Filling in the Gaps: Updates on Doxycycline Prophylaxis for Bacterial Sexually Transmitted Infections.

Over the past two decades, cases of sexually transmitted infections (STIs) due to syphilis, gonorrhea, and chlamydia have been rising in the United States, disproportionately among gay, bisexual, and other men who have sex with men (MSM), as well as racial and ethnic minorities of all genders. In this review, we address updates about the evidence on doxycycline post-exposure prophylaxis (doxy-PEP) for prevention of bacterial STIs, including efficacy, safety, antimicrobial resistance (AMR), acceptability, modeling population impact, and evolving guidelines for use. Equitable implementation of doxy-PEP will require evaluation of who is offered and initiates it, understanding patterns of use and longer-term STI incidence and AMR, provider training, and tailored community education.

#PrEP4Love: success and stigma following release of the first sex-positive PrEP public health campaign.

Pre-exposure prophylaxis (PrEP) is an effective yet under-utilised method for preventing HIV transmission in high-risk groups. Despite ongoing social marketing to increase PrEP awareness, few studies have evaluated public responses. This paper contextualises negative responses to Chicago's PrEP4Love campaign. In February 2016, a sex-positive ad campaign called PrEP4Love was launched online and throughout public spaces in Chicago. A gender and sexuality inclusive campaign, PrEP4Love is intended to be culturally responsive and sex positive, while retaining a focus on risk reduction. Advertisements prominently feature Black sexual minority men, and Black transgender women, and were strategically placed in diverse Chicago neighbourhoods. In response, there were 212 new callers to the PrEPLine during the two-month study period. Negative responses were concerned with: negatively depicting Black homosexuality (4), general anti-LGBTQ comments (7), adverse effects on children (6), sexually explicit nature (5), and general stigmatisation of racial minorities (4). Discussion focuses on sex-positive frameworks, normalising intimacy, stigma and historical mistrust of medical and pharmaceutical institutions, and the social meanings of biomedical prevention technologies (e.g. PrEP) in relation to dominant norms of sexuality and gender. This study is the first to investigate public responses to a sex-positive PrEP campaign. More studies of PrEP social marketing are needed to evaluate targeted public health campaigns to guide future PrEP promotion strategies.

MTN-017: A Rectal Phase 2 Extended Safety and Acceptability Study of Tenofovir Reduced-Glycerin 1% Gel.

Background: Human immunodeficiency virus (HIV) disproportionately affects men who have sex with men (MSM) and transgender women (TGW). Safe and acceptable topical HIV prevention methods that target the rectum are needed. Methods: MTN-017 was a phase 2, 3-period, randomized sequence, open-label, expanded safety and acceptability crossover study comparing rectally applied reduced-glycerin (RG) 1% tenofovir (TFV) and oral emtricitabine/TFV disoproxil fumarate (FTC/TDF). In each 8-week study period participants were randomized to RG-TFV rectal gel daily, or RG-TFV rectal gel before and after receptive anal intercourse (RAI; or at least twice weekly in the event of no RAI), or daily oral FTC/TDF. Results: MSM and TGW (n = 195) were enrolled from 8 sites in the United States, Thailand, Peru, and South Africa with mean age of 31.1 years (range 18-64). There were no differences in ≥grade 2 adverse event rates between daily gel (incidence rate ratio [IRR], 1.09; P = .59) or RAI gel (IRR, 0.90; P = .51) compared to FTC/TDF. High adherence (≥80% of prescribed doses assessed by unused product return and Short Message System reports) was less likely in the daily gel regimen (odds ratio [OR], 0.35; P < .001), and participants reported less likelihood of future daily gel use for HIV protection compared to FTC/TDF (OR, 0.38; P < .001). Conclusions: Rectal application of RG TFV gel was safe in MSM and TGW. Adherence and product use likelihood were similar for the intermittent gel and daily oral FTC/TDF regimens, but lower for the daily gel regimen. Clinical Trials Registration: NCT01687218.

