Reduce HIV Incidence Research Articles

Structural Determinants of Black MSM HIV Testing Coverage (2011-2016).

Over 30years into the US HIV/AIDS epidemic, Black men who have sex with men (BMSM) continue to carry the highest burden of both HIV and AIDS cases. There is then, an urgent need to expand access to HIV prevention and treatment for all gay and bisexual men, underscoring the importance of the federal initiative 'Ending the Epidemic: A Plan for America'. This research examines structural factors associated with BMSM HIV testing coverage over time (2011-2016) in 85 US Metropolitan Statistical Areas (MSAs). We calculated MSA-specific annual measures of BMSM HIV testing coverage (2011-2016). Variables suggested by the Theory of Community Action (i.e., need, resource availability, institutional opposition and organized support) were analyzed as possible predictors of coverage using multilevel modeling. Relationships between BMSM HIV testing and the following covariates were positive: rates of BMSM living with HIV (b = 0.28), percent of Black residents employed (b = 0.19), Black heterosexual testing rate (b = 0.46), health expenditures per capita (b = 0.16), ACT UP organization presence in 1992 (b = 0.19), and syringe service presence (b = 0.12). Hard drug arrest rates at baseline (b = -0.21) and change since baseline (b = -0.10) were inversely associated with the outcome. Need, resources availability, organized support and institutional opposition are important determinants of place associated with BMSM HIV testing coverage. Efforts to reduce HIV incidence and lessen AIDS-related disparities among BMSM in the US require improved and innovative HIV prevention approaches directed toward BMSM including a fuller understanding of structural factors that may influence place variation in BMSM testing patterns and risk behavior in places of high need.

The impact of localized implementation: determining the cost-effectiveness of HIV prevention and care interventions across six United States cities

Effective interventions to reduce the public health burden of HIV/AIDS can vary in their ability to deliver value at different levels of scale and in different epidemiological contexts. Our objective was to determine the cost-effectiveness of HIV treatment and prevention interventions implemented at previously documented scales of delivery in six US cities with diverse HIV microepidemics. Dynamic HIV transmission model-based cost-effectiveness analysis. We identified and estimated previously documented scale of delivery and costs for 16 evidence-based interventions from the US CDC's Compendium of Evidence-Based Interventions and Best Practices for HIV Prevention. Using a model calibrated for Atlanta, Baltimore, Los Angeles, Miami, New York City and Seattle, we estimated averted HIV infections, quality-adjusted life years (QALY) gained and incremental cost-effectiveness ratios (healthcare perspective; 3% discount rate, 2018$US), for each intervention and city (10-year implementation) compared with the status quo over a 20-year time horizon. Increased HIV testing was cost-saving or cost-effective across cities. Targeted preexposure prophylaxis for high-risk MSM was cost-saving in Miami and cost-effective in Atlanta ($6123/QALY), Baltimore ($18 333/QALY) and Los Angeles ($86 117/QALY). Interventions designed to improve antiretroviral therapy initiation provided greater value than other treatment engagement interventions. No single intervention was projected to reduce HIV incidence by more than 10.1% in any city. Combination implementation strategies should be tailored to local epidemiological contexts to provide the most value. Complementary strategies addressing factors hindering access to HIV care will be necessary to meet targets for HIV elimination in the United States.

The HIV epidemic in Latin America: a time to reflect on the history of success and the challenges ahead.

The HIV epidemic in Latin America: a time to reflect on the history of success and the challenges ahead.

The effect of 90-90-90 on HIV-1 incidence and mortality in eSwatini: a mathematical modelling study

