No abstract

NCT01761643.

Carbapenem-resistant Klebsiella pneumoniae (CRKP) is an increasingly common cause of health careassociated urinary tract infections. Antimicrobials with in vitro activity against CRKP are typically limited to polymyxins, tigecycline, and often, aminoglycosides. We conducted a retrospective cohort study of cases of CRKP bacteriuria at New York-Presbyterian Hospital from January 2005 through June 2010 to compare microbiologic clearance rates based on the use of polymyxin B, tigecycline, or an aminoglycoside. We constructed three active antimicrobial cohorts based on the active agent used and an untreated cohort of cases that did not receive antimicrobial therapy with Gram-negative activity. Microbiologic clearance was defined as having a follow-up urine culture that did not yield CRKP. Cases without an appropriate follow-up culture or that received multiple active agents or less than 3 days of the active agent were excluded. Eighty-seven cases were included in the active antimicrobial cohorts, and 69 were included in the untreated cohort. The microbiologic clearance rate was 88% in the aminoglycoside cohort (n ‫؍‬ 41), compared to 64% in the polymyxin B (P ‫؍‬ 0.02; n ‫؍‬ 25), 43% in the tigecycline (P < 0.001; n ‫؍‬ 21), and 36% in the untreated (P < 0.001; n ‫؍‬ 69) cohorts. Using multivariate analysis, the odds of clearance were lower for the polymyxin B (odds ratio [OR], 0.10; P ‫؍‬ 0.003), tigecycline (OR, 0.08; P ‫؍‬ 0.001), and untreated (OR, 0.14; P ‫؍‬ 0.003) cohorts than for the aminoglycoside cohort. Treatment with an aminoglycoside, when active in vitro, was associated with a significantly higher rate of microbiologic clearance of CRKP bacteriuria than treatment with either polymyxin B or tigecycline.

Young Latino men who have sex with men (MSM) are a highly vulnerable population for HIV infection. Pre-exposure prophylaxis (PrEP) is a novel biomedical HIV prevention tool that may aid in reducing the disparity in HIV incidence among Latino MSM. However, PrEP use is disproportionally low among Latino MSM and, therefore, identifying barriers along the PrEP continuum of care (the "PrEP cascade") would provide insight into how to best deploy PrEP interventions. Syndemics theory is a prominent framework employed in HIV prevention; however, to date, no known studies have applied this theory to PrEP. Thus, the aim of the current study was to explore the association between syndemics and the PrEP cascade, including the degree to which psychosocial and structural syndemic constructs are related to the PrEP cascade. Participants were 151 young Latino MSM (M age = 24 years; SD = 3) residing in San Diego, California, who completed a battery of online self-report measures. Results indicated high levels of syndemic indicators and varying levels of engagement across the PrEP cascade. As syndemic indicators increased, the odds of engagement across the PrEP cascade were significantly lowered. Psychosocial and structural syndemic factors accounted for unique variance in the PrEP cascade. Results highlight the need for combination interventions that address both psychosocial and structural barriers to PrEP use and persistence among young Latino MSM.

Background. Adherence is necessary for efficacy of preexposure prophylaxis (PrEP), and text-messaging methods are promising tools for both adherence assessment and support. Although PrEP adherence is variable, little research has examined patterns of variability or factors associated with longitudinal use.Methods. In the context of a randomized controlled trial of text-messaging versus standard of care for PrEP adherence, 181 men who have sex with men received once-daily tenofovir disoproxil fumarate/emtricitabine and daily adherence texts for 48 weeks. Growth mixture modeling (GMM) was used to identify subgroups of individuals with similar trajectories of text-reported adherence. Between-group differences in pharmacologic measures of adherence (ie, tenofovir diphosphate and emtricitabine triphosphate levels), as well as predictors and study-end attitudes associated with group membership, were examined.Results. GMM identified 4 trajectories of text-reported adherence. Classes with higher text-reported adherence had higher drug concentrations. Younger age and minority race were associated with lower adherence, and individuals in classes with lower adherence had greater baseline levels of depression, substance use concerns, and sexual risk. Differences in study satisfaction were also associated with adherence.Conclusions. This study supports the use of text-reported PrEP adherence. Identifying factors associated with less-than-optimal adherence may aid clinicians in anticipating at-risk patients requiring augmented intervention.Clinical trials registration. NCT01761643.

