"The Main Concern is HIV, Everything Else is Fixable": Indifference Toward Sexually Transmitted Infections in the Era of Biomedical HIV Prevention

The Best Predictor of Future Behavior May Be the Past: Exploring Behavior Change in Men Who Have Sex with Men Using Pre-exposure Prophylaxis in the Netherlands

Pre-exposure prophylaxis (PrEP) use prevents HIV transmission, and may lead to changes in sexual behavior. We aimed to explore sexual behavior over time, and identify predictors of behavior change in men who have sex with men (MSM) using PrEP at sexual health centers (SHC) in the Netherlands. We used longitudinal data from the national STI surveillance database (January 2018-June 2021) of HIV-negative MSM who first initiated PrEP in the national PrEP pilot. We modelled behavior change after PrEP initiation, and identified predictors of behavior change using multi-state Markov models. The probability of stopping group sex, chemsex, use of poppers or erection stimulants, and having ≥ 10 partners in the past 6 months among included MSM (n = 4,349, n SHC visits = 21,820) was higher compared to the probability of starting with these behaviors after PrEP initiation. However, MSM who used condoms consistently during anal sex had a high probability of changing to inconsistent condom use (0.8) at the next visit, and inconsistent condom users mostly remained inconsistent (0.8). First visit, visiting the SHC more often (vs. regular), and STI diagnosis were predictors of starting or continuing with most of the behaviors associated with increased risk. Behavior change was less likely among older participants (> 34 compared to ≤ 34 years), and during COVID-19 lockdown and post-lockdown periods compared to pre-COVID-19. Although condom use decreased over time, transitions towards stopping with other behaviors associated with increased likelihood of acquiring an STI after PrEP initiation were common. This may suggest increased sexual empowerment, especially among younger MSM. Predictors of behavior change may help to identify MSM who are likely to start with or continue to engage in these behaviors in the near future and to provide suitable and timely counselling about behavior and PrEP adherence.

Sexual Arousal-Delay Discounting: When Condoms Delay Arousal

Sexual arousal plays an important role in condom use decisions. However, combined effects of reduced sexual arousal and delay to achieving arousal on condom use decisions remain understudied. This study used a novel sexual arousal-delay discounting (SADD) task to measure individuals' willingness to use a condom in situations where condom use would (1) delay time to arousal and (2) reduce the level of arousal one could achieve even after the delay (e.g., 5 minutes to reach 50% arousal). In Study 1, U.S. college students (N = 115; Mage = 18.6) reported their willingness to have sex with a condom in hypothetical scenarios where the condom delayed and reduced their partner's sexual arousal. In Study 2, U.S. college students (N = 208; Mage = 19.6; 99% ≤ 24 years old) completed the same task for two partners-partner perceived as most desirable and partner perceived as least likely to have an STI. In this study, a condom would affect either participants' own or partner's arousal. Study 3 replicated Study 2 using a non-college sample in the U.S. (N = 227; Mage = 30.5; 84% ≥ 25 years old). Across studies, willingness to use a condom decreased as the delay to reduced arousal increased. This effect of SADD was stronger when condoms reduced participants' own (vs. partner's) arousal, whereas comparisons between most desirable and least likely-to-have-STI partners provided mixed findings. Men had higher discounting rates than women across conditions. Greater SADD was associated with lower condom use self-efficacy, providing initial evidence for the task's validity. The role of delayed arousal in condom use and implications are discussed.

Delay Discounting for HIV/STI Testing

Introduction

Wait time in healthcare is an important barrier to HIV/STI testing. Using a delay discounting approach, the current study examined a systematic reduction in testing likelihood as a function of delay (wait time) until testing.

Methods

In Study 1 (N = 421; data collected in 2019), participants were randomly assigned to either a chlamydia/gonorrhea group or HIV group. A delay discounting task asked them to report how likely they would get tested for the assigned STI if they had to wait for the test (the delay durations varied within persons). In Study 2 (N = 392; data collected in 2020), we added a smaller, sooner outcome (consultation without testing) and tested whether the effect of delay was mediated by perceived severity of the STIs.

