Reduce HIV Transmission Research Articles

Moral practices shaping HIV disclosure among young gay and bisexual men living with HIV in the context of biomedical advance

Biomedical advances in diagnostics, treatment and prevention increase the means available to reduce HIV transmission risk. Subsequent shifts in HIV status disclosure obligation and ethics may impact how those living with HIV view, enact and experience disclosure. We analysed focus group and interview data to explore how these changes are reflected in disclosure decision-making to sexual partners among young gay and bisexual men living with HIV in the USA. Three interrelated themes were identified: engaging with partners’ varying HIV knowledge; attribution of blame; and negotiating disclosure-related harms. Participants experienced blame from partners that questioned the timing of HIV testing, status disclosure and sex events without regards for viral suppression or use of pre-exposure prophylaxis. Substantial HIV stigma was described in response to disclosure, mitigated in some cases by partners’ higher HIV knowledge. Overall, an uneven diffusion of HIV treatment and prevention knowledge and continuing HIV stigma seemed to limit the translation of biomedical advances into improved disclosure experiences. Our findings suggest that young gay and bisexual men living with HIV may continue to perform much of the moral labour involved in disclosure by managing others’ reactions, correcting inaccurate sexual health information, and negotiating the risks of disclosure-related harm.

Impact of frequent testing on the transmission of HIV and N. gonorrhoeae among men who have sex with men: a mathematical modelling study

ObjectivesTo investigate the impact and efficiency of combined testing for HIV and other STIs on HIV and STI transmission among men who have sex with men (MSM) and to assess...

Multisite Study of Women Living With HIV's Perceived Barriers to, and Interest in, Long-Acting Injectable Antiretroviral Therapy.

Adherence to antiretroviral therapy (ART) is imperative for viral suppression and reducing HIV transmission, but many people living with HIV report difficultly sustaining long-term adherence. Long-acting injectable (LAI) ART has the potential to transform HIV treatment and prevention. However, little LAI ART-related behavioral research has occurred among women, particularly outside of clinical trials. Six Women's Interagency HIV Study sites: New York, Chicago, Washington DC, Atlanta, Chapel Hill, and San Francisco. We conducted 59 in-depth interviews with women living with HIV across 6 Women's Interagency HIV Study sites (10 per site; 9 at Washington DC). We interviewed women who were not included in LAI ART clinical trials but who receive care at university settings that will administer LAI ART once it is approved. Interviews were recorded, transcribed, and analyzed using thematic content analysis. Most women enthusiastically endorsed monthly LAI ART and would prefer it over pills. The following 3 reasons emerged for this preference: (1) convenience and confidentiality, (2) avoiding daily reminders about living with HIV, and (3) believing that shots are more effective than pills. Challenges remain, however, specifically around (1) medical mistrust, (2) concerns about safety and effectiveness, (3) pill burden for HIV and other conditions, and (4) barriers to additional medical visits. Most women preferred LAI ART over daily pills given its benefits, including convenience, privacy, and perceived effectiveness. Future research should incorporate more women into LAI ART trials to better understand and align development with user concerns and preferences to enhance uptake.

A Web-Based Intervention to Reduce Decision Conflict Regarding HIV Pre-Exposure Prophylaxis: Protocol for a Clinical Trial

