Who falls between the cracks? Identifying eligible PrEP users among people with Sub-Saharan African migration background living in Antwerp, Belgium.

INTRODUCTION: This study produces an estimate of the proportion of eligible PrEP users among people of Sub-Saharan African background based on the Belgian PrEP eligibility criteria and examines associations with socio-economic and demographic characteristics. METHODS: We performed logistic regression analysis on data of a representative community-based survey conducted among Sub-Saharan African communities (n = 685) living in Antwerp. RESULTS: Almost a third (30.3%) of the respondents were eligible to use PrEP. Those who were male, single, lower educated, undocumented, and had experienced forced sex were more likely to be eligible for PrEP use. The findings highlight the importance of taking intra-, interpersonal and structural HIV risk factors into account. CONCLUSIONS: The study shows high unmet PrEP needs in this population, especially among those with high vulnerability for HIV acquisition. A better understanding of barriers to PrEP use in this population group is needed to allow for equitable access.

The case for prescribing PrEP in community mental health settings.

Pre-exposure prophylaxis (PrEP) is a biomedical HIV prevention modality that is up to 99% effective in preventing HIV acquisition through sex if taken as directed. People with serious mental illness (eg, schizophrenia and bipolar disorder) are at high risk of acquiring HIV due to sexual behaviours, injection drug use, social factors, and structural discrimination that limits access to all types of preventive health services. We seek to show the importance of prioritising access to PrEP for people living with serious mental illness treated in community mental health settings. We describe barriers to prescribing PrEP, including provider attitudes and provider knowledge gaps, patient attitudes and knowledge, and systems issues. We also address the concerns that community mental health clinic administrators might have about taking on the responsibility of offering PrEP. In summary, despite the barriers to prescribing PrEP in these settings, we believe that there is a unique opportunity for community mental health settings to help address the HIV epidemic by facilitating the prescribing of PrEP to the at-risk populations they currently serve.

Virtual CROI 2020: Highlights of Epidemiology, Public Health, and Prevention Research.

At the 2020 Conference on Retroviruses and Opportunistic Infections, held virtually as a result of the emerging COVID-19 pandemic, trends in the HIV epidemic were highlighted, with decreasing HIV incidence reported across several countries, although key regions remain heavily impacted, including the US South. Adolescent girls and young women, men who have sex with men (MSM), transgender persons, and people who inject drugs continue to experience a high burden of new infections. Sexually transmitted infections during pregnancy can lead to a number of adverse outcomes in infants; novel strategies to detect and treat these infections are needed. Innovative HIV testing strategies, including self-testing and assisted partner services, are expanding the reach of testing; however, linkage to care can be improved. Novel preexposure prophylaxis (PrEP) delivery strategies are increasing uptake of PrEP in different groups, although adherence and persistence remain a challenge. Use of on-demand PrEP is increasing among MSM in the US. Strategies are needed to address barriers to PrEP uptake and persistence among cis- and transgender women. Several novel regimens for postexposure prophylaxis show promise.

Ending the HIV Epidemic Among Persons Who Inject Drugs: A Cost-Effectiveness Analysis in Six US Cities.

BACKGROUND: Persons who inject drugs (PWID) are at a disproportionately high risk of HIV infection. We aimed to determine the highest-valued combination implementation strategies to reduce the burden of HIV among PWID in 6 US cities. METHODS: Using a dynamic HIV transmission model calibrated for Atlanta, Baltimore, Los Angeles, Miami, New York City, and Seattle, we assessed the value of implementing combinations of evidence-based interventions at optimistic (drawn from best available evidence) or ideal (90% coverage) scale-up. We estimated reduction in HIV incidence among PWID, quality-adjusted life-years (QALYs), and incremental cost-effectiveness ratios (ICERs) for each city (10-year implementation; 20-year horizon; 2018 $ US). RESULTS: Combinations that maximized health benefits contained between 6 (Atlanta and Seattle) and 12 (Miami) interventions with ICER values ranging from $94 069/QALY in Los Angeles to $146 256/QALY in Miami. These strategies reduced HIV incidence by 8.1% (credible interval [CI], 2.8%-13.2%) in Seattle and 54.4% (CI, 37.6%-73.9%) in Miami. Incidence reduction reached 16.1%-75.5% at ideal scale. CONCLUSIONS: Evidence-based interventions targeted to PWID can deliver considerable value; however, ending the HIV epidemic among PWID will require innovative implementation strategies and supporting programs to reduce social and structural barriers to care.

