Perceptions among Dutch men who have sex with men and their willingness to use rectal microbicides and oral pre-exposure prophylaxis to reduce HIV risk--a preliminary study

Prevention of HIV in the MSM Population: A Cultural-Historical Comparison of Sweden and the Netherlands

The aim of this article is to compare the cultural-historical events and decisions regarding how to deal with the higher risks of HIV in MSM, and more specifically, gay populations in Sweden and the Netherlands. A narrative literature was used, based on 46 scientific articles and 20 additional semi-scientific resources. The themes of the arrival of HIV and AIDS, blood donations, offender/victim, the balance of risks with respect to the statistical probabilities and the human factor, and finally, prevention were discussed. It is concluded that certain context-specific historical events (the Dutch Bloody Sunday and the Swedish gay sauna ban) and culturally determined processes (trust in others in the Netherlands, and disapproval of casual sex in Sweden) have led to some important differences in how HIV and AIDS and the higher risks for gay men and MSM have been dealt with. In the Netherlands, there is a stronger protective attitude when it comes to the freedom and autonomy of MSM both when it comes to decisions about sexual behavior and to sharing any positive HIV status. In Sweden, on the other hand, there is a stronger tendency to enforce informing others of their HIV status. In both countries, despite efforts to prevent this, HIV has increased stigma for gay men and other MSM.

A Randomized, Open-Label, Crossover Phase 1 Safety and Pharmacokinetic Study of Oral Maraviroc and Maraviroc 1% Gel (the CHARM-03 Study)

The Combination HIV Antiretroviral Rectal Microbicide-3 (CHARM-03) study was a randomized, open-label, crossover Phase 1 safety and pharmacokinetic (PK) study of oral maraviroc (MVC) and MVC 1% gel. At a single site, healthy HIV-uninfected men and women were enrolled and randomized to an open label crossover sequence of eight consecutive daily exposures to MVC 300 mg dosed orally, MCV 1% gel dosed rectally, and MVC 1% gel dosed vaginally. Male participants received oral and rectal dosing and female participants received oral, rectal, and vaginal dosing. Assessments were undertaken at baseline and following each 8-day period and included collection of plasma, rectal/cervical tissue (CT), and rectal/endocervical/vaginal fluids. Eleven men and nine women were enrolled. Two participants withdrew from the study before receiving study product. There were 25 adverse events, of which 24 were Grade 1 (G1) and one was G2 (unrelated). After eight doses, MVC was quantifiable in all samples following oral, rectal, or vaginal product administration. The highest drug concentrations in plasma, rectal tissue (RT), and CT were associated with oral, rectal, and vaginal drug delivery, respectively. There were significant reductions in tissue drug concentrations when rectal and cervical biopsies were incubated in media before tissue processing for PK (p < .0001). Only oral MVC was associated with limited protection in the rectal explant HIV challenge model (p < .05). There were no immunological changes in RT, and all products were acceptable to participants. In conclusion, all products were found to be safe and acceptable and did not induce local inflammation. The lack of ex vivo efficacy demonstrated in study samples may be due to rapid disassociation of MVC from the explant tissue. ClinicalTrials.gov Identifier: NCT02346084.

Understanding factors influencing utilization of HIV prevention and treatment services among patients and providers in a heterogeneous setting: A qualitative study from South Africa

Despite advances made in HIV prevention and treatment interventions in South Africa, barriers to their utilization continue to exist. Understanding perspectives from patients and providers of healthcare can shed light on the necessary strategies to enhance uptake of HIV services. A cross-sectional qualitative study was conducted in July 2020 in Ekurhuleni District. Based on HIV prevalence estimates from a national survey, male condom use coverage and antiretroviral treatment (ART) initiation rates from routinely collected clinical data for 2012, we selected facilities from geographical areas with varying HIV prevalence and uptake of HIV services. In-depth interviews were conducted with adult (≥18 years) patients and healthcare workers in selected primary healthcare facilities. Thematic analysis was performed following a framework built around the social cognitive theory to describe behavioural, personal, and social/environmental factors influencing utilization of HIV services. Behavioural factors facilitating uptake of HIV services included awareness of the protective value of condoms, and the benefits of ART in suppressing viral load and preventing mother-to-child HIV transmission which was evident across geographical areas. Barriers in high prevalence areas included suboptimal condom use, fears of a positive HIV result, and anticipated HIV-related stigma while seeking healthcare services. Across the geographical areas, personal factors included ability to correctly use available services enhanced by knowledge acquired during counselling sessions and community-based health promotion activities. Further, social support from family reinforced engagement in care. Compared to low uptake areas, clinics in high uptake areas used care-facilitators, outreach teams and decanting programs to address the environmental barriers including staff shortages and long queues. Barriers at multiple levels prevent optimal utilization of HIV services, calling for strategies that target and address the different levels and tailored to needs of specific settings. Overall, improved delivery of HIV prevention or treatment interventions can be achieved through strengthening training of healthcare providers in facilities and communities and addressing negative sequelae from utilising services in low uptake areas.

