The effects of free condom distribution on HIV and other sexually transmitted infections in men who have sex with men.

BACKGROUND: HIV and other sexually transmitted infections remain a burden on men who have sex with men in the era of effective combination antiretroviral therapy. New prevention efforts are therefore needed. One of these approaches is the current country-wide free condom distribution at gay bars with darkrooms and gay saunas in the Netherlands. This study assessed the effects of free condom distribution on incidence and burden of disease of HIV and other sexually transmitted infections. METHODS: A static model was constructed to calculate the impact of free condom distribution on HIV, hepatitis C, chlamydia, gonorrhoea, and syphilis among men who have sex with men visiting these venues. Outcomes included new infections averted and disability-adjusted life years averted. Scenario studies were performed to predict the effects of a further increase of condom use, condom effectiveness and coverage. Lastly, cost-effectiveness and sensitivity analyses were performed. RESULTS: Our model showed that condom use at public sex venues increased after the intervention. Annual incidence risk decreased, ranging from 5.73% for gonorrhoea to 7.62% for HIV. The annual number of new infections averted was largest for chlamydia and gonorrhoea (261 and 394 infections, respectively), but 42 new HIV infections were averted as well. In scenarios where condom use and condom effectiveness were further increased, the number of infections reduced more extensively. Over 99% of the decrease in burden of disease was due to HIV. The intervention was cost-effective and cost-saving (for every €1 spent on condom distribution, €5.51 was saved) and remained this in all sensitivity analyses. CONCLUSIONS: Free condoms at public sex venues could reduce the transmission of HIV and other sexually transmitted infections. Condom distribution is an affordable and easily implemented intervention that could reduce the burden of disease in men who have sex with men substantially.

Time Spent with HIV Viral Load > 1500 Copies/mL Among Persons Engaged in Continuity HIV Care in an Urban Clinic in the United States, 2010-2015.

Persons with HIV who have entered care but have viral load > 1500 copies/mL may be the source of the majority of new HIV infections in the United States. We followed patients engaged in continuity care in the Johns Hopkins HIV Clinical Cohort between January 2010 and August 2015. We estimated person-time spent with viral load > 1500 copies/mL while in care after antiretroviral therapy (ART) initiation, while in care, and while alive. Person-time was classified according to the most recent viral load measurement. Of 11,283.1 person-years in care on after ART initiation, 11,954.7 person-years in care and 13,990.0 total person-years of follow-up spent alive, 12.5, 14.8%, and between 12.6 and 27.2%, respectively (depending on assumptions about the viral load of persons lost to clinic) were spent with viral load > 1500 copies/mL. Patients with lower baseline CD4 cell count, younger age, black race, history of injection drug use, or baseline hazardous alcohol use spent more time with viral load > 1500 copies/mL after ART initiation.

Using HIV Sequence and Epidemiologic Data to Assess the Effect of Self-referral Testing for Acute HIV Infection on Incident Diagnoses in San Diego, California.

BACKGROUND: Because recently infected individuals disproportionately contribute to the spread of human immunodeficiency virus (HIV), we evaluated the impact of a primary HIV screening program (the Early Test) implemented in San Diego. METHODS: The Early Test program used combined nucleic acid and serology testing to screen for primary infection targeting local high-risk individuals. Epidemiologic, HIV sequence, and geographic data were obtained from the San Diego County Department of Public Health and the Early Test program. Poisson regression analysis was performed to determine whether the Early Test program was temporally and geographically associated with changes in incident HIV diagnoses. Transmission chains were inferred by phylogenetic analysis of sequence data. RESULTS: Over time, a decrease in incident HIV diagnoses was observed proportional to the number primary HIV infections diagnosed in each San Diego region (P < .001). Molecular network analyses also showed that transmission chains were more likely to terminate in regions where the program was marketed (P = .002). Although, individuals in these zip codes had infection diagnosed earlier (P = .08), they were not treated earlier (P = .83). CONCLUSIONS: These findings suggests that early HIV diagnoses by this primary infection screening program probably contributed to the observed decrease in new HIV diagnoses in San Diego, and they support the expansion and evaluation of similar programs.

Antiretroviral Pre-Exposure Prophylaxis Does Not Enhance Immune Responses to HIV in Exposed but Uninfected Persons.

