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A Behavioral Economics Approach to Enhancing HIV Biomedical Prevention
Abstract
This thought piece critically examined the challenges in HIV prevention implementation, particularly the 'PrEP cliff' phenomenon, characterized by high discontinuation rates across the PrEP care continuum. Through a Behavioral Economics lens, specifically Salience Theory, we discussed patient decision-making and behavior patterns, highlighting gaps in previous PrEP service models. This piece advocates for a novel approach that leverages the immediate salience and perceived benefits of post-exposure prophylaxis (PEP) as a gateway to PrEP. We discuss empirical evidence supporting this model and brainstorm alternative intervention designs for more sustainable HIV prevention strategies. This piece aims to contribute to the field by offering innovative perspectives and solutions to improve the effectiveness of HIV biomedical interventions.
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Background
Pre-exposure prophylaxis (PrEP) and post-exposure prophylaxis (PEP) are well established methods of HIV prevention through the use of antiretroviral medications. However, the suitability of these tools for individuals with infrequent, higher-risk HIV exposures might be limited due to cost, high pill burden and/or barriers to care. PEP-in-pocket (PIP) involves prospectively identifying such individuals, proactively prescribing them 28 days of PEP medication, and providing instructions on when to self-initiate medications and how to follow up with care. We present long-term follow-up of a cohort of patients provided with PIP for HIV prevention.
Methods
We evaluated the clinical characteristics and outcomes of patients using PIP for HIV prevention. Patients referred for PrEP or PEP care were offered PIP if they reported a low frequency (0-4 per year) of higher-risk HIV exposures of any type. The HIV prevention method was chosen through shared decision-making between patients and clinicians and was outside the realm of this study. Patients were followed at regular 4-6 months intervals.
Results
We followed 112 patients prescribed PIP between the ages of 20-69 for a total of 183.8 patient-years. 108 (96%) patients were assigned male at birth. Thirty-five (31%) patients self-initiated a total of 69 courses of PIP during the observation period. Patients fluidly transitioned between HIV prevention modalities as circumstances warranted: 34 (31%) changed from PIP to PrEP, and 33 (30%) changed from PrEP to PIP. There were 18 episodes of bacterial sexually transmitted infections in 13 individuals (12%) using PIP. No HIV seroconversions were detected.
Conclusion
PIP is an innovative HIV prevention strategy for individuals with a lower frequency of higher-risk HIV exposures, and provides patients with autonomy and agency over their care. Patients may transition between PIP and PrEP based on evolving risk. PIP should be included with PEP and PrEP as a biomedical HIV prevention option for individuals at risk for infection.
Disclosures
Darrell Tan, MD PhD, Abbvie: Grant/Research Support|Gilead: Grant/Research Support|Glaxo Smith Kline: Grant/Research Support Isaac Bogoch, MD, MSc, BlueDot: Advisor/Consultant|NHL Players' Association: Advisor/Consultant
Introduction:
With recent approvals of long-acting (LA) HIV pre-exposure prophylaxis (PrEP) in the form of injectable cabotegravir and the dapivirine ring, programmes need to consider how to optimize the delivery of PrEP methods, including by leveraging lessons from the past decade of oral PrEP delivery.
Discussion:
Framed around differentiated service delivery building blocks, the major considerations for the delivery of LA PrEP are how to reach the populations who would most benefit from PrEP, where to locate PrEP services, how to reduce the user burden of accessing and continuing with PrEP, and how to integrate PrEP with other services. Demand creation for LA PrEP and education about new LA PrEP options should be co-developed with communities and be positively framed. Client-facing clinical decision support tools provide information about HIV prevention and PrEP options in non-technical ways and can support their informed decision-making about PrEP. Training for providers is needed to increase their ability to ask about sexual and drug use behaviours in a non-judgmental and comfortable manner as part of risk assessment, discuss harm reduction strategies and counsel about available PrEP options that fit clients' circumstances and needs. PrEP adherence support should include supportive counselling and be tailored to address an individual's particular barriers and needs. Reminders through text messaging or calls can foster PrEP persistence, given the narrow the window around dosing for injectable cabotegravir. Strategies are needed to expand PrEP delivery options, including telePrEP, pharmacy-based PrEP, key population-led services and mobile venues. Integrated delivery models are needed which include sexually transmitted infection testing and treatment, contraception for cis-women not desiring to become pregnant, PrEP for pregnant women in high HIV prevalence settings, and gender-affirming hormones and support for transgender persons.
Conclusions:
The outcome of expanding PrEP options through LA PrEP formulations is to increase PrEP coverage, adherence, persistence and effectiveness by offering a choice of PrEP that meets the needs of persons who would benefit from PrEP. The lessons learned from the delivery of oral PrEP about demand creation, informed client decision-making, provider training, adherence support and service delivery model are relevant to the delivery of LA PrEP and integration with other services.
Expanding on previous work, we present an HIV Prevention Cycle of Care model to facilitate understanding of the complexity of issues involved in pre-exposure prophylaxis implementation for gay, bisexual, and other men who have sex with men (MSM) in the USA, including individual, client-provider, and overarching issues such as health equity, stigma, and prevention nomenclature. The HIV prevention cycle of care applies to MSM who test negative for HIV. The Prevention Cycle of Care model includes seven steps: prevention knowledge, prevention self-awareness and preferences, prevention motivation, health-care access and cost, provider issues, adherence and persistence, and periodic reassessment and adjustment. HIV prevention is complex in an era of emerging multiple modalities, and more research is needed to successfully implement pre-exposure prophylaxis options over time and across diverse communities of MSM who are sexually active.
Engaging with the future to make better decisions in the present is key for sustainable development and climate change responses. In this conceptual paper, we suggest a scenario building approach that connects psychological principles of future thinking with future scenario development in order to advance the impact of scenarios. Future scenario work currently does not sufficiently consider processes of human communication, emotion, cognition and has only begun to focus on people’s local contexts in recent years. We argue that more understanding of psychological processes, such as cognitive biases and heuristics, as well as psychological distance, which typically occur in future thinking, can improve the impact of scenarios. Specifically, we provide a psychological basis for systematically integrating emotion-evoking aspects into future scenario development, using tailored narratives and visuals to make content tangible and meaningful for a broad spectrum of audiences, and adapting content temporally, spatially, and linguistically to audiences, in combination with inclusive and creative co-creation of scenarios and sustainable solutions. We explain why this approach has the potential to overcome some recognised cognitive biases hampering scenario impact and intended sustainable change processes, and can therefore support the co-development of sustainable and inclusive policies and solutions that empower and connect individuals, communities, and decision makers.
Purpose of Review
We explored different behavioral economics (BE) mechanisms through which pre-exposure prophylaxis (PrEP) initiation and adherence could be impacted and examined recent work using BE principles to further HIV prevention efforts. We also generated new intervention ideas based on existing HIV testing and ART adherence literature.