The only way is up: priorities for implementing long-acting antiretrovirals for HIV prevention and treatment.

PURPOSE OF REVIEW: Long-acting HIV treatment and prevention (LAHTP) can address some of the achievement gaps of daily oral therapy to bring us closer to achieving Joint United Nations Programme on HIV/AIDS Fast-track goals. Implementing these new technologies presents individual-level, population-level, and health systems-level opportunities and challenges. RECENT FINDINGS: To optimize LAHTP implementation and impact, decision-makers should define and gather relevant data to inform their investment case within the existing health systems context. Programmatic observations from scale-up of antiretroviral therapy, oral preexposure prophylaxis, voluntary medical male circumcision, and family planning offer lessons as planning begins for implementation of LAHTP. Additional data intelligence should be derived from formative studies, pragmatic clinical trials, epidemiologic and economic modeling of LAHTP. Key implementation issues that need to be addressed include optimal communication strategies for demand creation; target setting; logistics and supply chain of commodities needed for LAHTP delivery; human resource planning; defining and operationalizing monitoring and evaluating metrics; integration into health systems. SUMMARY: Successful LAHTP implementation can bolster treatment and prevention coverage levels if implementation issues outlined above are proactively addressed in parallel with research and development so that health systems can more rapidly integrate new technologies as they gain regulatory approval.

Cost-Effectiveness of a Statewide Pre-Exposure Prophylaxis Program for Gay, Bisexual, and Other Men Who Have Sex with Men.

Pre-exposure prophylaxis (PrEP) is an effective tool for preventing HIV infection among men who have sex with men (MSM), but its cost-effectiveness has varied across settings. Using an agent-based model, we projected the cost-effectiveness of a statewide PrEP program for MSM in Rhode Island over the next decade. In the absence of PrEP, the model predicted an average of 830 new HIV infections over ten years. Scaling up the existing PrEP program to cover 15% of MSM with ten or more partners each year could reduce the number of new HIV infections by 33.1% at a cost of $184,234 per quality-adjusted life-year (QALY) gained. Expanded PrEP use among MSM at high risk for HIV infection has the potential to prevent a large number of new HIV infections but the high drug-related costs may limit the cost-effectiveness of this intervention.

Getting to Zero Begins With Getting to Ten.

BACKGROUND STATEMENT: The global "90-90-90" targets introduced by UNAIDS in 2014-90% of people living with HIV will know their HIV status; 90% of those will be on antiretroviral treatment; and 90% of those will achieve viral suppression by 2020-have become more than a useful heuristic device, and now are the predominant framework for monitoring progress in the HIV response. Although this allows for important reflection on where HIV treatment gaps and opportunities exist in any particular context and globally, it deflects attention away from other very important aspects of HIV epidemics and their often-disproportionate impact on specific populations. Most significantly, it begs the question, what about the other 10-10-10? APPROACH: This article takes a critical look at the 90-90-90 targets and what is known about the 10-10-10 left behind to highlight some core issues and attendant questions that should be prioritized if we really intend to "get to zero." FINDINGS AND CONCLUSIONS: These issues include how the targets are measured in the first place, the limitations of focusing the global response only on antiretroviral treatment and only on people already living with HIV, and the need for more, basic social research to address the range of factors underlying disparities in who are and are not reached in the 90-90-90 framework.

Moving Metaphors: Shifting Institutional Responsibilities and Evidentiary Boundaries in the Commissioning of Pre-Exposure Prophylaxis for HIV.

In this article, we investigate how speakers in the U.K.'s House of Commons cited the same legislative context and medical research to arrive at contradictory conclusions regarding the Government's responsibility to fund pre-exposure prophylaxis (PrEP) as an HIV intervention. Because the Government had expressed that it would not comment on institutional responsibilities directly, given the likelihood of a legal challenge in response to the National Health Service withdrawing PrEP from the drug commissioning process, the Government's support of this decision could not be explicitly detailed. Our discourse analytic approach reveals how members of parliament adopted positions in the debate by using distinct metaphorical frames and lexical choices to linguistically encode assumptions that imply contrary interpretations of mutually agreed upon facts. This suggests that the concrete discursive practices used to cite evidence in policy-making discussions, regardless of the quality of the evidence, may have material consequences for evidence-based policy.

