The objective of this study is to identify individual-level factors and health venue utilization patterns associated with uptake of pre-exposure prophylaxis (PrEP) and to evaluate whether PrEP uptake behavior is further diffused among young men who have sex with men (YMSM) through health venue referral networks. A sample of 543 HIV-seronegative YMSM aged 16–29 were recruited in 2014–2016 in Chicago, IL, and Houston, TX. Stochastic social network models were estimated to model PrEP uptake. PrEP uptake was associated with more utilization of health venues in Houston and higher levels of sexual risk behavior in Chicago. In Houston, both Hispanic and Black YMSM compared to White YMSM were less likely to take PrEP. No evidence was found to support the spread of PrEP uptake via referral networks, which highlights the need for more effective PrEP referral network systems to scale up PrEP implementation among at-risk YMSM.

Youth experiencing homelessness (YEH) have a high risk of contracting HIV; however, they remain relatively unreached by pre-exposure prophylaxis (PrEP)-based HIV prevention initiatives. We used a cross-sectional mixed-methods study to explore PrEP knowledge, interest, facilitators, and barriers among YEH. Young adults were recruited from agencies serving YEH in Houston, TX (n = 30) and Los Angeles, CA (n = 15) to participate in an electronic self-report survey and a semistructured interview. Survey results indicate that 68.2% of YEH had low or no prior knowledge of PrEP, though 63.7% reported interest in taking PrEP. Qualitative results revealed facilitators of PrEP use, including high PrEP acceptability and awareness, and supportive social networks. Several barriers emerged, including medication-related barriers, adherence, cost, access barriers, low perceived HIV risk, perceived stigma of PrEP use, and low PrEP awareness. Despite high PrEP acceptability, PrEP use among YEH remains low partly due to low PrEP awareness, low perceived HIV risk, and medical mistrust.

Newer HIV regimens are typically taken once daily but vary in the number of pills required. Whether the number of pills in a once-daily HIV regimen affects clinical outcomes is unknown. We retrospectively compared adherence, retention in care, and virologic outcomes between patients starting a once daily single-tablet regimen (STR) to patients starting a once-daily multi-tablet regimen (MTR) in a publicly funded clinic in the United States. Outcomes were measured in the year after starting ART and included retention in care, virologic suppression, and medication possession ratio of at least 80%. Data from patients initiating therapy from 1 January 2008 to 31 December 2011 were analyzed with both unadjusted and propensity-score adjusted regression. Overall, 622 patients started with an STR (100% efavirenz-based) and 406 with an MTR (65% atazanavir-based and 35% darunavir-based) regimen. Retention in care was achieved in 80.7% of STR patients vs. 72.7% of MTR patients (unadjusted OR 1.57, 95% CI 1.17–2.11; adjusted OR 1.49, 95% CI 1.10–2.02). Virologic suppression occurred among 84.4% of STR patients vs. 77.6% of MTR patients (unadjusted OR 1.56; 95% CI 1.14–2.15; adjusted OR 1.41; 95% CI 1.02–1.96). There was no difference in the proportion of patients achieving at least 80% adherence, as measured by medication possession ratio (33.0% of STR patients and 30.1% of MTR patients; unadjusted OR 1.14; 95% CI 0.87–1.50; adjusted OR 1.04, CI 0.79–1.38). While it is difficult to eliminate confounding in this observational study, retention in care and virologic outcomes were better in patients prescribed STRs.

Background: The use of preexposure prophylaxis (PrEP) for HIV prevention was approved by the Food and Drug Administration in 2012, but delivery to at-risk persons has lagged. This critical review analyzes the current state of PrEP implementation in the United States, by reviewing barriers and innovative solutions to enhance PrEP access and uptake. Setting: Clinical care settings, public health programs, and community-based organizations (CBOs). Methods: Critical review of recent peer-reviewed literature. Results: More than 100 papers were reviewed. PrEP is currently provided in diverse settings. Care models include sexually transmitted disease clinics, community health centers, CBOs, pharmacies, and private primary care providers (PCPs). Sexually transmitted disease clinics have staff trained in sexual health counseling and are linked to public health programs (eg, partner notification services), whereas PCPs and community health centers may be less comfortable counseling and feel time-constrained in managing PrEP. However, PCPs may be ideal PrEP providers, given their long-term relationships with patients, integrating PrEP into routine care. Collaborations with CBOs can expand PrEP care through adherence support and insurance navigation. Pharmacies can deliver PrEP, given their experience with medication dispensing and counseling, and may be more accessible for some patients, but to address other health concerns, liaisons with PCPs may be needed. Conclusions: PrEP implementation in the United States is moving forward with the development of diverse models of delivery. Optimal scale-up will require learning about the best features of each model and providing choices to consumers that enhance engagement and uptake.

