The PrEP You Want: A Web-Based Survey of Online Cross-Border Shopping for HIV Prophylaxis Medications.

BACKGROUND: In response to the high cost of HIV pre-exposure prophylaxis (PrEP) medications in Canada, community organizations have created internet-based guides detailing how to legally order generic medications online and travel to collect them in the United States. However, little is known about the patients following these guides. OBJECTIVE: Our primary objective was to measure the proportion of Ontario gay, bisexual, and other men who have sex with men (GBMSM) accessing these online guides who intended to use the border-crossing approach. Our secondary objectives were to explore their demographic characteristics, their completion of the steps in the border-crossing approach, and the barriers they perceived. METHODS: Between July 20, 2017, and May 18, 2018, we administered two online surveys of GBMSM accessing an online border-crossing guide posted by a gay men's health organization in Ontario. Participants completed an open baseline survey posted on the border-crossing guide's Web page and a follow-up survey 3 months later. The data were analyzed using descriptive statistics. We used multivariable logistic regression to identify characteristics associated with the intention to use the border-crossing approach. RESULTS: Most of the 141 participants were young (median age 23, interquartile range 22-25 years) and black (79.4%; 112/141) GBMSM who had completed a college or an undergraduate degree (62.4%; 88/141). In addition, 19.9% (28/141) of them reported a total family income less than Can $30,000 and another 53.9% (76/141) reported income between Can $30,000 and Can $60,000. 54.6% (76/141) paid for medications entirely out of pocket. Most participants indicated that they were likely to complete a border-crossing approach: 80.1% (113/141) at baseline and 79.1% (87/110) at follow-up. The characteristics associated with the intention to use the approach included being black (adjusted odds ratio [aOR] 5.73, 95% CI 2.06-16.61), paying for medications out of pocket (aOR 5.18, 95% CI 1.82-17.04), and having a provider who was thought to be willing to prescribe PrEP (aOR 4.42, 95% CI 1.63-12.41). Comparing baseline and follow-up for the 110 participants who completed both surveys, 65.4% (72/110) and 80.0% (88/110) had discussed PrEP with a health care provider, 18.1% (20/110) and 25.4% (28/110) had obtained a PrEP prescription, and 8.2% (9/110) and 5.5% (6/110) had ordered medications to that mailbox, whereas only 1.0% (1/110) and 0.0% (0/110) had crossed the border to collect them at baseline and follow-up, respectively. Reported barriers included perceived concerns about the approach's legality (56.0%; 79/141), the security of personal health information (39.0%; 55/141), and the safety of online vendors (38.3%; 54/141). CONCLUSIONS: Despite high interest in pursuing an online border-crossing approach to get PrEP medications, such an approach may not be a viable option for PrEP scale-up among interested GBMSM because of logistical challenges and perceptions of safety and legitimacy.

Herpes simplex virus type 2 and HIV disease progression: a systematic review of observational studies.

BACKGROUND: Herpes simplex virus type 2 (HSV-2) is a common co-infection among HIV-infected adults that is hypothesized to accelerate HIV disease progression. METHODS: We searched Medline, EMBASE, relevant conference proceedings (2006-12) and bibliographies of identified studies without language restriction for cohort studies examining the impact of HSV-2 on highly active antiretroviral therapy-untreated HIV disease in adults. The exposure of interest was HSV-2 seropositivity or clinical/laboratory markers of HSV-2 activity. The primary outcome was HIV disease progression, defined as antiretroviral initiation, development of AIDS/opportunistic infection, or progression to CD4 count thresholds (≤ 200 or ≤ 350 cells/mm(3)). Secondary outcomes included HIV plasma viral load and CD4 count. RESULTS: Seven studies were included. No definitive relationship was observed between HSV-2 seropositivity and time to antiretroviral initiation (n=2 studies), CD4 ≤ 350 (n=1), CD4 ≤ 200 (n=1), death (n=1), viral load (n=6) or CD4 count (n=3). Although two studies each observed trends towards accelerated progression to clinical AIDS/opportunistic infection in HSV-2 seropositives, with pooled unadjusted hazard ratio=1.85 (95% CI=1.12,3.06; I2=2%), most OIs observed in the study for which data were available can occur at high CD4 counts and may not represent HIV progression. In contrast, a single study HSV-2 disease activity found that the presence of genital HSV-2 DNA was associated with a 0.4 log copies/mL increase in HIV viral load. CONCLUSIONS: Despite an observation that HSV-2 activity is associated with increased HIV viral load, definitive evidence linking HSV-2 seropositivity to accelerated HIV disease progression is lacking. The attenuating effects of acyclovir on HIV disease progression observed in recent trials may result both from direct anti-HIV activity as well as from indirect benefits of HSV-2 suppression.