Publications by authors named "Julia L Marcus"

84 Publications

A decision analytics model to optimize investment in interventions targeting the HIV PrEP cascade of care.

AIDS 2021 Apr 6. Epub 2021 Apr 6.

Department of Epidemiology, Emory University Division of Health Policy and Management, University of Minnesota Division of HIV/AIDS Prevention, Centers for Disease Control and Prevention Department of Population Medicine, Harvard Medical School.

Objectives: Gaps between recommended and actual levels of HIV preexposure prophylaxis (PrEP) use remain among men who have sex with men (MSM). Interventions can address these gaps, but it is unknown how public health initiatives should invest prevention funds into these interventions to maximize their population impact.

Design: We used a stochastic network-based HIV transmission model for MSM in the Atlanta area paired with an economic budget optimization model.

Methods: The model simulated MSM participating in up to three real-world PrEP cascade interventions designed to improve initiation, adherence, or persistence. The primary outcome was infections averted over 10 years. The budget optimization model identified the investment combination under different budgets that maximized this outcome given intervention costs from a payer perspective.

Results: From the base 15% PrEP coverage level, the three interventions could increase coverage to 27%, resulting in 12.3% of infections averted over 10 years. Uptake of each intervention was interdependent: maximal use of the adherence and persistence interventions depended on new PrEP users generated by the initiation intervention. As the budget increased, optimal investment involved a mixture of the initiation and persistence interventions, but not the adherence intervention. If adherence intervention costs were halved, the optimal investment was roughly equal across interventions.

Conclusions: Investments into the PrEP cascade through initiatives should account for the interactions of the interventions as they are collectively deployed. Given current intervention efficacy estimates, the total population impact of each intervention may be improved with greater total budgets or reduced intervention costs.
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http://dx.doi.org/10.1097/QAD.0000000000002909DOI Listing
April 2021

Prioritising pleasure and correcting misinformation in the era of U=U.

Lancet HIV 2021 03;8(3):e175-e180

Department of Population Medicine, Harvard Medical School, Boston, MA, USA; The Fenway Institute, Fenway Health, Boston, MA, USA.

There is widespread unawareness and disbelief regarding the evidence-based conclusion that people who have a sustained undetectable HIV viral load cannot sexually transmit HIV-ie, undetectable=untransmittable (U=U). Long-standing, misguided fear about HIV transmission persists; consequently, so does the policing of sexual expression and the penalisation of pleasure faced by people with HIV. Many people with HIV with an undetectable viral load have unnecessarily abstained from condomless sex, avoided serodifferent partnering, and had anxiety about onward sexual transmission due to perceived HIV risk that is now known to be non-existent. Some health professionals have refrained from correcting this misinformation because of concerns that people with HIV will engage in more condomless sex or have more sexual partners upon learning of U=U. Withholding information about U=U is thus rooted in behavioural assumptions and is scientifically unfounded. Moreover, withholding such information violates medical ethics, perpetuates health inequities, and infringes on the sexual health and human rights of people with HIV. Health professionals and the broader public health community have an ethical responsibility to actively address misinformation about HIV transmission and disseminate the U=U message to all people.
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http://dx.doi.org/10.1016/S2352-3018(20)30341-6DOI Listing
March 2021

HIV Preexposure Prophylaxis and Sexual Satisfaction Among Men Who Have Sex with Men.

Sex Transm Dis 2021 Feb 19. Epub 2021 Feb 19.

Department of Population Medicine, Harvard Medical School and Harvard Pilgrim Health Care Institute, Boston, MA The Fenway Institute, Fenway Health, Boston, MA Division of Infectious Diseases, Beth Israel Deaconess Medical Center, Boston, MA.

Abstract: In this large online survey of primarily men who have sex with men, those who used preexposure prophylaxis reported greater sexual satisfaction than non-users, including sexual sensations, sexual presence/awareness, and sexual exchange. Person-centered care and messaging may require acknowledging that some people use preexposure prophylaxis for reasons beyond HIV prevention.
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http://dx.doi.org/10.1097/OLQ.0000000000001361DOI Listing
February 2021

Projected HIV and Bacterial Sexually Transmitted Infection Incidence Following COVID-19-Related Sexual Distancing and Clinical Service Interruption.

J Infect Dis 2021 03;223(6):1019-1028

Department of Population Medicine, Harvard Medical School, Boston, Massachusetts, USA.

Background: The global COVID-19 pandemic has the potential to indirectly impact transmission dynamics and prevention of HIV and other sexually transmitted infections (STI). It is unknown what combined impact reductions in sexual activity and interruptions in HIV/STI services will have on HIV/STI epidemic trajectories.

Methods: We adapted a model of HIV, gonorrhea, and chlamydia for a population of approximately 103 000 men who have sex with men (MSM) in the Atlanta area. Model scenarios varied the timing, overlap, and relative extent of COVID-19-related sexual distancing and service interruption within 4 service categories (HIV screening, preexposure prophylaxis, antiretroviral therapy, and STI treatment).