Determinants of heterosexual men's demand for long-acting injectable pre-exposure prophylaxis (PrEP) for HIV in urban South Africa

Background

Heterosexual men in South Africa are a large key population to exposure to HIV, yet preferences for HIV pre-exposure prophylaxis (PrEP) among this population have not, to date, been investigated in the literature. This paper aims to explore HIV prevention preferences among heterosexual men in urban South Africa, as well as to examine the demand and characteristics of men who favour long-acting injectable (LAI) PrEP over condoms and oral PrEP.

Methods

Data were collected among 178 self-reported HIV-negative heterosexual men, who were given example products and information before being asked which they preferred. Multivariate logistic regression was used to analyse which characteristics were associated with product choice.

Results

48% (n = 85) of participants preferred LAI PrEP, while 33% (n = 58) and 20% (n = 35) chose oral PrEP and condoms respectively. Having children (marginal effect = 0.22; 95% CI [0.01, 0.44]) or having higher risk attitude scores (marginal effect = 0.03; 95% CI [0.01, 0.06]) was significantly associated with a choice of LAI PrEP, while those who had unprotected anal intercourse (marginal effect = − 0.42; 95% CI [− 0.57, − 0.27]) and those who were concerned with protection against other sexually transmitted infections over HIV (marginal effect = − 0.42; 95% CI [− 0.60, − 0.24]) appeared less likely to prefer LAI PrEP.

Conclusions

The results suggested a relatively high demand and theoretical acceptability for LAI PrEP among heterosexual men in urban South Africa, but there appeared to be fewer distinct predictors for the willingness to use LAI PrEP compared to studies conducted among gay and bisexual men and women. Nevertheless, the findings contribute to the mapping of the demand and determinants of heterosexual men’s preferences for novel antiretroviral-based prevention in sub-Saharan Africa, and the data could aid in the differentiated design of future HIV prevention strategies using LAI PrEP in conjunction with other methods.

Electronic supplementary material

The online version of this article (10.1186/s12889-019-7276-1) contains supplementary material, which is available to authorized users.

Sex Tourism and Pre-Exposure Prophylaxis Modality Preferences Among Men Who Have Sex With Men

Sex tourism among men who have sex with men (MSM) has been associated with increased risk for human immunodeficiency virus (HIV) due to sexually scripted environments characterized by multiple sexual partners, increased availability of alcohol and drugs, and limited availability of HIV-prevention services. The current study examined the knowledge of and likelihood of using different modalities of pre-exposure prophylaxis (PrEP), an important biomedical HIV-prevention strategy, among MSM in Paris who have engaged in sex tourism. A sample of 580 MSM from a highly popular geosocial-networking smartphone application in Paris, France, participated in the survey. Of the 580 MSM, 444 participants reported an HIV-negative status and represent the analytic sample for this study. Approximately 27% reported engaging in sexual tourism. MSM who engaged in sex tourism were more likely to aware of on-demand PrEP and more likely to express interest in using on-demand PrEP (adjusted risk ratio [aRR] = 1.26; 95% confidence interval [CI] = 1.03-1.53, aRR = 1.29; 95% CI = 1.04-1.61, respectively) than MSM who never engaged in sex tourism. Moreover, participants who engaged in sex tourism were more likely to express interest in rectal microbicides or both rectal and penile microbicides (aRR = 1.34; 95% CI = 1.13-1.59, aRR = 1.26; 95% CI = 1.03-1.55, respectively) than participants who had not engaged in sex tourism. With the high likelihood of interest in using alternative forms of PrEP in MSM who engage in sex tourism, this study suggests potential benefits for these alternative forms of PrEP for this specific population and underscores the importance of their continued development.

