Integrating HIV pre-exposure prophylaxis and harm reduction among men who have sex with men and transgender women to address intersecting harms associated with stimulant use: a modelling study.

Annick Bórquez,Alfonso Silva‐Santisteban,Javier Cepeda,Lucy T Tran,Frederick L Altice,Rebecca Mcketin,Natasha K Martin,Carlos F Cáceres,Louisa Degenhardt,Kelika Konda,Michael Farrell,Sherrie Kelly,Katherine Rich

doi:10.1002/jia2.25495

Abstract

IntroductionAmong men who have sex with men (MSM) and transgender women (TW), stimulant use is high and has been associated with an increased risk of HIV infection, suicide and cardiovascular disease (CVD) mortality. We used epidemic modelling to investigate these intersecting health harms among MSM/TW in Lima, Peru and assess whether they could be mitigated by prioritizing HIV pre‐exposure prophylaxis (PrEP) and harm reduction interventions among MSM/TW who use stimulants.MethodsWe adapted a dynamic model of HIV transmission among MSM/TW in Lima to incorporate stimulant use and increased HIV risk, suicide and CVD mortality. Among 6% to 24% of MSM/TW using stimulants (mostly cocaine), we modelled an increased risk of unprotected anal sex (RR = 1.35 [95%CI: 1.17 to 1.57]) obtained from local data, and increased risk of suicide (SMR = 6.26 [95%CI: 2.84 to 13.80]) and CVD (SMR = 1.83 [95%CI: 0.39 to 8.57]) mortality associated with cocaine use based on a global systematic review. We estimated the proportion of health harms occurring among MSM/TW who use stimulants in the next year (01‐2020/01‐2021). We also investigated the 10‐year impact (01‐2020/01‐2030) of: (1) PrEP prioritization for stimulant‐using MSM/TW compared to random allocation, and (2) integrating PrEP with a theoretical intervention halving stimulant‐associated risk.ResultsMSM/TW in Lima will experience high HIV incidence, suicide mortality and CVD mortality (1.6/100 py, and 0.018/100 py, 0.13/100 py respectively) in 2020. Despite stimulant using MSM/TW comprising an estimated 9.5% (95%CI: 7.8 to 11.5) of all MSM/TW, in the next year, 11% 95%CI (i.e. 2.5% to 97.5% percentile) 10% to 13%) of new HIV infections, 39% (95%CI: 18% to 60%) of suicides and 15% (95%CI: 3% to 44%) of CVD deaths could occur among this group. Scaling up PrEP among all stimulant using MSM/TW could prevent 19% (95%CI: 11% to 31%) more HIV infections over 10 years compared to random allocation. Integrating PrEP and an intervention to halve stimulant‐associated risks could reduce new HIV infections by 20% (95%CI: 10% to 37%), suicide deaths by 14% (95%CI: 5% to 27%) and CVD deaths by 3% (95%CI: 0% to 16%) over a decade.ConclusionsMSM/TW who use stimulants experience a disproportionate burden of health harms. Prioritizing PrEP based on stimulant use, in addition to sexual behaviour/gender identity criteria, could increase its impact. Integrated substance use, harm reduction, mental health and HIV care among MSM/TW is needed.

Highlights

Among men who have sex with men (MSM) and transgender women (TW), stimulant use is high and has been associated with an increased risk of HIV infection, suicide and cardiovascular disease (CVD) mortality
Scaling up pre-exposure prophylaxis (PrEP) among MSM/TW who use stimulants in combination with harm reduction interventions that reduce the excess risk of unprotected anal sex, suicide mortality and CVD mortality associated with stimulant use by 50%, would avert 20% (95%CI: 10% to 37%) of new HIV infections, 14% (95%CI: 5% to 27%) of suicide deaths and 3% (95%CI: 0% to 16%) of CVD deaths between 2020 and 2030 (Figure 3)
A PrEP prioritization strategy based on gender identity/sexual behaviour led to a 22% (95%CI: 9% to 41%) reduction in new HIV infections between 2020 and 2030, which is 23% greater than obtained through the prioritization strategy based on stimulant use

Summary

| INTRODUCTION

HIV prevalence among men who have sex with men (MSM) and transgender women (TW) is 19 [1,2] and 49-fold [3] higher, respectively, than the general population. Stimulants, such as cocaine and meth/amphetamines cause euphoria, sociability and energy [5], and can increase sexual desire, pleasure, prolong sexual performance and decrease sexual inhibition and pain sensation during anal intercourse [6,7,8,9]. We used a dynamic epidemic model to quantify the intersecting burden of stimulant use and HIV transmission, suicide and CVD mortality among MSM and TW in Lima [49], and to estimate the impact of PrEP prioritization by stimulant use and of PrEP integration with harm reduction services

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