be interested. Participants identified characteristics of the intervention, inner intervention setting, and outer intervention setting that will be influential in bringing LAI-PrEP to scale. Clinicians in the South have unique insights into the challenges of and opportunities for successful rollout of future PrEP regimens. Bringing these insights into a CFIR framework highlights the nuances surrounding LAI-PrEP, including structural concerns such as cost barriers and access to in-person healthcare services. It is critical to address these challenges to ensure successful implementation of new PrEP formulations.

Changes in Sexual Behavior, PrEP Adherence, and Access to Sexual Health Services Because of the COVID-19 Pandemic Among a Cohort of PrEP-Using MSM in the South

BACKGROUND

The coronavirus disease 2019 (COVID-19) pandemic has had unforeseen consequences on the delivery of HIV and sexually transmitted disease (STD) prevention services. However, little is known about how the pandemic has impacted pre-exposure prophylaxis (PrEP)-using men who have sex with men (MSM).

METHODS

Data come from an online cohort of PrEP-using MSM in the Southern United States from October 2019 to July 2020. Participants were administered 10 surveys in total, including 1 ad hoc survey specifically on COVID-19. We conducted a cross-sectional analysis of this ad hoc survey (n = 56) and present changes in sexual behaviors and utilization of and access to sexual health services. Using linear mixed-effect regression models, we also analyzed data from the larger cohort and document how sexual behaviors and PrEP use varied longitudinally across several months.

RESULTS

A fifth of participants discontinued or changed how often they take PrEP because of COVID-19. A quarter of the cohort documented challenges when attempting to access PrEP, HIV testing, or STD testing. For all sexual behaviors examined longitudinally-number of male sexual partners, anal sex acts, condomless anal sex, and oral sex (all measured in the past 2 weeks)-there was a decrease from February to April followed by an increase from April to June.

DISCUSSION

Our findings suggest reduced access to and utilization of STD and HIV services coupled with a continuation of behaviors which confer STD/HIV risk. Ensuring appropriate delivery of STD/HIV prevention services during this pandemic is imperative.

Pre-exposure Prophylaxis Uptake and Discontinuation Among Young Black Men Who Have Sex With Men in Atlanta, Georgia: A Prospective Cohort Study

BACKGROUND

Human immunodeficiency virus (HIV) preexposure prophylaxis (PrEP) has great potential to reduce HIV incidence among young black men who have sex with men (YBMSM); however, initiation and persistence for this group remain low. We sought to understand the patterns and predictors of PrEP uptake and discontinuation among YBMSM in Atlanta, Georgia.

METHODS

PrEP was offered to all participants in a prospective cohort of YBMSM aged 18-29 years not living with HIV. Time to PrEP uptake, first discontinuation, and final discontinuation were assessed using the Kaplan-Meier method. Cox proportional hazard models were used to identify predictors of uptake and discontinuation.

RESULTS

After 440 person-years of follow-up, 44% of YBMSM initiated PrEP through the study after a median of 122 days. Of PrEP initiators, 69% had a first discontinuation and 40% had a final discontinuation during the study period. The median time to first PrEP discontinuation was 159 days. Factors associated with PrEP uptake included higher self-efficacy, sexually transmitted infection (STI), and condomless anal intercourse. Factors associated with discontinuation included younger age, cannabis use, STI, and fewer sex partners. HIV incidence was 5.23/100 person-years (95% confidence interval [CI], 3.40-7.23), with a lower rate among those who started PrEP (incidence rate ratio, 0.39; 95% CI, .16-.92).

CONCLUSIONS

Persistent PrEP coverage in this cohort of YBMSM was suboptimal, and discontinuations were common despite additional support services available through the study. Interventions to support PrEP uptake and persistence, especially for younger and substance-using YBMSM, are necessary to achieve full PrEP effectiveness.

CLINICAL TRIALS REGISTRATION

NCT02503618.

