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"RAPID REDUCTION IN HIV DIAGNOSES AFTER TARGETED PrEP
IMPLEMENTATION IN NSW, AUSTRALIA" - PrEP NATAP Report 3
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"What Is The Impact of PrEP at the Population Level?" Grulich study addresses
from Jules: PrEP received quite a lot of attention at this CROI. Several successful projects were described as well as disparities and very limited PrEP access in the USA. As well, reported under separate cover by NATAP are studies presented at CROI reporting discontinuations and lost to flow up rates some of which were high. Bear in mind its Australia where one of the few HCV elimination projects is being attempted so as Grulich mentions the government has to make a commitment in order to undertake thee kinds of projects. Certainly in the USA HCV elimination has no commitment from the government. The CDC issued this announcement on March 6 2018: https://www.cdc.gov/nchhstp/newsroom/2018/croi-2018-PrEP-press-release.html describing the CDC commitment to PrEP and the ethnic disparities in access. Results indicate that, in 2015, approximately 500,000 African-Americans and nearly 300,000 Latinos across the nation could have potentially benefited from PrEP based on CDC clinical guidelines. However, only 7,000 prescriptions were filled at retail pharmacies or mail order services for African-Americans and only 7,600 for Latinos during a similar time period (September 2015 - August 2016). While racial and ethnic data were not available for one-third of the prescription data, the analysis found a substantial unmet prevention need.
"The high-level, targeted and rapid roll-out of PrEP in NSW led to a 35% decline in state-wide HIV diagnoses in MSM, and a 44% decline in early HIV infections in MSM, to levels unprecedented since the beginning of the HIV epidemic. This was achieved less than one year after the target recruitment was reached. In a concentrated epidemic with high testing and treatment coverage, PrEP scale up led to a rapid decline in HIV transmission at the population level.....PrEP use was about 3% of gay men in Sydney prior to study and rose to 17% one year later, they estimate this has risen to 25% but new daw will be available in one month, all this on a high level of treatment as prevention although prior to this study treatment as prevention did nit seem to have a great affect in reducing HIV incidence, its PrEP they say has. They have a state strategy committed to ending HIV, they told the state in the absence of PrEP that's not going to happen, if you have a govt committed to ending HIV it cannot happen without PrEP"
Below this following paragraph describing several successful USA PrEP projects and disparities is the presentation by Grulich on a successful PrEP implementation project in NSW, Australia.
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PrEP Use Increased & HIV New Cases Decreased in SF, Montreal, and Boston.
Disparities in Access Reported by gender, ethnicity, and geography & for IDUs.
One study reports 61,000 active PrEP prescriptions and 5% of the 1.2 million indicated for PrEP are potentially receiving it.
Another study reports the impact of low access for MSM African-Americans to PrEP on HIV incidence, new infections, which one could extrapolate to women of color.
1. In this CROI presentation by Buchbinder et al from SF PrEP use increasing over time: 37-45% of HIV negative MSM on PrEP in last year, based on 2 surveys, lower PrEP use in African-Americans. HIV diagnosis decreased 51% from 2012-2016,
CROI: Getting to Zero New Diagnoses in San Francisco: The Potential Role of PrEP (03/28/18)
CROI: Disparities in PrEP Uptake Among Primary Care Patients (03/28/18)
2. In the oral presentation on PrEP rollout in Kenya - "TAKING THE LEAP IN PrEP SCALE-UP: A GOOD TYPE OF CHALLENGE", Nelly Mugo the speaker says 22,000+ have initiated PrEP since last year: WEBCAST: http://www.croiwebcasts.org/console/player/37265?mediaType=audio&&crd_fl=0&ssmsrq=1520620818192&ctms=5000&csmsrq=5001
3. At a Montreal clinic from 2011 to 2016 HIV incidence dropped by 56%. PrEP consultations increased rapidly, from none to more than 8000 persons over that time.
CROI: DECREASES IN HIV INCIDENCE IN A MONTREAL CLINIC COINCIDE WITH EXPANDING PREP USE - (04/5/18)
4. In Boston st Fenway Clinic Ken Mayer reports in 2012 2.3% of 681 screened for rectal STI were prescribed PrEP, but in 2016 49% of 3,333 screened for rectal STI were prescribed PrEP, also reflecting that 50% were NOT prescribed PrEP. White and hispanic rectal STI patients were more likely to be prescribed PrEP than Black or API patients in 2014-2016. Younger patients were less likely to be described PrEP than older patients in 2014-2016. Cisgender women were least likely to be prescribed PrEP among patients screened for rectal STIs. In 2016, 55% of patients screened for rectal STIwith private insurance were prescribed PrEP, compared to 40% of those with Medicaid or other public health insurance (p<0.001) - reflecting disparities, which we have seen in many studies reported at this conference.
