Impact of HIV pre-exposure prophylaxis prescriptions on HIV diagnoses in New York city.

BACKGROUND: HIV preexposure prophylaxis (PrEP) has proven to be efficacious and effective in preventing HIV infections, but few studies have reported its impact in the real world. METHODS: We conducted an ecological analysis and compared the trends in HIV PrEP prescriptions with the trends in age-adjusted HIV diagnosis rates in New York City (NYC). Joinpoint regression analyses were used to identify any temporal trends in HIV diagnosis rates in NYC. RESULTS: The number of people filling at least one PrEP prescription in NYC increased from 2551 in 2014 to 35 742 in 2022. The overall age-adjusted HIV diagnosis rate steadily decreased from 48.1 per 100 000 in 2003 to 17.1 per 100 000 in 2022. After the rollout of PrEP, accelerated decreases were detected in some subpopulations including white men [2014-2019 annual percentage change (APC): -16.6%; 95% confidence interval (CI) -22.7 to -10.0], Asian/Pacific Islander men (2016-2022 APC: -9.8%), men aged 20-29 years (2017-2020 APC: -9.4%) and 40 -49 years (2014-2020 APC: -12.2%), Latino/Hispanic people aged 40-49 years (2015-2020 APC: -13.0%), white people aged 20-29 years (2012-2022 APC: -11.4%) and 40-49 years (2014-2018 APC: -27.8%), and Asian/Pacific Islander people aged 20-29 years (2017-2022 APC: -13.0). CONCLUSION: With a high coverage, PrEP can have a long-term impact in reducing HIV infections in a population, but if preexisting social determinants that contribute to racial, ethnic, and gender inequities are not well addressed, the implementation of PrEP can exacerbate these inequalities.

Inequities Along the Human Immunodeficiency Virus (HIV) Pre-exposure Prophylaxis Services Continuum for Black Women in the United States, 2015-2020.

OBJECTIVE: To estimate the number of women who received human immunodeficiency virus (HIV) and sexually transmitted infection (STI) testing and HIV pre-exposure prophylaxis (PrEP) services by race and ethnicity in seven THRIVE (Targeted Highly Effective Interventions to Reverse the HIV Epidemic)-funded jurisdictions and to estimate associations of age and syphilis and gonorrhea diagnoses with receipt of HIV PrEP services. METHODS: We analyzed data collected from 2015 to 2020 in Birmingham, Alabama; Baltimore City, Maryland; Washington, DC, New Orleans, Louisiana; Brooklyn, New York; Philadelphia, Pennsylvania; and Hampton Roads, Virginia. We compared Black women and women of additional racial and ethnic groups by age, HIV status at enrollment, receipt of STI testing and test positivity, and steps in the PrEP continuum (screened, eligible, referred, linked, and prescribed). We also examined the association of age, syphilis, or gonorrhea with the following steps in the PrEP continuum: screened, referred, linked, and prescribed. RESULTS: Black women made up 69.2% (8,758/12,647) of women served in THRIVE. Compared with non-Black women, Black women were more likely to have a positive test result for syphilis (3.3% vs 2.1%), gonorrhea (4.9% vs 3.5%), chlamydia (5.1% vs 1.9%), or more than one STI (1.4% vs 0.3%). Among women with negative HIV test results or unknown HIV status, Black women were more likely to be screened for PrEP eligibility (88.4% vs 64.9%). Among Black women, the proportion screened for PrEP was higher among those diagnosed with syphilis (97.3%) or gonorrhea (100%) than among those without an STI (88.1% and 87.8%, respectively). Among 219 Black women who presented with syphilis, only 10 (4.6%) were prescribed PrEP; among 407 with gonorrhea, only 11 (2.7%) were prescribed PrEP. CONCLUSION: Although most Black women seeking services received STI testing, the proportion of Black women who were eligible for PrEP and prescribed PrEP was low. To achieve national HIV-prevention goals, it is imperative that Black women have access to PrEP information and services.

Reasons for PrEP Discontinuation After Navigation at Sexual Health Clinics: Interactions Among Systemic Barriers, Behavioral Relevance, and Medication Concerns.

