Association between rectal gonorrhoea and HIV incidence in men who have sex with men: a meta-analysis

BackgroundIncidence of rectal gonorrhoea (GC) has been hypothesised as a correlate of HIV exposure in prevention trials of men who have sex with men (MSM). High rectal GC incidence in MSM trials of new biomedical prevention drugs may provide supportive evidence for ongoing HIV risk. Empirical evidence of correlation between rectal GC and HIV incidence is needed to assess whether high rectal GC rates reliably correlate with high risk of HIV.MethodsRectal GC and HIV are routinely tested in sexual health clinics (SHCs) throughout England. Through routine surveillance data collected at visits to SHCs, we assessed HIV incidence and new rectal GC diagnoses in repeat visits by HIV-negative MSM between 2011 and 2018, predating widespread roll-out of pre-exposure prophylaxis. Meta-analysis regression assessed population-level association between HIV and rectal GC incidence over time.FindingsBetween 2011 and 2018, HIV and rectal GC incidence was assessed in 541 056 HIV-negative MSM attending SHCs in England. HIV incidence among MSM attending SHCs fell from 1.26/100 person-years (PYs) in 2011 to 0.28/100 PYs in 2018. Rectal GC rates increased from 3.5/100 PYs to 11.1/100 PYs over the same period. The rate of HIV incidence decreased by 22.3% for each percent increase in rectal GC (95% CI –30.8 to –14.7, p<0.001).InterpretationAmong the population of MSM attending SHCs in England, rectal GC rates increased substantially while HIV incidence rates decreased between 2011 and 2018. HIV incidence likely decreased through expanded HIV testing, prompt antiretroviral treatment (ART) initiation and increased viral suppression in persons living with HIV, interventions that did not decrease rectal GC. Rectal GC may not be an ideal proxy for HIV incidence in trials, as HIV exposure risk is complex and context dependent, given effective HIV prevention interventions in MSM.Introduction

HIV incidence, viremia, and the national response in Eswatini: Two sequential population-based surveys

With the highest HIV incidence and prevalence globally, the government of Eswatini started a substantial scale-up of HIV treatment and prevention services in 2011. Two sequential large population-based surveys were conducted before and after service expansion to assess the impact of the national response. Cross-sectional, household-based, nationally representative samples of adults, ages 18 to 49 years, were sampled in 2011 and 2016. We measured HIV prevalence, incidence (recent infection based on limiting antigen ≤1.5 optical density units and HIV RNA ≥1000 copies/mL), viral load suppression (HIV RNA <1000 copies/mL among all seropositive adults) and unsuppressed viremia (HIV RNA ≥1000 copies/mL among all, regardless of HIV status) and assessed for temporal changes by conducting a trend analysis of the log ratio of proportions, using a Z statistic distribution. HIV prevalence remained stable from 2011 to 2016 [32% versus 30%, p = 0.10]. HIV incidence significantly declined 48% [2.48% versus 1.30%, p = 0.01]. Incidence remained higher among women than men [2011: 3.16% versus 1.83%; 2016: 1.76% versus 0.86%], with a smaller but significant relative reduction among women [44%; p = 0.04] than men [53%; p = 0.09]. The proportion of seropositive adults with viral load suppression significantly increased from 35% to 71% [p < .001]. The proportion of the total adult population with unsuppressed viremia decreased from 21% to 9% [p < .001]. National HIV incidence in Eswatini decreased by nearly half and viral load suppression doubled over a five-year period. Unsuppressed viremia in the total population decreased 58%. These population-based findings demonstrate the national impact of expanded HIV services in a hyperendemic country.

HIV epidemic in a province of the Brazilian Amazon region: Temporal trend analysis

Background: Although considerable progress has been made over the last decades, human immunodeficiency virus (HIV) incidence and acquired immunodeficiency syndrome (AIDS) mortality rates have remarkably increased in the Brazilian Amazon region. Here, we employed temporal analysis to determine the impact of public policies on the HIV epidemic in the state of Pará, Brazil, which has the second highest HIV incidence rate in the Amazon region.Design and Methods: This is an ecological study conducted in the state of Pará, employing secondary data of HIV/AIDS cases notified to the Information System for Notifiable Diseases, 2007–2018. The following epidemiological variables were collected: year of notification, municipality of residence, age, sex, education, exposure category, and HIV/AIDS diagnostic criteria. The study population was composed of 21,504 HIV/AIDS cases. The HIV/AIDS incidence rates were analyzed employing the temporal trend analysis (TTA) followed by the chi-square test and residue analysis to determine the association between the epidemiological variables and time series periods.Results: A total of 50% of the notifications were composed of AIDS cases. TTA identified two periods in HIV/AIDS incidence, with stabilization of cases in the first period (G1, 2007–2012) and an upward trend in the second period (G2, 2012–2018). The most prevalent epidemiological characteristics in G2 (versus G1) were as follows: young people, brown skin color, higher schooling, and homosexuals.Conclusion: Public policy to control HIV infection in the Brazilian Amazon region has been partially effective. HIV screening tests and treatment should be made widely available to eradicate HIV infection in the Amazon region by 2030.