Prevalence and types of rectal douches used for anal intercourse: results from an international survey.

BACKGROUND: Rectal products used with anal intercourse (AI) may facilitate transmission of STIs/HIV. However, there is limited data on rectal douching behavior in populations practicing AI. We examined the content, types of products, rectal douching practices and risk behaviors among those reporting AI. METHODS: From August 2011 to May 2012, 1,725 women and men reporting receptive AI in the past 3 months completed an internet-based survey on rectal douching practices. The survey was available in English, French, German, Mandarin, Portuguese, Russian, Spanish, and Thai and included questions on sexual behaviors associated with AI including rectal douching. Differences by rectal douching practices were evaluated using chi-square methods and associations between reported douching practices and other factors including age and reported STI history were evaluated using logistic regression analysis. RESULTS: Respondents represented 112 countries, were mostly male (88%), and from North America (55%) or Europe (22%). Among the 1,339 respondents (66%) who reported rectal douching, most (83%) reported always/almost always douching before receptive AI. The majority of rectal douchers reported using non-commercial/homemade products (93%), with water being the most commonly used product (82%). Commercial products were used by 31%, with the most common product being saline-based (56%). Rectal douching varied by demographic and risk behaviors. The prevalence of rectal douching was higher among men (70% vs. 32%; p-value < .01), those reporting substance-use with sex (74% vs. 46%; p-value < .01), and those reporting an STI in the past year (69% vs. 57% p-value < .01) or ever testing HIV-positive (72% vs. 53%; p-value < .01). In multivariable analysis, adjusting for age, gender, region, condom and lubricant use, substance use, and HIV-status, douchers had a 74% increased odds of reporting STI in the past year as compared to non-douchers [adjusted odds ratio (AOR) = 1.74; 95% CI 1.01-3.00]. CONCLUSION: Given that rectal douching before receptive AI is common and because rectal douching was associated with other sexual risk behaviors the contribution of this practice to the transmission and acquisition of STIs including HIV may be important.

Financing and Delivering Pre-Exposure Prophylaxis (PrEP) to End the HIV Epidemic.

The U.S. has the tools to end the HIV epidemic, but progress has stagnated. A major gap in U.S. efforts to address HIV is the under-utilization of medications that can virtually eliminate acquisition of the virus, known as pre-exposure prophylaxis (PrEP). This document proposes a financing and delivery system to unlock broad access to PrEP for those most vulnerable to HIV acquisition and bring an end to the HIV epidemic.

Community perspectives on developing a sexual health agenda for gay and bisexual men.

Community mobilization around gay rights in the late 1960s and 1970s led to the first efforts to improve the health of gay and bisexual men. In the 1980s the deadly AIDS epidemic was responded to with fierce organizing and community activism, primarily led by gay men. Today, community involvement is crucial to many advocacy and organizing efforts for the health of gay and bisexual men. This article begins with the roots of this history and then describes how they are reflected in a number of key health initiatives for this community including the National Black Gay Men's Advocacy Coalition, the Legacy Project, International Rectal Microbicide Advocates and the Gay Men's Health Agenda. A path forward is described in terms of next steps for advocacy for gay men's health and the health of gay and bisexual men of color emphasizing cultural viability, development of new leaders, and strategic alliances.

PrEP4Love: The Role of Messaging and Prevention Advocacy in PrEP Attitudes, Perceptions, and Uptake Among YMSM and Transgender Women.