SummaryBackgroundThe rapid scale-up of antiretroviral therapy (ART) towards the UNAIDS 90-90-90 goals over the last decade has sparked considerable debate as to whether universal test and treat can end the HIV-1 epidemic in sub-Saharan Africa. We aimed to develop a network transmission model, calibrated to capture age-specific and sex-specific gaps in the scale-up of ART, to estimate the historical and future effect of attaining and surpassing the UNAIDS 90-90-90 treatment targets on HIV-1 incidence and mortality, and to assess whether these interventions will be enough to achieve epidemic control (incidence of 1 infection per 1000 person-years) by 2030.MethodsWe used eSwatini (formerly Swaziland) as a case study to develop our model. We used data on HIV prevalence by 5-year age bins, sex, and year from the 2007 Swaziland Demographic Health Survey (SDHS), the 2011 Swaziland HIV Incidence Measurement Survey, and the 2016 Swaziland Population Health Impact Assessment (PHIA) survey. We estimated the point prevalence of ART coverage among all HIV-infected individuals by age, sex, and year. Age-specific data on the prevalence of male circumcision from the SDHS and PHIA surveys were used as model inputs for traditional male circumcision and scale-up of voluntary medical male circumcision (VMMC). We calibrated our model using publicly available data on demographics; HIV prevalence by 5-year age bins, sex, and year; and ART coverage by age, sex, and year. We modelled the effects of five scenarios (historical scale-up of ART and VMMC [status quo], no ART or VMMC, no ART, age-targeted 90-90-90, and 100% ART initiation) to quantify the contribution of ART scale-up to declines in HIV incidence and mortality in individuals aged 15–49 by 2016, 2030, and 2050.FindingsBetween 2010 and 2016, status-quo ART scale-up among adults (aged 15–49 years) in eSwatini (from 34·0% in 2010 to 74·1% in 2016) reduced HIV incidence by 43·57% (95% credible interval 39·71 to 46·36) and HIV mortality by 56·17% (54·06 to 58·92) among individuals aged 15–49 years, with larger reductions in incidence among men and mortality among women. Holding 2016 ART coverage levels by age and sex into the future, by 2030 adult HIV incidence would fall to 1·09 (0·87 to 1·29) per 100 person-years, 1·42 (1·13 to 1·71) per 100 person-years among women and 0·79 (0·63 to 0·94) per 100 person-years among men. Achieving the 90-90-90 targets evenly by age and sex would further reduce incidence beyond status-quo ART, primarily among individuals aged 15–24 years (an additional 17·37% [7·33 to 26·12] reduction between 2016 and 2030), with only modest additional incidence reductions in adults aged 35–49 years (1·99% [–5·09 to 7·74]). Achieving 100% ART initiation among all people living with HIV within an average of 6 months from infection—an upper bound of plausible treatment effect—would reduce adult HIV incidence to 0·73 infections (0·55 to 0·92) per 100 person-years by 2030 and 0·46 (0·33 to 0·59) per 100 person-years by 2050.InterpretationScale-up of ART over the last decade has already contributed to substantial reductions in HIV-1 incidence and mortality in eSwatini. Focused ART targeting would further reduce incidence, especially in younger individuals, but even the most aggressive treatment campaigns would be insufficient to end the epidemic in high-burden settings without a renewed focus on expanding preventive measures.FundingGlobal Good Fund and the Bill & Melinda Gates Foundation.

What do the Universal Test and Treat trials tell us about the path to HIV epidemic control?

IntroductionAchieving HIV epidemic control globally will require new strategies to accelerate reductions in HIV incidence and mortality. Universal test and treat (UTT) was evaluated in four randomized population‐based trials (BCPP/Ya Tsie, HPTN 071/PopART, SEARCH, ANRS 12249/TasP) conducted in sub‐Saharan Africa (SSA) during expanded antiretroviral treatment (ART) eligibility by World Health Organization guidelines and the UNAIDS 90‐90‐90 campaign.DiscussionThese three‐year studies were conducted in Botswana, Zambia, Uganda, Kenya and South Africa in settings with baseline HIV prevalence from 4% to 30%. Key observations across studies were: (1) Universal testing (implemented via a variety of home and community‐based testing approaches) achieved >90% coverage in all studies. (2) When coupled with robust linkage to HIV care, rapid ART start and patient‐centred care, UTT achieved among the highest reported population levels of viral suppression in SSA. Significant gains in population‐level viral suppression were made in regions with both low and high baseline population viral load; however, viral suppression gains were not uniform across all sub‐populations and were lower among youth. (3) UTT resulted in marked reductions in community HIV incidence when universal testing and robust linkage were present. However, HIV elimination targets were not reached. In BCPP and HPTN 071, annualized HIV incidence was approximately 20% to 30% lower in the intervention (which included universal testing) compared to control arms (no universal testing). In SEARCH (where both arms had universal testing), incidence declined 32% over three years. (4) UTT reduced HIV associated mortality by 23% in the intervention versus control communities in SEARCH, a study in which mortality was comprehensively measured.ConclusionsThese trials provide strong evidence that UTT inclusive of universal testing increases population‐level viral suppression and decreases HIV incidence and mortality faster than the status quo in SSA and should be adapted at a sub‐country level as a public health strategy. However, more is needed, including integration of new prevention interventions into UTT, in order to reach UNAIDS HIV elimination targets.

Undetectable viral load and HIV transmission dynamics on an individual and population level: where next in the global HIV response?

To examine recent literature on the efficacy and effectiveness of HIV treatment in preventing HIV transmission through sexual exposure, at both an individual and at a population level. Two recent studies on the individual-level efficacy of treatment as prevention (TasP) have added to the now conclusive evidence that HIV cannot be transmitted sexually when the virus is suppressed. However, four large cluster-randomized population-level trials on universal HIV testing and treatment in Africa have not delivered the expected impact in reducing HIV incidence at a population level. Two of these trials showed no differences in HIV incidence between the intervention and control arms, one demonstrated a nonsignificant lower incidence in the intervention arm, and the fourth trial found a reduction between the communities receiving a combination prevention package and the control arm, but no difference between the immediate treatment plus the prevention package and the control arm. Factors contributing to the disconnect between individual high-level efficacy and population-level effectiveness of TasP include undiagnosed infection, delays in linkage to care, challenges in retention and adherence to antiretroviral therapy (ART), time between ART initiation and viral suppression, and stigma and discrimination. Suppressive ART renders people living with HIV sexually noninfectious. However, epidemic control is unlikely to be achieved by TasP alone.