BackgroundHIV pre-exposure prophylaxis (PrEP) is recommended for populations at high ongoing risk for infection. There are noted racial disparities in the incidence of HIV and other sexually transmitted infections (STIs) for African, Caribbean, and Canadian Black (ACB, black) populations in Ontario, Canada. Although blacks represent only 4.7% of the Ontario population, they account for 30% of HIV prevalence and 25% of new infections in the province. The existing clinical public health practice toolkit has not been sufficient to optimize PrEP uptake, despite the overwhelming evidence of PrEP’s efficacy for reducing HIV transmission risk. Since its establishment as an effective HIV prevention tool, the major focus in behavioral research on PrEP has been on understanding and improving adherence. To date, there is no known formalized intervention in place designed to support ACB men and women at high risk of making high-quality decisions regarding the adoption of PrEP as an HIV prevention practice.ObjectiveWe propose 2 aims to address these gaps in HIV prevention and implementation science. First, the Ottawa Decision Support Framework (ODSF) for use in the PrEP decisional needs of black patients was adapted. Second, the decision support intervention to estimate effect size compared with control conditions in reducing decision conflict and predicting adherence over 60 days was pilot tested.MethodsIn aim 1, we propose a cross-sectional qualitative descriptive study using data collected from key informant interviews with eligible PrEP patients (n=30) and surveys with health professionals (n=20) involved in HIV PrEP management. Data obtained from aim 1 will be used to develop a decision support intervention based on the ODSF. In aim 2, the adopted decision support intervention using a block-randomized design to estimate effect size compared with control conditions in reducing decision conflict and predicting adherence over 60 days was pilot tested. Hypothesis testing will be de-emphasized in favor of generating effect size estimates.ResultsA research award was funded on March 25, 2017 (Multimedia Appendix 1). Ethical approval was received on March 25, 2019 (with supplemental approval received on May 10, 2019). Data collection started on April 9, 2019. As of September 30, 2019, we enrolled 29 patients and 24 health care providers for aim 1. We are currently analysing the data collected for aim 1. Aim 2 is scheduled to start in May 2020.ConclusionsThis study will provide evidence-based information on the decisional needs of black patients who are at risk of HIV and have been offered PrEP. The study will also test the effect of decision support intervention in reducing decision conflict, adoption of PrEP, and adherence to PrEP.International Registered Report Identifier (IRRID)PRR1-10.2196/15080

Healthcare-related stigma among men who have sex with men and transgender women in sub-Saharan Africa participating in HIV Prevention Trials Network (HPTN) 075 study

ABSTRACT The inability to access health services when needed is a critical barrier to HIV prevention, treatment and care among men who have sex with men (MSM) and transgender women (TGW). Using data collected in HPTN 075, we explored factors associated with any experienced healthcare-related stigma. HPTN 075 was a cohort study to assess the feasibility of recruiting and retaining MSM and TGW in clinical trials in sub-Saharan Africa. Of 401 MSM and TGW enrolled at four sites (Kisumu, Kenya; Blantyre, Malawi; Cape Town, Soweto, South Africa) 397 contributed to the analysis (79.9% cis-gender and 20.1% TGW). Of these, (45.3%; 180/397) reported one or more of healthcare-related stigma experiences. Most frequently reported experiences included fear to seek healthcare services (36.3%) and avoiding seeking such services because of the discovery of MSM status (29.2%). Few men and TGW (2.5%) reported having been denied health services because of having sex with men. In multivariable analysis, more participants in Soweto [adjusted odds ratio (AOR) = 2.60] and fewer participants in Blantyre (AOR = 0.27) reported any healthcare-related stigma experiences, in comparison to participants in Kisumu. MSM and TGW that did not have a supportive gay community to rely on were more likely to report any healthcare-related stigma experiences (AOR = 1.46), whereas MSM and TGW who reported high social support and who never had engaged in transactional sex were less likely to report such experiences (AOR = 0.76 and AOR = 0.43, respectively). Our results suggest that encouraging support groups for MSM and TGW as well as training and sensitizing healthcare staff, and the general community, on MSM and TGW health issues and cultural competence may reduce stigma, improve access to healthcare, which could ultimately reduce HIV transmission.

Sociocultural influences on attitudes towards pre-exposure prophylaxis (PrEP), history of PrEP use, and future PrEP use in HIV-vulnerable cisgender men who have sex with men across the U.S.

Despite its proven effectiveness in reducing HIV transmission, pre-exposure prophylaxis (PrEP) use remains low. This study used data from a 2017-2018 U.S. national cohort to investigate social influences on PrEP experience and future PrEP use among cisgender men who have sex with men. We used descriptive statistics and multivariable logistic analyses to examine social influences (e.g., how participants heard about PrEP and number of persons they knew taking PrEP) associated with each previous PrEP use and intentions to use PrEP. Among participants who knew of PrEP, commonly reported ways of first hearing about PrEP were through social media (27.4%) and friends (26.8%). These were also cited top influences on participants' current attitudes toward PrEP (friends 23.5%, social media 22.1%). Multivariable logistic regression analyses found that knowing more people taking PrEP was associated with increased odds of previously using PrEP and intending to use PrEP. Friends and social media were common and influential sources of information regarding PrEP. Results suggest that tapping into these social connections may effectively disseminate public health messaging about PrEP and encourage use among key populations to reduce HIV burden.