Results: A 50% relative decrease in sexual partnerships and interruption of all clinical services, both lasting 18 months, would generally offset each other for HIV (total 5-year population impact for Atlanta MSM, -227 cases), but have net protective effect for STIs (-23 800 cases). If distancing lasted only 3 months but service interruption lasted 18 months, the total 5-year population impact would be an additional 890 HIV cases and 57 500 STI cases.

Conclusions: Immediate action to limit the impact of service interruptions is needed to address the indirect effects of the global COVID-19 pandemic on the HIV/STI epidemic.
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http://dx.doi.org/10.1093/infdis/jiab051DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7928867PMC
March 2021

Secular Trends in Breast Cancer Risk Among Women With HIV Initiating ART in North America.

J Acquir Immune Defic Syndr 2021 May;87(1):663-670

Department of Epidemiology, Johns Hopkins University, Baltimore, MD.

Background: Studies suggest lower risk of breast cancer in women with HIV versus without HIV. These estimates may be biased by lower life expectancy and younger age distribution of women with HIV. Our analysis evaluated this bias and characterized secular trends in breast cancer among women with HIV initiating antiretroviral therapy. We hypothesized breast cancer risk would increase over time as mortality decreased.

Setting: Women with HIV prescribed antiretroviral therapy in the North American AIDS Cohort Collaboration on Research and Design (NA-ACCORD) from 1997 through 2016.

Methods: We estimated breast cancer hazard (cause-specific hazard ratios) and cumulative incidence accounting for competing risks (subdistribution hazard ratios) to assess changes in breast cancer risk over time. This was assessed overall (1997-2016) and within/across calendar periods. Analyses were adjusted for race/ethnicity and inverse probability weighted for cohort. Cumulative incidence was graphically assessed by calendar period and race/ethnicity.

Results: We observed 11,587 women during 1997-2016, contributing 63 incident breast cancer diagnoses and 1,353 deaths [73,445 person-years (median follow-up = 4.5 years)]. Breast cancer cumulative incidence was 3.2% for 1997-2016. We observed no secular trends in breast cancer hazard or cumulative incidence. There were annual declines in the hazard and cumulative incidence of death (cause-specific hazard ratios and subdistribution hazard ratios: 0.89, 95% confidence interval: 0.87 to 0.91) which remained within and across calendar periods.

Conclusions: These findings contradict the hypothesis of increasing breast cancer risk with declining mortality over time among women with HIV, suggesting limited impact of changing mortality on breast cancer risk. Additional inquiry is merited as survival improves among women with HIV.
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http://dx.doi.org/10.1097/QAI.0000000000002627DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8026587PMC
May 2021

Competing Health Risks Associated with the COVID-19 Pandemic and Response: A Scoping Review.

medRxiv 2021 Jan 8. Epub 2021 Jan 8.

Background: COVID-19 has rapidly emerged as a global public health threat with infections recorded in nearly every country. Responses to COVID-19 have varied in intensity and breadth, but generally have included domestic and international travel limitations, closure of non-essential businesses, and repurposing of health services. While these interventions have focused on testing, treatment, and mitigation of COVID-19, there have been reports of interruptions to diagnostic, prevention, and treatment services for other public health threats. We conducted a scoping review to characterize the impact of COVID-19 on HIV, tuberculosis, malaria, sexual and reproductive health, and malnutrition.

Methods: A scoping literature review was completed using searches of PubMed and preprint servers (medRxiv/bioRxiv) from January 1 to October 31 , 2020, using Medical Subject Headings (MeSH) terms related to SARS-CoV-2 or COVID-19 and HIV, tuberculosis, malaria, sexual and reproductive health, and malnutrition. Empiric studies reporting original data collection and mathematical models were included, and available data synthesized by region. Studies were excluded if they were not written in English.

Results: A total of 1604 published papers and 205 preprints met inclusion criteria, including 8.2% (132/1604) of published studies and 10.2% (21/205) of preprints: 7.3% (68/931) on HIV, 7.1% (24/339) on tuberculosis, 11.6% (26/224) on malaria, 7.8% (13/166) on sexual and reproductive health, and 12.1% (16/132) on malnutrition. Thematic results were similar across competing health risks, with substantial indirect effects of the COVID-19 pandemic and response on diagnostic, prevention, and treatment services for HIV, tuberculosis, malaria, sexual and reproductive health, and malnutrition.

Discussion: COVID-19 emerged in the context of existing public health threats that result in millions of deaths every year. Thus, effectively responding to COVID-19 while minimizing the negative impacts of COVID-19 necessitates innovation and integration of existing programs that are often siloed across health systems. Inequities have been a consistent driver of existing health threats; COVID-19 has worsened disparities, reinforcing the need for programs that address structural risks. Data reviewed here suggest that effective strengthening of health systems should include investment in public health with adequate funding to ensure continuity of care for emergent and existing public health threats.
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http://dx.doi.org/10.1101/2021.01.07.21249419DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7805463PMC
January 2021

Patient-Led Decision-Making for HIV Preexposure Prophylaxis.

