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Elevated HIV Prevalence and Correlates of PrEP Use Among a Community Sample of Black Men who Have Sex with Men...more STIs, more drug use, more sex partners, less likely to use condoms......
 
 
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JAIDS July 25 2018 - Eaton, Lisa A., PhD1; Matthews, Derrick D., PhD, MPH2; Bukowski, Leigh A., MPH3; Friedman, M. Reuel, PhD, MPH2; Chandler, Cristian J., PhD, MPH3; Whitfield, Darren L., PhD, MSW4; Sang, Jordan M., MPH3; Stall, Ron D., PhD3 The POWER Study Team
 
"Rates of STI were higher among participants taking PrEP as compared to participants not taking PrEP. Gonorrhea was most frequently reported (36% vs. 9%), followed by chlamydia (32% vs. 7%), syphilis (26% vs. 5%) and other STI (23% vs. 4%)......Individuals reporting current PrEP use were more likely to test HIV positive than individuals not reporting current PrEP use (32.3%, N=103/319 vs. 20.0%, N=639/3,193, aOR=1.68, 95%CI=1.31-2.15, p<.001, Table 1).......Participants currently using PrEP reported a greater number of male sex partners (M[mean]=6.48, SD[standard deviation]=11.03, M=3.77, SD=6.52), a greater number of receptive anal sex partners (M=2.81, SD =5.39, M=1.78, SD =3.56), and a greater number insertive anal sex partners (M=4.04, SD =6.78, M=2.50, SD =4.74) than participants not using PrEP (Table 3). Further, participants taking PrEP were less likely to report condom use during anal sex, both receptive (N=240, 63.2% vs. N=2856, 75.1%) and insertive"
 
"Of strong concern is the rate of HIV prevalence among individuals reporting PrEP use. Thirty-two percent of participants self-reporting current PrEP use tested HIV positive during study procedures. It is imperative to recognize that our findings reflect challenges to maintaining proper usage of PrEP rather than biological failure of PrEP to protect against HIV19,20. A preponderance of evidence, including multiple randomized controlled trials21 with MSM and evaluations of PrEP in clinical practice settings22 indicates that PrEP is highly effective in reducing likelihood of HIV infection when drug concentration levels consistent with high levels of adherence are maintained. Furthermore, extremely few breakthrough infections have been documented among adherent PrEP users23. Thus, HIV infections that have occurred among PrEP users are the result of suboptimal levels of drug concentrations due to challenges in adhering to PrEP medical regimens."
 
Overall, the findings demonstrate that strong attention needs to be given to how PrEP is being taken-up by individuals at-risk for HIV. Moreover, among individuals testing HIV positive, concerns about drug resistance, viral mutation, and delayed seroconversion when continuing PrEP use during acute HIV infection exist50. Based on our data, it is evident that in order to optimize PrEP, comprehensive strategies to following patients prescribed PrEP are needed. Trials of PrEP efficacy and delivery typically include well-resourced approaches to patient engagement including high levels of patient monitoring. In practice, as opposed to research, implementing a comprehensive plan for providing PrEP (e.g., quarterly check-ins, adherence support, sexual risk reduction counseling) poses greater challenges;48 the barriers to implementing CDC guidelines for PrEP administration must be addressed. PrEP has tremendous potential to slow the HIV epidemic, but the monitoring of PrEP delivery and uptake must be prioritized in order to maximize its impact."
 
ABSTRACT
 
Background: The HIV epidemic among Black men who have sex with men (BMSM) demands urgent public health attention. Pre-Exposure Prophylaxis (PrEP) is a highly efficacious option for preventing HIV, but characteristics of PrEP use among community samples of BMSM are not well-understood.
 
Methods: A serial cross-sectional survey assessment (N=4,184 BMSM reporting HIV negative/unsure status) and HIV testing were conducted at Black Gay Pride events in six US cities in 2014, 2015, 2016, and 2017.
 
