The fallacy of intimacy: sexual risk behaviour and beliefs about trust and condom use among men who have sex with men in South Africa

Predictors of Condom Use among College Students

Consistent condom use is recognized as one of the most effective strategies to prevent unwanted pregnancies and sexually transmitted infections. Despite their effectiveness, condoms remain fairly well used among younger people. The conception of appropriate measures to change behaviors needs a deep understanding of the factors underlying poor adherence to condom use. This study aims to identify the predictors of condom use among college students. A cross-sectional, correlational, and predictive study was conducted involving a convenience sample of 1946 university students, with an average age of 21 years (20.74 ± 2.32). Pender's Health Promotion Model (HPM) was used as a conceptual and methodological framework to understand the relationship between the predictors of condom use. An explanatory theoretical model of condom use behavior was established using path analysis. Condom use among young people is infrequent, with only 39.4% of respondents reporting consistent use. Perceived benefits, positive feelings, and interpersonal influences emerged as variables with the most explicitly positive influence on the commitment to condom use, a trend confirmed for both sexes. Commitment was the strongest predictor of condom use behavior (β = 0.580; p < 0.001). Pender's HPM is effective in explaining the relationships between the predictors of condom use.

Can oral sex be performed safely among men who have sex with men (MSM) and transgender women in Bangladesh? Challenges, complexities and the way forward

Introduction

There is currently ample research and intervention initiatives addressing anal sex and sexually transmitted infections (STIs) among gender and sexually diverse people (i.e., men who have sex with men (MSM) and transgender women). However, oral sex and oral STIs are not prioritized to the same extent, despite their concerning implications. This article aimed to delineate the underlying contexts of unprotected oral sex and the management challenges of oral STIs.

Methodology

This qualitative study constituted 30 in-depth interviews, 14 focus group discussions, and 10 key-informant interviews with gender and sexually diverse people, service providers of HIV interventions and sexuality researchers. Thematic analysis conventions were applied.

Results

Findings revealed various contexts of unprotected oral sex. In particular, we found a discordance between pleasure and protected sex where participants believed the two phenomena were mutually exclusive, therefore they did not want to compromise their pleasure by using condoms. Moreover, their low awareness, risk perception, and unchallenged misconceptions about the harms of unprotected oral sex fueled their hesitancy to use condoms during oral sex. Compared to anal sex and STIs, oral sex and STIs were less prioritized in the current HIV intervention modalities, where healthcare providers lacked adequate knowledge and training about oral sex and oral STIs, as well as their complexities.

Conclusions

In Bangladesh and several other settings, oral sex is considered a taboo, thus imbuing silence about this issue and its complexities. In this context, it is integral to eradicate the taboos and silence surrounding oral sex and oral STIs in order to strengthen the overall STI management strategy. Therefore, HIV/STI prevention programs and mainstream healthcare facilities need to underscore oral STI interventions, otherwise this issue would remain under-prioritized.

Vil NM, Bond KT, Mitchell JW, Juarez AC, Lambert F, Muheriwa SR, McMahon J. Dimensions of Sexual Health Conversations among U.S. Black Heterosexual Couples

Sexual health communication is an important feature of healthy intimate relationships; however, some couples may avoid discussing difficult matters (e.g., HIV/STI testing, sexual satisfaction) to minimize interpersonal conflict. From October 2018 to May 2019 in New York State, we conducted a multi-method descriptive pilot study to characterize Black heterosexual couples' (N = 28) sexual health conversations. Partners individually completed an online sexual health/relationship survey before engaging in-person for a joint dyadic qualitative in-depth interview. Quantitative descriptive statistics demonstrated that most absolute score differences among couple's preferences for sexual health outcomes, communal coping and sexual relationship power were mainly small, but greatest regarding extra-dyadic sexual behaviors. A qualitative descriptive approach discerned, motivation and norms for sexual health conversations, and communication patterns. Thematic and content analysis revealed two central themes: initiating and sustaining sexual health conversations, and leveraging features of the couples to promote sexual health. Integrated findings indicate that couples possess varied communication patterns that operate with motivations for sexual health conversations toward subsequent sexual health promotion. Equitable and skewed communication patterns emerged as relationship assets that can be leveraged to optimize sexual health. There is also opportunity for future work to address communication regarding extra-dyadic behavior and preferences. Asset-based considerations are discussed.

