Without PrEP, one-third of new HIV cases occur among low-risk MSM

Almost one in three gay and bisexual men diagnosed with HIV in sexual health clinics across the UK did not meet the ‘high risk’ criteria that would indicate to a clinician they would be good candidates for HIV. pre-exposure prophylaxis (PrEP).

And that means people who seem to be at low risk may still be good candidates for HIV prevention pills, said Ann Sullivan, MD, consulting physician at Chelsea and Westminster Hospital in London.

“If people show up for PrEP, they’ve self-identified that they need PrEP, [and] we should allow them to take PrEP, ”Sullivan said at the 18th European AIDS Society conference (EACS 2021). “We just have to trust the patients. People know their risk and we just have to accept that they know what they need the most. “

And although 95% of this trial is made up of gay and bisexual men, this philosophy applies to all other groups who might benefit from PrEP, including cisgender and transgender women and others of various genders. Latinos and Black Americans. In the United States, these groups represent almost half of those who could benefit from PrEP according to older guidelines, but represent only 8% of people currently taking PrEP.

The discovery also strengthens growing calls from healthcare providers to reduce PrEP control. For example, the U.S. Centers for Disease Control and Prevention (CDC) is underway, where updated draft PrEP guidelines direct clinicians to talk to all sexually active adolescents and adults about PrEP.

For the PrEP Impact trial, gay and bisexual men who received sexual health care at the UK’s National Health Service sexual health clinics were asked to enroll in the study based on the guidelines. national PrEP. These guidelines included being a cisgender man who had had sex with men not currently living with HIV and reporting anal sex without a condom in the past 3 months; have a male partner whose HIV status they do not know or who does not have an undetectable viral load and with whom they have had anal sex without a condom; or someone who does not meet these criteria but whom the clinician believes is a good candidate.

Between October 2017 and February 2020, a total of 17,770 gay and bisexual men and 503 transgender and non-binary people signed up for the trial and were matched with 97,098 gay and bisexual men who were not using PrEP. (Data from transgender participants has been reported in a separate presentation.) The median age was 27, with 14.4% of cisgender gay men aged 16 to 24. Three out of four cis men were white, most of them living in London. , and more than half were from very low income neighborhoods.

Participants and controls were assessed to determine if they were at a particularly high risk of acquiring HIV, such as having used PrEP, having had two or more HIV tests, having had a sexually transmitted bacterial infection (STI). rectal or have been in contact with someone with HIV or syphilis.

By the end of February 2020, 24 cisgender men on PrEP had contracted HIV compared to 670 in the control group, an 87% reduction in HIV acquisition. Only one of these 24 cis men had laboratory confirmation of high adherence to PrEP. However, since the hair samples used to judge the drug’s strength were not long enough, Sullivan and his colleagues were unable to assess whether the person was truly on the treatment for the entire duration. of the test.

But when they looked at the assessed behavior of people who contracted HIV, the two groups diverged. While 92% of people using PrEP had been diagnosed with STIs and other markers of increased risk, this was only true for 71% of people not taking PrEP. It meant, Sullivan said Medscape Medical Newsthat the PrEP testing guidelines were missed by 29% of those at low risk assessed for HIV who nevertheless contracted the virus.

The findings led Antonio Urbina, MD, who both prescribes PrEP and runs the PrEP program at Mount Sinai Medical Center in New York City, to the same conclusion Sullivan and his team came to: can be things that patients do not want to tell their clinicians about their risk, either because of their own internalized stigma or their calculation that they are not comfortable enough with their providers to be honest.

“It reinforces me that I need to ask more open-ended questions about the risk and then talk more about PrEP,” said Urbina, professor of medicine at the Icahn School of Medicine. “The risk is dynamic and changes. And the good thing about PrEP is that if the risk goes up or down, if you have PrEP on board, you keep that protection against HIV.

An accompanying presentation on transgender and non-binary impact trial participants found that only one of 503 PrEP users contracted HIV. But here, too, there were people who could have benefited from PrEP but did not take it: of the 477 trans and non-binary participants who served as controls, 97 were eligible under current guidelines but did not. took PrEP. One in four people refused the offer to take PrEP; the others could not take it because they lived outside the treatment area. This, combined with a significantly lower likelihood that black trans and non-binary people took PrEP, indicated that work needs to be done to meet people’s needs geographically and ethnically.

The data on gay men also raised the question “who is being left out” for Gina Simoncini, MD, medical director of the Philadelphia AIDS Healthcare Foundation Healthcare Center. Simoncini previously taught attending physicians at Temple University how to prescribe PrEP and has toured extensively for primary care providers on how to manage PrEP.

“My biggest problem with this data is what about people who don’t go to sexual health clinics? ” she said. “What about the child who is 16 years old and who can barely put his feet in the water of sex and who does not feel very comfortable going to a health clinic? sexual? family stigma and cultural stigma? The more we move towards primary care, the more people have to get into it.

Sullivan does not report any relevant financial relationship. Simoncini is an employee of the AIDS Healthcare Foundation and has received advisory board fees from ViiV Healthcare. Urbina sits on the scientific advisory boards of Gilead Sciences, ViiV Healthcare and Merck.

Heather Boerner is a science journalist based in Pittsburgh, Pennsylvania. His book, Positively negative: love, pregnancy, and science’s surprising victory over HIV, was released in 2014.

18th European AIDS Conference: Best Poster D2 / 7 and Best Poster D2 / 4. Presented October 28, 2021.

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