At-Home Diagnostics Solutions for Chlamydia and Gonorrhea

This Viewpoint discusses the US Food and Drug Administration’s authorization of marketing an at-home testing system for chlamydia and gonorrhea as a good first step in boosting access to screening and treatment and in reducing infection rates.

"Make it more than a pill, make it an experience of health:" results from an open pilot intervention to retain young African American men who have sex with men in PrEP care

Uptake and retention in clinical care for pre-exposure prophylaxis (PrEP) is suboptimal, particularly among young African American men who have sex with men (MSM) in the Deep South. We conducted a two-phase study to develop and implement an intervention to increase PrEP persistence. In Phase I, we conducted focus groups with 27 young African American MSM taking PrEP at a community health center in Jackson, Mississippi to elicit recommendations for the PrEP persistence intervention. We developed an intervention based on recommendations in Phase I, and in Phase II, ten participants were enrolled in an open pilot. Eight participants completed Phase II study activities, including a single intervention session, phone call check-ins, and four assessments (Months 0, 1, 3, and 6). Exit interviews demonstrated a high level of acceptability and satisfaction with the intervention. These formative data demonstrate the initial promise of a novel intervention to improve PrEP persistence among young African American MSM.

Perspectives on HIV pre-exposure prophylaxis (PrEP) implementation in Mississippi among Black women and clinical staff: Recommendations for clinical trauma-informed programs

Intimate partner violence (IPV) can constraint Black women's ability to prioritize and access Human Immunodeficiency Virus (HIV) pre-exposure prophylaxis (PrEP) services. Recent research has called for the development of trauma-informed PrEP implementation programs to improve the delivery of PrEP to Black cisgender women; however, many PrEP-prescribing settings do not reflect this recommendation. The current study sought to identify key components to develop a trauma-informed PrEP implementation program for Black cisgender women and clinical staff. We conducted focus groups with PrEP-eligible Black cisgender women (February-June 2019), and semi-structured interviews with clinical staff offering HIV prevention and treatment services (October-November 2020) in community healthcare clinics in Mississippi. Seven themes were identified as needed to facilitate integration of trauma-informed approaches into existing PrEP programs, including defining intimate partner violence (IPV), appropriate IPV screening and response, HIV prevention in abusive relationships, staff training needs, and creating supportive clinic environments. PrEP-eligible Black women and clinical staff generally agreed on how to best operationalize IPV screening and response, the importance of trauma-informed staff training, and the need for Black women-specific informational campaigns. However, Black women highlighted the need for providers to discuss HIV prevention in controlling relationships, and to respond to IPV disclosure. HIV pre-exposure prophylaxis has yet to achieve the potential impact observed in trials. Ultimately, realizing the HIV prevention potential of PrEP in the US necessitates centering the perspectives of Black cisgender women and staff to better integrate trauma-informed approaches.

Factors associated with suboptimal retention in HIV pre-exposure prophylaxis care among men who have sex with men

Despite the efficacy of HIV pre-exposure prophylaxis (PrEP), retention in care in the United States remains suboptimal. The goal of this study was to explore factors that lead to suboptimal retention in PrEP care for men who have sex with men (MSM) in real-world clinical settings in the United States. Trained interviewers conducted semi-structured interviews with MSM (N = 49) from three clinics who had been engaged in PrEP care in the Midwest (n = 15), South (n = 15), and Northeast (n = 19) geographic regions and had experienced a lapse in PrEP use. Factors that emerged as related to suboptimal retention in PrEP care included structural factors such as transportation and out-of-pocket costs; social factors such as misinformation on media and in personal networks; clinical factors such as frequency and timing of appointments; and behavioral factors such as changes in sexual behavior and low perceived risk for HIV. Participants suggested reducing the out-of-pocket costs of medications and lab visits, having flexible appointment times, culturally responsive services, and comprehensive patient navigation to help retention in care. These findings leveraged real-world experiences and opinions of patients to inform gaps in current services and how to make changes to optimize PrEP care.

Family-Related Factors and HIV-Related Outcomes Among Black Young Men Who Have Sex with Men in Mississippi

Given their disproportionate HIV incidence, there is a critical need to identify factors related to HIV risk among Black young men who have sex with men (YMSM) in the southeastern United States. This study investigated the association of family factors and HIV-related outcomes among Black YMSM in Mississippi ages 14-20 (n = 72). Multivariable regression models evaluated associations of family factors and outcomes. Greater parent/child communication about sex was associated with fewer lifetime male sex partners and lower odds of lifetime anal sex. Greater parental monitoring was associated with greater likelihood of future condom use. Sexual orientation disclosure was associated with more lifetime male sex partners. Parental monitoring and parent/child communication about sex were protective, suggesting that family-based interventions are promising for HIV prevention among Black YMSM in Mississippi. Results also indicated that YMSM who are "out" to family are important to reach, and families could be useful in encouraging healthy behaviors.

Pre-exposure Prophylaxis Discontinuation During the COVID-19 Pandemic Among Men Who Have Sex With Men in a Multisite Clinical Cohort in the United States

BACKGROUND

The coronavirus disease 2019 (COVID-19) pandemic continues to put strain on health systems in the United States, leading to significant shifts in the delivery of routine clinical services, including those offering HIV pre-exposure prophylaxis (PrEP). We aimed to assess whether individuals discontinued PrEP use at higher rates during the COVID-19 pandemic and the extent to which disruptions to usual clinical care were mitigated through telehealth.

METHODS

Using data from an ongoing prospective cohort of men who have sex with men (MSM) newly initiating PrEP in 3 mid-sized cities (n = 195), we calculated the rate of first-time discontinuation of PrEP use in the period before the COVID-19 pandemic and during the COVID-19 pandemic and compared these rates using incidence rate ratios (IRRs). Furthermore, we compared the characteristics of patients who discontinued PrEP use during these periods with those who continued to use PrEP during both periods.

RESULTS

Rates of PrEP discontinuation before the COVID pandemic and during the COVID-19 pandemic were comparable [4.29 vs. 5.20 discontinuations per 100 person-months; IRR: 1.95; 95% confidence interval (CI): 0.83 to 1.77]. Although no significant differences in the PrEP discontinuation rate were observed in the overall population, the rate of PrEP discontinuation increased by almost 3-fold among participants aged 18-24 year old (IRR: 2.78; 95% CI: 1.48 to 5.23) and by 29% among participants covered by public insurance plans at enrollment (IRR: 1.29; 95% CI: 1.03 to 5.09). Those who continued to use PrEP were more likely to have had a follow-up clinical visit by telehealth in the early months of the pandemic (45% vs. 17%).

CONCLUSIONS

In this study, rates of PrEP discontinuation were largely unchanged with the onset of the COVID-19 pandemic. The use of telehealth likely helped retain patients in PrEP care and should continue to be offered in the future.

Perspectives of people living with HIV-1 on implementation of long-acting cabotegravir plus rilpivirine in US healthcare settings: results from the CUSTOMIZE hybrid III implementation-effectiveness study

INTRODUCTION

The CUSTOMIZE hybrid III implementation-effectiveness study evaluated implementation of once-monthly long-acting (LA) cabotegravir + rilpivirine in diverse US healthcare settings. Here, we report patient participant perspectives after 12 months in CUSTOMIZE.

METHODS

CUSTOMIZE was a phase IIIb, 12-month study conducted from July 2019 to October 2020 at eight diverse US HIV clinics that enrolled virologically suppressed people living with HIV-1 (PLHIV) on a stable oral regimen to receive monthly cabotegravir + rilpivirine LA injections after a 1-month oral lead-in. Participants were administered quantitative surveys before injections at months 1 (baseline), 4 and 12. A randomly selected subset of participants was interviewed at baseline and month 12. Data collection at month 12 was completed by October 2020 (during the COVID-19 pandemic).

RESULTS

At baseline, 109 and 34 participants completed surveys and interviews, respectively; 87% were male; 35% were Black or African American. All participants who remained in the study at month 12 (n = 102) maintained HIV-1 RNA <50 copies/ml; two participants withdrew due to injection-related reasons. Mean total scores measuring acceptability and appropriateness of cabotegravir + rilpivirine LA were high at baseline (4.5-4.6 out of 5) and month 12 (4.7-4.9). At month 12, 74% of participants reported nothing interfered with receiving LA injections; injection pain or soreness was the most common concern (15%). Time spent in the clinic and coming to the clinic for monthly injections was very or extremely acceptable after 12 months for most participants (93% and 87%, respectively), with 64% reporting having spent ≤30 minutes in the clinic for injection visits. At month 12, 92% of participants preferred LA injections to daily oral tablets (3%); 97% plan to continue LA treatment going forward. In month 12 interviews, 24 (77%) of 31 participants reported the COVID-19 pandemic did not impact their ability to receive treatment.