Recent Findings
There is limited work that uses BE principles to design interventions to increase PrEP initiation and adherence, mostly involving financial incentives. The recent works highlighted involve financial incentives and demonstrate that key populations are open to accepting monetary incentives to increase PrEP initiation and improve adherence. However, there are mixed results on the long-term impacts of using incentives to modify behavior.
Summary
While there are a few ongoing studies that utilize BE principles to increase PrEP use, there is need to develop studies that test these concepts, to promote PrEP initiation and adherence. We suggest methods of exploring non-incentives-based ideas to increase PrEP use in key populations.
Purpose of Review
This scoping review summarises the literature on HIV prevention and management interventions utilizing behavioural economic principles encapsulated in the MINDSPACE framework.
Recent Findings
MINDSPACE is an acronym developed by the UK’s behavioural insights team to summarise nine key influences on human behaviour: Messenger, Incentives, Norms, Default, Salience, Priming, Affect, Commitment, and Ego. These effects have been used in various settings to design interventions that encourage positive behaviours. Currently, over 200 institutionalised behavioural insight teams exist internationally, which may draw upon the MINDSPACE framework to inform policy and improve public services. To date, it is not clear how behavioural insights have been applied to HIV prevention and management interventions.
Summary
After screening 899 studies for eligibility, 124 were included in the final review. We identified examples of interventions that utilised all the MINDSPACE effects in a variety of settings and among various populations. Studies from high-income countries were most common ( n = 54) and incentives were the most frequently applied effect ( n = 100). The MINDSPACE framework is a useful tool to consider how behavioural science principles can be applied in future HIV prevention and management interventions. Creating nudges to enhance the design of HIV prevention and management interventions can help people make better choices as we strive to end the HIV/AIDS pandemic by 2030.
Background
Pre-exposure prophylaxis (PrEP) has the potential to reduce transmission of HIV among Black cisgender women in the Southern United States (U.S.); however, national data suggests that PrEP initiation is lowest in the South and among Black women compared to other U.S. regions and white women. This study applied intersectionality and PrEP multilevel resilience frameworks to assess how socio-structural and clinical contexts shaped PrEP persistence among Black cisgender women in Mississippi.
Methods
Semi-structured interviews were conducted with eight Black cisgender women in Jackson, Mississippi. This sample was purposively recruited to include PrEP-initiated Black cisgender women.
Results
Six themes identified that shaped PrEP care among Black cisgender women: (1) internal assets, (2) sole responsibility to HIV prevention, (3) added protection in HIV serodifferent relationships, (4) financial issues, (5) trust and distrust in the medical system, and (6) side effects. Black cisgender women reported that PrEP persistence increased control over their sexual health, reduced anxiety about HIV, and promoted self-care. Black cisgender women also indicated that medication assistance programs increased PrEP affordability resulting in continued persistence.
Conclusions
In addition to preventing HIV, PrEP may yield secondary positive impacts on the health and relationships of Black cisgender women. However, very few Black cisgender women in the South are using PrEP given intersectional barriers and thus necessitates adaptive strategies to support PrEP initiation and persistence. Efforts aimed at increasing the coverage of PrEP among Black cisgender women should consider implementation strategies responsive to lived realities of Black women.
More than a decade after the first efficacy evidence for oral HIV pre-exposure prophylaxis (PrEP) was reported, PrEP uptake globally has been inadequate and global HIV prevention targets have been missed. Access to PrEP is still highly concentrated in a fairly small number of countries and, even within countries with widespread PrEP access, inequalities have emerged. More ambitious, high-priority global targets for PrEP uptake are required and could accelerate the HIV prevention response in a similar way to the success of the 90-90-90 testing and treatment targets. Health systems must be PrEP-friendly and allow PrEP to be prescribed in settings already attended by large numbers of HIV-negative individuals who are at risk. Several models have been advanced for the greater demedicalisation of PrEP. Individual-level barriers to PrEP uptake and persistence have been characterised, such as low awareness, low willingness to use PrEP, and the gap between self-perceived and actual HIV risk. Overcoming these barriers will require further efforts to understand and address them first. New PrEP modalities are emerging; as more options become available, we need to develop a greater understanding of the long-term patterns of PrEP use in different populations and to develop models of such use that can accommodate people alternating through periods of use and non-use, as well as switching between dosing regimens or modalities as they become available. Scaling up PrEP is crucial to achieving the UNAIDS prevention targets for 2030. Simply getting more people onto PrEP cannot be the only goal: the big-picture definition of success for PrEP programmes must be their impact on the HIV epidemic.
HIV post-exposure prophylaxis following sexual exposure (PEPSE) and pre-exposure prophylaxis (PrEP) are used by people at sexual risk of HIV acquisition, including men who have sex with men (MSM) [1]. MSM who are prescribed PEPSE have a 2.5-to 5-fold increase in HIV acquisition in the months after PEPSE compared with MSM not requiring PEPSE [2]. Owing to the high risk of HIV seroconversion due to ongoing risk behaviours, it is becoming commonplace for HIV-negative MSM requiring PEPSE (e.g. HIV sexual exposure within 72 h) to transition immediately to PrEP following the 28 days of PEPSE [3-4]. Inconsistent or non-PrEP use, particularly in marginalized and vulnerable MSM, is associated with HIV transmission, and therefore streamlined transition directly from PEPSE to PrEP is important [1,5]. We aimed to review how frequently PrEP is discussed and used by MSM following PEPSE. Brighton has a large MSM population served by a single sexual health clinic, with c. 6500 attendances by MSM annually. We use a standard PrEP proforma and coding to record PrEP discussion, offer and acceptance in all MSM seen. We reviewed the electronic notes of MSM who had accessed PEPSE between January 2018 and November 2020, and collected information on sexual assault, recreational drug use at the time of PEPSE initiation , whether direct transition to PrEP had been discussed , and if PrEP had been initiated after PEPSE. During the study period, 277 MSM accessed PEPSE. The median age (interquartile range) was 32 (26-43) years, 17 (6%) started PEPSE following a sexual assault, 36 (13%) were using recreational drugs during sex, and 30 (11%) had used PrEP before. Discussion about direct transition to PrEP after PEPSE was documented in 155 (56%) MSM, including 128 (51%) who had never used PrEP before, and 67 (24%) transitioned directly from PEPSE to PrEP. Clinicians were
Many Americans fail to get life-saving vaccines each year, and the availability of a vaccine for COVID-19 makes the challenge of encouraging vaccination more urgent than ever. We present a large field experiment ( N = 47,306) testing 19 nudges delivered to patients via text message and designed to boost adoption of the influenza vaccine. Our findings suggest that text messages sent prior to a primary care visit can boost vaccination rates by an average of 5%. Overall, interventions performed better when they were 1) framed as reminders to get flu shots that were already reserved for the patient and 2) congruent with the sort of communications patients expected to receive from their healthcare provider (i.e., not surprising, casual, or interactive). The best-performing intervention in our study reminded patients twice to get their flu shot at their upcoming doctor’s appointment and indicated it was reserved for them. This successful script could be used as a template for campaigns to encourage the adoption of life-saving vaccines, including against COVID-19.