DOT Diary: Developing a Novel Mobile App Using Artificial Intelligence and an Electronic Sexual Diary to Measure and Support PrEP Adherence Among Young Men Who Have Sex with Men

Young men who have sex with men (YMSM) are highly vulnerable to HIV. While pre-exposure prophylaxis (PrEP) has demonstrated effectiveness, adherence has been low among YMSM and difficult to measure accurately. In collaboration with a healthcare company, we configured an automated directly-observed therapy (aDOT) platform for monitoring and supporting PrEP use. Based on interest expressed in focus groups among 54 YMSM, we combined aDOT with an electronic sexual diary to provide feedback on level of protection during sex and to motivate app use. In an 8-week optimization pilot with 20 YMSM in San Francisco and Atlanta, the app was found to be highly acceptable, with median System Usability Scale scores in the "excellent" range (80/100). App use was high, with median PrEP adherence of 91% based on aDOT-confirmed dosing. Most (84%) participants reported the app helped with taking PrEP. These promising findings support further evaluation of DOT Diary in future effectiveness studies.

A Review of HIV Pre-exposure Prophylaxis Streamlining Strategies

Purpose of Review

Standard care for HIV pre-exposure prophylaxis (PrEP) in the USA creates substantial burdens for patients, clinicians, and the healthcare system; to optimize uptake, there is a need for innovative strategies to streamline its provision.

Recent Findings

Our review, structured by the expanded chronic care model, identified eleven promising strategies to streamline PrEP care. Approaches ranged widely in mechanism of action. Using text messages to support care was the only strategy with clinical trial evidence supporting its use. Other modalities such as patient navigation, telemedicine PrEP models, alternate dosing availability, same-day prescription, and provider training have promising pilot or associational data and seem likely to lower barriers to entering into or remaining in care. Many of the strategies have established success in related domains such as HIV care, meriting consideration in evaluating their use for PrEP.

Summary

Making PrEP care less burdensome will be an important part of bringing it to scale. Text message interventions have proven efficacy and merit broad adoption. Encouraging preliminary evidence for other strategies indicates the importance of building a stronger evidence base to clarify the effect of each strategy. Ongoing development of an evidence base should not delay the use of these promising strategies; instead, it calls for careful consideration for how each program may best match its environment to facilitate PrEP prescribing and use.

Mobile app development in health research: pitfalls and solutions

Mobile app health research presents myriad opportunities to improve health, and simultaneously introduces a new set of challenges that are non-intuitive and extend beyond typical training received by researchers. Informed by our experiences with app development for health research, we discuss some of the most salient pitfalls when working with emerging technology as well as potential strategies to avoid or resolve these challenges. To address challenges at the project level, we suggest strategies that researchers can use to future-proof their research, such as using theory and involving those with app development expertise as part of a research team. At the structural level, we include a new model to characterize the relationship between technology- and research-timelines, and provide ideas regarding how to best address this challenge. Given that screen-based time now predominates our lived experiences, it is important that health researchers have the capacity and structural support to develop interventions that utilize these technologies, assess them rigorously, and ensure their timely and equitable dissemination.

Assessing the performance of international pre-exposure prophylaxis (PrEP) eligibility guidelines in a cohort of Chinese MSM, Beijing, China 2009 to 2016

INTRODUCTION

PrEP is a powerful HIV prevention tool, and locally relevant eligibility criteria are necessary to optimize the prevention impact of PrEP. We assessed performance of existing national and international PrEP eligibility criteria to predict future HIV seroconversion among MSM in Beijing, China.

METHODS

Participants were MSM aged ≥18 years who enrolled in a cohort study between July 2009 and March 2016. Participants completed HIV testing, syphilis testing, and a questionnaire on recent sexual health behaviours at each follow-up visit and were followed until HIV seroconversion or dropout. We assessed PrEP eligibility at the most recent follow-up visit prior to the final study visit. Participants were classified as indicated for PrEP (or not) based on criteria from guidelines from Europe, Korea, South Africa, Taiwan, the United Kingdom, United States and the World Health Organization. To compare guideline performance, we calculated sensitivity, specificity, Youden's Index (YI), Matthew's Correlation Coefficient (MCC), F1 scores and diagnostic odds ratios. For each guideline, performance measures were compared to random allocation of PrEP by randomly selecting a proportion of participants equal to the proportion indicated.

RESULTS

There were 287 (17∙3%) incident HIV seroconversions among 1663 MSM. The number of men indicated for PrEP from different guidelines ranged from 556 (33∙4%) to 1569 (94∙2%). Compared to random allocation, sensitivity of algorithms to predict seroconversion ranged from slightly worse (-4∙7%) to 30∙2% better than random. However, in absolute terms, none of the sensitivity values increased by more than 11% when compared to random allocation. For all guidelines, specificity was not meaningfully better than random allocation. No guidelines had high binary classification performance measures.