Transactional Sex and Preferences for Pre-Exposure Prophylaxis (PrEP) Administration Modalities Among Men Who Have Sex With Men (MSM)

Pre-exposure prophylaxis (PrEP) is an important biomedical human immunodeficiency virus (HIV) prevention tool gaining more popularity among Parisian men who have sex with men (MSM) who engage in transactional sex. This study examines the knowledge of, and willingness to use, different modalities of PrEP among this subgroup. Broadcast advertisements were placed on a geosocial-networking smartphone application with a link to a Web-based survey during three 24-hour periods in October 2016. Modified Poisson regression models were used to assess the association between engagement in transactional sex and preferences for each of these PrEP modalities. A total of 444 respondents were included. About 14% reported engagement in transactional sex. In all, 90% of MSM who engaged in transactional sex were knowledgeable of daily oral PrEP, while 13.3% were knowledgeable about long-acting injectable PrEP or penile or rectal microbicides. They were more likely to be aware of long-acting injectable PrEP (aRR = 2.52, 95% CI = 1.16 to 5.47) and willing to use daily oral PrEP (aRR = 1.48; 95% CI = 1.11 to 1.98) or long-acting injectable PrEP (aRR = 1.40; 95% CI = 1.09 to 1.81) than MSM who had not engaged in transactional sex. Long-acting injectable PrEP may be an important HIV-prevention option for MSM who engage in transactional sex if this modality is proven effective.

Are Anal Sex Roles Associated with Preferences for Pre-Exposure Prophylaxis Administration Modalities Among Men Who Have Sex with Men?

The current study sought to examine awareness of, willingness to use, and preferences for available and theoretical administration modalities for HIV pre-exposure prophylaxis (PrEP) and the association of anal sex roles with these concepts among a sample of men who have sex with men (MSM) in Paris, France. Broadcast advertisements were placed on a popular geosocial-networking smartphone application for MSM to direct users to complete a Web-based survey. MSM answered questions on their recent engagement in condomless anal intercourse and awareness of and willingness to use PrEP in the form of once daily and event-driven pill regimens, long-acting injections, and penile and rectal microbicides as well as sexual roles. Multinomial regression models were fit to assess the association between behaviorally classified anal sexual role and preferences for one of these biomedical prevention modalities. A total of 482 HIV-uninfected MSM completed the survey, 48.1% of whom engaged in some form of condomless anal intercourse in the preceding 3 months. Most respondents (85.3%) had heard of once daily PrEP, but fewer respondents had heard of other prevention strategies. Assuming equal effectiveness, long-acting injections were the most commonly preferred (21.8%). Behaviorally defined "bottom" and "versatile" MSM more frequently preferred long-acting injections (32.9% of "bottoms" and 25.3% of "versatiles"). The development of long-acting injections to deliver antiretroviral drugs and topical microbicides may offer more convenient and acceptable options for HIV prevention among MSM, as MSM in this sample were willing to use them and would prefer to use them over currently available pill regimens.

Preexposure prophylaxis comprehension and the certainty of willingness to use preexposure prophylaxis among men who have sex with men in China

Preexposure prophylaxis (PrEP) is not available in China and the willingness to use PrEP among Chinese men who have sex with men (MSM) is not clear. The aim of this study was to better understand the association between PrEP comprehension and the willingness to use PrEP under varying conditions among MSM. An online survey investigating personal characteristics, PrEP comprehension, and PrEP willingness among MSM was conducted. A third of respondents (36.2%, 196 out of 541) reported that they would like to use PrEP. Compared with MSM with a basic level of PrEP comprehension, MSM with a high level were more likely to report clear choices: a willingness or unwillingness to use PrEP (82.4% versus 65.7%, p <0.01). Among 350 MSM willing to use PrEP or uncertain about uptake, those with a high level of PrEP comprehension were more likely to use PrEP daily (adjusted odds ratio [AOR] = 1.71, 95% confidence interval 1.04-2.80), and to use PrEP with mild or other side effects (AOR = 2.72 or 2.77). A high level of PrEP comprehension is a key factor in urging MSM to use PrEP under varying conditions. Our findings call attention to the need for health education to improve PrEP comprehension.

