Disproportionate rates of HIV are observed in Black women and men, especially in the Southern U.S. We observed limited uptake of PrEP services in our Southern community among these groups, particularly Black MSM relative to new HIV cases in Birmingham, AL; 18% accessed PrEP services compared to 50% of new HIV cases. Further research is needed to understand PrEP access and uptake in high-risk populations.

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HIV pre-exposure prophylaxis (PrEP) effectively prevents HIV acquisition among men who have sex with men (MSM), but PrEP uptake has been associated with sexually transmitted infections (STIs). The effect of PrEP on STIs in MSM in the Deep South of the United States is unknown. We performed a retrospective analysis of adult MSM at an American Deep South PrEP clinic to calculate the prevalence and incidence rate of bacterial STIs (chlamydia, gonorrhea, and syphilis) and identify associated risk factors by linking incident STI to patient-reported outcomes; 139 MSM accessed the clinic between 2014 and 2018 with baseline bacterial STI prevalence of 11%. Twenty-six of 81 eligible MSM on PrEP had incident STIs with an incidence rate of 33.1 cases per 100 person-years. Significantly higher proportions of high PrEP adherence, multiple sexual partners, and inconsistent condom use were seen in those with incident STI, and we identified MSM with both high PrEP adherence and multiple sexual partners as being at especially high risk for bacterial STIs (hazard ratio: 7.57, 95% confidence interval: 1.75–32.74). Bacterial STIs are common after initiating PrEP in this clinic, and MSM reporting high PrEP adherence and multiple sexual partners have a significant risk for incident STI. High-risk sexual behaviors persisted after starting PrEP, highlighting the importance of ongoing, intensive sexual health screening and interventions.

BackgroundPre-Exposure Prophylaxis (PrEP) effectively prevents HIV acquisition in men who have sex with men (MSM), if taken appropriately. Effective PrEP requires persistence in PrEP care. We defined the PrEP care continuum in a Deep South PrEP clinic and examined factors related to persistence in care among MSM.MethodsWe reviewed data for MSM at a university-affiliated PrEP clinic in Birmingham, AL from 2014–2018 to define the PrEP continuum at five major steps: screening, initial visit, follow-up visit, current persistence, and self-reported adherence. We defined persistence as attending a PrEP clinic visit in the last 6 months and nonpersistence as prior attendance without a visit in the last 6 months. We compared demographics, insurance status, and patient-reported behaviors from initial and most recent visits between those who persisted (“persisters”) and did not (“non-persisters”) using Wilcoxon rank sum, chi-square, or Fisher’s exact test.Results226 (100%) MSM were screened, 141 (62%) MSM attended an initial visit, 116 (51%) MSM attended follow-up, 43 (19.0%) persisted in PrEP care, and 29 (13%) MSM self-reported good adherence (figure). Among 139 MSM (46 persisters, 93 nonpersisters), persisters were older than nonpersisters (33 vs. 32 yr, P = 0.03), and were less likely to report inconsistent condom use at their initial visit (48% vs. 73%; P = 0.01) as compared with their last visit (69% vs. 63%, P = 0.13). 23% of persisters and 29% of nonpersisters were black (P = 0.39), and 98% of persisters and 90% of nonpersisters were insured (P = 0.50). 60% of persisters and 74% of nonpersisters had multiple sex partners at initial visit (P = 0.19) as compared with 56% and 60% at their last visit, respectively (P = 0.83).ConclusionAt a Deep South PrEP clinic, persistence overall was poor for MSM. More nonpersisters had inconsistent condom use, indicating higher risk despite nonpersistence. Although not statistically significant, nonpersisters were more likely to be black, uninsured, and have multiple sexual partners when compared with persisters. Disparities seen nationally in new HIV diagnoses are reflected in nonpersisters. Nonpersisters may not realize the extent of their risk of HIV acquisition and warrant intensive engagement interventions. Disclosures All authors: No reported disclosures.