Information, Motivation and Behavioral Skills as Mediators Between Sexual Minority Stigma and Condomless anal Sex Among Black South African Men Who have Sex with Men

We assessed pathways between sexual minority stigma and condomless anal intercourse (CAI) among two samples of Black South African men who have sex with other men (MSM). Two cross-sectional surveys were conducted in Tshwane, South Africa; one among 199 Black MSM and another among 480 Black MSM. Men reported on external and internalized experiences of sexual minority stigma, mental health, alcohol use, information-motivation-behavioral skills (IMB) model constructs, and CAI. Structural equation modeling was used to test whether external and internalized stigma were directly and indirectly associated with CAI. In both studies, external stigma and internalized stigma were associated with CAI through IMB model constructs. These results suggest a pathway through which stigma contributes to HIV risk. For HIV prevention efforts to be effective, strengthening safer sex motivation and thus decreasing sexual risk behavior likely requires reducing sexual minority stigma that MSM experience and internalize.

The social and sexual lives of Black sexual minority men 30 years of age and older in South Africa

Background

Black sexual minority men (SMM) ages 30 and older are under-represented in HIV studies in sub-Saharan Africa, despite being at increased risk of HIV infection and contributing to potential onward HIV transmission. To better understand the social and sexual lives of older Black South African SMM, we conducted in-depth interviews with SMM who were > 30 years old.

Methods

From March–September 2016, we recruited a convenience sample of 37 SMM ages 30 and older by partnering with an LGBTQ+ organization in Tshwane, Pretoria. Men were interviewed about various aspects of their lives, including their sexual orientation, social connectedness, experiences with stigma and perspectives on participating in research.

Results

Participants described their experiences with their sexual identities, cultural and social implications of disclosure, and their perspective on South Africa’s political perspectives on the LGBTQ+ community. Men described how these experiences influence their trust in research and comfort participating in studies.

Conclusions

Inferences drawn from these findings provide direction on how to improve middle-aged SMM’s representation in research, such as recruiting a higher proportion of older and middle-aged SMM to serve as seed participants and building stronger community partnerships to disseminate study findings to settings where data collection is conducted.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12889-022-14303-5.

Keep it positive: Exploring the relationship between stress, positive affect, wellbeing, and success of entrepreneurs

Entrepreneurs' wellbeing is of unprecedented importance given their crucial role in national economies in terms of job creation and innovation. In this research, we used a mixed methods approach to investigate the direct and indirect mechanisms by which entrepreneurs' wellbeing mediates the effects of stress on perceived entrepreneurial success. We theorize that entrepreneurs experience work-related stress and that the level of perceived wellbeing mediates the relationship between the entrepreneurs' stress and perceived success. We also hypothesize moderation effects by dispositional positive affect. We find that stress has direct negative effects on entrepreneurs' wellbeing and perceived success. However, an experience of positive affect significantly weakens the negative effects of stress by broadening and building entrepreneurs' cognitions. Drawing from our theoretical and empirical findings, we discuss implications for theory and practice in the domain of entrepreneurs' wellbeing.

The effects of intimate relationship characteristics on unprotected anal intercourse among same-sex male couples in China: a dyadic analysis using the actor-partner interdependence model

BACKGROUND

Unprotected anal intercourse (UAI) within the context of concurrent sexual relationship are prevalent among men who have sex with men (MSM) who have regular male sex partners and it aggravates the risk of HIV infection among this community. The aim of this study was to assess the effect of intimate relationship characteristics on UAI among MSM couples at the dyadic level.

METHODS

Two hundred four MSM couples were recruited from a HIV testing clinic from April 2017 to April 2018 in Guangzhou, China. The actor-partner interdependence model (APIM) was applied for dyadic analysis. Each MSM couple was divided into the insertive role and the receptive role according to their regular anal sex role. In this context, actor effect is the impact of an MSM's intimate relationship characteristics on his own UAI, and partner effect is the impact of his partner's intimate relationship characteristics on his UAI.