BACKGROUND: Pre-exposure prophylaxis (PrEP) for HIV prevention requires engagement throughout the PrEP care continuum. Using data from a PrEP navigation program, we examine reasons for PrEP discontinuation. SETTING: Participants were recruited from New York City Health Department Sexual Health Clinics with PrEP navigation programs. METHODS: Participants completed a survey and up to 3 interviews about PrEP navigation and use. This analysis includes 94 PrEP initiators that were PrEP-naive before their clinic visit, started PrEP during the study, and completed at least 2 interviews. Interview transcripts were reviewed to assess reasons for PrEP discontinuation. RESULTS: Approximately half of PrEP initiators discontinued PrEP during the study period (n = 44; 47%). Most participants (71%) noted systemic issues (insurance or financial problems, clinic or pharmacy logistics, and scheduling barriers) as reasons for discontinuation. One-third cited medication concerns (side effects, potential long-term side effects, and medication beliefs; 32%) and behavioral factors (low relevance of PrEP because of sexual behavior change; 34%) as contributing reasons. Over half (53.5%) highlighted systemic issues alone, while an additional 19% attributed discontinuation to systemic issues in combination with other factors. Of those who discontinued, approximately one-third (30%) restarted PrEP during the follow-up period, citing resolution of systemic issues or behavior change that increased PrEP relevance. CONCLUSIONS: PrEP continuation is dependent on interacting factors and often presents complex hurdles for patients to navigate. To promote sustained engagement in PrEP care, financial, clinic, and pharmacy barriers must be addressed and counseling and navigation should acknowledge factors beyond sexual risk that influence PrEP use.

PrEP Use and Correlates of Use Among a Large, Urban Sample of Men and Transgender Persons Who Have Sex with Men.

We examined recent pre-exposure prophylaxis (PrEP) use (past 6 months) and its correlates among a large sample of men who have sex with men and transgender and gender non-conforming persons participating in a home HIV self-testing program conducted by the New York City Health Department between 11/2016 and 1/2017. Correlates examined included demographic characteristics and HIV-related behaviors in the past 6 months. Associations with recent PrEP use were assessed using log-binomial regression. 400 (22.5%) of 1776 participants reported recent PrEP use. In adjusted models, recent PrEP use was associated with Manhattan residence [adjusted prevalence ratio (aPR) 1.26; 95% confidence interval (CI) (1.04, 1.53)], higher income [aPR 1.29; 95% CI (1.03, 1.62)], and having insurance [aPR 1.89; 95% CI (1.33, 2.69)]. All HIV-related behaviors, except for injection drug use, were individually associated with PrEP use. More research is needed to better understand barriers to PrEP use among patients who are low income and/or uninsured as this may help improve current public health efforts to increase PrEP uptake among disproportionately impacted populations.

Academic Detailing to Increase Prescribing of HIV Pre-exposure Prophylaxis.

Although HIV pre-exposure prophylaxis can decrease new cases of HIV by up to 99%, many patients who could benefit from pre-exposure prophylaxis never receive prescriptions for it. Because pre-exposure prophylaxis is indicated for patients who do not have an infectious disease, increasing pre-exposure prophylaxis prescribing by primary care and generalist clinicians represents a key element of the Ending the HIV Epidemic in the U.S. initiative. This review provides an overview of academic detailing and how it is currently being used to increase pre-exposure prophylaxis prescribing. Academic detailing is outreach education that engages with clinicians in 1-to-1 or small group interactions focused on identifying and addressing an individual clinician's needs to increase their use of evidence-based practices. Academic detailing has been proven in multiple previous research studies, and the principles required for successful implementation include interactivity, clinical relevance of content, and focus on defined behavior change objectives. Clinician barriers to pre-exposure prophylaxis prescribing may occur in the domains of knowledge, attitudes, or behavior, and academic detailing has the potential to address all of these areas. State and local health departments have developed academic detailing programs focused on pre-exposure prophylaxis prescribing and other elements of HIV prevention-sometimes describing the approach as public health detailing. Few studies of academic detailing for pre-exposure prophylaxis have been published to date; rigorous evaluation of HIV-specific adaptations and innovations of the approach would represent an important contribution. In the setting of the COVID-19 pandemic, interest in virtual delivery of academic detailing has grown, which could inform efforts to implement academic detailing in rural communities and other underserved areas. Increasing this capacity could make an important contribution to Ending the HIV Epidemic in the U.S. and other HIV prevention efforts.

Public Health Detailing to Promote HIV Pre- and Postexposure Prophylaxis Among Women's Healthcare Providers in New York City.