Results

In both studies, the subjective value of a delayed STI test was discounted. That is, people were less likely to undergo STI testing as the delay to STI testing increased. The chlamydia/gonorrhea group discounted delayed testing more than the HIV group (i.e., the effect of delay on testing decisions was stronger for the former). This effect was statistically mediated by perceived severity.

Conclusions

We found evidence for delay discounting for HIV/STI testing and that testing decisions were more susceptible to delay when the test was for relatively mild STIs.

Policy Implications

Even mild STIs can cause serious health damage if left untreated. The findings provide strong argument for policies aimed to reduce wait times in healthcare, especially for relatively mild STIs.

Web-Based Harm Reduction Intervention for Chemsex in Men Who Have Sex With Men: Randomized Controlled Trial

BACKGROUND

Men who have sex with men (MSM) who practice chemsex have a higher likelihood of engaging in risky sexual behaviors and higher rates of HIV infection and other sexually transmitted infections (STIs) than those who do not.

OBJECTIVE

This trial aimed to evaluate the effectiveness of a web-based intervention in reducing the sexual harms of chemsex among MSM.

METHODS

The study was a 2-arm, assessor-blinded, randomized, parallel-group trial with a 3-month follow-up period. The study was conducted in the year 2021 in Hong Kong. Underpinned by the theory of planned behaviors and a harm reduction approach, the intervention consisted of interactive components and knowledge-based information about chemsex. Participants in the control group received brief information and content about sexual violence. The primary outcome was self-efficacy in refusing risky sexual behaviors and chemsex, as measured by the Condom Self-Efficacy Scale (CSES), Self-Efficacy for Sexual Safety (SESS) instrument, and Drug Avoidance Self-Efficacy Scale (DASES). The secondary outcomes included intentions to have chemsex, actual engagement in chemsex, HIV and other STI testing, and condom use in the last 3 months. All outcomes were self-reported. An online structured questionnaire was used to collect data.

RESULTS

In total, 316 MSM enrolled in the study. The intervention group demonstrated a significantly larger improvement in condom-use self-efficacy (as measured by CSES scores; time-by-group interaction: β=4.52, 95% CI 2.03-7.02; P<.001), self-efficacy for sexual safety (as measured by SESS scores; time-by-group interaction: β=2.11, 95% CI 0.66-3.56; P=.004), and drug avoidance self-efficacy (as measured by DASES scores; time-by-group interaction: β=6.98, 95% CI 1.75-12.22; P=.009). Regarding the secondary outcomes, participants in the intervention group demonstrated a significantly larger reduction in the likelihood of having engaged in chemsex in the last 3 months (time-by-group interaction: odds ratio [OR]=0.23, 95% CI 0.10-0.53; P=.001) and likelihood of having had the intention to engage in chemsex in the last 3 months (time-by-group interaction: OR=0.37, 95% CI 0.18-0.78; P=.009). Participants in the intervention group also showed a significantly larger increase in the likelihood of having undergone HIV testing in the last 3 months (time-by-group interaction: OR=3.08, 95% CI 1.72-5.54; P<.001).

CONCLUSIONS

This study suggests that a web-based intervention with a harm reduction approach can enhance the self-efficacy of MSM in refusing risky sexual behaviors and chemsex and improve the uptake of HIV testing. We also provide initial evidence that such interventions can reduce both the intention of MSM to engage in chemsex and their actual engagement in chemsex.

TRIAL REGISTRATION

ISRCTN Registry ISRCTN20134522; https://www.isrctn.com/ISRCTN20134522.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

RR2-10.1186/s12889-021-10742-8.

