Informal PrEP use in Greece: The long, hard road to formal programmatic implementation.

Pre-exposure Prophylaxis Uptake, Adherence, and Persistence: A Narrative Review of Interventions in the U.S.

Toward Greater Pre-exposure Prophylaxis Equity: Increasing Provision and Uptake for Black and Hispanic/Latino Individuals in the U.S.

Strong evidence exists that daily pre-exposure prophylaxis (PrEP) is effective as an HIV preventive tool provided that there is good individual adherence 1. In 2014, the World Health Organization (WHO) issued new guidelines recommending PrEP use 2. In France, as a consequence of HIV/AIDS organizations' advocacy and the Agence Nationale de Recherche sur le Sida et les Hépatites Virales (ANRS) Intervention Préventive de l'Exposition aux Risques avec et pour les Gays (IPERGAY) trial results proving high efficacy of on-demand tenofovir (TDF)/emtricitabine (FTC) use in men who have sex with men (MSM) 3, health authorities have approved PrEP use for most-at-risk populations. Literature on awareness and acceptability of PrEP, and willingness to use it, mainly among MSM, 4 shows that, in countries where it is not officially accessible, some people are informally using antiretroviral (ARV) medication obtained in several ways outside of biomedical trials as a prevention tool 5, but data on this are still insufficient. In this context, AIDES, a French community-based organization (CBO), conducted the cross-sectional national “Flash PrEP” survey to characterize informal PrEP use in France. All people benefitting from AIDES' on-site and outreach activities filled in paper or online questionnaires, from March to May 2014, collecting data on: sociodemographic characteristics; awareness of PrEP authorization in the USA; willingness and intention to use PrEP when authorized; sexual behaviour; drug injection; risk perception and sexually transmitted infection (STI) awareness; HIV testing; post-exposure prophylaxis (PEP). Informal PrEP use at least once during one's lifetime was explored using the statement: “I have used ARV treatment at least once in my lifetime (received from a friend or partner, for example) before sexual intercourse to avoid HIV infection” (yes/no). The sampling bias introduced by collecting data with online and paper questionnaires was corrected by implementing the inverse propensity score weighting technique. Groups of respondents to paper (treatment group) and online (control group) questionnaires were balanced in terms of sociodemographic and socioeconomic characteristics, ensuring their comparability. Statistical analysis was performed using spss statistical software (version 17). A total of 2668 people filled in the questionnaire (71% online survey), of whom 4.6% (n = 123) declared informal PrEP use. Informal PrEP users were 74% MSM and 14.6% women; 91.9% were born in France, 61.8% had a university degree, and their median age was 31 [interquartile range (IQR) 25–41] years. More than one-third (38.2%) of the PrEP users self-perceived themselves to be at high or very high risk of HIV infection compared with 10.1% of those not using PrEP (P < 0.001). Seventy informal PrEP users had a main partner (56.9%), and this partner was serodiscordant for 14 MSM and one woman (21.4%). Factors associated with informal PrEP use, estimated using multivariate logistic regression adjusting for participants' sexual orientation (women, MSM, or heterosexual men), were as follows (Table 1): MSM; younger age; being aware of PrEP authorization in the USA; high or very high HIV risk self-perception; having, in the previous 12 months, injected drugs, used PEP or had at least two HIV tests; and never having used condoms with one's main partner. In contrast, being aware of having had (or not) an STI in the previous 12 months was inversely associated with informal PrEP use. These results show that informal PrEP use exists in France. Associated factors indicate that users are well informed about prevention tools, are highly exposed to HIV and monitor their risks, as they use both PEP and frequent HIV testing, suggesting that these people are linked with the health system and HIV/AIDS CBOs. The experiences reported by informal PrEP users in this study may be helpful in the design of future PrEP services, now that PrEP is authorized in France. We thank all the people who completed the “Flash PrEP” survey and all those who participated in the data collection. We would also like to thank our colleague Thomas Gonçalvez for his valuable help with the first steps of the database work.

