Truvada pills. (Credit: NIAID)
The long-awaited findings from HIV Prevention Trials Network study 073 (HPTN 073) were published Feb. 15 in Journal of the International AIDS Society. The study found that black men who have sex with men (BMSM) in three U.S. cities had very high adherence to pre-exposure prophylaxis (PrEP) when paired with culturally competent supportive services. This study is important in that it belies some of the common thinking that BMSM will not use PrEP and cannot maintain use enough to protect against HIV.
"If you take the time to engage men, you can get them to talk about these important risk factors. And in talking about them, you can help them define and develop effective strategies to assist them in not acquiring STIs [sexually transmitted infections] or HIV," said Darrell Wheeler, M.S.W., M.P.H., Ph.D., lead author of the study and professor of social welfare at the University of Albany.
The study focused specifically on 226 BMSM in three U.S. cities: Washington, D.C., Los Angeles, and Chapel Hill, North Carolina. Seventy-three percent of the participants identified as gay, and 20% identified as bisexual. All HPTN 073 participants were offered oral PrEP to be taken daily combined with client-centered care coordination. This intervention included a self-determination theorybased counseling approach to promote PrEP use along with service referral, linkage, and follow-up strategies to assist participants in addressing unmet psychosocial needs.
In the study, 178 of the men (79%) started PrEP, and 48 (21%) chose to not use the prevention pill. Of those who initiated PrEP, 64% were still using PrEP and had enough of the drug in their system to prevent HIV at six months. Whether using PrEP or not, 92% of all men were still enrolled in the study at the end of 12 months.
The study found that men were most likely to initiate PrEP if they'd had condomless anal sex with an HIV‐positive or unknown-status casual male partner. Men who were 25 and older, men who perceived themselves as "having enough money," and those who knew their partner(s) also used PrEP were all correlated with an increased likelihood of using PrEP. Also, there were fewer new HIV diagnoses among men who initiated PrEP than men who did not.
There were not many resources for black MSM to receive PrEP in North Carolina (one of the trial sites) before the study began, Wheeler said. HPTN 073 allowed for building an infrastructure to make PrEP more accessible, along with other services not limited to HIV prevention.
"We know that environment [and] context matters," said Wheeler. "If you're poor, you get less services and you have to wait longer. If you have poor housing, it has a negative consequence. We already know that. This has demonstrated that yes, this applies to this situation with this group of people as well."
Furthermore, the people who were using PrEP were not likely to see an increase in other STIs, which has been a major concern of some STI prevention advocates and providers. TheBodyPRO previously reported the results of a study from HPTN 073's STI findings.
Lisa Hightow-Weidman, M.D., M.P.H., a member of the protocol team and co-principal investigator at the University of North Carolina Chapel Hill, said that centering participants is beneficial to helping address the barriers for black MSM to use PrEP or engage in other STI risk reduction. "When you present folks with choice, information, and opportunity, they are able to synthesize that information and to make choices that reflect their needs, wants, desires, and health in the way they have the autonomy to do unlike other places," she said.
HPTN 073 differed from previous PrEP trials in several ways. It was one of the few studies to solely enroll black MSM in the United States. Also, unlike other PrEP trials, HPTN 073 was led by black gay researchers from the community designing the study and coordinating the research.
"It's personally gratifying. But equally important, I think it's vital to the nature of a scientific effort led by four black gay men which was the first in the network's history to ever be done by domestic black men. It is significant in that regard," said Wheeler. "There has never been a study led by a black gay man [on the U.S. domestic epidemic]. There have been men who have participated, but then to do a study where all of the principal leaders -- the co-chairs, the behavioral scientists, the intervention developers -- are all gay black men is evidence of putting cracks in the glass ceiling."
This strategy may have proved effective in recruiting as well as engaging study participants.
"If we black SGL [same-gender-loving] men are excluded, then it's no wonder why efforts are failing," said Daniel D. Driffin, M.P.H., director of external affairs with THRIVE SS, based in Atlanta. "Health departments and community-based organizations must become uncomfortable and challenged on the disservices to this community. We also have to incorporate new ideas; the days of having clients come to a brick and mortar in most cases can be skipped simply by online media."
Driffin added, "If systems are designed better, we could see increased services to black gay men."
Stephen Hicks is a writer and public health advocate with a background in sexual health and harm reduction. He is based in Washington, D.C.