Background: Publicly funded HIV-testing sites can identify HIV preexposure prophylaxis (PrEP) candidates and provide PrEP linkage. Setting: Harris Health System's HIV clinic, HIV-testing program, and HIV-prevention program (HPP) in Houston, TX, a high HIV-incidence city. Methods: A prospective assessment of individuals aged 18 years and older recruited from walk-in HIV testing from December 2013 to April 2015 included risk assessment, HIV testing, and self-administered survey, with follow-up surveys at 6 and 12 months and medical record review. Results: The mean age of our sample (n = 300) was 38.3 ± 11.7 years. Men constituted 63.1% of the sample and 53.7% were black non-Hispanic, 26.3% Hispanic, and 14.7% white non-Hispanic. Most were uninsured (63.5%). Only 27% always used condoms, although 67% perceived personal HIV risk. Of 300 participants, 64 (21.3%) linked to PrEP care and 49 (16.3%) took PrEP. In multivariable analysis, compared with heterosexual men, women [adjusted OR (aOR) 4.1, 95% CI: 1.5 to 11.1] and MSM (aOR 10.2, 95% CI: 3.4 to 31.0) were more likely to attend HPP and to take PrEP (aOR 3.0, 95% CI: 1.6 to 15.1 and 3.0, 95% CI: 1.1 to 8.3, respectively). Serodiscordance and PrEP interest correlated with program attendance (aOR 14.0, 95% CI: 6.1 to 32.3 and aOR 6.7, 95% CI: 1.8 to 25.4) and taking PrEP (aOR 13.1, 95% CI: 5.2 to 32.8 and 14.4, 95% CI: 1.8 to 166.9), respectively. Conclusions: Preexposure prophylaxis interest, being female or MSM, and serodiscordance correlated with PrEP linkage. Safety-net health systems can facilitate PrEP access in marginalized populations, but the PrEP initiation rates remain low.

Objectives Syphilis and HIV epidemics overlap, yet little is known about combined network and behavioural factors that drive syphilis-HIV coinfection. Our study objective was to assess network contexts and sexual behaviours associated with syphilis-HIV co-infection and monoinfection among a particularly vulnerable subgroup: young Black men who have sex with men (YBMSM). To achieve this objective, we examined factors associated with coinfection by each subgroup as classified by syphilis-HIV infection status: (A) HIV monoinfected, (B) syphilis monoinfected and (C) neither syphilis infected nor HIV infected. In addition, we further identified the factors that are associated with HIV infection or syphilis monoinfection. Methods Data were collected from a sample of 365 YBMSM, aged 16–29 years, recruited through respondent-driven sampling between 2014 and 2016, in two cities with large HIV epidemics: Houston, TX, and Chicago, IL. We conducted a series of multinomial logistic regression models to predict coinfection, HIV monoinfection and syphilis monoinfection as a function of network and sexual behavioural factors. Results Coinfection was associated with having network members who are coinfected or HIV infected within one’s social network. Syphilis monoinfection was associated with a higher number of social venues attended, and HIV monoinfection was associated with having more condomless top partners. Conclusion Public health interventions that address the diagnosis and treatment of syphilis infection and ensure that those with syphilis are being tested for HIV may be promising in limiting the synergy of syphilis-HIV infections in onward transmission. Advancing HIV and syphilis prevention efforts in high-prevalence networks may allow prioritisation of limited resources.

Newer HIV regimens are typically taken once daily but vary in the number of pills required. Whether the number of pills in a once-daily HIV regimen affects clinical outcomes is unknown. We retrospectively compared adherence, retention in care, and virologic outcomes between patients starting a once daily single-tablet regimen (STR) to patients starting a once-daily multi-tablet regimen (MTR) in a publicly funded clinic in the United States. Outcomes were measured in the year after starting ART and included retention in care, virologic suppression, and medication possession ratio of at least 80%. Data from patients initiating therapy from 1 January 2008 to 31 December 2011 were analyzed with both unadjusted and propensity-score adjusted regression. Overall, 622 patients started with an STR (100% efavirenz-based) and 406 with an MTR (65% atazanavir-based and 35% darunavir-based) regimen. Retention in care was achieved in 80.7% of STR patients vs. 72.7% of MTR patients (unadjusted OR 1.57, 95% CI 1.17-2.11; adjusted OR 1.49, 95% CI 1.10-2.02). Virologic suppression occurred among 84.4% of STR patients vs. 77.6% of MTR patients (unadjusted OR 1.56; 95% CI 1.14-2.15; adjusted OR 1.41; 95% CI 1.02-1.96). There was no difference in the proportion of patients achieving at least 80% adherence, as measured by medication possession ratio (33.0% of STR patients and 30.1% of MTR patients; unadjusted OR 1.14; 95% CI 0.87-1.50; adjusted OR 1.04, CI 0.79-1.38). While it is difficult to eliminate confounding in this observational study, retention in care and virologic outcomes were better in patients prescribed STRs.

