Online relationship seeking is common among adolescent sexual minority men (ASMM), yet research has primarily compared sexual health between ASMM who seek partners online with those who do not, overlooking heterogeneity in dating motivations. We examined associations between motivations for online relationship seeking (dates only vs. both dates/sex) and HIV-related behaviors and assessed racial/ethnic differences in these associations. Data from three timepoints were drawn from a 12-month HIV prevention intervention with ASMM in the U.S. Logistic regressions examined associations between motivations for online relationship seeking and HIV/STI testing, condomless sex without using pre-exposure prophylaxis (PrEP), and PrEP interest. The sample included 266 ASMM aged 13-18 years (Md = 17; 59% ASMM of color). Overall, 38% reported seeking dates only online, whereas 62% sought both dates/sex; the former group was significantly younger, p = .04. ASMM who sought both dates/sex online were more likely to test for HIV (p = .04) and STI (p = .01) than those seeking dates only. Hispanic ASMM were more likely than non-Hispanic peers to engage in condomless sex when not using PrEP (p = .001) and were less likely to test for HIV (p = .02). These findings highlight the need for tailored relationship and sexual health programs, particularly for Hispanic and younger ASMM who more often seek dates only.

BackgroundDespite major biomedical advances in HIV testing, prevention, and treatment, annual HIV transmissions in the United States remain above 30,000. Geographic access to pre-exposure prophylaxis (PrEP) is critical to HIV prevention efforts, particularly in regions with high HIV burdens, such as metro-Atlanta. Community-based organizations (CBOs) play a central role in delivering culturally competent prevention services, yet many rely on federal funding that is increasingly unstable. Understanding the potential impact of CBO closures on geographic access to PrEP is essential for anticipating inequities and informing policy. ObjectiveThe aim of this study was to estimate how hypothetical closures of federally funded CBOs providing PrEP affect geographic access to PrEP clinics by car and public transit across metro-Atlanta and to assess whether impacts differ by community racial/ethnic composition. MethodsWe identified 71 PrEP-providing clinics in metro-Atlanta (August 2025), including 12 CBOs. Using 3 simulated closure scenarios in which 25% of CBOs were randomly closed, we calculated one-way travel times from 2466 census block group (CBG) centroids to the nearest PrEP-providing clinic. Travel times were estimated for car and public transit across 3 weekdays and timepoints and then averaged per CBG. Two-sided paired t tests were used to compare the change in travel time compared to baseline. Logistic regression assessed associations between racial/ethnic plurality and increased travel times. ResultsUnder baseline conditions, 100% of CBGs had car access to a PrEP clinic within 30 minutes compared to only 41.6% (1027/2466) via public transit. Across closure scenarios, 732 CBGs (29.6%; representing over 1 million residents) experienced increased transit times (mean increase 1.2 minutes; range 0.0-11.6; P<.001), and 7 CBGs lost transit access entirely. For car travel, 1184 CBGs (48%; representing approximately 1.7 million residents) experienced increased drive times (mean increase 0.5 minutes; range 0.0-6.4; P=.03). Black-plurality CBGs had higher odds of increased drive times compared to White-plurality CBGs (odds ratio 1.37, 95% CI 1.15-1.63). ConclusionsEven limited closure of CBO PrEP providers meaningfully reduces geographic access to HIV prevention services, disproportionately affecting communities already experiencing transportation and HIV-related vulnerabilities. Sustained federal investment in CBOs is essential to preserve equitable PrEP access and prevent avoidable HIV infections.