Results: HIV prevalence was higher among BMSM self-reporting current PrEP use (1 out of 3 participants) than BMSM not self-reporting current PrEP use (1 out of 5 participants) (32.3%, N=103/319 vs. 20.0%, N=639/3,193, aOR=1.68, 95%CI=1.31-2.15). BMSM reporting current PrEP use (N=380) were more likely to report having a greater number of male sex partners (aOR=1.02, 95%CI=1.01-1.03), a STI diagnosis (aOR=2.44, 95%CI=1.88-3.16), and stimulant drug use (aOR=2.05, 95%CI=1.21-3.47) when compared to BMSM not reporting current PrEP use (N=3,804). PrEP use increased from 4.7% (2014) to 15.5% (2017) (aOR=1.19, 95%CI=1.13-1.25). Among PrEP users, inability to afford health care coverage was associated with testing HIV positive (aOR=2.10, 95%CI=1.24-3.56).
 
Conclusion: The high prevalence of HIV infection among BMSM reporting PrEP use is concerning. It does not, however, challenge the efficacy of PrEP itself but rather the uptake of the surrounding preventative package including behavioral risk reduction support, STI treatment, and medication adherence counseling. Further research to understand barriers to fully effective PrEP are needed in order to guide operational and behavioral interventions that close the gap on incident infection.
 
PrEP Awareness and Use. Across all cities and years, PrEP awareness and PrEP use were reported among 52.4% (N=2,194) and 9.1% (N=380) of participants, respectively. Date of assessment was significantly, positively associated with PrEP awareness (aOR=1.22, 95%CI=1.19-1.26) and PrEP use (aOR=1.19, 95%CI=1.13-1.25); PrEP awareness increased from 37.2% (2014) to 66.7% (2017), and current PrEP use increased from 4.7% (2014) to 15.5% (2017).
 
Sociodemographics. Across all participants, the average age was 30.47 (SD=9.69) and a majority of the sample identified as gay/same gender loving (N=3,253/77.7%). Most participants reported current employment (N=3,271/78.2%). A minority of participants reported residential instability (N=477/11.5%) and incomes <$30,000 (N=1,892/45.2%). Health care coverage (N=3,494/83.5%) and having a place to go to receive health care (N=3,292/78.7%) were frequently reported. Around three-fourths of participants reported their relationship status as single (N=3,135/75.7%). Participants reporting current PrEP use were more likely to report residential instability, being in a relationship (as opposed to being single), health care coverage, a place to go for health care, having tested for HIV in the past 6 months, and higher depression scores than individuals not currently on PrEP (Table 1).
 
In-field HIV testing results. A subsample of participants (N=3,512, 84% of both PrEP users and PrEP non-users) elected to engage in HIV testing during study activities. Individuals reporting current PrEP use were more likely to test HIV positive than individuals not reporting current PrEP use (32.3%, N=103/319 vs. 20.0%, N=639/3,193, aOR=1.68, 95%CI=1.31-2.15, p<.001, Table 1). Forty-four percent (N=1,579/3,512) of the sample elected to test with a local, community-based partner organization, and therefore, receive their results. The remaining sample (N=1,933/3,512) provided POWER Team with an oral mucosal swab for HIV testing for surveillance purposes, and therefore, did not receive results. PrEP users were more likely than non-PrEP users to provide POWER Team with an oral swab for HIV testing (66.3%, N=216/319, 55.1%, N=1,802/3,804, aOR=1.69, 95%CI=1.32-2.16, p<.001) than to test with a local partner.
 
Variables associated with testing HIV positive among PrEP users. PrEP users who tested HIV positive were more likely to report not being able to afford health care (OR=2.10, 95%CI=1.24-3.56, p<.05), not recently testing for HIV (OR=.48, 95%CI=.25-.92, p<.05), and having tested for HIV fewer times in the past two years (OR=.70, 95%CI=.55-.88, p<.05) than PrEP users who tested HIV negative. There were no differences between groups (HIV positive vs. HIV negative PrEP users) on demographics, drug use, alcohol use, sex behavior, depression, or STI diagnosis (Table 2).
 