CROI: INCREASING PREP UPTAKE, PERSISTENT DISPARITIES, IN AT-RISK PATIENTS IN A BOSTON COMMUNITY HEALTH CENTER - (04/5/18)
5. Dawn Smith reported updated estimates of the number of persons needing PrEP in the USA by race/ethnicity and transmission risk group: 1,144,550 is the number of estimated number of adults with PrEP indications in 2015. She estimated that 1,145,000 persons in the United States have an indication for taking PrEP, including 814,000 MSM (71%) , 258,000 heterosexuals (22.5%) , and 73,000 (6.3%) people who inject drugs. Compared with previous estimates, this new method of calculation increases the number of MSM who have a PrEP indication, and decreases the number of heterosexual and PWID who have a PrEP indication. While overall, 43.7% of persons with a PrEP indication are African American, 24.7% Latino, and 26.5% white, 38% of the estimated 814,000 MSM with PrEP indication were Black-African American compared to 27% Hispanic/Latino and 29% White, and of the estimated 258,000 heterosexuals with PrEP indications 63% were African Americans/Blacks. Of the 72,000 estimated PWID for PrEP indications 36.5% were Black/African-American, 20.6% Hispanic/Latino and 38.6% White. Smith said: "Nationwide, 14% of White, 1% of Black, 3 % of Hispanic, and 8% of all persons estimated to have indications for PrEP use in 2015 were prescribed PrEP during the 12 months Sept 2015 -Aug 2016". Yet, preliminary estimates of PrEP coverage, number of persons prescribed Truvada in USA was much higher in the Northeast with 15% estimated and lowest in the South with 4% estimated coverage, and about 7% to 8% in the West and Midwest.
CROI: By Race/ethnicity, Blacks Have Highest Number Needing PrEP in the United States, 2015 (03/28/18)
6. But disparities in PrEP use by women & Blacks are persistently reported. Jeness reported in a modeling study - If BMSM [black MSM] continuum parameters were equal to WMSM values, 17.7% of BMSM would be on PrEP, yielding a 47% decline in incidence. Reported by Dan Smith from CDC
- CROI: By Race/ethnicity, Blacks Have Highest Number Needing PrEP in the United States, 2015 (03/28/18)
7. This study is the first to describe the magnitude and distribution of active PrEP prescriptions - Distribution of Active PrEP Prescriptions and the PrEP-to-Need Ratio, US Q2 2017 - active PrEP prescriptions was 61,000 in the second quarter of 2017; 5% of the 1.2 million persons indicated for PrEP are potentially receiving PrEP protection. Previous estimate of cumulative PrEP starts were120,000 & the difference being "as individuals discontinue PrEP care". The prevalence of PrEP precriptind was nearly an order of magnitude lower for women than for men. Males had over ten times higher prevalence than females. Active prescription prevalence and PrEP-to-need ratios were lower among persons aged ≤24 and ≥ 55. The lowest levels of active prescription prevalence were in the center of the country. Lowest levels of PrEP-to-need ratio were in Southern states.The Northeast region had the highest prevalence and the Midwest the lowest. States in highest quartile of the percent of the population living in poverty, percent uninsured, and percent of residents being African American had lower PrEP-to-need ratios. Females, persons ≤24, residents of the South, and residents of non-Medicaid expansion states received lower levels of prescription in comparison to epidemic need
CROI: Distribution of Active PrEP Prescriptions and the PrEP-to-Need Ratio, US Q2 2017 - (03/07/18)
8. Injection Drug Users - Kuo and colleagues confirmed the substantial under-utilization of PrEP among injection drug users and heterosexuals at high risk, using data from the National Behavioral Surveillance System (Abstract 1030). Of people who inject drugs with a PrEP indication surveyed in 2015, only 9% had ever heard of PrEP, 1% had ever discussed PrEP with a health care practitioner, and fewer than 1% had ever received a PrEP prescription. None had ever taken PrEP. Of heterosexuals with indications for PrEP surveyed in 2016, only 13% had heard of PrEP, 3% had ever discussed PrEP with a health care practitioner, and fewer than 1% had ever received a PrEP prescription.