PrEParing for Preexposure Prophylaxis.

In 2012 the Food and Drug Administration (FDA) approved Truvada (emtricitabine [FTC] 200 mg/tenofovir disoproxil fumarate [TDF] 300 mg) for preexposure prophylaxis (PrEP) against HIV. There was a substantial decline in new HIV diagnoses which has since stabilized. The plateau is thought to be because preventative efforts are not reaching high-risk groups. About 1.2 million adults in the United States could benefit from PrEP but only 80,000 individuals are taking it. This article aims to increase provider awareness of PrEP so primary care providers feel confident discussing risk reduction options, initiating, and monitoring PrEP. A case based approached is used to achieve the objective. Target populations, baseline labs, follow up labs and monitoring parameters, and side effects of medication will be reviewed. Patient counseling with regards to dosing, administration, side effects and adverse events will be discussed. HIV prevention is an integral public health goal. PrEP is a way to achiveeve continued reduction in HIV incidence. PCPs should be offering PrEP to at risk individuals. Many nurse practitioners work as primary care providers, this article hopes to increase the confidence of PCPs in prescribing PrEP to those who would benefit from it.

Evaluating DREAMS HIV prevention interventions targeting adolescent girls and young women in high HIV prevalence districts in South Africa: protocol for a cross-sectional study

BackgroundYoung women in sub-Saharan Africa remain at the epicentre of the HIV epidemic, with surveillance data indicating persistent high levels of HIV incidence. In South Africa, adolescent girls and young women (AGYW) account for a quarter of all new HIV infections. Determined, Resilient, Empowered, AIDS-free, Mentored and Safe (DREAMS) is a strategy introduced by the United States President’s Emergency Plan for AIDS Relief (PEPFAR) aimed at reducing HIV incidence among AGYW in 10 countries in sub-Saharan Africa by 25% in the programme’s first year, and by 40% in the second year. This study will assess the change in HIV incidence and reduction in risk associated behaviours that can be attributed to the DREAMS initiative in South Africa, using a population-based cross-sectional survey.MethodsData will be collected from a household-based representative sample of AGYW (between the ages 12–24 years) in four high prevalence districts (more than 10% of the population have HIV in these districts) in South Africa in which DREAMS has been implemented. A stratified cluster-based sampling approach will be used to select eligible participants for a cross-sectional survey with 18,500, to be conducted over 2017/2018. A questionnaire will be administered containing questions on sexual risk behaviour, selected academic and developmental milestones, prevalence of gender based violence, whilst examining exposure to DREAMS programmes. Biological samples, including two micro-containers of blood and self-collected vulvovaginal swab samples, are collected in each survey to test for HIV infection, HIV incidence, sexually transmitted infections (STIs) and pregnancy. This study will measure trends in population level HIV incidence using the Limiting antigen (LAg) Avidity Enzyme Immuno-Assay (EIA) and monitor changes in HIV incidence.DiscussionEnding the HIV/AIDS pandemic by 2030 requires the continual monitoring and evaluation of prevention programmes, with the aim of optimising efforts and ensuring the achievement of epidemic control. This study will determine the impact DREAMS interventions have had on HIV incidence among AGYW in a ‘real world, non-trial setting’.

Modelling the impact of migrants on the success of the HIV care and treatment program in Botswana.

Botswana offers publicly financed HIV treatment to citizens, but not migrants, who comprised about 7% of the population in 2016. However, HIV incidence is not declining in proportion to Botswana's HIV response. In 2018, Botswana had 86% of citizens living with HIV diagnosed, 95% of people diagnosed on treatment, and 95% viral suppression among those on treatment. We hypothesised that continued exclusion of migrants is hampering reduction of HIV incidence in Botswana. Hence, we modelled the impact of including migrants in Botswana's HIV response on achieving 90-90-90 and 95-95-95 Fast-Track targets by 2020 and 2030, respectively. The Optima HIV model, with demographic, epidemiological, and behavioural inputs, was applied to citizens of and migrants to Botswana. Projections of new HIV infections and HIV-related deaths were compared for three scenarios to the end of 2030: (1) continued status quo for HIV testing and treatment coverage, and maintenance of levels of linkage to care, loss to follow-up, and viral suppression among citizens and migrants (baseline); (2) with scaled-up budget, optimised to achieve 90-90-90 and 95-95-95 Fast-Track targets by 2020 and 2030, respectively, for citizens only; and (3) scaled-up optimised budget to achieve these targets for both citizens and migrants. A baseline of 172,000 new HIV infections and 8,400 HIV-related deaths was projected over 2020-2030. Scaling up to achieve targets among citizens only averted an estimated 48,000 infections and 1,700 deaths. Achieving targets for both citizens and migrants averted 16,000 (34%) more infections and 442 (26%) more deaths. Scaling up for both populations reduced numbers of new HIV infections and deaths by 44% and 39% respectively compared with 2010 levels. Treating migrants when scaling up in both populations was estimated to cost USD 74 million over 2020-2030. Providing HIV services to migrants in Botswana could lead to further reductions in HIV incidence and deaths. However, even with an increased, optimised budget that achieves 95-95-95 targets for both citizens and migrants by 2030, the 90% incidence reduction target for 2020 will be missed. Further efficiencies and innovations will be needed to meet HIV targets in Botswana.

