Condom migration resulting from circumcision, microbicides and vaccines: brief review and methodological considerations

Dealing with pre-exposure prophylaxis-associated condom migration: changing the paradigm for men who have sex with men

The behavioural aspects of pre-exposure prophylaxis (PrEP) are challenging, particularly the issue of condom migration. Three vital questions are: (1) at the population-level, will condom migration lead to increases in non-viral sexually transmissible infections?; (2) how can clinic-based counselling best promote the dual use of condoms and PrEP?; and (3) in future PrEP trials, what are the 'best practices' that should be used to avoid type 1 and type 2 errors that arise without accounting for condom use behaviours? This communication piece addresses each question and suggests the risk of a 'PrEP only' focus to widening health disparities.

Offering Self-administered Oral HIV Testing as a Choice to Truck Drivers in Kenya: Predictors of Uptake and Need for Guidance While Self-testing

We assessed predictors of choosing self-administered oral HIV testing in the clinic with supervision versus the standard provider-administered blood test when offered the choice among 149 Kenyan truck drivers, described the types of guidance participants needed during self-testing and predictors of needing guidance. Overall, 56.38% of participants chose the self-test, 23.49% the provider-administered test, and 20.13% refused testing. In the adjusted regression models, each additional unit on the fatalism and self-efficacy scales was associated with 0.97 (p = 0.003) and 0.83 (p = 0.008) times lower odds of choosing the self-test, respectively. Overall, 52.38% of self-testers did so correctly without questions, 47.61% asked questions, and 13.10% required unsolicited correction from the provider. Each additional unit on the fatalism scale was associated with 1.07 times higher odds of asking for guidance when self-testing (p < 0.001). Self-administered oral HIV testing seems to be acceptable and feasible among Kenyan truck drivers, especially if given the opportunity to ask questions.

Sexual risk behaviour among people living with HIV according to the biomedical risk of transmission: results from the ANRS-VESPA2 survey

Introduction

People living with HIV (PLHIV) on antiretroviral therapy (ART), with sustained undetectable viral load (sUVL) and no history of sexually transmitted infections for at least six months, are considered to have a low risk of HIV transmission (LRT). We aimed to characterize, in a representative sample of French PLHIV, the sexual behaviour of LRT PLHIV compared with non-LRT PLHIV.

Methods

The cross-sectional ANRS-VESPA2 survey was conducted on adult PLHIV attending French hospitals in 2011. The LRT PLHIV group included participants with sUVL and no sexually transmitted infection for at least 12 months. Socio-behavioural and medical data were collected. Chi-square tests helped compare sexual risk indicators between LRT and non-LRT PLHIV. The survey's retrospective nature allowed us to perform complementary category-based analyses of LRT PLHIV according to whether they had sUVL for at least 18, 24 or 36 months in three socio-epidemiological groups: men who have sex with men (MSM), other men and women.

Results

Analysis included 2638 PLHIV diagnosed >12 months with available viral load data. The proportion of LRT PLHIV varied from 58% (≥12 months sUVL) to 38% (≥36 months sUVL). Irrespective of sUVL duration, we found the following: 1) LRT men (MSM and other men) were more likely to report having no sexual partner than their non-LRT counterparts. Among men having sexual partners in the previous 12 months, no significant difference was seen between LRT and non-LRT men in the number of sexual partners. LRT women were less likely to report having more than one sexual partner than non-LRT women; 2) LRT MSM were more likely to report being in sexually inactive couples than their non-LRT counterparts; 3) among sexually active participants, no difference was observed between LRT and non-LRT PLHIV concerning condom use with their serodiscordant steady partner or with their most recent casual sexual partners.

Conclusions

LRT PLHIV with sUVL ≥12 months did not report more sexual risk behaviours than their non-LRT counterparts. Because the same result was obtained for those having a sUVL ≥36 months, the hypothesis of increased sexual risk behaviour over time in PLHIV meeting non-transmission biomedical criteria is not supported.

Male circumcision for protection against HIV infection in sub-Saharan Africa: the evidence in favour justifies the implementation now in progress

This article responds to a recent 'controversy study' in Global Public Health by de Camargo et al. directed at three randomised controlled trials (RCTs) of male circumcision (MC) for HIV prevention. These trials were conducted in three countries in sub-Saharan Africa (SSA) and published in 2005 and 2007. The RCTs confirmed observational data that had accumulated over the preceding two decades showing that MC reduces by 60% the risk of HIV infection in heterosexual men. Based on the RCT results, MC was adopted by global and national HIV policy-makers as an additional intervention for HIV prevention. Voluntary medical MC (VMMC) is now being implemented in 14 SSA countries. Thus referring to MC for HIV prevention as 'debate' and viewing MC through a lens of controversy seems mistaken. In their criticism, de Camargo et al. misrepresent and misinterpret current science supporting MC for HIV prevention, omit previous denunciations of arguments similar to theirs, and ignore evidence from ongoing scientific research. Here we point out the flaws in three areas de Camargo et al. find contentious. In doing so, we direct readers to growing evidence of MC as an efficacious, safe, acceptable, relatively low-cost one-off biomedical intervention for HIV prevention.

