Sharing doxy-PEP at sex parties
Wouldn’t it be nice to get free STI prevention pills at a sex party? It depends. While using doxycycline for the prevention of STIs has shown success (see doxy-PEP guidelines from the CDC), it doesn’t mean that prescription medications can be used willy-nilly. Community education is needed and maybe changes to the healthcare system.
So warns a letter to The Lancet medical journal, in its December 2024 infectious disease issue (published online November 8). Authors Matthew J. Mimiaga and Nina T. Harawa talked with community members who distributed or received free doxy-PEP pills at sex parties.
“Although the desire to share medications such as DoxyPEP at sex parties might stem from a place of care for the community, it raises potentially important health risks that cannot be overlooked,” they write.
Although generally safe, doxycycline has drug-drug interactions that many individuals may not be aware of. For example, the authors note that doxy cannot be taken with:
- isotretinoin (commonly used to treat acne)
- systemic vitamin A derivatives, such as retinoids, which if taken together may cause intracranial hypertension and may even lead to permanent vision loss, and
- acitretin, a different type of retinoid
Some commonly used over-the-counter medications and supplements can also interact with doxycycline. These include:
- antacids
- iron supplements, and
- bismuth (for example, Pepto-Bismol)
As they tell the stories of people who come to the UCLA Center for LGBTQ+ Advocacy, Research & Health, they discuss the issue of gay men who are closeted from their primary care providers.
“Many individuals feel compelled to turn to alternatives outside the formal health-care system due to fears of judgement or inadequate access to culturally competent care. This concern highlights a need for HCPs [health care providers] and primary care settings to create safer, more inclusive environments where sexual and gender minorities can feel comfortable seeking guidance on sexual health and be informed about medications that can prevent HIV and other STIs,” write Mimiaga and Harawa. They are both with the Department of Epidemiology, UCLA Fielding School of Public Health at the University of California Los Angeles (UCLA).
TO READ the letter, which includes footnotes, GO TO bit.ly/41xEf0N.
New podcast for Black women and girls
The Empower program (SEE November+December 2024 Briefly) has launched the Girlfriends Podcast, a new series “dedicated to addressing the unique health challenges faced by Black women and girls, particularly in the context of HIV prevention.”
Topics include sexual health, mental well-being, access to healthcare, and “strategies for HIV prevention tailored to the needs of Black women and girls. Through insightful discussions, expert interviews, and personal stories, this podcast aims to empower Black women and girls to take control of their health, make informed decisions, and advocate for their well-being. Together, we can break down barriers, reduce stigma, and promote a healthier future for Black women everywhere.”
Topics of the first episodes include intergenerational trauma and health disparities, shattering stigma and cultivating cultural understanding for mental wellness, and boundaries and healing to nurture healthy relationships.
Meanwhile, new episodes from the Wellness Chronicles reported on in November+December include Safe & Sound: Your Guide to Healthy Intimacy.
GO TO healthhiv.org.
U.S. HIV guidelines updated
List of meds to start simplified, plus other changes
Some of the older HIV meds have finally hit the dust and are no longer options for first-line treatment, according to updated U.S. HIV guidelines. The drugs dropped were, for the most part, recommended only for certain situations that may exist for some people who are taking HIV medications for the first time.
The expert panel that puts together the guidelines explains that, “The regimens recommended by the Panel as initial ART [antiretroviral therapy] for people with HIV include those that have demonstrated clinical efficacy [good effect on health], have a high barrier to resistance [are not easily evaded by the virus], are well tolerated, and can be given as once-daily therapy.”
Dolutegravir, one of the newer drugs, remains on the list of what to start for most people with HIV under the brand names Dovato (a two-drug single-tablet regimen) and Tivicay (by itself, taken with Descovy or Truvada). The longtime single-tablet regimen (STR) Triumeq, however, was moved down to the start-in-certain-clinical-scenarios list “due to the need for HLA-B*5701 testing before initiating therapy, the potential increase in the risk of cardiovascular events, and the availability of other options for initial therapy.” The testing and potential cardio effects are not due to dolutegravir, but to one of the other medications contained in Triumeq, abacavir.
Oral rilpivirine remains play in certain scenarios under the brand name Edurant and as part of the single-tablet regimen Odefsey, but the STR Complera has been booted off the list. Complera contains the older medication tenofovir DF, while Odefsey contains the newer tenofovir alafenamide. Rilpivirine in the form of a long-acting injectable is available under the brand name Cabenuva (given with the long-acting injectable cabotegravir). Cabenuva does not yet have an approval from the U.S. Food and Drug Administration (FDA) for use as first-time HIV therapy. That approval is expected sometime this year.