Introduction HIV pre-exposure prophylaxis has been proven to be an effective tool in HIV prevention. However, numerous barriers still exist in pre-exposure prophylaxis implementation. Methods The framework of Intervention Mapping was used from August 2016 to October 2017 to describe the process of adoption, implementation, and maintenance of an HIV prevention program from 2012 through 2017 in Houston, Texas, that is nested within a county health system HIV clinic. Using the tasks outlined in the Intervention Mapping framework, potential program implementers were identified, outcomes and performance objectives established, matrices of change objectives created, and methods and practical applications formed. Results Results include the formation of three matrices that document program outcomes, change agents involved in the process, and the determinants needed to facilitate program adoption, implementation, and maintenance. Key features that facilitated successful program adoption and implementation were obtaining leadership buy-in, leveraging existing resources, systematic evaluation of operations, ongoing education for both clinical and nonclinical staff, and attention to emergent issues during launch. Conclusions The utilization of Intervention Mapping to delineate the program planning steps can provide a model for pre-exposure prophylaxis implementation in other settings.

Purpose: Evidence suggests that young adults experiencing homelessness (YEH) are at elevated risk of HIV compared to housed youth. Given the limited research on pre-exposure prophylaxis (PrEP) awareness among YEH, this study examined their PrEP knowledge and attitudes. Methods: Data from a cross-sectional survey among YEH (ages 18-26) (n = 1,427) in seven U.S. cities were used to assess their knowledge and attitudes regarding PrEP to inform HIV prevention efforts. Results: Participants were primarily male youth of color. The mean age was 20.9 years. While 66% felt at risk for HIV, only 14% strongly agreed that they try to protect themselves from getting infected with HIV. Most (84%) were eligible for PrEP based on risk, yet only 29% had knowledge of PrEP. Despite this, 59% reported they were likely/extremely likely to take PrEP. Access to free PrEP (55%), HIV testing (72%), healthcare (68%), and one-on-one (62%), and text messaging support (57%) were rated as very/extremely important for PrEP uptake and adherence. Conclusions: The results of this study suggest missed opportunities to prevent new HIV infections among YEH. Efforts to increase PrEP uptake among this population should consider provider- and system-level interventions to increase PrEP awareness, decrease PrEP-associated healthcare costs, improve access to PrEP providers, and provide in-person and text messaging support. (C) 2018 Society for Adolescent Health and Medicine. All rights reserved.

Purpose: Despite evidence suggesting that they are 16 times more likely to become HIV+ than their housed peers, homeless youth have low rates of uptake and adherence to PrEP or nPEP. Notwithstanding the documented HIV risk and the potential for PrEP and nPEP as feasible prevention strategies, little research has been conducted to determine the knowledge and attitudes regarding PrEP and nPEP among homeless young adults.

There are ~900,000 new HIV infections among women every year, representing nearly half of all new HIV infections globally. In the US, nearly one-fifth of all new HIV infections occur among women, and women from racial and ethnic minority communities experience disproportionately high rates of new HIV infections. Thus, there is a need to develop and implement effective HIV prevention strategies for women in the US and internationally, with a specific need to advance strategies in minority communities. Previous studies have demonstrated that oral HIV pre-exposure prophylaxis (PrEP), the use of antiretroviral medications by HIV-uninfected persons to prevent HIV acquisition, can reduce HIV incidence among women who are adherent to PrEP. However, to date, awareness and uptake of PrEP among women have been very limited, suggesting a need for innovative strategies to increase the knowledge of and access to PrEP among women in diverse settings. This narrative review summarizes the efficacy and safety data of PrEP in women, discusses considerations related to medication adherence for women who use PrEP, and highlights behavioral, social, and structural barriers to maximize the effectiveness of PrEP in women. It also reviews novel modalities for PrEP in women which are being developed and tested, including topical formulations and long-acting injectable agents that may offer advantages as compared to oral PrEP and proposes a community-oriented, social networking framework to increase awareness of PrEP among women. If women are provided with access to PrEP and support to overcome social and structural barriers to adhere to PrEP, this prevention strategy holds great promise to impact the HIV epidemic among women in the US and globally.