CROI: Assessing PrEP Needs Among Heterosexuals and People Who Inject Drugs, Washington, DC - (04/5/18)
9. "PrEP Deserts" Study by Weiss found geographic "deserts". 1 in 8 PrEP eligible MSM may have to drive 30 minutes or greater for PrEP. MSM in all geographic regions in the US have limited PrEP provider access. Large numbers of MSM live in "deserts" requiring long driving time to care. PrEP availability is greatest in the Northeast and urban areas, least in less urban areas and the South. Most MSM in "deserts" live in the South (53% - 60 minutes). Most deserts (>70% - 30 minutes, 95% - 60 minutes are in less urban areas. Desert for clinics offering services to uninsured are larger. PrEP deserts are less educated, have greater poverty, have lower MHI, and lesser proportions of African-Americans and Hispanic individuals. In the "South Atlantic" region had high MSM estimated population & PrEP eligible population, but by far the highest percent of individuals requiring 30 & 60 minute driving times. Using a national database of publicly-listed clinics that prescribe PrEP in the contiguous United States, we explored 'deserts' with low access to PrEP as defined by driving time to the closest clinic. MSM population estimates, county urbanicity, and PrEP provider data were sourced from public data and a national database of publicly listed PrEP providers. Using geographic information systems (GIS), we proportionally allocated county-level MSM estimates and a national PrEP-eligibility estimate to census tracts, areas with a median of 4000 persons. We mapped PrEP providers and calculated travel time, based on ideal traffic conditions, from census tract centroids to the nearest PrEP providers. We classified tracts as being part of a 'PrEP desert' based on 30-minute and 60-minute drive travel times to the nearest PrEP-providing clinic. CROI: Geographic Access to PrEP Clinics among US MSM: Documenting PrEP Deserts - (04/4/18)
10. Of note Linda Beer from the CDC reported "among HIV negative partner of MSM HIV patients in care 6% were taking PrEP and 27% were not taking PrEP and were the partner of a patient who was to viray suppressed", and taking PrEP was less common among Black/African Americans compared to Whites. -
CROI: Reported PrEP use among HIV-negative partners of US MSM receiving HIV medical care - (04/5/18)
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Reported by Jules Levin
CROI 2018 March 4-7 Boston MA
Andrew Grulich1, Rebecca J. Guy1, Janaki Amin2, Heather-Marie Schmidt3, Christine Selvey3, Jo Holden3, Karen Price4, Robert Finlayson5, Mark Bloch6, Iryna Zablotska1, Fengyi Jin1, David Smith7, Anna McNulty8, David A. Cooper1
1University of New South Wales, Sydney, NSW, Australia,2Macquarie University, North Ryde, NSW, Australia,3New South Wales Ministry of Health, Sydney, NSW, Australia,4ACON, Sydney, NSW, Australia,5Taylor Square Private Clinic, Sydney, NSW, Australia,6Holdsworth House Medical Practice, Sydney, NSW, Australia,7North Coast HIV Sexual Health Services, Lismore, NSW, Australia,8Sydney Sexual Health Centre, Sydney, NSW, Australia
WEBCAST: http://www.croiwebcasts.org/console/player/37190?mediaType=slideVideo&&crd_fl=1&ssmsrq=1523361154938&ctms=5000&csmsrq=775
Program Abstract:
Randomized trials of pre-exposure prophylaxis (PrEP) in men who have sex with men (MSM) have reported efficacy of more than 85%. Modelling predicts PrEP will have greatest population-level efficacy if rapidly targeted, with high coverage, to those at high risk. In New South Wales (NSW), more than 80% of HIV diagnoses occur in MSM. Despite substantial increases in testing and treatment since 2012, and the state approaching the UNAIDS 90/90/90 targets, annual HIV diagnoses varied little over the decade to 2016.
The expanded PrEP Implementation in Communities in NSW study (EPIC-NSW) is an open-label implementation study of the use of co-formulated TDF/FTC to prevent HIV.
Commencing March 1 2016, we aimed to recruit all estimated 3700 MSM at high-risk of HIV in NSW by end 2016, in over 20 clinics across the state. High-risk eligibility criteria were based on local epidemiologic data. Co-primary outcomes of the study are (a) HIV incidence among study participants, collected by electronic data capture from clinic data management systems and (b) state-wide HIV diagnoses in MSM, utilizing NSW Ministry of Health HIV surveillance data. HIV surveillance data were reported as (a) all diagnoses and (b) early infection, defined as likely HIV infection in the last 12 months, based on HIV testing history and/or clinical and/or laboratory diagnosis of recent infection.
The initial target of 3700 high-risk MSM was reached in October 2016, with an average monthly recruitment of 499 (range: 442-555). Recruitment is continuing (currently 7293). By September 2017 only one HIV seroconversion in a study participant was documented. In the first half-year of 2017 there were 101 HIV diagnoses in MSM in NSW, 35% lower than the 156 diagnoses in the half-year immediately prior to commencement of recruitment (June-Dec 2015). This was the lowest half-yearly number of HIV diagnoses in MSM since HIV surveillance commenced in NSW in 1985. Early HIV infections in MSM declined from 82 to 46, a 44% decrease.
The high-level, targeted and rapid roll-out of PrEP in NSW led to a 35% decline in state-wide HIV diagnoses in MSM, and a 44% decline in early HIV infections in MSM, to levels unprecedented since the beginning of the HIV epidemic. This was achieved less than one year after the target recruitment was reached. In a concentrated epidemic with high testing and treatment coverage, PrEP scale up led to a rapid decline in HIV transmission at the population level.
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