Introduction: The global HIV response, once a model of progress and innovation, faces a profound moment. Despite four decades of pivotal scientific and programmatic advances-most notably in antiretroviral therapy (ART) and pre-exposure prophylaxis (PrEP)-the world remains off track to meet the 2025 and 2030 targets for ending AIDS as a public health threat. New acquisitions and AIDS-related deaths remain unacceptably high, particularly among key populations and in low- and middle-income countries. The abrupt U.S. funding reversals in 2025 have severely disrupted support for HIV efforts. Cuts to U.S. and international institutions have compromised HIV prevention, treatment and surveillance systems worldwide, and may already have begun reversing two decades of progress. Discussion: To avert this crisis, the HIV and public health community, together with governments and global funders, must urgently invest in scaling long-acting treatment and prevention tools, rebuild disaggregated data systems and strengthen implementation science rooted in community-led approaches. Digital health technologies offer promise to enhance service delivery, surveillance, monitoring and evaluation, especially in resource-constrained settings, but demand ethical governance and infrastructure investment. The global research ecosystem must become more evenly distributed and inclusive, with a shift towards country-led partnerships, national data sovereignty and regional co-operation. Conclusions: Looking to 2030 and beyond, the strategy to end HIV should include expanded access to long-acting ART and PrEP, sustained investments in HIV vaccine and cure research, and robust monitoring and evaluation systems. Achieving epidemic control-and ultimately ending the HIV pandemic-will require not only biomedical tools but also political will, community leadership and equitable financing. The lessons of the past underscore that sustained progress is possible, but only if we meet this moment with urgency, imagination and solidarity.

95 Background: The National Comprehensive Cancer Network (NCCN) recommended germline testing for all patients with early onset colorectal cancer (EOCRC) in 2017. Older adults continued to rely on other pathways such as family history and universal immunohistochemistry (IHC) screening to identify Lynch syndrome (LS) carriers. Here, we describe cascade completion after abnormal IHC in the era of universal IHC screening for CRC. Methods: We reviewed deidentified data from the Emory Lynch Syndrome Screening Network (LSSN) database. This database tracks patients with cancers that are considered Lynch syndrome associated. We evaluated IHC results with deficient mismatch repair (dMMR); defined as loss of ≥1 protein on complete IHC. LS suspicious cases were those with MSH2/MSH6 loss or MLH1/PMS2 loss without BRAF mutation or MLH1 promoter methylation (obtained on reflex testing). Outcomes included referral for germline testing as well as completed genetic counseling/testing. Results: Among 565 patients with CRC (450 colon, 115 rectal) in the LSSN database diagnosed between 2013 to 2023, IHC was completed in 99.5% (562/565). dMMR was identified in 17.8% (100/562). Among dMMR tumors, MLH1/PMS2 loss (n=73), MSH2/MSH6 loss (n=17), and rare single protein losses (MSH6, PMS2, or MSH2 only) (n=10). Reflex testing was not completed in 20% of MLH1/PMS2 cases, leaving 41 patients suspicious for LS from the MLH1/PMS2 cohort. In total, 62 patients were LS suspicious. Among LS suspicious cases, 40% (25/62) were referred for germline testing and 29% (18/62) completed germline testing. 61% (11/18) of those tested carried a pathogenic variant. In age stratified analysis, 100 patients had EOCRC. Germline testing was completed in 27% (27/100) and 19% (5/27) carried a pathogenic variant. All 5 pathogenic variants were confined to dMMR tumors, while no variants were detected in pMMR tumors (0/19). In patients ≥50 years (n=461), 83 had tumor with dMMR, and 11% (9/83) were tested for germline mutations. Pathogenic mutation was identified in 44% (4/9) of those ≥50 years. Conclusions: In this cohort, the greatest missed opportunity for Lynch syndrome diagnosis was in patients ≥50 years. Despite a 44% pathogenic yield, most did not complete germline testing. Improving completion in older adults with abnormal IHC and ensuring universal uptake in younger patients are both essential to maximize Lynch carrier detection and enable cascade testing.