Pre-Exposure Prophylaxis Users' Attitudes About Sexually Transmitted Infections and Its Influence on Condom Use: A Mixed-Method Study in Belgium

Incidence rates of sexually transmitted infections (STIs) are rising among men who have sex with men (MSM). Since the rollout of HIV pre-exposure prophylaxis (PrEP), promoting condom use to prevent the spread of STIs has become more challenging. Using a mixed-method design, we explored MSM PrEP users' attitudes toward STIs, condoms, and condom use with nonsteady partners to prevent STIs. We triangulated data from 22 in-depth interviews conducted at a large HIV/STI clinic between August 2021 and January 2022 and an online survey among 326 PrEP users between September 2020 and January 2022. Interviews were analyzed iteratively using a thematic analysis approach. We used bivariate and multi-variate ordered logistic regression to analyze the online survey data. Themes identified in the qualitative data influencing condom use decisions to prevent STIs were as follows: (1) awareness (i.e., perceived severity of and susceptibility to STIs, condom counseling), (2) motivation (i.e., concerns about STIs, sexual pleasure and protection of own health), and (3) perceived social norms and practices (e.g., reduced condom use at community level). Overall, 10.7% of survey respondents consistently used condoms with nonsteady partners. Survey respondents who reported high or moderate levels of willingness to use condoms to prevent acquiring STIs were significantly more likely to use condoms for anal sex with nonsteady partners; those who initiated PrEP 6-12 months ago were less likely to use condoms. We found a wide variation in attitudes toward condom use for the prevention of STIs among MSM using PrEP. We recommend client-centered approaches, taking into account PrEP users' values and priorities toward STI prevention to help reduce the spread of STIs.

Protocol for an attention-matched randomized controlled trial of 2GETHER: a relationship education and HIV prevention program for young male couples

BACKGROUND

Young men who have sex with men (YMSM) are disproportionately impacted by the HIV epidemic in the USA, and a large number of new infections among YMSM occur in the context of main or primary partnerships. At the same time, healthy romantic relationships promote health and wellbeing by improving social support and encouraging healthy behaviors. Thus, we created 2GETHER: a relationship education and HIV prevention program for young male couples. 2GETHER is delivered face-to-face in a university setting and is composed of two group sessions and two individualized skills coaching sessions. We observed strong support of the feasibility, acceptability, and preliminary efficacy of 2GETHER in a pilot trial.

METHODS

We are conducting an attention-matched randomized controlled trial (RCT) to test the efficacy of 2GETHER relative to a control condition based on a well-validated positive affect enhancement program. Enrollment occurred between August 2017 and March 2021 in Chicago and surrounding areas, and we enrolled and randomized 128 dyads (N = 256 individuals). Follow-up is ongoing and we will examine primary and secondary behavioral outcomes at 12 months post-intervention, with interim follow-up at 3, 6, and 9 months post-intervention. The primary biomedical outcome is sexually transmitted infection incidence at a 12-month follow-up.

DISCUSSION

2GETHER is innovative in that it places an equal emphasis on relationship skill building and HIV prevention. Thus, the program has the potential to impact numerous health-related outcomes. Despite challenges related to the recruitment of couples and the COVID-19 pandemic, we were able to enroll a robust sample of young male couples with sufficient power to detect effects on study outcomes.

TRIAL REGISTRATION

ClinicalTrials.gov NCT03186534 .

The First 40 Years of AIDS: Promising Programs, Limited Success

HIV-prevention program planning, implementation, and evaluation began in the United States shortly after reports of a mysterious, apparently acquired, immune deficiency syndrome appeared in summer 1981. In San Francisco, New York City, and elsewhere, members of LGBT communities responded by providing accurate information, giving support, and raising money. During the first decade of the AIDS pandemic (1981–1990), social and behavioral scientists contributed by designing theory-based and practical interventions, combining interventions into programs, and measuring impact on behavior change and HIV incidence. In the second decade (1991–2000), federal, state, and local agencies and organizations played a more prominent role in establishing policies and procedures, funding research and programs, and determining the direction of intervention efforts. In the third decade (2001–2010), biomedical interventions were prioritized over behavioral interventions and have dominated attempts in the fourth decade (2011–2020) to integrate biomedical, behavioral, and structural interventions into coherent, efficient, and cost-effective programs to end AIDS.