BackgroundPre-exposure prophylaxis (PrEP) reduces HIV acquisition, but there are reports of high sexually transmitted infection (STI) rates among PrEP clients, possibly related to high-risk sexual behaviors (risk compensation). The study objective was to identify the prevalence and facilitators of STIs among men who have sex with men (MSM) at a Deep South PrEP clinic.MethodsThis was a retrospective analysis of MSM aged ≥18 years receiving STI testing at a university-affiliated PrEP clinic in Birmingham, AL from 2014 to 2018. Clients were screened for gonorrhea and chlamydia in the oropharynx, urine, and rectum by nucleic acid amplification test and syphilis by serological testing at least every 6 months. Results of STI testing and biannual patient-reported outcomes (PROs) for condomless anal sex, numbers of sexual partners within the last 3 months, and PrEP adherence were analyzed. The outcome of interest was any positive STI. We evaluated the association of STIs with these PROs using logistic regression.Results141 MSM met study criteria: 29 (21%) were age 18–24, 39 (28%) identified as black, 25 (18%) reported consistent condom use, 22 (17%) reported >7 sexual partners in the past 3 months, 97 (69%) were prescribed PrEP, and 41 (29%) had at least one positive STI test. By univariate analysis, sexual partner number >7 and PrEP adherence were significantly associated with STIs; age and race were not. In multivariable analysis (Table 1), >7 sexual partners and PrEP adherence were independently associated with STI infection.ConclusionIn a university-based PrEP Clinic in the Deep South, STIs were common in MSM. Our findings suggest that risky sexual behaviors among PrEP clients contribute to STIs, especially for those reporting PrEP adherence and high number of sexual partners, and highlight STI prevention opportunities.Table 1:Multivariable Analysis of STIs Among PrEP Clients at a University-affiliated PrEP ClinicWith STI N (%)Odds Ratio (95% CI)Consistent Condom useYes*5 (14)No28 (76)1.6 (0.5–5.2)Number partners/3 months02 (5)3.5 (0.3–38.3)1*5 (13)2–718 (46)1.7 (0.5–5.4)>714 (36)9.7 (2.4–40.2)AdherenceNot on PrEP*7 (17)Missed dose 0–2 weeks ago5 (12)1.2 (0.3–5.1)Missed Dose >2 weeks ago29 (71)4.7 (1.4-15.4) *denotes referentDisclosures All authors: No reported disclosures.

Many thanks to Dr. Clement et al. for their interest in our brief report, which highlighted the disparate uptake of PrEP by populations that are most affected by the HIV epidemic, in particular Black MSM in the United States Deep South. In our brief report, it was emphasized that community-based support systems, as well as, targeted messaging, and novel strategies may be necessary to increase uptake of PrEP in this high-risk population. As evident by our primary referral source, most patients in our cohort were referred by a sexual partner (34%) or healthcare provider (21%), and not by a community based organization (8%). This likely contributed to our initial PrEP cohort demographics, with underrepresentation of Black MSM.

IntroductionAfrican American women (AA), particularly those living in the Southeastern USA, experience disproportionately high rates of HIV infection. Pre-exposure prophylaxis (PrEP) is a highly effective HIV prevention tool that may circumvent barriers to traditional HIV prevention tools, such as condom use; however, very little is known about how to improve PrEP access and uptake among AA women who may benefit from PrEP use. This project aims to understand how to increase PrEP access among AA women in the rural Southern USA, which may ultimately affect HIV incidence in this population.Methods and analysisThe goal of the current study is to systematically adapt a patient–provider communication tool to increase PrEP uptake among AA women receiving care at a federally qualified health centre in Alabama. We will use an iterative implementation process, by assessing the feasibility, acceptability and preliminary impact of the tool on PrEP uptake, using a pilot preintervention/postintervention design (N=125). We will evaluate women’s reasons for declining a referral to a PrEP provider, reasons for incomplete referrals, reasons for not initiating PrEP after a successful referral and ongoing PrEP use at 3 and 12 months after PrEP initiation among our sample. The proposed work will significantly contribute to our understanding of factors impacting PrEP uptake and use among AA women, particularly in underserved areas in the Deep South that are heavily impacted by the HIV epidemic and experience worse HIV-related health outcomes relative to other areas in the USA.Ethics and disseminationThis protocol has been approved by the Institutional Review Board (IRB) at University of Alabama at Birmingham (Birmingham, AL; protocol 300004276). All participants will review a detailed informed consent form approved by the IRB and will provide written or verbal informed consent prior to enrolment. Results will be disseminated through peer-reviewed manuscripts, reports, and local, national and international presentations.Trial registration numberNCT04373551.