Analysis of HIV pre-exposure prophylaxis (PrEP) needs and PrEP use in Germany among men who have sex with men

Aims: We aim to estimate the number of HIV pre-exposure prophylaxis (PrEP) users among men having sex with men (MSM) in Germany from 2017 through 2020, and analyse if PrEP needs expressed in 2017 might have been met by the expansion of PrEP until 2020. Subject and methods: We estimated the number of PrEP users by using drug prescription data and information on on-demand/intermittent PrEP use from online surveys to determine the proportion of on-demand/intermittent and daily PrEP use as well as the average number of PrEP pills used. The number of MSM in need of PrEP in 2017 was estimated based on four groups defined among respondents to a large online survey, combining respondents with PrEP use intention and respondents indicating substantial sexual risks. The size of each group was estimated based on self-selection biases. MSM with PrEP need in 2017 were compared with the estimated number of persons taking PrEP by June 2020. Results: We estimated a total of 15,600 to 21,600 PrEP users in Germany by the end of June 2020, corresponding to 40–55% of men with PrEP use intention in 2017. A correlation between the regional distribution of PrEP use intention in 11/2017 and actual PrEP use by 06/2020 suggested an unequal regional distribution of unsatisfied needs. The number of men with unmet PrEP needs ranged between 27,500 and 93,000 in 06/2020. Conclusion: PrEP use in Germany has increased considerably between 10/2017 and 06/2020, but large regional inequalities persist. PrEP is not yet readily accessible, and there is a need to expand services and encourage uptake.Peer Reviewe

Transmitted drug resistance and subtype patterns of viruses from reported new HIV diagnoses in Germany, 2017–2020

Background The transmission of resistant HIV variants jeopardizes the effective use of antiretrovirals for therapy and prophylaxis. Molecular surveillance of new HIV diagnoses with a focus on prevalence and type of resistance associated mutations and the subtype of circulating viruses is mandatory. Method From 2017 to 2020, 11,527 new HIV diagnoses were reported in Germany to the Robert Koch Institute (RKI). Protease (PR) and reverse-transcriptase (RT) sequences were obtained from 4559 (39.6%) cases, and PR, RT and integrase (IN) sequences were obtained from 3097 (26.9%) cases. The sequences were analyzed with data from the national HIV reports. Results Among all cases in the analysis, the proportion of primary resistance was 4.3% for nucleoside reverse- transcriptase inhibitors (NRTIs), 9.2% for non-NRTI (NNRTIs), 3.3% for protease inhibitors (PIs) and 1.4% for integrase inhibitors (INIs). Dual-class resistance was highest for NRTIs/NNRTIs with 1.2%. There was no trend in the proportion of viruses resistant to drug classes. Most individual key mutations associated with relevant resistance had a prevalence below 1% including K65R (0.1%) and M184V (0.6%). A notable exception was K103NS, with a prevalence of 2.9% and a significant increase (pTrend=0.024) during 2017–2020. In this period, diagnoses of infections with HIV-1 subtype B were the most common at 58.7%, but its prevalence was declining (pTrend=0.049) while the frequency of minority subtypes (each < 1%) increased (pTrend=0.007). Subtype B was highest (75.6%) in men who have sex with men (MSM) and lowest in reported heterosexual transmissions (HETs, 22.6%). Conclusion The percentage of primary resistance was high but at a stable level. A genotypic determination of resistance is therefore still required before the start of therapy. The subtype diversity of circulating HIV-1 is increasing.Peer Reviewe

Barriers to using HIV pre-exposure prophylaxis (PrEP) and sexual behaviour after stopping PrEP: a cross-sectional study in Germany

