Parrying the Pitfalls of PrEP: Preventing Premature PrEP Discontinuation and STIs among Young Black MSM

摘要 亚特兰大男男性行为(YBMSM)的年轻黑人男性(18-29岁)艾滋病毒感染率很高 获得率(8.9%/年)和性传播感染(30%/年)。在过去的5年里，我们跟踪了300人的队列 在亚特兰大的YBMSM，并提供了PrEP，作为全面预防干预措施的一部分。 我们已经大量采用PrEP-超过40%的YBMSM发起PrEP-但我们也观察到 较高的PrEP停用率(占所有PrEP开始的39%)和新的STI诊断率持续较高。 即使队列中有44%的PrEP吸入率，艾滋病毒发病率仍保持在6.2%/年的高水平。这相当于30% 与PrEP前比较队列相比，HIV发病率有所下降，但仍然高得令人无法接受。 因此，我们建议继续我们的队列方法，但增加三种新的干预措施：(1)创新的 “预警”系统，以识别PrEP上的YBMSM谁有停止PrEP的风险，并提供 基于激励性访谈的同伴干预；(2)向每天拒绝接受PrEP的男性提供按需PrEP 或者他们计划停止每天的PrEP，因为他们不愿意每天服用一片药片或认为他们的风险 不常见；以及(3)为所有男性提供STI PEP和多西环素，无论是否使用PrEP，以避免新的STI。 这是一种以实施为重点的单臂队列方法，使用目标试验设计来模拟 过程措施的随机试验和评价。主要结果是PrEP的停用率 和新的性传播感染诊断率。

Abstract Young (aged 18-29) Black men who have sex with men (YBMSM) in Atlanta experience high rates of HIV acquisition (8.9%/year) and STI infection (30%/year). Over the past 5 years, we have followed a cohort of 300 YBMSM in Atlanta and have offered PrEP as part of a comprehensive package of prevention interventions. We have had substantial uptake of PrEP – over 40% of YBMSM initiated PrEP – but we have also observed high rates of PrEP discontinuation (39% of all PrEP starts) and ongoing high rates of new STI diagnoses. Even with 44% PrEP uptake in the cohort, HIV incidence remained high at 6.2%/year. This represents a 30% reduction in HIV incidence compared to our pre-PrEP comparison cohort, but is still unacceptably high. Therefore, we proposed to continue our cohort approach but to add three new interventions: (1) an innovative “early warning” system to identify YBMSM on PrEP who are at risk for discontinuing PrEP, and providing a motivational interviewing-based peer intervention; (2) offering on-demand PrEP to men who decline daily PrEP or who plan to stop daily PrEP because they are unwilling to take a daily pill or perceive their risks to be infrequent; and (3) offering STI PEP with doxycycline for all men, regardless of PrEP use, to avert new STIs. This is an implementation-focused, single arm cohort approach, using a target trial design to emulate a randomized trial and evaluation of process measures. Primary outcomes are rates of PrEP discontinuation and rates of new STI diagnoses.