Background Transmasculine people are at risk for HIV; yet few HIV prevention interventions have been developed for this population. We adapted an existing HIV prevention smartphone app for cisgender men who have sex with men to meet the sexual health needs of transmasculine people. Objective This study aims to assess the acceptability of the adapted app, Transpire, among transmasculine people living in Atlanta, Georgia, and Washington, DC, via in-depth interviews of participants in a pilot feasibility trial. Methods Participants used the Transpire app for 3 months as part of a pilot study of the app. Eligible participants were aged 18-34 years. There were no eligibility criteria with respect to race and ethnicity, and most participants were non-Hispanic White. At the end of the follow-up, participants were invited to participate in web-based in-depth interviews to discuss their experiences using the app and feedback on design and content. Interviews were transcribed and coded using a constant comparative approach. Three main themes were identified: sexual behavior, app experiences and feedback, and pre-exposure prophylaxis. Results Overall, participants found the app acceptable and thought that it would be a useful tool for themselves and their peers. Participants reported appreciating having a comprehensive information source available to them on their phones and reported learning more about HIV, sexually transmitted infections, and pre-exposure prophylaxis via the app. They also reported appreciating the inclusive language that was used throughout the app. Although the app included some resources on mental health and substance use, participants reported that they would have appreciated more resources and information in these areas as well as more comprehensive information about other health concerns, including hormone therapy. Representative quotes are presented for each of the identified themes. Conclusions There is a desire to have greater access to reliable sexual health information among transmasculine people. Mobile apps like Transpire are an acceptable intervention to increase access to this information and other resources. More evidence is needed, however, from more racially and ethnically diverse samples of transmasculine people.

Background: Previous models have estimated the total population attributable fraction of NG/CT on HIV incidence among men who have sex with men (MSM), but this does not represent realistic intervention effects. We estimated the potential impact of screening for NG/CT on downstream incidence of HIV among MSM. Methods: Using a network model, we estimated the effects of varying coverage levels for STI screening among different priority populations: all sexually active MSM regardless of HIV serostatus, MSM with multiple recent (past 6 months) sex partners regardless of serostatus, MSM without HIV, and MSM with HIV. Under the assumption that all screening events included a urethral test, we also examined the effect of increasing of the proportion of screening events that include rectal screening for NG/CT on HIV incidence. Results: Increasing annual NG/CT screening among sexually active MSM by 60% averted 4.7% of HIV infections over a 10-year period (interquartile range (IQR): 2.3, 7.3). More HIV infections were averted when screening was focused on MSM with multiple recent sex partners: 60% coverage among MSM with multiple recent sex partners averted 9.8% of HIV infections (IQR: 8.1, 11.6). Increased STI screening among MSM without HIV averted more new HIV infections compared to the transmissions averted due to screening MSM with HIV, but fewer NG/CT tests were needed among MSM with HIV to avert a single new HIV infection. Conclusions: NG/CT screening among MSM is expected to lead to modest but clinically relevant reductions in HIV incidence among MSM.

Background: Delay discounting has been found to be associated with numerous health-related outcomes, including risky sexual behaviour. To date, it is unclear whether delay discounting measured in different domains is associated within individuals. The goal of this study was to assess the concordance of monetary and sexual delay discounting in men who have sex with men. Methods: Participants completed an online survey, including the Monetary Choice Questionnaire and the Sexual Discounting Task. Linear regression models were used to assess the association between monetary and sexual discount rates. Results: Sexual discount rates did not predict monetary discount rates. There was a substantial amount of clustering of sexual discount rates, requiring sexual discounting data to be categorised. Conclusions: Monetary and sexual delay discounting are distinct processes that are not necessarily associated within individuals, and monetary delay discounting is not an appropriate proxy measure for sexual impulsivity. Data from the Sexual Discounting Task are typically rank-transformed for analysis. These data suggest that this might be an invalid method of analysis. Future studies should investigate the distribution of their data to determine if it is appropriate to analyse sexual discounting data as a continuous measure.