Understanding of Perceived Infectiousness and Its Influence on Sexual Behavior Among Individuals With Acute HIV Infection in Lilongwe, Malawi (HPTN 062).

We implemented HPTN 062, an acceptability and feasibility study of a motivational-interviewing (MI) intervention to reduce HIV transmission among individuals with acute HIV infection (AHI) in Lilongwe, Malawi. Participants were randomly assigned to receive either brief education or the MI intervention over 24 weeks; all participants received the same messages about AHI. We used mixed methods to assess participants' understanding of the association between AHI and viral load, and its connection to sexual behavior at 8 weeks. While most participants understood key aspects of AHI, MI-intervention participants gave substantially more detailed descriptions of their understanding. Nearly all participants, regardless of study arm, understood that they were highly infectious and would be very likely to transmit HIV after unprotected sex during AHI. Our findings suggest that messages about AHI delivered during the period of AHI are likely beneficial for ensuring that those with AHI understand their level of infectiousness and its association with forward transmission.

Population uptake of HIV testing, treatment, viral suppression, and male circumcision following a community-based intervention in Botswana (Ya Tsie/BCPP): a cluster-randomised trial

In settings with high HIV prevalence and treatment coverage, such as Botswana, it is unknown whether uptake of HIV prevention and treatment interventions can be increased further. We sought to determine whether a community-based intervention to identify and rapidly treat people living with HIV, and support male circumcision could increase population levels of HIV diagnosis, treatment, viral suppression, and male circumcision in Botswana. The Ya Tsie Botswana Combination Prevention Project study was a pair-matched cluster-randomised trial done in 30 communities across Botswana done from Oct 30, 2013, to June 30, 2018. 15 communities were randomly assigned to receive HIV prevention and treatment interventions, including enhanced HIV testing, earlier antiretroviral therapy (ART), and strengthened male circumcision services, and 15 received standard of care. The first primary endpoint of HIV incidence has already been reported. In this Article, we report findings for the second primary endpoint of population uptake of HIV prevention services, as measured by proportion of people known to be HIV-positive or tested HIV-negative in the preceding 12 months; proportion of people living with HIV diagnosed and on ART; proportion of people living with HIV on ART with viral suppression; and proportion of HIV-negative men circumcised. A longitudinal cohort of residents aged 16-64 years from a random, approximately 20% sample of households across the 15 communities was enrolled to assess baseline uptake of study outcomes; we also administered an end-of-study survey to all residents not previously enrolled in the longitudinal cohort to provide study end coverage estimates. Differences in intervention uptake over time by randomisation group were tested via paired Student's t test. The study has been completed and is registered with ClinicalTrials.gov (NCT01965470). In the six communities participating in the end-of-study survey, 2625 residents (n=1304 from standard-of-care communities, n=1321 from intervention communities) were enrolled into the 20% longitudinal cohort at baseline from Oct 30, 2013, to Nov 24, 2015. In the same communities, 10 791 (86%) of 12 489 eligible enumerated residents not previously enrolled in the longitudinal cohort participated in the end-of-study survey from March 30, 2017, to Feb 25, 2018 (5896 in intervention and 4895 in standard-of-care communities). At study end, in intervention communities, 1228 people living with HIV (91% of 1353) were on ART; 1166 people living with HIV (88% of 1321 with available viral load) were virally suppressed, and 673 HIV-negative men (40% of 1673) were circumcised in intervention communities. After accounting for baseline differences, at study end the proportion of people living with HIV who were diagnosed was significantly higher in intervention communities (absolute increase of 9% to 93%) compared with standard-of-care communities (absolute increase of 2% to 88%; prevalence ratio [PR] 1·08 [95% CI 1·02-1·14], p=0·032). Population levels of ART, viral suppression, and male circumcision increased from baseline in both groups, with greater increases in intervention communities (ART PR 1·12 [95% CI 1·07-1·17], p=0·018; viral suppression 1·13 [1·09-1·17], p=0·017; male circumcision 1·26 [1·17-1·35], p=0·029). It is possible to achieve very high population levels of HIV testing and treatment in a high-prevalence setting. Maintaining these coverage levels over the next decade could substantially reduce HIV transmission and potentially eliminate the epidemic in these areas. US President's Emergency Plan for AIDS Relief through the Centers for Disease Control and Prevention.

