Relationship characteristics and sexual risk-taking in young men who have sex with men

Latent Class Analysis of Sexual Partnerships and Substance Use Across Generations

Sexually transmitted infections (STIs) remain an important public health concern for people of all age groups, with older age groups experiencing a notable increase in STI burden. Historically, most research into STI risk behaviors has focused on adolescents and young adults, leaving a paucity of research on the ways STI risk factors change over the life course. Additionally, age and cohort trends in STI risk factors can be challenging to investigate with standard statistical tools as they can be collinear and are subject to sociocultural and generational influences. To help address these issues, we used multi-group latent class analysis to identify and compare risk behavior profiles defined by responses to three sexual activity and three substance use variables, across and within four age groups. We identified six behavior profiles in the unstratified dataset and five behavior profiles in each of the four age stratified groups. The five behavior profiles identified in each of the age categories appear to reflect a similar set of five underlying profile "archetypes," with the exact composition of each age category's five profiles varying in the magnitude that specific behaviors are endorsed. Interestingly, despite the similarity of profiles across the four age groups, analyses indicate that the experience of belonging to any one of these five archetypes differs by age group. This variance is likely due group specific age, period, and cohort effects, and may indicate that, when estimating one's STI risk, it is better to compare them to their peers than to the population as a whole.

Structural disadvantage and HIV risk - comparing risk factors between trans women's partnerships with cis men and trans women sexual partners

Introduction

Little is known about differences in HIV risk for trans women by partner gender, particularly with respect to social determinants and partner-level circumstances that affect behavior. We examined differences in demographic, social determinants, and HIV-related risk behaviors for trans women with cis men and trans women sexual partners.

Materials and Methods

Data are from a cross-sectional survey of trans women and their sexual partners conducted between April 2020 and January 2021. Interviews were held remotely during shelter-in-place due to Covid-19 via videoconference. Analysis characterizedassociations between HIV risk and protective behaviors comparing trans women with cisgender men partners to trans women with non-cisgender sexual partners.

Results

A total of 336 sexual partners were identified from 156 trans women. Trans women with cis men partners had significantly less education and employment and more incarceration and recidivism than trans women with trans women partners. Trans women and their cisgender men partners had shared experiences of unstable housing, incarceration, and HIV. Trans women with cisgender men partners reported significantly more sex exchange partners, receptive condomless sex, receptive or insertive condomless sex while using substances, and HIV infection compared to trans women with trans women partners.

Conclusions

Trans women with cisgender men sexual partners faced higher HIV risk than trans women with trans women sexual partners. These risks may be related to the social and economic drivers that both trans women and their cis men partners faced, including barriers to education and employment, along with incarceration and recidivism. Interventions focused on economic stability, workforce development and post incarceration re-entry support for housing and employment for trans women with cis men partners and the cisgender men partners as well may have the most impact on reducing HIV risk and incidence.

Comparing Repeated (Annual) Couples HIV Testing and Counseling to Individual HIV Testing and Counseling Among Male Couples at High Risk of HIV Infection: Protocol for a Randomized Control Trial

BACKGROUND

Couples HIV testing and counseling (CHTC) is now a standard of care prevention strategy recommended by the Centers for Disease Control and Prevention for sexual minority men (SMM) in relationships. Despite standard recommendations that couples complete CHTC every 6-12 months, no study has empirically evaluated the effects associated with CHTC retesting.

OBJECTIVE

This study aims to understand the benefits associated with continued dyadic engagement in the HIV prevention continuum through routine CHTC retesting, which is of particular importance for emerging-adult SMM in relationships who use drugs.

METHODS

Eligible couples for this CHTC retesting trial must already be enrolled in the 4Us trial, where they completed a CHTC session after their baseline survey. The purpose of the original 4Us trial was to test the efficacy of 2 intervention components for CHTC: a communication skills training video and a substance use module. Couples were eligible for the original 4Us trial if they identified as cisgender male, were in a relationship for 3 months or longer, were aged 17 years or older, and communicated in English. At least 1 partner had to be aged 17-29 years, report HIV negative or unknown serostatus, report use of at least 1 drug (cannabis, cocaine or crack, crystal methamphetamine, ketamine, gamma-hydroxybuterate [GHB], psychedelics, ecstasy, prescription medication misuse, opiates, and nitrates) use, and engage in condomless anal sex (CAS) acts with a casual partner or have a main partner who is nonmonogamous or serodiscordant. Those who complete the 4Us 12-month follow-up and remain in a relationship with the partner they participated in 4Us with are offered the opportunity to participate in this CHTC retesting trial. Those consenting are randomized to either CHTC retesting or individual HIV testing. Follow-up assessments are conducted 3 and 6 months after randomization to evaluate the effects of repeat CHTC on 2 primary outcomes: (1) CAS with a casual partner in the absence of preexposure prophylaxis (PrEP), and (2) CAS with a serodiscordant main partner who is not virally suppressed or concurrent CAS between main and casual partners in the absence of PrEP.

RESULTS

The CHTC retesting trial launched in January 2023, and enrollment is ongoing. As of February 2024, the study had enrolled 106 eligible participants (n=53 couples).

CONCLUSIONS

Findings from this CHTC retesting study will contribute to knowledge about the benefits associated with regular (repeated) CHTC testing versus routine individual HIV testing for SMM in relationships. The results of this trial will inform CHTC retesting guidance.

TRIAL REGISTRATION

ClinicalTrials.gov NCT05833074; htps://www.clinicaltrials.gov/study/NCT05833074.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

DERR1-10.2196/53023.

Substance use and variation in sexual partnership rates among young MSM and young transgender women: Disaggregating between and within-person associations

BACKGROUND

Substance use has been extensively linked to sexual behavior and HIV/STI risk among men who have sex with men (MSM) and transgender women (TW). However, the impact of specific substances and on specific partnership types is not well characterized. The current study seeks to estimate the association between specific substances and partnership rates while carefully disaggregating between and within-person associations to characterize the nature of these associations and inform prevention interventions.

METHODS

Using data from a longitudinal cohort (n = 1159) of young MSM (YMSM) and young TW (YTW), we utilized a series of hybrid mixed effect models to estimate the associations between substance use (i.e., heavy episodic drinking [HED], marijuana, cocaine, ecstasy, methamphetamine, poppers, prescription stimulant, prescription painkiller, and prescription depressants) and partnerships (i.e., one-time, casual, and main).

RESULTS

Results from multivariable models indicated people using substances had higher one-time (HED, poppers) and casual (HED, methamphetamine, poppers) partnership rates. In addition, participants reported higher rates of one-time (HED, ecstasy, methamphetamine, poppers) and casual partners (HED, marijuana, cocaine, methamphetamines, poppers) during periods of substance use.

CONCLUSION

These findings confirm that the highest rates of sexual activity occur among YMSM-YTW using substances during periods of substance use. Yet, these findings should caution researchers against simplistic generalizations as these associations differ across substance and partnership types. Efforts to promote the health of MSM-YTW who use substances should carefully consider this complexity as interventions accounting for the unique cultural context of substance use in these populations are most likely to be successful.

Biomedical and behavioral outcomes of 2GETHER: A randomized controlled trial of a telehealth HIV prevention program for young male couples

OBJECTIVE

This study evaluated the efficacy of the 2GETHER relationship education and HIV prevention program for young male couples in reducing risk for HIV.

METHOD

We conducted a comparative effectiveness randomized controlled trial of 2GETHER, a five-session hybrid group- and couple-based intervention delivered via videoconference, relative to a single-session HIV testing and risk reduction counseling protocol delivered to couples. We randomized 200 young male couples (N = 400) to 2GETHER or control from 2018 to 2020. Primary biomedical (i.e., rectal Chlamydia and Gonorrhea infection) and behavioral outcomes (i.e., condomless anal sex [CAS]) were measured at 12-months postintervention. Secondary outcomes were other HIV prevention and risk behaviors, relationship quality, and substance use. Multilevel regression was used to model intervention outcomes to account for clustering within couples. Postintervention change over time was modeled as a latent linear growth curve at the within-persons level.

RESULTS

We observed significant intervention effects on primary biomedical and behavioral HIV risk outcomes. Participants in 2GETHER had significantly lower odds of rectal STIs at 12-months relative to control. We also observed significantly steeper declines in the number of CAS partners and acts from baseline to 12-month follow-up in 2GETHER relative to control. Few differences were observed for secondary relationship and HIV-related outcomes.

CONCLUSIONS

2GETHER is an efficacious intervention that has a significant impact on both biomedical and behavioral HIV prevention outcomes among male couples. Couple-based HIV prevention programs enhanced with evidence-based relationship education may effectively reduce the most proximal predictors of HIV infection. (PsycInfo Database Record (c) 2023 APA, all rights reserved).

Exposure to Pornography and Adolescent Sexual Behavior: Systematic Review

BACKGROUND

Formative experiences in adolescence lay the foundation for healthy and pleasurable romantic and sexual relationships. Exposure to pornography may affect these experiences.