CONCLUSIONS

The performance of international indication guidelines in this sample was only slightly better than random allocation. Using such guidelines to screen out MSM self-identifying as interested in PrEP could lead to misallocation of resources and to good candidates for PrEP being denied access. For settings in which international guidelines perform poorly, alternative indication approaches should be considered.

Estimating the cumulative incidence of SARS-CoV-2 infection and the infection fatality ratio in light of waning antibodies

Background

Serology tests can identify previous infections and facilitate estimation of the number of total infections. However, immunoglobulins targeting severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) have been reported to wane below the detectable level of serological assays. We estimate the cumulative incidence of SARS-CoV-2 infection from serology studies, accounting for expected levels of antibody acquisition (seroconversion) and waning (seroreversion), and apply this framework using data from New York City (NYC) and Connecticut.

Methods

We estimated time from seroconversion to seroreversion and infection fatality ratio (IFR) using mortality data from March-October 2020 and population-level cross-sectional seroprevalence data from April-August 2020 in NYC and Connecticut. We then estimated the daily seroprevalence and cumulative incidence of SARS-CoV-2 infection.

Findings

The estimated average time from seroconversion to seroreversion was 3-4 months. The estimated IFR was 1.1% (95% credible interval: 1.0-1.2%) in NYC and 1.4% (1.1-1.7%) in Connecticut. The estimated daily seroprevalence declined after a peak in the spring. The estimated cumulative incidence reached 26.8% (24.2-29.7%) and 8.8% (7.1-11.3%) at the end of September in NYC and Connecticut, higher than maximum seroprevalence measures (22.1% and 6.1%), respectively.

Interpretation

The cumulative incidence of SARS-CoV-2 infection is underestimated using cross-sectional serology data without adjustment for waning antibodies. Our approach can help quantify the magnitude of underestimation and adjust estimates for waning antibodies.

Funding

This study was supported by the US National Science Foundation and the National Institute of Allergy and Infectious Diseases.

Changes in sexual behavior, PrEP adherence, and access to sexual health services due to the COVID-19 pandemic among a cohort of PrEP-using MSM in the South

Background

The COVID-19 pandemic has had unforeseen consequences on the delivery of HIV and STD prevention services. However, little is known about how the pandemic has impacted PrEP-using men who have sex with men (MSM).

Methods

Data come from an online cohort of PrEP-using MSM in the Southern United States from October 2019 to July 2020. Participants were administered ten surveys in total, including one ad hoc survey specifically on COVID-19. We conducted a cross-sectional analysis of this ad hoc survey (n=56) and present changes in sexual behaviors and utilization of and access to sexual health services. Using linear mixed-effects regression models, we also analyzed data from the larger cohort (n=78) and document how sexual behaviors and PrEP use varied longitudinally focusing on three months: February (pre-pandemic), April (early pandemic), and June (later in the pandemic).

Results

A fifth of participants discontinued or changed how often they take PrEP because of COVID-19. A quarter of the cohort documented challenges when attempting to access PrEP, HIV testing, or STD testing. For all sexual behaviors examined longitudinally-number of male sexual partners, anal sex acts, condomless anal sex, oral sex (all measured in the past 2 weeks)-there was a significant decrease from February to April followed by a significant increase from April to June.

Discussion

Our findings suggest reduced access to and utilization of STD and HIV services coupled with a continuation of behaviors which confer STD/HIV risk. Ensuring appropriate delivery of STD/HIV prevention services during this pandemic is imperative.

A Data Visualization and Dissemination Resource to Support HIV Prevention and Care at the Local Level: Analysis and Uses of the AIDSVu Public Data Resource

BACKGROUND

AIDSVu is a public resource for visualizing HIV surveillance data and other population-based information relevant to HIV prevention, care, policy, and impact assessment.

OBJECTIVE

The site, AIDSVu.org, aims to make data about the US HIV epidemic widely available, easily accessible, and locally relevant to inform public health decision making.

METHODS

AIDSVu develops visualizations, maps, and downloadable datasets using results from HIV surveillance systems, other population-based sources of information (eg, US Census and national probability surveys), and other data developed specifically for display and dissemination through the website (eg, pre-exposure prophylaxis [PrEP] prescriptions). Other types of content are developed to translate surveillance data into summarized content for diverse audiences using infographic panels, interactive maps, local and state fact sheets, and narrative blog posts.

