Knowledge of and willingness to take pre-exposure prophylaxis among men who have sex with men in Israel
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Abstract Background Oral pre-exposure prophylaxis (PrEP) with tenofovir disoproxil fumarate and emtricitabine (TDF/FTC) has been found to reduce viral acquisition among HIV-negative MSM. This cross-sectional study was conducted before pre-exposure prophylaxis (PrEP) licensure in Israel, and aimed to compare men who have sex with men (MSM) who had heard of PrEP with those who had not, as well as MSM willing to take PrEP with those who were hesitant or not willing to take PrEP. Methods HIV-negative MSM responded anonymously to questionnaires in 2017 regarding their knowledge of and willingness to take PrEP, prior use of PrEP and post-exposure prophylaxis (PEP), and their sexual behaviors. Results Among 1705 participants, 1431 (83.9%) had heard about PrEP. They were older and more often reported being Jewish, having an academic degree, self-identifying as gay/bisexual, being tested for HIV in the last year, participating in group sex, using alcohol or drugs before or during sex, and having prior use of PrEP/PEP compared with MSM who had not heard about PrEP. A total of 760 (44.8%) participants indicated that they would consider taking PrEP, 567 (33.5%) maybe would consider taking PrEP, and 367 (21.7%) would not take PrEP. Those who were willing to take PrEP had a lower level of education, were involved in high-risk sexual behaviors, used alcohol or drugs before or during sex, and had previously used PrEP/PEP compared with participants who maybe would consider taking or would not take PrEP. When participants were asked to indicate if they were willing to take PrEP at different potential efficacies and costs, the willingness to using PrEP increased with the potential efficacy of the drug and adversely related to its cost. Conclusions PrEP awareness was high, and 44.8% indicated willingness to take PrEP, especially those who reported high-risk sexual behaviors. This supports the current policy in Israel to allow PrEP to MSM who are at high-risk. In order to maintain a high level of PrEP-adherence, physicians should consider structural barriers, such as negative stigma of being promiscuous, lack of perceived HIV-risk, difficulties in accessing clinics or paying for PrEP, inability to follow-up or low tolerability of the medication.Keywords:
Pre-exposure prophylaxis
Emtricitabine
Anal intercourse
Post-exposure prophylaxis
Pre-exposure prophylaxis (PrEP) is one of the main methods recommended by international guidelines for preventing HIV infection, and increasing attention has been paid to it in China. In 2019, emtricitabine/tenofovir alafenamide (F/TAF) was approved by the US FDA as the second PrEP option besides emtricitabine/tenofovir disoproxil fumarate (F/TDF). This article reviews the latest international guideline recommendations on PrEP, and the relevant clinical study data, discusses the considerations and challenges in implementing PrEP in the context of clinical practice in China, and provides suggestions for improving the awareness, accessibility, affordability and adherence of PrEP.暴露前预防（PrEP）是国际指南推荐预防HIV感染的主要方式之一，在我国受到越来越多的关注。2019年，恩曲他滨联合丙酚替诺福韦（F/TAF）在美国获批成为继恩曲他滨联合富马酸替诺福韦二吡呋酯（F/TDF）后，第二个可用于PrEP的药物。本文结合最新国际指南、PrEP临床研究数据和我国实际情况，讨论PrEP在我国临床运用中的考量和挑战，并对提高PrEP认知、可及性、可负担性及用药依从性提出具体建议。.
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Pre-exposure prophylaxis (PrEP) and post-exposure prophylaxis (PEP) had been proved to be effective in HIV prevention among men who have sex with men (MSM) internationally. Use of either PrEP or PEP was found to be limited among Chinese MSM. Relatively little data was reported in China.Our program indicated that PEP was more acceptable than PrEP among MSM in China. Drugs of lower cost and related knowledge dissemination could increase PrEP and PEP uptake among MSM in China.PrEP and PEP are likely to contribute significantly to human immunodeficiency virus (HIV) prevention in China.