Importance:Long-acting injectable (LAI) pre-exposure prophylaxis (PrEP) has superior efficacy vs oral PrEP, and higher LAI-cabotegravir (CAB) persistence may optimize its HIV prevention impact. Objective:To characterize individuals using LAI-CAB compared with oral PrEP, to describe changes in national LAI-CAB vs oral PrEP use over time, and to examine longitudinal persistence among LAI-CAB users. Design, Setting, and Participants:This retrospective cohort study used pharmacy and medical claims from a database that covered a majority of all claims in the US from 2022 to 2024. Participants included persons with 1 or more claim for any PrEP drugs (oral or injectable). Exposure:PrEP use during the study period. Main Outcomes and Measures:Study outcomes were LAI-CAB use and persistence in care. LAI-CAB use was defined as at least 1 claim, and LAI-CAB yearly persistence was defined as at least 2 LAI-CAB claims for each of 2 biannual periods. Yearly persistence in any type of PrEP (PrEP persistence) was defined as at least 2 claims for PrEP medications (oral or injectable) for each of 2 biannual periods among LAI-CAB users. Multivariable logistic regression models were used to assess variables associated with LAI-CAB use compared with oral PrEP. Results:From 2022 to 2024, there were 24 194 LAI-CAB users, representing 3% of all 781 040 PrEP users. LAI-CAB users were young (mean [SD] age, 37.1 [11.4] years) and predominantly male (20 642 users [85%]); 656 (3%) were Asian, 4531 (19%) were Black, 4380 (19%) were Hispanic, 13 696 (58%) were White, and 414 (2%) were of other races and ethnicities. Most had commercial insurance (16 334 users [68%]) and had no copayment (13 507 users [82%]). LAI-CAB users were more likely than oral PrEP users to be covered by Medicaid (6256 of 24 194 users [26%] vs 108 589 of 770 833 users [14%]). In the most recent evaluated period (July to December 2024), LAI-CAB accounted for 4% (16 557 of 390 816 users) of PrEP users. Among users with sufficient data, LAI-CAB persistence was 50% (6020 of 12 118 users) at 1 year and 23% (785 of 3381 users) at 2 years. Overall PrEP persistence among LAI-CAB users, including transitions to oral PrEP, was 57% (6879 of 12 118 users) at 1 year and 30% (1019 of 3381 users) at 2 years. A greater proportion of female users initiated LAI-CAB (3551 users [15%]) than oral PrEP (83 274 users [11%]), but 2-year LAI-CAB persistence was lower among female users (61 users [13%]) than among male users (724 users [25%]). Conclusions and Relevance:In this national prescription claims cohort study, LAI-CAB use was a small share of overall PrEP use from 2022 to 2024. Approximately one-half of users were persistent in LAI-CAB or in PrEP at year 1, declining to about one-quarter and one-third, respectively, by year 2. The implementation of more effective new PrEP modalities alone is unlikely to substantially alter PrEP use in the US. Instead, structural supports and behavioral interventions are needed to facilitate scale-up of new, highly efficacious modalities.

# Background Antiretroviral therapy (ART) has become a cornerstone of human immunodeficiency virus (HIV) management. However, a challenge in HIV care and policy is ensuring individuals remain engaged in care and on treatment over time. Discontinuation of ART is common for various reasons, and prolonged treatment interruptions can lead to worse health outcomes at the individual level and increased HIV transmissions at the public health level. # Objective A cost-consequence analysis was conducted to evaluate the economic and public health impact of reducing the interval to ART restart among people with HIV (PWH) who have disengaged from care. # Methods A state transition disease model was developed to calculate the economic benefits from improving treatment restart patterns from a United States healthcare payer perspective. Two hypothetical cohorts of 1000 PWH who discontinued ART were compared: a standard-of-care cohort where restart occurs 32 weeks after discontinuation, and a comparator cohort exploring the impact of reducing the time between ART discontinuation and restart to 12 weeks. Individuals were assigned to CD4-related health states, and rates of viral suppression were considered. Four outcomes, ART costs, CD4 health state costs, CD4-related mortality, and new HIV transmissions were calculated over a three-year time horizon. Cost savings from averted HIV cases were valued based on the lifetime excess healthcare costs for a PWH. # Results Increasing the proportion of individuals restarting ART and reducing time to restart was estimated to avert 88 HIV transmissions. This corresponds to a number needed to treat, defined as the number of PWH who would need to experience the earlier restart pattern of the comparator cohort, of 11 to avoid one new transmission, and $101 083 857 lifetime cost savings. Cost savings attributable to improved CD4 counts in the cohort were also found. # Conclusion Enhancing ART restart patterns improves health and provides considerable cost savings by improving individuals’ CD4 counts and reducing new HIV transmissions from people who are viremic. Effective policies to promote care engagement and treatment adherence are predicted to improve the health of PWH and reduce new HIV cases.

