BACKGROUND: Daily, oral use of tenofovir disoproxil fumarate and emtricitabine (TDF-FTC) for preexposure prophylaxis (PrEP) is an effective strategy to prevent acquisition of human immunodeficiency virus (HIV) infection. It is important to monitor PrEP uptake at the national level to increase our understanding of trends in its utilization, but national HIV surveillance data do not include PrEP uptake. Our objective was to develop feasible methods to estimate PrEP uptake and to estimate uptake each year among commercially insured persons during 2010-2014. METHODS: We conducted a retrospective analysis of the 2010-2014 MarketScan database, a national sample of persons with commercial health insurance in the United States. We developed an algorithm to identify persons aged ≥16 years who were prescribed TDF-FTC for PrEP each year. We generated nationally representative estimates of prevalence of persons prescribed PrEP. RESULTS: We found a significantly increasing trend in the proportion of persons prescribed TDF-FTC for PrEP during the study period, with 417 users in 2010 and 9375 in 2014 (P < .001); 97% of PrEP users were male and 98% lived in metropolitan areas in 2014. During the study period, the numbers of women prescribed PrEP were low. CONCLUSIONS: Our analytic method provides the only feasible means to monitor PrEP uptake in the United States. Although a marked increasing trend in uptake was observed for men, the number of women who used PrEP remained very low during the study period. Interventions are needed to increase PrEP use by women at substantial risk of acquiring HIV infection.

In the United States, young people (ages 15-24 years) are disproportionately affected by human immunodeficiency virus (HIV) and other sexually transmitted diseases (STDs), due at least in part to inadequate or incorrect HIV/STD-related knowledge, attitudes, beliefs, and behavioral intentions (KABI). Comic book narratives are a proven method of HIV/STD prevention communication to strengthen KABI for HIV/STD prevention. Motion comics, a new type of comic media, are an engaging and low-cost means of narrative storytelling. The objective of this study was to quantitatively evaluate the effectiveness of a pilot six-episode HIV/STD-focused motion comic series to improve HIV/STD-related KABI among young people. We assessed change in HIV/STD knowledge, HIV stigma, condom attitudes, HIV/STD testing attitudes, and behavioral intentions among 138 participants in 15 focus groups immediately before and after viewing the motion comic series. We used paired t-tests and indicators of overall improvement to assess differences between surveys. We found a significant decrease in HIV stigma (p < .001) and increases in both HIV knowledge (p = .002) and behavioral intentions to engage in safe sex (p < .001). In summary, this motion comic intervention improved HIV/STD-related KABI of young adult viewers by reducing HIV stigma and increasing behavioral intentions to engage in safer sex. Our results demonstrate the promise of this novel intervention and support its use to deliver health messages to young people.

We appreciate the correspondence by Kippax and Holt [1] regarding explanations for the increases in condomless sex. We agree that there may have been changes in social norms due to the effectiveness of antiretroviral therapy (ART) that are not captured by our survey. Furthermore, the measures we used for seroadaptive behaviors were based on participants’ last sex act and do not reflect the complexities of negotiations for safer sex throughout a partnership. However, we disagree with Kippax and Holt [1] who propose that the predominance of concordant condomless sex in the survey suggests an increase in seroadaptive strategies. The percentage of condomless sex partnerships that was concordant does not increase over time. Further, seroadaptive behaviors are predicated on engaging in different sexual practices according to whether partners are HIV seroconcordant or serodiscordant. The important question is not whether concordant condomless sex is more likely than discordant condomless, as suggested by Kippax and Holt [1], but whether concordant condomless sex is more likely than would be expected by chance alone. If men are consciously choosing partners of the same serostatus, there should be more positive–positive and negative– negative partnerships than would occur by chance according to the marginal probabilities dictated by HIV prevalence and the number of partnerships in our sample. Using a Z test, we compared observed and expected percentages of concordant partnerships. Among MSM reporting condomless sex at last sex using all years combined, 15% were HIV-positive, 76% were HIV-negative, and 9% had unknown HIV status. We used this distribution to compute the expected frequencies of concordant condomless sex partnerships. Among condomless sex partnerships at last sex, 52% were HIV-negative concordant and 9% were HIV-positive concordant. We found evidence suggesting that HIV-negative MSM are not serosorting; they report concordant partners less frequently than what would be expected through random mixing when they engage in condomless anal sex (52% observed vs. 57% expected, P < 0.001), possibly due to insufficient information about their partners’ HIV status. In contrast, our data suggest that HIV-positive MSM may be purposely serosorting when they engage in condomless sex (9% observed vs. 2% expected, P < 0.001). Therefore, although we found evidence to suggest that HIV-positive MSM may be serosorting, the preponderance of concordant partnerships among HIV-negative MSM is not beyond what would be expected through random mixing.

