Epidemiology of HIV in Latin America and the Caribbean

Violence as Mediating Variable in Mental Health Disparities Associated to Sexual Orientation Among Mexican Youths

In this study, we explored the role of sex as an effect-modifying variable in the association between sexual orientation and mental health in Mexican youth. In addition, we tested if violent experiences in the family and the school and attitudes toward homosexuality could act as mediating variables in such association. Data from three representative surveys performed in 2007, 2009, and 2013 among Mexican high school students were analyzed. Two dimensions of sexual orientation were evaluated: romantic partnership and sexual behavior. The outcomes were negative and positive mood, suicidal ideation and intent, self-concept, and self-esteem. There were differences by gender because in males, there were more disparities in mental health associated with sexual orientation (suicidal ideation and attempt, negative and positive mood, negative self-concept, and family-related self-esteem) than in females (suicidal ideation and negative mood). Experiences of school violence were mediators in the relationship between sexual orientation and most health outcomes in males.

Awareness of Prevention Strategies and Willingness to Use Preexposure Prophylaxis in Brazilian Men Who Have Sex With Men Using Apps for Sexual Encounters: Online Cross-Sectional Study

Background

Geosocial networking (GSN) smartphone apps are becoming the main venue for sexual encounters among Brazilian men who have sex with men (MSM). To address the increased HIV incidence in this population, preexposure prophylaxis (PrEP) was recently implemented in the Brazilian public health system in the context of combined HIV prevention.

Objective

This study aimed to describe the characteristics of MSM using GSN apps for sexual encounters, their awareness of prevention strategies, and willingness to use PrEP.

Methods

This study was an online cross-sectional study conducted in 10 Brazilian state capitals from July 1 to July 31, 2016. The questionnaire was programmed on SurveyGizmo and advertised in two GSN apps used by MSM to find sexual partners (Hornet and Grindr). Inclusion criteria were >18 years of age, cisgender men, with an HIV-negative status. Eligible individuals answered questions on: demographics; behavior; and knowledge, preferences, and willingness to use PrEP, nonoccupational postexposure prophylaxis (nPEP), HIV self-testing (HIVST), and condoms. Logistic regression modeling was performed to assess the factors associated with daily oral PrEP willingness.

Results

During the study period, 8885 individuals provided consent and started the questionnaire. Of these, 23.05% (2048/8885) were ineligible, 6837 (6837/8885, 76.94%) initiated, and 5065 (5065/8885, 57.00%) completed the entire questionnaire and were included in the present analysis. Median age was 30 years (interquartile range: 25-36), most self-declared as MSM (4991/5065, 98.54%), white (3194/5065, 63.06%), middle income (2148/5065, 42.41%), and had 12 or more years of schooling (3106/5062, 61.36%). The majority of MSM (3363/5064, 66.41%) scored >10 points (high risk) on The HIV Incidence Risk for MSM Scale, but only 21.39% (1083/5064) had a low perceived likelihood of getting HIV in the next year. Daily use of apps for sex was reported by 35.58% (1798/5054). Most MSM (4327/5065, 85.43%) reported testing for HIV at least once in their lifetime and 9.16% (464/5065) used nPEP in the previous year. PrEP, nPEP, and HIVST awareness was reported by 57.89% (2932/5065), 57.39% (2907/5065), and 26.57% (1346/5065) of participants, respectively. Half of all respondents (2653/5065, 52.38%) were willing to use daily oral PrEP, and this finding was associated with higher numbers of male sexual partners (adjusted odds ratio [AOR] 1.26, 95% CI 1.09-1.47), condomless receptive anal intercourse (AOR 1.27, 95% CI 1.12-1.44), sex with HIV-positive partner versus no HIV-positive partner (one HIV-positive partner: AOR 1.36, 95% CI 1.11-1.67), daily use of apps for sexual encounters (AOR 1.48, 95% CI 1.17-1.87), high and unknown perceived likelihood of getting HIV in the next year (AOR 1.72, 95% CI 1.47-2.02 and AOR 1.39, 95% CI 1.13-1.70), sexually transmitted infection diagnosis (AOR 1.25, 95% CI 1.03-1.51), stimulant use (AOR 1.24, 95% CI 1.07-1.43), PrEP awareness (AOR 1.48, 95% CI 1.30-1.70), and unwillingness to use condoms (AOR 1.16, 95% CI 1.00-1.33).

Conclusions

Our results evidenced high-risk scores in the studied population, suggesting the importance of PrEP use. Those individuals presenting risky sexual behaviors were more willing to use PrEP. Nonetheless, only 58% (2932/5065) of individuals had heard about this prevention strategy. Efforts to increase awareness of new prevention strategies are needed, and mobile health tools are a promising strategy to reach MSM.

Associations between health literacy, HIV-related knowledge, and information behavior among persons living with HIV in the Dominican Republic

OBJECTIVES

To determine the health literacy levels of persons living with human immunodeficiency virus (HIV) (PLWH) at a health clinic in the Dominican Republic (DR) and assess associations between health literacy, HIV-related knowledge, and health information behavior (how patients need, seek, receive, and use information).

DESIGN AND SAMPLE

Cross-sectional, descriptive. Participants were 107 PLWH attending the Clinic.

MEASURES

A theoretically based, 64-item survey assessing information behavior and HIV-related knowledge was administered in Spanish through individual interviews. Health literacy was assessed using the Short Assessment of Health Literacy-Spanish and English.

RESULTS

On average, participants were 40.8 years old and had lived with HIV for 7.7 years. The majority (69.2%) had low health literacy. HIV-related knowledge and information behavior varied by health literacy level and uncertainty regarding a main indicator of disease progression, viral load, was demonstrated regardless of health literacy level. Participants with low health literacy were less likely to answer questions or answer questions correctly and many participants (39.2%) indicated viral transmission can occur through supernatural means.

CONCLUSIONS

Findings demonstrate unmet information need and that information received may not always be understood. Methods to improve health education are needed to ensure patients receive health information in an understandable way.

Interventions for Increasing HIV Testing Uptake in Migrants: A Systematic Review of Evidence

Migrants have been identified as being at greater risk for late HIV testing and diagnosis. Late diagnosis is of concern because timely diagnosis and initiation of treatment can both optimise health outcomes and reduce transmission. We reviewed and evaluated interventions that aimed to increase HIV testing uptake in migrant populations. Of 6511 papers retrieved, 10 met the inclusion criteria and were included in the review. Three types of interventions were identified (exposure to HIV prevention messages, HIV education programs, and direct offer of testing). All interventions were based on individual models of behaviour change targeting migrants or GPs. While important, interventions that also address broader health system and structural factors that contribute to late HIV-diagnosis in at-risk members of migrant populations are needed. Integrating PITC into existing primary healthcare settings shows promise of creating an enabling environment within patient-doctor relationships that can encourage HIV testing uptake among migrant populations.