Other drugs that are adios for the what-to-start category in certain clinical situations are:
- Sustiva (a single medication) and the STRs Atripla, Symfi, and Symfi Lo (all four contain efavirenz)
- The STRs Genvoya and Stribild (containing elvitegravir as the backbone medication)
- Isentress and Isentress HD (each containing a single medication, raltegravir)
- Evotaz and boosted Reyataz (each containing atazanavir)
Other updates
- New section on transplants in HIV
- New information in the sections on:
- Virologic Failure
- Optimizing Antiretroviral Therapy in the Setting of Viral Suppression
- HIV and the Older Person
- Substance Use Disorders and HIV
- Transgender People With HIV
- Hepatitis B Virus/HIV Coinfection
- Tuberculosis/HIV Coinfection
- Adherence to the Continuum of Care
- Drug-Drug Interactions
SEE footnotes and ratings from the table below in Guidelines for the Use of Antiretroviral Agents in Adults and Adolescents With HIV, updated September 12, 2024; GO TO clinicalinfo.hiv.gov.
Recommended starting regimens for most people with HIV without a history of using Apretude (CAB-LA) for PrEP:
(Previously recommended but now deleted drugs are struckthrough):
- Biktarvy (A1)
- Tivicay + Descovy or Truvada* (A1)
- Dovato* (A1)
Triumeq(downgraded to “certain clinical situations”)
Recommended starting regimen for people with a history of using Apretude (CAB-LA) for PrEP (no changes in this category):
- Symtuza (A3)
- Prezcobix + Descovy or Truvada* (A3)
- Boosted Prezista + Descovy or Truvada* (A3)
Recommended starting regimens in certain clinical situations
(Previously recommended but now deleted drugs are struckthrough):
- Triumeq (A1)
- Symtuza (B1)
- Prezcobix* + Descovy or Truvada* (A1) or Epzicom (B2)
- Delstrigo (B1)
- Pifeltro + Descovy (B3)
- Odefsey (B2)
CompleraStribildGenvoyaIsentress + Descovy or TruvadaIsentress HD + Descovy or TruvadaEvotaz + Descovy or TruvadaBoosted Reyataz + Descovy or TruvadaAtriplaSymfiSymfi LoSustiva + Descovy
U.S. HIV OI guidelines updated
Most recent updates to the U.S. HIV guidelines on opportunistic infections (OIs) in adults and adolescents living with HIV were released in November. These referred to vaccinations and included updated recommendations for COVID-19, flu, hepatitis B, and respiratory syncytial virus (RSV) vaccines.
Other updates from 2024 included information on:
- anal cancer screening and treatment (in the human papillomavirus, or HPV, section)
- coccidioidomycosis (including pregnancy, lung infections, and meningitis)
- cryptococcosis (including pregnancy)
- histoplasmosis (including severe disease and blood level monitoring)
- bacterial enteric infections (including drug resistance as well as pregnancy)
- candidiasis (yeast infection or thrush; updates include the newer medications ibrexafungerp and oteseconazole)
- pneumocystis pneumonia (PCP, including pregnancy and simplification of prevention, which is used in advanced HIV disease)
- toxoplasmosis (including pregnancy)
- Mycobacterium avium complex (MAC)
- leishmaniasis
SEE What’s New in the Guidelines at bit.ly/49wg1Gt. GO TO clinicalinfo.hiv.gov.
U.S. HIV OI guidelines for children updated
U.S. HIV guidelines for preventing and treating opportunistic infections (OIs) in children living with HIV, and children who were exposed to the virus (usually in utero) but did not acquire it, were updated in November. HIV.gov presented the following summary of the changes.
Bacterial infections
- Added vaccine recommendations for the use of pneumococcal vaccines PCV15, PCV20 and PPSV23 in children with HIV.
- Updated the literature [research findings] for bacterial infections, including epidemiology, infection risk and vaccine recommendations.
- Updated recommendations for the diagnostics and management of bacterial infections with considerations made for newer technology (including molecular testing), antimicrobial stewardship, and changes in relevant treatment guidelines.
Hepatitis C virus infection
- Recommended hepatitis C virus (HCV) RNA testing for infants between 2 to 6 months with perinatal [around the time of birth] HCV exposure.
- Added information and recommendations supporting the use of pangenotypic direct-acting antivirals (DAAs) [for treating HCV] in children aged 3 years and older.
- Noted treatment for HCV during pregnancy can be considered with shared decision-making [discussion between parents and medical providers]. [SEE the Hepatitis Drug Guide for more on treatment in pregnancy, JUL+AUG 2024.]
Last summer, on July 3, the pediatric OI guidelines also updated information regarding COVID-19:
- Published a new section describing the approach to the prevention and management of COVID-19 in children with and exposed to HIV.