CONCLUSIONS

Once-monthly cabotegravir + rilpivirine LA was highly acceptable among PLHIV who were virologically suppressed on a stable antiretroviral regimen and interested in trying LA therapy, with few participants reporting challenges receiving LA injections. Implementation data from CUSTOMIZE suggest that monthly LA injections provide a convenient and appealing treatment option for PLHIV.

Perspectives of healthcare providers on implementation of long-acting cabotegravir plus rilpivirine in US healthcare settings from a Hybrid III Implementation-effectiveness study (CUSTOMIZE)

Introduction

CUSTOMIZE evaluated the implementation of long‐acting (LA) cabotegravir + rilpivirine, a novel healthcare provider–administered injectable antiretroviral therapy regimen, in diverse US healthcare settings. Findings from staff‐study participants (SSPs) through 12 months of implementation are reported.

Methods

CUSTOMIZE was a phase IIIb, 12‐month, single‐arm, hybrid III implementation‐effectiveness study conducted from July 2019 to October 2020 at eight US clinics of five clinic types: private practice (n = 2), federally qualified health centre (n = 2), university (n = 2), AIDS Healthcare Foundation (n = 2) and health maintenance organization (n = 1). Eligible patient participants received monthly cabotegravir + rilpivirine LA injections after a 1‐month oral lead‐in. At baseline, month 4 and month 12, SSPs (n = 3 each per clinic), including physicians, nurses or injectors, and administrators, completed quantitative surveys and semi‐structured interviews to assess implementation outcomes (acceptability, appropriateness and feasibility of intervention measures), programme sustainability and SSP perceptions of, attitudes towards, and expectations for cabotegravir + rilpivirine LA. Month 12 data collection occurred during the COVID‐19 pandemic.

Results

In surveys, SSPs reported high mean total scores for acceptability, appropriateness and feasibility of cabotegravir + rilpivirine LA implementation at baseline (4.43, 4.52 and 4.38 of 5, respectively) and month 12 (4.45, 4.61 and 4.46 of 5, respectively), regardless of clinic type. At month 12, SSPs were positive about the implementation sustainability (mean Program Sustainability Assessment Tool score, 5.83 out of 7). At baseline, SSPs’ top concern was patients’ ability to maintain monthly appointments (81%); at month 12, 39% had this concern. The proportion of SSPs reporting patient injection pain or soreness as a barrier was consistent at month 12 versus baseline (48% vs. 46%). Most (78%) SSPs reported optimal implementation of cabotegravir + rilpivirine LA in their clinics was achieved in 1–3 months. In interviews, SSP‐reported strategies for successful implementation included teamwork, using a web‐based treatment planner and having a designated person to track appointment scheduling. In month 12 interviews, SSP‐reported structural changes needed for implementation included changing clinic hours and purchasing refrigerators.

Conclusions

In CUSTOMIZE, cabotegravir + rilpivirine LA was successfully implemented across a range of US healthcare settings. Barriers were mitigated with minor process adjustments.

Where's the "Everyday Black Woman"? An intersectional qualitative analysis of Black Women's decision-making regarding HIV pre-exposure prophylaxis (PrEP) in Mississippi

BACKGROUND

Black cisgender women in the U.S. South bear a disproportionate burden of HIV compared to cisgender women in other racial and ethnic groups and in any other part of the US. Critical to decreasing new HIV infections is the improved delivery of pre-exposure prophylaxis (PrEP) for Black cisgender women as it remains underutilized in 2021. Informed by intersectionality, the study sought to characterize the sociostructural influences on Black cisgender women's deliberations about PrEP within the context of interlocking systems of oppression including racism, sexism, and classism.

METHODS

Six focus groups were conducted with 37 Black women residing in Jackson, Mississippi. This sample was purposively recruited to include Black cisgender women who were eligible for PrEP but had never received a PrEP prescription.

RESULTS

Six themes were identified as concerns during PrEP deliberation among Black women: 1) limited PrEP awareness, 2) low perceived HIV risk, 3) concerns about side effects, 4) concerns about costs, 5) limited marketing, and 6) distrust in the healthcare system. Three themes were identified as facilitators during PrEP deliberations: 1) women's empowerment and advocacy, 2) need for increased PrEP-specific education, and 3) the positive influence of PrEP-engaged women's testimonials. Black women shared a limited awareness of PrEP exacerbated by the lack of Black women-specific marketing. Opportunities to support Black women-specific social marketing could increase awareness and knowledge regarding PrEP's benefits and costs. Black women also shared their concerns about discrimination in healthcare and distrust, but they felt that these barriers may be addressed by patient testimonials from PrEP-engaged Black women, empowerment strategies, and directly addressing provider biases.

CONCLUSIONS

An effective response to PrEP implementation among Black women in the South requires developing programs to center the needs of Black women and carry out active strategies that prioritize peer advocacy while reinforcing positive and mitigating negative influences from broader social and historical contexts.

A Pilot Study of a Patient Navigation Intervention to Improve HIV Pre-exposure Prophylaxis Persistence Among Black/African American Men Who Have Sex With Men

BACKGROUND

Suboptimal HIV pre-exposure prophylaxis (PrEP) care outcomes among Black/African American men who have sex with men (MSM) limits its population-level effects on HIV incidence. We conducted a pilot study of a brief patient navigation intervention aimed at improving PrEP initiation and persistence among Black/African American MSM in the Southern United States.

SETTING

Community health center in Jackson, MS.

METHODS

We recruited 60 Black/African American MSM aged 18-34 years who were newly prescribed PrEP. Participants were randomized to receive the clinic's current standard of care or an intervention condition including a single patient navigation session to discuss and address perceived barriers to initiating and maintaining access to PrEP and biweekly check-ins. Participants were followed over 6 months using survey assessments, medical chart review, and pharmacy purchase records to ascertain PrEP initiation and persistence.

RESULTS

Participants in the intervention condition were more likely to pick up their initial PrEP prescription [RR: 1.47; 95% confidence interval (CI): 1.10 to 1.97], be retained in PrEP care at 3 months (RR: 1.62; 95% CI: 1.01 to 2.59) and 6 months (RR: 1.38; 95% CI: 0.64 to 2.93), and have access to PrEP medications greater than 80% of all study days based on pharmacy fill records (RR: 3.00; 95% CI: 1.50 to 5.98).

CONCLUSION

A brief patient navigation intervention demonstrated proof-of-concept in improving PrEP initiation and persistence among Black/African American MSM in the Southern United States.

Projected Effects of Disruptions to Human Immunodeficiency Virus (HIV) Prevention Services During the Coronavirus Disease 2019 Pandemic Among Black/African American Men Who Have Sex With Men in an Ending the HIV Epidemic Priority Jurisdiction

Background

Disruptions in access to in-person human immunodeficiency virus (HIV) preventive care during the coronavirus disease 2019 (COVID-19) pandemic may have a negative impact on our progress towards the Ending the HIV Epidemic goals in the United States.

Methods

We used an agent-based model to simulate HIV transmission among Black/African American men who have sex with men in Mississippi over 5 years to estimate how different reductions in access affected the number of undiagnosed HIV cases, new pre-exposure prophylaxis (PrEP) starts, and HIV incidence.

Results

We found that each additional 25% decrease in HIV testing and PrEP initiation was associated with decrease of 20% in the number of cases diagnosed and 23% in the number of new PrEP starts, leading to a 15% increase in HIV incidence from 2020 to 2022.

Conclusions

Unmet need for HIV testing and PrEP prescriptions during the COVID-19 pandemic may temporarily increase HIV incidence in the years immediately after the disruption period.

Affirming and Inclusive Care Training for Medical Students and Residents to Reducing Health Disparities Experienced by Sexual and Gender Minorities: A Systematic Review

Purpose

Providing inclusive and comprehensive gender-affirming care is critical to reducing health disparities (gaps in care) experienced by sexual and gender minorities (SGM). Currently, little is known about how medical students and residents are being trained to address the health needs of SGM persons or of the most effective methods.

Methods

We conducted a systematic review of the research literature from 2000 to 2020 on the effectiveness of teaching medical students and residents on knowledge, attitudes, and skills in addressing the health of SGM persons and the strength of the research sample, design, and methods used.

Results

We identified a total of 36 articles that assessed the impact of medical student and resident education on knowledge, comfort, attitudes, confidence, and skills in working with SGM patients. All studies utilized quasi-experimental designs, and found efficacious results. No study examined the impact of training on patient outcomes.

Conclusion

Future studies will need to be powered and designed to assess the impact of training on patient outcomes.