Factors Associated With HIV Testing Among Men in Haiti: Results From the 2012 Demographic and Health Survey

HIV testing serves as the gateway to HIV prevention and treatment. However, research examining men's HIV testing behaviors in the Caribbean remains limited. The Andersen Behavioral Model of Health Services Utilization was used to examine factors associated with HIV testing among 7,354 men who participated in the 2012 Demographic and Health Survey conducted in Haiti. Few men (35%) reported having ever been tested for HIV. Logistic regression analyses revealed that HIV testing increased with education and wealth. Marital status was associated with HIV testing, with married men more likely to have been tested (adjusted odds ratio: 2.57, 95% CI [2.07, 3.19]) than unmarried men. Positive attitudes toward people living with HIV, indicated by willing to care for a relative who has HIV/AIDS, was also correlated with higher odds of having been tested (adjusted odds ratio: 1.28, 95% CI [1.08, 1.51]). Men who reported condom use during last sex were more likely to have been tested (odds ratio: 1.58, 95% CI [1.33, 1.88). The findings indicate that HIV testing rates remain low among men in Haiti and more efforts are needed to increase HIV testing among men who are not married, have low level of education, and engage in unprotected sex.

Social-ecological factors associated with HIV infection among men who have sex with men in Jamaica

In Jamaica, where homosexuality is criminalized, scant research has examined associations between sexual stigma and HIV infection. The study objective was to examine correlates of HIV infection among men who have sex with men (MSM) in Jamaica. We conducted a cross-sectional tablet-based survey with MSM in Jamaica using chain referral sampling. We assessed socio-demographic, individual, social, and structural factors associated with HIV infection. A logit-link model, fit using backwards-stepwise regression, was used to estimate a final multivariable model. Among 498 participants (median age: 24, interquartile range: 22-28), 67 (13.5%) were HIV-positive. In the multivariable model, HIV infection was associated with increased odds of socio-demographic (older age, odds ratio [OR]: 1.05, 95% confidence interval [CI]: 1.00-1.10]; residing in Kingston versus Ocho Rios [OR: 6.99, 95% CI 2.54-19.26]), individual (poor/fair versus excellent/good self-rated health [OR: 4.55, 95% CI: 1.81-11.42], sexually transmitted infection [STI] history [OR: 3.67, 95% CI: 1.61-8.38]), and structural (enacted sexual stigma [OR: 1.08, 95% CI: 1.01-1.15], having a health care provider [OR: 2.23, 95% CI: 1.06-4.66]) factors. This is among the first studies to demonstrate associations between sexual stigma and HIV infection in Jamaica. Findings underscore the need to integrate STI testing in the HIV care continuum and to address stigma and regional differences among MSM in Jamaica.

Factors Associated with Health Information Seeking, Processing, and Use Among HIV Positive Adults in the Dominican Republic

Effective treatment and management of human immunodeficiency virus (HIV) depend on patients' ability to locate, comprehend, and apply health information. This study's purpose was to identify characteristics associated with these skills among HIV positive adults in the Dominican Republic. An information behavior survey was administered to 107 participants then three logistic regressions were conducted to identify characteristics associated with information seeking, processing, and use. Never having cared for someone who was sick was significantly associated with less information seeking, processing, and use. Males were more likely to be active information seekers and those who had attended the clinic for six or fewer years were less likely to actively seek information. Younger individuals had increased odds of higher information processing and those without comorbidities had increased odds of more information use. Results may inform researchers, organizations, and providers about how patients interact with health information in limited resource settings.

Transmitted drug resistance in patients with acute/recent HIV infection in Brazil

Introduction

The widespread use of antiretroviral therapy increased the transmission of antiretroviral resistant HIV strains. Antiretroviral therapy initiation during acute/recent HIV infection limits HIV reservoirs and improves immune response in HIV infected individuals. Transmitted drug resistance may jeopardize the early goals of early antiretroviral treatment among acute/recent HIV infected patients.

Methods

Patients with acute/recent HIV infection who underwent resistance test before antiretroviral treatment initiation were included in this analysis. HIV-1 sequences were obtained using an in house protease/reverse transcriptase genotyping assay. Transmitted drug resistance was identified according to the Stanford HIV Database for Transmitted Drug Resistance Mutations, based on WHO 2009 surveillance list, and HIV-1 subtyping according to Rega HIV-1 subtyping tool. Comparison between patients with and without transmitted drug resistance was made using Kruskal–Wallis and Chi-square tests.

Results

Forty-three patients were included, 13 with acute HIV infection and 30 with recent HIV infection. The overall transmitted drug resistance prevalence was 16.3% (95% confidence interval [CI]: 8.1–30.0%). The highest prevalence of resistance (11.6%, 95% CI: 8.1–24.5) was against non-nucleoside reverse transcriptase inhibitors, and K103N was the most frequently identified mutation.

Conclusions

The high prevalence of nonnucleoside reverse transcriptase inhibitors resistance indicates that efavirenz-based regimen without prior resistance testing is not ideal for acutely/recently HIV-infected individuals in our setting. In this context, the recent proposal of including integrase inhibitors as a first line regimen in Brazil could be an advantage for the treatment of newly HIV infected individuals. However, it also poses a new challenge, since integrase resistance test is not routinely performed for antiretroviral naive individuals. Further studies on transmitted drug resistance among acutely/recently HIV-infected are needed to inform the predictors of transmitted resistance and the antiretroviral therapy outcomes among these population.

The global HIV epidemic: What the pathologist needs to know

The World Health Organization estimates that at the end of 2015, approximately 36.7 million people were living with HIV worldwide. An estimated 0.8% of adults aged 15-49 years are infected with HIV with women representing a little over half of these infections. The burden of the epidemic varies considerably between regions of the world and within countries. Sub-Saharan Africa is the region of the world with most infections accounting for approximately 70% of people living with HIV. In the United States the number of new infections decreased by 19% between 2005 and 2014 yet, close to 40,000 new infections occurred in 2015 and, as people with HIV live longer and new infections continue, the number of people living with HIV in the US now stands at nearly 1.2 million and continues to rise. Unprecedented funding initiatives for antiretroviral therapy have resulted in coverage of up to 46% of those in need globally. In recent years, studies have demonstrated that HIV-infected persons who are on antiretroviral therapy and suppressed do not transmit HIV thus the United Nations AIDS Program (UNAIDS) initiative of "treatment is prevention". The UNAIDS goals for 2020 are to have diagnosis of 90% of those infected, 90% of those infected will be on treatment and in 90% there will be viral suppression. Of note, for two of the goals, laboratory system strengthening is paramount.