BACKGROUND: Antiretroviral preexposure prophylaxis (PrEP), using daily oral combination tenofovir disoproxil fumarate plus emtricitabine, is an effective human immunodeficiency virus (HIV) prevention strategy for populations at high risk of HIV acquisition. Although the primary mode of action for the protective effect of PrEP is probably direct antiviral activity, nonhuman primate studies suggest that PrEP may also allow for development of HIV-specific immune responses, hypothesized to result from aborted HIV infections providing a source of immunologic priming. We sought to evaluate whether PrEP affects the development of HIV-specific immune response in humans. METHODS AND RESULTS: Within a PrEP clinical trial among high-risk heterosexual African men and women, we detected HIV-specific CD4(+) and CD8(+) peripheral blood T-cell responses in 10%-20% of 247 subjects evaluated. The response rate and magnitude of T-cell responses did not vary significantly between those assigned PrEP versus placebo, and no significant difference between those assigned PrEP and placebo was observed in measures of innate immune function. CONCLUSIONS: We found no evidence to support the hypothesis that PrEP alters either the frequency or magnitude of HIV-specific immune responses in HIV-1-exposed seronegative individuals. These results suggest that PrEP is unlikely to serve as an immunologic prime to aid protection by a putative HIV vaccine.

Survey of HIV care providers on management of HIV serodiscordant couples - assessment of attitudes, knowledge, and practices.

Human immunodeficiency virus (HIV) serodiscordant couples are at risk of sexual transmission of HIV between the infected and uninfected partner. We assessed New York area care providers for people living with HIV regarding attitudes, knowledge, and practice patterns toward fertility and conception in serodiscordant couples. Data were collected via a survey distributed in October 2013. Seventeen percent of respondents reported prescribing antiretroviral preexposure prophylaxis (PrEP) for a woman in a serodiscordant couple, and 38% percent of respondents reported having counseled serodiscordant couples on timed, unprotected intercourse without PrEP. Respondents who reported being "very" familiar with the data on HIV transmission in serodiscordant couples were more likely to report counseling their patients in timed, unprotected intercourse compared with those who reported less familiarity with the data (41% vs. 8%, p = 0.001). Although only 20% reported being "very" or "somewhat" familiar with the data on the safety of sperm washing with intrauterine insemination, those who did were more likely to have reported referring a patient for assisted reproductive technology (61% vs. 32%, p = 0.006). Effective patient counseling and referral for appropriate reproductive options were associated with knowledge of the literature pertaining to these options. This emphasizes the need for further provider education on reproductive options and appropriate counseling for serodiscordant couples.

HIV-Uninfected Kenyan Adolescent and Young Women Share Perspectives on Using Pre-Exposure Prophylaxis During Pregnancy.

To optimize scale-up of pre-exposure prophylaxis (PrEP) for pregnant women at risk of HIV in high HIV burden settings, implementation strategies must be developed that account for perceptions of PrEP in this unique population. Semistructured focus group discussions were conducted with 68 HIV-uninfected Kenyan pregnant and postpartum women without prior PrEP knowledge or experience. A qualitative descriptive analysis was performed, using a constant comparison approach, to identify key themes related to the values and rationale impacting potential PrEP use in pregnancy. Median age was 19.5 years and participants were either pregnant or had 1-2 children. Almost all (96%) were married or had a steady partner. Women felt pregnancy was a time of high HIV risk because they desired sex less frequently, which may lead their partners to have outside partnerships. This made PrEP an attractive HIV prevention option for themselves and their infants. Although women believed male partner behaviors influenced their HIV risk, many women perceived that male partners would react negatively, including becoming physically violent, if they discovered that women used PrEP. Clinicians were identified as potential facilitators of PrEP use who could explain PrEP to male partners on behalf of pregnant women. Women said that community-level stigma against HIV and potential for conflating PrEP with antiretroviral therapy (ART) would necessitate that PrEP use be discreet. Our results indicate the importance of addressing risk perception of women, concerns of male partners, HIV stigma, and benefits of PrEP for HIV prevention as programs are developed for pregnant women.

Acute HIV infection detection and immediate treatment estimated to reduce transmission by 89% among men who have sex with men in Bangkok.

