Continuous care engagement in clinical practice: perspectives on selected current strategies for people with HIV in the United States.

INTRODUCTION: Modern antiretroviral therapy is associated with reduced rates of HIV-related morbidity and mortality. HIV viral suppression and retention in care are critically important outcomes requiring successful continuous patient engagement. However, barriers to such engagement are complex and require innovative solutions. AREAS COVERED: A multistakeholder group of experts comprising clinicians and service delivery researchers assembled to clarify what constitutes engagement in HIV care and identify overarching themes that inform strategies in this field. This article captures this expert opinion and adds relevant literature on selected current best practices. EXPERT OPINION: The multistakeholder group felt strongly that a better understanding of the facilitators of continuous care engagement was critical. Unlike 'retention in care,' 'engagement in care' for an individual is nuanced, flexible, evolves and requires ongoing communication between patients, providers, and other key stakeholders. The following approaches highlight care engagement strategies at different stakeholder levels: 1) patient-level: personalized care and incentivization; 2) clinic-level: wraparound, co-localized, patient-centered low-barrier care, a diverse multidisciplinary team, patient support networks, and expanded use of telemedicine; 3) healthcare system-level: utilization of external partnerships. We propose a series of diverse and complementary approaches based on a more nuanced understanding of the qualitative aspects of engagement in care.

Ethnic identity and social support as mediators between childhood sexual abuse and depression among black men who have sex with men.

BACKGROUND: Survivors of childhood sexual abuse (CSA) often experience long-term adverse mental health effects, a trend that has been observed in research focusing on men who have sex with men (MSM), especially Black MSM. OBJECTIVE: The aim of this study was to investigate the direct and indirect effects of childhood sexual abuse on depression symptoms among Black MSM through early sexual debut, histories of incarceration, ethnic identity, and social support. In addition, we examine the role of social support and ethnic identity as mediators of depression symptoms. PARTICIPANTS AND SETTING: The HPTN 073 study enrolled and followed 226 HIV-uninfected Black MSM in three US cities (Los Angeles; Washington, DC; and Chapel Hill, North Carolina) from February 2013 to September 2015. Study participants were offered once-daily oral emtricitabine/tenofovir preexposure prophylaxis combined with counseling and followed for 52 weeks. METHODS: A path analysis was used to examine direct and indirect effects of CSA experiences on depression symptoms through incarceration, early sexual debut ethnic identity, and social support, and to see whether social support and ethnic identity mediated the relationship between incarceration and depression symptoms. RESULTS: Our results indicate that childhood sexual abuse was direct and positively associated with early sexual debut (ß = 0.21, p < .001). Both ethnic identity (ß = -0.14, p < .001) and social support (ß = -0.82, p < .001) were direct and negatively associated with depressive symptoms. CONCLUSION: Our research underscores the significant impact of CSA factors on the life trajectories of some Black MSM, including experiences such as incarceration, sexual debut, and depression symptoms.

HIV-1 Incidence, Adherence, and Drug Resistance in Individuals Taking Daily Emtricitabine/Tenofovir Disoproxil Fumarate for HIV-1 Pre-Exposure Prophylaxis: Pooled Analysis From 72 Global Studies.

BACKGROUND: Oral pre-exposure prophylaxis (PrEP) with emtricitabine/tenofovir disoproxil fumarate (F/TDF) has high efficacy against HIV-1 acquisition. Seventy-two prospective studies of daily oral F/TDF PrEP were conducted to evaluate HIV-1 incidence, drug resistance, adherence, and bone and renal safety in diverse settings. METHODS: HIV-1 incidence was calculated from incident HIV-1 diagnoses after PrEP initiation and within 60 days of discontinuation. Tenofovir concentration in dried blood spots (DBS), drug resistance, and bone/renal safety indicators were evaluated in a subset of studies. RESULTS: Among 17,274 participants, there were 101 cases with new HIV-1 diagnosis (0.77 per 100 person-years; 95% CI 0.63-0.94). In 78 cases with resistance data, 18 (23%) had M184I or V, one (1.3%) had K65R, and three (3.8%) had both mutations. In 54 cases with tenofovir concentration data from DBS, 45 (83.3%), 2 (3.7%), 6 (11.1%), and 1 (1.9%) had average adherence of <2, 2-3, 4-6, and ≥7 doses/week, respectively, and the corresponding incidence was 3.9 (95% CI 2.9-5.3), 0.24 (0.060-0.95), 0.27 (0.12-0.60), and 0.054 (0.008-0.38) per 100 person-years. Adherence was low in younger participants, Hispanic/Latinx and Black participants, cisgender women, and transgender women. Bone and renal adverse event incidence rates were 0.69 and 11.8 per 100 person-years, respectively, consistent with previous reports. CONCLUSIONS: Leveraging the largest pooled analysis of global PrEP studies to date, we demonstrate that F/TDF is safe and highly effective, even with less than daily dosing, in diverse clinical settings, geographies, populations, and routes of HIV-1 exposure.