Selenoprotein genetic variations and suboptimal selenium (Se) levels may contribute to the risk of colorectal cancer (CRC) development. We examined the association between CRC risk and genotype for single nucleotide polymorphisms (SNPs) in selenoprotein and Se metabolic pathway genes. Illumina Goldengate assays were designed and resulted in the genotyping of 1040 variants in 154 genes from 1420 cases and 1421 controls within the European Prospective Investigation into Cancer and Nutrition (EPIC) study. Multivariable logistic regression revealed an association of 144 individual SNPs from 63 Se pathway genes with CRC risk. However, regarding the selenoprotein genes, only TXNRD1 rs11111979 retained borderline statistical significance after adjustment for correlated tests (PACT = 0.10; PACT significance threshold was P < 0.1). SNPs in Wingless/Integrated (Wnt) and Transforming growth factor (TGF) beta-signaling genes (FRZB, SMAD3, SMAD7) from pathways affected by Se intake were also associated with CRC risk after multiple testing adjustments. Interactions with Se status (using existing serum Se and Selenoprotein P data) were tested at the SNP, gene, and pathway levels. Pathway analyses using the modified Adaptive Rank Truncated Product method suggested that genes and gene x Se status interactions in antioxidant, apoptosis, and TGF-beta signaling pathways may be associated with CRC risk. This study suggests that SNPs in the Se pathway alone or in combination with suboptimal Se status may contribute to CRC development.

Background Expedited partner therapy (EPT) is an intervention for patients with gonorrhea or chlamydia, providing index patients with prescriptions or medication to give to their partners. Expedited partner therapy is recommended for heterosexuals but not for men who have sex with men (MSM), partially due to concerns about overtreatment of uninfected partners and missed opportunities for human immunodeficiency virus (HIV) diagnosis. Methods We extended our stochastic network-based mathematical model of HIV, gonorrhea, and chlamydia among MSM to include EPT. The EPT implementation was simulated for 10 years. Counterfactual scenarios varied EPT coverage, provision, uptake, and partnership window duration. We estimated sexually transmitted infection (STI) incidence, proportion of infections averted, and process outcomes under each scenario. Results Delivery of EPT to 20% of eligible MSM index patients (coverage) reduced cumulative STI incidence by 27% (interquartile range, 13%-39%) over 10 years compared with current estimated STI screening levels. A 20% increase in providing medication to non-index partners (provision) averted 32% (interquartile range, 20%-41%) of STI infections compared with estimated STI screening levels. When targeted by partnership type, EPT solely to casual partners maximized the population-level infections averted. The proportion of partners given medication who had no current STI varied from 52% to 63%, depending on coverage level. The proportion of partners given medication with undiagnosed HIV infection was 4% across scenarios. Conclusions Expedited partner therapy could reduce bacterial STI incidence for MSM. However, this intervention could result in missed opportunities for HIV/STI prevention and a substantial increase in use of antimicrobials by STI-uninfected MSM, raising concerns about cost and antimicrobial resistance.