Using large-scale respondent driven sampling to monitor the end of an HIV epidemic among persons who inject drugs in Hai Phong, Viet Nam

Aims To describe the use of large-scale respondent driven sampling (RDS) surveys to demonstrate the “end of an HIV epidemic” (HIV incidence < 0.5/100 person-years) among persons who inject drugs (PWID) in a middle-income country. Large sample sizes are needed to convincingly demonstrate very low incidence rates. Methods 4 large surveys (Ns approximately 1500 each) were conducted among PWID in Hai Phong, Vietnam in 2016–2019. Respondent driven sampling (RDS) with a modification to add snowball sampling was used for recruiting participants. HIV incidence was measured through recency testing, repeat participants across multiple surveys and in a cohort study of PWID recruited from the surveys. RDS analytics (time to equilibria and homophilies for major variables) were used to assess similarities/differences in RDS only versus RDS plus snowball recruiting. Characteristics were compared among respondents recruited through standard RDS recruitment versus through snowball sampling. An overall assessment of the robustness of RDS to modification was made when adding a snowball sampling recruitment. Results RDS recruiting was very efficient in the first 5 weeks of each survey with approximately 180 respondents recruited per week. Recruiting then slowed considerably, and snowball sampling (permitting an individual respondent to recruit large numbers of new respondents) was added to the existing RDS recruiting. This led to recruiting within 13–14 weeks of 1383, 1451, 1444 and 1268 respondents, close to the target of 1500 respondents/survey. Comparisons of participants recruited through standard RDS method and respondents recruited through snowball methods showed very few significant differences. RDS analytics (quickly reaching equilibria, low homophilies) were favorable for both RDS recruited and total numbers of participants in each survey. DRug use and Infections in ViEtnam (DRIVE) methods have now been officially adopted in other provinces. Conclusions RDS appears to be quite robust with respect to adding a modest number of participants recruited through snowball sampling. Large sample sizes can provide compelling evidence for “ending an HIV epidemic” to policy makers in a PWID population in a middle income country setting.

866. Adherence to F/TDF for PrEP in Dried Blood Spots and HIV Infection Rates: A Pooled Analysis of Global PrEP Studies

Background The use of daily F/TDF for HIV pre-exposure prophylaxis (PrEP) substantially reduces HIV acquisition. Dried blood spot (DBS) tenofovir-diphosphate (TFV-DP) levels reflect TDF use over the past 6-8 weeks, providing an objective measure of adherence in people taking PrEP. Methods In a pooled analysis of 19 PrEP demonstration projects and clinical studies, 6,613 participants had at least one TFV-DP measurement in DBS and followed for at least 48 weeks and up to 96 weeks. We used a piecewise linear mixed-effects model to plot the least-square means with corresponding 95% confidence intervals (CI) of TFV-DP for adherence over time, and Poisson regressions to calculate HIV incidence rates (IR) by level of weighted average of TFV-DP. Results Of 6,613 participants, median age was 30 years (interquartile range 24−38), 5,449 (82%) were cisgender men, 806 (12%) were cisgender women, and 349 (5%) were transgender (316 transgender women, 2 transgender men, 31 unspecified). Adherence based on TFV-DP in DBS was consistently higher among participants who did not acquire HIV compared to those who did (Figure). Among all participants, 21%, 14%, 36%, and 29% has DBS consistent with taking &lt; 2, 2−3, 4−6, and ≥7 tablets of F/TDF PrEP per week (Table). Sixty-nine participants acquired HIV, with a median PrEP exposure of 0.82 years and an overall HIV IR (95% CI) of 1.16 (0.92, 1.47) per 100 person years. There was a strong association between adherence and HIV incidence [among individuals who took &lt; 2, 2−3, 4−6, and ≥7 tablets/week, the HIV IRs (95% CI) were 5.20 (4.03, 6.71), 0.38 (0.12, 1.18), 0.28 (0.12, 0.61), and 0.06 (0.01, 0.39), respectively. Overall IR (95% CI) of HIV infection among cisgender men was 1.25 (0.98, 1.60) per 100 patient-years. Four cisgender women and 2 transgender participants acquired HIV, corresponding to IRs (95% CI) of 0.71 (0.27, 1.90) and 0.63 (0.16, 2.53). Adherence by TFV-DP in DBS for F/TDF users who acquired HIV compared to those who did not. Note: ‘x’ on the Figure represents visit week when a new HIV infection was detected. HIV incidence rates (95% confidence intervals) by adherence to PrEP measured by level of TFV-DP in DBS up to 96 weeks after PrEP Initiation Conclusion This diverse, multi-national pooled analysis of F/TDF PrEP use provides the largest assessment to date of the adherence-HIV incidence relationship in people taking F/TDF for PrEP. The results suggest a high background HIV incidence in the pooled cohort and high efficacy in those adherent to PrEP. These findings support ongoing efforts to increase PrEP use among people who would benefit. Disclosures Albert Liu, MD, MPH, Gilead Sciences (Individual(s) Involved: Self): Gilead has donated study drug for studies I have led., Grant/Research Support, Other Financial or Material Support, Research Grant or Support; IAS-USA (Individual(s) Involved: Self): Honorarium for manuscript writing, Other Financial or Material Support; Viiv Healthcare (Individual(s) Involved: Self): Grant/Research Support, Research Grant or Support Raphael J. Landovitz, MD, MSc, Gilead Sciences (Individual(s) Involved: Self): Consultant; Janssen (Individual(s) Involved: Self): Consultant; Merck Inc (Individual(s) Involved: Self): Consultant; Roche (Individual(s) Involved: Self): Consultant Jared Baeten, MD, PHD, Gilead Sciences Inc. (Employee, Shareholder) David Magnuson, PharmD, Gilead Sciences Inc (Employee, Shareholder) Moupali Das, MD, Gilead Sciences Inc. (Employee, Shareholder) Christoph C. Carter, MD, Gilead Sciences Inc. (Employee, Shareholder) Li Tao, MD, PhD, Gilead Sciences Inc (Employee, Shareholder)