OBJECTIVE

We aimed to synthesize evidence published in the past decade on the relationship between exposure to pornography and sexual behavior (earlier age of first sex [<16 years], condomless sex, past-year multiple partners [>1], lifetime multiple partners [>1], group sex, sexual aggression including forced sex, paid sex, teenage pregnancy, and history of sexually transmitted infection) in adolescents aged between 10 and 19 years.

METHODS

We identified 19 eligible studies by searching MEDLINE, PsycINFO, Cochrane, CINAHL, Embase, and Web of Science databases from January 2010 to November 2022.

RESULTS

Out of 8 studies that assessed earlier age of first sex, 5 studies, including 1 longitudinal study, found a statistically significant association with exposure to pornography. Given that most studies were cross-sectional or had substantial limitations, causal inference could not be made. Also, exposure to pornography was not measured consistently. The evidence was conflicting or insufficient to draw any conclusions regarding other outcomes.

CONCLUSIONS

More quantitative research is needed to elucidate the association between pornography exposure and sexual behavior, and sex education should adopt evidence-based approaches to minimize the potential harms from pornography.

TRIAL REGISTRATION

PROSPERO International Prospective Register of Systematic Reviews CRD42021227390; https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=227390.

Assessing the Underestimation of HIV Risk Infection among Young Men Who Have Sex with Men in Argentina

The aim of this study is to describe the discordance between the self-perceived risk and actual risk of HIV among young men who have sex with men (YMSM) and its associated factors. An online, cross-sectional study was conducted with 405 men recruited from an Argentinian NGO in 2017. Risk discordance (RD) was defined as the expression of the underestimation of risk, that is, as a lower self-perception of HIV risk, as measured with the Perceived Risk of HIV Scale, than the current risk of HIV infection, as measured by the HIV Incidence Risk Index. Multivariate logistic regression models were used to analyze the associations between the RD and the explanatory variables. High HIV risk was detected in 251 (62%), while 106 (26.2%) showed high self-perceived risk. RD was found in 230 (56.8%) YMSM. The predictors that increased RD were consistent condom use with casual partners (aOR = 3.8 [CI 95:1.5-11.0]), the use of Growler to meet partners (aOR = 10.38 [CI 95:161-121.94]), frequenting gay bars (aOR = 1.9 [95% CI:1.1-3.5]) and using LSD (aOR = 5.44 [CI 95:1.32-30.29]). Underestimation of HIV risk in YMSM is associated with standard HIV risk behavior and modulated by psychosocial aspects. Thus, prevention campaigns aimed at YMSM should include these factors, even though clinical practice does not. Health professionals should reconsider adapting their instruments to measure the risk of HIV in YMSM. It is unknown what score should be used for targeting high-risk YMSM, so more research is needed to fill this gap. Further research is needed to assess what score should be used for targeting high-risk in YMSM.

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 .

Substance use is associated with condomless anal intercourse among men who have sex with men in India: a partner-level analysis

BACKGROUND

Men who have sex with men (MSM) bear a disproportionately high burden of new HIV infections while lagging behind other populations with respect to engagement across the HIV care continuum. General risk factors for condomless anal intercourse (CAI) among MSM are well studied but there is a paucity of partner-level data, where emerging evidence suggests that much of the variation in condom use occurs.

METHODS

MSM were recruited across 10 cities in India using respondent-driven sampling (RDS) from 2016-17. Among the individuals who reported sexual intercourse in the prior 6 months, condom use and partner characteristics of the last 4 partners were captured. Correlates of CAI at the individual and partner level were determined using Poisson regression models using generalized estimating equations and incorporating RDS-II weights, which weights estimates for the participant's network size.

RESULTS

Among the 8,086 individuals, 21,723 sexual partnerships were analyzed. The prevalence of CAI was 46.9% and most partners were casual or one-time (70.7%) with partner HIV status reported as unknown in 42.6% of the sexual encounters. In multivariable analyses, partner-level characteristics associated with higher likelihood of CAI included unknown partner HIV status (aPR vs. known HIV negative partner: 1.34; 95% confidence interval (CI): 1.27-1.43) and use of alcohol/ drugs prior to intercourse either sometimes (aPR 1.42; 95% CI: 1.33-1.51) or always (aPR 1.31; 95% CI: 1.23-1.41). At an individual level, any HIV treatment literacy was associated with a lower likelihood of CAI (aPR 0.80; 95% CI: 0.74-0.86).

CONCLUSIONS

To reduce HIV transmission among this population of MSM across India, combination interventions are likely needed. Interventions targeting substance use and education as well as initiatives to increase self-testing are urgently needed among MSM in India and have the potential to reduce HIV transmission in this high-risk population. Trial registration ClinicalTrials.gov Identifier: NCT01686750. Date of Registration: September 18, 2012.

Inter-partner Agreement of Condom Use and Sexual Positioning in Male Couples

Accurate, reliable self-reports of sexual behavior are a crucial component of valid HIV risk-estimation and behavioral intervention evaluation, yet this data's reliability remains understudied. The goal of this study was to describe interpartner agreement on recent receptive anal intercourse (AI) and condomless receptive AI frequencies, among a sample of male couples. We quantified interpartner agreement on self-reported receptive AI and condomless receptive AI (absolute and relative to AI frequency), and position and condom use during a couple's most recent AI, using cross-sectional data from male partners (US, 2016-2017; N = 718 individuals). Proportional and statistical agreement (intraclass correlation coefficients (ICC), kappa (k)) were assessed. Observed agreement for receptive AI frequency was 49.44% (ICC (95% CI): 0.82(0.79, 0.84)) and for relative receptive frequency, 59.05% (ICC: 0.96 (0.85, 0.96). Agreement on condomless receptive AI was 90.21% (ICC: 0.78 (0.75, 0.82), and for relative condomless receptive AI, 91.15% (ICC: 0.80 (0.77, 0.83). Most recent AI position agreement was 89.42% (k (95% CI): 0.84 (0.80, 0.88)), and condom use, 98.89% (k: 0.82 (0.87, 0.98)). Observed agreement was higher among those who reported consistent positioning and condom use. Further research on self-reported sexual behavior data is needed to improve research validity and intervention effectiveness.

Association of CAI Vulnerability and Sexual Minority Victimization Distress Among Adolescent Men Who Have Sex With Men

Adolescent men who have sex with men (AMSM) are at high HIV risk. Condomless anal intercourse (CAI) increases HIV risk and has been associated with interpersonal power imbalances, such as asymmetries in decision-making authority, social status, and emotional dependence, between male sexual partners. AMSM experience high levels of psychological and physical victimization due to their sexual minority status. Sexual minority victimization (SMV) is similarly associated with low interpersonal power and may relate to the extent to which AMSM are vulnerable to partner influences to engage in CAI. This online survey study of AMSM 14-17 years (N = 143) tested the hypothesis that experiences and attitudes reflecting vulnerability to partner CAI influence (CAI Vulnerability) and distress in response to experienced sexual minority victimization (SMV Distress) would be positively associated with participant and partner condom non-use during anal sex (CAI frequency). Approximately 35% reported they or their partner(s) had never or rarely used a condom. Positive correlations were found among partners' CAI frequency during sex with the participant, CAI Vulnerability, and SMV Distress. Multiple regression indicated CAI Vulnerability significantly accounted for the relation between SMV Distress and partner's CAI frequency. Findings suggest that distress in response to SMV may be associated with a diminished sense of interpersonal control resulting in CAI Vulnerability and subsequent more frequent instances of partner CAI. HIV prevention strategies designed to increase condom use among AMSM have the potential to benefit from procedures aimed at increasing interpersonal sexual assertiveness and decreasing distress associated with sexual minority victimization.

Psychosocial Support, Sexual Health, and HIV Risk among Older Men Who Have Sex with Younger Men

This study examines the extent to which older males are willing to offer psychosocial and sexual health promoting support to their younger male partners, as well as the individual and relationship-level factors associated with this willingness to provide support. In total, 324 men over the age of 45, who currently or previously had younger male sexual partners, completed an anonymous online survey. Results show that participants were most willing to provide emotional support to their younger male partners, followed by health-related encouragement, HIV/STI testing support, and financial support. Of note, HIV positive status and being in a "main partnership" were associated with greater willingness to provide financial support. These results suggest that older men are willing to provide psychosocial and health promotive support to younger male partners, which could be leveraged in targeted interventions to reduce HIV transmission.

Acceptability and Feasibility of a Telehealth Intervention for STI Testing Among Male Couples

Partnered gay, bisexual and other men who have sex with men (GBMSM) are less likely to engage in HIV and STI testing. We enrolled 51 male couples from a larger study of home HIV testing to test the feasibility of a dyadic home STI testing intervention delivered via telehealth, consisting of two telehealth sessions delivered via video-chat. In the first session, an interventionist demonstrated the specimen collection kits. In the second session, an interventionist delivered the STI results. Participants reported very high levels of acceptability of the intervention: 92% reported the telehealth calls quality as very good, 99% reported the sample collection instructions were clear, and 96% of respondents returned specimens for collection. 9% of participants tested positive for chlamydia or gonorrhea, and all were linked to care. The intervention has the potential to surmount economic, physical and stigma-related barriers to attending clinics for STI testing, but these results need to be further tested in more diverse samples of male couples.