Evolving Models and Ongoing Challenges for HIV Preexposure Prophylaxis Implementation in the United States.

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

The preexposure prophylaxis revolution; from clinical trials to programmatic implementation.

PURPOSE OF REVIEW: An investment in preexposure prophylaxis (PrEP) delivery must have public health impact in reducing HIV infections. Sustainable delivery of PrEP requires policy, integration of services, and synergy with other existing HIV prevention programs. This review discusses key policy and programmatic considerations for implementation and scale up of PrEP in Africa. RECENT FINDINGS: PrEP delivery has been delayed by concerns about adherence and delivery in 'real world' settings. Demonstration projects and clinical service delivery models are providing evidence of PrEP effectiveness with an impact much higher than that found in randomized clinical trials. Data confirm that PrEP uptake, adherence, and retention has been high, more so by persons who perceive themselves at high risk for HIV infection, and PrEP is well tolerated. PrEP delivery is more than dispensation of a pill and programs should address other risk drivers, which differ by population. In Africa, barriers to PrEP uptake and adherence include stigma among MSM and low HIV risk perception among young women. Additional data have provided insight into optimal points of service delivery, provider training requirements and quality assurance needs. Of the 2 million new HIV infections in 2014, 70% were in Africa. PrEP use is not lifelong, and use limited to periods of risk may be both effective and cost-effective for the continent. SUMMARY: HIV prevention programs should determine strategies to identify those at substantial risk for HIV infection, formulate and deliver PrEP in combination with interventions that target social drivers of HIV vulnerability specific to each population. Policy guidance for optimal combination of interventions and service delivery avenues, clinical protocols, health infrastructure requirements are required. Cost-effectiveness and efficiency data are essential for policy guidance to navigate ethical questions over use of antiretroviral therapy for HIV-negative individuals when treatment coverage has not been attained in many parts of Africa. Countries need to invest in purposeful advocacy at both local and global forums. Failure to implement PrEP will be a failure to protect future generations.

Current concepts for PrEP adherence in the PrEP revolution: from clinical trials to routine practice.

PURPOSE OF REVIEW: The review describes the current understanding of adherence to oral preexposure prophylaxis (PrEP), methods for adherence measurement, approaches to supporting PrEP adherence, and guidance for defining PrEP adherence goals within the larger context of HIV prevention. RECENT FINDINGS: PrEP adherence has generally been higher in recent trials, open-label extensions, and demonstration projects compared with the initial clinical trials; potential explanations include known PrEP efficacy and different motivations to take PrEP. Recent studies have explored adherence monitoring through electronic pill containers, short message service (SMS), and drug concentrations in hair and dried blood spots. The few PrEP adherence interventions developed to date include combinations of enhanced counseling, feedback of objective adherence measurement, and SMS. Conceptualization of PrEP adherence is evolving. The goal is not 100% adherence indefinitely, as it was in clinical trials. PrEP adherence should be defined with respect to HIV exposure, which varies over time by sexual behavior and use of other prevention strategies. SUMMARY: PrEP adherence beyond clinical trials has generally been high enough to achieve reliable HIV prevention. Future efforts to measure and support PrEP adherence should focus on the context of risk for HIV acquisition, accounting for dynamic behaviors and choices among HIV prevention options.

Antiviral prophylaxis and isolation for the control of pandemic influenza.

Before effective vaccines become available, antiviral drugs are considered as the major control strategies for a pandemic influenza. However, perhaps such control strategies can be severely hindered by the low-efficacy of antiviral drugs. For this reason, using antiviral drugs and an isolation strategy is included in our study. A compartmental model that allows for imported exposed individuals and asymptomatic cases is used to evaluate the effectiveness of control strategies via antiviral prophylaxis and isolation. Simulations show that isolation strategy plays a prominent role in containing transmission when antiviral drugs are not effective enough. Moreover, relatively few infected individuals need to be isolated per day. Because the accurate calculations of the needed numbers of antiviral drugs and the isolated infected are not easily available, we give two simple expressions approximating these numbers. We also derive an estimation for the total cost of these intervention strategies. These estimations obtained by a simple method provide a useful reference for the management department about the epidemic preparedness plans.