Barriers and facilitators to HIV testing among young men who have sex with men and transgender women in Kingston, Jamaica: a qualitative study

Introduction: Young men who have sex with men (MSM) in Jamaica have the highest HIV prevalence in the Caribbean. There is little information about HIV among transgender women in Jamaica, who are also overrepresented in the Caribbean epidemic. HIV-related stigma is a barrier to HIV testing among Jamaica’s general population, yet little is known of MSM and transgender women’s HIV testing experiences in Jamaica. We explored perceived barriers and facilitators to HIV testing among young MSM and transgender women in Kingston, Jamaica.

Methods: We implemented a community-based research project in collaboration with HIV and lesbian, gay, bisexual and transgender (LGBT) agencies in Kingston. We held two focus groups, one with young (aged 18–30 years) transgender women (n = 8) and one with young MSM (n = 10). We conducted 53 in-depth individual semi-structured interviews focused on HIV testing experiences with young MSM (n = 20), transgender women (n = 20), and community-based key informants (n = 13). We conducted thematic analysis to identify, analyze, and report themes.

Results: Participant narratives revealed social-ecological barriers and facilitators to HIV testing. Barriers included healthcare provider mistreatment, confidentiality breaches, and HIV-related stigma: these spanned interpersonal, community and structural levels. Healthcare provider discrimination and judgment in HIV testing provision presented barriers to accessing HIV services (e.g. treatment), and resulted in participants hiding their sexual orientation and/or gender identity. Confidentiality concerns included: clinic physical arrangements that segregated HIV testing from other health services, fear that healthcare providers would publicly disclose their status, and concerns at LGBT-friendly clinics that peers would discover they were getting tested. HIV-related stigma contributed to fear of testing HIV-positive; this intersected with the stigma of HIV as a “gay” disease. Participants also anticipated healthcare provider mistreatment if they tested HIV positive. Participants identified individual (belief in benefits of knowing one’s HIV status), social (social support) and structural (accessible testing) factors that can increase HIV testing uptake.

Conclusions: Findings suggest the need for policy and practice changes to enhance confidentiality and reduce discrimination in Jamaica. Interventions to challenge HIV-related and LGBT stigma in community and healthcare settings can enhance access to the HIV prevention cascade among MSM and transgender youth in Jamaica.

Awareness and Willingness to Use Pre-exposure Prophylaxis (PrEP) Among Men Who Have Sex with Men and Transgender Women in Brazil

Antiretroviral pre-exposure prophylaxis (PrEP) is recommended to prevent HIV infection among high-risk men who have sex with men (MSM) though not available in Brazil where the HIV epidemic persists unabated in this group. This cross-sectional study describes PrEP awareness and willingness and associated factors among MSM and transvestite/transgender women (trans women) pre-screened for the PrEP Brasil study. Awareness was reported by 61.3 % of the participants and was associated with age, education, site, study period and prior HIV testing. Most participants (82.1 %) were willing to use PrEP, which was associated with site, study period, number of male condomless anal sexual partners and anal sex with HIV positive/unknown partners. PrEP information is need among young and less educated individuals. Willingness to use PrEP was high and future studies should be conducted to confirm PrEP acceptability and the characteristics of the population who chose to adopt this intervention.

Late Diagnosis Due to Missed Opportunities and Inadequate Screening Strategies in HIV Infected Mexican Women

Late diagnosis of HIV remains a public health issue in Mexico. Most national programs target high-risk groups, not including women. More data on factors associated with late diagnosis and access to care in women are needed. In 2012-2013, Mexican women recently diagnosed with HIV were interviewed. Socio-cultural background, household-dynamics and clinical data were collected. Of 301 women, 49 % had <200 CD4 cells/mm³, 8 % were illiterate, 31 % had only primary school. Physical/sexual violence was reported by 47/30 %; 75 % acquired HIV from their stable partners. Prenatal HIV screening was not offered in 61 %; 40 % attended consultation for HIV-related symptoms without being tested for HIV. Seeking medical care ≥3 times before diagnosis was associated with baseline CD4 <200 cells/mm³ (adjusted OR 3.74, 95 % CI 1.88-7.45, p < 0.001). There were missed opportunities during prenatal screening and when symptomatic women seeked medical care. Primary care needs to be improved and new strategies implemented for early diagnosis in women.

Prevalence of human immunodeficiency virus infection and associated risk factors among prison inmates in the City of Florianópolis

INTRODUCTION

This study aimed to estimate the prevalence of human immunodeficiency virus (HIV) infection among prison inmates and to define the behavioral profile of infected individuals.

METHODS:

In total, 147 individuals were interviewed and provided biological material. The study population consisted of male individuals who presented at the health unit of the Florianopolis State Penitentiary.

RESULTS:

The prevalence of HIV infection was 2.1% (95% confidence interval, 0.4-5.8). With respect to the behavioral profile of individuals, no variable showed statistical significance.

CONCLUSIONS:

The prevalence of HIV infection among prison inmates was higher than that reported for the general population.

Mind the gap: implementation challenges break the link between HIV/AIDS research and practice

Sampling strategies such as respondent-driven sampling (RDS) and time-location sampling (TLS) offer unique opportunities to access key populations such as men who have sex with men (MSM) and transgender women. Limited work has assessed implementation challenges of these methods. Overcoming implementation challenges can improve research quality and increase uptake of HIV services among key populations. Drawing from studies using RDS in Brazil and TLS in Peru, we summarize challenges encountered in the field and potential strategies to address them. In Brazil, study site selection, cash incentives, and seed selection challenged RDS implementation with MSM. In Peru, expansive geography, safety concerns, and time required for study participation complicated TLS implementation with MSM and transgender women. Formative research, meaningful participation of key populations across stages of research, and transparency in study design are needed to link HIV/AIDS research and practice. Addressing implementation challenges can close gaps in accessing services among those most burdened by the epidemic.

Towards a fair consideration of PrEP as part of combination HIV prevention in Latin America

INTRODUCTION

Despite progress in scaling up antiretroviral treatment, HIV prevention strategies have not been successful in significantly curbing HIV incidence in Latin America. HIV prevention interventions need to be expanded to target the most affected key populations with a combination approach, including new high impact technologies. Oral pre-exposure prophylaxis (PrEP) is recommended as additional prevention choice for individuals at higher risk of infection and could become a cost-effective prevention tool. We discuss the barriers and solutions for a fair consideration of PrEP as part of combination HIV prevention strategies in Latin America.