Human Immunodeficiency Virus/Sexually Transmitted Infection Testing Preferences for Young Black Men Who Have Sex With Men in the Southeastern United States: Implications for a Post-COVID-19 Era

BACKGROUND

Little is known regarding human immunodeficiency virus (HIV)/sexually transmitted infection (STI) testing preferences for location, staffing, and hours of operation among Young Black men who have sex with men (YBMSM) in the Southeastern United States, a population at high risk for HIV/STIs. We used a discrete choice experiment to explore these preferences.

METHODS

Young Black men who have sex with men ages 16 to 35 years in Birmingham, AL and Jackson, MS completed online surveys evaluating their preferences (best/worst) for HIV/STI testing locations, staffing, hours, method of results notification, and cost. They also selected preferred combinations of these variables through choice tasks. Results were analyzed using joint best/worst and discrete choice experiment models.

RESULTS

Between June 2018 and December 2019, participants in Alabama (n = 54) and Mississippi (n = 159) completed online surveys. Both groups preferred stationary testing locations over mobile testing vans, with the most significant difference favoring STI testing-only clinics in Mississippi and local health departments in Alabama (P < 0.001). Technician-performed tests or self-testing were significantly less preferred compared with clinician-performed testing for both groups (P < 0.0001 and P < 0.0001, respectively). Free testing and phone results notification (versus text) were preferred by both groups. The most desirable combination among all participants was weekday clinician-performed testing at the health department for $5.

CONCLUSIONS

Young Black men who have sex with men in the Southeastern United States prefer traditional testing locations staffed by experienced personnel. Combination choices are influenced by services that are low or no cost. More research is needed to inform the best way(s) to provide affordable, high-quality HIV/STI testing services for YBMSM, particularly in the post-COVID-19 era when sexual health care delivery models are evolving toward home-based and remote health-focused strategies.

A Comparison of Single-Dose Versus Multidose Metronidazole by Select Clinical Factors for the Treatment of Trichomonas vaginalis in Women

BACKGROUND

In a randomized controlled trial of 2 g (single-dose) metronidazole (MTZ) versus 500 mg twice daily for 7 days (multidose) for Trichomonas vaginalis treatment, multidose was superior. We examined if the effect was similar by select clinical factors to determine if treatment recommendations could be targeted.

METHODS

The primary outcome was T. vaginalis repeat infection at test-of-cure (TOC) 4 weeks after completion of therapy. Analyses were stratified by T. vaginalis history, baseline genital symptoms, and concurrent diagnosis of bacterial vaginosis (BV) per Nugent score at baseline.

RESULTS

Women who returned for TOC (n = 540) were included. At baseline, 52.9% had a self-reported history of T. vaginalis; 79.3%, genital symptoms; 5.8%, a gonorrhea diagnosis; and 47.5%, BV. During follow-up, 97.4% took all MTZ as instructed and 34.5% had interval condomless sex with a baseline partner. At TOC, 14.8% tested positive for T. vaginalis. In stratified analysis, women randomized to single-dose MTZ had a higher rate of TOC T. vaginalis positivity than those randomized to multidose if they were symptomatic at baseline (21.4% vs. 10.8%, P = 0.003) or had a reported history of T. vaginalis (24.1% vs. 12.6%, P = 0.01). Test-of-cure T. vaginalis positivity was higher for women receiving a single dose (18.9%) versus multidose (10.8%), irrespective of baseline BV status (P > 0.06). In multivariable analysis, only a history of T. vaginalis and single-dose MTZ were independently associated with a positive TOC for T. vaginalis.

CONCLUSIONS

Although multidose MTZ is recommended for all women with T. vaginalis, it is especially important for women with a T. vaginalis history and, given high posttreatment infection rates, a TOC should be performed.

"PrEP's just to secure you like insurance": a qualitative study on HIV pre-exposure prophylaxis (PrEP) adherence and retention among black cisgender women in Mississippi

BACKGROUND

Pre-exposure prophylaxis (PrEP) has the potential to reduce transmission of HIV among Black cisgender women in the Southern United States (U.S.); however, national data suggests that PrEP initiation is lowest in the South and among Black women compared to other U.S. regions and white women. This study applied intersectionality and PrEP multilevel resilience frameworks to assess how socio-structural and clinical contexts shaped PrEP persistence among Black cisgender women in Mississippi.

METHODS

Semi-structured interviews were conducted with eight Black cisgender women in Jackson, Mississippi. This sample was purposively recruited to include PrEP-initiated Black cisgender women.

RESULTS

Six themes identified that shaped PrEP care among Black cisgender women: (1) internal assets, (2) sole responsibility to HIV prevention, (3) added protection in HIV serodifferent relationships, (4) financial issues, (5) trust and distrust in the medical system, and (6) side effects. Black cisgender women reported that PrEP persistence increased control over their sexual health, reduced anxiety about HIV, and promoted self-care. Black cisgender women also indicated that medication assistance programs increased PrEP affordability resulting in continued persistence.

CONCLUSIONS

In addition to preventing HIV, PrEP may yield secondary positive impacts on the health and relationships of Black cisgender women. However, very few Black cisgender women in the South are using PrEP given intersectional barriers and thus necessitates adaptive strategies to support PrEP initiation and persistence. Efforts aimed at increasing the coverage of PrEP among Black cisgender women should consider implementation strategies responsive to lived realities of Black women.

Efficacy and Safety of Single Oral Dosing of Secnidazole for Trichomoniasis in Women: Results of a Phase 3, Randomized, Double-Blind, Placebo-Controlled, Delayed-Treatment Study

Background

Trichomonas vaginalis is the most prevalent nonviral sexually transmitted infection. We evaluated the efficacy and safety of secnidazole vs placebo in women with trichomoniasis.

Methods

Women with trichomoniasis, confirmed by a positive T. vaginalis culture, were randomized to single-dose oral secnidazole 2 g or placebo. The primary endpoint was microbiological test of cure (TOC) by culture 6–12 days after dosing. At the TOC visit, participants were given the opposite treatment. They were followed for resolution of infection afterward and offered treatment at subsequent visits, if needed. Fifty patients per group (N = 100) provided approximately 95% power to detect a statistically significant difference between treatment groups.

Results

Between April 2019 and March 2020, 147 women enrolled at 10 sites in the United States. The modified intention-to-treat (mITT) population included 131 randomized patients (secnidazole, n = 64; placebo, n = 67). Cure rates were significantly higher in the secnidazole vs placebo group for the mITT population (92.2% [95% confidence interval {CI}: 82.7%–97.4%] vs 1.5% [95% CI: .0%–8.0%]) and for the per-protocol population (94.9% [95% CI: 85.9%–98.9%] vs 1.7% [95% CI: .0%–8.9%]). Cure rates were 100% (4/4) in women with human immunodeficiency virus (HIV) and 95.2% (20/21) in women with bacterial vaginosis (BV). Secnidazole was generally well tolerated. The most frequently reported treatment-emergent adverse events (TEAEs) were vulvovaginal candidiasis and nausea (each 2.7%). No serious TEAEs were observed.

Conclusions

A single oral 2 g dose of secnidazole was associated with significantly higher microbiological cure rates vs placebo, supporting a role for secnidazole in treating women with trichomoniasis, including those with HIV and/or BV.

Clinical Trials Registration

NCT03935217.

Living While Black, Gay, and Poor: The Association of Race, Neighborhood Structural Disadvantage, and PrEP Utilization Among a Sample of Black Men Who Have Sex With Men in the Deep South

Utilizing the Andersen Healthcare Utilization Model, we examined the role of neighborhood context on pre-exposure prophylaxis (PrEP) utilization among a sample of Black men who have sex with men (MSM) residing in a medium-sized city in the Deep South. Data were derived from a sample of 142 Black MSM aged 18-64 years who were eligible for PrEP from a community-based study known as "ACCELERATE!" We used multilevel structural equation modeling to assess PrEP use. Social support, sexual risk, and health care access were predictive of PrEP use. Notably, residing in a neighborhood with concentrated poverty was associated with decreased PrEP use. Our findings reveal neighborhood structural disadvantage is associated with decreased PrEP use among Black MSM, after adjusting of individual-level sociodemographic characteristics. There is an urgent need to develop HIV prevention interventions and programs that explicitly address structural-level factors to eliminate racial/ethnic differences in HIV.

Resistance-Guided Treatment of Gonorrhea: A Prospective Clinical Study

BACKGROUND

Novel treatment strategies to slow the continued emergence and spread of antimicrobial resistance in Neisseria gonorrhoeae are urgently needed. A molecular assay that predicts in vitro ciprofloxacin susceptibility is now available but has not been systematically studied in human infections.

METHODS

Using a genotypic polymerase chain reaction assay to determine the status of the N. gonorrhoeae gyrase subunit A serine 91 codon, we conducted a multisite prospective clinical study of the efficacy of a single oral dose of ciprofloxacin 500 mg in patients with culture-positive gonorrhea. Follow-up specimens for culture were collected to determine microbiological cure 5-10 days post-treatment.

