Differences in biological and behavioral HIV risk before, during, and after PrEP use among - PowerPoint Presentation

1. Differences in biological and behavioral HIV risk before, during, and after PrEP use among a national sample of gay and bisexual men in the United StatesH. Jonathon Rendina (Presenting)Jeffrey T. Parsons, Thomas H. F. Whitfield, Christian GrovPresented at the 22nd Annual International AIDS ConferenceJuly 24, 2018

2. BackgroundDespite high efficacy in preventing HIV transmission, PrEP provides no protection against other sexually transmitted infections (STIs)Debates about risk compensation continue, with concerns about increased rates of non-use of condoms during anal sex and increased incidence of STIs, particularly among gay, bisexual, and other men who have sex with men (GBMSM)Research on actual changes in both behavioral and biological risk indicators has been equivocalThe majority of research showing increased STI incidence was done in a pre-post fashionModeling studies suggest the more frequent testing may ultimately decrease STI incidence even in the face of some increase in infection rates2

3. Study aimsRelying on an observational cohort enrolled shortly after US FDA approval of PrEP and followed for 4 years, conduct within-person analyses of those who initiated PrEP use at some point during the study to:Examine changes in condomless sexual behavior prior to PrEP initiation, during PrEP use, and following PrEP discontinuationExamine changes in rectal STI incidence (GC/CT) prior to PrEP initiation, during PrEP use, and following PrEP discontinuation3

4. 4One Thousand Strong: Syndemics & Resilience for HIV Transmission in a National Sample of Vulnerable MenPrincipal Investigators: Jeffrey T. Parsons, PhD Christian Grov, PhD, MPHCo-I & Senior Research Scientist: Ana Ventuneac, PhDCo-I & Clinical Director: Tyrel J. Starks, PhDSenior Data Analyst: H. Jonathon Rendina, PhD, MPHResearch Scientist: Demetria Cain, MPHProject Director: Mark Pawson, MARecruitment Director: Ruben JimenezGraphic Designer: Chris Hietikko, MFAFunded by the National Institute of Drug Abuse: R01 DA03646

5. ParticipantsPotential participants were screened by Community Marketing Insights, Inc. (CMI) from over 22K GBM across the US.EligibilityLive in U.S. with permanent mailing address 18 years or olderBiologically male and identify as maleSelf-identify as HIV-negative and willing to complete at-home self-administered rapid HIV antibody testing and testing for urethral and rectal chlamydia and gonorrheaReport having sex with another man in the past year5

6. Relevant ProceduresPrEP status (never used, currently using, previously used) was assessed via self-report at every study assessment, which occurred annuallyA detailed measure of self-reported sexual behavior was provided Participants also completed a rectal swab from home that was assayed for GC/CTSelf-report data and biological samples were collected at up to four time points: Baseline (N = 1071)12M (94.9% retention)24M (91.7% retention) 36M (88.1% retention)6

7. Sample characteristicsMean Age = 37 Age Range = 18-817

8. PrEP use over time8

9. Statistical AnalysesThe present analyses focus on those who:Reported PrEP use during at least one assessment (n = 313, nvisits = 1098)GEE models adjusted for race, partner status, and time:Number of condomless anal sex (CAS) acts with a casual male partnerNumber of receptive CAS acts with a serodiscordant casual male partner (i.e., HIV-positive or status-unknown)Probability of a rectal STI diagnosisPresentation will focus on estimated marginal means (adjusted for covariates)9

10. PrEP status and number of CAS acts10P < 0.001P < 0.001

11. PrEP status and number of serodiscordant receptive CAS acts11P = 0.001P = 0.001

12. PrEP status and probability of rectal STI diagnosis (GC/CT)12p = 0.22p < 0.001

13. Summary of findingsWe have seen a substantial increase in PrEP use over the past 3 years, from 3% to 21% in this observational cohortPrEP discontinuation is also rising, with 5% former users at the final visitWithin-person analyses with multiple observations before, during, and after PrEP use support prior research regarding an increase in CAS, including receptive CAS with serodiscordant partnersHowever, we did not observe a significant increase in rectal STI infections in this study with multiple time points after uptakeThe data suggest that after using PrEP, all forms of risk studied had decreased even below the levels prior to PrEP initiation (with significant decreases in rectal STIs compared to pre-PrEP)13

14. LimitationsSelf-reported data on PrEP use and sexual behaviorSTI samples were self-collected – while on PrEP, people may have been getting tested more regularly and treated before our annual test kit was sent (practically, this is a good thing!)Motivations for both initiating and discontinuing PrEP were not examined, and these may help explain some of the differences observed14

15. Implications and Future DirectionsPrior studies using only 1 Pre-PrEP and 1 Post-PrEP data point may have inflated estimates of the risk of PrEP for STI infection due to potential spikes in risk immediately after initiationResearch is needed to explore the mechanisms through which CAS might change substantially without concomitant changes in STI incidence (increased testing and treatment? network/partner features?)PrEP appears to be serving its exact purpose for those GBMSM who use it – uptake occurs during times of higher (potential) risk behavior and is discontinued once that risk subsides15

16. Conclusions The HIV field is at an important decision point in ongoing debates about biomedical preventionIs it worthwhile to continue debating about risk compensation if what that means is a jump from 7% incidence to 10% in STIs?STIs are always important to consider and keep in mind, but the promise of PrEP for reducing HIV transmission seems far greater than the potential for increases in STI incidenceCritical to stop focusing on “use a condom every time” and use the multitude of options available in the “prevention toolkit” that can be tailored to each individual’s needs and desires for sexual healthA one-size-fits-all approach hasn’t workedWe need to meet people where they are to get them safely through periods of risk16

17. AcknowledgementsThe entire team of CHEST staff and interns, with special thanks to Demetria Cain, Mark Pawson, Ruben Jimenez, and Chloe MirzayiConsultants - Patrick Sullivan, Steven Kurtz, Beryl Koblin, and Victoria FryeNational Institute on Drug Abuse, particularly Jeffrey Schulden and Will AklinSyndemics & Resilience for HIV Transmission in a National Sample of Vulnerable Men (R01-DA036466; MPI: Parsons & Grov)Developing a mobile emotion regulation intervention for HIV-positive men (K01-DA039030; PI: Rendina)Emory CFAR, UIC Public Health Laboratory, and Alameda County Public Health Laboratory and Community Marketing & Insights (CMI)Our participants who volunteered their time17

18. Thank you!For inquiries or a copy of the slides, please contact me via:hrendina@hunter.cuny.edu @ProfRendina18