Preferences for HIV prevention strategies among newly arrived Asian-born men who have sex with men living in Australia: A discrete choice experiment.

The HIV epidemic in Australia is changing with higher risk for HIV among newly-arrived Asian-born men who have sex with men (MSM) compared to Australian-born MSM. We evaluated the preferences for HIV prevention strategies among 286 Asian-born MSM living in Australia for <5 years. A latent class analysis uncovered three classes of respondents who were defined by their preferences: "PrEP" (52%), "Consistent condoms" (31%), and "No strategy" (17%). Compared to the "No strategy" class, men in the "PrEP" class were less likely to be a student or ask their partner for their HIV status. Men in the "Consistent condoms" class were more likely to get information about HIV from online, and less likely to ask their partner for their HIV status. Overall, PrEP was the preferred HIV prevention strategy for newly arrived migrants. Removing structural barriers to access PrEP can accelerate progress toward ending HIV transmission.

Utilisation of pre-exposure prophylaxis (PrEP) for HIV prevention in the Australian general practice setting: a longitudinal observational study.

BACKGROUND: Pre-exposure prophylaxis (PrEP) became available through the Australian Pharmaceutical Benefits Scheme (PBS) on 1 April 2018 for HIV infection prevention in patients ≥18years at medium-to-high HIV risk. The aims were to investigate PrEP utilisation in general practice since PBS listing, and factors associated with discontinuation. METHODS: This longitudinal study included patients aged 18-74years attending general practices participating in MedicineInsight, a large-scale national primary care database of deidentified electronic health records, between October 2017 and September 2019. RESULTS: PrEP utilisation increased 10-fold following PBS listing. On average, patients had 9.7 PrEP prescriptions per year; a medication possession ratio of 80.8%. Of 1552 patients prescribed PrEP from April 2018, most were male (98.3%), aged 18-39years (59.3%), resided in major cities (86.7%) and in the two most socioeconomically advantaged quintiles (70.0%). Almost half (49.1%) of the patients were identified as new to PrEP. At study end, 65.1% were on active PrEP (16.5%, of whom had non-continuous use), 19.2% had discontinued PrEP and 15.7% were lost to follow up. Patients who discontinued were more likely to attend low rather than high PrEP caseload practices (adjusted odds ratio [aOR] 1.7; 95% CI: 1.0-2.8; P =0.047). The odds of non-continuous therapy was 2.9-fold higher in patients with bipolar disorder (aOR 2.89; 95% CI: 1.10-7.6; P =0.045). CONCLUSIONS: Following PBS listing, PrEP utilisation increased and stopping therapy was associated with attending low caseload practices. General practice education, particularly among low caseload practices, could help address these disparities.

Microelimination of Hepatitis C Among People With Human Immunodeficiency Virus Coinfection: Declining Incidence and Prevalence Accompanying a Multicenter Treatment Scale-up Trial.

BACKGROUND: Gay and bisexual men (GBM) are a key population affected by human immunodeficiency virus (HIV) and hepatitis C virus (HCV) coinfection. We aimed to measure HCV treatment effectiveness and to determine the population impact of treatment scale-up on HCV prevalence and incidence longitudinally among GBM. METHODS: The co-EC Study (Enhancing Care and Treatment Among HCV/HIV Coinfected Individuals to Eliminate Hepatitis C Transmission) was an implementation trial providing HCV direct-acting antiviral treatment in Melbourne, Australia, during 2016-2018. Individuals with HCV/HIV coinfection were prospectively enrolled from primary and tertiary care services. HCV viremic prevalence and HCV antibody/viremic incidence were measured using a statewide, linked, surveillance system. RESULTS: Among 200 participants recruited, 186 initiated treatment during the study period. Sustained virological response in primary care (98% [95% confidence interval {CI}, 93%-100%]) was not different to tertiary care (98% [95% CI, 86%-100%]). From 2012 to 2019, between 2434 and 3476 GBM with HIV infection attended our primary care sites annually, providing 13 801 person-years of follow-up; 50%-60% received an HCV test annually, and 10%-14% were anti-HCV positive. Among those anti-HCV positive, viremic prevalence declined 83% during the study (54% in 2016 to 9% in 2019). HCV incidence decreased 25% annually from 1.7/100 person-years in 2012 to 0.5/100 person-years in 2019 (incidence rate ratio, 0.75 [95% CI, .68-.83]; P < .001). CONCLUSIONS: High treatment effectiveness by nonspecialists demonstrates the feasibility of treatment scale-up in this population. Substantial declines in HCV incidence and prevalence among GBM provides proof-of-concept for HCV microelimination. CLINICAL TRIALS REGISTRATION: NCT02786758.