RESULTS

Of the 106 subjects possessing culture-positive infections with wild-type gyrA serine N. gonorrhoeae genotype, the efficacy of single-dose oral ciprofloxacin treatment in the per-protocol population was 100% (95% 1-sided confidence interval, 97.5-100%).

CONCLUSIONS

Resistance-guided treatment of N. gonorrhoeae infections with single-dose oral ciprofloxacin was highly efficacious. The widespread introduction and scale-up of gyrA serine 91 genotyping in N. gonorrhoeae infections could have substantial medical and public health benefits in settings where the majority of gonococcal infections are ciprofloxacin susceptible.

CLINICAL TRIALS REGISTRATION

NCT02961751.

Epidemiology, Clinical Features, and Outcomes of Hospitalized Adults with COVID-19: Early Experience from an Academic Medical Center in Mississippi

OBJECTIVES

To describe the demographics, clinical characteristics, and outcomes of hospitalized adults with coronavirus disease 2019 (COVID-19) in an academic medical center in the southern United States.

METHODS

Retrospective, observational cohort study of all adult patients (18 years and older) consecutively admitted with laboratory-confirmed severe acute respiratory syndrome-coronavirus-2 infection between March 13 and April 25, 2020 at the University of Mississippi Medical Center. All of the patients either survived to hospital discharge or died during hospitalization. Demographics, body mass index, comorbidities, clinical manifestations, and laboratory findings were collected. Patient outcomes (need for invasive mechanical ventilation and in-hospital death) were analyzed.

RESULTS

One hundred patients were included, 53% of whom were women. Median age was 59 years (interquartile range 44-70) and 66% were younger than 65. Seventy-five percent identified themselves as Black, despite representing 58% of hospitalized patients at our institution in 2019. Common comorbid conditions included hypertension (68%), obesity (65%), and diabetes mellitus (31%). Frequent clinical manifestations included shortness of breath (76%), cough (75%), and fever (64%). Symptoms were present for a median of 7 days (interquartile range 4-7) on presentation. Twenty-four percent of patients required mechanical ventilation and, overall, 19% died (67% of those requiring mechanical ventilation). Eighty-four percent of those who died were Black. On multivariate analysis, ever smoking (odds ratio [OR] 5.9, 95% confidence interval [CI] 1.2-28.6) and history of diabetes mellitus (OR 5.9, 95% CI 1.5-24.3) were associated with mortality, and those admitted from home were less likely to die (vs outside facility, OR 0.2, 95% CI 0.0-0.7). Neither age, sex, race, body mass index, insurance status, nor rural residence was independently associated with mortality.

CONCLUSIONS

Our study adds evidence that Black patients appear to be overrepresented in those hospitalized with and those who die from COVID-19, likely a manifestation of adverse social determinants of health. These findings should help guide preventive interventions targeting groups at higher risk of acquiring and developing severe COVID-19 disease.

Meet Me Where I Am: An Evaluation of an HIV Patient Navigation Intervention to Increase Uptake of PrEP Among Black Men Who Have Sex with Men in the Deep South

The southern region of the USA is the epicenter of the HIV epidemic. HIV disproportionately affects African Americans, particularly Black men who have sex with men (Black MSM). Given the alarming rates of new infections among Black MSM, there is an urgent need for culturally competent healthcare professionals who are trained to address the unique needs and barriers to uptake and adherence to HIV prevention, care, and treatment services. Utilizing a mixed method research approach, we conducted a process evaluation of Meet Me Where I Am, a 6-month, 6-session HIV/AIDS patient navigation training program for healthcare professionals and patient navigators working in organizations that provide HIV services to residents of central Mississippi, an area with high incidence and prevalence rates of HIV. A self-administered questionnaire after each session was given to participants to assess the acceptability, quality, and translational aspects of the training program. The overall positive feedback on the MMWIA training reflects the program's acceptability and feasibility. Participants found that the training was effective in providing the necessary knowledge and skills to deliver patient-centered HIV prevention-related navigation services. A majority (67%) of participants indicated that they felt they could apply the lessons learned within their healthcare settings to improve access to HIV prevention, care, and treatment services. If we are to reduce racial and ethnic disparities in HIV/AIDS, there is a critical need for culturally appropriate training programs designed to improve the ability of healthcare professionals and health systems to deliver culturally competent HIV prevention, care, and treatment services.

The ongoing HIV epidemic in American youth: challenges and opportunities

The incidence of human immunodeficiency virus (HIV) infection has been decreasing in the United States overall, except among youth, and in particular among Black and Latinx young men who have sex with men (MSM). In this review we summarize key drivers of the HIV epidemic among youth, as well as novel interventions geared specifically towards combating the epidemic among high-risk populations. Many factors driving the HIV epidemic among youth are related to systemic inequities, including lack of access to healthcare, inadequate education, and internalized and experience homophobia and racism. Developmentally, youth may feel that they are invulnerable and be willing to engage in risks. Moreover, HIV is often invisible for youth given advances in treatment and community stigma, limiting open discussion of risk and new preventive modalities. Outcomes from the HIV treatment cascade suggest that youth are less likely to be aware of their HIV infection status, less likely to link to and be engaged in care, and less likely to be virologically suppressed than older MSM and other populations of people living with HIV. Importantly, pre-exposure prophylaxis (PrEP) has been shown to be an effective tool for prevention of HIV infection that also appears to have disproportionately poor uptake among youth. Barriers to PrEP utilization appear to be quite heterogeneous, and include patient-, provider-, and structural-level barriers. Interventions important in improving HIV prevention will thus have to be multipronged and developed for culturally diverse populations. Cognitive behavioral therapy-based interventions are promising strategies as they are able to address a diverse array of barriers. New formulations of PrEP will also likely be instrumental in improving adherence. Since youth spend considerable amounts of time accessing digital media, the deployment of apps and other mobile phone-based interfaces offer unique opportunities to increase education and to facilitate HIV prevention for at risk youth. Multiple studies are underway to better inform the optimal delivery of treatment and prevention services for this complex and diverse population, and include novel sociobiological interventions and new modes of medication delivery that may lend themselves to overcoming obstacles specific to youth.

Pre-Exposure Prophylaxis Training among Medical Schools in the United States

Pre-Exposure Prophylaxis (PrEP) has been shown to be an effective method of HIV prevention for men who have sex with-men (MSM) and -transgender women (MSTGWs), serodiscordant couples, and injection drug users; however fewer than 50 000 individuals currently take this regimen. Knowledge of PrEP is low among healthcare providers and much of this lack of knowledge stems from the lack or exposure to PrEP in medical school. We conducted a cross sectional survey of medical schools in the United States to assess the degree to which PrEP for HIV prevention is taught. The survey consisted Likert scale questions assessing how well the students were prepared to perform each skill associated with PrEP delivery, as well as how PrEP education was delivered to students. We contacted 141 medical schools and 71 responded to the survey (50.4%). PrEP education was only reported to be offered at 38% of schools, and only 15.4% reported specific training for Lesbian, Gay, Bisexual, and Transgender (LGBT) patients. The most common delivery methods of PrEP content were didactic sessions with 11 schools reporting this method followed by problem-based learning, direct patient contact, workshops, and small group discussions. Students were more prepared to provide PrEP to MSM compared to other high-risk patients. Few medical schools are preparing their students to prescribe PrEP upon graduation. Further, there is a need to increase the number of direct patient contacts or simulations for students to be better prepared.

Scale up mHealth HIV interventions: site and public health perspectives and lessons learned from P3

A number of mobile health (mHealth) interventions have been shown to be effective and highly acceptable tools for improving human immunodeficiency virus (HIV) prevention and care for youth. Scale-up of efficacious technology-based interventions is challenging and best practices for scale-up have not been clearly established. Developers of mHealth interventions should have plans in mind for wide scale implementation throughout all stages of development including planning, during trials and during analysis and dissemination. We discuss an approach of focus on researchers, funders and potential implementers including members of the community, public health practitioners and policymakers during initial planning, trials, analysis and dissemination, and planning for scale-up. Development of the P3 (Prepared, Protected, emPowered) mobile application (app), an intervention built to encourage and increase pre-exposure prophylaxis (PrEP) adherence among young men who have sex with men (YMSM) and young transgender women who have sex with men (YTWSM), is discussed in terms of designing for scale-up and lessons learned.

1003. BIC/FTC/TAF Maintains Viral Suppression in Patients with Documented M184V/I Mutations: A Real World Experience

Background

The M184V/I mutation is a common mutation in treatment-experienced patients with HIV and confers high-level resistance to lamivudine and emtricitabine. Our objective is to assess the effectiveness of bictegravir (BIC)/emtricitabine (FTC)/tenofovir alafenamide (TAF) in a real-world setting in achieving and maintaining viral suppression in patients with documented M184V/I mutations.