INTRODUCTION: Equitable access to HIV pre- and postexposure prophylaxis for women is essential to ending the HIV epidemic. Providers' lack of knowledge and comfort in discussing and prescribing pre-exposure prophylaxis to women persist as barriers. METHODS: From May to November 2019, the New York City Health Department conducted its first public health detailing campaigns among women's healthcare providers to promote pre- and postexposure prophylaxis and the associated best practices. Over 2 campaigns (10 weeks each), trained Health Department representatives visited providers for 1-on-1 visits at select practices to promote key messages. Representatives distributed an Action Kit that addressed knowledge gaps and practice needs on providing pre-exposure prophylaxis and postexposure prophylaxis to cisgender and transgender women. Providers completed an assessment at the beginning of initial and follow-up visits, used to compare responses across visits. Statistically significant changes were evaluated by generalized linear models of bivariate outcomes, adjusted for nonindependence of providers at the same practice. RESULTS: Representatives visited 1,348 providers specializing in primary care (47%), women's health (30%), adolescent health (7%), infectious disease (4%), and other (12%) at 860 sites; 1,097 providers received initial and follow-up visits. Provider report of ever prescribing pre-exposure prophylaxis increased by 12% (n=119 providers); increases were reported in measures of taking sexual history, asking about partners' HIV status, providing postexposure prophylaxis, recognizing pre-exposure prophylaxis's effectiveness, and discussing and referring for pre-exposure prophylaxis. CONCLUSIONS: After public health detailing, women's healthcare providers report increased adoption of recommended practices that promote pre- and postexposure prophylaxis uptake and sexual wellness among women. Detailing may be adaptable to other regions and contexts to reach providers.

Five Waves of an Online HIV Self-Test Giveaway in New York City, 2015 to 2018.

BACKGROUND: HIV self-tests increase HIV status awareness by providing convenience and privacy, although cost and access may limit use. Since 2015, the New York City (NYC) Health Department has conducted 5 waves of an online Home Test Giveaway. METHODS: We recruited adult cisgender men who have sex with men (MSM) and transgender and gender-nonconforming (TGNC) individuals who had sex with men, who were living in NYC, not previously HIV diagnosed, and using paid digital advertisements (4-8 weeks per wave). Eligible respondents were e-mailed a code to redeem on the manufacturer's website for a free HIV self-test and an online follow-up survey ~2 months later. For key process and outcome measures, we present means across 5 waves. RESULTS: Across the 5 waves of Home Test Giveaway, there were 28,921 responses to the eligibility questionnaire: 17,383 were eligible, 12,182 redeemed a code for a free HIV self-test, and 7935 responded to the follow-up survey (46% of eligible responses). Among eligible responses, approximately half were Latino/a (mean, 32%) or non-Latino/a, black (mean, 17%). Mean report of never testing before was 16%. Among 5903 follow-up survey responses who reported test use, 32 reported reactive results with no known previous diagnosis (0.54%), of whom 78% reported receiving confirmatory testing. Report of likelihood of recommending the Home Test Giveaway to friends was high (mean, 96%). CONCLUSIONS: We recruited diverse NYC MSM and TGNC and distributed a large number of HIV self-tests to them. Among respondents who reported newly reactive tests, the majority reported confirmatory testing. This seems to be one acceptable way to reach MSM and TGNC for HIV testing, including those who have never tested before.

Public Health Detailing for Human Immunodeficiency Virus Pre-exposure Prophylaxis.

Despite the promise of human immunodeficiency virus (HIV) pre-exposure prophylaxis (PrEP), PrEP remains underutilized, often due to clinician factors. Academic or public health detailing is a process by which university and/or government groups employ the marketing practices of pharmaceutical companies to improve clinical practice. We describe the novel application of detailing to increase PrEP prescribing and related care in New York City and New England. Detailing can play a crucial role in PrEP implementation.

Preexposure Prophylaxis Monitoring in New York City: A Public Health Approach.

The scale-up of preexposure prophylaxis (PrEP) represents a paradigm shift in HIV prevention that poses unique challenges for public health programs. Monitoring of PrEP implementation at the population level is a national priority, with particular significance in New York City (NYC) given the substantial HIV burden and the prominence of PrEP in state and local Ending the Epidemic program plans. We highlight the importance of local monitoring and evaluation of PrEP implementation outcomes and describe the experience at the NYC Health Department, which includes engaging communities, triangulating a variety of data sources regarding PrEP implementation, and leveraging those data to help guide programming. In NYC, we used data from national surveillance systems and incorporated PrEP-related indicators into existing local data collection systems to help illustrate gaps in PrEP awareness and use. Ultimately, ensuring that PrEP achieves the desired impact at the population level depends on identifying disparities through appropriate and accurate measurement, and addressing them through evidence-based programs.

Mobility among youth in Rakai, Uganda: Trends, characteristics, and associations with behavioural risk factors for HIV.