DISCUSSION

Although demonstration projects are ongoing or being planned in a number of countries, to date no Latin American country has implemented a public PrEP programme. The knowledge of policymakers about PrEP implementation needs to be strengthened, and programmatic guidance and cost estimate tools need to be developed to support adequate planning. Despite high levels of awareness among health providers, especially if engaged in HIV or key population care, willingness to prescribe PrEP is still low due to the lack of national policies and guidelines. Key populations, especially men who have sex with men, transgender women and sex workers, have been engaged in demonstration projects, and qualitative research shows high awareness and willingness to use PrEP, especially if accessible in the public sector for free or at affordable price. Concerns of safety, adherence, effectiveness and risk compensation need to be addressed through targeted social communication strategies to improve PrEP knowledge and stimulate demand. Alliance among policymakers, civil society and representatives from key populations, healthcare providers and researchers will be critical for the design and successful implementation of PrEP demonstration projects of locally adapted delivery models. The use of mechanisms of joint negotiation and procurement of antiretrovirals could reduce costs and significantly increase the cost-effectiveness of PrEP.

CONCLUSIONS

PrEP is an additional prevention tool and should be implemented in combination and synergy with other prevention interventions. PrEP programmes should target high-risk individuals from key populations for higher cost-effectiveness. Demonstration projects may generate strategic information for and lead to the implementation of full-scale PrEP programmes.

Prevalence and Correlates of HIV Infection and HIV Testing Among Transgender Women in Jamaica

Transgender women are overrepresented in the Caribbean HIV epidemic. The study objective was to examine correlates of HIV infection and HIV testing among transgender women in Jamaica. We implemented a cross-sectional survey with transgender women in Kingston and Ocho Rios, Jamaica. We conducted multivariable logistic regression to identify factors associated with HIV testing and HIV infection. Among 137 transgender women [mean age 24.0; standard deviation (SD) 5.5], three-quarters (n = 103, 75.7%) had received an HIV test. Of these, one-quarter (n = 26, 25.2%) were HIV positive. In multivariable analyses, HIV testing was associated with: perceived HIV risk [adjusted odds ratio (AOR) 2.42, confidence interval (CI) 1.36-4.28], depression (AOR 1.34, CI 1.01-1.77), forced sex (AOR 3.83, CI 1.42-10.35), physical abuse (AOR 4.11, CI 1.44-11.72), perceived transgender stigma (AOR 1.23, 1.06-1.42), having a healthcare provider (AOR 5.89, CI 1.46-23.77), and lower HIV-related stigma (AOR 0.96, CI 0.92-0.99), incarceration (AOR 0.28, CI 0.10-0.78), and drug use (AOR 0.74, CI 0.58-0.95). HIV infection was associated with the following: homelessness (AOR 5.94, CI 1.27-27.74), perceived HIV risk (AOR 1.67, CI 1.02-2.72), depression (AOR 1.39, CI 1.06-1.82), STI history (AOR 56.79, CI 5.12-630.33), perceived (AOR 1.26, CI 1.06-1.51) and enacted (AOR 1.16, CI 1.04-1.29) transgender stigma, forced sex (AOR 4.14, CI 1.49-11.51), physical abuse (AOR 3.75, CI 1.39-10.12), and lower self-rated health (AOR 0.55, CI 0.30-0.98) and social support (AOR 0.79, CI 0.64-0.97). Transgender women in Jamaica experience high HIV infection rates and suboptimal HIV testing. Combination HIV prevention approaches should address transgender women's social and structural vulnerabilities.

High HIV prevalence and the internet as a source of HIV-related service information at a community-based organization in Peru: a cross-sectional study of men who have sex with men

Background

The HIV prevalence among men who have sex with men (MSM) in Peru (12.4 %) is 30 times higher than in the general adult population (0.4 %). It is critical for community-based organizations to understand how to provide HIV services to MSM while maximizing limited resources. This study describes the HIV prevalence and risk profiles of MSM seeking HIV services at a community-based organization in Lima, Peru. It then compares HIV prevalence between those who found out about the HIV services through different sources.

Methods

A cross-sectional study of MSM seeking HIV services at Epicentro Salud in Lima, Peru for the first time between April 2012 and October 2013. We compared HIV prevalence among MSM who found out about Epicentro via online sources of information (N = 419), those using in-person sources (friends, partners) (N = 907), and sex workers (N = 140) using multivariable logistic regression models.

Results

HIV prevalence was 18.3 % overall: 23.2 % among MSM using online sources, 19.3 % among sex workers, and 15.9 % among MSM using in-person sources. However, when compared to the in-person group, sexual risk behaviors were not statistically higher among MSM using online sources. For the sex worker group, some behaviors were more common, while others were less. After adjusting for confounders, the odds of having HIV was higher for the online group (Odds Ratio = 1.61; 95 % Confidence Interval: 1.19–2.18), but not for the sex worker group (OR = 1.12; 95 % CI: 0.68–1.86), compared to the in-person group.

Conclusion

Internet-based promotion appears to successfully reach MSM at high risk of HIV in Peru. Outreach via this medium can facilitate HIV diagnosis, which is the critical first step in getting infected individuals into HIV care. For community-based organizations working in resource-limited settings, this may be an effective strategy for engaging a subset of high-risk persons in HIV care.

Mortality in HIV-infected women, heterosexual men, and men who have sex with men in Rio de Janeiro, Brazil: an observational cohort study

BACKGROUND

Mortality in HIV-infected individuals might differ by sex and mode of HIV acquisition. We aimed to study mortality in HIV-infected women, heterosexual men, and men who have sex with men (MSM) in a cohort from Rio de Janeiro, Brazil.

METHODS

In this observational cohort study, we included HIV-infected women, heterosexual men, and MSM (aged ≥18 years) from the Instituto Nacional de Infectologia Evandro Chagas database who were enrolled between Jan 1, 2000, and Oct 30, 2011, and who had at least 60 days of follow-up. Causes of deaths, defined with the Coding of Death in HIV protocol, were documented. Cox proportional hazards models accounting for competing risks were used to explore risk factors for AIDS-related and non-AIDS-related deaths.