Background Persistence of individuals at risk of HIV with Pre-Exposure Prophylaxis (PrEP) is critical for its impact on the HIV epidemic. We analysed factors associated with stopping PrEP, barriers that may deter people from continuing PrEP and investigated sexual behaviour after stopping PrEP. Methods Current and former PrEP users in Germany were recruited to complete an anonymous online survey on PrEP use and sexual behaviour. Participants were recruited through dating apps, a PrEP community website, anonymous testing sites and peers. The results were analysed using descriptive methods and logistic regression. Results We recruited 4848 current and 609 former PrEP users in two study waves (July–October 2018, April–June 2019). Former PrEP users were more likely 18–29 years old than current users (adjusted OR = 1.6, 95% confidence interval (CI) 1.1–2.3). Moreover, they were more often unhappy with their sex life, which was more pronounced in former daily PrEP users (aOR = 4.5, 95% CI 2.9–7.1) compared to former on-demand users (aOR = 1.8, 95% CI 1.1–2.9, pinteraction = 0.005). The most common reason for stopping PrEP was a reduced need for PrEP (49.1%). However, 31.4% of former users identified logistic reasons and 17.5% stopped due to side effects. Former PrEP users using PrEP < 3 months were more likely to stop PrEP due to concerns over long-term side effects (32.0% vs. 22.5%, p = 0.015) and not wanting to take a chemical substance (33.2% vs. 24.0%, p = 0.020) compared to former PrEP users who used PrEP for longer. After stopping PrEP, 18.7% of former PrEP users indicated inconsistent condom use while having ≥4 sex partners within the previous 6 months. Former PrEP users with many partners and inconsistent condom use more often indicated logistic reasons for stopping (46.5% vs. 27.9%, p < 0.001) than did other former PrEP users. Conclusions To maximise persistence with PrEP we need to develop strategies for younger PrEP users, reduce logistic barriers to access PrEP, and to develop effective communication on side-effect management. Moreover, prevention strategies for people stopping PrEP are required, since some remain at high risk for HIV.Peer Reviewe

HIV, STI and renal function testing frequency and STI history among current users of self-funded HIV pre-exposure prophylaxis, a cross-sectional study, Germany, 2018 and 2019

Introduction: Users of pre-exposure prophylaxis (PrEP) require periodic testing for HIV, sexually transmitted infections (STI) and renal function. Before PrEP was made free of charge through statutory health insurance in late 2019, PrEP users in Germany had to pay for testing themselves. Aim: We investigated self-reported HIV, STI and renal function testing frequencies among self-funded PrEP users in Germany, factors associated with infrequent testing, and STI diagnoses. Methods: A cross-sectional anonymous online survey in 2018 and 2019 recruited current PrEP users via dating apps for men who have sex with men (MSM), a PrEP community website, anonymous testing sites and friends. We used descriptive methods and logistic regression for analysis. Results: We recruited 4,848 current PrEP users. Median age was 37 years (interquartile range (IQR): 30–45), 88.7% identified as male, and respectively 26.3%, 20.9% and 29.2% were tested less frequently for HIV, STI and renal function than recommended. Participants with lower STI testing frequency were significantly less likely to report STI diagnoses during PrEP use, especially among those with many partners and inconsistent condom use. Factors most strongly associated with infrequent testing included not getting tested before starting PrEP, using PrEP from informal sources and on-demand/intermittent PrEP use. Discussion: In a setting of self-funded PrEP, many users obtained medical tests less frequently than recommended, which can lead to missed diagnoses. Barriers to testing should be addressed to enable proper medical supervision. The suitability of testing frequencies to PrEP users with less frequent risk exposures needs to be evaluated.Peer Reviewe

Einfluss des Kriegs in der Ukraine auf gemeldete HIV-Neudiagnosen in Deutschland

Die HIV-Prävalenz in der Ukraine wurde im Jahr 2019 bezogen auf die Gesamtbevölkerung auf 0,9 – 1,0 % geschätzt, wobei die Prävalenz in bestimmten vulnerablen Gruppen deutlich höher liegen dürfte. Durch den Angriffskrieg Russlands auf die Ukraine mussten viele Menschen ihre Heimat verlassen. Im Rahmen der gesetzlichen HIV-Meldepflicht gemäß § 7 Abs. 3 IfSG sind alle HIV-Diagnosen in Deutschland meldepflichtig, einschließlich der Diagnosen von Personen, die von ihrer HIV-Infektion bereits wissen und erstmals nach Deutschland kommen. Im vorliegenden Bericht wird der Einfluss des Ukrainekriegs auf die deutschen HIV-Meldungen charakterisiert und diskutiert