Mobility, including migration and travel, influences risk of HIV. This study examined time trends and characteristics among mobile youth (15-24 years) in rural Uganda, and the relationship between mobility and risk factors for HIV. We used data from an annual household census and population-based cohort study in the Rakai district, Uganda. Data on in-migration and out-migration were collected among youth (15-24 years) from 43 communities from 1999 to 2011 (N = 112,117 observations) and travel among youth residents from 2003 to 2008 (N = 18,318 observations). Migration and travel were more common among young women than young men. One in five youth reported out-migration. Over time, out-migration increased among youth and in-migration remained largely stable. Primary reasons for migration included work, living with friends or family, and marriage. Recent travel within Uganda was common and increased slightly over time in teen women (15-19 years old), and young adult men and women (20-24 years old). Mobile youth were more likely to report HIV-risk behaviours including: alcohol use, sexual experience, multiple partners, and inconsistent condom use. Our findings suggest that among rural Ugandan youth, mobility is increasingly common and associated with HIV-risk factors. Knowledge of patterns and characteristics of a young, high-risk mobile population has important implications for HIV interventions.

Pharmacists' Knowledge and Practices Surrounding Expedited Partner Therapy for Chlamydia trachomatis, New York City, 2012 and 2014.

BACKGROUND: Health care providers in New York City can prescribe treatment for Chlamydia trachomatis (Ct) for a patient's partner without the partner having a medical evaluation ("prescription-expedited partner therapy" [EPT]), and use of prescription-EPT is common. However, there is little known about pharmacists' knowledge and practices surrounding EPT. METHODS: Two cross-sectional surveys, in 2012 and 2014, were conducted with representative samples of supervising pharmacists in NYC neighborhoods with high rates of Ct infection. RESULTS: In both survey years, the majority of pharmacists who agreed to participate returned a survey (2012: 81% [83/103], 2014: 61% [106/173]), and pharmacist and pharmacy characteristics were similar across the 2 surveys. Pharmacists' EPT-related knowledge and practice was generally low, with little change between 2012 and 2014. In both years, fewer than half of pharmacists knew EPT was legal (2012, 46%; 2014, 42%). There were even decreases in specific content knowledge; in 2014, significantly fewer of the pharmacists who knew EPT was legal, knew that the initials "EPT" must be written in the body of the prescription (2012: 58%; 2014: 36%, P < 0.05). Most pharmacists in both survey years reported they had never received an EPT prescription, and those who had reported only infrequent receipt. CONCLUSIONS: NYC pharmacists had low levels of knowledge and familiarity with EPT law and reported infrequent receipt of EPT prescriptions. Pharmacists and providers should be further educated about EPT laws and regulations so that prescription-EPT use can be accurately monitored, and to assure the success of this partner treatment strategy.

Factors associated with incident HIV infection versus prevalent infection among youth in Rakai, Uganda.

Factors associated with prevalent and incident HIV infection were compared among sexually experienced Ugandans aged 15-24. Most factors were similar. However, in women, older age and current marriage were associated with prevalent, but not incident, infection. It is important to recognize the limitations of prevalence analyses for identifying at-risk youth.

Evaluating the 2010 New York State HIV testing law in NYC ambulatory practices using electronic health records.

INTRODUCTION: In 2010, the New York State Legislature made it mandatory to offer an HIV test to people aged 13-64 years receiving hospital or primary care services, with limited exceptions. In this study, we used data from New York City practices to evaluate the impact of the law on HIV testing rates in ambulatory care. METHODS: We collected quarterly testing data from the electronic health records of 218 practices. We calculated overall and stratified crude testing rates. Using univariate and multivariate generalized estimating equation models, we assessed the odds of testing in the year before the law (baseline) versus the first and second year after the law's implementation (year 1 and year 2). RESULTS: During baseline, the odds of testing did not increase significantly. During year 1, the odds of testing significantly increased by 50% in the univariate model and 200% after adjusting for confounders. During year 2, the odds of testing increased 10%. This was only significant in the univariate model. The crude quarterly testing rate increased from 2.8% to 5.7% from baseline to year 2. CONCLUSIONS: Our evaluation showed that after the implementation of the HIV testing law, there was an increase in HIV testing among NYC ambulatory practices. Testing rates remained modest, but considerable improvement was seen in community health centers, in age ranges targeted by the law and in practices that were screening for HIV at baseline. This study suggests that legislation may be effective when used in a comprehensive prevention strategy.

HIV testing experience in New York City: offer of and willingness to test in the context of new legal support of routine testing.