The Decade-Long Chinese Methadone Maintenance Therapy Yields Large Population and Economic Benefits for Drug Users in Reducing Harm, HIV and HCV Disease Burden.

Objectives: We aimed to conduct a comprehensive evaluation of the population impact of methadone maintenance treatment (MMT) for its future program planning. Methods: We conducted a literature review of the effects of MMT in China on HIV and HCV disease burden, injecting, and sexual behaviors and drug-related harm during 2004-2015. Data synthesis and analysis were conducted to obtain the pooled estimates of parameters for a mathematical model which was constructed to evaluate the effectiveness and cost-effectiveness of the program. Results: Based on a review of 134 articles, this study demonstrated that MMT is highly effective in reducing crime-related, high risk sexual, and injecting behaviors. The model estimated US$1,037 m which was invested in MMT from 2004 to 2015 has prevented 29,463 (15,325-43,600) new HIV infections, 130,563 (91,580-169,546) new HCV infections, 10,783 (10,380-11,187) deaths related to HIV, HCV and drug-related harm, and 338,920.0 (334,596.2-343,243.7) disability-adjusted life years (DALYs). The costs for each prevented HIV infection, HCV infection, death, and DALY were $35,206.8 (33,594.8-36,981.4), $7,944.7 ($7,714.4-8,189.2), $96,193.4 (92,726.0-99,930.2), and $3,060.6 ($3,022.0-3,100.1) respectively. Conclusion: The Chinese MMT program has been effective and cost-effective in reducing injecting, injecting-related risk behaviors and adversities due to HIV/HCV infection and drug-related harm among drug users.

Characteristics of recently arrived Asian men who have sex with men diagnosed with HIV through sexual health services in Melbourne and Sydney.

OBJECTIVES: Asian men who have sex with men (MSM) who have recently arrived in Australia are an emergent risk group for HIV; however, little is known about how they compare to Australian MSM diagnosed with HIV. This study compared the characteristics of these two groups. METHODS: A retrospective, cross-sectional study of MSM diagnosed with HIV between January 2014 and October 2017 in Melbourne and Sydney public sexual health clinics. Asian MSM were those who had arrived in Australia within 4 years of diagnosis. RESULTS: Among 111 Asian men, 75% spoke a language other than English, 88% did not have Medicare and 61% were international students. Compared with Australian men (n=209), Asian men reported fewer male sexual partners within 12 months (median 4 versus 10, p<0.001), were less likely to have tested for HIV previously (71% versus 89%, p<0.001) and had a lower median CD4 count (326 versus 520, p<0.001). Among Asian men, HIV subtype CRF01-AE was more common (55% versus 16%, p<0.001) and subtype B less common (29% versus 73%, p<0.001). CONCLUSIONS: Asian MSM diagnosed with HIV reported lower risk and had more advanced HIV. Implications for public health: HIV testing and preventative interventions supporting international students are required.

Early initiation of antiretroviral therapy for people newly diagnosed with HIV infection in Australia: trends and predictors, 2004-2015.