- Added recommendations for the use of pre-exposure prophylaxis [OI PrEP] to fight off infections, including COVID-19 vaccination in all children and the monoclonal antibody pemivibart in certain populations.
- Added recommendations for the treatment of COVID-19 with ritonavir-boosted nirmatrelvir, remdesivir, and/or corticosteroids, depending on the age of the child, clinical presentation, and risk factors for progression.
TO read the Guidelines for the Prevention and Treatment of Opportunistic Infections in Children with and Exposed to HIV, GO TO clinicalinfo.hiv.gov.
Misinformation online fueled by outrage
Misinformation—that is, information that is wrong or an out-and-out lie—is more likely to be shared online when it makes people feel outraged. That’s according to a study published in the November 28, 2024 issue of Science.
“Misinformation remains a major threat to U.S. democratic integrity, national security, and public health. However, social media platforms struggle to curtail the spread of the harmful but engaging content. Across platforms, McLoughlin et al. examined the role of emotions, specifically moral outrage (a mixture of disgust and anger), in the diffusion of misinformation,” explains Ekeoma Uzogara in an editor’s summary of the study and its findings. “Compared with trustworthy news sources, posts from misinformation sources evoked more angry reactions and outrage than happy or sad sentiments. Users were motivated to reshare content that evoked outrage and shared it without reading it first to discern accuracy. Interventions that solely emphasize sharing accurately may fail to curb misinformation because users may share outrageous, inaccurate content to signal their moral positions or loyalty to political groups.”
GO TO science.org/doi/10.1126/science.adl2829.
Conservative media’s effect on vaccination
“COVID-19 underscored that public health crises are social-behavioral problems as much as biomedical problems. Rapid vaccine development and delivery provided an opportunity to minimize the pandemic’s damage. But vaccine hesitancy hindered vaccine uptake in the United States and elsewhere. Vaccine hesitancy cost hundreds of thousands of lives during the COVID-19 pandemic, not to mention vast social and economic costs,” reported an international study led by Marrissa D. Grant of the University of Colorado at Boulder.
The study found that following conservative media was associated with greater rejection of vaccination.
According to the study abstract (summary), “Findings show that, regardless of personal ideology, individuals who consumed less conservative media and had a more ideologically diverse media diet were more likely to be fully vaccinated and boosted. Additionally, consuming more conservative media was negatively associated with trust in science, but this relationship was weaker among those with a more ideologically diverse media diet.”
The authors noted that, “Vaccine hesitancy was identified as a top ten global threat in 2021 and remains a significant public health challenge.”
The study was published in the November 22, 2024 issue of Nature. It is available via open access (for free); GO TO nature.com/articles/s41598-024-77408-4.
Improving the taste of children’s HIV medicine
A spoonful of sugar may help the medicine go down, as the song says, but some researchers are finding a different way to deal with it.
In particular, researchers from the University of Strathclyde in Scotland and the University of Western Cape in South Africa teamed up to take aim at children’s HIV medicine.
“The standard conventional method [for improving the taste of medicine] involves adding sweeteners and flavoring agents for pediatric medicines, but this is often ineffective at masking strong bitterness and an unpleasant aftertaste can persist due to the short duration of the sweetener taste,” the University of Strathclyde reported in a press release. “Instead, by using co-crystallization—where two or more different molecules are combined to create a new crystalline structure—the unpleasant taste can be reduced.”
According to the release, around 100,000 infants and children under the age of 14 were living with HIV in sub-Saharan Africa as of 2023, per UNAIDS.
The research team began testing the use of co-crystallization with nevirapine (NVP), an HIV medication rarely used in the U.S. but commonly used in other parts of the globe.
“After creating five different co-crystal materials of NVP, they used an electrical tasting system to assess the results. The findings showed that co-crystallization could significantly reduce the bitterness of the drug, making it much easier to take,” the University of Strathclyde reported.
The research was published in the Royal Society of Chemistry Pharmaceutics Journal. GO TO bit.ly/3OSFBMd.
TO READ the December 5, 2024 press statement, GO TO bit.ly/41VVk4J.
World AIDS Day 2024
“World AIDS Day serves as an important reminder that we must remain steadfast in our commitment to prevent new HIV infections and provide essential services to all people living with HIV globally,” reported the U.S.-based HIV.gov.
“Collective Action: Sustain and Accelerate HIV Progress” was the theme for World AIDS Day 2024, commemorated on December 1.
“Together with our partners, the National Institutes of Health (NIH) commemorates World AIDS Day and affirms our commitment to bolstering the extraordinary gains achieved in HIV science and to persevering until we end HIV-related illness and stigma,” wrote Jeanne Marrazzo, MD, MPH, director of the National Institute of Allergy and Infectious Diseases (NIAID), and Geri Donenberg, PhD, associate director for AIDS Research and director of the Office of AIDS Research (OAR) at NIH.