Randomized controlled trial protocol for project BRIDGE: A telephone-administered motivational interviewing intervention targeting risky sexual behavior in older people living with HIV

PurposeBy 2020, 70% of people living with HIV in the United States will be greater than 50 years of age. As many as 37% of sexually active older people living with HIV (OPLWH) engage in HIV transmission sexual behaviors. In spite of repeated calls for secondary prevention interventions to reduce condomless sex in OPLWH, no age-appropriate, evidence-based secondary prevention interventions exist for this group. Furthermore, many OPLWH face barriers to engaging in face-to-face secondary prevention services because of HIV- and age-related stigma, comorbid mental and physical health conditions that complicate travel, or geographic isolation. High rates of depression in OPLWH may further complicate engagement in interventions intended to reduce HIV transmissions. Telephone-administered motivational interviewing may be a feasible and efficacious intervention for this population. MethodsThis randomized controlled trial will test the efficacy of a 5-session telephone-administered motivational interviewing plus behavioral skills training (teleMI+BST) intervention versus a 5-session telephone-administered coping effectiveness training (teleCET) control intervention to reduce condomless sex in OPLWH. A diverse sample of 336 OPLWH will be recruited across the U.S. The primary analysis will test the efficacy of teleMI+BST to reduce occasions of non-condom protected anal and vaginal intercourse with HIV serodiscordant sex partners. Secondary analyses will examine the efficacy of teleMI+BST to reduce depressive symptoms in mildly depressed OPLWH. ConclusionThis is the first large-scale RCT intended to reduce HIV sexual transmission risk behavior in OPLWH and will add to the literature on secondary prevention telehealth interventions for people living with HIV.ClinicalTrials.gov Identifier: NCT03004170. This trial has been conducted by the approval of the Institutional Review Board. Participants provided verbal consent to participate in this trial.

Effects of incentives on viral suppression in people living with HIV who use cocaine or opiates

BackgroundAntiretroviral therapy (ART) adherence is essential to maintenance of undetectable viral loads among people living with HIV, which improves health and reduces HIV transmission. Despite these benefits, some people living with HIV do not maintain the level of adherence required to sustain an undetectable viral load. This problem is particularly common among people who use drugs. ObjectiveTo determine effects of incentivizing viral suppression in people living with HIV who used cocaine or opiates. MethodsIn this secondary analysis of data collected during a randomized controlled trial, participants (N=102) with detectable HIV viral loads (>200 copies/mL) were randomly assigned to a Usual Care or Incentive group. Usual Care participants did not earn incentives for viral suppression. Incentive participants earned incentives ($10/day maximum) for providing blood samples with reduced or undetectable (<200 copies/mL) viral loads. All participants completed assessments every three months. Results collected during the first year were compared based on group assignment and drug use. ResultsAmong participants who used cocaine or opiates, Incentive participants (n = 27) provided more (OR:4.0, CI:1.6−10.3, p = .004) blood samples with an undetectable viral load (69 %) than Usual Care participants (n = 25; 41 %). Among participants who did not use cocaine or opiates, Incentive participants (n = 25) provided more (OR:4.1, CI:1.5−10.7, p = .005) blood samples with an undetectable viral load (78 %) than Usual Care participants (n = 25; 36 %). Effects of incentives did not differ by drug use (OR:1.0, CI:0.3−4.0, p = .992). ConclusionsIncentivizing viral suppression can promote undetectable viral loads in people living with HIV who use cocaine or opiates.

Effects of a Decision-Making Intervention to Help Decide Whether to Disclose HIV-Positive Status to Family Members on Well-Being and Sexual Behavior.