Multisensory integration research has allowed us to better understand how humans integrate sensory information to produce a unitary experience of the external world. However, this field is often challenged by the limited ability to deliver and control sensory stimuli, especially when going beyond audio–visual events and outside laboratory settings. In this review, we examine the scope and challenges of new technology in the study of multisensory integration in a world that is increasingly characterized as a fusion of physical and digital/virtual events. We discuss multisensory integration research through the lens of novel multisensory technologies and, thus, bring research in human–computer interaction, experimental psychology, and neuroscience closer together. Today, for instance, displays have become volumetric so that visual content is no longer limited to 2D screens, new haptic devices enable tactile stimulation without physical contact, olfactory interfaces provide users with smells precisely synchronized with events in virtual environments, and novel gustatory interfaces enable taste perception through levitating stimuli. These technological advances offer new ways to control and deliver sensory stimulation for multisensory integration research beyond traditional laboratory settings and open up new experimentations in naturally occurring events in everyday life experiences. Our review then summarizes these multisensory technologies and discusses initial insights to introduce a bridge between the disciplines in order to advance the study of multisensory integration.
Patients who use post-exposure prophylaxis (PEP) are at ongoing risk for HIV acquisition after completing PEP. While the Centers for Disease Control and Prevention recommends pre-exposure prophylaxis (PrEP) use immediately after PEP, some practitioners are hesitant to offer PEP-to-PrEP (PEP2PrEP). We began offering PEP2PrEP in the sexually transmitted infection clinic in Ottawa, Canada on August 5, 2018. During the first 16 months of PEP2PrEP, 61 patients requested PEP and 46 were initiated; 30 of these patients agreed to PEP2PrEP and 26 followed through. None of our PEP patients had confirmed HIV exposures; all fulfilled the initiation criterion of condomless anal sex with a male partner of unknown HIV-status. During the study, the number of PEP requests and initiations was statistical unchanged, yet the seroconversion rate among patients who used PEP decreased from 1.7% pre-PEP2PrEP to 0% post-PEP2PrEP. Regarding follow-up, most discontinuations occurred between the PrEP intake and 1-month follow-up visit.
As health professionals develop health communication for coronavirus disease 2019 (COVID-19), we implore that these communication approaches do not include fear appeals. Fear appeals, also known as scare tactics, have been widely used to promote recommended preventive behaviors. We contend that unintended negative outcomes can result from fear appeals that intensify the already complex pandemic and efforts to contain it. We encourage public health professionals to reevaluate their desire to use fear appeals in COVID-19 health communication and recommend that evidence-based health communication be utilized to address the needs of a specific community, help people understand what they are being asked to do, explain step-by-step how to complete preventative behaviors, and consider external factors needed to support the uptake of behaviors. To aid health professionals in redirecting away from the use of fear appeals, we offer a phased approach to creating health communication messages during the COVID-19 crisis.
Objective purpose: This review synthesized the literature examining the effects of virtual reality (VR)-based exercise on physiological, psychological, and rehabilitative outcomes in various populations. Design: A systematic review. Data sources: 246 articles were retrieved using key words, such as "VR", "exercise intervention", "physiological", "psychology", and "rehabilitation" through nine databases including Academic Search Premier and PubMed. Eligibility criteria for selecting studies: 15 articles which met the following criteria were included in the review: (1) peer-reviewed; (2) published in English; (3) randomized controlled trials (RCTs), controlled trials or causal-comparative design; (4) interventions using VR devices; and (5) examined effects on physiological, psychological, and/or rehabilitative outcomes. Descriptive and thematic analyses were used. Results: Of the 12 articles examining physiological outcomes, eight showed a positive effect on physical fitness, muscle strength, balance, and extremity function. Only four articles examined the effects on psychological outcomes, three showed positive effects such that VR exercise could ease fatigue, tension, and depression and induce calmness and enhance quality of life. Nine articles investigated the effects of VR-based exercise on rehabilitative outcomes with physiological and/or psychological outcomes, and six observed significant positive changes. In detail, patients who suffered from chronic stroke, hemodialysis, spinal-cord injury, cerebral palsy in early ages, and cognitive decline usually saw better improvements using VR-based exercise. Conclusion: The findings suggest that VR exercise has the potential to exert a positive impact on individual's physiological, psychological, and rehabilitative outcomes compared with traditional exercise. However, the quality, quantity, and sample size of existing studies are far from ideal. Therefore, more rigorous studies are needed to confirm the observed positive effects.
To manage the spread of coronavirus, health entities have urged the public to take preventative measures such as social distancing and handwashing. Yet, many appear reluctant to take these measures. Research is needed to understand factors underlying such reluctance, with the aim of developing targeted health interventions. We identify associating coronavirus with death as one such factor.
590 participants completed surveys in mid-March 2020, which included attitudes toward coronavirus, preventative behavioral intentions, and sociodemographic factors.
Associating coronavirus with death negatively predicted intentions to perform preventative behaviors. Further, associating coronavirus with death was not evenly distributed throughout the sample and was related with a number of sociodemographic factors including age, race, and availability of sick leave.
Following recommended preventative measures to slow the spread of coronavirus appears to relate to the degree to which people associate coronavirus with death. These findings can be used by public health researchers and practitioners to identify those for whom targeted health communication and interventions would be most beneficial, as well as to frame health messaging in ways that combat fatalism.
In perceptual decision making the brain extracts and accumulates decision evidence from a stimulus over time and eventually makes a decision based on the accumulated evidence. Several characteristics of this process have been observed in human electrophysiological experiments, especially an average build-up of motor-related signals supposedly reflecting accumulated evidence, when averaged across trials. Another recently established approach to investigate the representation of decision evidence in brain signals is to correlate the within-trial fluctuations of decision evidence with the measured signals. We here report results of this approach for a two-alternative forced choice reaction time experiment measured using magnetoencephalography (MEG) recordings. Our results show: (1) that decision evidence is most strongly represented in the MEG signals in three consecutive phases and (2) that posterior cingulate cortex is involved most consistently, among all brain areas, in all three of the identified phases. As most previous work on perceptual decision making in the brain has focused on parietal and motor areas, our findings therefore suggest that the role of the posterior cingulate cortex in perceptual decision making may be currently underestimated.
Introduction:
In settings where both daily and event-driven pre-exposure prophylaxis (PrEP) are offered to men who have sex with men (MSM), a clear understanding of the motives to choose between the different dosing-regimens can facilitate more effective PrEP implementation. We therefore studied the motives for choosing for, switching between, and stopping daily or event-driven PrEP.