The population-level impact of public health interventions depends on their implementation in real-world settings. This is the purview of implementation science. As the field of implementation science advances, there is growing recognition that complex health challenges demand solutions that account for the dynamic systems in which interventions unfold. Epidemiologists, trained to define causal relationships and quantify population-level effects, are uniquely positioned to contribute to this effort. Yet, realizing that potential requires moving beyond traditional epidemiologic methods, which can be reductionist in nature, and embracing tools from systems thinking. This paper illustrates how integrating epidemiologic methods with principles of systems thinking can strengthen implementation science and inform implementation strategies for evidence-based interventions in complex real-world settings.

When taken as a daily pill, pre-exposure prophylaxis (PrEP) requires sufficient levels of adherence to confer strong protection against HIV. For protection against HIV transmission via anal sex, this corresponds to at least 4 daily pills per week for those on a daily dosing regimen. Measuring oral PrEP adherence requires valid assessments of pill-taking; it also requires assessments of contemporaneous sexual behavior because PrEP adherence is only functionally relevant in the context of contemporaneous HIV vulnerability. We conducted an online cohort study of Black, PrEP-using men who have sex with men (MSM) to assess the alignment between self-reported PrEP adherence and condom use and concordance between self-reported PrEP adherence and laboratory-assessed adherence. Data collection occurred from 2021 to 2023. Participants completed 11 weekly surveys to report PrEP use and sexual behavior for the preceding 7 days. At the end of follow-up, they were asked to submit a dried blood spot sample for laboratory analysis. There were few periods of self-reported non-adherence, but, among these, condomless sex was frequent. Self-reported adherence was not predictive of laboratory-assessed adherence. Despite their cost, studies of PrEP adherence should incorporate laboratory measurements of adherence whenever feasible.

BackgroundPre-exposure prophylaxis (PrEP) is highly effective in preventing HIV transmission; yet, many people who would benefit from PrEP are not currently using it. Numerous programs and policies, including those provided under the US Ending the HIV Epidemic effort, have been implemented to increase PrEP use. Programs vary enormously, ranging from telemedicine PrEP support to electronic medical record prompts to social marketing and messaging campaigns. However, limited evidence exists regarding their relative impact on PrEP uptake. ObjectiveThe aims of the PREMISE (PrEP Epidemiology, Modeling, and Surveillance) research program are to (1) provide context for PrEP scale-up in the United States, (2) assess the impact of different programs and policies on PrEP use, and (3) model the impact of PrEP-related programs and policies on population health. MethodsThe primary outcomes of PrEP use and PrEP-to-need ratios will be extracted from a national medical data aggregator database that represents a majority of PrEP users in the United States. These data will inform all proposed analyses of the project: the dataset will allow the exploration of longitudinal trends in PrEP use by modality as a cohort study, it will be the outcome data for assessing changes associated with particular PrEP programs and policies for quasi-experiments, and it will provide baseline information to inform modeling regarding future impacts of PrEP policies and programs. The implementation of policies will be assessed using legal coding at the state level, and the implementation of programs across health jurisdictions will be assessed using a jurisdiction survey conducted in collaboration with participating health departments. Guided by a legal implementation framework, we will use descriptive and regression analyses to contextualize PrEP scale-up and use quasi-experimental designs to inform causal assessments of the effect of programs and policies. Here, we provide, as preliminary data, our extraction of PrEP prescribing from the national dataset. ResultsThis research was funded in August 2024. We obtained the national PrEP database and started data cleaning in March 2025. From 2016 to 2024, there were 20,394,619 claims for medications that were FDA-approved for PrEP, and we determined 13,644,979 claims to be PrEP prescriptions, representing over 1 million PrEP users. For medical benefit claims, there were 34,525 procedure claims for PrEP medications, and we determined 22,910 procedure claims to be for PrEP, representing over 6000 PrEP users. ConclusionsTo optimally use HIV prevention resources, it is critical to understand the effects of different programs and policies. Over 1 million people have started PrEP, and tracking how this scale-up has occurred by PrEP modality and user groups will inform future HIV prevention efforts. By collaborating with health jurisdictions, we will provide systematic data regarding the panoply of programs and policies that have been enacted to support PrEP use. International Registered Report Identifier (IRRID)DERR1-10.2196/80911