Curr HIV/AIDS Rep 2021 Feb 8;18(1):48-56. Epub 2021 Jan 8.

Harvard Medical School and Harvard Pilgrim Health Care Institute, 401 Park Dr, Ste 401, Boston, MA, 02215, USA.

Purpose Of Review: Shared decision-making is a process that involves bidirectional exchange of information between patients and providers to support patients in making individualized, evidence-based decisions about their healthcare. We review the evidence on patient-led decision-making, a form of shared decision-making that maximizes patient autonomy, as a framework for decisions about HIV preexposure prophylaxis (PrEP). We also assess the likelihood that patient-led decision-making occurs for PrEP and describe interventions to facilitate this process.

Recent Findings: Patient-led decision-making is likely to be uncommon for PrEP, in part because healthcare providers lack knowledge and training about PrEP. Few evidence-based interventions exist to facilitate patient-led decision-making for PrEP. There is a need for rigorously developed interventions to increase knowledge of PrEP among patients and healthcare providers and support patient-led decision-making for PrEP, which will be increasingly important as the range of available PrEP modalities expands.
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http://dx.doi.org/10.1007/s11904-020-00535-wDOI Listing
February 2021

Associations Among HIV Risk Perception, Sexual Health Efficacy, and Intent to Use PrEP Among Women: An Application of the Risk Perception Attitude Framework.

AIDS Educ Prev 2020 10;32(5):392-402

Texas Woman's University, Denton, Texas.

HIV risk perception is a known determinant of HIV prevention behaviors among vulnerable populations. Lesser known is the combined influence of risk perception and efficacy beliefs on PrEP use. We examined the associations between levels of risk perception and strength of efficacy beliefs on intent to use PrEP in a sample of adult Black and Latina women. Guided by the risk perception attitudes (RPA) framework, we used cluster analysis to identify four interpretable groups. We ran analysis of covariance models to determine the relationship between membership in the RPA framework groups and intention to use PrEP. Among the 908 women, the mean age was 29.9 years and participants were Latina (69.4%) and Black (25.6%). Results of the analysis show that women with low perception of HIV risk and strong efficacy beliefs had significantly less intent to use PrEP than women with high risk perception and weak efficacy beliefs.
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http://dx.doi.org/10.1521/aeap.2020.32.5.392DOI Listing
October 2020

Projected HIV and Bacterial STI Incidence Following COVID-Related Sexual Distancing and Clinical Service Interruption.

medRxiv 2020 Sep 30. Epub 2020 Sep 30.

Department of Population Medicine, Harvard Medical School and Harvard Pilgrim Health Care Institute.

Background: The global COVID-19 pandemic has the potential to indirectly impact the transmission dynamics and prevention of HIV and other sexually transmitted infections (STI). Studies have already documented reductions in sexual activity ("sexual distancing") and interruptions in HIV/STI services, but it is unknown what combined impact these two forces will have on longer-term HIV/STI epidemic trajectories.

Methods: We adapted a network-based model of co-circulating HIV, gonorrhea, and chlamydia for a population of men who have sex with men (MSM) in the Atlanta area. Model scenarios varied the timing, overlap, and relative extent of COVID-related sexual distancing in casual and one-time partnership networks and service interruption within four service categories (HIV screening, HIV PrEP, HIV ART, and STI treatment).

Results: A 50% relative decrease in sexual partnerships and interruption of all clinical services, both lasting 18 months, would generally offset each other for HIV (total 5-year population impact for Atlanta MSM: -227 cases), but have net protective effect for STIs (-23,800 cases). Greater relative reductions and longer durations of service interruption would increase HIV and STI incidence, while greater relative reductions and longer durations of sexual distancing would decrease incidence of both. If distancing lasted only 3 months but service interruption lasted 18 months, the total 5-year population impact would be an additional 890 HIV cases and 57,500 STI cases.

Conclusions: The counterbalancing impact of sexual distancing and clinical service interruption depends on the infection and the extent and durability of these COVID-related changes. If sexual behavior rebounds while service interruption persists, we project an excess of hundreds of HIV cases and thousands of STI cases just among Atlanta MSM over the next 5 years. Immediate action to limit the impact of service interruptions is needed to address the indirect effects of the global COVID pandemic on the HIV/STI epidemic.
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http://dx.doi.org/10.1101/2020.09.30.20204529DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7536881PMC
September 2020

SARS-CoV-2 transmission dynamics should inform policy.

Clin Infect Dis 2020 Sep 23. Epub 2020 Sep 23.

College of Public Health, Kent State University, Kent, USA.