Methods:
We used data (August 2015-June 2017) from the prospective, longitudinal, open-label Amsterdam PrEP demonstration study, in which daily (dPrEP) and event-driven PrEP (edPrEP) were offered to 374 HIV-negative MSM and two transgender persons. Participants self-selected the preferred PrEP-regimen at baseline and could switch regimens at three-monthly follow-up visits. We measured motives for choosing PrEP-regimen at baseline and for switching and stopping PrEP at follow-up visits. Open- and closed-end items were combined and qualitatively analysed.
Results:
Choices of PrEP-regimens were determined by personal and contextual factors, involving the perceived self-efficacy concerning adherence, the risk-context, and the anticipated impact of PrEP on physical and sexual wellbeing. dPrEP was preferred because of the anticipated better adherence and the fear of side-effects relating to edPrEP re-initiations. Moreover, dPrEP was perceived to be more effective than edPrEP. Motives to choose edPrEP were the expected physical burden of dPrEP, anticipated side-effects of dPrEP, and fear to forget daily doses. Regarding the risk-context: dPrEP was preferred for unplanned and/or frequent sex, while edPrEP was chosen when risk was predictable and/or less frequent. While some chose for dPrEP to gain more sexual freedom, others chose for edPrEP to minimize sexual risk episodes. Changes in the above factors, such as changing risk patterns, changing relationships or changing physical conditions, resulted in switching regimens. Choices to stop PrEP were related to lower sexual risk, adherence issues and side-effects.
Conclusions:
The great diversity of motives illustrates the importance of offering a choice of PrEP-regimens. In counselling of MSM starting PrEP, choices for PrEP-regimens may be addressed as a continuum of flexible and changeable options over time. This may help individuals choose the PrEP-regimen that best fits their current sexual context, priorities and personal capabilities and therefore will be more easily adhered to.
The purpose of this paper is to present a stepwise, multi-construct, innovative framework that supports the use of eHealth technology to reach sexual minority populations of color to establish trustworthiness and build trust. The salience of eHealth interventions can be leveraged to minimize the existing paradigm of medical mistrust among sexual minority populations of color living with chronic illnesses. These interventions include virtual environments and avatar-led eHealth videos, which address psychosocial and structural-level challenges related to mistrust. Our proposed framework addresses how eHealth interventions enable technology adoption and usage, anonymity, co-presence, self-disclosure, and social support and establish trustworthiness and build trust.
In February 2019, the U.S. Department of Health and Human Services proposed a strategic initiative to end the human immunodeficiency (HIV) epidemic in the United States by reducing new HIV infections by 90% during 2020-2030* (1). Phase 1 of the Ending the HIV Epidemic initiative focuses on Washington, DC; San Juan, Puerto Rico; and 48 counties where the majority of new diagnoses of HIV infection in 2016 and 2017 were concentrated and on seven states with a disproportionate occurrence of HIV in rural areas relative to other states.† One of the four pillars in the initiative is protecting persons at risk for HIV infection using proven, comprehensive prevention approaches and treatments, such as HIV preexposure prophylaxis (PrEP), which is the use of antiretroviral medications that have proven effective at preventing infection among persons at risk for acquiring HIV. In 2014, CDC released clinical PrEP guidelines to health care providers (2) and intensified efforts to raise awareness and increase the use of PrEP among persons at risk for infection, including gay, bisexual, and other men who have sex with men (MSM), a group that accounted for an estimated 68% of new HIV infections in 2016 (3). Data from CDC's National HIV Behavioral Surveillance (NHBS) were collected in 20 U.S. urban areas in 2014 and 2017, covering 26 of the geographic areas included in Phase I of the Ending the HIV Epidemic initiative, and were compared to assess changes in PrEP awareness and use among MSM. From 2014 to 2017, PrEP awareness increased by 50% overall, with >80% of MSM in 17 of the 20 urban areas reporting PrEP awareness in 2017. Among MSM with likely indications for PrEP (e.g., sexual risk behaviors or recent bacterial sexually transmitted infection [STI]), use of PrEP increased by approximately 500% from 6% to 35%, with significant increases observed in all urban areas and in almost all demographic subgroups. Despite this progress, PrEP use among MSM, especially among black and Hispanic MSM, remains low. Continued efforts to improve coverage are needed to reach the goal of 90% reduction in HIV incidence by 2030. In addition to developing new ways of connecting black and Hispanic MSM to health care providers through demonstration projects, CDC has developed resources and tools such as the Prescribe HIV Prevention program to enable health care providers to integrate PrEP into their clinical care.§ By routinely testing their patients for HIV, assessing HIV-negative patients for risk behaviors, and prescribing PrEP as needed, health care providers can play a critical role in this effort.
Purpose of Review
Seven years after TDF/FTC was approved for pre-exposure prophylaxis to reduce risks of HIV infection, there have been large increases in the number of persons using PrEP in the USA. However, recent data on pre-exposure prophylaxis (PrEP) use at the state level indicate that people living in the Southern United States are underserved by PrEP relative to their epidemic need. We sought to review possible reasons for inequitable uptake of PrEP in the South and identify implementation approaches to increase PrEP uptake in the South.
Recent Findings
Published literature, data on the locations of PrEP service providers, recent data on PrEP utilization from pharmacy prescription databases, HIV surveillance data and government data on healthcare providers, and health literacy indicate a confluence of factors in the South that are likely limiting PrEP uptake. A variety of approaches are needed to address the complex challenges to PrEP implementation in the South. These include considering alternative PrEP provision strategies (e.g., pharmacy-based PrEP, telemedicine-delivered PrEP), conducting gain-based stigma-reduction campaigns, increasing capacity for reimbursement for PrEP medications and services through policy change to expand Medicaid and to preserve access to Affordable Care Act–compliant health plans, expanding STI screening programs and improving integration of PrEP offering with delivery of positive STI results, using mHealth tools to screen groups at highest risk for HIV (e.g., men who have sex with men) periodically to increase correct perception of risk, and streamlining clinical procedures to allow same-day PrEP starts for patients without obvious medical contraindications.
Summary
Overcoming the structural, capacity, and policy challenges to increasing PrEP uptake in the South will require innovations in clinical approaches, leveraging technologies, and policy changes. The South has unique challenges to achieving equitable PrEP uptake, and addressing key barriers to expanded PrEP use will require multisectoral responses.
The neural mechanisms mediating sensory-guided decision-making have received considerable attention, but animals often pursue behaviors for which there is currently no sensory evidence. Such behaviors are guided by internal representations of choice values that have to be maintained even when these choices are unavailable. We investigated how four macaque monkeys maintained representations of the value of counterfactual choices—choices that could not be taken at the current moment but which could be taken in the future. Using functional magnetic resonance imaging, we found two different patterns of activity co-varying with values of counterfactual choices in a circuit spanning the hippocampus, the anterior lateral prefrontal cortex and the anterior cingulate cortex. Anterior cingulate cortex activity also reflected whether the internal value representations would be translated into actual behavioral change. To establish the causal importance of the anterior cingulate cortex for this translation process, we used a novel technique, transcranial focused ultrasound stimulation, to reversibly disrupt anterior cingulate cortex activity.