BACKGROUND: Despite high efficacy, use of pre-exposure prophylaxis (PrEP) remains low among young men who have sex with men (MSM) and transgender women (TW), primarily because of barriers such as stigma and resource awareness. We evaluated a social marketing campaign known as PrEP4Love that works to eliminate PrEP stigma; and awareness gaps through targeted advertising. SETTING: Chicago, Illinois. METHODS: Participants were enrolled within a cohort study of young MSM and TW (RADAR). Data were collected between June 2017 and April 2018 from HIV-negative individuals attending a follow-up visit. Surveys assessed demographics, PrEP attitudes and perceptions, and PrEP4Love campaign awareness. Associations between PrEP4Love awareness and PrEP perceptions, uptake, and behaviors were assessed using multiple logistic regression controlling for age, race/ethnicity, gender, sexual identity, and ever having used PrEP. RESULTS: Of 700 participants, the majority (75.9%) indicated seeing PrEP4Love ads in Chicago. Those who had seen ads were more likely to be out to their providers (odds ratio = 1.95; 95% confidence interval: 1.17 to 3.23) than those who had not, and those who had conversations were significantly more likely to have initiated the conversation themselves. Individuals who had seen ads were more likely to have taken PrEP in the last 6 months (odds ratio = 1.87; 95% confidence interval: 1.15 to 3.16) and more likely to believe their friends and the general public approved of and used PrEP. CONCLUSION: Social marketing campaigns are promising interventions that have the potential to alleviate barriers to HIV prevention, particularly among MSM and TW. Future research should evaluate the impact of these initiatives at multiple time points.

Black Cisgender Women's PrEP Knowledge, Attitudes, Preferences, and Experience in Chicago.

BACKGROUND: Although black cisgender women in Chicago continue to disproportionally account for new HIV diagnoses, few are on pre-exposure prophylaxis (PrEP). We used concurrent mixed-methods to understand women's PrEP knowledge, attitudes, experience, and preferences in Chicago. SETTING AND METHODS: We surveyed 370 HIV(-) cisgender women visiting a sexually transmitted infection clinic (n = 120) or emergency department (n = 250). Two focus groups were conducted with PrEP-naive women, and interviews were conducted with 7 PrEP-experienced women. Quantitative data were analyzed using descriptive statistics and multivariable logistic regression, and qualitative data using thematic analysis. RESULTS: Majority of women identified as black (83.0%) and had a regular source of health care (70.0%). In the past 6 months, 84.1% had vaginal or anal sex, most with inconsistent condom use (94.2%). Only 30.3% had heard of PrEP, but once explained, one-quarter considered starting PrEP, with protecting health (76.4%) and reducing HIV worry (58.1%) the most common reasons. Factors associated with considering PrEP included being Latina [adjusted odds ratio (aOR): 3.30, 95% confidence interval (CI): (1.21 to 8.99)], recent sexually transmitted infection [aOR: 2.39, 95% CI: (1.25 to 4.59)], and higher belief in PrEP effectiveness [aOR: 1.85, 95% CI: (1.22 to 2.82)]. Most (81.1%) had concerns about taking PrEP with side effects a common concern. Qualitative themes aligned with survey results, revealing a disconnection from current PrEP marketing, need for community-level PrEP education/outreach, and importance of provider trust. LESSONS LEARNED: Despite significant PrEP implementation work in Chicago, less than one-third of women in our study had heard of PrEP. Once informed, PrEP attitudes and interest were positive. Translating these results into interventions reflecting women's preferences and barriers is critical to increase PrEP uptake by cisgender women in Chicago and elsewhere.

Geospatial perspectives on health: The PrEP4Love campaign and the role of local context in health promotion messaging.

Pre-exposure prophylaxis (PrEP) remains one of the most effective biomedical interventions for the prevention of HIV transmission. However, uptake among populations most impacted by the HIV epidemic remains low. La rge-scale awareness and mobilization campaigns have sought to address gaps in knowledge and motivation in order to improve PrEP diffusion. Such campaigns must be cognizant of the historical, physical, and structural contexts in which they exist. In urban contexts, neighborhood segregation has the potential to impact health outcomes and amplify disparities. Therefore, we present novel geospatial approaches to the evaluation of a Chicago-based PrEP messaging campaign (PrEP4Love) in a 2018 cohort of men who have sex with men and transgender women, contextualizing results within the localized infrastructure and public health landscape, and examining associations between geographic location and campaign efficacy. Results revealed notable variance in rates of PrEP uptake associated with campaign exposure by Chicago planning area, which are likely explained by the historical and contemporary impacts of racist structures on physical environment and city infrastructure. Findings have important implications for the evaluation and implementation of future messaging campaigns, which should take the unique historical, structural, and geospatial factors of their particular settings into account in order to achieve maximum impact.