OBJECTIVE: Using published, nationally representative estimates, we calculated the total number of perinatally HIV-exposed and -infected infants born during 1978-2010, the number of perinatal HIV cases prevented by interventions designed for the prevention of mother-to-child transmission (PMTCT), and the number of infants exposed to antiretroviral drugs during the prenatal and intrapartum periods. DESIGN: We calculated the number of infants exposed to antiretroviral drugs since 1994, and the number of cases of mother-to-child HIV transmission prevented from 1994-2010 using published data. We generated confidence limits for our estimates by performing a simulation study. METHODS: Data were obtained from published, nationally-representative estimates from CDC. Model parameters included the annual numbers of HIV-infected pregnant women, the annual numbers of perinatally-infected infants, the annual proportions of infants exposed to antiretroviral drugs during the prenatal and intrapartum period, and the estimated mother-to-child transmission (MTCT) rate in the absence of preventive interventions. For the simulation study, model parameters were assigned distributions and we performed 1,000,000 repetitions. RESULTS: Between 1978 and 2010, an estimated 186,157 (95% CI: 185,312-187,003) HIV-exposed infants and approximately 21,003 (95% CI: 20.179-21,288) infected infants were born in the United States. Between 1994 and 2010, an estimated 124,342 (95% CI: 123,651-125,034) HIV-exposed infants were born in the U.S., and approximately 6,083 (95% CI: 5,931-6,236) infants were perinatally infected with HIV. During this same period about 100,207 (95% CI: 99,374-101,028) infants were prenatally exposed to antiretroviral drugs. As a result of PMTCT interventions, an estimated 21,956 (95% CI: 20,191-23,759) MTCT HIV cases have been prevented in the US since 1994. CONCLUSION: Though continued vigilance is needed to eliminate mother-to-child HIV transmission, PMTCT interventions have prevented nearly 22,000 cases of perinatal HIV transmission in the United States since 1994.

OBJECTIVE: Evaluate changes in condomless anal sex at last sex among men who have sex with men (MSM) and assess if these changes are associated with the adoption of serosorting and biomedical prevention. DESIGN: The National HIV Behavioral Surveillance is a crosssectional survey done in up to 21 cities in 2005, 2008, 2011 and 2014. METHODS: MSM were recruited through venue-based sampling. Among men reporting at least one male partner, we evaluated changes in condomless anal sex at last sex with a partner with (1) HIV-concordant (proxy for serosorting) or (2) HIV-discordant (discordant/unknown) status. We hypothesized that if concordant condomless sex was increasing while discordant was stable/declining, the increases could be driven by more men attempting to serosort. We used generalized estimating equations assuming a Poisson distribution and robust variance estimator to explore whether temporal changes in the outcomes varied by selected characteristics. We also assessed changes in condomless anal sex by antiretroviral therapy (ART) use among HIV-positive MSM. RESULTS: Among 5371 HIV-positive MSM, there were increases in concordant (19% in 2005 to 25% in 2014, P < 0.001) and discordant condomless sex (15 to 19%, P < 0.001). The increases were not different by ART use. Among 30 547 HIV-negative MSM, concordant (21 to 27%, P < 0.001) and discordant condomless sex (8 to 13%, P < 0.001) increased. CONCLUSION: Our data suggest that condom use decreased among MSM and that the trends are not explained by serosorting or ART. Promotion of condoms and increased access to preexposure prophylaxis are vital to ensure that the benefits of ART in reducing transmission of HIV are not undermined.

OBJECTIVES: As trials were assessing the safety and efficacy of daily oral antiretroviral preexposure prophylaxis (PrEP) for the prevention of HIV infection, there was a clear need to understand the evolution of knowledge of, and attitudes toward, PrEP among primary care clinicians. METHODS: Physicians and nurse practitioners were surveyed in 2009 (n = 1500), 2010 (n = 1504), 2012 (n = 1503), 2013 (n = 1507), 2014 (n = 1508) and 2015 (n = 1501) to assess their awareness of PrEP, willingness to prescribe PrEP, and whether they support use of public funds to pay for PrEP. Pharmacists (n = 251) were surveyed about PrEP in 2012 only. Descriptive statistics were computed for physician demographics and PrEP-related questions. Prevalence ratios for willingness to prescribe PrEP were computed using Poisson regression analysis. RESULTS: Awareness of PrEP was low among clinicians (2009: 24%, 2010: 29%) but increased after trials reported effectiveness (2012: 49%, 2013: 51%, 2014: 61%, 2015: 66%). Following a description of PrEP with an estimated effectiveness of 75%, across 6 of the study years 91% of clinicians indicated a willingness to prescribe PrEP to at least one group at high risk of HIV acquisition. A smaller majority of clinicians indicated support for public funding of PrEP in 2009: 59%, 2010: 53%, and 2013: 63%. CONCLUSIONS: In surveys conducted before and after the release of PrEP trial results, primary care clinicians were largely unaware of PrEP. They indicated high levels of willingness to prescribe it for patients at high risk of HIV acquisition and expressed interest in education about how to deliver this new clinical HIV prevention method. It will be important to continue monitoring clinician knowledge, attitudes, and practices as the use of PrEP increases in the US.