RESULTS

Of the 408 participants, 58.82% had UAI with regular male sex partner (UAI-RP) and 8.09% had concurrent UAI. Intimate relationship characteristics were associated with concurrent UAI, but not associated with UAI-RP. For the receptive role, his relationship investment exerted significant actor and partner effects on concurrent UAI (AOR actor = 1.31, P < 0.001; AOR partner = 1.17, P < 0.001). Meanwhile, receptive role's violence experience within relationship exerted significant actor effects on his own concurrent UAI (AOR actor = 6.43, P = 0.044).

CONCLUSIONS

Relationship investment and violence experience influenced concurrent UAI among MSM couples and it varied in different sex roles. Additional assistance on empowerment, relationship therapy and sexual agreement is urgently needed to reduce their high possibility on engagement of HIV-related risk behaviors.

Prevalence of condomless anal intercourse and associated risk factors among men who have sex with men in Bamako, Mali

BACKGROUND

Men who have sex with men (MSM) are disparately impacted by HIV in sub-Saharan Africa and condomless anal intercourse (CAI) is a major driver of HIV transmission. The objective of the current study was to identify factors associated with CAI among MSM in Bamako, Mali, among whom HIV prevalence was 13.7%.

METHODS

A bio-behavioral survey was conducted between October 2014 and February 2015 using respondent-driven sampling to recruit 552 adult MSM. Weighted statistical analyses were conducted to determine the prevalence of CAI with one's most recent male partner and survey logistic procedures were used to identify associated factors.

RESULTS

The prevalence of CAI with one's most recent male partner was 40.7%. Associated factors included: inability to get a condom when needed (aOR = 5.8, 95%CI: 2.7-12.3) and believing CAI is acceptable under some circumstances (aOR = 8.4, 95%CI: 4.4-16.2).

CONCLUSIONS

Programs addressing HIV among MSM in Mali should aim to increase access to condoms and education about HIV prevention through consistent condom use during anal intercourse.

Taking the Maximum Risks for Satisfaction: Understanding the Process of Condom Discontinuation among National Youth Service Corps' Members in Nigeria

Objectives: To examine the process of condom discontinuation among members of the National Youth Service Corps in Nigeria who had been required to take part in a compulsory one year national service right after tertiary graduation. Methods: We used a qualitative research design to achieve this objective. Results: Findings revealed that the motivations for condom discontinuation among our sample include the need to achieve pleasure, the perception of the withdrawal method skill as an alternative to condom use, intimacy and trust among others. Cultural influence such as the promise of marriage and proof of fertility motivated both men and women to discontinue condom use. For many, intermittent condom discontinuation was normal throughout the course of relationships. Also, while verbal communication was more common among males than females, non-verbal communication strategies were employed by more of the females in their condom discontinuation behaviour. Conclusions: Overall, the findings improve our understanding of how condom discontinuation processes occur among young people and concludes that many young people (respondents) are yet to grapple with the potential consequences of unsafe sex.

"Condoms Are Boring": Navigating Relationship Dynamics, Gendered Power, and Motivations for Condomless Sex Amongst Adolescents and Young People in South Africa

Condoms remain an important method for preventing HIV prevention and unintentional pregnancies, however their use in South Africa is sub-optimal. We analyzed survey data on reported condom use among 3009 sexually active adolescent girls and young women (AGYW) aged 15-24 years, and qualitative data from interviews and focus group discussions with 237 AGYW and 38 male peers. Our findings describe the current condom use landscape among adolescents and young people in South Africa, illustrating relationship dynamics, gendered power and notions of masculinity which influence condom negotiation and use in young heterosexual South Africans' sexual encounters.

Estimating the contribution of key populations towards HIV transmission in South Africa

INTRODUCTION

In generalized epidemic settings, there is insufficient understanding of how the unmet HIV prevention and treatment needs of key populations (KPs), such as female sex workers (FSWs) and men who have sex with men (MSM), contribute to HIV transmission. In such settings, it is typically assumed that HIV transmission is driven by the general population. We estimated the contribution of commercial sex, sex between men, and other heterosexual partnerships to HIV transmission in South Africa (SA).

METHODS

We developed the "Key-Pop Model"; a dynamic transmission model of HIV among FSWs, their clients, MSM, and the broader population in SA. The model was parameterized and calibrated using demographic, behavioural and epidemiological data from national household surveys and KP surveys. We estimated the contribution of commercial sex, sex between men and sex among heterosexual partnerships of different sub-groups to HIV transmission over 2010 to 2019. We also estimated the efficiency (HIV infections averted per person-year of intervention) and prevented fraction (% IA) over 10-years from scaling-up ART (to 81% coverage) in different sub-populations from 2020.