Estimating the Effect of PrEP in Black Men Who Have Sex with Men: A Framework to Utilize Data from Multiple Non-Randomized Studies to Estimate Causal Effects.

Black men who have sex with men (MSM) are disproportionately burdened by the HIV epidemic in the US. The effectiveness of pre-exposure prophylaxis (PrEP) in preventing HIV infection has been demonstrated through randomized placebo-controlled clinical trials in several populations. Importantly, no such trial has been conducted exclusively among Black MSM in the US, and it would be unethical and infeasible to do so now. To estimate the causal effects of PrEP access, initiation, and adherence on HIV risk, we utilized causal inference methods to combine data from two non-randomized studies that exclusively enrolled Black MSM. The estimated relative risks of HIV were: (i) 0.52 (95% confidence interval: 0.21, 1.22) for individuals with versus without PrEP access, (ii) 0.48 (0.12, 0.89) for individuals who initiated PrEP but were not adherent versus those who did not initiate, and (iii) 0.23 (0.02, 0.80) for individuals who were adherent to PrEP versus those who did not initiate. Beyond addressing the knowledge gap around the effect of PrEP in Black MSM in the US, which may have ramifications for public health, we have provided a framework to combine data from multiple non-randomized studies to estimate causal effects, which has broad utility.

Examining the Role of Autonomy Support, Goal Setting, and Care Coordination Quality on HIV PrEP Adherence in Black Men Who Have Sex with Men: HPTN 073.

Autonomy support is a concept that is derived from self-determination theory. Autonomy refers to the freedom to act as one chooses. The current study aimed to examine if autonomy support was associated with dried blood spot validated pre-exposure prophylaxis (PrEP) adherence, and whether the association was mediated by PrEP adherence goal setting and progress toward PrEP adherence goals. Our sample was drawn from Black men who have sex with men (MSM) from across three cities (Chapel Hill, NC; Los Angeles, CA; and Washington, DC) in the United States between February 2013 and September 2014. We used logistic regression to evaluate associations between study variables and path analysis to test mediation effects. Participants were, on average, 28 [standard deviation (SD) = 1.12] years old and 25% were unemployed. We found that MSM who experienced high autonomy support were more likely to adhere to PrEP [odds ratio (OR) = 1.17; 95% confidence interval: 1.00-1.38]. MSM who set PrEP adherence goals were more likely to adhere to PrEP. Moreover, MSM who reported making progress toward their goals were also more likely to adhere to PrEP. Finally, client perception of coordination quality enhanced the magnitude of the association between goal setting and goal progress and the effect size of goal progress on PrEP adherence. Autonomy support, goal setting, goal monitoring/evaluation, and care coordination quality influenced PrEP adherence among Black MSM. Our findings indicate that while it is important to set goals for PrEP adherence, goal setting may need to be accompanied by progress monitoring to achieve the maximal effect.

Implementation of Client-Centered Care Coordination for HIV Prevention with Black Men Who Have Sex with Men: Activities, Personnel Costs, and Outcomes-HPTN 073.