FINDINGS

We had 10 142 person-years of follow-up from 2224 individuals: 817 (37%) women, 554 (25%) heterosexual men, and 853 (38%) MSM. Of 103 deaths occurred, 64 were AIDS related, 31 were non-AIDS related, and eight were of unknown causes. In unadjusted analyses, compared with women, the hazard of AIDS-related deaths was higher for heterosexual men (hazard ratio [HR] 3·52, 95% CI 1·30-9·08; p=0·009) and for MSM (2·30, 0·89-5·94; p=0·084). After adjustment for age, CD4 cell counts, last HIV viral load, antiretroviral therapy use, and AIDS-defining infection, AIDS-defining malignant disease, and hospital admission during follow-up, the excess risk of AIDS-related death decreased for heterosexual men (adjusted HR 1·99, 0·75-5·25; p=0·163) but was unchanged for MSM (2·24, 0·82-6·11; p=0·114). Non-AIDS-related mortality did not differ by group.

INTERPRETATION

Compared with women, increased risk of AIDS-related death in heterosexual men was partly mitigated by risk factors for AIDS mortality, whereas the excess risk in MSM was unchanged. Further study of reasons for disparity in AIDS-related mortality by mode of transmission is needed.

FUNDING

US National Institutes of Health, Brazilian National Council of Technological and Scientific Development (CNPq), and Research Funding Agency of the State of Rio de Janeiro (FAPERJ).

Evaluating the utility of provider-recorded clinical status in the medical records of HIV-positive adults in a limited-resource setting

Provider-reported summaries of clinical status may assist with clinical management of HIV in resource poor settings if they reflect underlying biological processes associated with HIV disease progression. However, their ability to do so is rarely evaluated. Therefore, we aimed to assess the relationship between a provider-recorded summary of clinical status and indicators of HIV progression. Data were abstracted from 201 randomly selected medical records at a large HIV clinic in the Dominican Republic. Multivariable logistic regressions were used to examine the relationship between provider-assigned clinical status and demographic (gender, age, nationality, education) and clinical factors (reported medication adherence, CD4 cell count, viral load). The mean age of patients was 41.2 (SD = ±10.9) years and most were female (n = 115, 57%). None of the examined characteristics were significantly associated with provider-recorded clinical status. Higher CD4 cell counts were more likely for females (OR = 2.2 CI: 1.12-4.31) and less likely for those with higher viral loads (OR = 0.33 CI: 0.15-0.72). Poorer adherence and lower CD4 cell counts were significantly associated with higher viral loads (OR = 4.46 CI: 1.11-20.29 and 6.84 CI: 1.47-37.23, respectively). Clinics using provider-reported summaries of clinical status should evaluate the performance of these assessments to ensure they are associated with biologic indicators of disease progression.

HIV Testing in Non-Injection Drug Users: Prevalence and Associated Factors

The objective of this study was to estimate the prevalence of and identify factors associated with lifetime testing for the human immunodeficiency virus (HIV) in non-injection drug users (NIDU). A cross-sectional study was conducted with 323 individuals in clinics for chemical dependency in the state of Goiás in the Central-West region of Brazil. Logistic regression analysis was used to identify factors associated with lifetime HIV testing. Testing for HIV was associated with age, female gender, crack use, history of sexually transmitted infections, acquaintance with people living with HIV/AIDS and/or who had died from AIDS, and history of having received some instruction on HIV/AIDS prevention methods. It was found that only 26.6% reported having access to the HIV rapid test. We concluded determinants for HIV testing must be taken into account when planning prevention and programming strategies. These include the widening of testing coverage among NIDU, educational health actions, establishment of links between sexually transmitted infection prevention services and addiction treatment services, and the use of rapid tests to help people who are in contact with the virus learn about their HIV status, enter treatment, and improve their quality of life.

The Men Who Have Sex with Men HIV Care Cascade in Rio de Janeiro, Brazil

Brazil has a concentrated HIV epidemic and men who have sex with men (MSM) are disproportionately affected. Yet, no data is available on the HIV care cascade for this population. This study aimed to assess the HIV care cascade among MSM newly diagnosed through innovative testing strategies in Rio de Janeiro. Data from 793 MSM and travestites/transgender women (transwomen) tested for HIV at a non-governmental LGBT organization and a mobile testing unit located at a gay friendly venue were analyzed. A 12-month-after-HIV-diagnosis-censored cohort was established using CD4, viral load and combination antiretroviral therapy (cART) longitudinal data from those diagnosed with HIV. A cross-sectional HIV care cascade was built using this data. The relative risks of achieving each cascade-stage were estimated using generalized linear models according to age, self-declared skin-color, education, history of sexually transmitted diseases (STD), drug use and prior HIV testing. From Jan-2013 to Jan-2014, 793 MSM and transwomen were tested, 131 (16.5%) were HIV-infected. As of January 2015, 95 (72.5%) were linked to HIV care, 90 (68.7%) were retained in HIV care, 80 (61.1%) were on cART, and 50 (38.2%) were virally suppressed one year after HIV diagnosis. Being non-white (Relative risk [lower bound; upper bound of 95% confidence interval] = 1.709 [1.145; 2.549]) and having a prior HIV-test (1.954 [1.278; 2.986]) were associated with an HIV-positive diagnosis. A higher linkage (2.603 [1.091; 6.211]) and retention in care (4.510 [1.880; 10.822]) were observed among those who were older than 30 years of age. Using community-based testing strategies, we were able to access a high-risk MSM population and a small sample of transwomen. Despite universal care coverage and the test-and-treat policy adopted in Brazil, the MSM cascade of care indicates that strategies to increase linkage to care and prompt cART initiation targeted to these populations are critically needed. Interventions targeting non-white and young MSM should be prioritized.

HIV-1 subtype B: Traces of a pandemic

Human migration is a major process that shaped the origin and dissemination of HIV. Within HIV-1, subtype B (HIV-1B) is the most disseminated variant and it is assumed to be the causative agent in approximately 11% of all cases of HIV worldwide. Phylogenetic studies have revealed that HIV-1B emerged in Kinshasa (Africa) and was introduced into the Caribbean region via Haiti in or around 1966 by human migration. After localized dispersion, the virus was brought to the United States of America via homosexual/bisexual contact around 1969. Inside USA, the incidence of HIV-1B infection increased exponentially and it became established in the population, affecting not only homosexual individuals but also heterosexual individuals and injecting drug users. Soon after, the virus was disseminated and became established in other regions, including Europe, Asia, Latin America, and Australia. Recent studies suggest that, in addition to this pandemic clade, several lineages have emerged from Haiti and reached other Caribbean and Latin American countries via short-distance dissemination. Different subtype B genetic variants have also been detected in these epidemics. Four genetic variants have been described to date: subtype B', which mainly circulates in Thailand and other Asian countries; a specific variant mainly found in Trinidad and Tobago; the GPGS variant, which is primarily detected in Korea; and the GWGR variant, which is mainly detected in Brazil. This paper reviews the evolution of HIV-1B and its impact on the human population.

