Communication of HIV viral load to guide sexual risk decisions with serodiscordant partners among San Francisco men who have sex with men

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

Background Regular sexual partnerships among gay and bisexual men (GBM) who practice condomless anal intercourse (CLAI) have not been well characterised in terms of partnership type, HIV seroconcordance and risk of HIV transmission. Primarily sexual regular partnerships, although commonly reported by gay men, have largely been ignored in research and HIV prevention. Among regular partners reporting CLAI with each other, we determined factors differentiating romantic or committed relationships from partnerships organised primarily around sex ('fuckbuddies') and estimated the proportion of CLAI presenting risk for HIV transmission.

METHODS

An online, cross-sectional survey of Australian GBM was conducted. Univariate and multivariate generalised estimating equations were used to determine statistical associations.

RESULTS

Men reported on 2250 regular sexual partnerships. Over half the partnerships were romantic or committed relationships. Over half the partnerships were HIV-negative seroconcordant (54.9%), 3.1% were HIV-positive seroconcordant, 5.2% were serodiscordant and 36.8% were of unknown seroconcordance. Potential risks presented by CLAI were sometimes mitigated by protective factors, such as having a clear spoken agreement about sex with outside partners, having fewer outside partners, openly discussing HIV risk and having an agreement to reduce risk from outside partners. These protective factors were more often found in romantic or committed relationships than among primarily sexual partnerships, and were less often found in partnerships of unknown seroconcordance.

CONCLUSION

CLAI is more common among regular sexual partnerships considered to be of a romantic, committed nature. However, factors associated with such romantic or committed partnerships can also protect against HIV transmission risk. Unknown seroconcordance, particularly lack of communication about HIV status among primarily sexual partnerships, is a key risk factor that needs to be addressed by HIV education.

HIV viral load: a concept analysis and critique

In this article, we examine the concept of HIV viral load and how it has evolved over time (1995-2013) in the field of HIV/AIDS. Although the term viral load is used extensively in this field, few efforts have been directed toward the conceptualization of HIV viral load, which is often left unquestioned, undertheorized, and portrayed as a neutral and objective laboratory value that has remained relatively stable over time--with the exception of progressive advancements in technology, techniques, and sensitivity. The purpose of this article is to apply the evolutionary concept analysis method developed by Rodgers (1989, 2000a) to the concept of HIV viral load. To set the stage, we establish the need for a concept analysis of HIV viral load and provide an overview of the evolutionary view. Then, drawing on the steps proposed by Rodgers (2000a), we outline the process of data collection, management, and analysis. We then offer an in-depth discussion of the findings (attributes, antecedents, and consequences) informed by Wuest's (2000) critical approach to concept analysis. We conclude by highlighting the implications of this analysis for clinical practice, research, and theory.

A scoping review and thematic analysis of social and behavioural research among HIV-serodiscordant couples in high-income settings

BACKGROUND

While HIV incidence has stabilized in many settings, increases in health and wellbeing among many people living with HIV/AIDS suggest that the number of HIV-serodiscordant relationships is growing. Given the deficit of reviews addressing social and behavioural characteristics of HIV-serodiscordant couples within high-income settings, our objective was to understand the scope of the published literature, identify evidence gaps, and suggest future research needs.

METHODS

Ten electronic databases were searched. Studies were included if they were reported in English, used primary data, were from the combination antiretroviral (cART) era (>1996), reported on social or behavioural aspects, included any fraction of primary (i.e., stable) relationships, and were conducted in high-income settings. Studies that identified their unit of analysis as either the dyad or individual member of the couple were included. Studies were coded according to a thematic framework.

RESULTS

Included studies (n = 154) clustered into eight themes: risk behaviours (29%), risk management (26%), reproductive issues (12%), relationship quality (9%), serostatus disclosure (7%), adherence to antiretroviral therapy (7%), vulnerability (5%), and social support (3%). The proportion of studies conducted among heterosexual couples, same-sex male couples, and mixed cohorts were 42%, 34%, and 24%, respectively. Most studies (70%) were conducted in the United States, 70% of all studies were quantitative (including interventions), but only one-third were focused on couples (dyads) where both partners are recruited to a study. Over 25% of studies focused on sexual risk among same-sex male couples.

CONCLUSIONS

Future research efforts should focus on the interrelationship of risk management strategies and relationship quality, social determinants of health and wellbeing, HIV testing, vulnerable populations, reproductive issues among same-sex couples, disclosure of serodiscordant status to social networks, dyadic studies, population-based studies, and interventions to support risk management within couples. Additional population-based studies and studies among marginalized groups would be helpful for targeting research and interventions to couples that are most in need. As HIV-positive partners are typically the link to services and research, innovative ways are needed for reaching out to HIV-negative partners. Our review suggests that significantly more research is needed to understand the social and behavioural contexts of HIV-serodiscordant relationships.

Motivations to test for HIV among partners in concordant HIV-negative and HIV-discordant gay male couples

Previous studies of HIV testing among gay men describe the motivations, facilitators and barriers, behaviors, and demographic characteristics of individuals who test. What little research focuses on HIV testing among gay men in relationships shows that they do not test regularly or, in some cases, at all-their motivations to test have not been investigated. With so little data on HIV testing for this population, and the continued privileging of individually focused approaches, gay men in relationships fall into a blind spot of research and prevention efforts. This study examined motivations to test for HIV using qualitative data from both partners in 20 gay male couples. Analysis revealed that the partners' motivations were either event-related (e.g., participants testing at the beginning of their relationship or HIV-negative participants in an HIV-discordant relationship testing after risky episode with their discordant primary partner) or partner-related (e.g., participants testing in response to a request or suggestion to test from their primary partner or participants testing out of concern for their primary partner's health and well-being). These data provide insight into relationship-oriented motivations to test for HIV for gay men in relationships and, in doing so, evidence their commitment to their primary partner and relationship. These motivations can be leveraged to increase HIV testing among gay men in relationships, a population that tests less often than single gay men, yet, until recently, has been underserved by prevention efforts.