BACKGROUND: Black men who have sex with men (MSM) experience disproportionate rates of HIV infection in the USA, despite being no more likely to engage in sexual risk behaviors than other MSM racial/ethnic groups. HIV pre-exposure prophylaxis (PrEP) has been shown to reduce risk of HIV acquisition; however, rates of PrEP use among Black MSM remain low. Clinical, psychosocial, and structural factors have been shown to impact PrEP use and adherence among Black MSM. Care coordination of HIV prevention services has the potential to improve PrEP use and adherence for Black MSM, as it has been shown to improve HIV-related care outcomes among people living with HIV. METHODS: Client-centered care coordination (C4) is a multi-level intervention designed to address clinical, psychosocial, and structural barriers to HIV prevention services for Black MSM within HPTN 073, a PrEP demonstration project among Black MSM in three cities in the USA. The current study examined the implementation process of C4, specifically investigating the activities, cost, time, and outcomes associated with the C4 intervention. RESULTS: On average, participants engaged in five care coordination encounters. The vast majority of care coordination activities were conducted by counselors, averaging 30 min per encounter. The cost of care coordination was relatively low with a mean cost of $8.70 per client encounter. CONCLUSION: Although client-centered care coordination was initially implemented in well-resourced communities with robust HIV research and service infrastructure, our findings suggest that C4 can be successfully implemented in resource constrained communities.

Freedom as Prevention: Mechanisms of Autonomy Support for Promoting HIV Pre-Exposure Prophylaxis Use and Condom Use among Black MSM in 3 US Cities-HPTN 073.

Healthcare providers who use controlling or coercive strategies may compel short-term enactment of HIV and sexually transmitted infection prevention behaviors but may inadvertently undermine their client's motivation to maintain those behaviors in the absence of external pressure. Autonomous motivation refers to the self-emanating and self-determined drive for engaging in health behaviors. It is associated with long-term maintenance of health behaviors. We used structural equation modeling to investigate whether autonomy support was associated with increased odds of therapeutic serum levels of pre-exposure prophylaxis, through a pathway that satisfies basic psychological needs for autonomous self-regulation and competence regarding pre-exposure prophylaxis use. We also investigated whether autonomy support was associated with decreased odds of condomless anal intercourse via the same psychological needs-satisfaction pathway of autonomous self-regulation and competence regarding condom use. We tested these two theorized pathways using secondary data from a longitudinal sample of Black men who have sex with men from across three cities in the US (N = 226). Data from the sample fit the theorized models regarding the pathways by which autonomy support leads to the presence of therapeutic PrEP levels in serum (χ2 = 0.56; RMSEA = 0.04; CFI = .99, TLI = 0.98) and how it also leads to decreased odds of condomless anal intercourse (χ2 = 0.58; RMSEA = 0.03; CFI = 0.99; TLI = 0.98). These findings provide scientific evidence for the utility of self-determination theory as a model to guide intervention approaches to optimize the implementation and impact of PrEP for Black men who have sex with men.

Optimizing PrEP Continuance: A Secondary Analysis Examining Perceived Autonomy Support and Care Coordination Quality among Black MSM in HPTN 073.

At the end of year 2018, it was estimated that in the United States over 1 million people were living with HIV. Although Black/African American individuals comprise an estimated 13.4% of the US population, as of 2019, they represented an estimated 42% of all new HIV diagnoses in 2018. PrEP use among Black men who have sex with men has not reached levels sufficient to have a population impact on HIV incidence. The purpose of this study was to examine whether high perceived autonomy support and care coordination quality were associated with PrEP continuation. Secondary analyses were conducted on data with 226 Black MSM in three US cities. Participants who were PrEP users and scored higher on autonomy support at week 8 were significantly more likely to continue PrEP (OR 1.48; 95% CI 1.04-2.11). Perception of coordination quality did not differ between PrEP users and non-users at any of the visits. Although coordination quality was not statistically significant, greater than half of PrEP users and non-PrEP users utilized the C4 services. Addressing social, individual, and structural barriers to PrEP may benefit Black MSM irrespective of their PrEP use.

Client-Centered Care Coordination (C4™) for HIV/STI Prevention: a Theoretical, Conceptual, and Methodological Overview-HIV Prevention Trials Network (HPTN) 073.

