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Table.  Characteristics of HIV-Negative MSM Using and Sharing PrEP Medication in a Diverse Sample From 3 US Cities, 2018
Characteristics of HIV-Negative MSM Using and Sharing PrEP Medication in a Diverse Sample From 3 US Cities, 2018
1.
Centers for Disease Control and Prevention. Preexposure prophylaxis for the prevention of HIV infection in the United States—2017 Update: a clinical practice guideline. 2017. Accessed March 16, 2020. https://www.cdc.gov/hiv/pdf/risk/prep/cdc-hiv-prep-guidelines-2017.pdf
2.
US Food & Drug Administration. Truvada for PrEP fact sheet: ensuring safe and proper use. Accessed March 16, 2020. https://www.fda.gov/media/83586/download
3.
Mansergh  G, Koblin  BA, Colfax  GN, McKirnan  DJ, Flores  SA, Hudson  SM; Project MIX Study Team.  Preefficacy use and sharing of antiretroviral medications to prevent sexually-transmitted HIV infection among US men who have sex with men.   J Acquir Immune Defic Syndr. 2010;55(2):e14-e16. doi:10.1097/QAI.0b013e3181f27616PubMedGoogle ScholarCrossref
4.
Mansergh  G, Koblin  B, Colfax  GN, Flores  SA, Hudson  SM; Project MIX Study Team.  ‘Less education’ is associated with use and sharing of antiretroviral medications for prophylaxis of HIV infection by US men who have sex with men.   Sex Transm Infect. 2011;87(6):510. doi:10.1136/sextrans-2011-050188PubMedGoogle ScholarCrossref
5.
Sullivan  PS, Sanchez  TH, Zlotorzynska  M,  et al.  National trends in HIV pre-exposure prophylaxis awareness, willingness and use among United States men who have sex with men recruited online, 2013 through 2017.   J Int AIDS Soc. 2020;23(3):e25461. doi:10.1002/jia2.25461PubMedGoogle Scholar
6.
Sullivan  PS, Zahn  R, Wiatrek  SE,  et al.  HIV prevention via mobile messaging for men who have sex with men (M-Cubed): protocol for a randomized controlled trial.   JMIR Res Protoc. 2019;8(11):e16439. doi:10.2196/16439PubMedGoogle Scholar
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    Research Letter
    Infectious Diseases
    September 11, 2020

    HIV Pre-exposure Prophylaxis Medication Sharing Among HIV-Negative Men Who Have Sex With Men

    Author Affiliations
    • 1Division of HIV/AIDS Prevention, Centers for Disease Control and Prevention, Atlanta, Georgia
    • 2The Fenway Institute, Fenway Health, Boston, Massachusetts
    • 3Department of Medicine, SUNY Downstate Health Sciences University, Brooklyn, New York
    • 4Department of Systems, Population, and Leadership, School of Nursing, University of Michigan, Ann Arbor
    • 5Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, Georgia
    JAMA Netw Open. 2020;3(9):e2016256. doi:10.1001/jamanetworkopen.2020.16256
    Introduction

    When used as recommended by clinicians, pre-exposure prophylaxis (PrEP) is an effective and clinically recommended daily medication for prevention of HIV infection among sexually active men and women who do not consistently use condoms during sexual intercourse.1 Clinicians and their patients can decide whether PrEP is warranted and appropriate to prevent HIV infection.