Cannabis and Alcohol Co-Use and Condomless Anal Sex Among Men Who have Sex with Men Living with HIV: An Event-Level Analysis

Men who have sex with men (MSM) account for more than two thirds of new HIV diagnoses annually. Sexual behavior that increases risk for onward transmission of HIV is associated with both alcohol and cannabis use. However, little is known about the influence of cannabis and alcohol co-use on engagement in condomless anal sex (CAS). The current study explored daily associations between substance use and CAS among HIV-positive MSM using a 42-day timeline followback interview (N = 101). Generalized estimating equation (GEE) logistic regression models were used to examine the association between cannabis and alcohol co-use and CAS at the sexual event while controlling for study site, condition, adherence to antiretroviral therapy, sex-related alcohol expectancies, and partner type. Participants provided data for 1052 sexual activity days, 60.7% of which involved CAS. Of 638 CAS days, 9.1% involved no substances, 72.0% involved either cannabis or alcohol use, and 18.9% involved cannabis and alcohol co-use. Results indicated that the odds of engaging in CAS were higher for sexual events in which cannabis and alcohol co-use occurred (aOR 2.98; 95% CI 1.27, 6.97) compared to events in which no substance use occurred (p = 0.012), but this relationship was no longer significant when cannabis and alcohol co-use was compared to single substance use (aOR 1.57; 95% CI 0.85, 2.90; p = 0.15). Future research should identify specific substance use (e.g., quantity) and partner characteristics (e.g., level of intoxication) that may uniquely influence the relationship between cannabis and alcohol co-use and condomless sex.

Patterns of Online and Offline Partnering, Partnership Characteristics, and Condomless Sex Among Adolescent Sexual Minority Males in the USA

Online partner-seeking among adolescent sexual minority males (ASMM) has been associated with condomless anal sex. Two hypotheses may explain this association: that online venues facilitate HIV transmission risk behavior more than offline venues (accentuation), or that individuals who tend to engage in these behaviors are more likely to seek partners online (self-selection). We examined these hypotheses in 700 13-18 year-old ASMM who completed the baseline survey of an effectiveness trial of an HIV prevention program in 2018-2020. The survey assessed demographic, sexual, and venue characteristics of male anal sex partnerships in the past 3 months. Many participants (83%) reported ≥ 1 online-met partner; most were met via sexual networking applications and were older than offline-met partners. Having met partners online, but not whether a particular partner was met online, was associated with greater odds of receptive condomless sex. Findings support the self-selection hypothesis, which has implications for HIV prevention in ASMM.

Individual and partnership characteristics associated with consistent condom use in a cohort of cisgender men who have sex with men and transgender women in Nigeria

BACKGROUND

This study reports on the individual and partnership characteristics that influence consistent condom use in cisgender men who have sex with men (MSM) and transgender women (TGW) attending trusted community centers that provide HIV prevention and treatment services in Nigeria.

METHODS

Adults assigned male at birth who reported anal sex with male partners who enrolled between March 2013-2019 and had information about at least one male sexual partner were included in these analyses. At enrollment and follow-up visits every 3 months for up to 18 months, participants were administered detailed questionnaires that collected information about demographics, sexual practices, HIV risk behaviors, and characteristics and behaviors of their partners in the previous year (at enrollment) or the preceding 3 to 6-months (at follow-up visits). Logistic regression models with generalized estimating equations were used to assess the odds ratio (OR) and 95% confidence intervals (CI) of individual, partner, and partnership characteristics associated with consistent condom use (CCU). A participant was defined as consistently using condom if they reported always using condoms all the time they had insertive, receptive or both types of anal sex with a male partner.

RESULTS

At the individual level, CCU was positively associated with higher education, disclosure of key population status to a healthcare worker and negatively associated with poor access to condoms. At the partner and partnership level, CCU was associated with partners with higher education (aOR: 1.36; 95% CI: 1.07-1.72), casual relationships (aOR: 1.22; 95% CI: 1.11-1.34) and relationships in which partners encouraged the participant to use condoms with other partners (aOR: 1.14; 95% CI: 1.02-1.28). Relationships in which the partner was married to a woman and/or the partner's HIV status positive or unknown were negatively associated with CCU.

CONCLUSIONS

These findings suggest that individuals in relationships where partners were more open and encouraged safer sex were more likely to consistently use condoms. HIV prevention programs should consider leveraging communication to sexual partners to encourage condom use as this may support condom use with other sexual partners. Given sustained and growing HIV and STI epidemics among MSM and TGW, even with pre-exposure prophylaxis scale-up, it is crucial to continue to study optimal implementation strategies to increase condom use.

Profiles of HIV Risk, Sexual Power, and Decision-Making among Sexual Minority Men of Color Who Engage in Transactional Sex: A Latent Profile Analysis

Though the transmission of HIV is preventable, there were still 37,968 new documented cases in the United States in 2018. HIV incidence is disproportionate in sexual minority men of color. The purpose of this study was to examine sexual relationship power risk profiles to identify distinct subgroups within the profiles who carry the highest HIV risk. Latent class profile analysis was used to identify subgroups of sexual minority men of color at the highest risk for contracting HIV based on their sexual power profiles. Among 322 sexual minority men, we identified four latent profiles. Profile 1: Low transactional sex and high power (n = 133; 14.3%); Profile 2: Transactional sex, high decision-making in sexual relationships, and low control in sexual relationship (n = 99; 30.7%); Profile 3: Low transactional sex, low decision-making, and moderate control (n = 43; 13.4%); Profile 4: High transactional sex and low power (n = 47; 14.6%). LPA was useful to identify distinct subgroups based on measures of sexual risk and relationship sexual power. Findings carry significant implications for developing tailored strategies to increase HIV knowledge and related HIV prevention and risk reduction services for sexual minority men of color who engage in transactional sex.

The PrEP Cascade in a National Cohort of Adolescent Men Who Have Sex With Men

BACKGROUND

Pre-exposure prophylaxis (PrEP) has been an available biomedical intervention for at-risk adolescents for over 2 years; however, progression from awareness to uptake and adherence has been slow. In response, we map adolescent men who have sex with men (AMSM) onto the PrEP Motivation Cascade to identify stages for intervention.

METHODS

We analyzed PrEP-related attitudinal and behavioral data from a US national cohort of 1398 AMSM.

RESULTS

A majority of the sample (53.9%) were identified as appropriate PrEP candidates. Of those identified as appropriate candidates, 51.8% were precontemplative (stage 1; unwilling to take or believing they were inappropriate candidates for PrEP), and 48.2% reached contemplation (stage 2; willing and self-identified as appropriate candidates). Only 16.3% of candidates reached preparation (stage 3; seeing PrEP as accessible and planning to initiate PrEP), and 3.1% reached PrEP action (stage 4; prescribed PrEP). Although few of the AMSM identified as appropriate candidates were on PrEP, most users (87%) reported high adherence to 4+ doses per week (stage 5; PrEP maintenance). Factors associated with reaching later stages were being older, being out to parents, and engaging in previous HIV/sexually transmitted infection testing.

CONCLUSIONS

AMSM PrEP use falls short of recommended levels. PrEP campaigns are needed to raise awareness by targeting key AMSM subgroups that underestimate the appropriateness of use. Equally important, parents and health providers of AMSM should serve educational roles to help facilitate potential PrEP uptake, by motivating adolescents and giving them the skills needed to request, fill, and adhere to a prescription.

Minority Stressors and Identity Affirmation as Predictors of Condomless Sex Among Self-Identified Bisexual Men: The Role of Partner Gender

Bisexual men are at increased risk for HIV/STI and early pregnancy involvement compared to heterosexual men, and minority stressors (e.g., enacted and internalized stigma) are associated with sexual risk behavior in samples of gay and bisexual men. However, few studies have specifically focused on bisexual men, and little is known about the unique predictors of sexual risk behavior in this population. Further, few studies have focused on positive sexual orientation-related factors such as identity affirmation, which may be protective against sexual risk behavior. As such, the goals of the current study were to examine minority stressors and identity affirmation as predictors of condomless sex among self-identified bisexual men, and whether these associations differed as a function of partner gender. We used four waves of data spanning 24 months from a subset of self-identified bisexual men in a larger cohort of gay and bisexual men ages 16-29 years at enrollment. At each wave, participants reported on up to four partners, allowing us to examine within-person associations. We used mixed effects negative binomial models to examine the associations between our predictors (discrimination, internalized binegativity, and identity affirmation) and condomless sex acts. In addition, we tested whether partner gender moderated each of the associations by including interaction effects in each of the models. Results indicated that higher levels of internalized binegativity and lower levels of identity affirmation were associated with less condomless sex with female partners, but they were not associated with condomless sex with male partners. Discrimination was not associated with condomless sex with male or female partners. These findings suggest that predictors of condom use among self-identified bisexual men differ as a function of partner gender, and they highlight the need to identify strategies to promote sexual health while also supporting positive identity development in this population.