Methods

This case series is comprised of treatment-experienced HIV-positive patients with documented historical or newly-identified M184V/I mutations who were placed on BIC/FTC/TAF as a switch strategy or as therapy for patients who had failed a prior regimen. Patients with any resistance to tenofovir or bictegravir were excluded. Our primary outcome was sustained viral suppression at 12 months after initiation of BIC/FTC/TAF.

Results

We included 33 patients (94% black, 52% male, median age 49, range 36-63) with an M184V/I mutation. The majority (91%) showed sustained viral suppression at 12 months of treatment. Non-adherence to medication was the common factor in all three cases of treatment failure. One patient developed an R263K mutation while on therapy, which conferred low-level resistance to bictegravir. There were no other instances of newly-acquired resistance to any of the components of BIC/FTC/TAF.

Conclusion

Our results demonstrate high success rates of BIC/FTC/ATF in achieving and maintaining viral suppression in patients with documented M184V/I mutations who adhere to medications in a real-world setting with a single instance of new treatment-emergent resistance to bictegravir. These findings are congruent with reported sub-group analysis in clinical trial data and support the use of BIC/FTC/TAF in patients with M184V/I mutations.

Disclosures

Leandro A. Mena, MD, MPH, Binx Health (Grant/Research Support)Evofem (Grant/Research Support)Gilead Science (Consultant, Grant/Research Support, Speaker’s Bureau)GSK (Grant/Research Support)Janssen (Grant/Research Support)Merck (Consultant, Grant/Research Support)Roche Molecular (Consultant, Grant/Research Support)SpeedDx (Grant/Research Support)ViiV Healthcare (Consultant, Grant/Research Support, Speaker’s Bureau)

1037. Qualitative Findings from a Hybrid III Implementation-Effectiveness Study to Explore Perspectives of Health-care Staff on Early Implementation of Cabotegravir and Rilpivirine Long Acting (CAB+RPV LA) Injectable HIV treatment in the US (CUSTOMIZE)

Background

CAB+RPV LA administered monthly for HIV treatment is non-inferior to daily oral ART at maintaining HIV suppression but concerns about implementation of this novel treatment paradigm remain. CUSTOMIZE, an implementation-effectiveness study, examined barriers and facilitators to successful implementation of CAB+RPV LA in US HIV clinics.

Methods

Semi-structured qualitative interviews were conducted with physicians, injectors, and administrators across diverse clinics in US without previous CAB+RPV LA experience at Baseline (BL) (N=26) and after patients received the 4^th monthly injection of CAB + RPV LA (interim) (N=24). Consolidated Framework for Implementation Research (CFIR) guided the interviews to evaluate barriers and facilitators to implementation. Interviews were recorded, transcribed, and coded using ATLAS.ti then analyzed for trends.

Results

At BL, 58% of study staff expected CAB+RPV LA would meet the needs of patients. Staff reported perceived advantages for patients: reduced stigma of pill bottles (38%), ability to live/travel in a “carefree” manner (31%) and removing the daily reminder of HIV (20%). At BL, most administrators had resource concerns: additional refrigeration, transportation, and staffing. Some clinics (38%) needed to purchase a refrigerator to store CAB+RPV LA. Some physicians noted a potential need for improved parking or expanded hours. At interim, most staff (71%) reported no change in official clinic hours; but 50% of injectors and 38% of administrators reported changing work hours to accommodate injection visits before clinic or at lunchtime. Existing appointment reminder systems and transportation support were reported as facilitators to implementation. Many staff (46%) noted additional visits increased coordination of other care needs. Most staff (67%) noted high patient acceptance and positive attitudes facilitated successful implementation of CAB + RPV LA.

Conclusion

Some staff had concerns about implementation initially, but at study interim minimal practice changes were needed to operationalize CAB+RPV LA effectively. Patient interest heightened staff desire to implement CAB+RPV LA in their clinics. Staff are optimistic that monthly CAB+RPV LA is manageable with minimal disruption to routine care in US HIV care settings.

Disclosures

Maggie Czarnogorski, MD, MPH, ViiV Healthcare (Employee) Cindy Garris, MSPH, GlaxoSmithKline (Other Financial or Material Support, Stockholder)ViiV Healthcare (Employee) Paul Wannamaker, BA, ViiV Healthcare (Employee) Ronald D’Amico, DO, MSc, GlaxoSmithKline (Shareholder)ViiV Healthcare (Employee) Carolyn Selenski, PhD, GSK (Employee, Shareholder) Colleen A. McHorney, PhD, Evidera (Employee) Larissa Stassek, MPH, Evidera (Employee) Gary I. Sinclair, MD, ViiV (Speaker’s Bureau) Leandro A. Mena, MD, MPH, Binx Health (Grant/Research Support)Evofem (Grant/Research Support)Gilead Science (Consultant, Grant/Research Support, Speaker’s Bureau)GSK (Grant/Research Support)Janssen (Grant/Research Support)Merck (Consultant, Grant/Research Support)Roche Molecular (Consultant, Grant/Research Support)SpeedDx (Grant/Research Support)ViiV Healthcare (Consultant, Grant/Research Support, Speaker’s Bureau) David Margolis, MD, MPH, GlaxoSmithKline (Shareholder)ViiV Healthcare (Employee)

982. Formal Education Improves Southeastern United States Primary Care Residents’ Understanding and Attitudes Towards HIV Pre-Exposure Prophylaxis: Results of a Regional Survey

Background

HIV pre-exposure prophylaxis (PrEP) has been identified as one of the pillars of the national plan to end the HIV epidemic. Notably, southern states have also been shown to have the lowest PrEP-to-need ratio in the country, and previous work on assessing clinician understanding of and attitudes towards PrEP has mainly focused on in-practice physicians, nurse practitioners, and other clinicians. We aimed to assess the attitudes towards and understanding of PrEP among residents training in programs categorized as primary care in the Southeastern United States.

Methods

Program directors in ACGME approved residency programs in Family Medicine, Internal Medicine, Internal Medicine-Pediatrics, and Obstetrics and Gynecology were asked to distribute an invitation with a link to the survey to their residents during a six week period in May and June 2019. The survey contained questions that assessed demographics, type of program, PrEP awareness, knowledge, attitudes, and formal education Logistic regression was utilized to assess association between formal PrEP education and comfort levels with PrEP and other STI related topics.

Results

We identified approximately 7,574 residents across 247 residencies in 11 states. We received 217 responses to our survey, of which 203 had complete data for analysis. The majority of the sample was 25-29 years old (75%), male (53%), White (46%), and PGY-2 (48%). Twenty-one percent of the sample received formal education on PrEP. After controlling for demographic variables, residents with prior formal PrEP education were more likely to be comfortable taking sexual history from LGBTQI patients, discussing/providing PrEP, discussing PrEP efficacy, discussing PrEP monitoring, side effects, drug resistance, and adherence compared to residents who did not have formal PrEP education (Table 1).

Association Between Formal PrEP Education and Comfort Levels with Discussing PrEP and other STI Related Topics

Conclusion

We found a strong association between formal PrEP education and resident’s confidence in discussing PrEP. Investing in formal resident education programs in the Southern region will be important in achieving the Ending the HIV Epidemic’s goal of reducing new infections by 75% in 5 years and 90% in 10 years.

Disclosures

Leandro A. Mena, MD, MPH, Binx Health (Grant/Research Support)Evofem (Grant/Research Support)Gilead Science (Consultant, Grant/Research Support, Speaker’s Bureau)GSK (Grant/Research Support)Janssen (Grant/Research Support)Merck (Consultant, Grant/Research Support)Roche Molecular (Consultant, Grant/Research Support)SpeedDx (Grant/Research Support)ViiV Healthcare (Consultant, Grant/Research Support, Speaker’s Bureau)

Rapid Antiretroviral Therapy (ART) Initiation at a Community-Based Clinic in Jackson, MS

Background

Rapid antiretroviral therapy (ART), ideally initiated within twenty-four hours of diagnosis, may be crucial in efforts to increase virologic suppression and reduce HIV transmission. Recent studies, including demonstration projects in large metropolitan areas such as Atlanta, Georgia; New Orleans, Louisiana; San Francisco, California; and Washington D.C., have demonstrated that rapid ART initiation is a novel tool for expediting viral suppression in clinical settings. Here we present an evaluation of the impact of a rapid ART initiation program in a community-based clinic in Jackson, MS.

Methods

We conducted a retrospective chart review of patients who were diagnosed with HIV at Open Arms Healthcare Center or were linked to the clinic for HIV care by the Mississippi State Department of Health Disease Intervention Specialists from January 1, 2016 to December 31, 2018. Initial viral load, CD4+ T cell count, issuance of an electronic prescription (e-script), subsequent viral loads until suppressed and patient demographics were collected for each individual seen in clinic during the review period. Viral suppression was defined as a viral load less than 200 copies/mL. Rapid ART initiation was defined as receiving an e-script for antiretrovirals within seven days of diagnosis.