Past present: Relationship dynamics may differ among discordant gay male couples depending on HIV infection history

Discordant couples are unique because neither partner shares the same serostatus. Yet research overlooks how they became discordant, mistakenly assuming that they have always been that way and, by extension, that being discordant impacts the relationship in a similar manner. This study examines HIV infection history and its impact on relationship dynamics using qualitative data from 35 discordant gay male couples. Most couples met discordant (69%); however, many did not (31%). Those couples that met discordant felt being discordant had a lesser impact on their sexual and relational satisfaction, while those that did not meet discordant felt it had a greater impact, reporting sexual frustration and anxiety over seroconverting. This suggests that relationship dynamics may differ for discordant couples depending on HIV infection history. HIV prevention and counseling services for discordant couples can be better tailored and more effective when differences in HIV infection history are recognized.

Notes on the concepts of 'serodiscordance' and 'risk' in couples with mixed HIV status

Serodiscordant primary relationships, in which one partner is HIV-positive and the other is HIV-negative, are increasingly recognised as a key context for the transmission of HIV globally. Yet insights into the dynamics of serodiscordance remain relatively limited. I argue that to understand what makes serodiscordant couples engage in sexual practices that increase the chance of transmission, we need to examine what HIV 'risk' actually means in different cultures and contexts. A 'socially situated' approach to HIV risk moves beyond its scientific conceptualisation as an objective 'fact', revealing a diversity of perceptions and competing risks. It also reveals that couples do not necessarily perceive their mixed HIV status in terms of 'difference', a common assumption that predetermines serodiscordance and thereby obscures its many and complex enactments. I draw on examples from the social research literature to illustrate how serodiscordance is shaped in different ways by local practices, priorities, and meanings. I argue that it is within these lived contexts that perceptions and negotiations of 'risk' arise and, thus, where couples' sexual practices need to be situated and understood. Such insights are timely as HIV research and prevention grapple with emerging scientific data that challenge traditional understandings about HIV transmission risk.

HIV risk behavior among HIV-infected men who have sex with men in Bangkok, Thailand

We assessed prevalence of sexually transmitted infection (STIs), sexual risk behaviors, and factors associated with risk behaviors among HIV-infected MSM attending a public STI clinic serving MSM in Bangkok, Thailand. Between October 2005-October 2007, 154 HIV-infected MSM attending the clinic were interviewed about sexual risk behaviors and evaluated for STIs. Patients were examined for genital ulcers and had serologic testing for syphilis and PCR testing for chlamydia and gonorrhea. Results showed that sexual intercourse in the last 3 months was reported by 131 men. Of these, 32% reported anal sex without a condom. STIs were diagnosed in 41%. Factors associated with having sex without a condom were having a steady male partner, having a female partner and awareness of HIV status <1 month. Sexual risk behaviors and STIs were common among HIV-infected MSM in this study. This highlights the need for increased HIV prevention strategies for HIV-infected MSM.

Intentional abstinence among homeless and unstably housed persons living with HIV/AIDS

Some persons living with HIV/AIDS (PLWHA) engage in periods of sexual abstinence. Baseline data from a larger study of homeless/unstably housed PLWHA indicated that 20% (125/644) intentionally abstained from sex in the past 90 days. Reasons included: (1) 'not interested' (n = 78); (2) did not want to infect someone (n = 46); and (3) did not have a partner (n = 37). Abstinence was less likely among all who had a main partner. Among men who have sex with men (MSM), abstinence was less likely among those with a detectable viral load. It was more likely among heterosexual men who were experiencing current housing problems and who had at least a high school education. Among women, abstinence was less likely among African Americans and those whose social networks were more aware of their HIV status. Better understanding of motivations to abstain may improve how programs serving PLWHA address this issue.

Discordance in HIV-1 viral loads and antiretroviral drug concentrations comparing semen and blood plasma

OBJECTIVES

For individuals not on antiretroviral therapy, the risk of heterosexual transmission of HIV appears negligible when blood plasma (BP) viral loads are <1500 HIV-1 RNA copies/mL. It is not clear whether this observation can be extrapolated to individuals on highly active antiretroviral therapy (HAART). Because of differential tissue penetration, antiretroviral drug concentrations may be sufficient to maintain an undetectable viral load in the BP yet not achieve adequate levels to suppress HIV in the genital tract. Therefore, we wanted to correlate HIV viral loads and drug concentrations in semen plasma (SP) and BP.

METHODS

Thirty-three men were included. All were on combination antiretroviral therapy with an undetectable BP viral load for at least 1 year. Blood and semen samples were collected within 2 h of each other and tested for HIV RNA by the NucliSens QT (bioMerieux, St Laurent, QC, Canada) method; drug concentrations were determined by liquid chromatography tandem mass spectrometry.

RESULTS

Two of the 33 patients (6.1%) with BP viral loads below detection had time-matched HIV viral loads in SP > or =700 copies/mL. Both patients were on efavirenz, the SP concentrations of which were < or =10% of the levels in BP and well below the minimal therapeutic drug monitoring target concentration required to suppress HIV.

CONCLUSIONS

Because, at least in part, of poor drug penetration into the genital tract, an undetectable HIV viral load in the BP does not guarantee an undetectable viral load in semen. In view of this, caution should be taken in concluding that patients on HAART with suppressed viraemia are sexually non-infectious.