Risk Factors Associated With HIV Among Men Who Have Sex With Men (MSM) in Ecuador

The Joint United Nations Program on HIV/AIDS estimates that between 0.3% and 0.7% of adults aged 15 to 49 years were living with HIV in Ecuador in 2013. However, very little is known about the HIV prevalence rate among men who have sex with men (MSM) in that country. A cross-sectional survey was conducted to investigate the knowledge, attitudes, and practices regarding HIV/AIDS as well as to estimate the prevalence of HIV among MSM in one of the cities with high HIV prevalence rates in Ecuador. In this study, questionnaires were administered to 307 adult MSM. An HIV prevalence of 10% was observed. Knowledge about HIV was high; 91% of participants could identify how HIV is transmitted. Although consistent condom use for anal sex was relatively high (89%) among participants who reported having pay-for-service clients, only 64% reported using a condom during oral sex with a client. Participants who had multiple male sexual partners (i.e., their stable male partners plus other partner[s]) had 3.7 times higher odds of testing positive for HIV compared with those who did not. They also had reduced odds of condom use. Participants who were forced to have anal receptive sex had 3 times higher odds of testing positive for HIV. Despite the finding that participants exhibited high knowledge about HIV/AIDS, a high prevalence rate of HIV was observed, which warrants targeted behavioral interventions. These data are consistent with MSM being one of the highest at-risk population groups for HIV in this region of Ecuador.

Health-information needs of HIV-positive adults in Latin America and the Caribbean: an integrative review of the literature

An assessment of information needs is essential for care planning for patients living with chronic diseases such as human immunodeficiency virus (HIV). The extent to which these assessments have been conducted in Latin America and the Caribbean (LAC) is unknown. The purpose of this study was, therefore, to identify, evaluate, and summarize what research has been conducted to examine patient perceptions of their health-information needs among adults living with HIV in LAC. Using an integrative review methodology, a literature search of six databases was conducted in April and May 2015. Inclusion criteria were peer-reviewed articles published in English or Spanish that assessed the information needs of HIV-positive patients living in LAC. The quality of included articles was assessed and relevant characteristics of each article were extracted, compared, and presented. Searches returned 1885 citations, 11 of which met inclusion criteria. Studies included were conducted in 8 of 33 countries, used multiple research designs, demonstrated varying needs between populations, and found numerous unmet information needs. Information about HIV in general, methods of infection transmission, antiretroviral medications, other sexually transmitted diseases, and effective coping mechanisms were the most commonly mentioned needs. Healthcare providers were the largest and most reliable source of health information for many participants and it was emphasized that in order for health education to be effective, programs should include both individual and group components. Patients indicated that they may have difficulty processing and using information through an incorrect understanding of medications, not changing risk behaviors, and by stating that information can be overwhelming or poorly communicated. Further research on information needs is warranted so that healthcare providers and organizations may provide the information patients need to appropriately manage their health.

High prevalence of multiple syndemic conditions associated with sexual risk behavior and HIV infection among a large sample of Spanish- and Portuguese-speaking men who have sex with men in Latin America

The HIV epidemic in Latin America is highly concentrated in men who have sex with men (MSM). In the United States, multiple co-occurring psychosocial conditions have been shown to act as intertwined epidemics to potentiate HIV transmission among MSM. To date, no study has examined the role of syndemics and condomless sex among MSM in Latin America. In 2012, an online survey was conducted among members of the largest social/sexual networking website for MSM in Latin America. Participants were asked about demographics, sexual behaviors, HIV/STI diagnoses, and psychosocial well-being, including depression, suicidal ideation, hazardous alcohol use, hard drug use during sex, history of childhood/adolescent sexual abuse, intimate partner violence, and sexual compulsivity. Multivariable logistic generalized estimation equations were used to assess the relationship of syndemic factors and (1) engagement in higher risk condomless anal sex and (2) self-report of prior HIV diagnosis. Among 24,274 survey respondents, 74.6 % of the sample had at least one syndemic factor. In an additive model, syndemics were associated with increased odds of higher risk condomless anal sex, ranging from adjusted odds ratio of 1.31 (95 % CI 1.20, 1.43) for one syndemic factor to 4.06 (95 % CI 3.25, 5.09) for 6/7 syndemic factors. Similarly, syndemics were associated with increased odds of HIV infection (p < .0001). This study provides initial evidence that intertwined syndemics increase HIV risk behavior and HIV infection among MSM in Latin America. In the Latin American context, comprehensive HIV prevention interventions for MSM should be developed and tested that simultaneously address co-occurring psychosocial conditions and HIV risk.

The syphilis care cascade: tracking the course of care after screening positive among men and transgender women who have sex with men in Lima, Peru

OBJECTIVES

Syphilis is endemic among men who have sex with men (MSM) and transgender women in Latin America. The objective of this study was to assess if those who screen positive for syphilis are receiving appropriate care and treatment.

METHODS

We use data from the 2011 Peruvian National HIV Sentinel Surveillance to describe the syphilis care cascade among high-risk MSM and transgender women. Medical records from participants who had a positive syphilis screening test at two of the enrolment sites in Lima were reviewed to determine their subsequent course of care.

RESULTS

We identified a cohort of 314 syphilis seropositive participants (median age: 30, 33.7% self-identified as transgender). Only 284/314 (90.4%) participants saw a physician for evaluation within 28 days of their positive test. Of these, 72/284 (25.4%) were asked to return for confirmatory results before deciding whether or not to start treatment; however, 45/72 (62.5%) of these participants did not follow up within 28 days. Of the people prescribed three weekly doses of penicillin, 34/63 (54%) received all three doses on time.

CONCLUSIONS

Many MSM and transgender women with a positive syphilis screening test are lost at various steps along the syphilis care cascade and may have persistent infection. Interventions in this population are needed to increase testing, link seropositive patients into care and ensure that they receive appropriate and timely treatment.