Clinical trial data have shown that oral pre-exposure prophylaxis (PrEP) is efficacious when taken as prescribed; however, PrEP adherence is complex and must be understood within the context of variable risk for HIV infection and use of other HIV prevention methods. Different levels of adherence may be needed in different populations to achieve HIV prevention, and the optimal methods for achieving the necessary adherence for both individual and public health benefits are unknown. Guidance for PrEP use must consider these questions to determine the success of PrEP-based HIV prevention programs. In this article, we propose a new paradigm for understanding and measuring PrEP adherence, termed prevention-effective adherence, which incorporates dynamic HIV acquisition risk behaviors and the use of HIV alternative prevention strategies. We discuss the need for daily PrEP use only during periods of risk for HIV exposure, describe key issues for measuring and understanding relevant behaviors, review lessons from another health prevention field (i.e., family planning), and provide guidance for prevention-effective PrEP use. Moreover, we challenge emerging calls for sustained, near perfect PrEP adherence regardless of risk exposure and offer a more practical and public health-focused vision for this prevention intervention.

Awareness and Willingness to Use HIV Pre-exposure Prophylaxis Among Men Who Have Sex With Men in Rwanda: A Cross-Sectional Descriptive Survey.

Knowledge and Use of Preexposure and Postexposure Prophylaxis Among Attendees of Minority Gay Pride Events, 2005 Through 2006

Prevention of HIV transmission is fundamental to ending the HIV epidemic. Pre-exposure prophylaxis (PrEP) with oral tenofovir-emtricitabine (TDF-FTC) is an established HIV-prevention method; however, most PrEP services in Europe have been targeted at men who have sex with men (MSM). A survey in 2021 by Women Against Viruses in Europe (WAVE) showed considerable variation in PrEP access and guidance for women throughout Europe. WAVE therefore commissioned this systematic review to provide insight into PrEP provision and barriers to uptake for women in Europe. PubMed, Embase, and Scopus were searched for studies (January 2013-May 2021) that reported on actual (e.g., efficacy and safety) or hypothetical (e.g., awareness, barriers, PrEP impact models) use of oral PrEP involving women (including cis, transgender, pregnant, migrant, and breastfeeding women). Search terms included HIV, pre-exposure prophylaxis (specifically TDF-FTC), and women. Studies performed outside of the World Health Organization European region were excluded. The search identified 4716 unique citations, and 45 peer-reviewed articles (44 studies) were included. The majority of these studies (34/44 [77%]) included recipients or potential recipients of PrEP, representing 4699 women (243 transgender women). However, few studies were women focused (4/34 [12%]) or took place outside of Western Europe (3/34 [9%]). Across the three clinical studies that reported women-specific outcomes (60 transgender women, 13 pregnant, and 19 cis women), no breakthrough infections were recorded during the use of PrEP. Lack of awareness of PrEP, low self-estimation of HIV acquisition risk, concerns about stigma, lack of protection against other sexually transmitted infections, and PrEP interaction with hormones (for transgender women) were identified as barriers to use. The remaining studies examined healthcare professionals' perceptions of PrEP (9/44 [20%]), asked for public opinion (2/44 [5%]), or modelled the potential of PrEP for HIV prevention (1/44 [2%]). This review revealed a notable lack of literature on PrEP for cis and transgender women in Europe. This is synonymous with a lack of PrEP provision for women in this region. Barriers to PrEP uptake are complex and rooted in institutional and societal stigma, which must be addressed at policy level. HIV prevention with PrEP is not 'one size fits all' and requires a nuanced gender-responsive approach. Further research into the use of PrEP in cis, pregnant, breastfeeding, and transgender women is essential if we are to stop HIV transmission by 2030.

IntroductionEstimates of HIV prevalence amongst gender minorities are determined exclusively from scarce data for transgender women (TGW) who, globally, are disproportionately affected by HIV.1 Data for transgender men (TGM) and...

Long-acting injectable cabotegravir: implementation science needed to advance this additional HIV prevention choice.