Results

Between January 1, 2016 and December 31, 2018, 70 individuals were diagnosed with HIV and presented to Open Arms Healthcare Center, of which 63 (90%) completed an initial HIV counseling visit. Twenty-seven percent of patients were provided with an e-script for ART within 7 days of diagnosis. The median time to linkage to care for this sample was 12 days and 5.5 days for rapid ART starters (p < 0.001). Median time from diagnosis to viral suppression was 55 days for rapid ART starters (p = 0.03), a 22 day decrease from standard time to viral suppression.

Conclusion

Our results provide a similar level of evidence that rapid ART initiation is effective in decreasing time to viral suppression. Evidence from this evaluation supports the use of rapid ART initiation after an initial HIV diagnosis, including same-day treatment.

Foretelling the Future: Predicting STI Diagnosis and Its Implications for Ending the HIV Epidemic among Black Men Who Have Sex with Men

Despite evidence of the link between STI and HIV transmission, STI rates remain alarmingly high, particularly among racial/ethnic minorities. This study examined the relationship between earlier STI diagnoses (gonorrhea and chlamydia) and future STI acquisition and its implications for HIV prevention among a sample of urban Black men who have sex with men (Black MSM). Data from a cohort of 600 Black MSM (15-29 years of age) residing in a medium-size Southern city enrolled in a HIV prevention intervention were analyzed. We used multivariate logistic regression to assess the association between STI diagnosis (baseline: Time 1) and subsequent STI diagnosis (90-day post-diagnosis: Time 2). Repeated measures analyzed at Time 1 and Time 2 included condomless sex, insertive and receptive sex, concurrent sexual partnerships, multiple partners, and age of partner. Independent of socio-demographic factors, we found having a prior GC/CT increased the likelihood of a future GC/CT by a factor of 15 (OR = 15.2, p = 0.01). Participants were statistically more likely to have been diagnosed with an extragenital STI (OR = 2.3, p = 0.05). Present findings suggest that time of initial STI diagnosis is a critical period in which to intervene to reduce future STI/HIV acquisition. Screening guidelines should be expanded to include testing for extragenital infection. STI screening and treatment and counseling programs should be culturally appropriate to account for the unique needs and the social and environmental context of the population. Additional research is needed to design STI prevention interventions that address social and environmental factors to reduce sexual risk behaviors that increase HIV vulnerability for Black MSM.

Validation of the HIV Pre-exposure Prophylaxis Stigma Scale: Performance of Likert and Semantic Differential Scale Versions

Stigma regarding HIV pre-exposure prophylaxis (PrEP) is commonly implicated as a factor limiting the scale-up of this highly effective HIV prevention modality. To quantify and characterize PrEP stigma, we developed and validated a brief HIV PrEP Stigma Scale (HPSS) among a group of 279 men who have sex with men (MSM). Scale development was informed by a theoretical model to enhance content validity. We assessed two scale versions, Semantic Differential and Likert, randomizing the order in which scales were presented to participants. Both scales demonstrated high internal consistency. The Likert scale had substantially better construct validity and was selected as the preferred option. Scale scores demonstrated construct validity through association with constructs of interest: healthcare distrust, HIV knowledge, perceived proportion of friends/partners on PrEP, perceived community evaluation of PrEP, and perceived effectiveness of PrEP. The scale accounted for 25% of the total variance in reported willingness to be on PrEP, indicating the substantial role PrEP stigma may have on decisions to initiate PrEP. Given increased efforts to roll-out PrEP, having a valid tool to determine the level and types of PrEP stigma in individuals, groups, and communities can help direct implementation plans, identify goals for stigma reduction, and monitor progress over time.

eTest: a limited-interaction, longitudinal randomized controlled trial of a mobile health platform that enables real-time phone counseling after HIV self-testing among high-risk men who have sex with men

BACKGROUND

HIV disproportionately affects men who have sex with men (MSM) in the USA, and new infections continue to increase, particularly among African American (AA) and Hispanic/Latino (H/L) MSM. Rates of HIV testing are particularly low among AA and H/L MSM, and innovative approaches to encourage testing may help address high incidence in these men. HIV self-testing (HST) may be an important tool for increasing rates and frequency of testing. HST may be particularly well-suited for AA and H/L MSM, given that stigma and mistrust of medical care contribute to low testing rates. Despite its promise, however, many are concerned that HST does not sufficiently connect users with critical post-testing resources, such as confirmatory testing and care among those who test positive, and that these limitations may result in delayed linkage to care.

METHODS

We developed a mobile health platform (eTest) that monitors when HST users open their tests in real time, allowing us to provide timely, "active" follow-up counseling and referral over the phone. In this study, 900 high-risk MSM (with targets of 40% AA, 35% H/L) who have not tested in the last year will be recruited from social media and other gay-oriented websites in several major cities. Over 12 months, participants will be randomly assigned to receive (1) HST with post-test phone counseling and referral (eTest condition), (2) HST without active follow-up (standard condition), or (3) reminders to get tested for HIV at a local clinic (control) every 3 months. Primary outcomes include rates of HIV testing, receipt of additional HIV prevention services, and PrEP initiation verified by clinical medical records.

DISCUSSION

This study tests whether providing more active counseling and referral after HST encourages more regular HIV testing and engagement with other prevention services among MSM, compared to more passive approaches or clinic-based testing alone. It will also explore the cost-effectiveness and emotional/behavioral effects of these two strategies.

TRIAL REGISTRATION

ClinicalTrials.gov identifier NCT03654690 . Registered on 31 August 2018.

A Theoretically Based Mobile App to Increase Pre-Exposure Prophylaxis Uptake Among Men Who Have Sex With Men: Protocol for a Randomized Controlled Trial

Background

HealthMindr is a mobile phone HIV prevention app for men who have sex with men (MSM). In a previous pilot study, HealthMindr was found to be acceptable among users and to demonstrate preliminary effectiveness for increasing pre-exposure prophylaxis (PrEP) uptake among MSM. PrEP is a highly effective HIV prevention intervention; however, uptake remains low.

Objective

The aim of this study will be to assess the efficacy of a mobile app for increasing PrEP uptake among MSM in the southern United States.

Methods

In this randomized controlled trial, we will assess the efficacy of HealthMindr for increasing PrEP uptake among MSM in the following three southern US cities: Atlanta, Georgia; Jackson, Mississippi; and Washington, DC. In total, 657 men will be recruited and randomized to intervention and control arms in a 2:1 ratio. Participants in the intervention arm will receive access to the full HealthMindr app, with information and resources about PrEP (eg, frequently asked questions, risk assessment tool, and PrEP provider locator), other HIV prevention information, ability to order free HIV/sexually transmitted infection test kits, and additional resources related to substance use and mental health. Participants in the control arm will use the HealthMindr app but will only have access to the study timeline and a message center to communicate with study staff. Participants will complete quarterly surveys to assess self-reported PrEP uptake over 12 months of follow-up. Self-reported PrEP uptake will be verified by dried blood spot testing and/or uploading a photograph of a PrEP prescription.

Results

Participant recruitment began in January 2020.

Conclusions

This trial will determine whether the HealthMindr app can increase PrEP uptake among MSM in the southern United States.

Trial Registration

ClinicalTrials.gov NCT03763942; https://clinicaltrials.gov/ct2/show/NCT03763942

International Registered Report Identifier (IRRID)

PRR1-10.2196/16231

Leveraging Community Engagement: The Role of Community-Based Organizations in Reducing New HIV Infections Among Black Men Who Have Sex with Men

There is growing recognition that a singular focus on biomedical treatments is insufficient to address the HIV prevention and health-care needs of Black men who have sex with men (Black MSM). Ending the HIV epidemic requires a multifactorial approach accounting for the social, cultural, economic, and environmental factors that drive transmission of HIV and other STDs. The two case studies presented were implemented by community-based organizations that have extensive experience with the target population and previous experience implementing HIV prevention-related programs and projects in the Jackson, Mississippi, metropolitan area. Culturally appropriate HIV prevention interventions that explicitly acknowledge the social determinants of health, particularly stigma and discrimination, both racial and sexual, are critical to reducing the number of new infections. These culturally appropriate and locally derived HIV prevention interventions provide a model for HIV health-care providers, public health officials, and community leaders to address the unique needs of Black MSM.