A Crowdsourcing Open Contest to Design Pre-Exposure Prophylaxis Promotion Messages: Protocol for an Exploratory Mixed Methods Study.

BackgroundIn the United States, black men who have sex with men (BMSM) are disproportionately affected by HIV. Pre-exposure prophylaxis (PrEP) can reduce HIV incidence. However, real-world implementation of PrEP outside of clinical trials has identified racial disparities in PrEP awareness, uptake, and adherence. In the context of a long history of medical mistrust and power imbalances between scientists and community members, strategies to increase uptake of PrEP among BMSM should consider ways to ensure messages address the needs and priorities of the community. Crowdsourcing contests shift traditional individual tasks to a large group and may enhance community engagement.ObjectiveThis paper describes the research protocol of a contest approach to soliciting PrEP promotion messages among BMSM in Baltimore.MethodsOpen-contest implementation and evaluation will proceed as follows: (1) organize a community steering group; (2) develop platforms to solicit crowd input; (3) engage the community to contribute ideas through a Web-based forum and in-person events; (4) evaluate contest entries using both community panel judge assessment and crowd voting; (5) utilize mixed methods to evaluate feasibility, acceptability, and community engagement; and (6) disseminate contest results.ResultsThis study was funded by the National Institutes of Health (National Institute of Mental Health: R34MH116725) in May 2018 and was approved by the institutional review board in April 2018. The open contest started in February 2019, and data analyses for the mixed method evaluation are expected to complete in December 2019.ConclusionsThe contest will potentially bring new ideas in developing more impactful and locally defined PrEP promotion campaigns. We will determine whether an open-contest approach is acceptable among BMSM in Baltimore. If successful, this study can inform future projects using a similar approach on how to identify and implement programs and policies that are more responsive to community needs and that build up community assets.International Registered Report Identifier (IRRID)DERR1-10.2196/15590

Using Longitudinal Phylogenetic-Network Study to Understand HIV Treatment-as-Prevention in Southwest China: A Population-Based Observational Study

Background: WHO has recommended that antiretroviral therapy be provided to all HIV patients to reduce future HIV transmission at the population level. Aside from the HPTN 071 (PopART) community based randomized trial which indicated that universal testing and treatment can reduce HIV incidence at the population level, such a public health strategy has not previously been studied in real-world settings. Methods: In this longitudinal phylogenetic-network study in Guangxi, China, the longitudinal baseline and follow-up data was collected from HIV patients in 2014 and newly diagnosed HIV patients from 2015 to 2018, respectively. We used a genetic distance threshold of 0.75% to analyze the proportions of genetic linkage between annual newly diagnosed HIV patients with HIV patients at baseline stratified by treatment. Findings: Among 804 newly diagnosed HIV patients during 2015-2018, 399 (49.6%) of them genetically linked to HIV patients at baseline during 2014-2017. The overall proportion of genetic linkage between newly diagnosed HIV patients during 2015-2018 with untreated and treated HIV patients at baseline during 2014-2017 was 6.2% and 2.9%, respectively. The prevention efficacy in HIV transmission for treated HIV patients was 53.5% (95% CI: 42.0%-65.0%). There was no significant reduction in HIV transmission among treated HIV patients on dropout or with missing viral load measures. Interpretation: Combined with the HPTN 071 (PopART) study, our study results strongly support the feasibility of treating all HIV patients for future reductions in HIV transmission at the population level in real-world settings. Comprehensive intervention prevention programs are urgently needed. Funding Statement: This study was supported by the Guangxi Science and Technology Bureau (Grant AB16380213), Guangxi Medical and Health Project (Z20170126), National Natural Science Foundation of China (Grants 11971479, 81460510 and 81360442), Guangxi Bagui Honor Scholarship, Ministry of Science and Technology of China (2018ZX10721102-006, 2018ZX10715008), and Chinese State Key Laboratory of Infectious Disease Prevention and Control. Declaration of Interests: The authors declare that they have no conflicts of interest. Ethics Approval Statement: The institutional review board (IRB) of the Guangxi CDC approved this study.