Assessing the Reliability of Self-Reported Sexual Behavior Among Male Couples

Coupled gay, bisexual, and other men who have sex with men (GBMSM) are at particularly high risk for HIV, and a clear understanding of behavioral risk is key to effective interventions. Accurate behavioral self-reports are a crucial component of valid sexual health research, yet reliability of these data remains understudied. This study aimed to quantify and identify predictors of dyadic discordance in reported 3-month anal intercourse (AI) occurrence and frequency. Using cross-sectional data from 407 male couples in the U.S. (2016-2017), we calculated proportional dyadic concordance and used dyad-level logistic and linear regression to identify demographic, behavioral, and relationship traits associated with the odds of discordant frequency reports and the relative difference between discordant partner reports. Couples had high levels of concordant reports of 3-month anal AI occurrence (97%) but low interpartner agreement in reported frequency (37%). After adjustment, the odds of discordance were significantly associated with dyadic employment and differences on the Communal Coping to Reduce HIV Threat Scale (CCS) (p < .05). Among frequency-discordant couples, the mean relative difference between partner reports was 52.80% ± 35.91% (M ± SD). After adjustment, relative differences between partners' reported AI frequencies were positively associated with interpartner differences in CCS (p < .05). These results indicate that among GBMSM couples in committed partnerships, self-reported sexual behavior data may be impacted by granularity, recall, and relationship characteristics. Further research in this area is warranted to better understand measurement error in self-reported sexual activity data.

Developmental Barriers to Couples' HIV Testing and Counseling Among Adolescent Sexual Minority Males: A Dyadic Socio-ecological Perspective

Couples HIV Testing and Counseling (CHTC) is now a standard of care for partnered sexual minority men. While adolescent sexual minority men (ASMM; ages 15-19) face disproportionate HIV risk, the emergent nature of relationships and communication skills may present challenges to accessing and engaging in CHTC. This study utilized qualitative data from 28 ASMM recruited in 4 urban centers in the USA during the formative stage of Adolescent Trials Network study ATN-156. Participants were cis-male, HIV-negative, and in a relationship with a similarly-aged cis-male partner. Thematic analysis indicated low and high levels of commitment were barriers to CHTC. Concerns about caregiver attitudes towards HIV testing were salient. Adolescents' perception of structural barriers highlighted reliance on caregiver resources, which limited access to sexual health services. Prevention programming must address structural barriers to access encountered by adolescents. ASMM in relationships may benefit from programming that includes options for individual and dyadic participation.

Sexual risk-taking among young Swedish men testing for STI

OBJECTIVES

This study investigates sexual risk-taking among young men testing for sexually transmitted infections (STI).

SAMPLING METHOD

452 participants (aged 18-30) completed surveys concerning their backgrounds, sexual risk-taking, and experience with STI.

RESULTS

Over one-third had used alcohol during their last sexual encounter, one-fifth were reluctant to use condoms due to concerns about erection difficulties, 14.7% had experienced sexual coercion and one-fifth reported having had contracted the most common STI, chlamydia trachomatis (CT). Older participants (aged 25-30) were more reluctant to use condoms because of erection worries and to report having had CT. Immigrant men reported more unprotected sex while men who have sex with men (MSM) were more exposed to sexual coercion than others, but less likely to use alcohol when having sex.

CONCLUSIONS

There are important differences in sexual risk-taking within the group of young men testing for sexually transmitted infections which need to be taken into account in developing effective counselling and promotion strategies in sexual and reproductive health care. Further research on young men's sexual risk-taking is needed to broaden understanding of factors associated with young men's sexual health.

Delivering PrEP to adults with "low" or "no" HIV risk and youth: experiences and perspectives of PrEP providers

Health care providers have an important role to play in expanding PrEP uptake to populations disproportionately burdened by HIV. In this study, in-depth, semi-structured qualitative interviews were conducted with 20 PrEP providers in Los Angeles, California to explore their experiences and perspectives prescribing PrEP. Overall, the findings indicate that providers generally adhered to US CDC clinical guidelines in determining PrEP eligibility. However, they also identified special considerations with respect to adults with "low" or "no" HIV risk. Three themes were developed from the data related to the delivery of PrEP to such individuals: 1) patients may not disclose sexual behaviours; 2) patient autonomy and agency; and 3) the importance of PrEP in gay male monogamous relationships. Two additional themes were identified related to prescribing PrEP to young people under the age of consent: 4) the need for more PrEP and sexual health education with youth and 5) challenges in providing PrEP to youth without parental consent. Findings highlight the importance of providing PrEP to patients who could potentially benefit from adoption, whether or not they present with clear behavioural indicators for PrEP. Providers should also consider the potential barriers to delivering PrEP to youth to ensure successful adoption among members of this population.

Examining the Effect of Internalized HIV-Related Stigma on Perceptions of Research Participation among HIV-Positive African American Women

HIV-related stigma may influence ethical concerns in health disparity populations, particularly groups with histories of race, gender, and class oppression in medical research such as African American women. However, a dearth of research has examined how HIV-related stigma influences perceptions of the research process among African American women who participate in health research. The goal of the current study was to examine whether HIV-related stigma experienced on the micro-level, specifically internalized HIV-related stigma, is associated with reactions to research participation in 5 domains: attitudes toward participation, perceptions of research benefits, emotional reactions, perceived drawbacks of the research, and global evaluations of the research. We also examine whether internalized HIV-related stigma is associated with difficulty in answering questions related to sensitive topics. We found that women with higher levels of internalized HIV-related stigma reported more emotional reactions to research, perceived more drawbacks of the research, and expressed more difficulty in answering sensitive questions. Understanding how HIV-related stigma influences perceived risks and benefits of research participation may play an important role in guiding best practices for ethical engagement with HIV-positive African American women who participate in health research.

Assessing the HIV Prevention Needs of Young Gay and Bisexual Men in the PrEP Era: An Analysis of Trends in Australian Behavioural Surveillance, 2014-2018

Data from repeated, national behavioural HIV surveillance was used to identify similarities and differences between young gay and bisexual men (YGBM) aged 16-24 (n = 1608) and older GBM aged 25-49 (n = 6266), in order to quantify risks and identify gaps in HIV prevention. Trend analyses from 2014 to 2018 are also reported. While there were similar rates of condomless anal intercourse with casual partners in both age groups, YGBM had lower rates of HIV testing and PrEP use but also fewer male partners. Our results suggest most YGBM have lower HIV risk than older GBM but a minority merit enhanced testing and prevention efforts.

Exploring Diversity in HIV Research in the Sexual Partnerships of Australian Gay and Bisexual Men

Gay and bisexual men engage in a variety of sexual partnerships, but the most common distinction made in HIV research and behavioral surveillance is a binary between "regular" and "casual" partners. The "regular partner" category is often perceived as pertaining to ongoing coupled "boyfriend" relationships, with the literature to date rarely troubling what actually constitutes a "regular partner." Some emerging literature has identified "fuckbuddy" partnerships as a type of regular partnership requiring attention, but it is relatively new and not well understood. Currently, assumptions of the regular partner category do not capture how men perceive and conduct commitment in different sexual partnerships that could also be considered "regular," and the implications this has for HIV prevention. Drawing on in-depth interviews with a sample of 61 Australian gay-identified men, we explore a diversity of partnership types that represent unique ways of enacting commitment. We identify three sexual partnerships: "fuckbuddies," dating, and serial monogamy, each with specific issues for HIV risk and prevention. These partnerships suggest important differences in the way men conceive of and practice intimacy and sex.

Age- and Race/Ethnicity-Specific Sex Partner Correlates of Condomless Sex in an Online Sample of Hispanic/Latino, Black/African-American, and White Men Who Have Sex with Men

We sought to identify and compare correlates of condomless receptive anal intercourse with HIV-positive or unknown status partners (CRAI) for younger (< 25 years) and older (≥ 25 years) Hispanic/Latino, black/African-American, and white men who have sex with men (MSM). Baseline data from the Evaluation of Rapid HIV Self-Testing among MSM Project (eSTAMP), a randomized controlled trial with MSM (n = 2665, analytical sample size = 2421), were used. Potential correlates included participants' sociodemographic characteristics and HIV status as well as the characteristics of participants' partners. Younger Hispanic/Latino and black men were most likely to report having older sex partners (≥ 50% of partners being at least 5 years older), and having older partners was a significant correlate of CRAI among younger Hispanic/Latino and white men. Regardless of race/ethnicity, not knowing one's HIV status was a significant correlate of CRAI among younger men, whereas having a black sex partner was a significant correlate among older men. HIV prevention initiatives could address these and other correlates specific to race/ethnicity groups to target their prevention resources and messaging.