HIV prevalence, sexual behaviours and engagement in HIV medical care among an online sample of sexually active MSM in Venezuela

In Venezuela, members of a social and sexual partner networking site for men who have sex with men (MSM) completed an online survey regarding sexual behaviours and HIV medical care. Among the 2851 respondents, self-reported HIV prevalence was 6.6%. Of participants living with HIV, 73.2% reported taking antiretroviral medication and 56.6% reported complete adherence within the past month. Participants living with HIV were more likely to be older (aOR = 1.04 per one-year increase in age, 95% CI: 1.02, 1.06) and diagnosed with a sexually transmitted infection in the previous year (aOR 3.26, 95% CI: 2.11, 5.04). These data provide further understanding of the HIV epidemic among MSM in Venezuela, and potential targets for HIV prevention interventions.

Phylodynamics of major HIV-1 subtype B pandemic clades circulating in Latin America

OBJECTIVE

To obtain a comprehensive description of the evolutionary and demographic history of major HIV-1 subtype B pandemic (BPANDEMIC) clades circulating in Latin America.

DESIGN

A total of 6789 HIV-1 subtype B pol sequences collected from seven different Latin American countries between 1990 and 2011 were combined with BPANDEMIC reference sequences (n = 500) from the United States and France.

METHODS

Major BPANDEMIC clades were identified by maximum likelihood phylogenetic analysis with sequential pruning of ambiguously positioned taxa. Time scale and demographic reconstructions were performed using a Bayesian coalescent-based method.

RESULTS

We identified 12 major BPANDEMIC monophyletic lineages mainly composed by Latin American sequences and that together comprise 36% of all subtype B sequences from the region here included. Four clades belong to two major regional lineages that comprise sequences from at least two neighboring countries, whereas the other eight clades were country-specific. The median age of major Latin American BPANDEMIC clades encompass a period of two decades (1968-1988), although most of them probably arose before the early 1980s. All major clades seem to have experienced an initial period of exponential growth, with median epidemic growth rates that range from 0.50 yearto 0.94 year, followed by a recent decline in growth rate.

CONCLUSION

About one-third of HIV-1 subtype B infections in Latin America originated from the spread of a few BPANDEMIC founder strains probably introduced in the region since the late 1960s. Despite their initial successful dissemination, all major BPANDEMIC clades showed signs of subsequent epidemic stabilization.

High HIV Burden in Men Who Have Sex with Men across Colombia's Largest Cities: Findings from an Integrated Biological and Behavioral Surveillance Study

BACKGROUND

Among Latin America's concentrated HIV epidemics, little is known about men who have sex with men (MSM) in Colombia, the region's third largest country. To date, surveillance studies have been limited to Bogota, while 80% of HIV cases and deaths originate from Colombia's other cities and departments. The extent to which interventions should prioritize MSM outside of Bogota is unknown.

METHODS

We recruited 2603 MSM using respondent-driven sampling from seven of Colombia's largest cities. HIV prevalence was estimated by site from dried blood spot samples. Behavioral data were collected through face-to-face interviews and risk factors for HIV infection analyzed using weighted, multi-level logistical regression models accounting for recruitment patterns.

RESULTS

Across cities, HIV prevalence averaged 15%, varied from 6% to 24% and was highest in Cali, Bogota, and Barranquilla. In the past 12 months, 65% of MSM had ≥ 5 casual male partners and 23% had a female partner. Across partnerships (i.e., casual, stable, and commercial), the proportion of MSM engaging in unprotected sex was ≥ 52% with male partners and ≥ 66% with female partners. Self-reported history of STI (24%) and past-year illicit drug use (38%) were also common. In multivariate analysis, age ≥ 35 (adjusted odds ratio [AOR], 19.2) and 25-39 (AOR, 5.6) relative to ≤ 18-24 years, identifying as homosexual relative to heterosexual (AOR 0.1), meeting casual partners on the Internet (adjusted odds ratio [AOR], 3.1) and age of sexual debut of ≤ 13 years (AOR, 3.1) predicted HIV infection. HIV testing and prevention messaging reached just 24% of MSM in the past year.

CONCLUSIONS

Findings support consistently elevated HIV burden among MSM throughout Colombia's largest cities and a need for enhanced behavioral prevention and HIV testing, emphasizing men who use the Internet as well as physical venues to meet sex partners.

Pre-exposure prophylaxis for men and transgender women who have sex with men in Brazil: opportunities and challenges

INTRODUCTION

The World Health Organization recently released guidelines on the use of pre-exposure prophylaxis (PrEP) for prevention of HIV infection among men and transgender women (TGW) who have sex with men based on results of randomized clinical trials. The aim of this commentary is to discuss the opportunities and challenges of incorporating PrEP into the Brazilian continuum of HIV care and prevention for men who have sex with men (MSM) and TGW.

DISCUSSION

Key aspects of the AIDS epidemic among MSM and TGW in Brazil and the comprehensive Brazilian response to the epidemic are presented. The universal access to health care provided through the Brazilian Unified Health System (SUS) and the range of prevention and care services already available countrywide to HIV-positive individuals and at-risk MSM and TGW are identified as the main facilitators for the implementation of PrEP. Limited PrEP awareness among MSM, TGW and health care providers, low HIV testing frequency and low HIV risk perception among MSM and TGW represent the core challenges to be addressed. Data generated by demonstration projects in Brazil will provide an important contribution to PrEP rollout in Brazil.

CONCLUSIONS

The implementation of PrEP in Brazil is feasible. A synergistic rollout of treatment as prevention and PrEP will maximize public health and individual benefits of the country's comprehensive response to the AIDS epidemic.

Global epidemiology of HIV

The number of persons living with HIV worldwide reached approximately 35.3 million in 2012. Meanwhile, AIDS-related deaths and new HIV infections have declined. Much of the increase in HIV prevalence is from rapidly increasing numbers of people on antiretroviral treatment who are now living longer. There is regional variation in epidemiologic patterns, major modes of HIV transmission, and HIV program response. It is important to focus on HIV incidence, rather than prevalence, to provide information about HIV transmission patterns and populations at risk. Expanding HIV treatment will function as a preventive measure through decreasing horizontal and vertical transmission of HIV.