It is generally agreed that striking a balance between resuming economic and social activities and keeping the effective reproductive number (R0) below 1 using non-pharmaceutical interventions is an important goal until and even after effective vaccines become available. Therefore, the need remains to understand how the virus is transmitted in order to identify high-risk environments and activities that disproportionately contribute to its spread so that effective preventative measures could be put in place. Contact tracing and household studies in particular provide robust evidence about the parameters of transmission. In this viewpoint, we discuss the available evidence from large-scale, well-conducted contact tracing studies from across the world and argue that SARS-CoV-2 transmission dynamics should inform policy decisions about mitigation strategies for targeted interventions according to the needs of the society by directing attention to the settings, activities and socioeconomic factors associated with the highest risks of transmission.
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http://dx.doi.org/10.1093/cid/ciaa1442DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7543342PMC
September 2020

Gaps in Sexually Transmitted Infection Screening among Men who Have Sex with Men in PrEP Care in the United States.

Clin Infect Dis 2020 Jul 23. Epub 2020 Jul 23.

Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, GA.

Background: The U.S. Centers for Disease Control and Prevention (CDC) recommends comprehensive sexually transmitted infection (STI) screening every 3-6 months for men who have sex with men (MSM) using HIV preexposure prophylaxis (PrEP). The gaps between these recommendations and clinical practice by region have not been quantified.

Methods: We used survey data collected from the internet-based ARTnet study between 2017 and 2019 on STI screening among MSM across the U.S., stratified by current, prior, and never PrEP use. Poisson regression models with robust error variance were used to model factors, including residence in the Southeast, associated with consistent ("always" or "sometimes") exposure site-specific STI screening during PrEP care.

Results: Of 3259 HIV-negative MSM, 19% were currently using PrEP, 6% had used PrEP in the past, and 75% had never used PrEP. Among ever PrEP users, 87%, 78%, 57%, and 64% reported consistent screening for STIs by blood sample, urine sample or urethral swab, rectal swab, or pharyngeal swab, respectively, during PrEP care. Compared to PrEP users in all other regions, PrEP users in the Southeast were significantly less likely to be consistently screened for urogenital (adjusted prevalence ratio [aPR], 0.86; 95% confidence interval [CI], 0.76-0.98) and rectal STIs (aPR, 0.76; 95% CI, 0.62-0.93) during PrEP care.

Conclusions: Substantial gaps exist between CDC recommendations for STI screening during PrEP care and current clinical practice, particularly for rectal and pharyngeal exposure sites that can harbor asymptomatic infections and for MSM in Southeast states where the STI burden is substantial.
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http://dx.doi.org/10.1093/cid/ciaa1033DOI Listing
July 2020

Tenofovir Alafenamide for HIV Preexposure Prophylaxis.

Ann Intern Med 2020 07;173(1):78

Harvard Medical School and Harvard Pilgrim Health Care Institute, Boston, Massachusetts (J.L.M.).

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http://dx.doi.org/10.7326/L20-0301DOI Listing
July 2020

Comparison of Overall and Comorbidity-Free Life Expectancy Between Insured Adults With and Without HIV Infection, 2000-2016.

JAMA Netw Open 2020 06 1;3(6):e207954. Epub 2020 Jun 1.

Division of Research, Kaiser Permanente Northern California, Oakland.

Importance: Antiretroviral therapy (ART) has improved life expectancy for individuals with HIV infection, but recent data comparing life span and comorbidity-free years by HIV status are lacking.

Objective: To quantify the gap in life span and comorbidity-free years by HIV status among adults with access to care.

Design, Setting, And Participants: This matched cohort study used data from insured adults with and without HIV infection (aged ≥21 years) matched 1:10 at medical centers of Kaiser Permanente in northern and southern California and the mid-Atlantic states of Washington DC, Maryland, and Virginia from January 1, 2000, through December 31, 2016. Data were analyzed from September 1, 2019, through March 31, 2020.

Exposures: HIV status and, for individuals with HIV infection, ART initiation at a CD4 cell count of 500/μL or greater.

Main Outcomes And Measures: Overall life expectancy and expected years free of major chronic comorbidities, including chronic liver disease, chronic kidney disease, chronic lung disease, diabetes, cancer, and cardiovascular disease.

Results: Of 39 000 individuals with HIV infection and 387 785 matched uninfected adults, 374 421 (87.7%) were male, with a mean (SD) age of 41.4 (10.8) years. Among 359 244 individuals with known race/ethnicity, 90 177 (25.1%) were non-Hispanic black and 87 191 (24.3%) were Hispanic. From 2000 to 2003, overall life expectancy at age 21 years of age was 37.6 years among individuals with HIV infection and 59.7 years among uninfected adults, (difference, 22.1 years; 95% CI, 20.2-24.0 years). From 2014 to 2016, overall life expectancy at 21 years of age among individuals with HIV infection increased to 56.0 years compared with 65.1 years among uninfected adults (difference, 9.1 years; 95% CI, 7.9-10.2 years). During 2011 to 2016, individuals with HIV infection who initiated ART with a CD4 cell count of 500/μL or greater had a life expectancy at 21 years of age of 57.4 years compared with 64.2 years among uninfected adults (difference, 6.8 years; 95% CI, 5.0-8.5 years). From 2000 to 2003, the expected number of comorbidity-free years remaining at 21 years of age was 11.3 for individuals with HIV infection and 26.6 years for uninfected adults (difference, 15.3 years; 95% CI, 13.9-16.6 years). This difference in comorbidity-free years persisted over time but decreased to 9.5 years (95% CI, 7.7-11.2 years) for individuals with HIV infection who initiated ART at a CD4 cell count of 500/μL or greater.

