How partnership type and HIV seroconcordance affect HIV transmission risk in regular sexual partnerships: a cross-sectional survey of Australian gay and bisexual men

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.

Characteristics of Agreements to have Condomless Anal Intercourse in the Presence of an Undetectable Viral Load Among HIV Serodiscordant Male Couples in Australia, Brazil and Thailand

The use of undetectable viral load (VL) to negotiate condomless anal intercourse (CLAI) in HIV serodiscordant male relationships has become more common as more data regarding the effectiveness of antiretroviral treatments for the prevention of HIV transmission has been described. We examined viral load agreements (VLAs) for condomless sex in the presence of an undetectable VL in 343 HIV serodiscordant male couples in Australia, Brazil and Thailand. Factors associated with having a VLA included having agreements for the HIV-positive partner to report his VL result (p < 0.001), agreeing that VL affects agreements about sexual practice (p < 0.001), the HIV-negative partner's perception of his partner's undetectable VL (p < 0.001), the couple's belief in the efficacy of undetectable VL in preventing HIV transmission (p < 0.001), and the couple engaging in CLAI with each other (p < 0.001). Over time, these agreements became more common although 49.3% of couples in the sample never had a viral load agreement. As these agreements become more common, further education is required to support male couples in using them safely.

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.

Gay Men's Relationship Agreements in the Era of Pre-exposure Prophylaxis: An Analysis of Australian Behavioural Surveillance Data

Using repeated, cross-sectional behavioural surveillance data from Australia, we assessed trends in relationship agreements and casual sex among HIV-negative and untested gay and bisexual men who had regular partners during 2013-2018. We conducted three analyses: (i) trends in relationship agreements and casual sex over time; (ii) bivariate comparisons of PrEP users and non-PrEP-users to identify factors associated with PrEP use; and (iii) multivariate logistic regression to identify factors independently associated with PrEP use. The analysis of trends over time included 21,593 men, from which a sub-sample (n = 3764) was used to compare PrEP users and non-PrEP-users. We found a large increase in agreements that allowed condomless sex with casual partners, particularly by PrEP users in relationships (nearly 40% of whom had such an agreement). A further 34% of PrEP users reported having casual condomless sex without an agreement that permitted that behaviour, while 13% of non-PrEP-users also reported condomless sex with casual partners without an agreement. PrEP use was independently associated with having agreements permitting condomless sex with casual partners, recent condomless sex with casual partners, having greater numbers of male partners, recent post-exposure prophylaxis use, having an HIV-positive regular male partner, and recent condomless sex with regular male partners. Our findings show a shift away from relationship agreements in which condomless sex was only sanctioned between regular partners.

Strategies used by gay male HIV serodiscordant couples to reduce the risk of HIV transmission from anal intercourse in three countries

INTRODUCTION

There are few data about the range of strategies used to prevent sexual HIV transmission within gay male serodiscordant couples. We examined HIV prevention strategies used by such couples and compared differences between countries.

METHODS

Opposites Attract was a cohort study of male serodiscordant couples in Australia, Brazil and Thailand, from May 2014 (Australia) or May 2016 (Brazil/Thailand) to December 2016. At visits, HIV-positive partners had viral load (VL) tested; HIV-negative partners reported sexual behaviour and perceptions of their HIV-positive partner's VL results. Within-couple acts of condomless anal intercourse (CLAI) were categorized by strategy: condom-protected, biomedically protected (undetectable VL and/or pre-exposure prophylaxis [PrEP]), or not protected by either (HIV-negative partners engaging in insertive CLAI, receptive CLAI with withdrawal, or receptive CLAI with ejaculation).

RESULTS

A total of 343 couples were included in this analysis (153 in Australia, 93 in Brazil and 97 in Thailand). Three-quarters of HIV-positive partners were consistently virally suppressed (<200 copies/mL) during follow-up, and HIV-negative partners had correct perceptions of their partner's VL result for 76.5% of tests. One-third of HIV-negative partners used daily PrEP during follow-up. Over follow-up, 73.8% of couples had CLAI. HIV-negative partners reported 31,532 acts of anal intercourse with their HIV-positive partner. Of these, 46.7% were protected by condoms, 48.6% by a biomedical strategy and 4.7% of acts were not protected by these strategies. Australian couples had fewer condom-protected acts and a higher proportion of biomedically protected acts than Brazilian and Thai couples. Of the 1473 CLAI acts where the perceived VL was detectable/unknown and were not protected by PrEP (4.7% of all acts), two-thirds (n = 983) were when the HIV-negative partner was insertive (strategic positioning). Of the 490 acts when the HIV-negative partner was receptive, 261 involved withdrawal and 280 involved ejaculation. Thus, <1% of acts were in the highest risk category of receptive CLAI with ejaculation.

CONCLUSIONS

Couples used condoms, PrEP or perceived undetectable VL for prevention in the majority of anal intercourse acts. Only a very small proportion of events were not protected by these strategies. Variation between countries may reflect differences in access to HIV treatment, education, knowledge and attitudes.

