This Week in HIV Research: Rethinking PrEP Guidelines

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OK, we realize we covered a lot of research last week on HIV pre-exposure prophylaxis (PrEP). We promise we're not falling into a rut! But our top story in this week's review of recently published peer-reviewed science on HIV is a valuable addition to the evolving conversation about how to discuss PrEP with patients -- just as our other highlighted studies are valuable to conversations around critical topics in HIV care.

This week's highlights include:

  • An expert analysis on where the U.S. Center for Disease Control's official PrEP guidelines fall short -- and how they can be better.
  • Support for partner notification services as a bulwark against onward HIV transmission among black men who have sex with men (MSM) and their partners.
  • Findings that end-state liver disease is no longer the primary cause of death among Canadians coinfected with HIV and hepatitis C.
  • New insights into correlates of lower HIV treatment adherence among people on methadone maintenance therapy. (Spoiler alert: Stigma doesn't help.)

If you're interested in PrEP or any of our other subjects of note this week, let's take a gander together at each of these new manuscripts. To beat HIV, you have to follow the science!

Barbara Jungwirth is a freelance writer and translator based in New York. Follow Barbara on Twitter: @reliabletran.

Myles Helfand is the executive editor and general manager of TheBody and TheBodyPRO. Follow Myles on Twitter: @MylesatTheBody.

Alternative Proposed to CDC's PrEP Guidelines

A multi-disciplinary group of experts critiqued the U.S. Centers for Disease Control and Prevention's criteria for prescribing pre-exposure prophylaxis and proposed an alternative set of PrEP indicators in Clinical Infectious Diseases.

The authors identified the following problems with the guidelines:

  • Providers are expected to discuss PrEP only if they believe the patient to be at risk of acquiring HIV.
  • Criteria in the summary of guidance and indications textboxes do not fully match.
  • Separate risk categories based on sexual behavior or drug use confound various aspects of a person's identity and behavior.
  • Network- and community-level HIV transmission risks or a partner's viral suppression status are not taken into account.
  • Recommendations for condom use while on PrEP are unclear.

The experts recommend instead that PrEP be discussed as part of routine care and indicators be assessed at the individual, partner, and network/community levels. They also urge providers to offer PrEP to patients who ask for it even if they don't match the CDC's risk indicators, and to inform their patients that using condoms in addition to PrEP prevents not only HIV, but also sexually transmitted infections and pregnancy.

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Partner Services for Black MSM Can Help Prevent Onward HIV Transmissions

African-American partners of MSM and transgender folk who were notified through partner services had high rates of undiagnosed HIV, researchers reported in Morbidity and Mortality Weekly Report. Partner services let people who are newly diagnosed with HIV notify their sexual partners of a potential seroconversion through a health department instead of person-to-person.

In this 2016 study, 43% of those recently diagnosed and offered partner services were African American; 76% of them were interviewed for partner services. The partners of 78% of African Americans interviewed were notified, 47% of the notified partners were tested, and 17% of those tested were newly diagnosed with HIV. However, the diagnosis rate was much higher among partners who are MSM (37%) and transgender people (38%).

In addition to detecting seroconversions, partner services can also re-engage people who had dropped out of care and link HIV-negative people to PrEP services, study authors concluded. By getting people diagnosed and treated, partner services also help to prevent onward HIV transmissions, they added.

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Liver Disease Is No Longer Primary Killer of HIV/HCV-Coinfected Canadians

Since the advent of direct acting antiviral drugs (DAA) for hepatitis C (HCV) treatment, end-stage liver disease has been overtaken by other, non-HCV-related causes of death among people coinfected with HIV and HCV, a Canadian study published in AIDS found.

Researchers compared data for two periods, 2003-2012 and 2013-2017 (before and after the DAA use began in Canada), and stratified participants into two age groups, 20-49 years old and 50-80 years old. Forty-two percent of the 1,634 study participants received at least one course of HCV treatment; 68% of these were with DAAs.

The overall death rate was 32.9 per 1,000 person-years, with 2% of deaths related to AIDS, 18% to drug overdoses, and 17% to liver disease. During 2013-2017, liver disease as a cause of death was overtaken by drug overdoses in the younger group and smoking-related illnesses in the older group. However, people with advanced liver fibrosis and poor HIV control still died from liver issues in either period.

HCV treatment should prioritize those with advanced fibrosis and interventions targeting modifiable risk factors should be included in routine HIV/HCV care, study authors recommended.

Fear of Stigma Associated With Lower Treatment Adherence in People on Methadone

Greater fear of stigma was associated with suboptimal adherence to antiretroviral therapy in people on methadone maintenance therapy in a small study published in the Journal of Acquired Immune Deficiency Syndromes.

Participants who reported taking ≥ 95% of their HIV drugs as prescribed during the prior month were deemed to be optimally adherent. Overall, 64% of the 121 participants were adherent by that measure. Viral suppression and higher motivation to take antiretrovirals were positively correlated with adherence (adjusted odds ratios [aOR] = 6.470 and 1.171, respectively), while anticipated HIV-related stigma was negatively correlated (aOR = 0.384).

Current injection drug use was not associated with lower adherence in those with high motivation (aOR = 1.086); by contrast, such an association was seen among those with lower motivation. In people with substance use disorders, motivation levels tend to be lower, study authors explained. They recommended interventions, such as treating underlying depression or better explaining the benefits of antiretroviral therapy, to increase motivation. "New strategies that specifically address anticipated stigma may enhance [antiretroviral] adherence among HIV-positive methadone-maintained patients as well as their overall health status," they concluded.