IntroductionUntil September 2019, pre‐exposure prophylaxis (PrEP) with tenofovir disoproxil/emtricitabine for HIV prevention was not covered by health insurance plans in Germany, and was only available through private prescriptions with self‐pay or through informal non‐prescription sources. The objective of this study was to investigate the proportion of informal PrEP use among PrEP users and to identify factors of public health relevance that might be associated with informal PrEP use.MethodsWe conducted a cross‐sectional study recruiting PrEP users independent of their PrEP source. Clients from anonymous community testing checkpoints, users of three dating apps for men who have sex with men residing in Germany and users of a PrEP community website, were recruited to complete a short anonymous online survey. Participants were recruited between 24 July and 3 September 2018. The results were analysed using univariable and multivariable logistic regressions.ResultsWe recruited 2005 participants currently using PrEP. The median age was 38 years, and 80.3% of the participants identified themselves as male (missing: 19.1%). Overall, 71.6% obtained PrEP through medical services with a private prescription or a clinical trial, and 17.4% obtained PrEP through informal sources (missing: 11.0%). The most common informal sources were ordering online from another country (8.8%), travel abroad (3.6%), and friends (2.5%). Factors associated with informal PrEP use were on demand/intermittent dosing (adjusted OR: 3.5, 95% CI 2.5 to 5.0) and not receiving medical tests during PrEP use (adjusted OR: 3.2, 95% CI 2.0 to 5.2). In addition, informal PrEP users who did not take PrEP daily had a strongly increased risk of starting PrEP without prior medical tests (adjusted stratum‐specific OR = 31.7, 95% CI 4.6 to 219.5).ConclusionsInformal PrEP use was associated with a higher risk of not getting tested before and during PrEP use, which could lead to HIV infections resistant to tenofovir and emtricitabine if people with undiagnosed HIV use PrEP. Health insurance plans that cover PrEP and the accompanying routine tests could ensure adequate medical supervision of PrEP users and reduce barriers to PrEP use. Our findings strongly support the implementation of PrEP programmes in countries with similar patterns of informal PrEP use.

IntroductionGay social networking apps have grown in popularity among men who have sex with men offering opportunities for rapid and confidential collection of vital data as well as social connection. The goal of our study was to explore factors associated with utilization of pre‐exposure prophylaxis (PrEP) and antiretroviral treatment (ART), and self‐reported undetectable viral load (UVL) using data collected by the gay social networking app Hornet.MethodsIn 2016, the Global Forum on MSM & HIV (MSMGF) partnered with Hornet, to support an educational initiative called Blue‐Ribbon Boys. One aspect of the initiative prompts Hornet users to answer a short series of yes‐no questions about their sexual health. Using survey responses, we evaluated factors associated with PrEP and ART use as well as self‐reported UVL by fitting separate multivariable generalized estimating equation models.ResultsIn total, 16,008 unique Hornet users started the survey, of which 12,126 (76%) provided sufficient data for analyses. Of the 10,774 HIV‐negative men, 13% reported PrEP use in the past year. PrEP use was associated with a recent sexually transmitted infection (STI) test or treatment (aOR = 2.19, CI = 1.49 to 3.21); and taking steps to protect oneself from HIV (aOR = 1.41, CI = 1.13 to 1.76). Among HIV‐positive Hornet users (n = 1243), ART use was associated with older age (each year increase aOR = 1.02, CI = 1.01 to 1.04), a recent STI test or treatment (aOR = 4.54, CI = 2.65 to 7.78); and awareness of unlikely HIV transmission with UVL (aOR = 1.53, CI = 1.03 to 2.26). UVL was associated with older age (each year increase aOR = 1.03, CI = 1.01 to 1.04), a recent STI test or treatment (aOR = 4.84, CI = 2.74 to 8.55), and awareness of unlikely HIV transmission with UVL (aOR = 1.98, CI = 1.37 to 2.85).ConclusionsStudy findings underscore the importance of STI testing and treatment as well as information about HIV transmissibility for encouraging PrEP and ART use. Our findings also reveal age disparities, which can undermine incidence reduction among gay men. Gay social networking apps can be effectively used for rapid data collection and sexual health promotion with men who have sex with men. STI testing and treatment programmes offer important opportunities for encouraging PrEP and ART use. Information about HIV transmissibility with consistent ART use should be incorporated into prevention messaging tailored to various age groups.