Considering the partnership theme of the day, they thanked U.S. partners around the globe “who model and demand the scientific excellence required to propel groundbreaking HIV science. Above all, we thank the clinical trial participants who allow their individual health experiences to become evidence that improved the lives of others.”
The comprehensive NIH statement covers disturbing trends in HIV acquisition around the world and some of the latest scientific findings around HIV, including behavioral studies, prevention, drug development, a vaccine, and a cure.
“Looking to the future, we can envision ending HIV as a health threat. There is more evidence than ever before that a vaccine and cure are possible,” Marrazzo and Donenberg note in their conclusion. “Yet, it is essential that HIV research dovetail with expanded access and acceptability for people who historically have benefited less from HIV research advances and remain overrepresented in the pandemic. Furthermore, we must address HIV-related coinfections and conditions that disproportionately affect people with HIV, especially as they age, including tuberculosis, sexually transmitted infections, viral hepatitis, and mpox.”
GO TO http://bit.ly/49R7UVb.
Using PrEP to help end HIV around the world
“In Zimbabwe, the fact that PrEP was initially promoted for men who have sex with men and commercial sex workers created a sense of stigma around its use, leaving some people at risk of HIV reluctant to take PrEP, out of fear of being associated with groups that are criminalized or experience social and political discrimination,” writes Katherine E. Bliss in a policy brief for the prominent think tank Center for Strategic and International Studies (CSIS), based in Washington, D.C. “Interviews with potential PrEP users in Kisumu County in Kenya revealed that some adolescent girls at risk of HIV were hesitant to take the products out of concern that their parents would instead believe they were taking antiretrovirals to treat the virus.”
Stigma is one challenge discussed in Closing the Prevention Gap: Expanding Access to Pre-Exposure Prophylaxis (PrEP) Options to Sustain the Global HIV Response.
“How and where PrEP is dispensed impacts initiation and retention as well. The fact that PrEP services are primarily available through HIV clinics in many contexts reinforces potential users’ concerns over being erroneously perceived as living with HIV,” continues Bliss, who is a senior fellow and director of immunizations and health system resilience with the Global Health Policy Center of CSIS. “At the same time, health worker concerns that prescribing PrEP will lead to high-risk sexual behavior and a rise of sexually transmitted infections have led them to limit recommending PrEP for some clients. As an alternative, disseminating PrEP through youth-friendly spaces, including DREAMS programs [a partnership to reduce HIV rates in adolescent girls and young women], as well as pharmacies, primary health care settings, or even family planning programs may create space for adolescent girls and young women, in particular, to feel comfortable seeking guidance regarding PrEP and access to the products.”
Ending the epidemic by 2030—the goal of UNAIDS and health organizations around the globe —needs (in part) to increase access to biomedical prevention methods like HIV PrEP, according to the report.
“The recent development of highly effective, long-acting PrEP methods makes this a pivotal moment for global HIV prevention efforts. … Success will depend on ensuring a comprehensive set of PrEP options are produced, financed, and delivered in a way that makes them available, affordable, and acceptable to populations most vulnerable to HIV,” Bliss writes.
TO HEAR a 5-minute recording on the report by Bliss and to read the brief itself, GO TO csis.org/analysis/closing-prevention-gap.
Access to HIV and hep C medications
Nailing down information on how to access or pay for medical care can be difficult. The National ADAP Working Group (NAWG) helps people follow the financial resources near them, including veterans programs, Medicaid, and the Patient Assistance Programs (PAPs) available through pharmaceutical companies. “ADAP” stands for AIDS Drug Assistance Program, of which there is one in every state and in U.S. territories.
NAWG’s HIV/HCV Co-Infection Watch – October 2024 updates and maps out coverage of viral hepatitis medications. The states on the U.S. map are highlighted in different colors depending on the coverage of their government. The Watch also provides a round-up of other access news, such as insurance coverage for long-acting HIV prevention medications under the Affordable Care Act.
Other updates from NAWG include a two-and-a-half minute video on prescription drug affordability boards (PDABs) and their threat to HIV service delivery, titled PDABs Price Control Wolves in Sheep’s Clothing, and online reports that include studies on transgender violence and the impact of anti-LGBTQ+ legislation on HIV prevention; the intergenerational impact of aging with HIV; and how HIV prevention pills are free, but insurers are still charging the people who take them. Sign up for updates online.
GO TO tiicann.org.
NAWG is a program of the Community Access National Network (CANN), which was formerly the Ryan White CARE Act Title II Community AIDS National Network.
