Bloomberg School of Public Health, Johns Hopkins University, Baltimore, Maryland, USA.
School of Medicine, Johns Hopkins University, Baltimore, Maryland, USA.
BMJ Open. 2019 Mar 4;9(3):e023453. doi: 10.1136/bmjopen-2018-023453.
OBJECTIVES: (NG) and (CT) increase the risk of HIV transmission among men who have sex with men (MSM). Diagnosis of NG/CT may provide an efficient entry point for prevention of HIV through the delivery of pre-exposure prophylaxis (PrEP); however, the additional population-level impact of targeting PrEP to MSM diagnosed with NG/CT is unknown. DESIGN: An agent-based simulation model of NG/CT and HIV cocirculation among MSM calibrated against census data, disease surveillance reports and the US National HIV Behavioral Surveillance study. SETTING: Baltimore City, Maryland, USA. INTERVENTIONS: PrEP implementation was modelled under three alternative scenarios: (1) PrEP delivery at NG/CT diagnosis (targeted delivery), (2) PrEP evaluation at NG/CT screening/testing and (3) PrEP evaluation in the general community (untargeted). MAIN OUTCOME: The projected incidence of HIV after 20 years of PrEP delivery under two alternatives: when equal numbers of MSM are (1) screened for PrEP or (2) receive PrEP in each year. RESULTS: Assuming 60% uptake and 60% adherence, targeting PrEP to MSM diagnosed with NG/CT could reduce HIV incidence among MSM in Baltimore City by 12.4% (95% uncertainty range (UR) 10.3% to 14.4%) in 20 years, relative to no PrEP. Expanding the coverage of NG/CT screening (such that individuals experience a 50% annual probability of NG/CT screening and evaluation for PrEP on NG/CT diagnosis) can further increase the impact of targeted PrEP to generate a 22.0% (95% UR 20.1% to 23.9%) reduction in HIV incidence within 20 years. When compared with alternative implementation scenarios, PrEP evaluation at NG/CT diagnosis increased impact of PrEP on HIV incidence by 1.5(95% UR 1.1 to 1.9) times relative to a scenario in which PrEP evaluation happened at the time of NG/CT screening/testing and by 1.6 (95% UR 1.2 to 2.2) times relative to evaluating random MSM from the community. CONCLUSIONS: Targeting MSM infected with NG/CT increases the efficiency and effectiveness of PrEP delivery. If high levels of sexually transmitted infection screening can be achieved at the community level, NG/CT diagnosis may be a highly effective entry point for PrEP initialisation.
目标：（NG）和（CT）增加了男男性行为者（MSM）中 HIV 传播的风险。NG/CT 的诊断可能为通过提供暴露前预防（PrEP）来预防 HIV 提供了一个有效的切入点；然而，针对诊断出 NG/CT 的 MSM 提供 PrEP 的额外人群层面的影响尚不清楚。
设计：基于人口普查数据、疾病监测报告和美国国家 HIV 行为监测研究，对 MSM 中 NG/CT 和 HIV 共同传播的基于代理的模拟模型进行了校准。
设置：美国马里兰州巴尔的摩市。
干预措施：根据三种替代方案，对 PrEP 的实施进行建模：（1）NG/CT 诊断时提供 PrEP（靶向性提供），（2）NG/CT 筛查/检测时评估 PrEP，（3）社区内评估 PrEP（非靶向性）。
主要结果：在两种替代方案下，在 20 年的 PrEP 提供后，预计 HIV 的发病率：（1）每年为相同数量的 MSM 筛查 PrEP，或（2）每年为他们提供 PrEP。
结果：假设 60%的使用率和 60%的依从率，将 PrEP 针对诊断出 NG/CT 的 MSM，可以将巴尔的摩市 MSM 中的 HIV 发病率在 20 年内降低 12.4%（95%不确定性范围（UR）为 10.3%至 14.4%），而不使用 PrEP。扩大 NG/CT 筛查的覆盖范围（使个体每年有 50%的机会接受 NG/CT 筛查，并在 NG/CT 诊断时评估 PrEP）可以进一步提高靶向 PrEP 的效果，从而在 20 年内将 HIV 发病率降低 22.0%（95%UR 为 20.1%至 23.9%）。与替代实施方案相比，在 NG/CT 诊断时评估 PrEP 将 PrEP 对 HIV 发病率的影响提高了 1.5 倍（95%UR 为 1.1 至 1.9），而在 NG/CT 筛查/检测时评估 PrEP 的情况下提高了 1.6 倍（95%UR 为 1.2 至 2.2），而在评估社区中随机 MSM 的情况下提高了 1.6 倍（95%UR 为 1.2 至 2.2）。
结论：针对感染 NG/CT 的 MSM 提高了 PrEP 提供的效率和效果。如果能够在社区层面实现高水平的性传播感染筛查，那么 NG/CT 诊断可能是启动 PrEP 的一个非常有效的切入点。
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