An HIV diagnosis is often followed by uncertainty, questions over next steps, and concerns over how to share the diagnosis with others. The goal of the current study was to investigate the effects of an intervention designed to help people living with HIV decide whether or not they want to disclose their status to family members (i.e., decision-making process rather than actual disclosure) and the subsequent decision on their well-being and sexual behavior. Additionally, differences in outcomes among men who have sex with men (MSM), heterosexual men (HSM), and women were examined. A total of 346 women and men living in the Southeastern part of the United States. Participated in the study, which consisted of a baseline assessment, followed by randomization into either the disclosure intervention or attention control case management group. Both treatments consisted of seven sessions over a 12-month period. Results from repeated measures ANOVA indicated that although there was no significant intervention effect, participants in both groups reported some improvements in well-being and decreases in risky sexual behavior. However, no consistent differences in outcomes emerged among MSM, HSM, and women. Assisting with the disclosure decision-making process and reducing HIV transmission risk should continue to be an essential focus in future research endeavors and for frontline professionals dedicated to HIV-related care and prevention.

HIV testing and treatment coverage achieved after 4 years across 14 urban and peri-urban communities in Zambia and South Africa: An analysis of findings from the HPTN 071 (PopART) trial.

BackgroundIn 2014, the Joint United Nations Programme on HIV/AIDS (UNAIDS) set the 90-90-90 targets: that 90% of people living with HIV know their HIV status, that 90% of those who know their HIV-positive status are on antiretroviral therapy (ART), and that 90% of those on treatment are virally suppressed. The aim was to reach these targets by 2020. We assessed the feasibility of achieving the first two targets, and the corresponding 81% ART coverage target, as part of the HIV Prevention Trials Network (HPTN) 071 Population Effects of Antiretroviral Therapy to Reduce HIV Transmission (PopART) community-randomized trial.Methods and findingsThe study population was individuals aged ≥15 years living in 14 urban and peri-urban “PopART intervention” communities in Zambia and South Africa (SA), with a total population of approximately 600,000 and approximately 15% adult HIV prevalence. Community HIV care providers (CHiPs) delivered the PopART intervention during 2014–2017. This was a combination HIV prevention package including universal home-based HIV testing, referral of HIV-positive individuals to government HIV clinic services that offered universal ART (Arm A) or ART according to national guidelines (Arm B), and revisits to HIV-positive individuals to support linkage to HIV care and retention on ART. The intervention was delivered in 3 “rounds,” each about 15 months long, during which CHiPs visited all households and aimed to contact all individuals aged ≥15 years at least once.In Arm A in Round 3 (R3), 67% (41,332/61,402) of men and 86% (56,345/65,896) of women in Zambia and 56% (17,813/32,095) of men and 71% (24,461/34,514) of women in SA participated in the intervention, among 193,907 residents aged ≥15 years. Following participation, HIV status was known by 90% of men and women in Zambia and by 78% of men and 85% of women in SA. The median time from CHiP referral of HIV-positive individuals to ART initiation was approximately 3 months. By the end of R3, an estimated 95% of HIV-positive women and 85% of HIV-positive men knew their HIV status, and among these individuals, approximately 90% of women and approximately 85% of men were on ART. ART coverage among all HIV-positive individuals was approximately 85% in women and approximately 75% in men, up from about 45% at the start of the study. ART coverage was lowest among men aged 18 to 34 and women aged 15 to 24 years, and among mobile individuals/in-migrants. Findings from Arm B were similar. The main limitations to our study were that estimates of testing and treatment coverage among men relied on considerable extrapolation because, in each round, approximately one-third of men did not participate in the PopART intervention; that our findings are for a service delivery model that was relatively intensive; and that we did not have comparable data from the 7 “standard-of-care” (Arm C) communities.ConclusionsOur study showed that very high HIV testing and treatment coverage can be achieved through persistent delivery of universal testing, facilitated linkage to HIV care, and universal treatment services. The ART coverage target of 81% was achieved overall, after 4 years of delivery of the PopART intervention, though important gaps remained among men and young people. Our findings are consistent with previously reported findings from southern and east Africa, extending their generalisability to urban settings with high rates of in-migration and mobility and to Zambia and SA.Trial registrationClinicalTrials.gov NCT01900977.