Introduction Men who have sex with men (MSM) and transgender women (TGW) are at increased risk for acquiring HIV, but there are limited HIV incidence data for these key populations in Africa. Understanding HIV prevalence and incidence provides important context for designing HIV prevention strategies, including pre‐exposure prophylaxis (PrEP) programmes. We describe HIV prevalence, awareness of HIV infection, HIV incidence and associated factors for a cohort of MSM and TGW in Cape Town and Port Elizabeth, South Africa. Methods From 2015 to 2016, MSM and TGW in Cape Town and Port Elizabeth were enrolled and prospectively followed for 12 months, receiving a comprehensive package of HIV prevention services. HIV testing was conducted at baseline and at follow‐up visits (targeted for three, six and twelve months). All HIV‐negative PrEP‐eligible participants were offered PrEP enrolment during the first four months of study participation. We determined HIV prevalence among participants at baseline, and incidence by repeat screening of initially HIV‐negative participants with HIV tests at three, six and twelve months. Results Among 292 participants enrolled, HIV prevalence was high (43%; 95% CI: 38 to 49) and awareness of HIV status was low (50%). The 167 HIV‐negative participants who were followed prospectively for 144.7 person‐years; nine incident HIV infections were documented. Overall annual incidence was 6.2% (CI: 2.8 to 11.8) and did not differ by city. Annual HIV incidence was significantly higher for younger (18 to 19 years) MSM and TGW (MSM: 21.8% (CI: 1.2 to 100); TGW: 31.0 (CI: 3.7, 111.2)). About half of participants started PrEP during the study; the annual incidence of HIV among 82 (49%) PrEP starters was 3.6% (CI: 0.4, 13.1) and among those who did not start PrEP was 7.8% (CI: 3.1, 16.1). Conclusions HIV incidence was high among MSM and TGW in the context of receiving a comprehensive package of prevention interventions and offering of PrEP. PrEP uptake was high; the observed incidence of HIV in those who started PrEP was about half the incidence of HIV in those who did not. Future implementation‐oriented studies should focus on decisions to start and continue PrEP for those at highest risk, including young MSM.

Introduction Men who have sex with men (MSM) and transgender women (TGW) experience high incidence and prevalence of sexually transmitted infections (STI), and data are needed to understand risk factors for STIs in these populations. The Sibanye Health Project was conducted in Cape Town and Port Elizabeth, South Africa from 2015 to 2016 to develop and test a package of HIV prevention interventions for MSM and TGW. We describe the incidence, prevalence and symptoms of Chlamydia trachomatis (CT), Neisseria gonorrhea (NG) and syphilis observed during the study. Methods Participants completed HIV testing at baseline. All participants who were HIV negative were followed prospectively. Additionally, a sample of participants identified as living with HIV at baseline was selected to be followed prospectively so that the prospective cohort was approximately 20% HIV positive; the remaining participants identified as HIV positive at baseline were not followed prospectively. Prospective participants were followed for 12 months and returned for clinic‐based STI/HIV testing and assessment of STI symptoms at months 6 and 12. Additional HIV/STI testing visits could be scheduled at participant request. Results Following consent, a total of 292 participants attended a baseline visit (mean age = 26 years), and 201 were enrolled for the 12‐month prospective study. Acceptance of screening for syphilis and urethral NG/CT was near universal, though acceptance of screening for rectal NG/CT was lower (194/292; 66%). Prevalence of urethral CT and NG at baseline was 10% (29/289) and 3% (8/288) respectively; incidence of urethral CT and NG was 12.8/100 person‐years (PY) and 7.1/100 PY respectively. Prevalence of rectal CT and NG at baseline was 25% (47/189) and 16% (30/189) respectively; incidence of rectal CT and NG was 33.4/100 PY and 26.8/100 PY respectively. Prevalence of syphilis at baseline was 17% (45/258) and incidence was 8.2/100 PY. 91%, 95% and 97% of diagnosed rectal NG/CT, urethral NG/CT and syphilis infections, respectively, were clinically asymptomatic. Conclusions Prevalence and incidence of urethral and rectal STIs were high among these South African MSM and TGW, and were similar to rates in other settings in the world. Clinical symptoms from these infections were rare, highlighting limitations of syndromic surveillance and suggesting the need for presumptive testing and/or treatment to address the STI epidemic among MSM/TGW in South Africa.

Stigma regarding HIV pre-exposure prophylaxis (PrEP) is commonly implicated as a factor limiting the scale-up of this highly effective HIV prevention modality. To quantify and characterize PrEP stigma, we developed and validated a brief HIV PrEP Stigma Scale (HPSS) among a group of 279 men who have sex with men (MSM). Scale development was informed by a theoretical model to enhance content validity. We assessed two scale versions, Semantic Differential and Likert, randomizing the order in which scales were presented to participants. Both scales demonstrated high internal consistency. The Likert scale had substantially better construct validity and was selected as the preferred option. Scale scores demonstrated construct validity through association with constructs of interest: healthcare distrust, HIV knowledge, perceived proportion of friends/partners on PrEP, perceived community evaluation of PrEP, and perceived effectiveness of PrEP. The scale accounted for 25% of the total variance in reported willingness to be on PrEP, indicating the substantial role PrEP stigma may have on decisions to initiate PrEP. Given increased efforts to roll-out PrEP, having a valid tool to determine the level and types of PrEP stigma in individuals, groups, and communities can help direct implementation plans, identify goals for stigma reduction, and monitor progress over time.