Intervention Messaging About Pre-Exposure Prophylaxis Use Among Young, Black Sexual Minority Men

Approximately 1.1 million individuals in the United States are living with HIV/AIDS. HIV disproportionately affects young, black men who have sex with men (YBMSM). Recent biomedical advances, including the use of antiretroviral therapy as pre-exposure prophylaxis (PrEP), hold promise for preventing HIV infections. However, PrEP uptake remains slow among those most at-risk. To develop and test an intervention to address HIV disparities in YBMSM, we conducted qualitative interviews with 29 YBMSM from Jackson, Mississippi, to learn more about their views of PrEP. Twenty-nine PrEP-eligible YBMSM were enrolled and participated in either semistructured interviews or focus groups. They were asked about PrEP use, messaging, and promotion. Data were coded based on an iteratively developed coding scheme and entered into NVivo to facilitate thematic analysis. Our analysis identified the following three main themes: (1) the role of setting, context, and stigma in health care, (2) targeted PrEP messaging is further stigmatizing, and (3) recommendations for PrEP messaging and care. YBMSM in our sample felt highly stigmatized in their current environment and felt that PrEP messaging targeting YBMSM only enhanced their sense of marginalization. They concluded that broad and inclusive messaging would be just as relevant and cause less stigma. Our findings were somewhat surprising, as several prior studies benefited from using targeted materials to engage YBMSM in HIV prevention and PrEP uptake. The study's location may explain this difference in findings, which suggests the importance of considering local conditions and opinions when developing interventions for HIV prevention among minority populations.

An Electronic Pre-Exposure Prophylaxis Initiation and Maintenance Home Care System for Nonurban Young Men Who Have Sex With Men: Protocol for a Randomized Controlled Trial

BACKGROUND

Pre-exposure prophylaxis (PrEP) is highly efficacious for preventing HIV but has not yet been brought to scale among at-risk persons. In several clinical trials in urban areas, technology-based interventions have shown a positive impact on PrEP adherence. In rural and small-town areas in the United States, which often do not have geographically proximal access to PrEP providers, additional support may be needed. This may be particularly true for younger persons who are more likely to face multiple barriers to accessing PrEP services. Home-based care, accomplished through a tailored mobile phone app, specimen self-collection (SSC), and interactive video consultations, could increase both PrEP initiation and persistence in care.

OBJECTIVE

The goal of this study is to assess the initiation and persistence in PrEP care for those randomized to a home-care intervention (electronic PrEP, ePrEP) relative to those assigned to the standard of care (control) condition. We will conduct additional assessments, including quantitative and qualitative analyses, to contextualize trial results and facilitate scale-up.

METHODS

This 2-arm, randomized controlled trial will enroll young men who have sex with men (YMSM) aged between 18 and 24 years from rural areas of Georgia, Mississippi, and North Carolina. The trial will seek to recruit a diverse sample, targeting 50% participation among highly impacted groups of black or Latino men who have sex with men. Intervention participants will receive a study app that incorporates a messaging platform, a scheduling and milestone-based tracking system for PrEP care progress, electronic behavioral surveys, and interactive video consultations with a clinician. Complemented by SSC kits mailed to laboratories for standard PrEP-related monitoring, the ePrEP system will allow participants to access PrEP care without leaving their homes. YMSM randomized to the control condition will receive a listing of nearest local PrEP providers to receive standard PrEP care. Both groups will complete quarterly electronic surveys. The primary outcome, assessed at 6 and 12 months after randomization, will be the difference in the proportion of intervention versus control participants that achieve protective levels of the active metabolite of oral PrEP (tenofovir diphosphate in dried blood spots).

RESULTS

Enrollment will begin in May 2019, with study completion in 2022.

CONCLUSIONS

This trial will determine whether home PrEP care provided through an app-based platform is an efficacious means of expanding access to PrEP care for a diverse group of YMSM in rural and small-town areas of the United States.

TRIAL REGISTRATION

ClinicalTrials.gov NCT03729570; https://clinicaltrials.gov/ct2/show/NCT03729570 (Archived by WebCite at http://www.webcitation.org/78RE2Qizf).

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

PRR1-10.2196/13982.

Missed Opportunities to Prescribe HIV Pre-Exposure Prophylaxis by Primary Care Providers in Saint Louis, Missouri

PURPOSE

Optimal HIV pre-exposure prophylaxis (PrEP) scale-up in the United States requires prescribing by primary care providers (PCPs). We assessed barriers to patients obtaining PrEP from their PCPs.

METHODS

Patients seeking PrEP at an Infectious Diseases (ID) Clinic in St. Louis, Missouri from 2014 to 2016 were asked about demographics, sexual behaviors, whether PrEP was initially sought from their PCP, and barriers to obtaining PrEP from their PCP. Multivariable logistic regression was performed to identify predictors for having asked a PCP for PrEP.

RESULTS

Among 102 patients, the median age was 29 years, 58% were white, and 88% were men who have sex with men. Most (65%) had a PCP and, of these, 48% had asked their PCP for PrEP, but were not prescribed it. About half (52%) reported that their PCPs perceived prescribing PrEP as specialty care. Many (39%) indicated that they felt uncomfortable discussing their sexual behaviors with their PCP. Patients with an HIV-positive sex partner in the last 3 months were less likely to ask for PrEP from their PCPs than others (Adjusted Odds Ratio: 0.07; 95% CI: 0.01-0.53). Eighty-three percent of patients were referred to a new PCP with whom they could feel more comfortable discussing PrEP.

CONCLUSIONS

During initial PrEP implementation, ID specialists can play an important role in providing education and linking PrEP patients to PCPs. However, PCPs may need additional training about PrEP and how to provide culturally sensitive sexual healthcare, if widespread scale-up is to be effective in decreasing HIV incidence.

Is Sex with Older Male Partners Associated with Higher Sexual Risk Behavior Among Young Black MSM?

Participants at a sexual health clinic completed a survey with questions regarding sexual risk behavior and partner characteristics. Of 585 participants eligible for analysis, 124 reported generally having older male partners. These participants were significantly more likely to be HIV-infected (p < 0.001), have four or more sex partners as a "bottom" (p = 0.04), have concurrent partners (p = 0.01), and have partners suspected of having an sexually transmitted infection (p = 0.05) than participants without older partners. With analysis restricted to HIV- individuals, risk behaviors did not differ significantly between the groups. HIV- individuals with older partners may be at increased risk of HIV infection due to increased HIV prevalence among older sexual partners and not due to increased risk behaviors with these partners.

Sexual Networks, Dyadic Characteristics, and HIV Acquisition and Transmission Behaviors Among Black Men Who Have Sex With Men in 6 US Cities

The role of sexual networks in the epidemiology of human immunodeficiency virus (HIV) among black men who have sex with men (MSM) is poorly understood. Using data from 1,306 black MSM in the BROTHERS Study (2009-2010) in the United States, we examined the relationships between multiple sexual dyadic characteristics and serodiscordant/serostatus-unknown condomless sex (SDCS). HIV-infected participants had higher odds of SDCS when having sex at least weekly (odds ratio (OR) = 2.41, 95% confidence interval (CI): 1.37, 4.23) or monthly (OR = 1.94, 95% CI: 1.17, 3.24) versus once to a few times a year. HIV-uninfected participants had higher odds of SDCS with partners met offline at sex-focused venues (OR = 1.79, 95% CI: 1.15, 2.78) versus partners met online. In addition, having sex upon first meeting was associated with higher odds of SDCS (OR = 1.49, 95% CI: 1.21, 1.83) than was not having sex on first meeting, while living/continued communication with sexual partner(s) was associated with lower odds of SDCS (weekly: OR = 0.64, 95% CI: 0.47, 0.85; monthly: OR = 0.60, 95% CI: 0.44, 0.81; yearly: OR = 0.58, 95% CI: 0.39, 0.85) versus discontinued communication. Persons with primary/steady nonprimary partners versus commercial partners had lower odds of SDCS regardless of HIV serostatus. This suggests the need for culturally relevant HIV prevention efforts for black MSM that facilitate communication with sexual partners especially about risk reduction strategies, including preexposure prophylaxis.

Experiences of Antihomosexual Attitudes and Young Black Men Who Have Sex with Men in the South: A Need for Community-Based Interventions

PURPOSE

In 2012, Jackson, Mississippi, had the third highest incidence rate of human immunodeficiency virus (HIV) among young Black men who have sex with men (MSM). The goal of this qualitative study (the initial phase of an HIV prevention clinical trial) was to explore how cultural norms regarding antihomosexual attitudes interfere with the safe sex practices and relationship norms of young Black MSM in Mississippi.

METHODS

Nine focus groups (N = 54) were conducted with young Black MSM aged 18-29. Participants were recruited through medical providers at local sexually transmitted infection clinics and through community organizers at local LGBT outreach programs. The data were analyzed through the use of grounded theory, multiple coders for consistency and intercoder reliability, and a qualitative data analysis software.