We used group-based trajectory models to identify four distinct trajectory patterns of adherence to pre-exposure prophylaxis (PrEP) among 20,696 users. Only 44.5% were consistently PrEP adherent, with younger age, being female, or having substance use disorder or depression associated with early discontinuation. Public health efforts are needed to improve PrEP adherence.
Background: Latinx sexual minority men experience the greatest second highest human immunodeficiency virus (HIV) burden in the United States. Pre-exposure prophylaxis (PrEP) is the most effective HIV prevention tool available, however, PrEP uptake remains low among this group. Methods: This two-arm pilot randomized controlled trial study aimed to assess the feasibility and preliminary efficacy of delivering an online culturally targeted video intervention that aims to increase PrEP uptake intentions among Latinx sexual minority men. The intervention group received a culturally targeted video that contained the same PrEP information as the control group and incorporated positive aspects of Latinx masculinity (i.e., caballerismo). Participants were recruited through Amazon's MTurk crowd-sourcing platform. A total of twenty-five participants met the study inclusion criteria ( N = 25). Results: The control group had a higher mean PrEP intentions score ( M: 3.3, 95% CI: 2.7–3.9) when compared with the intervention group. A moderate, negative, linear correlation was observed between machismo and PrEP intention scores ( r = −.34). In contrast, a small, positive correlation was found between caballerismo and PrEP intentions ( r = .19). Conclusions: While the culturally targeted video intervention did not increase PrEP use intentions, the study highlights the importance of understanding and addressing cultural factors such as Latin masculinity.
Objective
HIV prevention service delivery models that offer product choices, and the option to change preferences over time, may increase prevention coverage. Outpatient departments in sub-Saharan Africa diagnose a high proportion of new HIV infections, but are an understudied entry point to biomedical prevention.
Design
Individually randomized trial of dynamic choice HIV prevention (DCP) intervention vs. standard-of-care (SOC) among individuals with current/anticipated HIV exposure risk at outpatient departments in rural Kenya and Uganda (SEARCH; NCT04810650).
Methods
Our DCP intervention included 1) product choice (oral pre-exposure prophylaxis [PrEP] or post-exposure prophylaxis [PEP]) with option to switch over time, 2) HIV provider- or self-testing, 3) service location choice (community vs. clinic-based), 4) provider training on patient-centered care. Primary outcome was proportion of follow-up covered by PrEP/PEP over 48 weeks assessed via self-report.
Results
We enrolled 403 participants (61% women; median 27 years, IQR 22,37). In the DCP arm, 86% ever chose PrEP, 15% ever chose PEP over 48 weeks; selection of HIV self-testing increased from 26% to 51% and of out-of-facility visits from 8% to 52%. Among 376/403 (93%) with outcomes ascertained, time covered by PrEP/PEP was higher in DCP (47.5%) vs. SOC (18.3%); difference=29.2% (95%CI:22.7–35.7%; p < 0.001). Effects were similar among women and men (28.2% and 31.0% higher coverage in DCP, respectively) and larger during periods of self-reported HIV risk (DCP 64.9% vs. SOC 26.3%; difference=38.6%; 95%CI:31.0–46.2%; p < 0.001).
Conclusion
A dynamic choice HIV prevention intervention resulted in two-fold greater time covered by biomedical prevention products compared to standard-of-care in general outpatient departments in eastern Africa.
Background and objective:
Human immunodeficiency virus (HIV) continues to affect sexual and gender minorities, predominantly men who have sex with men (MSM). Stigma, medical mistrust, and apprehension towards discussing sexual health with one's medical provider are significant barriers in seeking or accessing preventive services. Those obstacles could be surpassed through novel digital and electronic health interventions, specifically with virtual avatar technology. Avatars are digital self-representative agents that are controlled with an interactive electronic device. Avatars allow for virtual self-immersion within infinitely customizable environments to practice skill building, fostering relationships and more, through an optional incognito approach. The objective of this narrative review is to examine recent uses of and developments in avatar technology, highlight the personalization attribute of this technology, and evaluate its strengths and limitations as a tool for HIV prevention among MSM.
Methods:
We reviewed recent scientific literature generated by PubMed that use virtual avatar technology in HIV prevention and treatment among populations put at risk. Articles that met the inclusion criteria were then categorized on how the avatar technology was used.
Key content and findings:
We identified eleven studies that met inclusion criteria. Avatar technology was found to create a comfortable environment for participants to address and discuss their sexual behaviors with less hesitation. Avatars can build rapport with populations put at high risk, creating an opportunity for reevaluation of their sexual behavior while assisting them in being able seek information, preventive services, or treatment for HIV or other sexually transmitted infections (STIs).
Conclusions:
Given the increased use of digital technology in health and prevention, avatars might be useful in sexual health education and HIV prevention among populations put at risk. The benefits and potential in utilizing this technology for HIV prevention are highlighted.
We construct and run an experiment to test the most basic choice effect predicted by Salience Theory. Subjects allocate wealth between a risky and a safe investment. While we vary an apparent payoff ratio to influence salience, treatments have economically equivalent consequences. Most other theories of behavior then predict zero effect. Our experimental findings are strongly consistent with the behavioral implication of a continuous version of Salience Theory. We provide a novel structural estimate on the strength of salience. In our setting, increasing the relative payoff contrast by one percent is equivalent to an increased odds ratio by about 0.4 percent.
Objectives:
Crowdsourcing, which taps into the wisdom of crowds, has been successful in generating strategies to enhance HIV self-testing (HIVST) uptake. We determined the cost-effectiveness of a crowdsourced intervention (one-off or annual) compared to a control scenario (no crowdsourcing) among men who have sex with men (MSM) living in China.
Design:
Economic evaluation.
Methods:
We used data from our cluster randomized controlled trial of MSM (NCT02796963). We used a micro-costing approach to measure direct health costs ($USD2017) from a health provider perspective. Using outputs from a dynamic transmission model over a 20-year time horizon, we estimated the incremental cost-effectiveness ratios (ICER) using cost per disability adjusted life years (DALYs) averted with 3% discounting. An intervention was considered highly cost-effective if it was less than one gross domestic product (GDP, $8,823) per DALY averted.
Results:
Across all cities, the crowdsourced intervention was highly cost-effective compared to the control scenario (ICER ranged from $2,263 to 6,152 per DALY averted for annual crowdsourcing; $171 to 204 per DALY averted for one-off crowdsourcing). The one-off intervention was cost-saving in Guangzhou and Qingdao. Sensitivity analyses confirmed the robustness of the findings; specifically, changes in discounting, costs of the crowdsourced intervention, costs of HIV testing and cost of ART did not alter our conclusions.