Conclusions And Relevance: The results suggest that life expectancy of adults with HIV infection may be near that of life expectancy of individuals without HIV infection, but greater attention is needed to prevention of comorbidities among individuals with HIV infection.
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http://dx.doi.org/10.1001/jamanetworkopen.2020.7954DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7296391PMC
June 2020

Early Adopters of Event-driven Human Immunodeficiency Virus Pre-exposure Prophylaxis in a Large Healthcare System in San Francisco.

Clin Infect Dis 2020 Dec;71(10):2710-2712

Department of Adult and Family Medicine, Kaiser Permanente San Francisco Medical Center, San Francisco, California, USA.

Among 279 patients within a large healthcare system in San Francisco, event-driven HIV pre-exposure prophylaxis using a 2-1-1 regimen was a desirable alternative to daily dosing. Problems with adherence, planning sex in advance, or side effects were infrequent (13.9%). We found no new HIV infections over 136 person-years of follow-up.
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http://dx.doi.org/10.1093/cid/ciaa474DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7744988PMC
December 2020

To Contact Tracing... and Beyond!

Clin Infect Dis 2021 Feb;72(4):724-725

Department of Population Medicine, Harvard Medical School and Harvard Pilgrim Health Care Institute, Boston, Massachusetts, USA.

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http://dx.doi.org/10.1093/cid/ciaa717DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7884804PMC
February 2021

Artificial Intelligence and Machine Learning for HIV Prevention: Emerging Approaches to Ending the Epidemic.

Curr HIV/AIDS Rep 2020 06;17(3):171-179

Beth Israel Deaconess Medical Center, Division of Infectious Diseases, 110 Francis St., W/LMOB Suite GB, Boston, MA, 02215, USA.

Purpose Of Review: We review applications of artificial intelligence (AI), including machine learning (ML), in the field of HIV prevention.

Recent Findings: ML approaches have been used to identify potential candidates for preexposure prophylaxis (PrEP) in healthcare settings in the USA and Denmark and in a population-based research setting in Eastern Africa. Although still in the proof-of-concept stage, other applications include ML with smartphone-collected and social media data to promote real-time HIV risk reduction, virtual reality tools to facilitate HIV serodisclosure, and chatbots for HIV education. ML has also been used for causal inference in HIV prevention studies. ML has strong potential to improve delivery of PrEP, with this approach moving from development to implementation. Development and evaluation of AI and ML strategies for HIV prevention may benefit from an implementation science approach, including qualitative assessments with end users, and should be developed and evaluated with attention to equity.
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http://dx.doi.org/10.1007/s11904-020-00490-6DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7260108PMC
June 2020

Nondaily Use of HIV Preexposure Prophylaxis in a Large Online Survey of Primarily Men Who Have Sex With Men in the United States.

J Acquir Immune Defic Syndr 2020 06;84(2):182-188

Department of Population Medicine, Harvard Medical School and Harvard Pilgrim Health Care Institute, Boston, MA.

Background: Event-driven dosing of HIV preexposure prophylaxis (PrEP) using a 2-1-1 regimen is efficacious for men who have sex with men (MSM). However, data are limited on the prevalence, correlates, and patterns of nondaily PrEP use in the United States.

Setting: Nationwide online survey.

Methods: We distributed a survey to assess experiences with PrEP, including nondaily use, in May 2019 on geosocial networking sites commonly used by MSM.

Results: Among 9697 respondents, the mean age was 43 years, 67% were non-Hispanic white, and 90% were MSM. Nearly all (91.0%) had heard of PrEP, 40.1% ever used PrEP, and 33.3% used PrEP in the past 6 months. Most (60.6%) were interested in nondaily PrEP. Those without health insurance and those with higher incomes were more likely to be interested in nondaily PrEP. Of the 3232 who used PrEP in the past 6 months, 176 (5.4%) reported nondaily use. Fewer sexual partners, frequent sex planning, and substance use were associated with nondaily use. Common reasons for nondaily use were inconsistent sexual activity (59%) and cost (49%). The most prevalent regimen was event driven (48.3%); of those, 64.7% used 2-1-1. Of nondaily users, 24.0% used PrEP on a regular schedule but not every day, including only on weekends or days starting with T or S.

Conclusions: Given substantial interest in nondaily PrEP, and use of nondaily strategies that have not been evaluated in clinical studies, there is a need for US public health authorities to provide guidance on safe and effective nondaily dosing for MSM.
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http://dx.doi.org/10.1097/QAI.0000000000002332DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7228850PMC
June 2020

Life Expectancy of Insured People With and Without Hepatitis C Virus Infection, 2007-2017.