A Global Estimate of the Acceptability of Pre-exposure Prophylaxis for HIV Among Men Who have Sex with Men: A Systematic Review and Meta-analysis

Pre-exposure prophylaxis (PrEP) is a new biomedical intervention for HIV prevention. This study systematically reviews the acceptability of PrEP among men who have sex with men (MSM) worldwide. We searched major English databases to identify English-language articles published between July 2007 and July 2016, which reported the acceptability of PrEP and associated population characteristics. Meta-analysis was conducted to estimate a pooled acceptability, and meta-regression and subgroup analysis were used to analyse heterogeneities. The estimated acceptance from included sixty-eight articles was 57.8% (95% confidence internal 52.4-63.1%). MSM who were younger (4/5 studies, range of adjusted odds ratio (aOR) = 1.39-3.47), better educated (aOR = 1.49-7.70), wealthier (aOR = 1.31-13.03) and previously aware of PrEP (aOR = 1.33-3.30) showed significantly higher acceptance. Male sex workers (84.0% [26.3-98.7%] were more likely to accept PrEP than general MSM. Self-perceived low efficacy, concern about side effects, adherence, affordability, and stigma were main barriers. This review identifies a moderate acceptability of PrEP in MSM. Efficacy, perception of HIV risk and experienced stigma determine its acceptance.

Rectal Douching Among Men Who Have Sex with Men in Paris: Implications for HIV/STI Risk Behaviors and Rectal Microbicide Development

Rectal douching is a common but potentially risky practice among MSM; MSM who douche may be ideal candidates for rectal microbicides as HIV prevention. Herein we explored rectal douching and its association with condomless receptive anal intercourse (CRAI), group sex, rates of HIV and other STIs, and likelihood to use rectal microbicide gels. We recruited a sample of 580 MSM from a geosocial-networking smartphone application in Paris, France in 2016. Regression models estimated adjusted risk ratios (aRRs) for associations between rectal douche use and (1) engagement in CRAI, (2) group sex, (3) self-reported HIV and STI diagnoses, and (4) likelihood to use rectal microbicide gels for HIV prevention. 54.3% of respondents used a rectal douche or enema in the preceding 3 months. Douching was significantly associated with CRAI (aRR: 1.77), participation in group sex (aRR: 1.42), HIV infection (aRR: 3.40), STI diagnosis (aRR: 1.73), and likelihood to use rectal microbicide gels (aRR: 1.78). Rectal douching is common among MSM, particularly those who practice CRAI, and rectal microbicide gels may be an acceptable mode of HIV prevention for MSM who use rectal douches.

MTN-017: A Rectal Phase 2 Extended Safety and Acceptability Study of Tenofovir Reduced-Glycerin 1% Gel

Background

Human immunodeficiency virus (HIV) disproportionately affects men who have sex with men (MSM) and transgender women (TGW). Safe and acceptable topical HIV prevention methods that target the rectum are needed.

Methods

MTN-017 was a phase 2, 3-period, randomized sequence, open-label, expanded safety and acceptability crossover study comparing rectally applied reduced-glycerin (RG) 1% tenofovir (TFV) and oral emtricitabine/TFV disoproxil fumarate (FTC/TDF). In each 8-week study period participants were randomized to RG-TFV rectal gel daily, or RG-TFV rectal gel before and after receptive anal intercourse (RAI; or at least twice weekly in the event of no RAI), or daily oral FTC/TDF.

Results

MSM and TGW (n = 195) were enrolled from 8 sites in the United States, Thailand, Peru, and South Africa with mean age of 31.1 years (range 18-64). There were no differences in ≥grade 2 adverse event rates between daily gel (incidence rate ratio [IRR], 1.09; P = .59) or RAI gel (IRR, 0.90; P = .51) compared to FTC/TDF. High adherence (≥80% of prescribed doses assessed by unused product return and Short Message System reports) was less likely in the daily gel regimen (odds ratio [OR], 0.35; P < .001), and participants reported less likelihood of future daily gel use for HIV protection compared to FTC/TDF (OR, 0.38; P < .001).

Conclusions

Rectal application of RG TFV gel was safe in MSM and TGW. Adherence and product use likelihood were similar for the intermittent gel and daily oral FTC/TDF regimens, but lower for the daily gel regimen.

Clinical Trials Registration

NCT01687218.