Emerging evidence from a systematic review of safety of pre-exposure prophylaxis for pregnant and postpartum women: where are we now and where are we heading?

IntroductionHIV incidence is high during pregnancy and breastfeeding with HIV acquisition risk more than doubling during pregnancy and the postpartum period compared to when women are not pregnant. The World Health Organization recommends offering pre‐exposure prophylaxis (PrEP) to pregnant and postpartum women at substantial risk of HIV infection. However, maternal PrEP national guidelines differ and most countries with high maternal HIV incidence are not offering PrEP. We conducted a systematic review of recent research on PrEP safety in pregnancy to inform national policy and rollout.MethodsWe used a standard Preferred Reporting Items for Systematic Reviews and Meta‐Analysis (PRISMA) approach to conduct a systematic review by searching for completed, ongoing, or planned PrEP in pregnancy projects or studies from http://www.clinicaltrials.gov, PubMed and NIH RePORTER from 2014 to March 2019. We performed a systematic review of studies that assess tenofovir disoproxil fumarate (TDF)‐based oral PrEP safety in pregnant and breastfeeding HIV‐uninfected women.Results and discussionWe identified 14 completed (n = 5) and ongoing/planned (n = 9) studies that evaluate maternal and/or infant outcomes following PrEP exposure during pregnancy or breastfeeding. None of the completed studies found differences in pregnancy or perinatal outcomes associated with PrEP exposure. Nine ongoing studies, to be completed by 2022, will provide data on >6200 additional PrEP‐exposed pregnancies and assess perinatal, infant growth and bone health outcomes, expanding by sixfold the data on PrEP safety in pregnancy. Research gaps include limited data on (1) accurately measured PrEP exposure within maternal and infant populations including drug levels needed for maternal protection; (2) uncommon perinatal outcomes (e.g. congenital anomalies); (3) infant outcomes such as bone growth beyond one year following PrEP exposure; (4) outcomes in HIV‐uninfected women who use PrEP during pregnancy and/or lactation.ConclusionsExpanding delivery of PrEP is an essential strategy to reduce HIV incidence in pregnancy and breastfeeding women. Early safety studies of PrEP among pregnant women without HIV infection are reassuring and ongoing/planned studies will contribute extensive new data to bolster the safety profile of PrEP use in pregnancy. However, addressing research gaps is essential to expanding PrEP delivery for women in the context of pregnancy.

The Potential Epidemiological Impact of COVID-19 on the HIV/AIDS Epidemic and the Cost-Effectiveness of Linked, Opt-Out HIV Testing: A Modeling Study in Six US Cities

Background: Widespread viral and serological testing for SARS-CoV-2 may present a unique opportunity to also test for HIV infection. We estimated the potential impact of adding linked, opt-out HIV testing alongside SARS-CoV-2 testing on HIV incidence and the cost-effectiveness of this strategy in six US cities.Methods: We calibrated a dynamic compartmental HIV transmission model to match the epidemiological characteristics of six US cities (Atlanta, Baltimore, Los Angeles, Miami, New York City, Seattle). For each city, we constructed three sets of scenarios: (1) sustained current levels of HIV-related treatment and prevention services (status quo); (2) temporary disruptions in health services and changes in sexual and injection risk behaviours at discrete levels between 0%-50%; and (3) linked HIV and SARS-CoV-2 testing offered to 10%-90% of the adult population in addition to scenario (2). We estimated cumulative HIV infections between 2020-2025, as well as incremental costs, quality-adjusted life years, and incremental cost-effectiveness ratios of linked HIV testing over 20 years.Findings: In the absence of linked, opt-out HIV testing, we estimated a best-case scenario (50% reduction in risk behaviours and no service disruptions) of 6,733 fewer HIV infections between 2020-2025 (16.5% decrease), and a worst-case scenario (no behavioural change and 50% reduction in service access) of 3,669 additional HIV infections (9.0% increase) across cities. If HIV testing could be offered to 10%-90% of the adult population, we estimated that a total of 576-7,225 (1.6%-17.2%) new infections could be averted. The intervention would require an initial investment of $20M-$218M across cities; however, the intervention would ultimately result in savings in health care costs in each city.Interpretation: Although COVID-19-related disruptions in HIV-related services may increase or decrease HIV incidence, a campaign in which HIV testing is linked with SARS-CoV-2 testing could substantially reduce HIV incidence and reduce direct and indirect health care costs attributable to HIV.Funding Statement: US NIH-NIDA Grant No. R01-DA041747Declaration of Interests: XZ, EK, SC, MP, WSA, CNB, CDR, DJF, BDLM, SHM, JM, LRM, BRS, SAS and BN declare no competing interests.

Associations Between Neighborhood Problems and Sexual Behaviors Among Black Men Who Have Sex with Men in the Deep South: The MARI Study.