Introduction: There are few culturally informed, theory-driven evidence-based strategies to support PrEP use among Black MSM. This paper describes the theoretical foundation and conceptual development of C4™ to support the prevention of HIV and other STIs. Methods: C4™ integrates self-determination theory with comprehensive risk counseling and services using an integrative anti-racism lens. C4™ was implemented in a 52-week HIV prevention demonstration project to facilitate PrEP use and adherence among Black MSM (N=225) in three US cities from 2014-2017. Results: PrEP use was 79%, with 91% of PrEP users starting within 30-days. 12-month retention in C4™ was 92%. Care coordination encounters focused primarily on clients' needs related to PrEP adherence (43%) and sexual health (19%). Over the 12-month period, a substantial proportion of the men made progress towards their PrEP adherence goals at the 8-week (83%), 26-week (75%) and 52-week (81%) study visits. Conclusions: C4™ is a multi-level, multi-component intervention that dually targets individual-level motivations and capacities of Black MSM and the healthcare facility-level attitudes, behaviors and processes that characterize the climates where Black MSM receive services. Policy Implications: Public health policy efforts to scale-up PrEP may consider C4™ as a tool to optimize the use of PrEP and PrEP program retention with Black MSM. C4™ is also a tool for healthcare facilities to transform their models of service delivery towards improving the implementation PrEP services, including ensuring racial equity in the prevention impact of novel PrEP formulations such as long-acting injectable and potential future long-acting oral regimens.

Sexual Risk Profiles Among Black Sexual Minority Men: Implications for Targeted PrEP Messaging.

Black gay, bisexual, and other Black sexual minority men (BSMM) continue to experience some of the largest sexual health disparities in the U.S. Engaging BSMM in PrEP is crucial to improving sexual health outcomes and reducing disparities. However, knowledge of the profiles of sexual risk and PrEP initiation among this group is limited. This study used latent class analysis to identify HIV risk and PrEP initiation patterns among BSMM in the HPTN 073 Study (n = 226). Guided by current Centers for Disease Control screening guidelines, latent class indicators included relationship status, condom use, number of sexual partners, substance use, sexually transmitted infection (STI) history, and partner HIV status. Age and PrEP initiation were used in a multinomial regression to identify correlates of class membership. Three latent classes were identified: Single, Condomless Partners, Single, Multiple Partners, and Serodiscordant Partners. Single, Condomless Partners had the highest conditional probabilities of having greater than three male partners, substance use before sex, and receiving an STI diagnosis. Serodiscordant Partners had a 100% conditional probability of condomless sex and having a male partner living with HIV. BSMM who initiated PrEP were less likely to be classified as Single, Condomless Partners than Serodiscordant Partners (AOR = 0.07, 95% CI = 0.02, 0.66). Findings support the need for culturally relevant tailored and targeted messaging for BSMM with multiple sexual risk indicators.

Risk compensation in HIV PrEP adherence among Black men who have sex with men in HPTN 073 study.

While HIV infections among men who have sex men (MSM) have started to decline in the United States, Black MSM continue to experience disproportionate rates of HIV infection. The purpose of this secondary analysis is to examine risk perception and its influence on PrEP adherence among Black MSM from HPTN 073. Risk perception was measured using the adapted Perceived Vulnerability to HIV Scale. The associations between risk perception and PrEP adherence were tested using generalized estimation equation model for time-variant repeated measures. Risk perception was not significantly associated with PrEP adherence. These findings suggest an there was no risk compensation among PrEP users, and inconsistency in perceived risk for HIV. Future studies should investigate the rationale for long term adherence to PrEP among Black MSM.

Development of a Black Caucus within the HIV Prevention Trials Network (HPTN): Representing the Perspectives of Black Men Who Have Sex with Men (MSM).

Black men who have sex with men (MSM) have disproportionate HIV disease burden in the United States. Black MSM have been underrepresented in biomedical research, including HIV clinical trials, due to a myriad of socio-structural, socio-cultural, and psychosocial factors. The HIV Prevention Trials Network (HPTN) 061, a feasibility study of a multi-component HIV prevention intervention for Black MSM in six US cities, incorporated the development and implementation of a Black Caucus as a culturally grounded model for the integration of Black MSM in clinical trials and research in HPTN. Based on a qualitative methodological approach, we describe the formation and implementation of the Black Caucus from the perspective of Black MSM key community stakeholders. Three major themes emerged from the qualitative narratives: (1) the role of the Black Caucus in shaping the HPTN, (2) how the Black Caucus addresses the needs of Black MSM communities pertaining to the influence of race and sexual identity, and (3) socio-cultural needs of Black MSM. These findings have implications for the provision of culturally congruent expertise, community engagement, cultural mistrust, recruitment and retention of Black MSM in HIV clinical trials, culturally-relevant study design and implementation, and the role of developing Black MSM prevention researchers.