BACKGROUND:Doxycycline postexposure prophylaxis (doxyPEP) must reach people at high risk for bacterial STIs to reduce STI rates and inequities. PrEP-to-Need Ratios (PNR) identified inequities in PrEP by measuring PrEP prescriptions relative to HIV rates. We evaluated a novel application of the PNR framework to doxyPEP for STIs to identify inequities in doxyPEP by race/ethnicity. METHODS:Using cross-sectional clinical and surveillance datasets, we compared doxyPEP use relative to STI diagnoses, a measure of need, among patients eligible for a doxyPEP prescription seen at San Francisco City Clinic in the three years following release of citywide doxyPEP guidelines (October 2022). "Use" was defined as having received a prescription for or self-reporting taking doxyPEP. "Need" was the number of unique patients diagnosed with at least one chlamydia, gonorrhea, or early syphilis infection. The doxyPEP-to-Need Ratio (dPNR) was calculated as the ratio of "use" to "need" and was compared by race/ethnicity and year. RESULTS:By the end of the evaluation period (September 2025), doxyPEP use was highest among eligible Latine patients (76%), then Asian (71%) and White (67%) patients, and lowest among Black patients (59%). However, because Latine and Black patients had similarly higher rates of doxyPEP-preventable infections compared to Asian and White patients, dPNR was consistently higher for Asian and White patients compared to Latine and Black patients. Latine and Black patients experienced persistently lower doxyPEP use relative to need compared to White patients. CONCLUSIONS:dPNR is a novel and useful metric for identifying actionable inequities in doxyPEP access for STI prevention.

OBJECTIVE:This review aims to identify the contribution of user experience features and underlying technical features to sustained engagement in unguided chatbots for improving health-related behaviors. MATERIALS AND METHODS:Following PRISMA-2020 guidelines, we conducted a systematic review, searching PubMed, ACM, APA PsycINFO, Cochrane, Web of Science, and IEEE Xplore from June to September 2022 and updated in April 2025. Data was analyzed via Synthesis without Meta-Analysis (SWiM), to understand the relationship between user engagement overall and individual experience metrics. RESULTS:Customizable avatars and flexible input interactions may enhance overall user engagement. Conversely, pre-scripted content that lacks personalization and emotional support negatively impacts user satisfaction and adherence to health interventions. Other features contributing to sustained engagement are in-app technical assistance, user learning features, and crisis support systems. A strong positive correlation (r = 0.808, n = 16) was observed between user satisfaction and engagement, specifically for satisfaction dimensions including need fulfillment (r = 0.872, n = 6), willingness to recommend chatbot (r = 0.817, n = 4) and user enjoyment (r = 0.971, n = 3) in SWiM analysis. The limited application of large language models and retrieval augmented generation techniques may constrain the quality of support available to users and overall sustained engagement. CONCLUSION:Effective unguided chatbot design requires an emphasis on interactive educational elements, in-app technical assistance and crisis support, and personalized content. This can be achieved with high context awareness, input understanding, and quality content generation. Our findings suggest that user satisfaction is a primary driver of sustained engagement, though further research is needed to validate individual user satisfaction features for sustained engagement.