There is a disproportionately high HIV incidence among Black men who have sex with men (MSM) despite equal or lower levels of HIV risk behaviors compared to White MSM. Due to high levels of racial segregation in the U.S., Black MSM have an elevated likelihood of living in neighborhoods that contain psychosocial stressors, which, in turn, may increase behaviors promoting HIV infection. We examined associations between perceived neighborhood problems and sexual behaviors among Black MSM in the Deep South, a population at highest risk of HIV. Data came from the MARI Study, which included Black MSM ages 18-66years recruited from the Jackson, MS, and Atlanta, GA, metropolitan areas (n = 377). Participants completed questions about neighborhood problems (e.g., excessive noise, heavy traffic/speeding cars and trash/litter) and sexual behaviors (e.g., condomless sex and drug use before or during sex). We used Poisson's regression model with robust standard errors to estimate the adjusted prevalence ratio (aPR; 95% confidence intervals [CI]) of neighborhood problems (coded as tertiles [tertile 1 = low neighborhood problems, tertile 2 = medium neighborhood problems, tertile 3 = high neighborhood problems] as well as continuously) with sexual behaviors, after adjustment for sociodemographic characteristics and other variables. About one-fourth of the sample reported at least one neighborhood problem, with the most common (31.6%) being no/poorly maintained sidewalks, which indicates an infrastructural problem. In multivariable models, compared to those in the lowest tertile, those reporting more neighborhood problems (tertile 2: aPR = 1.49, 95% CI = 1.04, 2.14 and tertile 3: aPR = 1.53, 95% CI = 1.05, 2.24) reported more drug use before or during sex (p for trend = .027). Neighborhood problems may promote behaviors (e.g., drug use before or during sex) conducive to HIV infection. Structural interventions could improve community infrastructure to reduce neighborhood problems (e.g., no/poorly maintained sidewalks and litter). These interventions may help to reduce HIV incidence among Black MSM in the Deep South.

On-demand pre-exposure prophylaxis with tenofovir disoproxil fumarate plus emtricitabine among men who have sex with men with less frequent sexual intercourse: a post-hoc analysis of the ANRS IPERGAY trial

ANRS IPERGAY found that on-demand pre-exposure prophylaxis (PrEP) with oral tenofovir disoproxil fumarate plus emtricitabine was associated with an 86% relative reduction of HIV-1 incidence compared with placebo among men who have sex with men at high risk of HIV. We aimed to investigate whether on-demand PrEP was similarly effective among individuals with lower exposure to HIV risk. Participants in the ANRS IPERGAY trial were randomly assigned to receive PrEP (fixed-dose combination of 300 mg tenofovir disoproxil fumarate and 200 mg emtricitabine per pill) or placebo. The primary endpoint was the diagnosis of HIV-1 infection. Pill uptake was assessed by counting returned pills at each follow-up and by estimating tenofovir concentration from frozen plasma samples. Participants were interviewed at each visit to assess the pattern of PrEP use. All participants enrolled in the modified intention-to-treat population of the double-blind phase of the ANRS IPERGAY trial were eligible for this post-hoc analysis. We calculated the total follow-up time for periods of less frequent sexual intercourse with high PrEP adherence (15 pills or fewer per month taken systematically or often during sexual intercourse). To estimate the time of HIV acquisition, fourth-generation HIV-1/2 ELISA assays, plasma HIV-1 RNA assays, and western blot analyses were done with use of frozen samples, and the stage of HIV infection was defined according to Fiebig staging. HIV incidence was compared between the two treatment groups among individuals who had less frequent sexual intercourse with high PrEP adherence. The ANRS IPERGAY trial is registered with ClinicalTrials.gov, NCT01473472. 400 participants who were randomly assigned to receive PrEP (n=199) or placebo (n=201) between Feb 22, 2012, and Oct 17, 2014, were included in this analysis. 270 participants had at least one period of less frequent sexual intercourse with high PrEP adherence during the study, representing 134 person-years of follow-up and 31% of the total study follow-up. During these periods, participants in both groups reported a median of 5·0 (IQR 2·0-10·0) episodes of sexual intercourse per month and used a median of 9·5 (6·0-13·0) pills per month. Six HIV-1 infections were diagnosed in the placebo group (HIV incidence of 9·2 per 100 person-years; 95% CI 3·4-20·1) and none were diagnosed in the tenofovir disoproxil fumarate plus emtricitabine arm (HIV incidence of 0 per 100 person-years; 0-5·4; p=0·013), with a relative reduction of HIV incidence of 100% (95% CI 39-100). A choice between daily or on-demand PrEP regimens could be offered to men who have sex with men who have less frequent sexual intercourse. ANRS (France Recherche Nord and Sud Sida-HIV Hépatites), the Canadian HIV Trials Network, Fonds Pierre Bergé (Sidaction), Gilead Sciences, and the Bill & Melinda Gates Foundation.