BACKGROUND: In the United States, routine HIV testing is recommended for persons aged 13-64 years. In 2010, New York State passed a law mandating offer of testing in most health-care settings. We report on the consumer perspective in New York City (NYC) shortly after the law's enactment. METHODS: We analyzed data from a 2011 telephone survey representative of NYC adults aged 18-64 years (n = 1,846). This analysis focused on respondents' report of HIV test offer at last clinical visit and of willingness to test if recommended by their doctor. Offer and willingness were estimated by age, gender, race/ethnicity, education, income, marital status, sexual identity, partner number, and HIV testing history; associations were examined using multivariable regression. RESULTS: Among NYC adults, 35.7% reported an HIV test in the past year and 31.8% had never tested. Among 86.7% with a clinical visit in the past year, 31.4% reported being offered a test at last visit. Offer was associated with younger age, race/ethnicity other than white, non-Hispanic, lower income, and previous testing. Only 6.7% of never-testers were offered a test at last clinical visit. Willingness to test if recommended was high overall (90.2%) and across factors examined. CONCLUSIONS: After a new law was enacted in support of routine HIV testing, approximately 1 in 3 New Yorkers aged 18-64 years were offered a test at last clinical visit; 9 in 10 were willing to test if recommended by their doctor. This suggests that patient attitudes will not be a barrier to complete implementation of the law.

Trends in HIV acquisition, risk factors and prevention policies among youth in Uganda, 1999-2011.

OBJECTIVE: The objective of this study is to understand how trends in HIV acquisition among youth can be influenced by change in HIV risk factors, social factors and prevention and treatment programmes. DESIGN: Trends in HIV incidence (per 1000 person-years), by sex and age group, were estimated using data from youth (15-24 years: n = 22,164) in the Rakai Community Cohort Study. Trends in HIV incidence were compared with trends in previously identified HIV risk factors, social factors and programmes. METHODS: Poisson and linear regression were used to test for statistical significance and decomposition was used to calculate attribution of risk factors to HIV incidence. RESULTS: Substantial declines between 1999 and 2011 occurred in sexual experience, multiple partners and sexual concurrency among adolescents and young adults. HIV acquisition declined substantially (86%, P = 0.006) among adolescent women (15-19 years) but not among men or young adult women. Changes in HIV incidence and risk behaviours coincided with increases in school enrolment, decline in adolescent marriage, availability of antiretroviral therapy (ART) and increases in male medical circumcision (MMC). Much of the decline in HIV incidence among adolescent women (71%) was attributable to reduced sexual experience; the decline in sexual experience was primarily attributable to increasing levels of school enrolment. CONCLUSION: Dramatic decreases in HIV incidence occurred among adolescent women in Rakai. Changes in school enrolment and sexual experience were primarily responsible for declining HIV acquisition over time among adolescent women. Given limited improvement among young men and young adult women, the need for effective HIV prevention for young people remains critical.

Characterization of three novel human papillomavirus types isolated from oral rinse samples of healthy individuals.

BACKGROUND: Despite the strong evidence of HPV infection as the etiological agent in a subset of oral cancer, oral α-HPV detection is rare in healthy individuals, and little is known of the existing of novel HPV types in oral cavity. OBJECTIVE: We determined whether novel HPV types can be isolated from oral rinse samples collected from healthy individuals. STUDY DESIGN: We performed rolling circle amplification (RCA) coupled with degenerated PCR assay on 48 oral rinse samples to amplify novel HPV types. Full length HPV DNA was cloned using long range PCR. Quantitative type specific Taqman assays were used to determine the prevalence of novel HPV types in 158 archived oral tissue samples. RESULTS: We were able to isolate four novel human papillomavirus types. Full length HPV DNA was cloned for three of the four novel HPV types. All four HPV types belong to the genus Gammapapillomavirus (γ-PV), where HPV 171 is most closely related to HPV 169, showing 88% similarity; HPV 172 is most closely related to HPV 156, showing 70% similarity; HPV 173 is most closely related to HPV 4, showing 73% similarity; oral sample lavage (OSL) 37 is most closely related to HPV 144, showing 69% similarity. Finally, we showed that HPV 173 was rarely present in oral tissues (2/158), HPV 172 was only detected in normal oral tissues (25/76), and HPV 171 was more prevalent in malignant oral tissues (17/82 vs. 10/76, p=0.21). CONCLUSIONS: Novel γ-HPV types are present in oral cavity of healthy individuals.

Adolescent risk-taking, cancer risk, and life course approaches to prevention.

Adolescent risk-taking may have long-term consequences for adult cancer risk. Behaviors such as smoking and sexual activity, commonly initiated during adolescence, may result--decades later--in cancer. Life course epidemiology focuses on unique vulnerabilities at specific development periods and their importance to later development of disease. A life course epidemiological perspective that integrates social and biological risk processes can help frame our understanding how specific adult cancers develop. Moreover, life course perspectives augment traditional public health approaches to prevention by emphasizing the importance of unique windows of opportunity for prevention.