Aufbau, Struktur und Ergebnisse eines freiwilligen Mpox-Impfmonitorings in Deutschland

Nachdem im Mai 2022 erstmals Mpox-Fälle in Deutschland nachgewiesen wurden, empfiehlt die Ständige Impfkommission (STIKO) die Impfung gegen Mpox als Postexpositionsprophylaxe nach Mpox-Exposition sowie als Indikationsimpfung für Personen mit einem erhöhten Expositions- und Infektionsrisiko (z. B. während eines Mpox-Ausbruchs). Im Rahmen eines freiwilligen Impfmonitorings wird die Inanspruchnahme von Mpox-Impfungen in Deutschland systematisch erfasst und an das Robert Koch-Institut (RKI) übermittelt. Die Impfung gegen Mpox stellt eines der zentralen Präventionsinstrumente dar, um ein Wiederaufflammen von Mpox in Deutschland zu verhindern. Aufgrund der seit dem Spätsommer 2022 stark zurückgegangenen Anzahl von Erst- und Zweitimpfungen erscheint es wichtig, effektive Kampagnen zur Steigerung der Impfmotivation in Bevölkerungsgruppen mit erhöhtem Risiko für eine Mpox-Infektion durchzuführen.Peer Reviewe

The impact of regional socioeconomic deprivation on the timing of HIV diagnosis: a cross-sectional study in Germany

Background: HIV infections which are diagnosed at advanced stages are associated with significantly poorer health outcomes. In Germany, the proportion of persons living with HIV who are diagnosed at later stages has remained continuously high. This study examined the impact of regional socioeconomic deprivation on the timing of HIV diagnosis. Methods: We used data from the national statutory notification of newly diagnosed HIV infections between 2011 and 2018 with further information on the timing of diagnosis determined by the BED-Capture-ELISA test (BED-CEIA) and diagnosing physicians. Data on regional socioeconomic deprivation were derived from the German Index of Socioeconomic Deprivation (GISD). Outcome measures were a non-recent infection based on the BED-CEIA result or an infection at the stage of AIDS. The effect of socioeconomic deprivation on the timing of diagnosis was analysed using multivariable Poisson regression models with cluster-robust error variance. Results: Overall, 67.5% (n = 10,810) of the persons were diagnosed with a non-recent infection and 15.2% (n = 2746) with AIDS. The proportions were higher among persons with heterosexual contact compared to men who have sex with men (MSM) (76.8% non-recent and 14.9% AIDS vs. 61.7% non-recent and 11.4% AIDS). MSM living in highly deprived regions in the countryside (< 100 k residents) were more likely to have a non-recent infection (aPR: 1.16, 95% CI: 1.05–1.28) as well as AIDS (aPR: 1.41, 95% CI: 1.08–1.85) at the time of diagnosis compared to MSM in less deprived regions in the countryside. No differences were observed among MSM from towns (100 k ≤ 1 million residents) or major cities (≥ 1 million residents), and no differences overall in the heterosexual transmission group. Conclusions: An effect of socioeconomic deprivation on the timing of HIV diagnosis was found only in MSM from countryside regions. We suggest that efforts in promoting HIV awareness and regular HIV testing are increased for heterosexual persons irrespective of socioeconomic background, and for MSM with a focus on those living in deprived regions in the countryside.Peer Reviewe

Sexual and Mental Health Inequalities across Gender Identity and Sex-Assigned-at-Birth among Men-Who-Have-Sex-with-Men in Europe: Findings from EMIS-2017.