Understanding barriers to PrEP initiation is critical to maximizing access. In a prior pilot study, respondents picking up an initial oral PrEP prescription reported cost and coverage issues. The current study utilizes a larger sample size to more robustly assess reported pharmacy-level barriers to initial dispensation.Table 1.Characteristics of Survey Respondents by PrEP Dispensation Group, Walgreens Pharmacy Clients, United States, 2024a.Includes none of the above and prefer not to answer.b.Includes American Indian or Alaska Native, Middle Easter or North African, and prefer not to answer.c.Government funded includes Medicare Part D, Medicare Part B, managed Medicaid, and state Medicaid.d.Includes California, Colorado, DC, Florida, Illinois, Indiana, Iowa, Massachusetts, New Mexico, New York, Ohio, Oklahoma, Virginia, and Washington State.e.Cost data unavailable due to no pickup within 30 days or otherwise missing data.DAP, drug assistance program; OOP, out-of-pocket; PAP, patient assistance program; PrEP, pre-exposure prophylaxis; y, years.Table 2.Unadjusted Odds Ratios For PrEP Dispensation Within 14 Days for Variables Related to Cost and Coverage, Walgreens Pharmacy Clients, United States, 2024Statistical significance indicated by red text.CI, confidence interval; DAP, drug assistance program; OOP, out-of-pocket cost; OR, odds ratio; PrEP, pre-exposure prophylaxis. Adults with a recent (≤7 months prior) initial PrEP prescription and no record of HIV medications in the Walgreen’s Pharmacy database were invited to complete a 35 question survey. The survey was deployed electronically (Mar to Dec 2024) to eligible and consenting participants. Topics included attitudes toward PrEP, out-of-pocket (OOP) costs, and prescription fill rejection reasons. Responses were compared between individuals who picked up their first PrEP prescription within 14 days (prompt pickup [PP]) and individuals who did not pick up within 14 days (delayed/no pickup [D/NP]) using t-tests and Chi-square/Fisher’s exact tests (significance threshold p≤0.05). Associations between predictor variables and pickup status were evaluated with univariable (ULR) and multivariable logistic regression (MLR) analysis.Table 3.Unadjusted Odds Ratios For PrEP Dispensation Within 14 Days for Variables Related to PrEP Attitudes, Stigma, and Self-Efficacy, Walgreens Pharmacy Clients, United States, 2024Statistical significance indicated by red text.CI, confidence interval; HCP, healthcare provider; LGB, lesbian, gay, or bisexual; OR, odds ratio; PrEP, pre-exposure prophylaxis; y, years. Of 39,596 invited individuals, 773 responded; 80.9% (n=625) had PP and 19.1% (n=148) had D/NP. Respondent characteristics were similar between groups, with the exception of OOP costs (Table 1). Among D/NP respondents, 46.6% paid $0 for PrEP and 46.6% had no cost data, primarily due to no pickup, as compared with 83.5% and 1.6%, respectively, of PP respondents. In the ULR analysis, cost and coverage considerations and financial burden were significantly associated with pickup group, in the predicted directions; non-significant associations were observed with health-related social factors (Table 2). MLR results (not shown) were consistent with ULR results. No strong associations were found between pickup group and other assessed factors, including PrEP attitudes, stigma, and self-efficacy (Table 3). Cost concerns and insurance coverage issues were significantly more prevalent among individuals with D/NP versus PP of their first PrEP prescription. To further encourage PrEP initiation, efforts should target increasing prescription affordability and streamlining medical authorization processes. Patrick S. Sullivan, DVM, PhD, Gilead Sciences Inc.: Grant/Research Support|Gilead Sciences Inc.: Speaker fees|Merck: Grant/Research Support|ViiV Healthcare: Grant/Research Support JeanPierre Coaquira Castro, MPH, Gilead Sciences, Inc.: employee and shareholder Krisha Patel, BS, MPH, Walgreens Real World Evidence-Clinical Trials: Employee Alice Hsiao, PharmD, Gilead Sciences, Inc.: Employee and shareholder Iyue Sung, PhD, Walgreens Real World Evidence-Clinical Trials.: Employee Jessica Citronberg, PhD, Walgreens Real World Evidence-Clinical Trials: Employee Michael Bogart, n/a, Gilead Sciences, Inc.: Employee|Gilead Sciences, Inc.: Stocks/Bonds (Public Company) Woodie Zachry, RPh, PhD, Gilead Sciences, Inc.: Employee and shareholder