Post-exposure prophylaxis in the era of pre-exposure prophylaxis: a study of post-exposure prophylaxis use in South-East Queensland since the Pharmaceutical Benefits Scheme listing of pre-exposure prophylaxis

Both post-exposure prophylaxis (PEP) and pre-exposure prophylaxis (PrEP) involve the use of antiretroviral drugs taken by HIV-uninfected individuals to reduce HIV acquisition risk. While PEP has been available in Australia for many years, PrEP became widely accessible in 2018 after listing on the Pharmaceutical Benefits Scheme (PBS). Studies have reported on the impact of PrEP on condom use. The impact of PrEP on the use of PEP in Australia has not been reported. This project examined PEP use across three public sexual health services in South-East Queensland, Australia, comparing rates in 2016 (prePBS-listed PrEP) and 2019 (postPBS-listed PrEP), to determine if PEP prescribing, and the characteristics of people accessing PEP, have changed. Results showed that PEP prescribing made up 2.85% of all clients seen in 2016, dropping to 2.33% in 2019, reflecting a decrease of 0.5% (p = 0.048). There was a significant increase in Medicare-ineligible clients accessing PEP (9% in 2016; 21% in 2019; p = 0.002) and a significant increase in PrEP-experienced clients accessing PEP between the two study periods (4% in 2016; 14% in 2019; p ≤ 0.001). The marginal decrease in PEP prescribing highlights that PEP remains an important option especially for those with barriers to accessing and adhering to daily PrEP.

Does HIV Pre-Exposure Prophylaxis Modify the Effect of Partnership Characteristics on Condom Use? A Cross-Sectional Study of Sexual Partnerships Among Men Who Have Sex with Men in San Francisco, California

Increasing rates of sexually transmitted infections (STIs) in the United States among men who have sex with men (MSM) have raised concerns that pre-exposure prophylaxis (PrEP) has been associated with higher engagement in condomless anal intercourse (CAI). While partnership characteristics have previously been found to influence condom use, the extent to which PrEP use may modify their effect on CAI remains unknown. A secondary analysis of 535 sexual partnerships from a cross-sectional study in San Francisco was conducted to evaluate interactions between PrEP use and partnership characteristics on CAI. Bivariate and multivariate generalized estimating equation (GEE) logistic regression models were used to estimate relative measures of association, adjusted for confounding by seroconcordance and partnership type, as well as account for repeated partnerships per respondent. Partnerships where both partners used biomedical prevention had significantly greater odds of CAI [odds ratio (OR) = 5.19, 95% confidence interval (CI): 2.27-11.9] compared to those where only one partner used biomedical prevention, while those where neither partner used biomedical prevention had significantly lower odds of CAI (OR = 0.61, 95% CI: 0.40-0.93). There was no significant association between meeting place (online vs. offline) and sexual risk taking (OR = 1.03, p = 0.894). Having one partner disclose their HIV status (compared to neither partner having disclosed) was associated with significantly higher odds of CAI among partnerships of PrEP-using MSM [adjusted OR (aOR) = 5.28, 95% CI: 1.91-14.61], while the association was not significant among the partnerships of non-PrEP-using MSM (aOR = 1.29, 95% CI: 0.75-2.21). Differences in condom use among MSM using PrEP may not be well explained by differences in the effect of partnership characteristics. MSM using PrEP appear to commonly practice biomedical matching and high engagement in CAI with other biomedical prevention users, which could indicate relatively concentrated sexual networks and partly explain their disproportionate risk for STIs. Future studies should further investigate biomedical matching to develop interventions that further promote the sexual health of those using PrEP.

Baseline Preferences for Daily, Event-Driven, or Periodic HIV Pre-Exposure Prophylaxis among Gay and Bisexual Men in the PRELUDE Demonstration Project

INTRODUCTION

The effectiveness of daily pre-exposure prophylaxis (PrEP) is well established. However, there has been increasing interest in non-daily dosing schedules among gay and bisexual men (GBM). This paper explores preferences for PrEP dosing schedules among GBM at baseline in the PRELUDE demonstration project.

MATERIALS AND METHODS

Individuals at high-risk of HIV were enrolled in a free PrEP demonstration project in New South Wales, Australia, between November 2014 and April 2016. At baseline, they completed an online survey containing detailed behavioural, demographic, and attitudinal questions, including their ideal way to take PrEP: daily (one pill taken every day), event-driven (pills taken only around specific risk events), or periodic (daily dosing during periods of increased risk).

RESULTS

Overall, 315 GBM (98% of study sample) provided a preferred PrEP dosing schedule at baseline. One-third of GBM expressed a preference for non-daily PrEP dosing: 20% for event-driven PrEP, and 14% for periodic PrEP. Individuals with a trade/vocational qualification were more likely to prefer periodic to daily PrEP [adjusted odds ratio (aOR) = 4.58, 95% confidence intervals (95% CI): (1.68, 12.49)], compared to individuals whose highest level of education was high school. Having an HIV-positive main regular partner was associated with strong preference for daily, compared to event-driven PrEP [aOR = 0.20, 95% CI: (0.04, 0.87)]. Participants who rated themselves better at taking medications were more likely to prefer daily over periodic PrEP [aOR = 0.39, 95% CI: (0.20, 0.76)].

DISCUSSION

Individuals' preferences for PrEP schedules are associated with demographic and behavioural factors that may impact on their ability to access health services and information about PrEP and patterns of HIV risk. At the time of data collection, there were limited data available about the efficacy of non-daily PrEP schedules, and clinicians only recommended daily PrEP to study participants. Further research investigating how behaviours and PrEP preferences change correspondingly over time is needed.

TRIAL REGISTRATION

ClinicalTrials.gov NCT02206555. Registered 28 July 2014.