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Although the balance of recent evidence supports the efficacy of antiretroviral (ARV)-based pre-exposure prophylaxis (PrEP) against HIV-1 infection, recent negative trial results are perplexing. Of seven trials with available HIV endpoints, three different products have been tested: tenofovir 1% vaginal gel, oral tenofovir disoproxil fumarate (TDF) tablets, and TDF/emtricitabine tablets. Six of these trials were conducted exclusively in sub-Saharan Africa; all found the products to be well tolerated, and four demonstrated effectiveness. Furthermore, the HIV Prevention Trial Network (HPTN) 052 trial recently confirmed that antiretroviral treatment leads to 96% reduction in transmission to HIV-negative partners in HIV-serodiscordant couples. These results, along with human and animal data, provide substantial evidence for the efficacy of antiretroviral-based HIV prevention. Yet assessment of oral TDF/emtricitabine in the FEM-PrEP study and of oral and vaginal tenofovir in the Microbicide Trial Network (MTN)-003 trial (VOICE) was stopped for futility. How do we make sense of these discrepant results? We believe that adherence is a key factor, although it cannot be the only factor. Expanding upon a recent editorial in the Lancet, we discuss the impact of suboptimal product adherence on PrEP efficacy in the context of variable drug concentration at the exposure site, integrity of the vaginal epithelium, and the role of acute infection.
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The US Centers for Disease Control and Prevention (CDC) has issued guidance for the broad use of pre-exposure prophylaxis for HIV prevention—better known by the shorthand PrEP—which builds on interim guidance issued in 2012. Truvada is a single pill containing two commonly used HIV drugs, tenofovir and emtricitabine, and it is the only product that currently carries a label indication for PrEP, although studies of other drugs for PrEP are under way. When taken daily it provides greater than 90% protection against HIV infection. The new guidance recommended PrEP as an option for four groups of people:
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Background
HIV post-exposure prophylaxis following sexual exposure (PEPSE) and pre-exposure prophylaxis (PrEP) are used by people at sexual risk of HIV acquisition including men who have sex with men (MSM). Owing to the high risk of HIV seroconversion due to on-going risk behaviours, it is becoming commonplace for HIV-negative MSM requiring PEPSE (e.g. HIV sexual-exposure within 72-hours) to transition immediately to PrEP following the 28-days of PEPSE. We aimed to review how frequently PrEP is discussed and used by MSM following PEPSE.Method
We reviewed the electronic notes of MSM who had accessed PEPSE between January 2018 – November 2020 and collected information on sexual assault, recreational drug use at the time of PEPSE initiation, whether direct transition to PrEP had been discussed, and if PrEP had been initiated after PEPSE.Results
During the study period, 277 MSM accessed PEPSE. The median age was 32 years (IQR 26–43), 17 (6%) started PEPSE following a sexual assault, 36 (13%) were using recreational drugs during sex and 30(11%) had used PrEP previously. Discussion about direct transition to PrEP after PEPSE was documented in 155 (56%) MSM, including 128 (51%) MSM who had never used PrEP before, and 67 (24%) MSM actually transitioned directly from PEPSE to PrEP. Clinicians were more likely to discuss PEPSE to PrEP transition in MSM with prior PrEP use (p<0.0001), and MSM were more likely to transition to PrEP from PEPSE if they had used PrEP previously (p<0.00001).Conclusion
Only 56% of MSM who used PEPSE had a documented discussion about transitioning to PrEP and only a 24% actually transitioned from PEPSE to PrEP. Where indicated, MSM who access PEPSE should have a documented discussion and ideally transition immediately onto PrEP following completion of PEPSE.Pre-exposure prophylaxis
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HIV pre-exposure prophylaxis (PrEP) is now available in the UK. However, some men who have sex with men (MSM) continue to use HIV post-exposure prophylaxis following sexual exposure (PEPSE) and are not using PrEP. It is important to characterize MSM having condomless anal sex who are not using PrEP.In a cross-sectional analysis, we compared the characteristics of MSM who used PEPSE in 2021 with MSM using PEPSE in 2017.Overall, 126 MSM used PEPSE in January to June 2017 and 28 MSM used PEPSE in January to June 2021, a 78% decline in PEPSE use. Those MSM using PEPSE in 2021 were significantly younger (27 vs. 35 years, p < 0.01), more likely to identify as black or from another minority ethnic group [29% (8/28) vs. 8% (10/126); p < 0.01], more likely to attend as a result of a group sex encounter [35% (10/28) vs. 16% (10/126); p = 0.03], more likely to attend following sex involving recreational drug use [32% (9/28) vs. 13% (16/126); p = 0.02], and more likely to initiate PEPSE in the emergency department [35% (10/28) vs. 19% (24/126); p = 0.04] compared with MSM attending in 2017. Those MSM using PEPSE in 2021 were significantly less likely to attend follow-up appointments compared with the 2017 cohort [71% (20/28) vs. 87% (110/126); p < 0.05]. Ninety-five per cent of MSM using PEPSE in 2021 were initiated on PrEP at follow-up.Despite PrEP being readily available, some MSM continue using PEPSE and these MSM are significantly more likely to be younger, from black or minority ethnic groups, to engage in group sex involving recreational drugs and to attend the emergency department for PEPSE compared with MSM attending in 2017. Increasing the accessibility of PrEP for this group of MSM is important in order to optimize HIV prevention strategies.
