Background Human immunodeficiency virus (HIV) preexposure prophylaxis (PrEP) has great potential to reduce HIV incidence among young black men who have sex with men (YBMSM); however, initiation and persistence for this group remain low. We sought to understand the patterns and predictors of PrEP uptake and discontinuation among YBMSM in Atlanta, Georgia. Methods PrEP was offered to all participants in a prospective cohort of YBMSM aged 18–29 years not living with HIV. Time to PrEP uptake, first discontinuation, and final discontinuation were assessed using the Kaplan-Meier method. Cox proportional hazard models were used to identify predictors of uptake and discontinuation. Results After 440 person-years of follow-up, 44% of YBMSM initiated PrEP through the study after a median of 122 days. Of PrEP initiators, 69% had a first discontinuation and 40% had a final discontinuation during the study period. The median time to first PrEP discontinuation was 159 days. Factors associated with PrEP uptake included higher self-efficacy, sexually transmitted infection (STI), and condomless anal intercourse. Factors associated with discontinuation included younger age, cannabis use, STI, and fewer sex partners. HIV incidence was 5.23/100 person-years (95% confidence interval [CI], 3.40–7.23), with a lower rate among those who started PrEP (incidence rate ratio, 0.39; 95% CI, .16–.92). Conclusions Persistent PrEP coverage in this cohort of YBMSM was suboptimal, and discontinuations were common despite additional support services available through the study. Interventions to support PrEP uptake and persistence, especially for younger and substance-using YBMSM, are necessary to achieve full PrEP effectiveness. Clinical Trials Registration NCT02503618.

Background HIV incidence among US young, black MSM (YBMSM) is high, and structural barriers (e.g. lack of health insurance) may limit access to Pre-Exposure Prophylaxis (PrEP). Research studies conducted with YBMSM must ensure access to the best available HIV prevention methods, including PrEP. Methods We implemented an optional, non-incentivized PrEP program in addition to standard HIV prevention services in a prospective, observational cohort of HIV-negative YBMSM in Atlanta, GA. Provider visits and lab costs were covered; participant insurance plans and/or the manufacturer assistance program were used to obtain drug. Factors associated with PrEP initiation were assessed with prevalence ratios and time to PrEP initiation with Kaplan-Meier methods. Results Of 192 enrolled YBMSM, 4% were taking PrEP at study entry. Of 184 eligible men, 63% indicated interest in initiating PrEP, 10% reported no PrEP interest, and 27% wanted to discuss PrEP again at a future study visit. Of 116 interested men, 46% have not attended a PrEP initiation appointment. Sixty-three men (63/184; 34%) initiated PrEP; 11/63 (17%) subsequently discontinued PrEP. The only factor associated with PrEP initiation was reported STI in the prior year (PR 1.50, 95%CI 1.002-2.25). Among interested men, median time to PrEP initiation was 16 weeks (95% CI 7–36). Conclusions Despite high levels of interest, PrEP uptake may be suboptimal among YBMSM in our cohort even with amelioration of structural barriers that can limit use. PrEP implementation as standard of HIV prevention care in observational studies is feasible; however, further research is needed to optimize uptake for YBMSM.

Human immunodeficiency virus (HIV) preexposure prophylaxis (PrEP) has high biomedical efficacy; however, awareness, access, uptake, and persistence on therapy remain low among black men who have sex with men (BMSM), who are at highest risk of HIV in the United States. To date, discussions of "PrEP failure" have focused on one typology: rare, documented HIV acquisitions among PrEP users with adequate serum drug levels (ie, biomedical failure). In our cohort of HIV-negative young BMSM in Atlanta, Georgia, we continue to observe a high HIV incidence (6.2% annually at interim analysis) despite access to free PrEP services. Among 14 seroconversions, all were offered PrEP before acquiring HIV. Among these participants, we identified 4 additional typologies of PrEP failure that expand beyond biomedical failure: low PrEP adherence, PrEP discontinuation, PrEP contemplation without initiation, and PrEP refusal. We describe the 5 typologies and suggest interventions to improve PrEP effectiveness among those at highest risk.

b Piperacillin-tazobactam (PTZ) is frequently used as empirical and targeted therapy for Gram-negative sepsis. Time-dependent killing properties of PTZ support the use of extended-infusion (EI) dosing; however, studies have shown inconsistent benefits of EI PTZ treatment on clinical outcomes. We performed a retrospective cohort study of adult patients who received EI PTZ treatment and historical controls who received standard-infusion (SI) PTZ treatment for presumed sepsis syndromes. Data on mortality rates, clinical outcomes, length of stay (LOS), and disease severity were obtained. A total of 843 patients (662 with EI treatment and 181 with SI treatment) were available for analysis. Baseline characteristics of the two groups were similar, except for fewer female patients receiving EI treatment. No significant differences between the EI and SI groups in inpatient mortality rates (10.9% versus 13.8%; P ‫؍‬ 0.282), overall LOS (10 versus 12 days; P ‫؍‬ 0.171), intensive care unit (ICU) LOS (7 versus 6 days; P ‫؍‬ 0.061), or clinical failure rates (18.4% versus 19.9%; P ‫؍‬ 0.756) were observed. However, the duration of PTZ therapy was shorter in the EI group (5 versus 6 days; P < 0.001). Among ICU patients, no significant differences in outcomes between the EI and SI groups were observed. Patients with urinary or intra-abdominal infections had lower mortality and clinical failure rates when receiving EI PTZ treatment. We did not observe significant differences in inpatient mortality rates, overall LOS, ICU LOS, or clinical failure rates between patients receiving EI PTZ treatment and patients receiving SI PTZ treatment. Patients receiving EI PTZ treatment had a shorter duration of PTZ therapy than did patients receiving SI treatment, and EI dosing may provide cost savings to hospitals.T he current prevalence of multidrug-resistant (MDR) Gramnegative infections challenges clinicians to ensure appropriate and pharmacokinetically optimized antimicrobial therapy for patients with presumed Gram-negative infections (1-5). Piperacillin-tazobactam (PTZ) is frequently administered as empirical or targeted therapy for hospitalized patients who have risk factors for Pseudomonas aeruginosa or other MDR Gram-negative organisms.␤-Lactam antimicrobials, including PTZ, exhibit time-dependent killing properties, in which fractional time above the MIC is a critical factor determining pharmacological outcomes (6, 7). Monte Carlo simulations have been used to identify a higher probability of target attainment when PTZ is administered using extended infusion (EI) or continuous infusion (CI) for Gram-negative infections, including P. aeruginosa (8-12).EI and CI PTZ protocols have been adopted in many hospitals in an effort to optimize the effectiveness of PTZ treatment. However, clinical studies have shown inconsistent benefits of EI versus standard-infusion (SI) PTZ protocols, in terms of mortality rates, length of stay (LOS), and clinical outcomes. Many of those studies were limited by small sample sizes, exclusion of patients who d...

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