HIV incidence and risk contributing factors among men who have sex with men in Benin: A prospective cohort study

Men who have sex with Men (MSM) are a key population in the transmission of Human Immunodeficiency Virus (HIV) infection. In Benin, there is a lack of strategic information to offer appropriate interventions for these populations who live hidden due to their stigmatization and discrimination. The objective is to identify contributing factors that affect HIV incidence in the MSM population. Study of a prospective cohort of 358 HIV-negative MSM, aged 18 years and over, reporting having had at least one oral or anal relationship with another man during the last 12 months, prior to recruitment. The monitoring lasted 30 months with a follow-up visit every six months. Univariate analyses and a Cox proportional hazards multivariate regression were used to examine the association between bio-behavioral, socio-demographic and knowledge-related characteristics with HIV incidence. The retention rate for the follow-up of the 358 participants was 94.5%. On the 813.5 person-years of follow-up, 48 seroconversions with an HIV incidence of 5.91 per 100 person-years were observed (95% CI: 4.46–7.85). Factors associated with the high risk of HIV were age (HR = 0.4; 95% CI: 0.2–0.8), living in couple (HR = 0.5 95% CI: 0.2–0.96) and the lack of condom systematic use with a male partner during high-risk sex (HR = 3.9; 95% CI: 1.4–11.1). HIV incidence is high within MSM population and particularly among young people. Targeted, suitable and cost-effective interventions for the delivery of the combination prevention package in an environment free of stigma and discrimination are necessary and vital for reaching the 90x90x90 target.

Characteristics of Sex Events, Partners, and Motivations and Their Associations with HIV-Risk Behavior in a Daily Diary Study of High-Risk Men Who Have Sex with Men (MSM)

In the United States, men who have sex with men (MSM) continue to be at high-risk for HIV and other STIs, and condoms represent the most popular, affordable, and accessible method of prevention. Although a vast body of research has explored various factors associated with condom use in MSM, fewer studies have explored situation-level characteristics that affect their decisions about sex partners and condom use. Daily diary studies are well-suited to help improve our understanding of these event-level factors in detail, including the sex events themselves, partner characteristics, and motivations. As part of a larger study using ecological momentary assessment methods, high-risk MSM completed daily diary surveys about their sexual behavior on their smartphones each day for 30 days. This study explored detailed descriptive characteristics of sex events, partner characteristics, and motivations for sex and condom use, and examined whether specific aspects of these characteristics were associated with having condomless anal sex (CAS) with high-risk partners. High-risk CAS was common among MSM, with the majority of participants having met their partners online and many reporting sex the same day they met. Results showed that the odds of CAS were not higher with partners met online versus those met in other ways, but MSM were more likely to have asked online partners about their HIV status and testing history before sex. The odds of engaging in high-risk CAS was higher when MSM reported intimacy or self-assurance motives. Not having condoms readily available was a CAS motivation reported more commonly when MSM had sex with high-risk partners. Findings suggest that interventions should incorporate strategies that help MSM be safer specifically when meeting partners online and when having sex for intimacy or re-assurance. Interventions that remind MSM to carry condoms at opportune moments may also help reduce some HIV risk.

Associations of spatial mobility with sexual risk behaviors among young men who have sex with men in New York City: A global positioning system (GPS) study

Spatial contexts and spatial mobility are important factors of the HIV epidemic and sexually transmitted infections. Using global positioning system (GPS) devices, we examined the associations of objectively measured spatial mobility with sexual risk behaviors among gay, bisexual and other men who have sex with men (MSM) in New York City. This observational study included a subgroup of 253 HIV-negative MSM from the Project 18 Cohort Study, who participated in the GPS monitoring sub-study. Spatial mobility was measured as (1) distance traveled and (2) activity space size defined as daily path area during 2-week of GPS tracking. We examined the associations of these measures with numbers of male sexual partners and condomless anal intercourse (CAI) acts during last six months using quasi-Poisson models, adjusting for socio-demographics. Results demonstrated that spatial mobility was positively associated with sexual risk behaviors, for example, with CAI (incidence rate ratio [IRR] = 1.01 for a 10 km increase in distance traveled and IRR = 1.04 for a 1 km² increase in 50 m-buffer activity space size). Our findings may enhance the understanding of spatial contexts of HIV risk. Future studies should be conducted to examine the mechanisms for the associations between spatial mobility behaviors with sexual risk behaviors as well as the influence of neighborhood characteristics in various neighborhood contexts, which may guide the place-based HIV prevention services.

High Rates of Unprotected Receptive Anal Intercourse and Their Correlates Among Young and Older MSM in Brazil

The aim of this study was to estimate the prevalence and factors associated with unprotected receptive anal intercourse (URAI), stratified by age (18-24 or 25 + years old), in a sample of 4,129 MSM recruited by respondent driven sampling in 12 Brazilian cities in 2016. The prevalence of URAI was higher among younger MSM (41.9% vs 29.7%) (p < 0.01). Multivariate analysis indicated that perception of risk, sexual identity, self-rated health status, and having commercial sex were associated with URAI among younger MSM. History of sexual violence, sex with younger partners, having 6 + partners and unprotected sexual debut were associated with URAI among older MSM. Marital status, having stable partner, and reporting sex with men only were associated with URAI in both groups. Despite access to condoms and lubricants, preventive efforts may not be reaching MSM effectively. Age specific intervention approaches, including stigma, discrimination, and perception of risk must be considered.

HIV Prevention Method Preferences Within Sexual Partnerships Reported by HIV-Negative MSM and TW in Tijuana, Mexico

To assess the potential for decreased condom use as pre-exposure prophylaxis (PrEP) is scaled-up in Latin America, we examined HIV prevention method preferences (neither PrEP nor condoms, condoms only, PrEP only, or PrEP with condoms) within 1302 sexual partnerships reported by 397 HIV-negative men who have sex with men (MSM) and transgender women (TW) in Tijuana, Mexico. Using PrEP with condoms (56%) was preferred to using condoms only (24%), using PrEP only (17%), and using neither PrEP nor condoms (3%). Compared to using condoms only, using PrEP only was preferred within primary (adjusted odds ratio [AOR] = 4.13, 95% confidence interval [CI] 1.92, 8.90) and condomless sex practicing (AOR = 6.97, 95% CI 3.92, 12.40) partnerships, suggesting PrEP use may not displace condom use among MSM and TW in Tijuana and other similar settings.

Feasibility and Acceptability of an Electronic Health HIV Prevention Toolkit Intervention With Concordant HIV-Negative, Same-Sex Male Couples on Sexual Agreement Outcomes: Pilot Randomized Controlled Trial

BACKGROUND

There is a need to develop innovative and accessible dyadic interventions that provide male couples with the behavioral skills to manage the risk of HIV transmission within their relationship.

OBJECTIVE

We conducted a pilot randomized controlled trial (RCT) to assess the feasibility and acceptability of the electronic health (eHealth) HIV prevention toolkit intervention to encourage seroconcordant negative male couples in the United States to establish and adhere to a sexual agreement (SA).

METHODS

Eligible, consented couples were randomly assigned to the intervention or education control and followed up for 6 months, with assessments occurring every 3 months after baseline. Acceptability items were assessed at both follow-up assessments. Descriptive and comparative statistics summarized cohort characteristics, relationship dynamics, and SA outcomes for the entire cohort and by trial arm. To examine the association between couples' relationship dynamics and their establishment of an SA over time and by trial arm, multilevel logistic regression analyses were performed with a random intercept to account for correlations of repeated measurements of relationship dynamics at months 3 and 6; the odds ratio (OR) of establishment of an SA and the corresponding 95% confidence interval were then reported.

RESULTS

Overall, 7959 individuals initiated screening. Reasons for individual ineligibility varied. An electronic algorithm was used to assess couple-level eligibility, which identified 1080 ineligible and 266 eligible dyads. Eligible couples (n=149) were enrolled in the pilot RCT: 68 received the intervention and 81 received the education control. Retention was 71.5% (213/298 partnered men) over the 6 months. Participants reported high acceptability of the intervention along with some areas for improvement. A significantly higher proportion of couples who received the intervention established an SA at 6 months compared with those who received the education control (32/43, 74% vs 27/50, 54%; P=.05). The OR of establishing an SA for couples in the intervention versus those in the control condition was greater than 2 when controlling for a number of different relationship dynamics. In addition, the odds of establishing an SA increased by 88% to 322% for each unit increase in a variety of averaged relationship dynamic scores; the opposite result was found for dynamics of stigma. Differences between trial arms for SA type and adherence were nonsignificant at each assessment. However, changes in these 2 SA aspects were noted over time. The average number of items couples included in their SA was 18, and about one-fourth to one-third of couples included HIV prevention items.

CONCLUSIONS

The findings demonstrate strong evidence for the acceptability and feasibility of the eHealth toolkit as a brief, stand-alone, couples-based HIV prevention intervention. These findings support the need to update the toolkit and evaluate it in a larger clinical trial powered for efficacy.

TRIAL REGISTRATION

ClinicalTrials.gov NCT02494817; http://clinicaltrials.gov/ct2/show/NCT02494817.