#PrEP4Love: An Evaluation of a Sex-Positive HIV Prevention Campaign.

BACKGROUND: Pre-exposure prophylaxis (PrEP) is an effective but underutilized method for preventing HIV transmission in communities vulnerable to HIV. Public health campaigns aimed at increasing PrEP awareness and access have less evaluation data. OBJECTIVE: The aim of this study was to evaluate Chicago's PrEP campaign, PrEP4Love (P4L), a campaign that uses health equity and sex-positivity approaches for information dissemination. METHODS: P4L launched in February 2016 and remains an active campaign to date. The analysis period for this paper was from the launch date in February 2016 through May 15, 2016. Our analysis reviews the Web-based reach of the campaign through views on social media platforms (Facebook and Instagram), smart ads, or ads served to individuals across a variety of Web platforms based on their demographics and browsing history, and P4L website clicks. RESULTS: In total, 40,913,560 unique views were generated across various social media platforms. A total of 24,548 users clicked on P4L ads and 32,223,987 views were received from smart ads. The 3 most clicked on ads were STD Signs & Symptoms-More Information on STD Symptoms, HIV & AIDS Prevention, and HIV Prevention Medication. An additional 6,970,127 views were gained through Facebook and another 1,719,446 views through Instagram. There was an average of 182 clicks per day on the P4L website. CONCLUSIONS: This is the first study investigating public responses to a health equity and sex-positive social marketing campaign for PrEP. Overall, the campaign reached millions of individuals. More studies of PrEP social marketing are needed to evaluate the relationship of targeted public health campaigns on stigma and to guide future PrEP promotion strategies.

The Motivational PrEP Cascade Guides Interpretation of Early PrEP Linkage to Care for Young Black Men Who Have Sex With Men: The Case of Chicago's PrEPLine.

Pre-exposure prophylaxis (PrEP) uptake remains low among Black men who have sex with men (BMSM). PrEPLine, launched in August 2015, based in Chicago, was designed to support PrEP linkage among BMSM. PrEPLine moves clients through the Motivational PrEP Cascade, addresses barriers, and tracks outcomes. Study findings suggest that three variables (i.e., being gay/same gender loving, living more than 15 miles from a clinic location, rescheduling an appointment) demonstrated a significant positive association with initiating PrEP. A subanalysis of BMSM found that two variables (i.e., living on the West Side of Chicago relative to those living on the South Side, and among those living in communities with a higher rate of poverty [more than 30%], relative to those living in communities with a lower rate of poverty [less than 20%]) demonstrated a significant negative association with initiating PrEP.

Antiretroviral pre-exposure prophylaxis implementation in the United States: a work in progress.

INTRODUCTION: After the initial approval of the use of tenofovir disoproxil fumarate-emtricitabine (TDF/FTC) by the US Food and Drug Administration in 2012 for anti-HIV pre-exposure prophylaxis (PrEP), uptake was initially limited, but more recent community surveys and expert opinion suggest wider acceptance in some key populations. DISCUSSION: Demonstration projects are underway to determine the best practices in the United States to identify at-risk individuals in primary care and sexually transmitted disease clinics who could benefit from PrEP. Studies of PrEP in combination with behavioural interventions are being evaluated. Studies to evaluate the use of PrEP by HIV-uninfected women in HIV-discordant couples interested in safe conception are also getting underway. The optimal deployment of PrEP as part of a comprehensive national HIV/AIDS strategy in the United States has been limited by lack of knowledge among some at-risk people and by some medical providers indicating that they do not feel sufficiently knowledgeable and comfortable in prescribing PrEP. Studies are underway to determine how to assist busy clinicians to determine which of their patients could benefit from PrEP. Although most federal health insurance programmes will cover most of the costs associated with PrEP, underinsured patients in states that have not enacted health reform face additional challenges in paying for PrEP medication and appropriate clinical monitoring. CONCLUSIONS: PrEP implementation in the United States is a work in progress, with increasing awareness and uptake among some individuals in key populations.