Trends in HIV Prevention, Treatment, and Incidence in a Hyperendemic Area of KwaZulu-Natal, South Africa

In Africa, the persistently high HIV incidence rate among young women is the major obstacle to achieving the goal of epidemic control. To determine trends in coverage of HIV prevention and treatment programs and HIV incidence. This cohort study consisted of 2 sequential, community-based longitudinal studies performed in the Vulindlela and Greater Edendale area in KwaZulu-Natal, South Africa. Participants enrolled from June 11, 2014, to June 22, 2015 (2014 survey), with a single follow-up visit from June 24, 2016, to April 3, 2017 (2016 cohort), or enrolled from July 8, 2015, to June 7, 2016 (2015 survey), with a single follow-up visit from November 7, 2016, to August 30, 2017 (2017 cohort). Men and women aged 15 to 49 years were enrolled in the 2014 and 2015 surveys, and HIV-seronegative participants aged 15 to 35 years were followed up in the 2016 and 2017 cohorts. Analysis was conducted from January 1 through December 31, 2018. HIV prevention and treatment programs in a real-world, nontrial setting. Trends in sex- and age-specific HIV incidence rates, condom use, voluntary medical male circumcision, knowledge of HIV-seropositive status, uptake of antiretroviral therapy, and viral suppression. A total of 9812 participants (6265 women [63.9%]; median age, 27 years [interquartile range, 20-36 years]) from 11 289 households were enrolled in the 2014 survey, and 10 236 participants (6341 women [61.9%]; median age, 27 years [interquartile range, 20-36 years]) from 12 247 households were enrolled in the 2015 survey. Of these, 3536 of 4539 (annual retention rate of 86.7%) completed follow-up in the 2016 cohort, and 3907 of 5307 (annual retention rate of 81.4%) completed follow-up in the 2017 cohort. From 2014 to 2015, condom use with last sex partner decreased by 10% from 24.0% (n = 644 of 3547) to 21.6% (n = 728 of 3895; P = .12) in men and by 17% from 19.6% (n = 1039 of 6265) to 16.2% (n = 871 of 6341; P = .002) in women. Voluntary medical male circumcision increased by 13% from 31.9% (1102 of 3547) to 36.1% (n = 1472 of 3895); P = .007) in men, and the proportion of women reporting that their partner was circumcised increased by 35% from 35.7% (n = 1695 of 4766) to 48.2% (n = 2519 of 5207; P < .001). Knowledge of HIV-seropositive status increased by 21% from 51.8% (n = 504 of 3547) to 62.9% (n = 570 of 3895; P < .001) in men and by 14% from 64.6% (n = 1833 of 6265) to 73.4% (n = 2182 of 6341; P < .001) in women. Use of antiretroviral therapy increased by 32% from 36.7% (n = 341 of 3547) to 48.6% (n = 432 of 3895; P < .001) in men and by 29% from 45.6% (n = 1251 of 6265) to 58.8% (n = 1743 of 6341; P < .001) in women; HIV viral suppression increased by 20% from 41.9% (n = 401 of 3547) to 50.3% (n = 456 of 3895; P = .005) in men and by 13% from 54.8% (n = 1547 of 6265) to 61.9% (n = 1828 of 6341; P < .001) in women. Incidence of HIV declined in women aged 15 to 19 years from 4.63 (95% CI, 3.29-6.52) to 2.74 (95% CI, 1.84-4.09) per 100 person-years (P = .04) but declined marginally or remained unchanged among men and women in other age groups. This study showed a significant decline in HIV incidence in young women; however, to further reduce HIV incidence, HIV prevention and treatment program coverage must be intensified and scaled up.

Health Care Provider Perspectives on Pre-exposure Prophylaxis: A Qualitative Study.

Although pre-exposure prophylaxis (PrEP) requires a prescription from a health care provider, we lack unanimity in guidelines for the identification of the ideal provider type to prescribe PrEP. The purpose of our study was to understand clinician perspectives on provider categories to determine who is best suited to prescribe this medication to HIV-uninfected patients. We conducted 28 in-depth interviews between September 2017 and January 2018 with current prescribers of PrEP. Qualitative findings indicated that providers were split on recommended PrEP prescriber type. Five themes emerged that centered on the explicit identification of the issue of opportunity for providers to educate their patients on PrEP and offer this medication to at-risk populations. To effectively maximize presentation for care and subsequently amplify uptake of PrEP, growing the base of providers who offer PrEP to eligible patients can provide a meaningful public health impact on reducing HIV incidence.

Can the United States achieve 90-90-90?