OBJECTIVES: To determine trends in and predictors of early treatment for people newly diagnosed with human immunodeficiency virus (HIV) infection in Australia. DESIGN, SETTING: Retrospective cohort analysis of routinely collected longitudinal data from 44 sexual health clinics participating in the Australian Collaboration for Coordinated Enhanced Sentinel Surveillance (ACCESS) program. PARTICIPANTS: Patients diagnosed with HIV infections, January 2004 - June 2015. MAIN OUTCOME MEASURES: Commencement of antiretroviral therapy within 6 months of HIV diagnosis (early treatment); demographic, clinical, and risk group characteristics of patients associated with early treatment; trends in early treatment, by CD4+ cell count at diagnosis. RESULTS: 917 people were diagnosed with HIV infections, their median age was 34 years (interquartile range [IQR]: 27-43 years), and 841 (92%) were men; the median CD4+ cell count at diagnosis was 510 cells/µL (IQR, 350-674 cells/µL). The proportion of patients who received early treatment increased from 17% (15 patients) in 2004-06 to 20% (34 patients) in 2007-09, 34% (95 patients) in 2010-12, and 53% (197 patients) in 2013-15 (trend, P < 0.001). The probability of early treatment, which increased with time, was higher for patients with lower CD4+ cell counts and higher viral loads at diagnosis. CONCLUSIONS: The proportion of people newly diagnosed with HIV in sexual health clinics in Australia who received treatment within 6 months of diagnosis increased from 17% to 53% during 2004-2015, reflecting changes in the CD4+ cell count threshold in treatment guidelines. Nevertheless, further strategies are needed to maximise the benefits of treatment to prevent viral transmission and morbidity.

HIV Testing With and Without a Clinical Consultation Among Men Who Have Sex With Men: A Randomized Controlled Trial.

BACKGROUND: Increasing the frequency of HIV testing among men who have sex with men (MSM) maximizes the preventive effect of antiretroviral therapy, by reducing time to diagnosis and treatment. SETTING: Melbourne Sexual Health Centre, Australia. METHODS: This randomized controlled trial evaluated whether access to testing, without seeing a clinician would increase testing frequency. MSM attending for HIV testing between July 2014 and April 2015 were randomized in 1:1 ratio to the intervention arm (access to HIV and syphilis testing at 300 pathology centers, without requiring consultations) or the control arm (consultation at every test), without blinding. The primary outcome was the incidence of HIV testing over 12 months. RESULTS: Of 443 men referred, 422 were randomized, 3 HIV positives at baseline were excluded, and 419 were analyzed. Of 208 control, 202 (97.1%) and 200 (94.8%) of 211 intervention group members were followed to 12 months. The intervention group had 453 tests in 205.6 person-years, incidence rate was 2.2 (95% confidence interval [CI]: 2.0 to 2.4) tests per year. The control group had 432 tests during 204.0 person-years, incidence rate was 2.1 (95% CI: 1.9 to 2.3) tests per year, and incidence rate ratio was 1.04 (95% CI: 0.89 to 1.2; P = 0.63). The annual rate of consultations was as follows: intervention, 1.61 (95% CI: 1.44 to 1.79); controls, 2.12 (95% CI: 1.92 to 2.33); rate ratio, 0.76 (95% CI: 0.65 to 0.88; P = 0.0001). There was no difference in quality of life scores (P = 0.61). CONCLUSIONS: MSM permitted HIV and syphilis testing outside of clinical consultations did not test more frequently than controls but had 24% fewer consultations, reducing service demand. TRIAL REGISTRATION: ACTRN12614000760673.

Understanding the Targeting and Uptake of HIV Testing Among Gay and Bisexual Men Attending Sexual Health Clinics.

We assessed trends in HIV testing outcomes during a period of clinic-based initiatives introduced to increase HIV testing among gay and bisexual men (GBM) attending sexual health clinics (SHCs) in New South Wales (NSW). A cohort of 25,487 HIV-negative GBM attending 32 SHCs in NSW (2009-2015) was classified into six sub-groups each year based on client-type (new/existing), risk-status (low/high-risk), and any recent HIV testing. Poisson regression methods were used to assess HIV testing outcomes in sub-groups of GBM. HIV testing outcomes and the sub-groups with greatest statistically significant annual increases were: individuals attending (26% in high-risk existing clients with recent testing); testing uptake (4% in low-risk existing clients with no recent testing); testing frequency (6% in low-risk existing clients with no recent testing and 5% in high-risk existing clients with recent testing); and total tests (31% in high-risk existing clients with recent testing). High-risk existing clients with recent testing had a 13% annual increase in the proportional contribution to total tests. Our findings show improved targeting of testing to high-risk GBM at NSW SHCs. The clinic-based initiatives should be considered for translation to other similar settings.