Some men who have sex with men (MSM) were assigned female at birth (AFB) and/or identify as trans men. Little is known about how these men differ from other MSM. We compared sexual and mental health indicators from the European MSM Internet Survey (EMIS-2017), comparing men AFB and/or currently identifying as trans men with those assigned male at birth (AMB) who identified as men. EMIS-2017 was an opportunistic 33-language online sexual health survey for MSM recruiting throughout Europe. We used regression models adjusting for age, country of residence and employment status to examine differences across groups. An analytic sample of 125,720 men living in 45 countries was used, of which 674 (0.5%) were AFB and 871 (0.7%) identified as trans men. The two sub-groups were not coterminous, forming three minority groups: AFB men, AFB trans men and AMB trans men. Minority groups were younger and more likely unemployed. Anxiety, depression, alcohol dependence and sexual unhappiness were more prevalent in sex/gender minority men. Conversely HIV and STI diagnoses were less common. AMB trans men were most likely to have sexual risk behavior with steady partners and to have unmet health promotion needs, and were least likely to be reached by interventions. Sex assigned at birth and trans identification were associated with different sexual and mental health needs. To facilitate service planning and to foster inclusion, sex-assigned-at-birth and current gender identity should be routinely collected in health surveys

Schätzung der Anzahl von HIV-Neuinfektionen im Jahr 2021 und der Gesamtzahl von Menschen, die Ende 2021 mit HIV in Deutschland leben

Die Anzahl der HIV-Neuinfektionen in Deutschland sowie bei Menschen deutscher Herkunft, die sich im Ausland mit HIV infiziert haben, wird für das Jahr 2021 auf 1.800 ge¬schätzt und liegt damit in gleicher Höhe wie 2020 (nach aktualisierter Schätzung ebenfalls etwa 1.800 Neuinfektionen). Der Anteil der diagnostizierten HIV-Infektionen liegt wie im Vorjahr bei etwa 90 %. Der Anteil der antiretroviral therapierten HIV-Infektionen liegt bei 96 %, von denen ebenfalls etwa 96 % als erfolgreich therapiert gelten. Somit sind zumindest zwei der drei Zielwerte des von UNAIDS formulierten „95-95-95-Ziels“ erreicht. Wie das Epidemiologische Bulletin 47/2022 ausführt, bedarf es jedoch weiterer Anstrengungen, um den Rückgang der HIV-Neuinfektionen zu verstetigen: Neben einer Reduktion der HIV-Neuinfektionen muss auch die Anzahl der nicht diagnostizierten Infektionen verringert und eine Therapie für alle in Deutschland lebenden Menschen mit HIV zugänglich gemacht werden.Peer Reviewe

HIV-Studien und HIV-Projekte am Robert Koch-Institut

Neben der gesetzlich geregelten Surveillance von HIV-Neudiagnosen in Deutschland erfolgt am RKI auch die Durchführung verschiedener Studienprojekte, die im Epidemiologischen Bulletin 49/2019 vorgestellt werden. Das Rückgrat der erweiterten HIV-Surveillance in Deutschland bilden vier Studien: das Monitoring rezenter HIV-Infektionen in Deutschland (InzSurv-HIV), die Molekulare Surveillance von HIV-Neudiagnosen (MolSurv-HIV), die HIV-1 Serokonverterstudie und die Klinische Surveillance der HIV-Erkrankung (ClinSurv-HIV). Bei InzSurv-HIV und MolSurv-HIV werden Proben von Patienten untersucht, die gerade neu diagnostiziert wurden. Bei der HIV-1 Serokonverterstudie und bei ClinSurv-HIV handelt es sich um Kohortenstudien. Ergänzend dazu wird am RKI auch das AIDS-Fallregister betrieben, in dem seit 1982 auf freiwilliger Basis anonym durch die behandelnden Ärzte berichtete AIDS-Erkrankungsfälle und -Todesfälle in Deutschland zusammengetragen und ausgewertet werden