Open Forum Infect Dis 2020 Feb 5;7(2):ofaa044. Epub 2020 Feb 5.

Kaiser Permanente Division of Research, Oakland, California, USA.

Among 25 291 and 4 921 830 people with and without hepatitis C, life expectancy at age 20 increased 1.8 years and 0.3 years from the interferon to interferon-free era, respectively. Increases were highest for racial and/or ethnic minority groups with hepatitis C.
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http://dx.doi.org/10.1093/ofid/ofaa044DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7043807PMC
February 2020

Preexposure Prophylaxis for Human Immunodeficiency Virus Infection for Men Who Have Sex with Men and Transgender Persons:: What Dermatologists Need to Know.

Dermatol Clin 2020 Apr 23;38(2):233-238. Epub 2019 Nov 23.

Department of Population Medicine, Harvard Medical School, Harvard Pilgrim Health Care Institute, Boston, MA 02215, USA.

HIV remains an important public health concern in the United States, particularly for men who have sex with men (MSM) and transgender persons. With HIV preexposure prophylaxis (PrEP), persons who are HIV-uninfected take antiretroviral medications to prevent HIV infection. The most common PrEP regimen involves taking a single pill daily and is very effective in reducing risk of HIV infection, with few adverse effects. Barriers to PrEP access exist for MSM and transgender persons. Dermatologists can help combat the ongoing HIV epidemic among MSM, transgender persons, and others by understanding why, when, and how PrEP should be considered as an HIV prevention approach.
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http://dx.doi.org/10.1016/j.det.2019.10.008DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7183314PMC
April 2020

Has Pre-exposure Prophylaxis Made a Difference at a Population Level? Jury Is Still Out.

Clin Infect Dis 2020 Dec;71(12):3152-3153

Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts, USA.

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http://dx.doi.org/10.1093/cid/ciz1236DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7819505PMC
December 2020

More Screening or More Disease? Gonorrhea Testing and Positivity Patterns Among Men in 3 Large Clinical Practices in Massachusetts, 2010-2017.

Clin Infect Dis 2020 Dec;71(9):e399-e405

Department of Population Medicine, Harvard Medical School and Harvard Pilgrim Health Care Institute, Boston, Massachusetts, USA.

Background: Gonorrhea diagnosis rates in the United States increased by 75% during 2009-2017, predominantly in men. It is unclear whether the increase among men is being driven by more screening, an increase in the prevalence of disease, or both. We sought to evaluate changes in gonorrhea testing patterns and positivity among men in Massachusetts.

Methods: The analysis included men (aged ≥15 years) who received care during 2010-2017 in 3 clinical practice groups. We calculated annual percentages of men with ≥1 gonorrhea test and men with ≥1 positive result, among men tested. Log-binomial regression models were used to examine trends in these outcomes. We adjusted for clinical and demographic characteristics that may influence the predilection to test and probability of gonorrhea disease.

Results: On average, 306 348 men had clinical encounters each year. There was a significant increase in men with ≥1 gonorrhea test from 2010 (3.1%) to 2017 (6.4%; adjusted annual risk ratio, 1.12; 95% confidence interval, 1.12-1.13). There was a significant, albeit lesser, increase in the percentage of tested men with ≥1 positive result (1.0% in 2010 to 1.5% in 2017; adjusted annual risk ratio, 1.07; 95% confidence interval, 1.04-1.09).

Conclusions: We estimated significant increases in the annual percentages of men with ≥1 gonorrhea test and men with ≥1 positive gonorrhea test result between 2010 and 2017. These results suggest that observed increases in gonorrhea rates could be explained by both increases in screening and the prevalence of gonorrhea.
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http://dx.doi.org/10.1093/cid/ciaa066DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7904080PMC
December 2020

Tenofovir Alafenamide for HIV Preexposure Prophylaxis: What Can We DISCOVER About Its True Value?

Ann Intern Med 2020 02 14;172(4):281-282. Epub 2020 Jan 14.

Harvard Medical School, Harvard Pilgrim Health Care Institute, and The Fenway Institute, Boston, Massachusetts (J.L.M.).

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http://dx.doi.org/10.7326/M19-3337DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7217716PMC
February 2020

Machine Learning for Human Immunodeficiency Virus Prevention in Rural Africa: The SEARCH for Sustainability.

Clin Infect Dis 2020 Dec;71(9):2334-2335

Harvard Medical School and Harvard Pilgrim Health Care Institute, Boston, Massachusetts, USA.

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http://dx.doi.org/10.1093/cid/ciz1101DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7713679PMC
December 2020

Words Matter: Putting an End to "Unsafe" and "Risky" Sex.

Sex Transm Dis 2020 01;47(1):1-3

School of Public Health, Oregon Health and Science University─Portland State University, Portland, OR.

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http://dx.doi.org/10.1097/OLQ.0000000000001065DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6953392PMC
January 2020

Use of Intrauterine Devices and Risk of Human Immunodeficiency Virus Acquisition Among Insured Women in the United States.

