Full length articlePost-exposure prophylaxis use and recurrent exposure to HIV among men who have sex with men who use crystal methamphetamine
Introduction
Crystal methamphetamine (CM) is a highly addictive psychostimulant that has been linked to high-risk sexual behavior and incident HIV infection among men who have sex with men (MSM; Gonzales et al., 2010, Koblin et al., 2006, Mayer et al., 2013). The use of CM is considerably more prevalent among MSM in the United States than in the general population, with the prevalence of use nearly 10 times greater (Colfax and Shoptaw, 2005, Mimiaga et al., 2012b). It has been well established that CM use is predictive of higher risk sexual encounters, including low rates of condom use, an increase in number of sexual partners, including anonymous partners, and prolonged sexual encounters spanning multiple days (Benotsch et al., 2012, Halkitis et al., 2001, Rajasingham et al., 2012).
Post-exposure prophylaxis (PEP) consists of a 28-day course of antiretroviral therapy (ART) given prophylactically within 72 h of a high-risk exposure (Smith et al., 2005). Although PEP efficacy in humans has never been tested in a randomized controlled trial, it has been shown to reduce the odds of HIV seroconversion in animal models (Tsai et al., 1995) and following health care workers’ needle stick exposures in a nested case control study (Cardo et al., 1997, Jain and Mayer, 2014). Although CM-using MSM might benefit from biomedical HIV prevention strategies such as PEP or pre-exposure prophylaxis (PrEP), concerns related to the ability of users to adhere to ART regimens have limited prescription of PEP for this subpopulation (Landovitz et al., 2012, O’Connor, 1999, Oldenburg et al., 2013). Furthermore, evidence suggests that MSM who use stimulants are significantly less likely to be aware of PEP as an HIV prevention strategy, which further limits its use among this group (Liu et al., 2008). A key component to the success of PEP is an individual's ability to identify high-risk exposures, know where to get treatment, and seek medical attention within 72 h, in addition to their ability to complete the prescribed regimen.
The purpose of the present study is two-fold. First, we sought to characterize the effect of event-level and chronic CM use and sexual risk behavior during the exposure that led to PEP, compared to individuals who accessed PEP but had not used CM. Event-level CM use may affect risk-taking behavior differentially compared to chronic use, and thus we attempt to understand the effect of CM use at the time of event independently of whether or not the individual is a chronic methamphetamine user. Second, we sought to assess the relationship between repeat PEP use and long-term outcomes following presentation for PEP in MSM with CM use compared to those who had not used CM. A better understanding of the context of risk prior to, and after, first PEP use and the trajectory of subsequent PEP use among MSM who use CM will help to inform the optimal deployment of biomedical HIV prevention strategies for this group of MSM.
Section snippets
Study sample
Data for this study were derived from a retrospective longitudinal review of all PEP users at Fenway Community Health in Boston, MA between July 1, 1997 and August 1, 2013. Full methods for the study have been previously reported (Jain et al., 2014). Briefly, patients with a prescription for a one month course of an antiretroviral medication combination in their electronic medical record during this time period who were HIV-uninfected were screened for study eligibility. Inclusion criteria
Descriptive statistics
Of 788 MSM who sought PEP between July 1, 1997 and August 1, 2013, 58 (7.4%) had a documented chronic CM use disorder at the time of their first PEP prescription. Among the 788 MSM who sought PEP, there were 1,130 PEP prescriptions during the observation period (range 1 to 15 prescriptions per patient). Of these, CM was used during 84 (7.4%) of exposures that led to seeking PEP. Median follow-up time was 1.9 years (IQR 1.1 to 4.6 years) among MSM with a CM use disorder and 1.0 (IQR 0.1 to 3.1
Discussion
The results of this study indicate that a substantial proportion of Boston MSM who sought PEP following a high-risk exposure had used CM, and that these individuals knew where and how to seek treatment within 72 h of the exposure. MSM who used CM were more likely to return for repeat PEP than those who did not use this stimulant, suggesting high levels of recurrent risk, as well as the ability to identify risky exposures and access care quickly following exposure. However, despite repeat PEP
Role of the funding source
The sponsors did not have a role in the design and conduct of the study; collection, management, analysis and interpretation of the data; and preparation, review or approval of the manuscript.
Contributors
CEO designed the study, collected data, carried out statistical analyses, and drafted the manuscript. SJ designed the study, collected data, interpreted results, and drafted and critically reviewed the manuscript. KHM designed the study, interpreted results, critically reviewed the manuscript, and provided study oversight. MJM designed the study, interpreted results, critically reviewed the manuscript, and provided study oversight. All authors have read and approved the final version of the
Conflicts of interest
None to declare.
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