Conclusions:
Scaling up a one-off or annual crowdsourced HIV prevention intervention in four cities in China was very likely to be cost-effective. Further research is warranted to evaluate the feasibility of scaling up crowdsourced HIV prevention interventions in other settings and populations.
Women in the USA represent 15% of new HIV diagnoses but only 5% of pre-exposure prophylaxis (PrEP) users. We sought to characterise communicative appeals and messaging frames used in US visual media to cultivate PrEP demand among cisgender and transgender women using content analysis methodology. We catalogued and coded media items (images and videos) from US PrEP marketing campaigns featuring women. Production and content characteristics were abstracted, and communicative appeals from media items were qualitatively coded in duplicate. We then descriptively summarised production and content characteristics and identified discrete subgroups of media items, clustering around specific messaging frames, through qualitative thematic analysis. Racial/ethnic minorities and sexual/gender minority women were heavily featured, and numerous media items leveraged cognitive and social communicative appeals to promote PrEP. We identified three unique messaging frames emerging from coded media items, portraying PrEP as: (1) necessary prevention (protection frame), (2) a desirable yet accessible commodity (aspiration frame), and (3) a conduit to sexual autonomy (empowerment frame). To effectively communicate PrEP information and promote PrEP to women, PrEP marketing should leverage alternative appeals (subjective norms, self-efficacy), address anticipated barriers to uptake (stigma, cost, medication interactions), and deconstruct misconceptions of PrEP use(rs).
We review the fast-growing work on salience and economic behavior. Psychological research shows that salient stimuli attract human attention bottom up due to their high contrast with surroundings, their surprising nature relative to recalled experiences, or their prominence. The Bordalo, Gennaioli & Shleifer (2012, 2013b, 2020) models of salience show how bottom-up attention can distort economic choice by distracting decision makers from their immediate goals or from relevant choice attributes. This approach unifies probability weighting, menu effects, reference points, and framing as distinct manifestations of bottom-up attention. We highlight new predictions and discuss open conceptual questions, as well as potential applications in finance, industrial organization, advertising, and politics.
Expected final online publication date for the Annual Review of Economics, Volume 14 is August 2022. Please see http://www.annualreviews.org/page/journal/pubdates for revised estimates.
Background
Poor adherence to oral HIV pre-exposure prophylaxis (PrEP) diminishes its clinical and public health benefits. This study synthesises evidence regarding discontinuation, adherence, and reinitiation of PrEP among geographically diverse PrEP users.
Methods
We did a systematic review and meta-analysis evaluating studies published in MEDLINE, Embase, and Cochrane Central Register of Controlled Trials from inception to Dec 18, 2020. We included longitudinal studies that presented data for PrEP discontinuation, defined as investigator-reported loss to follow-up or participant self-reported PrEP stoppage. Data were extracted from published reports and assessed for risk of bias. We used a random-effects meta-analysis to pool estimates of discontinuation and I² and τ² to evaluate heterogeneity. This study is registered with PROSPERO, CRD42020155675.
Findings
We identified 4129 records, of which 59 articles were included (n=43 917 participants). 41·0% (95% CI 18·8–63·5) of participants discontinued PrEP within 6 months, with the highest rates in observational studies. The discontinuation rate in sub-Saharan Africa (47·5%, 95% CI: 29·4–66·4%) was higher than in other regions (p<0·001). Discontinuation rates were lower in studies with adherence interventions than in those without (24·7% vs 36·7%, p=0·015). Gay or bisexual men who have sex with men and transgender women offered daily or non-daily dosing options had lower discontinuation rates than those offered daily dosing alone (21·6% vs 31·5%; p<0·001). The pooled suboptimal adherence within 6 months was 37·7% (95% CI 8·4–66·9). Among people who discontinued PrEP, 47·3% (95% CI 31·5–63·2) reinitiated PrEP within 1 year of PrEP initiation. The included studies had poor quality in terms of study design, with a moderate risk of bias.
Interpretation
Strategies to encourage reinitiating PrEP for new or persistent risk should be a focus of future PrEP implementation strategies.
Funding
National Institutes of Health and Nature Science Foundation of China.
Background:
Agriculture is one of the most hazardous occupations in the USA. Especially, tractor rollover incidents are the leading cause of farming-related injuries or deaths. This study examines the effect of a VR intervention (Virtual Reality Intervention for Safety Education; VRISE) on behavioral intentions for occupational safety and identifies a psychological mechanism that shows how the immersive technology works.
Methods:
VRISE was developed by a multidisciplinary team of agricultural educators, computer scientists and communication specialists. It was designed to provide a virtual environment where users practice tractor operation and try to avoid several rollover hazards. The participants (291 high school students) were recruited at the 2019 National Future Farmers Association Convention & Expo and randomly assigned to one of three conditions: two different types of control groups (Control1: No treatment group and Control2: 2D Screen group) and the treatment group.
Results:
Findings show that, through the immersive VR experience, the VR intervention enhanced perceived threat of tractor-related accidents which in turn, led to improved behavioral intentions for tractor safety.
Conclusions:
Findings shed light on the effectiveness of a VR intervention to improve public health outcomes, especially in occupational safety education, where unsafe practices often result in injury and fatality.
Background:
A goal of the US Department of Health and Human Services' Ending the HIV Epidemic (EHE) in the United States initiative is to reduce the annual number of incident HIV infections in the United States by 75% within 5 years and by 90% within 10 years. We developed a resource allocation analysis to understand how these goals might be met.
Methods:
We estimated the current annual societal funding [$2.8 billion (B)/yr] for 14 interventions to prevent HIV and facilitate treatment of infected persons. These interventions included HIV testing for different transmission groups, HIV care continuum interventions, pre-exposure prophylaxis, and syringe services programs. We developed scenarios optimizing or reallocating this funding to minimize new infections, and we analyzed the impact of additional EHE funding over the period 2021-2030.
Results:
With constant current annual societal funding of $2.8 B/yr for 10 years starting in 2021, we estimated the annual incidence of 36,000 new cases in 2030. When we added annual EHE funding of $500 million (M)/yr for 2021-2022, $1.5 B/yr for 2023-2025, and $2.5 B/yr for 2026-2030, the annual incidence of infections decreased to 7600 cases (no optimization), 2900 cases (optimization beginning in 2026), and 2200 cases (optimization beginning in 2023) in 2030.
Conclusions:
Even without optimization, significant increases in resources could lead to an 80% decrease in the annual HIV incidence in 10 years. However, to reach both EHE targets, optimization of prevention funding early in the EHE period is necessary. Implementing these efficient allocations would require flexibility of funding across agencies, which might be difficult to achieve.
Purpose of review:
Preexposure prophylaxis (PrEP) is a critical strategy to curb new HIV infections globally. National and global targets have been set for people starting PrEP. However, global PrEP initiations fell short of UNAIDS 2020 targets, and reflection is needed on how we set and meet targets for PrEP use.