RESULTS

Three major themes were identified during the analysis: (1) resiliency and condom use, (2) inconsistent condom use among closeted young Black MSM, and (3) intimate partner violence (IPV) among closeted young Black MSM. Black MSM in Mississippi continue to be highly stigmatized within their social networks (i.e., families, sexual partners, and community).

CONCLUSIONS

The findings suggest that cultural and community norms regarding antihomosexual attitudes may be a barrier to the practices of safe sex and a contributing factor to IPV among young Black MSM. There is a need for tailored interventions that address these cultural norms and establish social and community support for young Black MSM in Mississippi.

Rationale, Design and Methods of the Ecological Study of Sexual Behaviors and HIV/STI among African American Men Who Have Sex with Men in the Southeastern United States (The MARI Study)

BACKGROUND

This paper describes the rationale, design, and methodology of the Ecological Study of Sexual Behaviors and HIV/STI among African American Men Who Have Sex with Men (MSM) in the Southeastern United States (U.S.; known locally simply as the MARI Study).

METHODS

Participants are African American MSM aged 18 years and older residing in the deep South.

RESULTS

Between 2013 and 2015, 800 African American MSM recruited from two study sites (Jackson, MS and Atlanta, GA) will undergo a 1.5-hour examination to obtain anthropometric and blood pressure measures as well as to undergo testing for sexually transmitted infections (STI), including HIV. Intrapersonal, interpersonal, and environmental factors are assessed by audio computer-assisted self-interview survey. Primary outcomes include sexual risk behaviors (e.g., condomless anal sex) and prevalent STIs (HIV, syphilis, gonorrhea, and Chlamydia).

CONCLUSION

The MARI Study will typify the HIV environmental 'riskscape' and provide empirical evidence into novel ecological correlates of HIV risk among African American MSM in the deep South, a population most heavily impacted by HIV. The study's anticipated findings will be of interest to a broad audience and lead to more informed prevention efforts, including effective policies and interventions, that achieve the goals of the updated 2020 U.S. National HIV/AIDS Strategy.

Association between BVAB1 and high Nugent scores among women with bacterial vaginosis

As part of a larger study using 454 pyrosequencing to investigate the vaginal microbiota of women with bacterial vaginosis (BV), we found an association between a novel BV-associated bacterium (BVAB1) and high Nugent scores and propose that BVAB1 is the curved Gram-negative rod traditionally identified as Mobiluncus spp. in vaginal Gram stains.

"I Don't Have a Problem With It, But Other Guys Do": An Exploration of Condom Negotiation among Young Black Men Who Have Sex with Men in the South

Condom negotiation among young Black men who have sex with men in the Southern United States was explored using the theory of reasoned action. Fifty-four (18- to 29-year-old) males participated in nine focus group interviews. Discussions elicited condom use and negotiation attitudes, beliefs and social norms. Positive personal attitudes (respect of self, personal health concerns) and high negotiation self-efficacy was emphasized. Conversely, social norms revealed non-prioritized condom use behavior. Divergence between individual and community indicates theoretical models targeting sexual communication must address external factors (social, economic, political context), which intersects with individual intentions, attitudes to influence HIV prevalence in this community.

Families of choice and noncollegiate sororities and fraternities among lesbian and bisexual African-American women in a southern community: implications for sexual and reproductive health research

Background Self-identified lesbian and bisexual African-American women living in the southern United States are a relatively hidden subpopulation within the lesbian, gay, bisexual and transgender (LGBT) community. Existing research suggests that African-American lesbian and bisexual women are at high risk for sexually transmissible infections (STIs), but the sexual and reproductive health needs of this population are just beginning to be understood.

METHODS

We conducted four focus groups and five individual interviews with 24 lesbian and bisexual African-American women living in the Jackson, Mississippi, metropolitan area, recruited through the local STI clinic and through word of mouth. We aimed to characterise the role of two types of social organisations (lesbian families and noncollegiate lesbian sororities and fraternities) among the local LGBT community, and their influence on the sexual health of their members.

RESULTS

Both types of social organisations serve positive functions for their members. Lesbian families provide support and stability; this appears beneficial for younger individuals, who may lack support from biological families. Lesbian sororities and fraternities are visible due to their emphasis on community service, and offer a strong sense of solidarity and belonging. In both organisation types, discussions about sex were common, although members acknowledged a lack of information regarding safer sex among lesbian and bisexual women.

CONCLUSIONS

Existing social organisations within the LGBT community, such as lesbian families and lesbian sororities and fraternities, should be incorporated into community-based popular opinion leader or lay heath advisor interventions in an effort to meet the sexual and reproductive health needs of marginalised populations.

Role flexing: how community, religion, and family shape the experiences of young black men who have sex with men

While the disproportionate impact of HIV on young black men who have sex with men (MSM) is well documented, the reasons for this disparity remain less clear. Through in-depth interviews, we explored the role of familial, religious, and community influence on the experiences of young black MSM and identified strategies that these young men use to negotiate and manage their sexual minority status. Between February and April 2008, 16 interviews were conducted among HIV-infected and HIV-uninfected young (19- to 24-year-old) black MSM in the Jackson, Mississippi, area. Results suggest that overall, homosexuality remains highly stigmatized by the men's families, religious community, and the African American community. To manage this stigma, many of the participants engaged in a process of "role flexing," in which individuals modified their behavior in order to adapt to a particular situation. The data also provided evidence of internalized homophobia among a number of the participants. The impact of stigma on risk behavior should be more fully explored, and future intervention efforts need to explicitly address and challenge stigma, both among young men themselves and the communities in which they reside. Attention should also be paid to the role masculinity may play as a driver of the HIV epidemic among young black MSM and how this knowledge can be used to inform prevention efforts.

Delivering laboratory results by text message and e-mail: a survey of factors associated with conceptual acceptability among STD clinic attendees

OBJECTIVE

This study examines factors associated with the acceptability of receiving sexually transmitted disease (STD) laboratory results by text message and e-mail among clinic attendees.

SUBJECTS AND METHODS

An anonymous self-administered survey was conducted with a convenience sample of STD clinic attendees in South Carolina and Mississippi in 2009-2010. In total, 2,719 individuals with a median age of 26 years (interquartile range, 21-32 years) completed the survey.

RESULTS

More than 70% had Internet access at home, and 80% reported using text messaging daily. Participants preferred receiving laboratory results by text message compared with e-mail (50.2% versus 42.3%; p<0.001). Acceptability of receiving laboratory results by text message was higher with younger age (adjusted odds ratio [aOR] 1.13; 95% confidence interval [CI] 1.10-1.26), daily use of text messaging (aOR 1.30; 95% CI 1.14-1.49), and reporting cell phone and text message as the preferred choice of regular communication with the clinic (aOR 2.31; 95% CI 1.50-3.58) and was significantly lower in female subjects (aOR 0.89; 95% CI 0.81-0.98) and those with college-level education (aOR 0.88; 95% CI 0.77-0.99).

CONCLUSIONS

A majority of STD clinic attendees have access to cell phones and Internet. The acceptability of receiving STD laboratory results electronically may facilitate test result delivery to patients and expedite treatment of infected individuals.

Missed opportunities for HIV testing in health care settings among young African American men who have sex with men: implications for the HIV epidemic

Limited health care access and missed opportunities for HIV and other sexually transmitted infection (STI) education and testing in health care settings may contribute to risk of HIV infection. In 2008, we conducted a case-control study of African American men who have sex with men (MSM) in a southeastern city (Jackson, Mississippi) with an increase in numbers of newly reported HIV cases. Our aims were to evaluate associations between health care and HIV infection and to identify missed opportunities for HIV/STI testing. We queried 40 potential HIV-infected cases and 936 potential HIV-uninfected controls for participation in this study. Study enrollees included HIV-infected cases (n=30) and HIV-uninfected controls (n=95) who consented to participate and responded to a self-administered computerized survey about sexual risk behaviors and health care utilization. We used bivariate analysis and logistic regression to test for associations between potential risk factors and HIV infection. Cases were more likely than controls to lack health insurance (odds ratio [OR]=2.5; 95% confidence interval [CI]=1.1-5.7), lack a primary care provider (OR=6.3; CI=2.3-16.8), and to not have received advice about HIV or STI testing or prevention (OR=5.4; CI=1.3-21.5) or disclose their sexual identity (OR=7.0; CI=1.6-29.2) to a health care provider. In multivariate analysis, lacking a primary health care provider (adjusted odds ratio [AOR]=4.5; CI=1.4-14.7) and not disclosing sexual identity to a health care provider (AOR=8.6; CI=1.8-40.0) were independent risk factors for HIV infection among African American MSM. HIV prevention interventions for African American MSM should address access to primary health care providers for HIV/STI prevention and testing services and the need for increased discussions about sexual health, sexual identity, and sexual behaviors between providers and patients in an effort to reduce HIV incidence and HIV-related health disparities.