Network-Level Correlates of Sexual Risk Among Male Sex Workers in the United States: A Dyadic Analysis

BACKGROUND

Male sex workers (MSWs) are at increased risk of HIV infection in the United States. Research is limited on sexual and drug use network characteristics of MSWs.

SETTING

Community-based organization and health center in 2 US Northeast cities.

METHODS

One hundred MSWs completed a behavioral assessment and sexual and drug network inventory. Using dyadic analyses, we assessed whether network characteristics, including sex worker-male client age, race, and HIV status homophily and risk multiplexity (ie, overlap in drug-use and sex networks), were associated with condom use.

RESULTS

MSW participants' mean age was 33.6. Two-thirds identified as Black or Latino, 12% identified as heterosexual, and 90% reported recent drug use. Participants reported an average of 5.3 male clients in the past month (SD = 3.4), and having anal sex with 74% of these clients, at a rate of 2.2 times per month (SD = 4.6). Participants reported inconsistent condom use during anal sex with 53% of clients. In multivariable models, inconsistent condom use was more common in relationships with presumed HIV status homophily [odds ratio (OR): 1.25; 95% confidence interval (CI): 1.07 to 1.46] and sexual and drug network multiplexity (OR: 1.19; 95% CI: 1.09 to 1.30); and less common within relationships where the client is older than the MSW participant (OR: 0.83; 95% CI: 0.74 to 0.93). Number of multiplex relationships was positively associated with number of condomless anal sex acts with male clients (incidence rate ratio: 1.35; 95% CI: 1.19 to 1.54).

CONCLUSIONS

Network characteristics may contribute to disproportionate HIV risk among MSWs. Modeling studies should include network characteristics when simulating HIV transmission, and future HIV interventions should address the role of networks.

Discordant Reporting of Partner Labels, HIV Testing and Sexual Behavior Among a Sample of Partnered Men Who have Sex with Men in the US

There is growing evidence that sexual behaviors among male couples are strongly shaped by emotional and quality characteristics of the relationship, and that the labels that men attach to their relationships may indicate how men perceive and engage in risk taking. There has been a lack of attention to how male couples label their relationships, and how discordant understandings of relationship labels may shape HIV risk behavior. Using data from a sample of 804 partnered men who have sex with men, this analysis examines associations between discordant relationship labeling and participation in HIV testing and sexual behavior. Men who labeled their relationship differently from their partners were less likely to have been recently tested for HIV and more likely to engage in sexual risk. The results underscore the need to develop interventions that provide spaces and skills for men to learn how to effectively navigate HIV risks in their relationships.

Relationship Education and HIV Prevention for Young Male Couples Administered Online via Videoconference: Protocol for a National Randomized Controlled Trial of 2GETHER

Background

Young men who have sex with men have a high HIV incidence, and a substantial proportion of incident infections occur in the context of main partnerships. However, romantic relationships also provide numerous benefits to individual health and wellbeing. 2GETHER is a relationship education and HIV prevention program for young male couples, and the 2GETHER USA randomized controlled trial (RCT) was launched to establish the efficacy of an online version of 2GETHER.

Objective

The objective of 2GETHER is to optimize relationship functioning in young male couples as a method to improve communication about sexual risk behaviors and reduce HIV transmission. In the 2GETHER USA study, 2GETHER was adapted for online administration to couples across the United States via videoconferencing. The intervention in question aims to address the unique needs of couples from varied racial/ethnic backgrounds and geographic regions.

Methods

This is a comparative effectiveness RCT of 2GETHER USA relative to existing public health practice (control). 2GETHER USA is a hybrid group- and individual-level intervention that delivers three weekly online group discussion sessions for skills delivery, followed by two individualized couple sessions that focus on skills implementation in each couple. The control condition differs by participant HIV status: (1) the Testing Together protocol for concordant HIV-negative couples; (2) medication adherence and risk reduction counseling for concordant HIV-positive couples; or (3) both protocols for serodiscordant couples. Follow-up assessments are delivered at 3-, 6-, 9-, and 12-months post-intervention in both conditions. Testing for rectal and urethral Chlamydia and Gonorrhea occurs at baseline and 12-month follow-up. The primary behavioral outcome is condomless anal sex with serodiscordant serious partners or any casual partners. The primary biomedical outcome is sexually transmitted infection incidence at a 12-month follow-up.

Results

As of October 11, 2019, the trial has enrolled and randomized 140 dyads (Individual N=280). Enrollment will continue until we randomize 200 dyads (N=400). Assessment of intervention outcomes at 3-, 6-, 9-, and 12-months is ongoing.

Conclusions

2GETHER is innovative in that it integrates relationship education and HIV prevention for optimizing the health and wellbeing of young male couples. The 2GETHER USA online adaptation has the potential to reach couples across the United States and reduce barriers to accessing health care services that are affirming of sexual minority identities for those who live in rural or under-resourced areas.

Trial Registration

ClinicalTrials.gov NCT03284541; https://clinicaltrials.gov/ct2/show/NCT03284541

International Registered Report Identifier (IRRID)

DERR1-10.2196/15883

Condom-Associated Erectile Function, But Not Other Domains of Sexual Functioning, Predicts Condomless Insertive Anal Sex Among Young Men Who Have Sex with Men

Condoms effectively prevent against HIV, especially when used in conjunction with biomedical strategies such as PrEP and viral suppression. However, consistent use of condoms in the real world has been a continual health promotion challenge, even among populations at highest risk, such as young men who have sex with men (YMSM). Inconsistent condom use may be related to poor sexual functioning, but limited research exists. The analytic sample comprised 688 racially diverse YMSM aged 16-29 (M = 22.9 years) living in Chicago, IL (19.2% living with HIV). Using multivariable logistic regression, we examined longitudinal associations between condom-associated sexual functioning (erectile function, orgasm satisfaction, global satisfaction, and anal discomfort) and condomless insertive anal sex (CIAS) and condomless receptive anal sex (CRAS) 6 months later. CIAS at Time 2 was associated with condom-associated erectile function at the bivariate and multivariable levels, even after controlling for CIAS at Time 1 (p < .05). Condom-associated erectile function, orgasm satisfaction, and global satisfaction predicted Time 2 CRAS in bivariate models, but none remained significant in the multivariable models. Age, having had a serious partner in the past 6 months, and HIV/PrEP status at Time 2 were significant predictors of CIAS/CRAS in some but not all models. Future interventions to improve consistent condom use should specifically highlight information and skills on how to use condoms within real-world contexts rather than from a clinical perspective. Our results also support the importance of biomedical strategies for those who have continued problems with sexual functioning when using condoms.

Navigating the Long Road Forward for Maximizing PrEP Impact Among Adolescent Men Who Have Sex with Men

Preexposure prophylaxis (PrEP) has tremendous potential to decrease new HIV infections among populations at high risk, such as men who have sex with men (MSM). That potential is already becoming realized among adult MSM, where PrEP uptake has increased rapidly in the past several years. However, expanding PrEP access to adolescent MSM (AMSM) will be more challenging. This commentary reviews the existing scientific literature relevant to PrEP use for AMSM and highlights critical areas in need of further attention before PrEP is likely to impact the HIV epidemic among adolescents. We highlight concerns that need to be addressed in the areas of (1) achieving adequate coverage of PrEP in the adolescent population, (2) increasing awareness and access, (3) supporting adherence and maintenance, and (4) ensuring that PrEP does not perpetuate existing disparities. Across all of these domains, we highlight the central roles of parents and healthcare providers in supporting AMSM PrEP utilization. Finally, we suggest a number of areas of future research that must be addressed before PrEP is likely to see wide implementation among AMSM.

Relationship power and HIV risk among young Black men who have sex with men in the Southern United States

Background The purpose of this study was to examine the impact of relationship power on HIV risk behaviour among young Black men who have sex with men (MSM) in the Southern US.

METHODS

Data from 425 Black/African American males aged 18-29 years who reported recent anal intercourse with a male partner were analysed. Five selected measures of relationship power were tested for correlation and association with protected receptive anal intercourse using contingency tables and logistic regression analysis.

RESULTS

Acts of 100% protected receptive anal intercourse were common (n=277, 65.2%). Men who reported low barriers to condom negotiation were significantly more likely to report protected acts (P<0.001). Men who reported 100% protected acts were less likely to report financial dependence on male sexual partners and serosorting behaviour (12.0% vs 20.7%, P=0.02; 31.5% vs 49.8%, P<0.001 respectively).

CONCLUSION

Future efforts should further examine the role of relationship power in HIV risk among young Black MSM, including the intersection of individual, dyadic and social-structure risks.

Individual and Network Factors Associated With Racial Disparities in HIV Among Young Men Who Have Sex With Men: Results From the RADAR Cohort Study

BACKGROUND

Individual sexual risk behaviors have failed to explain the observed racial disparity in HIV acquisition. To increase understanding of potential drivers in disparities, we assessed differences across individual, network, and social determinants.

METHODS

Data come from RADAR (N = 1015), a longitudinal cohort study of multilevel HIV-risk factors among young men who have sex with men (YMSM) aged 16-29 years in Chicago, IL. Data collection includes biological specimens; network data, including detailed information about social, sexual, and drug-use networks; and psychosocial characteristics of YMSM.

