A Novel Combination HIV Prevention Strategy: Post-Exposure Prophylaxis with Contingency Management for Substance Abuse Treatment Among Methamphetamine-Using Men Who Have Sex with Men

Abstract

Methamphetamine use has been associated with HIV transmission among men who have sex with men (MSM). However, providers have been hesitant to utilize post-exposure prophylaxis (PEP) in populations of stimulant users. This single-arm, open label pilot study sought to demonstrate the safety, feasibility, and acceptability of PEP combined with the drug abstinence intervention of contingency management (CM) in methamphetamine-using MSM. HIV-uninfected MSM reporting recent methamphetamine use were recruited to a CM intervention. Those who reported a recent high-risk sexual or injection drug exposure to an HIV-infected or serostatus unknown source were initiated on tenofovir/emtricitabine (Truvada)-based PEP. Participants were followed over 3 months for infectious/biologic, behavioral, and drug use outcomes. Fifty-three participants enrolled in the study; 35 participants (66%) initiated PEP after a high-risk exposure. The median time from exposure to medication administration was 37.8 h (range 12.5-68.0 h). Twenty-five (71.4%) PEP initiators successfully completed the treatment course. Median medication adherence was 96% (IQR 57-100%), and medication was generally well tolerated. Methamphetamine abstinence during CM treatment increased PEP adherence (2% [95% CI +1-+3%]) per clean urine toxicology sample provided), and increased the odds of PEP course completion (OR 1.17, 95% CI 1.04-1.31). One incident of HIV seroconversion was observed in a participant who did not complete PEP treatment, and reported multiple subsequent exposures. Findings demonstrate that PEP, when combined with CM, is safe, feasible, and acceptable as an HIV prevention strategy in methamphetamine-using MSM.

Differences in Attitudes About HIV Pre-Exposure Prophylaxis Use Among Stimulant Versus Alcohol Using Men Who Have Sex with Men

“…(20) It is likely that the use of PrEP by MSM who use other stimulants, such as crystal methamphetamine, may have similar effects. It has been well established that crystal methamphetamine and cocaine use are associated with higher-risk sexual behavior and incident HIV infection,(5,7,10,12,21) and previous studies have shown stronger associations between stimulant use and serodiscordant condomless anal intercourse than with alcohol use. (22) Stimulant users may therefore be particularly good candidates for PrEP, and understanding perceived barriers and facilitators to uptake and adherence may improve effectiveness of PrEP implementation programs.…”

“…(7,12) Since optimal adherence is required to achieve PrEP efficacy and subsequently decrease risk of HIV acquisition, substance use could limit the effectiveness of PrEP if substance using MSM are unable to take PrEP as prescribed. Although prior studies have suggested that stimulant use did not affect PrEP adherence(16), in the current study substance users expressed concern about their ability to adhere to treatment.…”

“…(11) Combination HIV prevention interventions that include post-exposure prophylaxis (PEP) (antiretroviral administered to HIV- uninfected individuals after potential exposure to HIV) may be a viable approach for crystal methamphetamine-using MSM. (12) However, crystal methamphetamine-using MSM who have sought out PEP have also been shown to have higher recurrent exposure to HIV than their non-crystal methamphetamine using counterparts(7), suggesting that longer-term strategies may be needed for this sub-population. In addition, although medications exist to treat alcohol dependency, these medications have not been shown to be associated with reduction in HIV risk.…”

Individual-Level, Partnership-Level, and Sexual Event-Level Predictors of Condom Use During Receptive Anal Intercourse Among HIV-Negative Men Who Have Sex with Men in Los Angeles

“…Although consistent condom use remains an essential HIV prevention strategy even in the context of PrEP (13), daily oral PrEP, which does not rely on event-specific adherence, may be a more feasible risk reduction strategy for methamphetamine using MSM with non-main partners. Available data do not support concerns that biomedical HIV prevention strategies, such as PrEP, cannot be successfully implemented with people who use drugs (37,38). …”

Evaluating HIV prevention strategies for populations in key affected groups: the example of Cabo Verde

“…Given the potential for PrEP and PEP to reduce the acquisition of HIV infection among sex workers, MSM and people who use and inject drugs (Izulla et al 2013; Landovitz et al 2012; Mack et al 2014; McGowan 2014), future research should be conducted to examine the feasibility of these interventions in this setting.…”