Clin Infect Dis 2020 05;70(10):2221-2223

Department of Epidemiology, University of North Carolina at Chapel Hill.

Concerns have been raised about progestin-containing contraceptives and the risk of human immunodeficiency virus (HIV) acquisition. Based on health insurance data from women in the United States with intrauterine device (IUD) insertions during 2011-2018, there was no increased risk of incident HIV diagnosis for levonorgestrel-releasing IUDs versus copper IUDs.
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http://dx.doi.org/10.1093/cid/ciz791DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7201418PMC
May 2020

Working Toward Broad and Equitable Access to HIV Preexposure Prophylaxis.

Am J Public Health 2019 09;109(9):1160-1161

Julia L. Marcus and Douglas S. Krakower are with the Department of Population Medicine, Harvard Medical School and Harvard Pilgrim Health Care Institute, Boston, MA. Douglas S. Krakower is also with the Division of Infectious Diseases, Beth Israel Deaconess Medical Center, Boston.

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http://dx.doi.org/10.2105/AJPH.2019.305254DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6686886PMC
September 2019

Use of electronic health record data and machine learning to identify candidates for HIV pre-exposure prophylaxis: a modelling study.

Lancet HIV 2019 10 5;6(10):e688-e695. Epub 2019 Jul 5.

Department of Adult and Family Medicine, Kaiser Permanente San Francisco Medical Center, San Francisco, CA, USA.

Background: The limitations of existing HIV risk prediction tools are a barrier to implementation of pre-exposure prophylaxis (PrEP). We developed and validated an HIV prediction model to identify potential PrEP candidates in a large health-care system.

Methods: Our study population was HIV-uninfected adult members of Kaiser Permanente Northern California, a large integrated health-care system, who were not yet using PrEP and had at least 2 years of previous health plan enrolment with at least one outpatient visit from Jan 1, 2007, to Dec 31, 2017. Using 81 electronic health record (EHR) variables, we applied least absolute shrinkage and selection operator (LASSO) regression to predict incident HIV diagnosis within 3 years on a subset of patients who entered the cohort in 2007-14 (development dataset), assessing ten-fold cross-validated area under the receiver operating characteristic curve (AUC) and 95% CIs. We compared the full model to simpler models including only men who have sex with men (MSM) status and sexually transmitted infection (STI) positivity, testing, and treatment. Models were validated prospectively with data from an independent set of patients who entered the cohort in 2015-17. We computed predicted probabilities of incident HIV diagnosis within 3 years (risk scores), categorised as low risk (<0·05%), moderate risk (0·05% to <0·20%), high risk (0·20% to <1·0%), and very high risk (≥1·0%), for all patients in the validation dataset.

Findings: Of 3 750 664 patients in 2007-17 (3 143 963 in the development dataset and 606 701 in the validation dataset), there were 784 incident HIV cases within 3 years of baseline. The LASSO procedure retained 44 predictors in the full model, with an AUC of 0·86 (95% CI 0·85-0·87) for incident HIV cases in 2007-14. Model performance remained high in the validation dataset (AUC 0·84, 0·80-0·89). The full model outperformed simpler models including only MSM status and STI positivity. For the full model, flagging 13 463 (2·2%) patients with high or very high HIV risk scores in the validation dataset identified 32 (38·6%) of the 83 incident HIV cases, including 32 (46·4%) of 69 male cases and none of the 14 female cases. The full model had equivalent sensitivity by race whereas simpler models identified fewer black than white HIV cases.

Interpretation: Prediction models using EHR data can identify patients at high risk of HIV acquisition who could benefit from PrEP. Future studies should optimise EHR-based HIV risk prediction tools and evaluate their effect on prescription of PrEP.

Funding: Kaiser Permanente Community Benefit Research Program and the US National Institutes of Health.
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http://dx.doi.org/10.1016/S2352-3018(19)30137-7DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7152802PMC
October 2019

Using HIV Risk Prediction Tools to Identify Candidates for Pre-Exposure Prophylaxis: Perspectives from Patients and Primary Care Providers.

AIDS Patient Care STDS 2019 08 17;33(8):372-378. Epub 2019 Jun 17.

3Department of Population Medicine, Harvard Medical School and Harvard Pilgrim Health Care Institute, Boston, Massachusetts.