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In 2012, the World Health Organization (WHO) released tenofovir/emtricitabine (TDF/FTC) as pre-exposure prophylaxis drug to help people at risk of HIV infection in specific populations, and various clinical trials and real-world data have confirmed the effectiveness of TDF/FTC in preventing HIV infection. In 2019, propofol tenofovir combined with emtricitabine (TAF/FTC) was approved in the United States as the second oral drug for pre-exposure prophylaxis(PrEP). However, for people who cannot take the drug or have poor adherence to the drug, second-generation PrEP, or long-acting antiretrovirals, provide more options. This artical reviewed the research progress of the first generation of oral PrEP and the new PrEP developed in recent years to provide reference for the promotion of HIV PrEP in China.2012 年WHO发布了将替诺福韦/恩曲他滨（TDF/FTC）作为HIV暴露前预防（PrEP）药物用于降低特定人群中HIV感染风险，各类临床试验及真实世界的数据均证实了TDF/FTC在预防HIV感染方面的有效性。2019年，丙酚替诺福韦/恩曲他滨（TAF/FTC）在美国获得批准，成为第二个可用于PrEP口服药物。然而，对于不能口服药物或服用依从性较差的人群，第二代PrEP药物即长效抗病毒药物为其提供较多选择。本文综述第一代PrEP口服药物和近年研发的第二代PrEP药物的研究进展，为我国推广PrEP提供参考。.
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Importance
About 40 000 Americans and 2 million people worldwide are newly infected with HIV each year. The combination antiretroviral regimen, tenofovir disoproxil fumarate (TDF)/emtricitabine, taken as a single pill once daily, has been shown to prevent HIV transmission but is used by fewer than 20% of people who could benefit in the United States.Observations
PubMed was searched on February 15, 2018, using the search termspre-exposure,prophylaxis,HIV, andPrEPto identify English-language articles published between 2010 and 2018. Four placebo-controlled randomized clinical trials have demonstrated that preexposure prophylaxis (PrEP) with daily dosing of TDF/emtricitabine significantly reduces HIV acquisition in men who have sex with men, high-risk heterosexuals, and injection drug users who share injection equipment. The efficacy of daily TDF/emtricitabine exceeds 90% but is highly correlated with degree of adherence. TDF/emtricitabine is safe and well-tolerated. Only 2% of people discontinue PrEP because of adverse effects. Sexually transmitted infections are common among those using PrEP. Resistance to TDF/emtricitabine when used for PrEP is rare (<0.1%) and usually occurs when PrEP is inadvertently prescribed to individuals with undiagnosed acute HIV infection who have false-negative findings on HIV antibody/antigen testing due to HIV infection acquired within 7 to 10 days of testing. Effective methods are needed to identify individuals at high risk for acquiring HIV, ensure their access to PrEP, and maximize medication adherence.Conclusions and Relevance
TDF/emtricitabine is an effective and safe therapy for preventing HIV transmission. Increasing prescription of TDF/emtricitabine for patients at risk of acquiring HIV has the potential to reduce new HIV infections.Emtricitabine
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HIV pre-exposure prophylaxis (PrEP) with daily oral tenofovir disoproxil fumarate (TDF) or TDF–emtricitabine (FTC) has been shown to be effective against sexual and injection-drug related HIV acquisition in four out of six large clinical trials. This article reviews the pharmacology of TDF and FTC as it relates both to PrEP efficacy and the emergence of viral resistance, summarizes the six trials and the inherent challenges to PrEP they highlighted, and proposes some future areas for further exploration.
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Currently, PrEP refers to prophylactic daily oral use of tenofovir disoproxil fumarate/emtricitabine (TDF/FTC), a formulation that is indicated in Canada for the treatment of HIV infection. Although licensed only in the United States for PrEP, this formulation is used off label in Canada for
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