Purpose: The number of individuals who have started a regimen for HIV pre-exposure prophylaxis (PrEP) in the United States is not well characterized but has been on the rise since 2012. This analysis assesses the distribution of PrEP use nationally and among subgroups. Methods: A validated algorithm quantifying tenofovir disoproxil fumarate/emtricitabine for PrEP in the United States was applied to a national prescription database to determine the quarterly prevalence of PrEP use. HIV diagnoses from 2016 were used as an epidemiological proxy for PrEP need. The PrEP-to-need ratio (PnR) was defined as the number of PrEP users divided by new HIV diagnoses. Results: A total of 70,395 individuals used PrEP in the fourth quarter of 2017: 67,166 males and 3229 females. Nationally, prevalence of PrEP use was 26/100,000 (range across states per 100,000 [RAS/100k]: 4–73) and the PnR was 1.8 (RAS: 0.5–6.6). Prevalence of PrEP use among males and females, respectively, was 50/100,000 and 2/100,000 (RAS/100k: 7–143 and 0.3–7) and PnR was 2.1 and 0.4 (RAS: 0.6–7.1 and 0.1–4.0). Prevalence of PrEP use was lowest among individuals aged less than or equal to 24 and more than or equal to 55 years (15/100,000 and 6/100,000, RAS/100k: 1–45 and 0.4–14), with PnR 0.9 and 1.5 (RAS: 0.2–5.6 and 0.3–7.0). The Northeast had the highest PnR (3.3); the South had the lowest (1.0). States with Medicaid expansion had more than double the PnR than states without expansion. Conclusions: Available data suggest that females, individuals aged less than or equal to 24 years and residents of the South had lower levels of PrEP use relative to epidemic need. These results are ecological, and misclassification may attenuate results. PnR is useful for future assessments of HIV prevention strategy uptake.

Purpose: Pre-exposure prophylaxis (PrEP) with oral emtricitibine/tenofovir disoproxil fumarate (TDF/FTC) reduces the risk of HIV infection by >90% when taken as prescribed. Trends in prevalence of PrEP use, which account for persons who have stopped PrEP, increased through 2016, but have not been described since. Methods: Annual prevalence estimates of unique, TDF/FTC PrEP users (individuals with ≥1 day of a filled PrEP prescription in a given year) in the United States (US) were generated for 2012–2017 from a national prescription database. A validated algorithm was used to distinguish users of TDF/FTC for HIV or chronic Hepatitis B treatment or postexposure prophylaxis from PrEP users. We calculated annual prevalence of PrEP use overall and by age, sex, and region. We used log-transformation to calculate estimated annual percent change (EAPC) in the prevalence of PrEP use. Results: Annual prevalence of PrEP use increased from 3.3/100,000 population in 2012 to 36.7 in 2017 –a 56% annual increase from 2012 to 2017 (EAPC: +56%). Annual prevalence of PrEP use increased faster among men than among women (EAPC: +68% and +5%, respectively). By age group, annual prevalence of PrEP use increased fastest among 25- to 34-year olds (EAPC: +61%) and slowest among ≥55-year olds (EAPC: +52%) and ≤24-year olds (EAPC: +51%). In 2017, PrEP use was lowest in the South (29.8/100,000) and highest in the Northeast (62.3/100,000). Conclusions: Despite overall increases in the annual number of TDF/FTC PrEP users in the US from 2012 to 2017, the growth of PrEP coverage is inconsistent across groups. Efforts to optimize PrEP access are especially needed for women and for those living in the South.