Clinical guidelines for HIV pre-exposure prophylaxis (PrEP) include risk prediction tools to identify appropriate candidates. We conducted a qualitative interview study to explore the potential acceptability, interpretation, and anticipated impact of such tools from the perspectives of men who have sex with men (MSM) and primary care providers (PCPs). Our purposive sample of English-speaking participants included: (1) MSM reporting HIV risk behaviors ( = 32; median age = 38 years; 53% non-Hispanic white; 22% high school degree or less education); (2) PCPs specializing in health care for MSM ( = 12); and (3) PCPs in general practice ( = 19). MSM participants questioned the ability of risk tools to predict HIV acquisition, and their perceptions of what might constitute a high HIV risk score varied widely. Many MSM participants believed that receiving a high score would prompt them to consider PrEP or other risk reduction strategies. Some believed that the data would be useful, particularly if discussed with their providers, whereas others anticipated feeling fear, anxiety, or mistrust. PCPs expressed more confidence in HIV risk prediction and imagined integrating tools with medical histories and their clinical judgment to assess risk. PCPs were most enthusiastic about adopting HIV risk prediction as a teaching tool to help patients visualize and reduce risk, their concerns about time constraints notwithstanding. In conclusion, our findings suggest that PCPs' views of HIV risk prediction tools are generally positive, whereas MSM participants' are more mixed. Given that both groups emphasized the value of contextualizing risk, shared decision making may be needed to implement HIV risk prediction tools effectively.
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http://dx.doi.org/10.1089/apc.2019.0056DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6661917PMC
August 2019

Hepatitis C treatment uptake and response among human immunodeficiency virus/hepatitis C virus-coinfected patients in a large integrated healthcare system.

Int J STD AIDS 2019 06 2;30(7):689-695. Epub 2019 May 2.

10 Harvard Medical School and Harvard Pilgrim Health Care Institute, Boston, MA, USA.

U.S. guidelines recommend that patients coinfected with human immunodeficiency virus (HIV) and hepatitis C virus (HCV) be prioritized for HCV treatment with direct-acting antiviral agents (DAAs), but the high cost of DAAs may contribute to disparities in treatment uptake and outcomes. We evaluated DAA initiation and effectiveness in HIV/HCV-coinfected patients in a U.S.-based healthcare system during October 2014-December 2017. Of 462 HIV/HCV-coinfected patients, 276 initiated DAAs (70% cumulative proportion treated over three years). Lower likelihood of DAA initiation was observed among patients with Medicare (government-sponsored insurance) versus commercial insurance (adjusted rate ratio [aRR] = 0.62, 95% CI = 0.46-0.84), patients with drug abuse diagnoses (aRR = 0.72, 95% CI = 0.54-0.97), patients with CD4 cell count <200 cells/µl versus ≥500 (aRR = 0.45, 95% CI = 0.23-0.91), and patients without prior HCV treatment (aRR = 0.68, 95% CI = 0.48-0.97). There were no significant differences in DAA initiation by age, gender, race/ethnicity, socioeconomic status, HIV transmission risk, alcohol use, smoking, fibrosis level, HIV RNA levels, antiretroviral therapy use, hepatitis B infection, or number of outpatient visits. Ninety-five percent of patients achieved sustained virologic response (SVR). We found little evidence of sociodemographic disparities in DAA initiation among HIV/HCV-coinfected patients, and SVR rates were high. Efforts are needed to increase DAA uptake among coinfected Medicare enrollees, patients with drug abuse diagnoses, patients with low CD4 cell count, and patients receiving first-time HCV treatment.
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http://dx.doi.org/10.1177/0956462419836520DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6529258PMC
June 2019

National and International Dimensions of Human Immunodeficiency Virus-1 Sequence Clusters in a Northern California Clinical Cohort.

Open Forum Infect Dis 2019 Apr 14;6(4):ofz135. Epub 2019 Mar 14.

Division of Infectious Diseases, Department of Medicine, Stanford University, California.

Background: Recent advances in high-throughput molecular epidemiology are transforming the analysis of viral infections.

Methods: Human immunodeficiency virus (HIV)-1 sequences from a Northern Californian cohort (NCC) of 4553 antiretroviral-naive individuals sampled between 1998 and 2016 were analyzed together with 140 000 previously published global sequences. The HIV-TRAnsmission Cluster Engine (HIV-TRACE) was used to infer a transmission network comprising links between NCC and previously published sequences having a genetic distance ≤1.5%.

Results: Twenty-five percent of NCC sequences were included in 264 clusters linked to a published sequence, and approximately one third of these (8.0% of the total) were linked to 1 or more non-US sequences. The largest cluster, containing 512 NCC sequences (11.2% of the total), comprised the subtype B lineage that traced its origin to the earliest North American sequences. Approximately 5 percent of NCC sequences belonged to a non-B subtype, and these were more likely to cluster with a non-US sequence. Twenty-two NCC sequences belonged to 1 of 4 large clusters containing sequences from rapidly growing regional epidemics: CRF07_BC (East Asia), subtype A6 (former Soviet Union), a Japanese subtype B lineage, and an East/Southeast Asian CRF01_AE lineage. Bayesian phylogenetics suggested that most non-B sequences resulted from separate introductions but that local spread within the largest CRF01_AE cluster occurred twice.

Conclusions: The NCC contains national and international links to previously published sequences including many to the subtype B strain that originated in North America and several to rapidly growing Asian epidemics. Despite their rapid regional growth, the Asian epidemic strains demonstrated limited NCC spread.
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http://dx.doi.org/10.1093/ofid/ofz135DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6483754PMC
April 2019