HIV and STDs: December 2018

The trick to HIV care is ABA: Always Be ARTing.  We’re long past the age of deeming patients with HIV “not ready for ART”; if you aren’t, here’s data from UCSF showing why you should be.  The authors performed a retrospective review of outcomes in a vulnerable patient population referred to their rapid ART initiation program between 2013 and 2017.  Patients had been referred from testing sites to receive either same-day or next-day intake appointments, where in addition to a multidisciplinary evaluation and insurance enrollment, they were offered ART.  The authors evaluated subsequent engagement in care and rates of viral suppression and rebound among these high-risk patients starting ART at their initial visits.

A total 225 patients were referred to the program during the study period, of whom 96% initiated ART.  The mean age was 30 years, 51% engaged in substance use, 48% had a psychiatric diagnosis, and 31% lacked stable housing.  By one year after intake, 96% of patients had achieved at least one HIV viral load <200 copies/ml; 15% of patients experienced viral rebound at some point, but 78% subsequently suppressed, and 92% had achieved suppression by their last recorded viral load.

So, even in a group of patients with every risk factor for ART treatment failure, the large majority were able to reach and maintain virologic control when offered ART.  Give folks a chance!  30585846


MSM who use drugs: are they bad candidates for PrEP, or the best candidates for PrEP?  Medicine has an unfortunate history of writing off substance users under prejudical presumptions that they’re unlikely to be adherent to care or will somehow abuse the resources they’re provided (OPAT in injection drug users, I’m looking at you).  Among MSM, use of alcohol, stimulants, and injection drugs is associated with more frequent risky sexual behavior and more frequent transmission of HIV.  Pre-exposure HIV prophylaxis (PrEP) dramatically reduces HIV transmission, but does so in an adherence-dependent manner - and intermittent adherence to PrEP in a patient who has acquired HIV is a setup for development of NRTI resistance.  Hence the question of this study: do MSM who use drugs take their PrEP as prescribed?

This study is a secondary analysis of CCTG 595, a trial enrolling adult MSM and transgender women without HIV but at elevated risk for HIV acquisition (e.g. >1 long-term HIV-positive sex partners, condomless anal intercourse with multiple HIV-positive or unknown status sex partners, or >1 condomless anal sex partner and an STI diagnosis in the preceding 3 months).  CCTG 595 participants received PrEP with daily tenofovirDF-emtricitabine and were randomized to receive or not received text message reminders about PrEP adherence. At each visit adherence was assessed via questionnaires as well as by dried blood spot assay for tenofovir levels.  In this study, the authors examined the adherence data stratified by participants’ drug use, both in terms of the frequency and type of substances used.

A total 394 participants completed the study’s baseline substance use questionnaire, of whom 88% reported any alcohol use, 73% reported any other drug use, and 39% reported frequent drug use.  Three hundred and twenty two participants were followed through the end (week 48) of the study; substance use remained unchanged throughout.  The substance users had higher PHQ9 depression scores, which increased with more frequent use; otherwise the groups were similar. 

Overall, 83% of participants had adequate blood spot tenofovir levels at the end of the study, and 44% had levels reflecting near-perfect PrEP adherence.  There was no association between substance use and adequate of blood tenofovir levels (all p > 0.05) in both univariate and multivariate analyses, including when substance users were stratified by frequency and type of substance use.  What the authors did find was a higher incidence of STIs in the stimulant users (48% vs 21% for nonusers; p<0.001), which was specifically driven by users of “poppers” and methamphetamine.  Interestingly, frequent baseline substance use was significantly associated with study completion (HR for early termination from the study 0.54; p=0.036).  I have no idea what to make of that.

Bottom line?  MSM who use drugs were just as likely as nonusers to adhere to PrEP and maintain therapeutic tenofovir levels in their blood.  Given that this population is at increased risk for HIV acquisition, they ought to be preferentially targeted for PrEP prescription. 30457536

Digital rectal examination aids in the diagnosis of anal cancer among people living with HIV.  Anal cancer is usually detected at a late stage and carries a high morbidity. This prospective study evaluated the utility of annual DRE in screening for anal cancer among MSM with HIV, who are at particularly high risk for this disease.  The authors recruited Australian MSM from a sexual health center, two outpatient practices, and a tertiary hospital.  The men were followed for two years and had DREs recommended at baseline, 1 year, and 2 years; abnormal DREs provoked referral to a colorectal surgeon.

Three hundred and twenty-seven MSM enrolled in the study (mean age 51 years, 32% smokers, mean CD4 count 630 cells/ul); 71% received all three DREs, 22% received two DREs, and 7% received one DRE.  The patients found the procedure acceptable and had low rates of adverse events (not feeling in control of their body in 2%, anal pain and bleeding in 1% each). Four percent of the DREs resulted in a referral to a colorectal surgeon, and one Stage 1 anal cancer was detected, giving a number needed to test of 862.  While yes, that is a lot of a DREs, the authors note that the specialty referral rate they observed is about average for cancer screening.  Expect to see annual DREs being recommended for our MSM patients with HIV soon.  30516346

A more nuanced approach to querying patients improves ascertainment of their gender identities.  To recap for folks who don’t know: your sex assigned at birth (i.e.; physical phenotype – male, female, or intersex) is not the same thing as your gender identity (i.e.; the expression of gender you feel most comfortable/authentic with – male, female, or non-binary AKA not neatly fitting into either of the previous categories), which is not the same thing as your sexual orientation (i.e. who you’d prefer to be in a relationship/bed with – men, women, either/all, or nobody).  I hope we can all agree that knowing your patient’s biologic sex is important.  Everyone who treats patients with HIV and/or STDs should further understand why knowing about your patient’s sexual orientation and specific sex practices is important.  Why is knowing your patient’s gender identity important?  Because people react really poorly to being misgendered!  And also because these are unique patient populations who have unique health needs.

On to the study.  In 2016, the King County STD clinic in Seattle changed their intake form, which had a single question about gender (“Do you identify as male, female, or transgendered?” with the options male, female, transgender male to female, and transgender female to male), to have multiple questions about gender.  First, the new form asks “what gender do you consider yourself?” and in addition to the previous stated options includes non-binary/genderqueer and a write-in option.  Second, it asks “what sex was recorded on your original birth certificate?”  Finally, it asks what pronouns the patient prefers to use (he/him, she/her, or a write-in option). 

The authors reviewed intake data over the twelve months before and after the change to see if this improved the identification of transgender and non-binary patients. In the year prior to the change, 6,671 patients completed the form, as did 7,197 patients the year after.  The number of patients identified as transgender or non-binary increased from 0.5% to 2.4% (p<0.001) after the change in the form’s questions – meaning that nearly 80% of transgender and non-binary patients were being missed by the original question.  The increase reflected both additional detection of patients identifying as non-binary and additional detection of transgender patients (e.g. patients who prior to the change had been answering the single question with their preferred gender identity rather than “transgender nonpreferred to preferred gender”).  Two-thirds of nonbinary/genderqueer patients had been assigned male sex at birth versus one-third assigned female.  Transgender women were more likely than transgender men to specifically identify as transgender (80% vs 48%; p=0.004) but the change in questionnaire increased detection of all minority gender groups. 

Transgender patients were less likely to know their HIV status and half as likely to be on PrEP versus their cisgender MSM peers; they were also more likely to have unstable housing, use drugs, and engage in transactional sex.  In other words, transgender and non-binary folks are a particularly vulnerable and at-risk population, both for HIV acquisition and poor adherence to and outcomes of HIV care – so it’s all the more critical that we identify them and make sure we’re providing them the resources and effective, gender-affirming care they need. 30516726