Risk factors for HIV infection among married couples in Rakai, Uganda: a cross-sectional study

BackgroundAlthough married couples can be at an elevated risk of HIV infection, few studies have explored the risk factors for HIV infection at the couple-level. We explored the risk factors for HIV infection among married couples in settings with differing HIV prevalence levels in Rakai, Uganda.MethodsThis was a cross-sectional study conducted among 664 heterosexual couples living in three HIV prevalence strata (low: 9–11.2%; medium: 11.4–20% or high HIV prevalence: 21–43%) in Rakai District, south-western Uganda, between November 2013 and February 2014. Data were collected on socio-demographic and behavioural characteristics from all consenting adults and aggregated to allow for couple-level analyses. We conducted bivariate and multivariable Logistic regression to assess the factors that were independently associated with HIV infection among married couples. Data were analysed using STATA statistical software (version 14.1).ResultsOf the 664 couples, 6.4% (n = 42) were in HIV-discordant relationships; 5.8% (n = 39) were in concordant HIV-positive relationships while 87.8% (n = 583) were in concordant HIV-negative relationships. At the bivariate analysis, we found that residing in a high HIV prevalence stratum, reporting extra-marital relations, age difference between partners and number of previous marriages were significantly associated with being part of an HIV infected couple. After adjusting for potential cofounders, living in a high HIV prevalence stratum (Adjusted OR [AOR] =2.31, 95% CI: 1.52, 3.52), being in a third or higher order relationship (AOR = 3.80, 95% CI: 2.30, 6.28), and engagement in extra-marital relations (AOR = 1.75; 95% CI: 1.19, 2.59) were associated with couple HIV infection. Individuals that had stayed together for six or more years had 28% odds of being part of an HIV infected couple (AOR = 0.28; 95%CI: 0.18, 0.43).ConclusionLiving in a high HIV prevalence stratum, engagement in extra-marital relations and having a higher number of previous marriages were significant risk factors for HIV infection among married couples. Long marital duration was associated with reduced risk of HIV infection. Interventions that increase marital stability and those that promote pre-marital couples’ HIV testing before marital formation can reduce HIV transmission risk among married couples in this setting.

Louisiana’s Intentional Exposure to HIV Policy: The Social Construction of Target Populations

ABSTRACT In 1987, Louisiana became one of the first states to put laws in place to criminalize intentional HIV exposure. Unfortunately, the law does not correlate with science nor does it evidence any effectiveness in reductions in HIV transmissions. In spite of this, it took over 30 years before Louisiana’s HIV exposure criminalization law was amended to be more scientifically accurate. There remains little research to determine the impact this policy has on public health efforts to reduce transmissions of HIV. This article will apply the social construction of target populations theory to Louisiana’s HIV exposure criminalization law to explore the reasons for the action and inaction that led to the introduction and promotes the continued use of a law that does not demonstrate any effectiveness in actually reducing rates of HIV transmissions.

Microeconomic Intervention to Reduce HIV Transmission in Economically Disadvantaged Transgender Women

Microeconomic Intervention to Reduce HIV Transmission in Economically Disadvantaged Transgender Women

Diverging trends in incidence of HIV versus other sexually transmitted infections in HIV-negative MSM in Amsterdam.

We investigated changes in incidence rates of HIV and sexually transmitted infections (STIs) and trends in sexual behavior in MSM from 2009 to 2017. Open prospective cohort study. HIV-negative MSM enrolled in the Amsterdam Cohort Studies were included. Participants semiannually completed a questionnaire on sexual behavior and were tested for HIV-1, syphilis, and urethral, anal and pharyngeal chlamydia and gonorrhea. Time trends in incidence rates were analyzed using exponential survival models. During follow-up, 42 of 905 MSM acquired HIV. The HIV incidence rate was 1.9/100 person-years [95% confidence interval (CI) 1.0-3.7] in 2009 and decreased to 0.5/100 person-years (95% CI 0.2-1.4) in 2017 (P = 0.03). The largest decrease was observed in participants aged at least 35 years (P = 0.005), while the trend remained stable in 18-34 year olds (P = 0.4). The incidence rate for any bacterial STI was 16.8/100 person-years (95% CI 13.4-21.0) in 2010, and increased to 33.1/100 person-years (95% CI 29.0-37.9) in 2017 (P < 0.001). Between 2009 and 2017, the percentage reporting condomless anal sex with casual partners increased from 26.9 to 39.4% (P < 0.001), and the mean number of casual partners from eight (95% CI 8-8) to 11 (95% CI 10-11) (P = 0.05). Condomless anal sex with steady partner(s) remained stable over time (P = 0.5). Among MSM in Amsterdam, incidence rates of HIV versus other STI show diverging trends. The increase in STI incidence coincides with a decrease in condom use with casual partners. The decrease in HIV incidence, despite increased sexual risk behavior, suggests that other HIV prevention methods have been successful in reducing HIV transmission among MSM.