Risk compensation following male circumcision: results from a two-year prospective cohort study of recently circumcised and uncircumcised men in Nyanza Province, Kenya

We present the results of the first study of longitudinal change in HIV-associated risk behaviors in men before and after circumcision in the context of a population-level voluntary medical male circumcision (VMMC) program. The behaviors of 1,588 newly circumcised men and 1,598 age-matched uncircumcised controls were assessed at baseline, 6, 12, 18 and 24 months of follow-up. Despite the precipitous decline in perception of high HIV risk among circumcised men (30-14 vs. 24-21 % in controls) and increased sexual activity among the youngest participants (18-24 years; p-time < 0.0001, p-group = 0.96), all specific risk behaviors decreased over time similarly in both groups. The proportion of men reporting condom use at last sex increased for both groups, with a greater increase among circumcised men (30 vs. 6 %). We found no evidence of risk compensation in men following circumcision. Concerns about risk compensation should not impede the widespread scale-up of VMMC initiatives.

Health, trust, or "just understood": explicit and implicit condom decision-making processes among black, white, and interracial same-sex male couples

Among gay and bisexual men, primary partners are a leading source of HIV infection. Trust, intimacy, and advancements in HIV treatment may impact same-sex male (SSM) couples' decisions to engage in unprotected anal intercourse (UAI). This qualitative study explored how Black, White and interracial couples discussed, and made decisions regarding condoms. Qualitative interviews were conducted with 48 SSM couples in the New York and San Francisco metropolitan areas. Stratified purposive sampling was used to include Black (n = 16), White (n = 17), and interracial (Black-White) (n = 15) couples. Twenty-six couples were concordant HIV-negative and 22 were HIV-discordant. Interviews were recorded, transcribed, coded, and analyzed using a grounded theory approach. Some couples described explicit processes, which involved active discussion, while others described implicit processes, where condom-use decisions occurred without any explicit discussion. These processes also differed by race and HIV status. Black couples tended to report condom-use as "just understood." White, HIV-discordant couples decided not to use condoms, with some identifying the HIV-positive partner's suppressed viral load and high CD4 count as deciding factors. After an unplanned episode of UAI, White, HIV-negative couples tended to discontinue condom use while Black HIV-negative couples decided to revert to using condoms. HIV prevention efforts focused on same-sex, male couples must consider the explicit/implicit nature of condom decision-making processes. Understanding differences in these processes and considering relationship dynamics, across race and HIV status, can promote the development of innovative couple-level, HIV prevention interventions.

A comparison of condom use perceptions and behaviours between circumcised and intact men attending sexually transmitted disease clinics in the United States

This investigation compared circumcised and intact (uncircumcised) men attending sexually transmitted infection (STI) clinics on condom perceptions and frequencies of use. Men ( N = 316) were recruited from public clinics in two US states. Circumcision status was self-reported through the aid of diagrams. Intact men were less likely to report unprotected vaginal sex ( P < 0.001), infrequent condom use ( P = 0.02) or lack of confidence to use condoms ( P = 0.049). The bivariate association between circumcision status and unprotected sex was moderated by age ( P < 0.001), recent STD acquisition ( P < 0.001) and by confidence level for condom use ( P < 0.001). The bivariate association between circumcision status and infrequent condom use was also moderated by age ( P = 0.002), recent STI acquisition ( P = 0.02) and confidence level ( P = 0.01). Multivariate findings supported the conclusion that intact men may use condoms more frequently and that confidence predicts use, suggesting that intervention programmes should focus on building men's confidence to use condoms, especially for circumcised men.

Study designs for identifying risk compensation behavior among users of biomedical HIV prevention technologies: balancing methodological rigor and research ethics

The growing evidence base for biomedical HIV prevention interventions - such as oral pre-exposure prophylaxis, microbicides, male circumcision, treatment as prevention, and eventually prevention vaccines - has given rise to concerns about the ways in which users of these biomedical products may adjust their HIV risk behaviors based on the perception that they are prevented from infection. Known as risk compensation, this behavioral adjustment draws on the theory of "risk homeostasis," which has previously been applied to phenomena as diverse as Lyme disease vaccination, insurance mandates, and automobile safety. Little rigorous evidence exists to answer risk compensation concerns in the biomedical HIV prevention literature, in part because the field has not systematically evaluated the study designs available for testing these behaviors. The goals of this Commentary are to explain the origins of risk compensation behavior in risk homeostasis theory, to reframe risk compensation as a testable response to the perception of reduced risk, and to assess the methodological rigor and ethical justification of study designs aiming to isolate risk compensation responses. Although the most rigorous methodological designs for assessing risk compensation behavior may be unavailable due to ethical flaws, several strategies can help investigators identify potential risk compensation behavior during Phase II, Phase III, and Phase IV testing of new technologies. Where concerns arise regarding risk compensation behavior, empirical evidence about the incidence, types, and extent of these behavioral changes can illuminate opportunities to better support the users of new HIV prevention strategies. This Commentary concludes by suggesting a new way to conceptualize risk compensation behavior in the HIV prevention context.

Condom use: still a sexual health staple

This article introduces and summarizes the contents of this special edition. Given the exceptional potential of condoms to avert epidemics of sexually transmitted infections and teen or unintended pregnancy - even in low-resource environments - this in-depth examination of current knowledge, practice, and issues with condoms and their use is an important asset for educators and practitioners worldwide.