This Week in HIV Research: What Risk Compensation?

The high STI rates sometimes seen in studies involving men who have sex with men (MSM) on PrEP are reflective of a continuation of pre-PrEP risk behaviors, rather than men foregoing condoms once they are taking biomedical HIV prevention, Australian researchers reported in JAMA Network Open.

The study authors compared rates of STI diagnoses that occurred up to one year before participants started PrEP to diagnoses that occurred up to two years after PrEP initiation. All 2,404 participants were MSM reporting behaviors that put them at high risk of acquiring HIV. The study found that 50% of participants had at least one STI diagnosis pre-PrEP, compared to 52% post-PrEP. STI rates were on an upward trajectory before starting PrEP and stabilized once participants began taking biomedical HIV prevention.

The quarterly STI testing that accompanies PrEP prescribing allows for quick identification and treatment of asymptomatic men, which may lower STI rates over time, study authors wrote. However, they cautioned that more treatment may also accelerate the development of antimicrobial resistance and put a strain on health services.

The findings show that the same people who are at high risk of acquiring HIV—and thus candidates for PrEP—are also at high risk of acquiring STIs, Jenell Stewart and Jared M. Baeten of the University of Washington in Seattle, Wash., wrote in a JAMA Network Open commentary. Health care providers’ focus should thus be on harm reduction, including better STI care, not stigmatizing condomless sex, they argued. “Unfortunately, rather than focus on promoting sexual health, too often the implicit focus of discussions around STIs and PrEP shifts to preventing sexual behavior rather than preventing HIV and STIs,” they concluded.

When states expand Medicaid eligibility, more people get tested for HIV, more people become aware of their status, and more people begin taking PrEP—all of which ultimately helps curb onward transmission of HIV, an analysis reported in the American Journal of Preventive Medicine showed.

Researchers quantified county-level HIV-related indicators before and after the Medicaid provision in the Affordable Care Act was implemented and compared them to counties in states that did not expand Medicaid eligibility. Overall, 14% more residents learned their serostatus after Medicaid expansion than before, mainly as a result of increased testing; overall HIV infection rates did not increase in these areas.

The change in diagnosis rate was driven by diagnoses among people who inject drugs, although substance use levels remained stable. Thus, the increase in diagnoses was not driven by behavioral changes, but by better access to testing and treatment, the researchers found. In an examination of STI rates, the study authors found that gonorrhea rates dropped—likely because of prompt treatment and thus fewer transmissions—but that the level of other STIs did not change.

The relationship between HIV diagnoses and Medicaid expansion was especially pronounced in low-income rural counties that had a high rate of uninsured residents before the ACA. Just as with COVID-19, HIV testing is important to prevent the virus from spreading, study author Bita Fayaz Farkhad, Ph.D., of the University of Illinois Urbana-Champaign explained in a press release: “Expanding insurance coverage to low-income individuals through Medicaid could facilitate HIV prevention and improve HIV-related health outcomes.”

People living with serious mental illness are often at high risk of acquiring HIV and could be prescribed PrEP by the mental health care providers whom they are already seeing, a viewpoint in The Lancet HIV posited. The eight co-authors spanned a range of backgrounds and areas of expertise across several U.S. universities and organizations.

Currently, the responsibility for providing PrEP is often punted between primary care providers and HIV specialists, the authors wrote. Meanwhile, psychiatric providers already counsel patients on HIV risk reduction behaviors, suggesting an opportunity to fill a gap in PrEP provision that has helped result in a continuance of slow PrEP uptake throughout the U.S.

That said, little is known about the attitudes and knowledge psychiatric providers currently have regarding biomedical HIV prevention, or about the attitudes of people accessing community mental health services. The viewpoint’s authors called for further research in these areas. One barrier to prescribing PrEP in mental health settings may be the necessary HIV and STI testing, although the authors suggested such services could be outsourced to primary care or HIV clinics, which may already be co-located with mental health services.

Another major barrier remains the health insurance reimbursement structure, which may not pay psychiatrists for non-mental health services and/or may require patients to pay part of PrEP’s (high) cost. But these issues can be overcome, the viewpoint authors noted, concluding: “It is important to remember that HIV care and treatment advocacy has led the way in promoting health care as a form of social justice, one in which no individual is neglected.”

HIV service providers changed their practices quickly once the COVID-19 pandemic hit but are struggling with financial and other issues, a Kaiser Family Foundation survey of Ryan White Care Act-funded HIV services found.

The survey was conducted between August 18 and September 4, 2020. Before the novel coronavirus, 22% of 161 survey respondents reported that they offered telehealth services; that proportion increased to 99% during the pandemic. These virtual visits have improved retention in care and helped to reach young people, but also leave out unstably housed people and those living in rural areas without broadband infrastructure, among others, survey respondents generally agreed.

As the pandemic continues, lack of laboratory work is becoming a concern. Eighty-nine percent of respondents said they now provide multi-month antiretroviral prescriptions and 70% offer on-site COVID testing, but they often do so with fewer resources: 27% of respondents reported staff layoffs or furloughs, and another 27% reported a reduction in staff hours—despite 30% of respondents reporting that they had seen an increase in new clients.

Forty percent of respondents said their clients’ insurance mix had changed: More people are uninsured or have lost private coverage, and more people rely on Medicaid than before the pandemic, with the financial effects of those changes being felt by care providers.

Other issues raised by the survey included insufficient PPE (reported by 10% of respondents), insufficient access to COVID testing (22%), and not enough space to allow for social distancing at the clinic (32%).