Background: Inaccurate HIV risk perception by men who have sex with men (MSM) is a barrier to HIV prevention. Providing information about objective HIV risk could improve preexposure prophylaxis (PrEP) uptake. Methods: PrEP Accessibility Research & Evaluation 2 (PrEPARE2) was a randomized controlled trial of MSM to determine if an objective risk score affects future PrEP uptake. Participants completed a baseline survey to assess demographics, risk behaviors and HIV selfperceived risk (SPR). The survey generated a calculated HIV risk score (CalcR), estimating HIV risk based on reported condomless anal intercourse and sexually transmitted infections, and was provided to individuals in the intervention arm. Participants were contacted 8 weeks later to determine if they initiated PrEP. Results: Of 171 participants (median age 32; 37% Hispanic or Non-Hispanic Black; median 5 sexual partners in past 6 months), 81% had heard of PrEP, and 57% thought they were good PrEP candidates. SPR had poor agreement with CalcR (kappa=0.176) with 38% underestimating their HIV risk. At week 8, only 14 of 135 participants had initiated PrEP with no difference between arms (CalcR 11%, control 10%, p>0.99). The most common reason for not starting PrEP was low HIV risk perception. There was a relative decrease in SPR over time (p=0.06) but no difference between arms (p=0.29). Conclusion: Providing an objective HIV risk score alone did not increase PrEP uptake. HIV testing performed at testing sites may be a crucial time to correct misperceptions about risk and initiate same-day PrEP given enthusiasm for PrEP on testing day to facilitate greater uptake.

Background: A public health concern regarding HIV pre-exposure prophylaxis (PrEP) is sexual risk compensation (i.e., increased unsafe sex among PrEP users that may undermine prevention efforts). Methods: This demonstration study (NCT#01761643; initiated in 2013) included 398 men who have sex with men (MSM) who initiated PrEP and were followed over 48 weeks at 4 sites in Southern California. Wilcoxon signed-rank tests compared prior 30-day number of sex partners and condomless insertive and receptive anal sex acts (CIAS and CRAS, respectively) at weeks 4, 12, 24, 36 and 48 to baseline. At 2 sites, PrEP users were also compared to a lagged, comparison group of 99 MSM who did not receive PrEP over 24 weeks using linear regression models, adjusting for age, race/ethnicity, education, and respective baseline scores. Logistic regression compared week 24 sexually transmitted infection (STI) rates. Results: Over 48 weeks in the PrEP group, there were significant decreases in the number of unknown HIV status sex partners and increases in CRAS at all study visits; there was no consistent change in number of HIV+ sex partners or CIAS. Among participants at two sites, there were no significant differences between PrEP and non-PrEP users in change in number of partners, CIAS, CRAS, or STI rates at week 24. Conclusions: Among early adopters of PrEP, there is some evidence for sexual risk compensation. Results support current guidelines of regular STI screening and behavioral risk reduction and adherence counseling with the provision of PrEP.

Background. HPV vaccination may prevent thousands of cases of cervical cancer. We aimed to evaluate the understanding and acceptance of the HPV vaccine among adolescents. Methods. A questionnaire was distributed to adolescents at health clinics affiliated with a large urban hospital system to determine knowledge pertaining to sexually transmitted diseases and acceptance of the HPV vaccine. Results. 223 adolescents completed the survey. 28% were male, and 70% were female. The mean age for respondents was 16 years old. Adolescents who had received the HPV vaccine were more likely to be female and to have heard of cervical cancer and Pap testing. Of the 143 adolescents who had not yet been vaccinated, only 4% believed that they were at risk of HPV infection and 52% were willing to be vaccinated. Conclusions. Surveyed adolescents demonstrated a marginal willingness to receive the HPV vaccine and a lack of awareness of personal risk for acquiring HPV.