Development and Validation of the Personalized Sexual Health Promotion (SexPro) HIV Risk Prediction Model for Men Who Have Sex with Men in the United States.

Accurate HIV risk assessment among men who have sex with men (MSM) is important to help providers assess risk, and target HIV prevention interventions. We sought to develop an evidence-based HIV risk assessment tool for US MSM that is inclusive of Black MSM. Data from four large longitudinal cohorts of MSM were used to develop (EXPLORE), and validate (VAX004, HPTN061, and HVTN505). These data included visits in which participants self-reported HIV risk behavior and underwent HIV testing. We developed a pooled logistic model for incident HIV infection based on self-reported risk behaviors during the 6 months before each study visit. A total of 4069 MSM were used for the development cohort, and 8047 MSM in the three validation cohorts through 2013. The final model includes age (< 35, ≥ 35); Black race and Latino ethnicity; numbers of HIV-negative anal sex partners; number of insertive or receptive anal intercourse episodes; having 1 HIV-negative partner only; self-reported substance use; and bacterial sexually transmitted infection diagnosis. The model showed good discrimination in internal validation (C-statistic = 79.5). The external validation cohorts also showed good discrimination, with C-statistics of 73.1, 71.0, 71.9 in VAX004, HPTN061, and HVTN505 respectively, and acceptable calibration. We developed and validated an HIV risk assessment tool for MSM, which showed good predictive ability, including among the largest cohort of HIV-uninfected Black MSM in the US. This tool is available online (mysexpro.org) and can be used by providers to support targeting of HIV prevention interventions such as pre-exposure prophylaxis for MSM.

The Social Context of HIV Prevention and Care among Black Men Who Have Sex with Men in Three U.S. Cities: The Neighborhoods and Networks (N2) Cohort Study.

Background: In many parts of the world, stark racial disparities in human immunodeficiency virus (HIV) prevalence, incidence, prevention, and care outcomes persist among gay, bisexual, and other men who have sex with men (MSM), with Black MSM significantly impacted in the United States (U.S.). Individual-level characteristics, including sexual behaviors and socioeconomic status, do not fully account for racial/ethnic disparities in HIV among MSM. We hypothesize that neighborhood contexts and network characteristics influence risk for HIV infection as well as HIV-related prevention and care behaviors. As such, the study design includes the use of real-time geospatial methods and in-depth assessments of multiple network typologies to investigate the impact of neighborhood and network-level factors on HIV prevention and treatment among Black MSM residing in longstanding priority HIV elimination areas in the U.S., namely Chicago, Illinois and in the Deep South (Jackson, Mississippi and New Orleans, Louisiana) (n = 450, n = 50, and n = 100, respectively). We describe the design, sampling methods, data collection, data management methods, and preliminary findings of the ongoing 'Neighborhoods and Networks (N2) Cohort Study'. Methods/Design: N2 employs a prospective longitudinal design. The sample includes Black MSM participants in Chicago recruited via respondent-driven sampling and assessed every six months over two years of follow-up. Participants enrolled in Jackson and New Orleans are being recruited through existing health and community services and assessed every six months over one year of follow-up. Mobility within and between neighborhoods is being assessed using global positioning system (GPS) technology. Social and sexual networks among Black MSM are being studied through egocentric network inventories as well as newer methods of creating meso-level networks that involve social media (Facebook) and mobile phone contacts. Key HIV prevention outcomes such as pre-exposure prophylaxis (PrEP) care engagement, and HIV/STI (sexually transmitted infections) biomarkers will be examined at baseline and follow-up. Results: As of 31 December 2018, a total of 361 men were enrolled across all study sites: 259 in Chicago and 102 in the Deep South (75 in New Orleans and 27 in Jackson). At baseline, participants ranged in age from 17 to 65 years old (mean = 34.3, standard deviation = 5.1) with 123 men (34.1%) self-reported as HIV positive. While HIV treatment levels were similar between sites, men in the Deep South reported higher rates of adherence than men in Chicago (63.3% versus 49.4%, p = 0.03). Sexual risk profiles were mainly the same between men from different study sites, with 22.9% of men in Chicago and 28.9% in the Deep South reporting consistent condom use during vaginal and anal sex (p = 0.26). Regarding their home neighborhoods, men in the Deep South were more likely than those in Chicago to characterize theirs as having a good reputation (43.1% versus 24.7%, p < 0.001) and as being safe (37.3% versus 21.2%, p = 0.002). Conclusions: The focus on Black MSM in the N2 Study will allow for a nuanced exploration of the attitudes, beliefs, behaviors, and practices of a diverse group of Black MSM. The study is also positioned to provide novel insight about neighborhood and network characteristics that influence HIV-related behaviors. A health equity framework ensures that Black MSM are not explicitly or implicitly deemed as deviant, disordered, or the non-reference group. Findings from N2 will provide guidance for the implementation of more impactful HIV prevention interventions that engage a diverse population of Black MSM as we work toward HIV elimination in the U.S.