Unprotected sexual practices among men who have sex with women and men who have sex with men living with HIV/AIDS in Rio de Janeiro

Combined antiretroviral therapy is now acknowledged for preventing new HIV infections, besides decreasing mortality and morbidity. However, in many Latin America countries the epidemic is still driven by unprotected sexual intercourse. This study aims to describe sexual practices related to HIV/STD and to evaluate factors associated to unprotected sex among men who have sex with women (MSW) and men who have sex with men (MSM) under care at a reference center for HIV in Rio de Janeiro, Brazil. A cross-sectional study, nested in a Brazilian clinical cohort, evaluated the sexual practices of 404 sexually active HIV-positive MSW and men who have MSM. Approximately 30 % of them reported unprotected sexual practices during the 6 months prior to the interview. Most frequent risky practices reported were unprotected vaginal sex among MSW and unprotected receptive anal sex among MSM. Factors increasing the chance of unprotected sexual practices among MSW were the partner's desire of becoming pregnant (OR 2.81; CI 95 %: 1.36-5.95). To have received comments about excessive consumption of alcohol (OR 2.43; CI 95 %: 1.01-5.83), illicit drug use (OR 4.41; CI 95 %: 1.75-11.60) and lived in marital situation (OR 2.10; CI 95 %: 1.09-4.08) were significantly associated with unsafe sexual practices among MSM. The results highlight that health care of men living with HIV, as well as the prevention strategies, must consider the particularities of sexual behavior practiced by people who differ in sexual orientation.

The changing face of HIV in Latin America and the Caribbean

Latin America and the Caribbean (LAC) is a region with similarities and important disparities. In recent years LAC has witnessed achievements, with HIV prevalence rates relatively stable for LA and decreasing for the Caribbean. However average values hide differences. General population HIV prevalence in LAC is 0.4 % on average. In the Caribbean there are fewer new HIV infections but HIV prevalence among adults exceeds 1 % in several countries. It is estimated that 31 % of adults living with HIV in LA and 52 % of adults in the Caribbean are women. Unprotected sex is the main route of HIV transmission in LAC. Men who have sex with men and transgender women are the populations with the highest prevalence (10.6 % and 17.7 % respectively); however other key populations such as female sex workers (4.9 %), drug users (range 1 %-49.7 % for intravenous drug users), prisoners and indigenous populations are also important. LAC has the highest anti-retroviral treatment coverage of any low- and middle-income region in the world, but women and children are less likely than men to receive treatment. There is an important pending agenda to address the gaps in information, prevention, and care for HIV in LAC.

Operations research study to implement HIV and syphilis point-of-care tests and assess client perceptions in a marginalised area of Lima, Peru

In Peru, a significant proportion of people tested for HIV and syphilis do not receive timely results. Our objective was to assess the institutional feasibility of implementing simultaneous HIV/syphilis point-of-care tests and client perceptions regarding these point-of-care tests. Point-of-care tests were implemented in a hospital consultation room in a marginalised zone of Lima. A time-series design was used to compare the proportion of tested clients who received timely results, with and without the point-of-care test intervention. Experience and satisfaction with point-of-care tests was evaluated with 149 people. In the 6 months without intervention, 69% and 61% of clients tested for HIV and syphilis, respectively, received their results within the required 45-minute window. During the 2-month point-of-care test intervention, all clients tested for HIV (n = 387) and syphilis (n = 398) received their results within 45 minutes. All clients surveyed were completely satisfied (52%) or satisfied (48%) with the simultaneous HIV/syphilis point-of-care test screening process. Additionally, 73% strongly agreed with the statement 'I feel satisfied with the rapid testing process.' Screening using point-of-care tests represents an important opportunity to reduce the time, resource and cost burden for users and institutions and increase the proportion of users receiving their test results in a timely manner.

The global north: HIV epidemiology in high-income countries

PURPOSE OF REVIEW

The epidemiology of HIV epidemics provides the roadmap for prioritization of programmes and serves over time to evaluate broadly the successes and challenges in prevention. The purpose of this review was to summarize recent information about the epidemiology of HIV in high-income countries with concentrated HIV epidemics.

RECENT FINDINGS

Data from 26 countries were organized and analysed, and a systematic review of published literature relating to epidemiology in these countries was conducted. Our major findings illustrated strong patterns in epidemiology by mode of HIV acquisition: in most high-income countries, new HIV diagnoses attributable to male-female sex have been stable or decreasing, whereas new HIV diagnoses attributable to male-male sex have been stable or increasing. Late diagnoses of HIV infection are common. Prevalence of HIV in high-income countries has risen over the past 5 years as death rates have been stable or decreasing. Reports of the epidemiology of HIV among sex workers and transgendered persons are rare.

SUMMARY

The epidemiology of HIV in high-income countries in 2013 depicts both the successes and challenges of HIV prevention. The stable to decreasing death rates and stable or declining trends in heterosexual populations are likely attributable, at least in part, to the broader availability of effective treatments for HIV and relatively broad availability of antiretroviral treatment in these countries. However, late diagnoses undermine the individual and public health value of antiretroviral treatment, and epidemics of HIV among MSM remain largely uncontrolled despite broad availability and coverage of treatment.

Unprotected sex among men who have sex with men living with HIV in Brazil: a cross-sectional study in Rio de Janeiro

Background

Many countries are facing concentrated HIV epidemics among vulnerable populations, including men who have sex with men (MSM). Unprotected anal intercourse (UAI) is the main HIV transmission route among them and its understanding in the different cultures and how it relates to HIV transmission, re-infection and development of HIV antiretroviral resistance has important public health implications. Data on UAI among Brazilian MSM are scarce. This study aims to evaluate the prevalence and associated factors of UAI among HIV-infected MSM who had sex with seronegative or male partners with an unknown serostatus.

Method

A cross-sectional study nested in a cohort was conducted in Rio de Janeiro, Brazil. The one hundred and fifty five MSM included in the study answered an ACASI interview and provided biological samples. Generalized linear models were used to identify variables associated with UAI.

Results

Overall, UAI with an HIV-negative or unknown serostatus male partner was reported by 40.6% (63/155) of MSM. Lifetime sexual abuse or domestic violence was reported by 35.9%, being more frequent among MSM who reported UAI compared to those who did not (P = 0.001). Use of stimulants before sex was reported by 20% of the MSM, being slightly higher among those who reported UAI (27.0% vs. 15.2%; P = 0.072). Commercial sex was frequent among all MSM (48.4%). After multivariate modeling, the report of sexual abuse or domestic violence (OR = 2.70; 95% CI: 1.08-7.01), commercial sex (OR = 2.28; 95% CI: 1.04- 5.10), the number of male sexual partners (p = 0.039) and exclusively receptive anal intercourse (OR = 0.21; 95% CI: 0.06-0.75) remained associated with UAI. CD4 levels, HIV viral load and antiretroviral therapy were not associated with UAI.

Conclusion

The UAI prevalence found with negative or unknown HIV status partners points out that other interventions are needed as additional prevention tools to vulnerable MSM. The main factors associated with UAI were a lifetime history of violence, commercial sex and the number of male sexual partners. This clustering of different behavioral, health and social problems in this population reinforce the need of a comprehensive approach on treating and preventing HIV among MSM.