Facing increased sexually transmitted infection incidence in HIV preexposure prophylaxis cohorts: what are the underlying determinants and what can be done?

The combined incidence of chlamydia, gonorrhoea and syphilis in MSM PrEP (preexposure prophylaxis) cohorts now frequently exceeds 100 per 100 person years. The efficacy of antiretroviral PrEP in reducing HIV transmission has led to efforts to find similar biomedical ways reduce sexually transmitted infection (STI) incidence. We review the recent evidence for these and other strategies. Doxycycline PrEP/postexposure prophylaxis has been shown to reduce the incidence of syphilis and chlamydia but not gonorrhoea. A meningococcal vaccine has been found to result in a lower incidence of gonorrhoea. Novel insights into the role of the pharynx in the transmission of gonorrhoea have led to clinical trials of oral antiseptics to reduce the spread of gonorrhoea. Intensified STI screening has been introduced in a number of clinics. Serious concerns have however been raised about the emergence of resistance to each of these strategies. This is particularly true for doxycycline PrEP which is not advocated by any guidelines we reviewed. Randomized controlled trials are urgently required to ascertain the benefits and risks of interventions to reduce STIs in MSM PrEP cohorts.

Prevalence and attitudes to HIV testing among adults visiting public outpatient clinics in Rome: results of the MeDi (Measuring health Disparities in HIV prevention) survey. Part 1.

It is estimated that, in Italy, 12 000-18 000 (11-13% of 130 000) HIV-infected subjects are not aware of their serostatus. People in this condition may visit the healthcare system multiple times without being diagnosed. If tested on one of these occasions, they could modify their high-risk behaviours and benefit from treatment, factors that reduce HIV transmission. In Italy, no data on HIV testing in the general population are available so far and little is known on the relationship between socioeconomic determinants (at individual and neighbourhood levels) and testing uptake. A large anonymous survey was performed in 2012-2014 on more than 10 000 individuals 18-59 years old who underwent 21 public ambulatories in Rome to determine the proportion of subjects tested for HIV and factors related to testing uptake. Subjects' socio-demographic characteristics, sexual orientation, number of sexual partners, HIV risk behaviour, HIV testing uptake were collected by a self-administered questionnaire. Level of area deprivation was measured at the postal code level by the index of social disadvantage (ISD). Multilevel Poisson regressions were carried out to take heterogeneity between clusters (post code and clinics) into account. Among people participating in the study, 58.1% of subjects self-reported to have been tested at least once for HIV. Those who had one high risk behaviour for HIV-infection were 11% more likely to test than those not reporting any, and subjects who had had a STI (sexually-transmitted-infection) in the past were 12% more likely to test than those who had not had a STI. However only 44% (54% among subjects aged 18-35 years) of those with self-reported risks of contracting HIV had been tested at least once in life. This percentage increases, as expected, with the level of education, but, even so, about 40% of university educated subjects self-reporting risks of contracting HIV had never undergone an HIV test. This study highlights that, while the percentage of subjects tested is even higher than observed in other western nations, only 44% of subjects, self-reporting risks of contracting HIV, had tested at least once in life and about 40% of university educated subjects self reporting risks of contracting HIV had never tested.

Relationship Education and HIV Prevention for Young Male Couples Administered Online via Videoconference: Protocol for a National Randomized Controlled Trial of 2GETHER.