RESULTS

Over 10 years, AIDSVu.org has used an expanded number of data sources and has progressively provided HIV surveillance and related data at finer geographic levels, with current data resources providing HIV prevalence data down to the census tract level in many of the largest US cities. Data are available at the county level in 48 US states and at the ZIP Code level in more than 50 US cities. In 2019, over 500,000 unique users consumed AIDSVu data and resources, and HIV-related data and insights were disseminated through nearly 4,000,000 social media posts. Since AIDSVu's inception, at least 249 peer-reviewed publications have used AIDSVu data for analyses or referenced AIDSVu resources. Data uses have included targeting of HIV testing programs, identifying areas with inequitable PrEP uptake, including maps and data in academic and community grant applications, and strategically selecting locations for new HIV treatment and care facilities to serve high-need areas.

CONCLUSIONS

Surveillance data should be actively used to guide and evaluate public health programs; AIDSVu translates high-quality, population-based data about the US HIV epidemic and makes that information available in formats that are not consistently available in surveillance reports. Bringing public health surveillance data to an online resource is a democratization of data, and presenting information about the HIV epidemic in more visual formats allows diverse stakeholders to engage with, understand, and use these important public health data to inform public health decision making.

HIV prevalence and incidence in a cohort of South African men and transgender women who have sex with men: the Sibanye Methods for Prevention Packages Programme (MP3) project

INTRODUCTION

Men who have sex with men (MSM) and transgender women (TGW) are at increased risk for acquiring HIV, but there are limited HIV incidence data for these key populations in Africa. Understanding HIV prevalence and incidence provides important context for designing HIV prevention strategies, including pre-exposure prophylaxis (PrEP) programmes. We describe HIV prevalence, awareness of HIV infection, HIV incidence and associated factors for a cohort of MSM and TGW in Cape Town and Port Elizabeth, South Africa.

METHODS

From 2015 to 2016, MSM and TGW in Cape Town and Port Elizabeth were enrolled and prospectively followed for 12 months, receiving a comprehensive package of HIV prevention services. HIV testing was conducted at baseline and at follow-up visits (targeted for three, six and twelve months). All HIV-negative PrEP-eligible participants were offered PrEP enrolment during the first four months of study participation. We determined HIV prevalence among participants at baseline, and incidence by repeat screening of initially HIV-negative participants with HIV tests at three, six and twelve months.

RESULTS

Among 292 participants enrolled, HIV prevalence was high (43%; 95% CI: 38 to 49) and awareness of HIV status was low (50%). The 167 HIV-negative participants who were followed prospectively for 144.7 person-years; nine incident HIV infections were documented. Overall annual incidence was 6.2% (CI: 2.8 to 11.8) and did not differ by city. Annual HIV incidence was significantly higher for younger (18 to 19 years) MSM and TGW (MSM: 21.8% (CI: 1.2 to 100); TGW: 31.0 (CI: 3.7, 111.2)). About half of participants started PrEP during the study; the annual incidence of HIV among 82 (49%) PrEP starters was 3.6% (CI: 0.4, 13.1) and among those who did not start PrEP was 7.8% (CI: 3.1, 16.1).

CONCLUSIONS

HIV incidence was high among MSM and TGW in the context of receiving a comprehensive package of prevention interventions and offering of PrEP. PrEP uptake was high; the observed incidence of HIV in those who started PrEP was about half the incidence of HIV in those who did not. Future implementation-oriented studies should focus on decisions to start and continue PrEP for those at highest risk, including young MSM.

Sexually transmitted infection screening, prevalence and incidence among South African men and transgender women who have sex with men enrolled in a combination HIV prevention cohort study: the Sibanye Methods for Prevention Packages Programme (MP3) project

INTRODUCTION

Men who have sex with men (MSM) and transgender women (TGW) experience high incidence and prevalence of sexually transmitted infections (STI), and data are needed to understand risk factors for STIs in these populations. The Sibanye Health Project was conducted in Cape Town and Port Elizabeth, South Africa from 2015 to 2016 to develop and test a package of HIV prevention interventions for MSM and TGW. We describe the incidence, prevalence and symptoms of Chlamydia trachomatis (CT), Neisseria gonorrhea (NG) and syphilis observed during the study.