To summarize recent trends in knowledge of HIV status, care and viral suppression, and the status of implementation of relevant contextual requirements for the United States to achieve the 90-90-90 goals. Recently, the US government announced a plan to decrease HIV incidence by over 90% by 2030. Reaching this goal may require higher targets than 90-90-90. The United States is on course to reach 90-90-90 goals in the near future, with 86% of persons with HIV aware of their infection, 74% of persons with diagnosed infection in care, and 83% of persons in care with viral suppression in 2016. Some high-burden subnational jurisdictions have already achieved these goals. The United States is likely to reach 90-90-90 targets in the near future. However, to reduce HIV incidence by at least 90% by 2030, the United States will need to rapidly meet the new 95-95-95 targets and deploy a comprehensive strategy with novel approaches to testing, retaining persons with HIV on treatment, and preventing new infections with preexposure prophylaxis and comprehensive syringe services programs.

Awareness and uptake of layered HIV prevention programming for young women: analysis of population-based surveys in three DREAMS settings in Kenya and South Africa

BackgroundThe DREAMS Partnership is an ambitious effort to deliver combinations of biomedical, behavioural and structural interventions to reduce HIV incidence among adolescent girls and young women (AGYW). To inform multi-sectoral programming at scale, across diverse settings in Kenya and South Africa, we identified who the programme is reaching, with which interventions and in what combinations.MethodsRandomly-selected cohorts of 606 AGYW aged 10–14 years and 1081 aged 15–22 years in Nairobi and 2184 AGYW aged 13–22 years in uMkhanyakude, KwaZulu-Natal, were enrolled in 2017, after ~ 1 year of DREAMS implementation. In Gem, western Kenya, population-wide cross-sectional survey data were collected during roll-out in 2016 (n = 1365 AGYW 15–22 years). We summarised awareness and invitation to participate in DREAMS, uptake of interventions categorised by the DREAMS core package, and uptake of a subset of ‘primary’ interventions. We stratified by age-group and setting, and compared across AGYW characteristics.ResultsAwareness of DREAMS was higher among younger women (Nairobi: 89%v78%, aged 15-17v18–22 years; uMkhanyakude: 56%v31%, aged 13-17v18–22; and Gem: 28%v25%, aged 15-17v18–22, respectively).HIV testing was the most accessed intervention in Nairobi and Gem (77% and 85%, respectively), and school-based HIV prevention in uMkhanyakude (60%). Among those invited, participation in social asset building was > 50%; > 60% accessed ≥2 core package categories, but few accessed all primary interventions intended for their age-group. Parenting programmes and community mobilisation, including those intended for male partners, were accessed infrequently.In Nairobi and uMkhanyakude, AGYW were more likely to be invited to participate and accessed more categories if they were: aged < 18 years, in school and experienced socio-economic vulnerabilities. Those who had had sex, or a pregnancy, were less likely to be invited to participate but accessed more categories.ConclusionsIn representative population-based samples, awareness and uptake of DREAMS were high after 1 year of implementation. Evidence of ‘layering’ (receiving multiple interventions from the DREAMS core package), particularly among more socio-economically vulnerable AGYW, indicate that intervention packages can be implemented at scale, for intended recipients, in real-world contexts. Challenges remain for higher coverage and greater ‘layering’, including among older, out-of-school AGYW, and community-based programmes for families and men.

Using Interrupted Time Series Analysis to Measure the Impact of Legalized Syringe Exchange on HIV Diagnoses in Baltimore and Philadelphia.

Background:Syringe exchange programs (SEP) reduce HIV incidence associated with injection drug use (IDU), but legislation often prohibits implementation. We examined the policy change impact allowing for SEP implementation on HIV diagnoses among people who inject drugs in 2 US cities.Setting:Philadelphia, PA, and Baltimore, MD.Methods:Using surveillance data from Philadelphia (1984–2015) and Baltimore (1985–2013) for IDU-associated HIV diagnoses, we used autoregressive integrated moving averages modeling to conduct 2 tests to measure policy change impact. We forecast the number of expected HIV diagnoses per city had policy not changed in the 10 years after implementation and compared it with the number of observed diagnoses postpolicy change, obtaining an estimate for averted HIV diagnoses. We then used interrupted time series analysis to assess the immediate step and trajectory impact of policy change implementation on IDU-attributable HIV diagnoses.Results:The Philadelphia (1993–2002) model predicted 15,248 new IDU-associated HIV diagnoses versus 4656 observed diagnoses, yielding 10,592 averted HIV diagnoses over 10 years. The Baltimore model (1995–2004) predicted 7263 IDU-associated HIV diagnoses versus 5372 observed diagnoses, yielding 1891 averted HIV diagnoses over 10 years. Considering program expenses and conservative estimates of public sector savings, the 1-year return on investment in SEPs remains high: $243.4 M (Philadelphia) and $62.4 M (Baltimore).Conclusions:Policy change is an effective structural intervention with substantial public health and societal benefits, including reduced HIV diagnoses among people who inject drugs and significant cost savings to publicly funded HIV care.