Sex behaviors. Participants currently using PrEP reported a greater number of male sex partners (M[mean]=6.48, SD[standard deviation]=11.03, M=3.77, SD=6.52), a greater number of receptive anal sex partners (M=2.81, SD =5.39, M=1.78, SD =3.56), and a greater number insertive anal sex partners (M=4.04, SD =6.78, M=2.50, SD =4.74) than participants not using PrEP (Table 3). Further, participants taking PrEP were less likely to report condom use during anal sex, both receptive (N=240, 63.2% vs. N=2856, 75.1%) and insertive (N=250, 65.8% vs. N=2,823, 74.2%), than participants not on PrEP. There were no differences in transactional sex across PrEP use groups.
 
Substance use and sexually transmitted infections. Participants currently taking PrEP were more likely to report marijuana (30% vs. 22%), amyl nitrates (13% vs. 4%), stimulants (16% vs. 6%), erectile dysfunction medications (8% vs. 2%), heroin (6% vs. 3%), and opiate (7% vs. 2%) use in the past three months than non-PrEP users (Table 3). Moreover, participants currently taking PrEP were more likely to report problematic alcohol use (32% vs. 18%, as assessed by CAGE), yet equally likely to report instances of heavy episodic drinking (51% vs. 54%). Rates of STI were higher among participants taking PrEP as compared to participants not taking PrEP. Gonorrhea was most frequently reported (36% vs. 9%), followed by chlamydia (32% vs. 7%), syphilis (26% vs. 5%) and other STI (23% vs. 4%).
 
PrEP use. The multivariable model with PrEP use as the outcome demonstrated multiple significantly associated variables (Table 4). Residential instability (aOR=3.28, 95%CI=2.42-4.45), currently having health care coverage (aOR=2.41, 95%CI=1.64- 3.56), having tested for HIV in the prior 6 months (aOR=3.83, 95%CI=2.79-5.21), greater number of male sex partners (aOR=1.02, 95%CI=1.01-1.04), any past year STI diagnosis (aOR=2.43, 95%CI=1.88-3.15), and recent stimulant use (aOR=2.01, 95%CI=1.18-3.15) were all positively associated with a greater likelihood of reporting PrEP use. All other associations were non-significant.
 
PrEP access. Among a subsample of participants reporting PrEP use (N=201/380); items added in latter two years of data collection), PrEP access variables were assessed. Participants using PrEP were most likely to report receipt of PrEP through a prescription from a health care provider (N=153, 76.1%). Access was also reported via receipt from someone other than health care provider, including friend or sex partner (N=13, 6.5%), receipt from purchasing online (N=12, 6.0%), and receipt from an other, unspecified source (N=21, 5.5%) (note: participants could choose more than one option to denote how they received PrEP).
 
Conclusions
 
Overall, the findings demonstrate that strong attention needs to be given to how PrEP is being taken-up by individuals at-risk for HIV. Moreover, among individuals testing HIV positive, concerns about drug resistance, viral mutation, and delayed seroconversion when continuing PrEP use during acute HIV infection exist50. Based on our data, it is evident that in order to optimize PrEP, comprehensive strategies to following patients prescribed PrEP are needed. Trials of PrEP efficacy and delivery typically include well-resourced approaches to patient engagement including high levels of patient monitoring. In practice, as opposed to research, implementing a comprehensive plan for providing PrEP (e.g., quarterly check-ins, adherence support, sexual risk reduction counseling) poses greater challenges;48 the barriers to implementing CDC guidelines for PrEP administration must be addressed. PrEP has tremendous potential to slow the HIV epidemic, but the monitoring of PrEP delivery and uptake must be prioritized in order to maximize its impact.

 
 
 
 
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