    Despite clinical guidelines on PrEP, some patients share their medication. Before the US Food and Drug Administration approval of antiretroviral therapy (ART) for HIV PrEP2 and the release of the US Centers for Disease Control and Prevention’s updated clinical guidelines on PrEP for prevention of HIV infection,1 research found that small proportions of HIV-negative men who have sex with men (MSM) who used ART in off-label strategies of preexposure (2% of MSM) and postexposure (4% of MSM) prophylaxis shared medication.3 A lower educational level, that is, having a high school diploma or less (adjusted odds ratio [aOR], 2.7 [95% CI, 1.0-7.2]; P = .05) vs some post–high school education and a college degree or more (aOR, 9.3; 95% CI, 1.1-76.9) was associated with sharing postexposure prophylaxis medication but not with sharing PrEP medication.4

    These findings underscore the importance of ongoing surveillance to better understand the prevalence of sharing nonprescribed, daily oral PrEP medication and to develop strategies to address this public health issue. Given the rapidly increasing use of PrEP medication by MSM,5 it is critical for clinicians to monitor PrEP use to ensure its safety and effectiveness, appropriate use, and to minimize complications and the potential development of PrEP-resistant HIV strains.

    Methods

    The protocol for this cross-sectional study was approved by the institutional review board of Emory University. Participants provided written informed consent to enroll in the study. This report adheres to the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) reporting guideline.

    We analyzed baseline data from the 2018 M-Cubed Study, a randomized clinical trial of the use of a mobile app for prevention of HIV infection among sexually active MSM in Atlanta, Georgia; Detroit, Michigan; and New York City, New York.6 Participants were asked the following question: “Are you currently taking PrEP to prevent HIV?” If the answer was yes, a follow-up question was asked: “Have you ever shared your PrEP medication with others?” (yes/no). An unpaired, 2-sided χ2 test was used for the bivariate analysis, with P < .05 considered statistically significant. Multivariable logistic regression analyses were controlled for demographic characteristics (race/ethnicity, age group, educational level, and city) to assess for differences in individuals who use and share PrEP medication, with results reported as adjusted odds ratios (aORs) with 95% CIs.

    Results

    This cross-sectional study included 755 HIV-negative MSM (mean [SD] age of 33.7 [11.2] years; 399 White individuals [52.9%], 146 Black/African American individuals [19.3%], 95 Hispanic/Latino individuals [12.6%], and 115 [15.2%] self-identified as other or mixed race/ethnicity). At baseline assessment, 243 individuals (32.2%) reported that they were currently receiving PrEP medication (Table). Of these individuals, 26 (10.7%) reported sharing PrEP medication, and only 12 (5.0%) had ever used PrEP on demand (ie, use of PrEP before and after sex). Multivariable logistic regression analyses adjusted for race/ethnicity, age group, educational level, and city found that MSM aged 30 to 39 years (vs those aged ≥40 years) had nearly twice the odds of reporting current PrEP use (aOR, 1.70 [95% CI, 1.11-2.61]; P = .02). Men with a higher educational attainment (vs men with ≤post–high school education) were more likely to report current PrEP use (4-year college degree: aOR, 1.54 [95% CI, 1.04-2.29]; P = .03 and >4-year college degree: aOR, 2.04 [95% CI, 1.34-3.10]; P = .001). Men from Detroit, Michigan (vs Atlanta, Georgia) were less likely to report current use of PrEP medication (aOR, 0.64 [95% CI, 0.43-0.97]; P = .03), with no differences in current use of the medication found between participants from New York City, New York, and Atlanta, Georgia. Among current PrEP users, sharing PrEP medication was more frequently reported by younger men (aged 18-29 years: aOR, 12.19 [95% CI, 1.43-103.86]; P = .02; aged 30-39 years: 9.78 [95% CI, 1.19-80.23]; P = .03) vs older men (aged ≥40 years) and by those with some graduate education (aOR, 3.67 [95% CI, 1.06-12.73]; P = .04) compared with some post–high school education or less.

    Discussion

    Increasing numbers of MSM use daily oral PrEP medication. In this study, more than 1 in 10 current PrEP users shared their PrEP medication. Regular assessment of the extent and the context of PrEP medication sharing could aid clinicians in creating messages to discourage medication sharing while promoting prescribed and clinically monitored use of PrEP. This study is limited by its use of self-reported information from MSM living in 3 US cities. Additional research is needed on factors that facilitate PrEP medication sharing, such as cost-savings, convenience, unawareness of potential consequences, and other factors. Younger and highly educated men, in particular, could benefit from messaging about the potential consequences of sharing PrEP medication.