Recent findings:
Recent literature documents challenges to meeting ambitious goals for PrEP coverage in multiple phases of PrEP: PrEP initiations are limited by gaps in the identification of those who might benefit from PrEP. Conversely, getting PrEP to those who need it most is threatened by inaccurate risk perception and HIV and PrEP stigma. Once people are on PrEP, a substantial number discontinue PrEP in the first year (the 'PrEP Cliff'), a finding that is robust across groups of PrEP users (e.g., women, men who have sex with men, transwomen) and across global prevention settings. Further, PrEP inequities - by which we refer to utilization of PrEP in a specific group that is not commensurate with their epidemic risk - threaten the overall population benefit of PrEP because those at highest risk of acquiring HIV are not adequately protected.
Summary:
To realize global goals for PrEP utilization and impact, we must address multiple points of PrEP delivery programs that address not just PrEP starts, but also retention in PrEP and measurement and accountability to PrEP equity. We call for new approaches to better identify PrEP candidates, suggest additional research to address the known and consistent reasons for PrEP discontinuations, and advocate for metrics to measure and be accountable to PrEP equity.
Men who have sex with men (MSM) in the United States are at disproportionate risk for HIV. Once-daily pre-exposure prophylaxis (PrEP) for HIV prevention is a highly effective method of preventing HIV infection; however, optimal adherence is necessary to maintain effectiveness. Many studies have profiled perceived barriers to adherence among at-risk MSM; however, nearly a decade after FDA approval, there has been little work examining experienced barriers to adherence among MSM who have previously used the medication. To assess the current state of this literature and its implications for behavioral interventions, we conducted a meta-ethnography (i.e., A systematic review and synthesis of qualitative studies) of experiences with PrEP use among cis-gender MSM in the United States. We found that structural-level interventions, such as telehealth and pharmacist-prescribed approaches to PrEP distribution, may circumvent barriers to uptake and adherence for some MSM, but may not be enough for already underserved communities, such as MSM of color. Furthermore, interpersonal-level factors, such as enacted PrEP stigma by providers and peers, highlight the necessary consideration of social identity in the branding of PrEP for HIV prevention. Tailored interventions should consider experienced barriers to PrEP adherence across socioecological levels to be most effective.
Background
MSM are disproportionately affected by HIV, a joint strategy of behavioral interventions and chemoprophylaxis, e.g. HIV post-exposure prophylaxis (PEP), is promising to reduce HIV infection. Worldwide PEP is recommended, and it has been prescribed to MSM over the past decade in many countries since 1990s. In order to better understand the role PEP played in HIV prevention among MSM, we reviewed literature to describe the global utilization of PEP.
Methods
We searched the following databases for publications in English through 19 May 2018: Pubmed, Scoups, Embase, the Cochrane Library and Web of Science. Eligible articles reported the following data on nPEP among MSM: reasons for and/or the uptake of nPEP, adherence to treatment guidelines, and HIV seroconversion among MSM prescribed PEP.
Fifty-six studies were included
Medical records showed nPEP prescriptions increased significantly among MSM, who accounted for the majority of nPEP users in most settings, ranging from 57% to 88.1%. Twenty-eight studies reported on the uptake of PEP among MSM, with an overall pooled proportion of 8.1% (95% CI 5.6% to 10.5%). One-fifth of MSM nPEP users obtained repeated prescription. With regard to reasons for nPEP use, unprotected receptive anal intercourse was more frequent than unprotected insertive anal intercourse (35–65.8% vs 20–28.8%). The pooled full completion (28-day course) was 91.6% (95%CI: 89.9–93.2%), with 100% adherence to the regimen ranging from 52% to 85%. Ten studies reported 498 HIV seroconversions among 18908 MSM, which resulted in a post use HIV incidence of 0.97 to 7.2 per 100 person-years. but there is no clear linkage between nPEP use and HIV seroconversions.
Conclusion
Our review demonstrated that PEP is underutilized as a HIV prevention strategy. Efforts are needed to raise awareness and knowledge of nPEP and engage MSM in this chemoprophylaxis. Efforts are also needed to reinforce completion and adherence among nPEP users.
Disclosure
No significant relationships.
ABSTRACT Despite abundant evidence on its safety, tolerability and cost-effectiveness, post-exposure prophylaxis (PEP) has not been officially approved for non-occupational use in China. This study aims to assess awareness of, willingness to use, and actual experience with PEP in gay, bisexual and other men who have sex with men (GBM) in China and to explore potential associations between demographic, behavioral, and psychosocial factors and PEP-related outcomes. We recruited a convenience sample through community venue-based strategies, peer referrals, and online advertisement in four cities of China in 2018. We used bivariable and multivariable logistic regression to test associations between potential predictors and PEP outcomes. Over 60% of men reported having heard of PEP prior to the survey, 70% would be willing to use it if exposed to HIV, and 6% reported having used PEP. Awareness of PEP was associated with higher education, more frequent HIV testing, knowing someone who seroconverted in the past two years, having sex with only men in the past six months, and lower perceived risk of HIV infection. PEP willingness was associated with more frequent HIV testing, being worried about becoming HIV infected, prior awareness and favorable attitudes towards PEP among friends. Findings suggest PEP is an underutilized diomedical HIV prevention intervention among GBM in China. Clinical guidance on non-occupational PEP use, as well as communication campaigns targeting social networks of GBM are needed to address barriers to PEP awareness and uptake. ARTICLE HISTORY
Background:
Annual human immunodeficiency virus (HIV) diagnoses in the United States (US) have plateaued since 2013. We assessed whether there is an association between uptake of pre-exposure prophylaxis (PrEP) and decreases in HIV diagnoses.
Methods:
We used 2012-2016 data from the US National HIV Surveillance System to estimate viral suppression (VS) and annual percentage change in diagnosis rate (EAPC) in 33 jurisdictions, and data from a national pharmacy database to estimate PrEP uptake. We used Poisson regression with random effects for state and year to estimate the association between PrEP coverage and EAPC: within jurisdictional quintiles grouped by changes in PrEP coverage, regressing EAPC on time; and among all jurisdictions, regressing EAPC on both time and jurisdictional changes in PrEP coverage with and without accounting for changes in VS.
Results:
From 2012 to 2016, across the 10 states with the greatest increases in PrEP coverage, the EAPC decreased 4.0% (95% confidence interval [CI], -5.2% to -2.9%). On average, across the states and District of Columbia, EAPC for a given year decreased by 1.1% (95% CI, -1.77% to -.49%) for an increase in PrEP coverage of 1 per 100 persons with indications. When controlling for VS, the state-specific EAPC for a given year decreased by 1.3% (95% CI, -2.12% to -.57%) for an increase in PrEP coverage of 1 per 100 persons with indications.
Conclusions:
We found statistically significant associations between jurisdictional increases in PrEP coverage and decreases in EAPC independent of changes in VS, which supports bringing PrEP use to scale in the US to accelerate reductions in HIV infections.
