A recent study of survey data published in the Journal of the International AIDS Society identified several factors associated with HIV seroconversion among people who belong to sexual minorities and have sex with men, including race, ethnicity, education, housing, and methamphetamine use.

“PrEP has been FDA-approved since 2012 and is one of the most effective biomedical methods of preventing the spread of HIV,” Christian Grov, PhD, MPH, a distinguished professor in the Department of Community Health and Social Sciences at the CUNY Graduate School, New York, told Physician’s Weekly. “Yet uptake of PrEP remains out of pace with need.”

Dr. Grov and colleagues conducted an observational cohort study of 6,059 people belonging to sexual or gender minorities who have sex with men. All patients were HIV-seronegative at the beginning of the four-year study and were clinically indicated for, but had not started on, PrEP. From 2017 to 2022, participants completed at-home online assessments and provided saliva samples to detect HIV antibodies using at-home collection kits. Dr. Grov and colleagues offered participants information on PrEP and resources for obtaining PrEP if they wanted to start taking it.

“Our primary outcomes were examining factors associated with PrEP uptake and discontinuation as well as factors associated with being diagnosed with HIV over the course of the four years of follow up,” Dr. Grov explained.

Factors Associated With HIV Seroconversion

At enrollment, participants were a median of 29 years old, and about half (52.3%) were White. The next most common racial identity in the study was Hispanic/Latinx (24.5%), Black/ African American (10.7%), and other racial or ethnic groups (12.5%). The participants all lived in the United States and Puerto Rico.

Dr. Grov and colleagues reported that 303 patients (5%) seroconverted during the study period. Compared with participants who did not seroconvert, greater proportions of patients were Hispanic/Latinx (29.7%) and Black/ African American (15.5%). In contrast, they wrote, Hispanic/Latinx and Black/African American participants made up 24.2% and 10.4% of patients, respectively, who did not seroconvert.

Education was also a factor. According to Dr. Grov and colleagues, more than one-third of participants (38.2%) had a bachelor’s degree or higher, but only 24.5% of those who seroconverted attained this level of education, compared with 39.3% of those who did not seroconvert.

Participants who seroconverted also showed greater rates of housing instability and food insecurity, Dr. Grov and colleagues wrote. Of the total population, 29.8% had experienced housing insecurity in the previous year, whereas 27.6% faced food insecurity. Among participants who seroconverted, however, these proportions were significantly larger: 40.9% of those who seroconverted experienced food insecurity, and 39.9% experienced housing instability, compared with just 29.3% facing housing instability and 27% facing food insecurity among those who did not seroconvert.

Perhaps the most striking factor was methamphetamine use, according to the researchers. Nearly half (46.9%) of participants who seroconverted used methamphetamines, Dr. Grov and colleagues wrote, versus 21% of participants who did not seroconvert.

“One thing that stood out to us was the extent to which methamphetamine was associated with HIV acquisition,” Dr. Grov said. “Of all HIV seroconversions observed during followup assessments (at 12, 24, 36, and 48 months), methamphetamine was reported in the 12 months prior 42.2% of the time. Given the observational nature of the study and that assessments were done annually, we cannot infer causality, but there is a clear indicator that people who use methamphetamine might benefit from enhanced HIV prevention and engagement in HIV care.”

Dr. Grov also noted that methamphetamines lower inhibition and increase libido, altering users’ behavior in a way that may make them directly more vulnerable to HIV seroconversion. Methamphetamine also has the potential to disrupt people’s lives in ways that make them more vulnerable to indirect factors that increase HIV risk, such as job loss (and thus health insurance loss) and housing instability.

Researchers acknowledged limitations to the study, which was not a nationally representative sample but rather a sample of people who are vulnerable to HIV. The authors also noted that the study may have slightly undercounted HIV seroconversions because only participants who completed the survey were counted.

“The Together 5000 study observed high vulnerability to HIV acquisition and low PrEP uptake among a community-based prospective cohort of sexual and gender-minority individuals who have sex with men,” Dr. Grov and colleagues concluded. “Those having adopted PrEP were at the lowest risk for acquiring HIV over the course of the study—meanwhile, those having adopted PrEP who later discontinued it demonstrated exceptional vulnerability to subsequent HIV seroconversion. Thus, not only are interventions necessary to engage individuals into PrEP care, but also retain them, and re-engage those who may fall out of PrEP care. Interventions may increase their impact by prioritizing Black/Latinx individuals, those experiencing housing instability, with less education, and those who use methamphetamine.”

The researchers are performing a follow-up study to learn more about how methamphetamine use impacts vulnerability to HIV infection, including biological vulnerability through rectal inflammation. That research is expected to continue through 2027.