METHODS

Participants completed HIV testing at baseline. All participants who were HIV negative were followed prospectively. Additionally, a sample of participants identified as living with HIV at baseline was selected to be followed prospectively so that the prospective cohort was approximately 20% HIV positive; the remaining participants identified as HIV positive at baseline were not followed prospectively. Prospective participants were followed for 12 months and returned for clinic-based STI/HIV testing and assessment of STI symptoms at months 6 and 12. Additional HIV/STI testing visits could be scheduled at participant request.

RESULTS

Following consent, a total of 292 participants attended a baseline visit (mean age = 26 years), and 201 were enrolled for the 12-month prospective study. Acceptance of screening for syphilis and urethral NG/CT was near universal, though acceptance of screening for rectal NG/CT was lower (194/292; 66%). Prevalence of urethral CT and NG at baseline was 10% (29/289) and 3% (8/288) respectively; incidence of urethral CT and NG was 12.8/100 person-years (PY) and 7.1/100 PY respectively. Prevalence of rectal CT and NG at baseline was 25% (47/189) and 16% (30/189) respectively; incidence of rectal CT and NG was 33.4/100 PY and 26.8/100 PY respectively. Prevalence of syphilis at baseline was 17% (45/258) and incidence was 8.2/100 PY. 91%, 95% and 97% of diagnosed rectal NG/CT, urethral NG/CT and syphilis infections, respectively, were clinically asymptomatic.

CONCLUSIONS

Prevalence and incidence of urethral and rectal STIs were high among these South African MSM and TGW, and were similar to rates in other settings in the world. Clinical symptoms from these infections were rare, highlighting limitations of syndromic surveillance and suggesting the need for presumptive testing and/or treatment to address the STI epidemic among MSM/TGW in South Africa.

Willingness to Use Home Collection Methods to Provide Specimens for SARS-CoV-2/COVID-19 Research: Survey Study

Background

Innovative laboratory testing approaches for SARS-CoV-2 infection and immune response are needed to conduct research to establish estimates of prevalence and incidence. Self-specimen collection methods have been successfully used in HIV and sexually transmitted infection research and can provide a feasible opportunity to scale up SARS-CoV-2 testing for research purposes.

Objective

The aim of this study was to assess the willingness of adults to use different specimen collection modalities for themselves and children as part of a COVID-19 research study.

Methods

Between March 27 and April 1, 2020, we recruited 1435 adults aged 18 years or older though social media advertisements. Participants completed a survey that included 5-point Likert scale items stating how willing they were to use the following specimen collection testing modalities as part of a research study: home collection of a saliva sample, home collection of a throat swab, home finger-prick blood collection, drive-through site throat swab, clinic throat swab, and clinic blood collection. Additionally, participants indicated how the availability of home-based collection methods would impact their willingness to participate compared to drive-through and clinic-based specimen collection. We used Kruskal-Wallis tests and Spearman rank correlations to assess if willingness to use each testing modality differed by demographic variables and characteristics of interest. We compared the overall willingness to use each testing modality and estimated effect sizes with Cohen d.

Results

We analyzed responses from 1435 participants with a median age of 40.0 (SD=18.2) years and over half of which were female (761/1435, 53.0%). Most participants agreed or strongly agreed that they would be willing to use specimens self-collected at home to participate in research, including willingness to collect a saliva sample (1259/1435, 87.7%) or a throat swab (1191/1435, 83.1%). Willingness to collect a throat swab sample was lower in both a drive-through setting (64%) and clinic setting (53%). Overall, 69.0% (990/1435) of participants said they would be more likely to participate in a research study if they could provide a saliva sample or throat swab at home compared to going to a drive-through site; only 4.4% (63/1435) of participants said they would be less likely to participate using self-collected samples. For each specimen collection modality, willingness to collect specimens from children for research was lower than willingness to use on oneself, but the ranked order of modalities was similar.

Conclusions

Most participants were willing to participate in a COVID-19 research study that involves laboratory testing; however, there was a strong preference for home specimen collection procedures over drive-through or clinic-based testing. To increase participation and minimize bias, epidemiologic research studies of SARS-CoV-2 infection and immune response should consider home specimen collection methods.