Pre-exposure prophylaxis initiation and adherence among Black men who have sex with men (MSM) in three US cities: results from the HPTN 073 study.

INTRODUCTION: Randomized clinical trials have demonstrated the efficacy of antiretroviral pre-exposure prophylaxis (PrEP) in preventing HIV acquisition among men who have sex with men (MSM). However, limited research has examined initiation and adherence to PrEP among Black MSM (BMSM) in the United States (US) who are disproportionately represented among newly HIV infected and late to care individuals. This research reports on the HIV Prevention Trials Network 073 (HPTN 073) study aimed to examine PrEP initiation, utilization and adherence among Black MSM utilizing the theoretically principled, culturally informed and client-centered care coordination (C4) model. METHODS: The HPTN 073 study enrolled and followed 226 HIV-uninfected Black MSM in three US cities (Los Angeles, CA; Washington DC; and Chapel Hill, NC) from February 2013 through September 2015. Study participants were offered once daily oral emtricitabine/tenofovir (FTC/TDF) PrEP combined with C4 and followed up for 52 weeks. Participants received HIV testing, risk reduction education and clinical monitoring. RESULTS: Of the 226 men enrolled, 178 participants initiated PrEP (79%), and of these 64% demonstrated PrEP utilization at week 26 (mid-point of the study) based on pharmacokinetic testing. Condomless anal sex with an HIV-infected or unknown status casual male partner was statistically significantly associated with a greater likelihood of PrEP initiation (adjusted odds ratio (OR) 4.4, 95% confidence interval (CI) 1.7, 11.7). Greater age (≥25 vs. <25, OR 2.95, 95% CI 1.37 -6.37), perception of having enough money (OR 3.6, 95% CI 1.7 to 7.7) and knowledge of male partner taking PrEP before sex (OR 2.22, 95% CI 1.03 to 4.79) were statistically significantly associated with increased likelihood of PrEP adherence at week 26. Annualized HIV incidence was 2.9 (95% CI 1.2 to 7.9) among those who initiated PrEP, compared to 7.7 (95% CI 2.5 to 24.1) among those who did not initiate PrEP (p = 0.18). CONCLUSIONS: Results suggest a high level of PrEP initiation among at-risk Black MSM, a group historically characterized as hard to reach. The data support the importance of addressing contextual factors that affect PrEP initiation and adherence, and of additional research on the ultimate benefit of PrEP in HIV prevention among Black MSM.

Short Communication: Viral Genetic Linkage Analysis Among Black Men Who Have Sex With Men (HIV Prevention Trials Network 061).

Analysis of viral genetic linkage can reveal generalized transmission patterns within a population. The HIV Prevention Trials Network 061 study evaluated HIV incidence among black men who have sex with men. HIV genotypes from 169 men who were HIV infected at enrollment and 23 men who seroconverted during the study were analyzed for genetic linkage. This analysis showed some associations of viral linkage with income, study site, and timing of infection.

Incidence and Correlates of Sexually Transmitted Infections Among Black Men Who Have Sex With Men Participating in the HIV Prevention Trials Network 073 Preexposure Prophylaxis Study.