Background Accurate estimates of the population sizes of men who have sex with men (MSM) are essential for evaluating HIV-related interventions. We aimed to estimate MSM populations at county and state levels using recent data from the decennial census and the National Health and Nutrition Examination Survey.Methods We used 2020 Decennial Census data to calculate a weight for each U.S. county, reflecting the proportion of male-male partner households relative to counties of similar urbanicity based on the 2013 National Center for Health Statistics Urban-Rural Classification Scheme. We applied these weights to urbanicity-stratified estimates of the prevalence of adult men who reported sex with a man in the past 12 months, derived from National Health and Nutrition Examination Survey (2015-2020). Multiplying these percentages by adult male populations produced county estimates, which were aggregated to state levels.Results We estimated approximately 2.1 million MSM in the United States, representing 1.7% of adult males. State-level estimates ranged from 0.3% in Wyoming (n = 675) to 3.7% in the District of Columbia (n = 9709). California had the largest MSM population (n = 318 612; 2.1%), followed by Florida (n = 191 199; 2.3%) and Texas (n = 173 751; 1.6%). At the county level, Los Angeles County, CA, had the largest MSM population (n = 82 513; 2.1%), followed by Cook County, IL (n = 39 580; 2.0%), and Broward County, FL (n = 34 321; 4.7%). Broward County, FL (4.7%), and San Francisco County, CA (4.6%), had the highest proportions relative to their male populations.Conclusions County- and state-level MSM estimates provide crucial denominators for calculating disease rates and informing public health interventions.

Importance: Pre-exposure prophylaxis (PrEP) is a proven effective intervention to reduce risk for HIV infection, but changes in PrEP coverage or out of pocket costs could reduce PrEP coverage, resulting in excess HIV infections and costs. Objective: To estimate the impacts of federal policy changes on PrEP coverage, new HIV infections and costs associated with new HIV infections Design: Estimation of excess HIV infections under different policy impacts were conducted using parameters from a previously published ecological model of the relationship between PrEP coverage and new HIV infections. Costs were estimated for treatment of infections not averted under scenarios Setting: United States Participants: No individual participation in research activities; population-based data sources were used to describe the population-level PrEP use and new diagnoses under different hypothetical changes in PrEP coverage. Exposures: Percent of people with indications for PrEP who are taking PrEP Main Outcome and Measures: Estimated change in new HIV infections under different assumptions of change in PrEP coverage; costs of treatment for avoidable HIV infections and net costs of avoidable infections after accounting for costs of PrEP programs. Results: Even modest reductions in PrEP coverage would result in thousands of avoidable HIV infections. A 10% reduction in PrEP coverage would result in 26,783 avoidable HIV infections and over $1 billion in medical cost for treatment of HIV infections. Conclusions and Relevance: Changes in policy that reduce PrEP uptake would result in avoidable HIV infections and increased costs for HIV treatment. Maintaining policies and programs that support PrEP uptake offers benefits for health and is estimated to result in net cost savings. ### Competing Interest Statement Patrick Sullivan reports the payment to the institution and consulting fees from Gilead Sciences and Merck. Stephanie DuBose, Gordon Le and Kamaria Biscoe report grant support from Gilead Sciences. KHM's home instituion received unrestricted research grants from Gilead Sciences, Merck, Inc, and ViiV Healthcare, and he has served on scientific advisory boards for these organizations. Jeffrey Crowley reports grants to his institution from Gilead Sciences, Merck and Viiv Healthcare, speaker fees from Gilead Sciences and Viiv Healthcare, and support for meeting attendance from Gilead Sciences and Viiv Healthcare. All other authors report no conflicts. ### Funding Statement This work was supported by the Center for AIDS Research at Emory University (P30 AI050409). ### Author Declarations I confirm all relevant ethical guidelines have been followed, and any necessary IRB and/or ethics committee approvals have been obtained. Yes I confirm that all necessary patient/participant consent has been obtained and the appropriate institutional forms have been archived, and that any patient/participant/sample identifiers included were not known to anyone (e.g., hospital staff, patients or participants themselves) outside the research group so cannot be used to identify individuals. Yes I understand that all clinical trials and any other prospective interventional studies must be registered with an ICMJE-approved registry, such as ClinicalTrials.gov. I confirm that any such study reported in the manuscript has been registered and the trial registration ID is provided (note: if posting a prospective study registered retrospectively, please provide a statement in the trial ID field explaining why the study was not registered in advance). Yes I have followed all appropriate research reporting guidelines, such as any relevant EQUATOR Network research reporting checklist(s) and other pertinent material, if applicable. Yes All data used in these analyses are publicly available through AIDSVu.org and CDCAtlasPlus

