Department of Medicine, University of California San Diego, La Jolla, CA, USA.
National Drug and Alcohol Research Center, University of New South Wales, Sydney, NSW, Australia.
J Int AIDS Soc. 2020 Jun;23 Suppl 1(Suppl 1):e25495. doi: 10.1002/jia2.25495.
Among men who have sex with men (MSM) and transgender women (TW), stimulant use is high and has been associated with an increased risk of HIV infection, suicide and cardiovascular disease (CVD) mortality. We used epidemic modelling to investigate these intersecting health harms among MSM/TW in Lima, Peru and assess whether they could be mitigated by prioritizing HIV pre-exposure prophylaxis (PrEP) and harm reduction interventions among MSM/TW who use stimulants.
We adapted a dynamic model of HIV transmission among MSM/TW in Lima to incorporate stimulant use and increased HIV risk, suicide and CVD mortality. Among 6% to 24% of MSM/TW using stimulants (mostly cocaine), we modelled an increased risk of unprotected anal sex (RR = 1.35 [95%CI: 1.17 to 1.57]) obtained from local data, and increased risk of suicide (SMR = 6.26 [95%CI: 2.84 to 13.80]) and CVD (SMR = 1.83 [95%CI: 0.39 to 8.57]) mortality associated with cocaine use based on a global systematic review. We estimated the proportion of health harms occurring among MSM/TW who use stimulants in the next year (01-2020/01-2021). We also investigated the 10-year impact (01-2020/01-2030) of: (1) PrEP prioritization for stimulant-using MSM/TW compared to random allocation, and (2) integrating PrEP with a theoretical intervention halving stimulant-associated risk.
MSM/TW in Lima will experience high HIV incidence, suicide mortality and CVD mortality (1.6/100 py, and 0.018/100 py, 0.13/100 py respectively) in 2020. Despite stimulant using MSM/TW comprising an estimated 9.5% (95%CI: 7.8 to 11.5) of all MSM/TW, in the next year, 11% 95%CI (i.e. 2.5% to 97.5% percentile) 10% to 13%) of new HIV infections, 39% (95%CI: 18% to 60%) of suicides and 15% (95%CI: 3% to 44%) of CVD deaths could occur among this group. Scaling up PrEP among all stimulant using MSM/TW could prevent 19% (95%CI: 11% to 31%) more HIV infections over 10 years compared to random allocation. Integrating PrEP and an intervention to halve stimulant-associated risks could reduce new HIV infections by 20% (95%CI: 10% to 37%), suicide deaths by 14% (95%CI: 5% to 27%) and CVD deaths by 3% (95%CI: 0% to 16%) over a decade.
MSM/TW who use stimulants experience a disproportionate burden of health harms. Prioritizing PrEP based on stimulant use, in addition to sexual behaviour/gender identity criteria, could increase its impact. Integrated substance use, harm reduction, mental health and HIV care among MSM/TW is needed.
在男男性行为者（MSM）和跨性别女性（TW）中，兴奋剂的使用量很高，并且与 HIV 感染、自杀和心血管疾病（CVD）死亡率增加有关。我们使用流行性病学模型来研究利马秘鲁的 MSM/TW 中这些相互交织的健康危害，并评估通过优先考虑 MSM/TW 中使用兴奋剂者的 HIV 暴露前预防（PrEP）和减少伤害干预措施是否可以减轻这些危害。
我们改编了利马 MSM/TW 中 HIV 传播的动态模型，以纳入兴奋剂的使用和增加的 HIV 风险、自杀和 CVD 死亡率。在使用兴奋剂的 MSM/TW 中（主要是可卡因），我们根据当地数据模拟了无保护肛交的风险增加（RR=1.35[95%CI：1.17 至 1.57]），以及与可卡因使用相关的自杀风险增加（SMR=6.26[95%CI：2.84 至 13.80]）和 CVD 死亡率增加（SMR=1.83[95%CI：0.39 至 8.57]）。我们估计了下一年（2020 年 1 月至 2021 年 1 月）使用兴奋剂的 MSM/TW 中发生健康危害的比例。我们还调查了：（1）与随机分配相比，针对使用兴奋剂的 MSM/TW 优先考虑 PrEP 的 10 年影响（2020 年 1 月至 2030 年 1 月）；（2）将 PrEP 与减少兴奋剂相关风险的理论干预措施相结合的 10 年影响。
2020 年，利马的 MSM/TW 将经历高 HIV 发病率、自杀死亡率和 CVD 死亡率（1.6/100py 和 0.018/100py，0.13/100py 分别）。尽管使用兴奋剂的 MSM/TW 估计占所有 MSM/TW 的 9.5%（95%CI：7.8%至 11.5%），但在明年，11%（95%CI：2.5%至 97.5%），10%（95%CI：18%至 60%）的自杀和 15%（95%CI：3%至 44%）的 CVD 死亡可能发生在这一群体中。与随机分配相比，在所有使用兴奋剂的 MSM/TW 中扩大 PrEP 的使用可以在 10 年内预防 19%（95%CI：11%至 31%）的 HIV 感染。将 PrEP 与减少兴奋剂相关风险的干预措施相结合，可以减少 20%（95%CI：10%至 37%）的新 HIV 感染、14%（95%CI：5%至 27%）的自杀死亡和 3%（95%CI：0%至 16%）的 CVD 死亡。
使用兴奋剂的 MSM/TW 经历了不成比例的健康危害负担。根据兴奋剂的使用情况，除了性行为/性别认同标准外，优先考虑 PrEP 可以提高其效果。需要为 MSM/TW 提供综合的物质使用、减少伤害、心理健康和 HIV 护理。