Is wetter better? An evaluation of over-the-counter personal lubricants for safety and anti-HIV-1 activity.

Because lubricants may decrease trauma during coitus, it is hypothesized that they could aid in the prevention of HIV acquisition. Therefore, safety and anti-HIV-1 activity of over-the-counter (OTC) aqueous- (n = 10), lipid- (n = 2), and silicone-based (n = 2) products were tested. The rheological properties of the lipid-based lubricants precluded testing with the exception of explant safety testing. Six aqueous-based gels were hyperosmolar, two were nearly iso-osmolar, and two were hypo-osmolar. Evaluation of the panel of products showed Gynol II (a spermicidal gel containing 2% nonoxynol-9), KY Jelly, and Replens were toxic to Lactobacillus. Two nearly iso-osmolar aqueous- and both silicone-based gels were not toxic toward epithelial cell lines or ectocervical or colorectal explant tissues. Hyperosmolar lubricants demonstrated reduction of tissue viability and epithelial fracture/sloughing while the nearly iso-osmolar and silicon-based lubricants showed no significant changes in tissue viability or epithelial modifications. While most of the lubricants had no measurable anti-HIV-1 activity, three lubricants which retained cell viability did demonstrate modest anti-HIV-1 activity in vitro. To determine if this would result in protection of mucosal tissue or conversely determine if the epithelial damage associated with the hyperosmolar lubricants increased HIV-1 infection ex vivo, ectocervical tissue was exposed to selected lubricants and then challenged with HIV-1. None of the lubricants that had a moderate to high therapeutic index protected the mucosal tissue. These results show hyperosmolar lubricant gels were associated with cellular toxicity and epithelial damage while showing no anti-viral activity. The two iso-osmolar lubricants, Good Clean Love and PRÉ, and both silicone-based lubricants, Female Condom 2 lubricant and Wet Platinum, were the safest in our testing algorithm.

Preference and practices relating to lubricant use during anal intercourse: implications for rectal microbicides.

BACKGROUND: The importance of the acceptability of rectal microbicides for HIV and sexually transmissible infections (STIs) prevention is widely recognised. Given relatively consistent use of lubricants for anal intercourse (AI) and the potential for lubricant-like rectal microbicides, understanding barriers to lubricant use may help inform hurdles likely to be encountered once a rectal microbicide becomes available. METHODS: We conducted an internet-based survey using a 25-item questionnaire to assess AI and lubricant use, including lubricant preferences and barriers to use. RESULTS: The majority of the 6124 respondents who reported AI were male (93%), 25 years or older (80%) and from North America (70%). Consistent condom use during AI was reported by a minority (35%) and consistent lubricant use was reported by over half of respondents. Reasons for non-use differed by age and region. Among men, those <25 years were more likely to report barriers around cost compared with those 45 and older (odds ratio (OR) = 6.64; 95% confidence interval (CI) 3.14-14.03). European men (OR = 1.92; 95% CI 1.50-2.45), Latin American women (OR = 3.69; 95% CI 1.27-10.75) and Asian women (OR = 4.04; 95% CI 1.39-11.78) were more likely to report sexual preference as a reason for non-use. CONCLUSIONS: Rectal lubricants are widely used, but barriers to use vary by age and region for dry sex. A lubricant-like rectal microbicide would potentially be acceptable and such a product may be useful as a method of HIV prevention. However, targeted marketing and educational approaches may be needed to enhance use and acceptability of such a product.