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Internalized homophobia (IH) negatively impacts the mental health of adolescent sexual minority men (ASMM), while self-esteem is posited to bolster their mental health. In a repeated-measures study with 599 ASMM (Mean age = 16.2 [ SD = 1.3]; 75.6% racial and ethnic minorities), longitudinal structural equation models investigated the relationships among IH, self-esteem, and mental health (depression and anxiety), as well as the mediating role of self-esteem. Higher self-esteem at earlier time points was significantly associated with lower anxiety and depressive symptoms. The hypothesized mediation pathways were not statistically significant. Subgroup analyses revealed that the protective effect of self-esteem against anxiety was significant for racial and ethnic minority ASMM but not for their non-Hispanic White counterparts. These findings highlight the need for tailored interventions that address the unique experiences of ASMM from diverse racial and ethnic backgrounds.

Objectives: Posttraumatic stress disorder (PTSD) may affect antiretroviral therapy (ART) response and clinical outcomes for veterans with HIV (VWH) receiving care in the Department of Veterans Affairs (VA). Objectives are to estimate the associations between PTSD and ART nonadherence, modifications, and failure; measure effect modification by number of deployments and combat exposure; and examine how these associations vary over time. Design: In this prospective cohort study of all VWH on ART who deployed to Iraq and Afghanistan and receive care in the VA (n = 3206), patients entered at ART initiation and were censored in December 2022, totaling 22 261 person-years of follow-up. Methods: Marginal structural log-binomial and Poisson models were fitted with a time-dependent exposure, adjusted for time-independent and time-dependent confounding and informative censoring, to estimate the associations between PTSD and ART nonadherence, modifications, and failure. Marginal structural shared frailty models were fitted to examine time-varying associations. Results: PTSD increased the risk [adjusted risk ratio, 95% confidence interval (CI)] of ART nonadherence by 6% (1.06 [1.00, 1.13]) and the rate (adjusted incidence rate ratio, 95% CI) of ART modifications by 38% (1.38 [1.19, 1.58]). Multiple deployments amplified the association with ART nonadherence by 14%; combat exposure did not modify any association examined. The association with ART modifications increased during the first decade post-PTSD-diagnosis but subsequently stabilized. Conclusions: PTSD increased ART nonadherence and ART modifications. Providers should screen for PTSD so that it can help guide medical decisions and treatment; particular attention should be paid to Veterans with multiple combat deployments.

PURPOSE:To introduce an equity-based method for assessing public transit access to health services and apply it to pre-exposure prophylaxis (PrEP) clinics in metro-Atlanta. METHODS:Census block groups (CBGs) were analyzed with PrEP clinics identified via PrEP Locator. One-way public transit times were estimated using the Google Maps Distance Matrix API. CBGs were classified as public transit deserts if transit options were unavailable or if travel time was > 30 min. T-tests compared sociodemographic characteristics of CBGs with and without public transit. Linear regression assessed the association of a 5 % increase in priority populations with transit times. RESULTS:Among 2466 CBGs, one-quarter lacked public transit access to PrEP and two-thirds were transit deserts. Median travel time was 32 min. CBGs with transit access had significantly higher proportions of Black, Hispanic/Latinx, young men (aged 25-34), and residents living below the poverty line (P < .001). Increases in the proportion of Hispanic/Latinx residents, young men, and residents living under the poverty line were associated with shorter transit times, with no association for Black residents. CONCLUSIONS:Public transit access to PrEP was low in Atlanta, and overall public transit times were long. Current PrEP locations are aligned with priority populations, but additional work is needed to ensure equity is met for Black and Hispanic/Latinx residents.