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    Article Information

    Accepted for Publication: June 27, 2020.

    Published: September 11, 2020. doi:10.1001/jamanetworkopen.2020.16256

    Open Access: This is an open access article distributed under the terms of the CC-BY License. © 2020 Mansergh G et al. JAMA Network Open.

    Corresponding Author: Gordon Mansergh, PhD, CDC Division of HIV/AIDS Prevention, 1600 Clifton Rd, Mailstop E37, Atlanta Georgia 30329 (gcm2@cdc.gov).

    Author Contributions: Drs Mansergh and Sullivan had full access to all of the data in the study and take responsibility for the integrity of the data and the accuracy of the data analysis.

    Concept and design: Mansergh, Mayer, Hirshfield, Sullivan.

    Acquisition, analysis, or interpretation of data: Mansergh, Mayer, Stephenson, Sullivan.

    Drafting of the manuscript: Mansergh, Sullivan.

    Critical revision of the manuscript for important intellectual content: All authors.

    Statistical analysis: Mansergh.

    Obtained funding: Hirshfield, Stephenson, Sullivan.

    Administrative, technical, or material support: Mansergh, Hirshfield, Stephenson, Sullivan.

    Supervision: Mansergh, Sullivan.

    Conflict of Interest Disclosures: Dr Mayer reported receiving research grants from Gilead and Merck and serving on their scientific advisory boards. No other disclosures were reported.

    Funding/Support: This research was funded by a Centers for Disease Control and Prevention cooperative agreement.

    Role of the Funder/Sponsor: The funder was involved in the design and conduct of the study; management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication.

    Disclaimer: The findings and conclusions in this report are those of the authors and do not necessarily represent the views of the Centers for Disease Control and Prevention.

    Additional Contributions: The authors thank the M-Cubed Study staff and participants.

    References
    1.
    Centers for Disease Control and Prevention. Preexposure prophylaxis for the prevention of HIV infection in the United States—2017 Update: a clinical practice guideline. 2017. Accessed March 16, 2020. https://www.cdc.gov/hiv/pdf/risk/prep/cdc-hiv-prep-guidelines-2017.pdf
    2.
    US Food & Drug Administration. Truvada for PrEP fact sheet: ensuring safe and proper use. Accessed March 16, 2020. https://www.fda.gov/media/83586/download
    3.
    Mansergh  G, Koblin  BA, Colfax  GN, McKirnan  DJ, Flores  SA, Hudson  SM; Project MIX Study Team.  Preefficacy use and sharing of antiretroviral medications to prevent sexually-transmitted HIV infection among US men who have sex with men.   J Acquir Immune Defic Syndr. 2010;55(2):e14-e16. doi:10.1097/QAI.0b013e3181f27616PubMedGoogle ScholarCrossref
    4.
    Mansergh  G, Koblin  B, Colfax  GN, Flores  SA, Hudson  SM; Project MIX Study Team.  ‘Less education’ is associated with use and sharing of antiretroviral medications for prophylaxis of HIV infection by US men who have sex with men.   Sex Transm Infect. 2011;87(6):510. doi:10.1136/sextrans-2011-050188PubMedGoogle ScholarCrossref
    5.
    Sullivan  PS, Sanchez  TH, Zlotorzynska  M,  et al.  National trends in HIV pre-exposure prophylaxis awareness, willingness and use among United States men who have sex with men recruited online, 2013 through 2017.   J Int AIDS Soc. 2020;23(3):e25461. doi:10.1002/jia2.25461PubMedGoogle Scholar
    6.
    Sullivan  PS, Zahn  R, Wiatrek  SE,  et al.  HIV prevention via mobile messaging for men who have sex with men (M-Cubed): protocol for a randomized controlled trial.   JMIR Res Protoc. 2019;8(11):e16439. doi:10.2196/16439PubMedGoogle Scholar
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