RESULTS

Compared to white YMSM (24.8%) and Hispanic YMSM (30.0%), black YMSM (33.9%) had a higher prevalence of both HIV (32%; P < 0.001) and rectal sexually transmitted infections (26.5%; P = 0.011) with no observed differences in pre-exposure prophylaxis use. Black YMSM reported lower rates of sexual risk behaviors and more lifetime HIV tests (P < 0.001) compared with all other YMSM; however, they were also significantly less likely to achieve viral suppression (P = 0.01). Black YMSM reported the highest rate of cannabis use (P = 0.03) as well as greater levels of stigma (P < 0.001), victimization (P = 0.04), trauma (P < 0.001), and childhood sexual abuse (P < 0.001). White YMSM reported higher rates of depression (P < 0.001) and alcohol use (P < 0.001). In network analyses, significant differences existed across network characteristics with black YMSM having the lowest transitivity (P = 0.002), the highest density (P < 0.001), and the highest homophily (P < 0.001).

CONCLUSIONS

Black YMSM do not report higher rates of HIV-risk behaviors, but social and network determinants are aligned toward increased HIV risk. These results suggest that network interventions and those addressing social determinants may help reduce disparities.

Using the Experience Sampling Method to Study Sexual Risk Behavior among Men Who Have Sex With Men (MSM)

Toward the goal of advancing understanding of rates of HIV transmission among men who have sex with men (MSM) populations, this article provides preliminary data on the use of the experience sampling method (ESM) in a sample of 165 MSM. Participants completed 6 weeks of experience sampling in two 3-week measurement bursts with a 3-week rest interval. Criterion validity of the random and retrospective daily assessments was supported by expected within-person correlations between sexual risk behavior and sexual arousal. Participants reported some sexual activity with a male partner on 18.62% of the days, condomless anal sex (CAS) on 6.52% of days, and not using condoms on 66.56% of days they had anal sex. Over half of the variability in CAS was at the within-person level, which suggests the significance of time varying contextual factors. Finally, CAS reports were relatively stable across the study, suggesting a lack of reactivity to the self-monitoring.

Acceptability and Feasibility of a Telehealth Intervention for Sexually Transmitted Infection Testing Among Male Couples: Protocol for a Pilot Study

Background

Gay, bisexual, and other men who have sex with men (MSM) are at elevated risk for acquiring sexually transmitted infections (STIs) in the United States, especially chlamydia and gonorrhea. While research has indicated main partners over casual partners may play a central role in STI risk, the frequency of STI screening among MSM couples is particularly low. Self-sample collection for chlamydia and gonorrhea screening has been shown to be highly accurate, and at-home STI testing has been shown to be highly acceptable among diverse populations. However, there is little research exploring the feasibility and acceptability of at-home chlamydia and gonorrhea screening among MSM couples. Our pilot study aims to help evaluate the viability of this screening modality as an intervention tool for MSM couples

Objective

The objective of this study was to assess the feasibility and acceptability of an at-home chlamydia and gonorrhea sample collection and remote lab testing program among a sample of 50 MSM couples living in the United States.

Methods

This pilot study enrolled 50 MSM couples, ranging from 18-40 years old and living in the United States, who participated in a larger at-home HIV testing randomized controlled trial. Participating couples completed a pretest instructional video call and then had the option of completing at-home sample collection across three bodily sites (rectal swab, pharyngeal swab, and urine sample) for remote chlamydia and gonorrhea lab testing. For participants who completed any sample collection, they received their results via a posttest video call. All participants completed an online survey examining satisfaction and acceptability of the home testing process, experience with logistics, willingness to test at home in the future, recent sexual risk behavior, STI testing history, and linkage to care. A subset of 10 couples completed an in-depth interview about their attitudes towards the sample collection process, different decisions they made while collecting their samples, and their experience accessing treatment (for those who received a positive result).

Results

Recruitment began in September 2017, and as of March 2019 a total of 50 couples have been enrolled. Overall, 49/50 couples have returned their samples and completed the posttest delivery call, and 10 in-depth interviews have been completed and transcribed.

Conclusions

Screening MSM couples at home for chlamydia and gonorrhea and providing video-facilitated results delivery may offer a tailored approach to address the increasing prevalence of these STIs. By collecting data on how MSM couples experience at-home STI screening, this project will provide valuable insight into the utility of such a service delivery program to public health interventionists and researchers alike.

International Registered Report Identifier (IRRID)

DERR1-10.2196/14481

Adolescent Male Couples-Based HIV Testing Intervention (We Test): Protocol for a Type 1, Hybrid Implementation-Effectiveness Trial

Background

Young men who have sex with men (YMSM), particularly those who are partnered, are at unique risk for HIV. YMSM are among those at highest risk for HIV. Meanwhile, despite the fact that primary partners account for many—possibly most—new HIV infections, partnered men who have sex with men perceive themselves to be at much lower risk for HIV infection and therefore test less often than single men. In response to the risk of primary partner HIV transmission, couples HIV testing and counseling (CHTC) procedures have been developed for use in adult populations. Although promising, YMSM couples may require additional support to complete CHTC given their developmental context in which sexual and romantic relationships are relatively new, and communication skills are emergent.

Objective

The aim of this study was to test the additive benefit of adjunct treatment components tailored for YMSM, which enhance communication skills before the completion of CHTC. The intervention tests a continuum of prevention packages including assertive communication training videos and motivational interviewing focused on assisting with identification and development (MI-AID) before entering into the dyadic intervention components. This protocol is part of the Adolescent Medicine Trials Network (ATN) Scale It Up program described in this issue.

Methods

This is a comparative effectiveness trial that will be executed in 3 phases. Phase 1 will gather qualitative data related to intervention development and implementation from partnered YMSM at 4 subject recruitment venues (SRVs). Phase 2 will compare a continuum of these interventions in a pilot randomized controlled trial (RCT) at 2 SRVs. Phase 3 will compare the most successful adapted intervention package from phase 2 to CHTC as usual in a larger RCT at 4 SRVs. This phase is focused on implementation and sustainment phases of the Exploration, Preparation, Implementation, and Sustainment framework.

Results

Phase 1 data will be drawn from qualitative interviews with partnered YMSM (n=24) and staff from ATN sites (n=20). Baseline enrollment for phase 2 is expected to begin across 2 SRVs in June 2018 (n_couples=36). In phase 2, survey data collection along with HIV and sexually transmitted infection (STI) testing will occur at baseline, and 1- and 3-month (postintervention) follow-ups. Phase 3 will begin enrollment across 4 SRVs in September 2019 (n_couples=144) and follow-ups will occur at 1, 3, 6, and 9 months postintervention.

Conclusions

Although MI-AID, video-based assertive communication training, and CHTC have established efficacy when administered on their own, this study will be the first to evaluate the strongest adjunctive version of these interventions to address the specific developmental needs of partnered YMSM.

Trial Registration

ClinicalTrials.gov NCT03386110; http://clinicaltrials.gov/ct2/show/NCT03386110 (Archived by WebCite at http://www.webcitation.org/75mlO7GCx)

International Registered Report Identifier (IRRID)

DERR1-10.2196/11186

Relationship Dynamics in the Context of Binge Drinking and Polydrug Use Among Same-Sex Male Couples in Atlanta, Boston, and Chicago

An estimated one- to two-thirds of incident HIV infections among U.S. men who have sex with men (MSM) occur within the context of a primary relationship. The existing, yet limited, literature on sexual risk behavior among same-sex couples suggests that MSM with main partners are more often to report having lower perceived HIV risk, higher unrecognized HIV infection, and increased frequency of condomless anal intercourse with their primary partner. Furthermore, numerous studies document the strong relationship between polydrug use and binge drinking with HIV infection among MSM. However, more research is needed that identifies how individual- and relationship-level factors are related to polydrug use and binge drinking in the context of same-sex male relationships. We used baseline data collected as part of a prospective randomized controlled trial of 160 same-sex male couples (total N = 320 individuals). In 2015, recruitment commenced in three U.S. cities: Atlanta, GA, Boston, MA, and Chicago, IL. Participants completed a self-report assessment using an audio-computer-assisted self-interview system during their baseline enrollment visit. We collected information on participants' sociodemographic characteristics, drug and alcohol use, individual- and relationship-level variables of interest, as well as relationship quality. Multinomial logistic regression models were fit for three different categories of polydrug use and of binge drinking for which (1) both partners exhibited the behavior, (2) only the respondent exhibited the behavior, or (3) only the partner exhibited the behavior. Participants' age ranged from 18 to 69 (M = 35.9). The sample majority (77.5%) was White (248/320), with 12.2% Black (39/320) and 10.3% Multiracial (33/320); 68.4% had completed a college degree; and 9.6% were unemployed. A high proportion (62.2%) reported any drug use, including marijuana; 45% reported using drugs other than marijuana; and 18.1% reported polydrug use. Overall, 22.2% reported current binge drinking. Age discordance and being in a long-term relationship (6 or more years) were associated with a decreased odds of polydrug use among couples; being in an interracial dyad, recent history of arrest, living with HIV, and self-reported clinically significant depressive symptoms were associated with an increased odds of polydrug use. Additionally, being the older partner and reporting higher levels of internalized homophobia decreased odds for binge drinking, while recent history of arrest, living with HIV, and feeling more loved in their relationship were associated with an increased odds of binge drinking. Findings have implications for developing interventions to reduce substance use and promote health among same-sex male couples. Future research would benefit by using longitudinal study designs to understand the individual-, relationship-, and structural-level factors that potentiate polydrug use and binge drinking among same-sex male couples.