BackgroundYoung men who have sex with men have a high HIV incidence, and a substantial proportion of incident infections occur in the context of main partnerships. However, romantic relationships also provide numerous benefits to individual health and wellbeing. 2GETHER is a relationship education and HIV prevention program for young male couples, and the 2GETHER USA randomized controlled trial (RCT) was launched to establish the efficacy of an online version of 2GETHER.ObjectiveThe objective of 2GETHER is to optimize relationship functioning in young male couples as a method to improve communication about sexual risk behaviors and reduce HIV transmission. In the 2GETHER USA study, 2GETHER was adapted for online administration to couples across the United States via videoconferencing. The intervention in question aims to address the unique needs of couples from varied racial/ethnic backgrounds and geographic regions.MethodsThis is a comparative effectiveness RCT of 2GETHER USA relative to existing public health practice (control). 2GETHER USA is a hybrid group- and individual-level intervention that delivers three weekly online group discussion sessions for skills delivery, followed by two individualized couple sessions that focus on skills implementation in each couple. The control condition differs by participant HIV status: (1) the Testing Together protocol for concordant HIV-negative couples; (2) medication adherence and risk reduction counseling for concordant HIV-positive couples; or (3) both protocols for serodiscordant couples. Follow-up assessments are delivered at 3-, 6-, 9-, and 12-months post-intervention in both conditions. Testing for rectal and urethral Chlamydia and Gonorrhea occurs at baseline and 12-month follow-up. The primary behavioral outcome is condomless anal sex with serodiscordant serious partners or any casual partners. The primary biomedical outcome is sexually transmitted infection incidence at a 12-month follow-up.ResultsAs of October 11, 2019, the trial has enrolled and randomized 140 dyads (Individual N=280). Enrollment will continue until we randomize 200 dyads (N=400). Assessment of intervention outcomes at 3-, 6-, 9-, and 12-months is ongoing.Conclusions2GETHER is innovative in that it integrates relationship education and HIV prevention for optimizing the health and wellbeing of young male couples. The 2GETHER USA online adaptation has the potential to reach couples across the United States and reduce barriers to accessing health care services that are affirming of sexual minority identities for those who live in rural or under-resourced areas.Trial RegistrationClinicalTrials.gov NCT03284541; https://clinicaltrials.gov/ct2/show/NCT03284541International Registered Report Identifier (IRRID)DERR1-10.2196/15883

The impact of a syndemic theory-based intervention on HIV transmission risk behaviour among men who have sex with men in India: Pretest-posttest non-equivalent comparison group trial

This study aimed to examine the effect of a syndemic theory-based intervention to reduce condomless anal intercourse among men who have sex with men (MSM) in India. In 2016/17, a pre- and post-test comparison group design was used to implement a syndemic theory-based intervention among 459 MSM (229, intervention; 230, standard-of-care comparison) recruited through non-governmental organizations in Chandigarh, India. The intervention group received two-session peer-delivered motivational interviewing-based HIV risk reduction counselling and skills training to improve sexual communication/negotiation and condom use self-efficacy, and screening/management of psychosocial health problems. The intervention's effect on consistent condom use was estimated using difference-in-differences (DiD) approach. Mediation analysis assessed the extent to which intervention effects on the outcome were mediated by changes in psychosocial health problems and condom use self-efficacy. A process evaluation assessed implementation fidelity and intervention acceptability. Baseline consistent condom use was 43% in the intervention group and 46% in the standard-of-care group. Baseline survey findings demonstrated that a psychosocial syndemic of problematic alcohol use, internalised homonegativity and violence victimisation synergistically increased condomless anal intercourse. Using DiD, we estimated that the intervention increased consistent condom use with male partners by 16.4% (95% CI: 7.1, 25.7) and with female partners by 28.2% (95% CI: 11.9, 44.4), and decreased problematic alcohol use by 24.3% (95%CI: −33.4, −15.3), depression by 20.0% (95% CI: −27.6, −12.3) and internalised homonegativity by 34.7% (95% CI: −43.6%, −25.8%). The mediation analysis findings suggested that the intervention might have improved consistent condom use by decreasing internalised homonegativity and by increasing condom use self-efficacy. The process evaluation showed high levels of acceptability/satisfaction among participants and high levels of implementation fidelity. A syndemic theory-based intervention tailored for MSM in India is feasible, acceptable, and can reduce HIV transmission risk behaviour as well as problematic alcohol use, depression and internalised homonegativity.