The presence of chlamydia, gonorrhea, or syphilis infection is a significant risk factor for HIV acquisition and transmission and disproportionately impacts men who have sex with men (MSM) and transgender women. While HIV preexposure prophylaxis (PrEP) reduces HIV risk, its use may influence sexual behaviors, potentially increasing sexually transmitted infection (STI) exposure. Conversely, PrEP users are often more engaged in care, regularly screened and treated for STIs, and may access other prevention tools such as doxycycline postexposure prophylaxis. Studies on the relationship between PrEP use and STIs have shown mixed results. This cross-sectional analysis included 392 participants (381 cisgender MSM; 11 transgender women) enrolled in the US-based Multicenter AIDS Cohort Study/WIHS Combined Cohort Study between 2021 and 2024 who were sexually active in the year prior to STI testing and HIV negative at their most recent study visit. We assessed whether bacterial STI positivity (i.e., laboratory-confirmed chlamydia and gonorrhea at the urethral, pharyngeal, and/or rectal sites and/or current/past syphilis infection) differed by current PrEP use (yes/no). Multi-variable logistic regression models included sociodemographic and behavioral covariates that were associated with bacterial STI positivity at p < 0.05, with the most parsimonious models selected based on the lowest Akaike Information Criterion. Overall, 32.7% reported current PrEP use. Syphilis was the most prevalent STI (6.8%), followed by chlamydia (3.2%) and gonorrhea (2.1%); 11.7% of PrEP users tested positive for at least one STI, compared with 6.1% of non-PrEP users. Among PrEP users, 37.9% reported stopping or decreasing condom use, and 31.6% reported an increased number of sex partners after initiating PrEP. In both bivariate and multi-variable models, PrEP use was associated with higher odds of gonorrhea positivity (adjusted odds ratio = 4.70, 95% confidence interval [CI]: 1.10-20.04, p = 0.037) and greater odds of being positive for at least one STI (crude odds ratio = 1.94, 95% CI: 1.06-3.90, p = 0.041). No significant differences were observed for chlamydia and syphilis by PrEP use status. Overall, these findings suggest that current PrEP users (vs. non-PrEP users) have an increased odds of bacterial STI positivity, particularly gonorrhea, in a diverse, multi-city cohort of HIV negative, sexually active MSM and transgender women in the United States PrEP remains highly effective in preventing HIV, and our results underscore the importance of integrated sexual health services that support ongoing STI screening and prevention alongside PrEP use among sexual and gender minorities.

Black sexual minority men who have sex with men (MSM) in the United States are at disparate risk for contracting HIV infection, but pre-exposure prophylaxis (PrEP) use is suboptimal. Social network methods were used to recruit a community sample of racial minority MSM and transgender women (TGW) in two Midwestern US cities. 250 PrEP-eligible (HIV-negative) participants completed measures assessing current and intended PrEP use; demographic characteristics; PrEP knowledge, attitudes, norms, stigma, and self-efficacy; and structural barriers to PrEP. Multivariate analyses established predictors of current and intended PrEP use. Only 12% of participants reported currently using PrEP, which was associated with greater PrEP knowledge and not having a main partner, with trends for greater PrEP use by younger participants and those with partners living with HIV. Among participants not currently on PrEP, strength of PrEP use intentions was associated with higher PrEP knowledge, PrEP descriptive social norms, and PrEP use self-efficacy. This study is among few to directly compare Black who have adopted PrEP with those who have not. Its findings underscore the potential benefits of employing social network approaches for strengthening PrEP use peer norms, increasing PrEP knowledge and self-efficacy, and optimizing PrEP uptake among racial minority MSM and TGW.

Time to consider elimination of HIV in China

Disparities of HIV risk and PrEP use among transgender women of color in South Florida