Historical and Developmental Changes in Condom Use Among Young Men Who Have Sex with Men Using a Multiple-Cohort, Accelerated Longitudinal Design

Young men who have sex with men (YMSM) have the highest HIV incidence in the U.S. The last 5 years has seen emergence of new methods for HIV prevention and societal shifts in gay rights. It is important to understand if there have been generational shifts in condom use during the developmental transition from adolescents to young adulthood. To disentangle history from development, we require a multiple-cohort, longitudinal design-a methodology never before applied to study YMSM. We followed three cohorts of YMSM recruited in 2007, 2010, and 2015 (N = 1141) from the ages of 17-26 years and modeled their longitudinal change over time in counts of anal sex acts and the ratio of condomless anal sex (CAS) acts to anal sex acts using latent curve growth modeling. We found that there was no significant developmental change in raw counts of anal sex acts, but there was a significant decline in the ratio of anal sex acts that were condomless. We also found significantly different patterns for ratio of CAS acts for the 2015 cohort. The 2015 cohort reported a significantly lower ratio of CAS acts at age 17, but significantly higher growth in ratio of CAS acts over development. The present study suggests that YMSM recruited in 2015 have very different trajectories of CAS compared to previous cohorts, including lower risk in late adolescence, but with the potential for higher risk after the transition into adulthood.

Pre-Exposure Prophylaxis (PrEP) Use and Condomless Anal Sex: Evidence of Risk Compensation in a Cohort of Young Men Who Have Sex with Men

BACKGROUND

Young men who have sex with men (YMSM) are disproportionately impacted by HIV. Pre-exposure prophylaxis (PrEP) is highly effective at preventing HIV acquisition. It remains unclear if PrEP use increases rates of condomless sex (ie, risk compensation), which may increase risk of infection if PrEP adherence is not optimal. This study aimed to examine whether PrEP use and PrEP adherence were associated with change in sexual risk behaviors in a large longitudinal cohort of YMSM reporting on multiple sexual partnerships over time.

METHOD

Data were obtained from the first 3 visits of an ongoing cohort study of YMSM in Chicago (analytic N = 953; 14.1% HIV-positive at baseline). Participants reported up to 4 sexual partnerships at each visit, including sexual behavior, PrEP use, and PrEP adherence within partnerships.

RESULTS

YMSM reported higher rates of receptive condomless anal sex (CAS) in partnerships during which they were on PrEP compared with those when they were not on PrEP. This association was consistent across both HIV-negative and HIV-positive participants reporting on partnerships with both perceived HIV-negative/unknown and HIV-positive partners. The rate of receptive CAS was higher in PrEP nonadherent partnerships compared with non-PrEP partnerships. The rate of receptive CAS was also higher in PrEP nonadherent than adherent partnerships, but this was not statistically significant.

CONCLUSIONS

These analyses provide compelling data suggesting that YMSM are engaging in risk compensation when on PrEP. If rates of receptive CAS are highest among YMSM who are PrEP nonadherent, PrEP as a prevention strategy could fail to curb HIV incidence among YMSM.

"Condoms are … like public transit. It's something you want everyone else to take": Perceptions and use of condoms among HIV negative gay men in Vancouver, Canada in the era of biomedical and seroadaptive prevention

BACKGROUND

The emergence of biomedical and seroadaptive HIV prevention strategies has coincided with a decline in condom use among gay men.

METHODS

We undertook a social ecological analysis of condom use and perceptions using nineteen semi-structured interviews with HIV negative gay men in Vancouver, Canada who used HAART-based prevention strategies.

RESULTS

Contributors to inconsistent condom use were found at various levels of the social ecological model. Ongoing concern regarding HIV transmission and belief in the proven efficacy of condoms motivated contextual use. When condoms were not used, participants utilized seroadaptive and biomedical prevention strategies to mitigate risk.

CONCLUSIONS

These findings indicate that notions of "safety" and "risk" based on consistent condom use are eroding as other modes of prevention gain visibility. Community-based and public health interventions will need to shift prevention messaging from advocacy for universal condom use toward combination prevention in order to meet gay men's current prevention needs. Interventions should advance gay men's communication and self-advocacy skills in order to optimize these strategies.

Applying resilience theory models to contextualize economic-dependent partnerships as a risk factor for HIV among young men who have sex with men

Economic-dependent partnerships (EDP) are an understudied HIV risk correlate among young men who have sex with men (YMSM) in the U.S. We explored whether YMSM's psychological resilience buffered against the effect of socioeconomic disadvantage on EDPs, after accounting for other psychosocial risks. Data come from an observational study assessing YMSM's HIV vulnerabilities. We developed indices for socioeconomic disadvantage, psychosocial profiles, and cumulative promotive factors. Multivariable logistic regressions tested the main associations of these indices on EDPs. Protective models tested whether psychosocial profiles exacerbated and cumulative promotive factors buffered the effects of socioeconomic disadvantage on EDPs. 31% and 23% of YMSM reported EDPs with main and casual partners, respectively. For both outcomes, we found support for adjusted compensatory models. Socioeconomic disadvantage was associated with increased odds of EDPs with main (AOR = 1.45, p < .001) and casual (AOR = 1.47, p < .001) partners. Psychosocial profiles were also associated with increased odds of EDPs with main (AOR = 1.53, p = .001) and casual (AOR = 1.67, p < .001) partners. Cumulative promotive factors was associated with decreased odds of EDPs with main (AOR = 0.66, p = .003) and casual (AOR = 0.72, p = .035) partners. Our findings elucidate the need for multilevel interventions that provide opportunities for socioeconomic advancement and improve psychosocial/psychological functioning for at-risk YMSM.

The Development and Testing of a Relationship Skills Intervention to Improve HIV Prevention Uptake Among Young Gay, Bisexual, and Other Men Who Have Sex With Men and Their Primary Partners (We Prevent): Protocol for a Randomized Controlled Trial

BACKGROUND

Young gay, bisexual, and other men who have sex with men (YMSM) continue to be the group most heavily impacted by HIV in the United States. Substantial evidence indicates that up to two-thirds of new HIV infections occur in the context of a main partnership. Couples HIV testing and counseling (CHTC) has been shown to be a promising and effective strategy for increasing HIV prevention uptake among male couples; however, YMSM who are new to relationships may not have yet developed the efficacy, negotiation, and communication skills to navigate HIV testing in their relationship and communicate around developing a prevention plan.

OBJECTIVE

This study aims to develop and test a relationship skills-focused HIV prevention intervention for YMSM and their partners. The intervention consists of two telehealth-delivered sessions: the first focuses on relationship skills and the second consists of CHTC and prevention planning. Both sessions are attended by both members of the dyad.

METHODS

This protocol describes the development of the proposed intervention (We Prevent) and pilot test to examine its feasibility and preliminary efficacy. The intervention will include two motivational interviewing-based sessions: session one is a relationship skills-building session, focused on techniques to explore and build communication skills in a relationship, to help YMSM develop and enhance necessary skills for their current and future relationships; the second session is a CHTC session with YMSM and their partners, to help them develop an HIV prevention plan. Through qualitative data collection and a one-arm pilot with YMSM, we will develop and refine a developmentally appropriate relationship skills session as an addition to the current CHTC intervention. We will then conduct a pilot randomized controlled trial (RCT), comparing the acceptability, feasibility, and preliminary efficacy of the adapted two-session telehealth intervention for YMSM versus a control group receiving one session only-a CHTC session delivered via telehealth.

RESULTS

The We Prevent intervention is designed to increase uptake of HIV prevention, shown through self-reported reductions in condomless sex and increases in knowledge and uptake of pre-exposure prophylaxis. In addition, the intervention is designed to increase HIV and sexually transmitted infection (STI) testing. STI incidence is examined as a secondary outcome. A cost-input analysis will examine the costs associated with intervention delivery to inform future scale-up of the intervention.

CONCLUSIONS

Drawing on theory and existing CHTC protocols delivered with video-based counseling, this proposed intervention affords the opportunity to empower YMSM with the skills necessary to communicate with their partners and protect themselves from HIV in their current and future relationships.

TRIAL REGISTRATION

Clinicaltrials.gov NCT03551938; https://clinicaltrials.gov/ct2/show/NCT03551938 (Archived by WebCite at http://www.webcitation.org/73omJCz1a).

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

RR1-10.2196/10370.