INTRODUCTION: Antiretroviral treatment (ART) reduces HIV transmission. Despite increased ART coverage, incidence remains high among men who have sex with men (MSM) in many places. Acute HIV infection (AHI) is characterized by high viral replication and increased infectiousness. We estimated the feasible reduction in transmission by targeting MSM with AHI for early ART. METHODS: We recruited a cohort of 88 MSM with AHI in Bangkok, Thailand, who initiated ART immediately. A risk calculator based on viral load and reported behaviour, calibrated to Thai epidemiological data, was applied to estimate the number of onwards transmissions. This was compared with the expected number without early interventions. RESULTS: Forty of the MSM were in 4th-generation AHI stages 1 and 2 (4thG stage 1, HIV nucleic acid testing (NAT)+/4thG immunoassay (IA)-/3rdG IA-; 4thG stage 2, NAT+/4thG IA+/3rdG IA-) while 48 tested positive on third-generation IA but had negative or indeterminate western blot (4thG stage 3). Mean plasma HIV RNA was 5.62 log10 copies/ml. Any condomless sex in the four months preceding the study was reported by 83.7%, but decreased to 21.2% by 24 weeks on ART. After ART, 48/88 (54.6%) attained HIV RNA <50 copies/ml by week 8, increasing to 78/87 (89.7%), and 64/66 (97%) at weeks 24 and 48, respectively. The estimated number of onwards transmissions in the first year of infection would have been 27.3 (95% credible interval: 21.7-35.3) with no intervention, 8.3 (6.4-11.2) with post-diagnosis behaviour change only, 5.9 (4.4-7.9) with viral load reduction only and 3.1 (2.4-4.3) with both. The latter was associated with an 88.7% (83.8-91.1%) reduction in transmission. CONCLUSIONS: Disproportionate HIV transmission occurs during AHI. Diagnosis of AHI with early ART initiation can substantially reduce onwards transmission.

Serodiscordance and prevention of HIV: perceptions of individuals in stable and non-stable relationships / Sorodiscordância e prevenção do HIV: percepções de pessoas em relacionamentos estáveis e não estáveis / Suero discordancia y prevención del VIH: percepciones de personas en relaciones estables y no estables

Policies regarding post-sexual exposure prophylaxis (PEP) and the “treatment as prevention” strategy have strengthened preventive measures against HIV transmission. This study aimed to describe the perceptions of people with HIV/AIDS regarding prevention of sexual transmission of HIV in the context of serodiscordance. Two focus groups were conducted, with 13 HIV-positive participants who were in serodiscordant relationships: one group with people in stable partnerships and the other in non-stable relationships. Just over a third of participants were aware of PEP and “treatment as prevention”. There was a consensus that it is easier to use safe-sex practices in non-stable serodiscordant relationships, it is easier to use safe-sex practices. Some advantages of the new policies were mentioned, despite the concern that condom use might be neglected. The importance of healthcare teams’ actions among serodiscordant couples regarding prevention of sexual transmission of HIV was highlighted.

Políticas referentes à profilaxia pós-exposição sexual (PEP sexual) e a estratégia “tratamento como prevenção” reforçaram as ações preventivas da transmissão do HIV. Este estudo objetivou descrever percepções de pessoas com HIV/aids sobre a prevenção da transmissão do HIV no contexto da sorodiscordância. Foram conduzidos dois grupos focais com 13 participantes com relacionamentos sorodiscordantes: um com pessoas em parcerias estáveis e outro em parcerias não estáveis. Pouco mais de um terço dos participantes tinham conhecimento sobre a PEP e o “tratamento como prevenção”. Houve consenso de que há mais facilidade na adoção de práticas sexuais seguras nas parcerias sorodiscordantes não estáveis. Vantagens das novas políticas foram relatadas, não obstante o receio de que possa haver negligência quanto ao uso do preservativo. Destaca-se a relevância da atuação de equipes de saúde com casais sorodiscordantes quanto à prevenção da transmissão sexual do HIV.

Políticas referentes a la profilaxis post-exposición sexual (PEP sexual) y la estrategia de “tratamiento como prevención” reforzaron las acciones preventivas de la transmisión del VIH. El objetivo del estudio fue describir percepciones de personas con VIH/sida sobre la prevención de la transmisión del VIH en el contexto de la “suero discordancia”. Se realizaron dos grupos focales con 13 participantes con relaciones “suero discordantes”: uno con personas en relación estable y otro en relación no estable. Poco más de un tercio de los participantes tenía conocimiento sobre la PEP y el “tratamiento como prevención”. Hubo consenso de que hay más facilidad en la adopción de prácticas sexuales seguras en las relaciones “suero discordantes” no estables. Se relataron las ventajas de las nuevas políticas, a pesar del recelo de que pueda haber negligencia en lo que se refiere al uso del preservativo. Se destaca la relevancia de la actuación de equipos de salud con parejas “suero discordantes” a la prevención de la transmisión sexual del VIH.