Background:The Routine Universal Screening for HIV program provides opt-out HIV testing and linkage to care for emergency department (ED) patients in Harris Health System, Houston, TX. Seventy-five percent of patients testing positive in this program have been previously diagnosed. Whether linkage to care is increased among these patients is unknown. Methods:We conducted a retrospective cohort study of persons tested for HIV in the ED between 2008 and 2012 but had a previously documented positive HIV test ≥1 year prior. Outcomes were engagement in care (≥1 HIV outpatient visits in 6 months), retention in care (≥2 HIV outpatient visits in 12 months, at least 3 months apart), and virologic suppression (<200 copies/mL in 12 months) compared before and after the ED visit. Analysis was conducted using McNemar test and multivariate conditional logistic regression. Results:A total of 202,767 HIV tests identified 2068 previously diagnosed patients. The mean age was 43 years with 65% male and 87% racial and ethnic minorities. Engagement in care increased from 41.3% previsit to 58.8% postvisit (P < 0.001). Retention in care increased from 32.6% previsit to 47.1% postvisit (P < 0.001). Virologic suppression increased from 22.8% previsit to 34.0% postvisit (P < 0.001). Analyses revealed that engagement in care after visit improved most among younger participants (ages 16–24 years), retention improved across all groups, and virologic suppression improved most among participants aged 25–34 years. Conclusions:Routine opt-out HIV testing in an ED paired with standardized service linkage improves engagement, retention, and virologic suppression in previously diagnosed patients.

IntroductionTruvada® (TVD) was approved in July 2012 by the US FDA for pre‐exposure prophylaxis (PrEP) in combination with safer sex practices to reduce the risk of sexually acquired HIV‐1 in high‐risk adults. This study explores the characteristics of US PrEP users and their prescribers over the past two years.Materials and MethodsA previously described algorithm was used to identify TVD for PrEP by excluding use for HIV treatment, post‐exposure prophylaxis, and off‐label treatment of chronic hepatitis B. National electronic patient level data from ~55% of all US retail pharmacies that dispensed TVD between January 1, 2012 and March 31, 2014 was collected. De‐identified patient‐level data including prescription refill data, medical claims and patient demographics were analyzed via logistic regression to estimate the odds of change by year.ResultsA total of 3253 unique individuals who started TVD for PrEP between January 1, 2012 and March 31, 2014 were included in this analysis. Women comprised 42.0% of PrEP users. Although mean age was 38.1+11.9 years, with males being significantly older (39.3+11.6) than females (36.4+12.3), 11.5% of individuals were under 25 years old. The proportion of males under 25 was 7.4% (95% CI 6.3–8.7); significantly lower than that of women, 17.2% (95% CI 15.3–19.3). New starts have increased from 293 in 2012 to 472 Q1 2014. During the 12‐month period ending March 31, 2013 and March 31, 2014 the number of new starts among females dropped from 44.5% to 22.9%.Sixty‐eight percent of TVD for PrEP prescriptions were written by five specialties: internal medicine (19%), family practice (18%), infectious diseases (11%), nurse practitioners (10%) and physician assistants (10%).ConclusionsThe population of TVD for PrEP users in the US nationally appears to be shifting demographically. It continues to be initiated mostly by primary care providers. Over a two‐year period new starts of Truvada for PrEP have increased considerably among males. While the overall proportion of female users decreased between Q1 2012 and Q1 2014, females that started on PrEP are younger than males. More community‐level data on PrEP usage will be helpful in informing local efforts to integrate PrEP in HIV prevention messaging and services.

Limited data exist regarding attitudes and acceptability of topical and oral HIV pre-exposure prophylaxis (PrEP) among US black women. This investigation explored interest in HIV chemoprophylaxis and modes of use. Five focus groups enrolled 26 black women recruited from an inner-city community health center and affiliated HIV testing sites. Thematic analysis utilized Atlas.ti. Most women expressed interest in PrEP, as many reported condom failure concerns. Most women preferred a pill formulation to intravaginal gel because of greater perceived privacy and concerns about vaginal side effects and gel leakage. Women who had taken pills previously advocated daily dosing and indicated adherence concerns about episodic or post-coital PrEP. Many women desired prophylactic strategies that included partner testing. Urban black women are interested in utilizing PrEP; however, misgivings exist about gel inconvenience and potential side effects for themselves and their partners. Most women preferred oral PrEP, dosed daily.