Am J Epidemiol. 2024 Jan 8;193(1):6-16. doi: 10.1093/aje/kwad097.
Antiretroviral preexposure prophylaxis (PrEP) is highly effective in preventing human immunodeficiency virus (HIV) infection, but uptake has been limited and inequitable. Although interventions to increase PrEP uptake are being evaluated in clinical trials among men who have sex with men (MSM), those trials cannot evaluate effects on HIV incidence. Estimates from observational studies of the causal effects of PrEP-uptake interventions on HIV incidence can inform decisions about intervention scale-up. We used longitudinal electronic health record data from HIV-negative MSM accessing care at Fenway Health, a community health center in Boston, Massachusetts, from January 2012 through February 2018, with 2 years of follow-up. We considered stochastic interventions that increased the chance of initiating PrEP in several high-priority subgroups. We estimated the effects of these interventions on population-level HIV incidence using a novel inverse-probability weighted estimator of the generalized g-formula, adjusting for baseline and time-varying confounders. Our results suggest that even modest increases in PrEP initiation in high-priority subgroups of MSM could meaningfully reduce HIV incidence in the overall population of MSM. Interventions tailored to Black and Latino MSM should be prioritized to maximize equity and impact.
抗逆转录病毒药物事前预防(PrEP)在预防人类免疫缺陷病毒(HIV)感染方面非常有效,但采用率有限且存在不公平现象。虽然在男男性行为者(MSM)中开展的临床试验正在评估增加 PrEP 采用率的干预措施,但这些试验无法评估其对 HIV 发病率的影响。来自观察性研究对 PrEP 采用干预措施对 HIV 发病率的因果影响的估计,可以为干预措施扩大规模提供决策依据。我们使用了马萨诸塞州波士顿芬威健康社区医疗中心从 2012 年 1 月到 2018 年 2 月间,HIV 阴性的 MSM 的纵向电子健康记录数据,随访时间为 2 年。我们考虑了几种高优先级亚组中增加 PrEP 起始机会的随机干预措施。我们使用广义 g 公式的反概率加权新估计量,调整了基线和随时间变化的混杂因素,估计了这些干预措施对 MSM 人群 HIV 发病率的影响。我们的研究结果表明,即使在 MSM 的高优先级亚组中适度增加 PrEP 的起始率,也可能会显著降低 MSM 总人口的 HIV 发病率。应该优先考虑针对黑人和拉丁裔 MSM 的量身定制的干预措施,以实现公平和效果最大化。
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