Journal Article Annotations
2019, 2nd Quarter
Annotations by John Grimaldi MD and Mary Ann Cohen MD, FAPM
July 2019
Also of interest:
US Preventive Services Task Force, Owens DK1,2, Davidson KW3, Krist AH4,5, Barry MJ6, Cabana M7, Caughey AB8, Curry SJ9, Doubeni CA10, Epling JW Jr11, Kubik M12, Landefeld CS13, Mangione CM14, Pbert L15, Silverstein M16, Simon MA17, Tseng CW18,19, Wong JB20.
PMID: 31184747
DOI: 10.1001/jama.2019.6390
This report summarizes the evidence supporting the new U.S. Preventive Services Task Force recommendation for the use of preexposure prophylaxis (PrEP) in individuals at high risk for acquiring HIV. The Grade A recommendation is based on the high quality of studies reviewed and high level of certainty that tenofovir disoproxil fumarate (TDF) monotherapy or combined tenofovir disoproxil fumarate and emtricitabine (TDF/FTC) effectively prevent HIV transmission. The evidence-base for methods of implementing PrEP are less robust. There is insufficient evidence to recommend the use of a specific assessment tool to predict which individuals at risk through sexual behaviour or injection drug use (IDU) are most likely to acquire HIV. However, epidemiologic data and Centers for Disease Control and Prevention (CDC) guidelines have identified risk factors that can be used to guide selection of appropriate candidates for PrEP. This reports also draws attention to both the importance of taking an adequate sexual and drug use history as well as the obstacles involved such as stigma and provider bias. There is convincing evidence of a strong association between PrEP adherence and effectiveness, yet adherence rates are suboptimal in some subpopulations and vary across racial/ethnic and age groups and transmission categories. A systematic review of studies of adverse effects of tenofovir-containing PrEP regimens found adequate evidence that harms “associated with PrEP were small, including kidney and gastrointestinal adverse effects.” In summary, PrEP is one among many effective HIV prevention tools whose net benefits depend on several additional factors including adherence, careful risk assessment, context such as baseline community or network prevalence rates, and the use of and availability of other prevention strategies such as condom use, needle exchange programs and behavioral counselling programs
1 Department of Psychology, University of Miami, Coral Gables, FL, 33146-2510, USA. aharkness@miami.edu.
2 Department of Psychology, University of Miami, Coral Gables, FL, 33146-2510, USA.
3 The Fenway Institute, Fenway Community Health, Boston, MA, USA.
4 Department of Psychiatry, Massachusetts General Hospital/Harvard Medical School, Boston, MA, USA.
5 Department of Medicine, Beth Israel Deaconess Medical Center, Boston, MA, USA.
6 Department of Medicine, Harvard Medical School, Boston, MA, USA.
Findings:
This study analysed longitudinal data collected over a one-year period from two prior secondary HIV prevention trials. Multilevel modeling was used to determine the effect of 6 co-occurring psychosocial conditions on the likelihood of serodiscordant condomless anal sex (CAS) among 390 HIV-positive sexual minority men. Syndemic conditons comprised childhood sexual abuse (CSA), PTSD, anxiety disorders, depression, alcohol abuse, polysubstance and/or stimulant use. At each of the 5 time points, 30% or more of the sample met criteria for one or more of the following most commonly occurring syndemic conditions: CAS, PTSD, anxiety disorders and polysubstance and/or stimulant use. At each time point, 20% or more of the sample reported 0-2 syndemic conditions, while 5-15% reported 3-4 conditions. Syndemic conditions significantly increased the likelihood of participants engaging in CAS. Each additional condition increased the odds of CAS by 41% (OR 1.41; 95% CI [1.16, 1.70]; p=0004). Between-person and within-person analyses yielded similar results. The average number of syndemic conditions was associated with the likelihood that a participant would engage in serodiscordant CAS. Within participants, an increase in the number of syndemic conditions between time points was associated with engaging in serodiscordant CAS.
Strengths and limitations:
This is the first longitudinal study of HIV-positive sexual minority men to explore the association between psychosocial syndemic conditions and serodiscordant CAS. Many previous studies, using a cross-sectional design and involving HIV-negative sexual minority men, examined the effect of syndemics on other outcomes such as HIV-positive status. Previous longitudinal studies have also primarily used HIV-negative sexual minority men with seroconversion as an outcome measure. Other longitudinal studies of HIV-positive sexual minority men have used medication adherence as an outcome. The original study from which this secondary analysis drew its data, was conducted before the widespread introduction of “treatment as prevention” as an HIV prevention strategy and Undetectable equals Untransmittable (U=U) as a powerful public health message. Consequently, the study did not differentiate between participants’ viral load status and seropositioning. This study’s reliance on a secondary analysis necessarily limited the measures used. PTSD, CSA and social anxiety disorder were measured at baseline only. Generalized anxiety disorder and panic disorder were measured across all time points thus permitting anxiety scores to vary over time. The study was not designed to assess the relative effects of each syndemic condition on CAS.
Relevance:
This study has relevance to aspects of public health, disparities in healthcare and personal wellbeing of individuals living with HIV. Sexual minority men have the highest rate of HIV incidence among individuals at risk and constitute the largest subgroup of people living with HIV. Understanding how psychosocial factors interact and combine to facilitate behaviors that lead to HIV transmission will inform development of more effective HIV prevention interventions. For example, varying levels of distress over time related to psychosocial conditions and an individual’s limited ability to manage distress may mediate CAS and other at-risk behaviours. This pathway could provide one target for risk reduction interventions. The study confirmed findings from previous studies of high rates psychosocial conditions in sexual minority men. Targeting individual conditions may enhance overall wellbeing and thus free internal resources to be used for self-care behaviors. This study suggests the value in integrating secondary prevention practices with treatment of co-occurring syndemic conditions. Another implication is expanding the scope of secondary prevention to include sexual health in general and interventions that view sex as “pleasurable, assertive and positive.” Future syndemics research should also examine social determinants of health and wellbeing such as stigma, poverty, marginalization and structural violence. These studies should also account for the effect of geographic region, race/ethnicity, age, and/or socioeconomic class on health related outcomes.
Type of study:
This study was a secondary analysis of data from 2 HIV prevention trials. One trial was a randomized controlled trial with the active intervention delivered by medical social workers. The other study did not have a control group and used a peer-delivered version of the same intervention.