Background:
Many gay and bisexual men (GBM) experience HIV anxiety, particularly around condomless anal intercourse. HIV pre-exposure prophylaxis (PrEP) is an effective HIV prevention strategy that may reduce HIV anxiety among GBM.
Methods:
The Following Lives Undergoing Change (Flux) Study is a national, online, open-prospective observational study of licit and illicit drug use among GBM in Australia. In 2018, participants responded to newly included items regarding anxiety about HIV transmission. Stratifying GBM as high or low risk as determined by the Australian PrEP Guidelines, we assess whether PrEP use is associated with lower levels of HIV anxiety. Multivariate logistic regression was used to compare factors associated with PrEP use among GBM at high risk (PrEP-eligible) and low risk (PrEP-ineligible) of HIV infection. Results are reported as adjusted odds ratios and corresponding 95% confidence intervals.
Results:
Among 1547 men, the mean age was 37.1 years (SD 13.1). Men aged 25 years or younger had higher HIV anxiety scores than older men. Among PrEP-eligible men, men who use PrEP reported lower levels of HIV anxiety (adjusted odds ratio = 0.92; 95% confidence interval = 0.87 to 0.99; P < 0.001). No differences were observed on HIV anxiety among PrEP-ineligible men.
Conclusions:
Among PrEP-eligible men, PrEP use was independently associated with lower levels of HIV anxiety. In addition to avoiding HIV infection, PrEP use may help reduce anxiety among men at risk of HIV. This feature of PrEP could be promoted as part of demand creation initiatives to increase PrEP uptake.
Background:
HIV Pre-exposure prophylaxis and post-exposure prophylaxis are two major biomedical HIV prevention modalities. The utility of these prevention tools for individuals with infrequent high-risk HIV exposures remains uncertain. HIV post-exposure prophylaxis-in-pocket ("PIP") may be an effective HIV prevention tool in such situations. Here we present long-term follow up of a cohort of patients initiated on PIP for HIV prevention.
Methods:
We retrospectively evaluated clinical characteristics of patients initiated on PIP as a primary HIV prevention tool between January 1, 2016 to May 31, 2019 at the Toronto General Hospital HIV Prevention Clinic and St. Michael's Hospital HIV Clinic, both in Toronto, Canada. Patients were referred for consideration of a biomedical HIV prevention modality. Individuals with a low frequency of high-risk exposures to HIV were initiated on PIP after counselling, and were followed at regular intervals. Demographic and clinical data was collected with a standardized form.
Results:
A total of 79 patients were initiated on PIP as a primary HIV prevention modality and followed for a mean duration of 14.8 months combining for a total of 97.3 patient-years. Twenty one (26.6%) patients used their PIP, and 32 courses of PIP were taken during the study period. Transitions between HIV prevention modalities included 13 (16.5%) patients who transitioned from PrEP to PIP, and 22 (27.8%) patients who transitioned from PIP to PrEP. No HIV seroconversions were detected during the course of this study.
Conclusion:
PIP is helpful HIV prevention modality for individuals with a low frequency of high-risk HIV exposures.
The key purpose of this article is to provide a comprehensive overview of the literature on perspective-taking from within mainstream psychology and behavior analysis. The primary focus will be on the behavior-analytic approach to perspective-taking, which is divided into what may be described as (1) traditional behavior analysis; (2) an area within behavior analysis that is concerned specifically with human language and cognition, known as Relational Frame Theory (RFT); and (3) an updated version of RFT that is used to provide the beginnings of a detailed and systematic account of the processes involved in perspective-taking abilities.
Background:
HIV pre-exposure prophylaxis (PrEP) has great potential to reduce HIV incidence among young black men who have sex with men (YBMSM) but 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 HIV-negative YBMSM aged 18-29. For initiators, time on and off PrEP was recorded. Time to PrEP uptake, first discontinuation, and final discontinuation were assessed with the Kaplan-Meier method, with Cox proportional hazard models used to identify factors associated with 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 (IQR 44-275). 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 (IQR 97-237). Factors associated with PrEP uptake included higher self-efficacy, sexually transmitted infection, 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% CI 3.40-7.23) with lower rate among those who started PrEP (incidence rate ratio 0.39 [95% CI 0.16-0.92]).
Conclusions:
Persistent PrEP coverage in this cohort of YBMSM was suboptimal and discontinuations common despite additional support services available through the study. Interventions to support PrEP uptake and persistence, especially for younger and substance-using YBMSM, will be necessary to achieve full PrEP effectiveness.
This paper presents evidence that consumers underreact to taxes that are not salient and characterizes the welfare consequences of tax policies when agents make such optimization errors. The empirical evidence is based on two complementary strategies. First, we conducted an experiment at a grocery store posting tax inclusive prices for 750 products subject to sales tax for a three week period. Scanner data show that this intervention reduced demand for the treated products by 8 percent. Second, we find that state-level increases in excise taxes (which are included in posted prices) reduce alcohol consumption significantly more than increases in sales taxes (which are added at the register and are hence less salient). We develop simple, empirically implementable formulas for the incidence and efficiency costs of taxation that account for salience effects as well as other optimization errors. Contrary to conventional wisdom, the formulas imply that the economic incidence of a tax depends on its statutory incidence and that a tax can create deadweight loss even if it induces no change in demand. Our method of welfare analysis yields robust results because it does not require specification of a positive theory for why agents fail to optimize with respect to tax policies.
Background:
Black and Latina transgender women (BLTW) face significant HIV disparities with estimated HIV prevalence up to 50% and annual incidence rates as high as 2.8 per 100 person-years. However, few studies have evaluated the acceptability and uptake of high-impact HIV prevention interventions among BLTW.
Setting:
Data collection took place in Baltimore, MD and Washington, DC from May 2015-May 2017.
Methods:
This mixed methods study included quantitative interviewer-administered surveys, key informant interviews, and focus group discussions. Rapid HIV testing followed each survey. Logistic regression models tested associations between legal gender affirmation (i.e., desired name and gender marker on identity documents), transgender pride, history of exchange sex, HIV risk perception, and willingness to take pre-exposure prophylaxis (PrEP). Transcripts of qualitative data were coded to identify common themes related to engagement in HIV prevention.
Results:
Among 201 BLTW, 56% tested HIV-positive and 87% had heard of PrEP. Only 18% who had heard of PrEP had ever taken it. Of the 72 self-reported HIV-negative or status-unknown BLTW who had never taken PrEP, 75% were willing to take it. In multivariable analyses, history of exchange sex was associated with willingness to take PrEP, whereas greater HIV knowledge and transgender pride were associated with lower likelihood of willingness to take PrEP. Concern about drug interactions with hormone therapy was the most frequently reported barrier to PrEP uptake.
Conclusion:
Noting the disconnect between PrEP willingness and uptake among BLTW, HIV prevention programs could bridge this gap by responding to identified access barriers and incorporating community-derived strategies.