BACKGROUND: The HIV Prevention Trials Network (HPTN) Study 073 (HPTN 073) assessed the feasibility, acceptability, and safety of preexposure prophylaxis (PrEP) for black men who have sex with men (BMSM). The purpose of this analysis was to characterize the relationship between PrEP uptake and use and incident sexually transmitted infections (STIs) among participants enrolled in HPTN 073. METHODS: A total of 226 human immunodeficiency virus (HIV)-uninfected BMSM were enrolled in 3 US cities; all participants received client-centered care coordination (C4) and were offered daily oral PrEP. Participants were followed for 12 months with STI testing (rectal and urine nucleic acid amplification test for gonorrhea and chlamydia, rapid plasma reagin for syphilis) conducted at baseline, week 26, and week 52. Logistic regression was used to examine associations between STI incidence and PrEP uptake. Generalized estimating equations were used to evaluate associations between age, PrEP acceptance, sexual behaviors, and incident STIs. RESULTS: Baseline STI prevalence was 14.2%. Men aged <25 years were more likely to have a baseline STI (25.3% vs 6.7%; odds ratio [OR], 4.39; 95% confidence interval [CI:, 1.91, 10.11). Sixty participants (26.5%) acquired ≥1 STI during follow-up; the incidence rate was 34.2 cases per 100 person-years (95% CI, 27.4, 42.9). In adjusted analyses, baseline STI diagnosis (OR, 4.23; 95% CI, 1.82, 9.87; P < .001) and additional C4 time (OR, 1.03; 95% CI, 1.00, 1.06; P = .027) were associated with having an incident STI. STI incidence was not associated with PrEP acceptance or adherence. CONCLUSIONS: While we found higher rates of STIs in younger BMSM, overall rates of STI were lower than in prior PrEP trials, with no increase over time. BMSM with STIs at PrEP initiation may require additional interventions that target STI acquisition risk. CLINICAL TRIALS REGISTRATION: NCT01808352.

Recruitment of Underrepresented Minority Researchers into HIV Prevention Research: The HIV Prevention Trials Network Scholars Program.

Most U.S. investigators in the HIV Prevention Trials Network (HPTN) have been of majority race/ethnicity and sexual orientation. Research participants, in contrast, have been disproportionately from racial/ethnic minorities and men who have sex with men (MSM), reflecting the U.S. epidemic. We initiated and subsequently evaluated the HPTN Scholars Program that mentors early career investigators from underrepresented minority groups. Scholars were affiliated with the HPTN for 12-18 months, mentored by a senior researcher to analyze HPTN study data. Participation in scientific committees, trainings, protocol teams, and advisory groups was facilitated, followed by evaluative exit surveys. Twenty-six trainees have produced 17 peer-reviewed articles to date. Research topics typically explored health disparities and HIV prevention among black and Hispanic MSM and at-risk black women. Most scholars (81% in the first five cohorts) continued HIV research after program completion. Alumni reported program-related career benefits and subsequent funding successes. Their feedback also suggested that we must improve the scholars' abilities to engage new research protocols that are developed within the network. Mentored engagement can nurture the professional development of young researchers from racial/ethnic and sexual minority communities. Minority scientists can benefit from training and mentoring within research consortia, whereas the network research benefits from perspectives of underrepresented minority scientists.

Analysis of HIV Integrase Resistance in Black Men Who Have Sex with Men in the United States.

Resistance to reverse transcriptase and protease inhibitors was frequently detected in HIV from black men who have sex with men (MSM) enrolled in the HIV prevention trials network (HPTN) 061 study. In this study, integrase strand transfer inhibitor (INSTI) resistance was analyzed in black MSM enrolled in HPTN 061 (134 infected at enrollment and 23 seroconverters) and a follow-up study, HPTN 073 (eight seroconverters). The ViroSeq HIV-1 Integrase Genotyping Kit (Abbott Molecular) was used for analysis. Major INSTI resistance mutations were not detected in any of the samples. HIV from 14 (8.4%) of the 165 men, including 4 (12.9%) of 31 seroconverters, had accessory or polymorphic INSTI-associated mutations. The most frequently detected mutation was E157Q. These findings are promising because INSTI-based regimens are now recommended for first-line antiretroviral treatment and because long-acting cabotegravir is being evaluated for pre-exposure prophylaxis.