This Week in HIV Research: Where the Rubber Meets the Ring
Amidst our extensive ongoing focus on PrEP (a.k.a. pre-exposure prophylaxis) and U=U (a.k.a. “undetectable equals untransmittable” messaging) as HIV interventions in the U.S., we can easily overlook major developments in other HIV prevention methods. Take the dapivirine vaginal ring, for instance, which recently received a nod from European regulators for use by cisgender women in resource-poor regions of the world.
As our global HIV prevention quiver fills with ever more arrows, it’s important to understand how and whether these weapons complement one another. Thus the need for valuable research like the studies we explore in our lead story this week—one of four summaries we’ve got of recently published HIV research with clinical relevance.
Here’s what we have in store for you this week:
- A pair of complementary studies find no concerns with concomitant use of vaginal rings with external or internal latex condoms.
- A modeling study suggests that many lives can be saved in the U.S. by screening men who have sex with men (MSM) more frequently for HIV than guidelines currently recommend.
- A survey of Black MSM regarding substance use finds little impact on PrEP initiation or adherence—except where chemsex is involved.
- An examination of anti-LGTBQ policies in the U.S. finds that MSM with HIV fare worse in states where such policies are the most strict.
We’ve got additional deets to dish on each study, so let’s get going. To beat HIV, you have to follow the science!
Vaginal Rings Can Be Used With Both External and Internal Condoms
Neither male condoms nor FC2 condoms break or slip more often when a vaginal ring is also used, a pair of studies published in Journal of Acquired Immune Deficiency Syndromes showed.
In the male condom study, 68 couples engaging in penile-vaginal intercourse used a total of 275 external latex condoms. Condoms failed 2.2% of the time when a silicone ring—a placebo for a dapivirine PrEP ring—was used and 4% when no ring was used.
Condom failure rates were slightly below those observed in the general population, likely because study participants had experience with the product and were also counseled on its use. Feeling the ring—reported by 67% of women and 45% of men—did not impact sexual pleasure.
A second study reported in the same journal showed non-inferiority of the ring when used together with an FC2 (sometimes referred to as “female”) condom, which itself features an internal ring. Seventy-nine heterosexual couples used 596 FC2 condoms, which failed 14% of the time with the silicone ring and 16% of the time without it.
Women were trained in the use of these condoms, but few participants had prior experience with them. This fact may have played a role in 46% of women and 47% of men reporting discomfort when using the two products together.
Nonetheless, each study shows that a vaginal ring does not affect condom failure rates, their authors concluded. The manuscripts were published not long after the European Medicines Agency adopted a positive opinion of the ring’s use among adult cisgender women in resource-poor countries.
Quarterly HIV Screening of Adolescent MSM Cost-Effective in the Long Run
In the U.S., screening young MSM at high risk of acquiring HIV every three months (instead of adhering to current guidelines, which recommend annual screening for MSM) will lengthen life spans while being cost-effective, a mathematical model published in Clinical Infectious Diseases showed.
The model found that, compared to the status quo, moving to quarterly HIV testing for 15-year-old MSM would increase life expectancy by 4.3 quality-adjusted years among those who seroconvert and by 2.5 QALY among all young MSM at high risk of HIV acquisition.
That said, improving implementation of the currently recommended annual testing would significantly increase both the proportion of MSM who are diagnosed and virologically suppressed by age 30 compared to current practice, the authors noted. Since young people tend not to seek health care very often, they should be offered HIV testing anytime they do show up at a health care provider office, they recommended.
"Ultimately, our study underscores the value of ongoing research to examine the most effective ways to increase HIV screening among youth," said senior study author Andrea Ciaranello, M.D., M.P.H., of Massachusetts General Hospital in a press release.
In an accompanying commentary, Bruce R. Schackman, Ph.D., of Weill Cornell Medicine pointed out that quarterly HIV testing is also the standard for people receiving PrEP, thus suggesting that frequent testing and PrEP care could be integrated. He also called for developmentally and culturally appropriate interventions to encourage both testing and PrEP uptake among adolescent MSM.
Chemsex Aside, Substance Use Doesn’t Dampen PrEP Initiation or Adherence in Black MSM
Black MSM who use substances are generally just as likely as other Black MSM to adhere to PrEP, with the exception of people who use stimulants while engaging in condomless anal intercourse, an analysis of data from the HPTN 073 trial that was published in Journal of Acquired Immune Deficiency Syndromes found.
HPTN 073 included 226 Black HIV-negative MSM in a PrEP demonstration project. Use of alcohol, marijuana, or poppers was not associated with a change in the likelihood that a participant would initiate PrEP. Similarly, the use of any of those substances by participants on PrEP was not associated with a lower likelihood of maintaining blood levels of tenofovir that were sufficient to confer protection against HIV. However, blood levels were found to be lower specifically among those who used stimulants before or during condomless anal intercourse, suggesting lower PrEP adherence among this group.
In post hoc analyses, a history of having been in jail or prison was associated with such stimulant use. Black men are more likely to have such a history than their white counterparts, the researchers noted.
A prior study had found no association between chemsex and PrEP adherence, the authors stated. However, it was conducted among mostly white men in the UK and relied on self-report, which may explain the difference in results.
Findings in the current study may help increase health care providers’ willingness to prescribe PrEP to Black MSM who use substances, but also show that enhanced services are needed for MSM who use stimulants to ensure that they benefit from PrEP, study authors concluded.
State Discrimination Against Sexual Minorities Is Tied to HIV Outcomes
MSM who are living with HIV fared better in U.S. states with the highest degree of policy-level support for people who are not cisgender or heterosexual compared to states with low policy support, a longitudinal analysis published in Journal of Acquired Immune Deficiency Syndromes showed.
The study looked at laws relating to nondiscrimination based on sexual orientation, same-sex marriage, joint adoptions, hate crimes based on sexual orientation, HIV criminalization, and related issues. It then compared the policy landscape in each area to local U.S. Centers for Disease Control data on overall and late HIV diagnoses, AIDS diagnoses, and mortality. Researches included data from 2008-2014 on 94 metropolitan statistical areas in 38 states.
Overall, states with high policy support had 39% fewer HIV diagnoses, 31% fewer late diagnoses, and 14% lower AIDS mortality among MSM compared to low policy support states. Further, 27% of all HIV diagnoses, 21% of all late HIV diagnoses, and 10% of all AIDS-attributed deaths could be attributed to low policy support, the researchers found.
One possible explanation for the observed associations is that MSM may hide their sexual identity in states without protections for sexual minorities and are then less likely to seek HIV testing or care. Thus, fewer MSM are virally suppressed, increasing the likelihood of onward transmission, the study authors theorized.
An alternative explanation is that relatively healthy MSM leave unsupportive states and move to states with a more favorable policy climate. However, such migratory patterns have not been observed in other studies.
“The state-level policy climate related to sexual minorities was associated with HIV health outcomes among MSM and could be a potential public health tool for HIV prevention and care,” study authors concluded.