RESULTS

Sex between FSWs and their paying clients, and between clients with their non-paying partners contributed 6.9% (95% credibility interval 4.5% to 9.3%) and 41.9% (35.1% to 53.2%) of new HIV infections in SA over 2010 to 2019 respectively. Sex between low-risk groups contributed 59.7% (47.6% to 68.5%), sex between men contributed 5.3% (2.3% to 14.1%) and sex between MSM and their female partners contributed 3.7% (1.6% to 9.8%). Going forward, the largest population-level impact on HIV transmission can be achieved from scaling up ART to clients of FSWs (% IA = 18.2% (14.0% to 24.4%) or low-risk individuals (% IA = 20.6% (14.7 to 27.5) over 2020 to 2030), with ART scale-up among KPs being most efficient.

CONCLUSIONS

Clients of FSWs play a fundamental role in HIV transmission in SA. Addressing the HIV prevention and treatment needs of KPs in generalized HIV epidemics is central to a comprehensive HIV response.

Association between Psychological Factors and Condom Use with Regular and Nonregular Male Sexual Partners among Chinese MSM: A Quantitative Study Based on the Health Belief Model

Objective

The Chinese men who have sex with men (MSM) population is suffering from a high HIV infection rate owing to unprotected anal sex. The Health Belief Model (HBM) has been proven to be an effective frame associated with behavior maintenance. Based on HBM, we analyzed the beliefs associated with consistent condom use behavior with regular and nonregular partners among MSM to better provide targeted interventions and services.

Methods

A study was conducted in Sichuan Province, China, from November 2018 to April 2019, and 801 eligible participants were recruited by snowball sampling. Sociodemographic characteristics, AIDS-related characteristics, sexual behaviors, condom use behavior, and dimensions of HBM were investigated. Univariate, single multivariate, and summary multivariate models were employed to analyze the factors associated with consistent condom use.

Results

Of all participants, 39.1% and 53.6% had had anal sex with regular and nonregular partners in the last six months, respectively. Only 56.5% of them had used condoms consistently with regular partners, and only 60% of them had used condoms consistently with nonregular partners. When taking consistent condoms use with regular partners as the dependent variable, the dimensions of perceived threats (ORM = 1.28, 95% CI: 1.10, 1.49), perceived barriers (ORM = 0.70, 95% CI: 0.60, 0.82), self-efficacy (ORM = 1.23, 95% CI: 1.14, 1.32), and cues to action (ORM = 1.21, 95% CI: 1.02, 1.43) showed significant associations with the dependent variable. When taking consistent condoms use with nonregular partners as the dependent variable, the dimensions of perceived barriers (ORM = 0.77, 95% CI: 0.67, 0.89), self-efficacy (ORM = 1.22, 95% CI: 1.13, 1.32), and cues to action (ORM = 1.53, 95% CI: 1.30, 1.80) showed significant associations with the dependent variable.

Conclusions

More attention should be focused on how to decrease the obstructive factors of condom use, how to improve the confidence of condom use, and how to layout more cues to action to promote consistent condom use behavior with regular and nonregular partners during anal sex among Chinese MSM.

Considerations for Research on Sexually Transmitted Infections (STIs): Reflections of an STI Clinician-Researcher

Sexually transmitted infections (STIs) have been explored in various sexual subgroups. While excellent, these analyses have primarily occurred from uniquely biologic, epidemiologic, or sociologic perspectives. Missing from these discussions has been in-depth presentations of the dynamics of STI transmission from all three viewpoints simultaneously. In this paper, I present information about STI transmission for each STI, including considerations of prevalence, and then review the STI research and of the concept of risk. I then apply these three considerations to a fictitious case study to show their importance and utility. I close by arguing that this information could strengthen future sociologic reviews of STIs and sexual health by helping such researchers include more nuanced understandings about STIs.

How men who have sex with men experience HIV health services in Kampala, Uganda

In sub-Saharan Africa, men who have sex with men (MSM) are socially, largely hidden and face disproportionate risk for HIV infection. Attention to HIV epidemics among MSM in Uganda and elsewhere in sub-Saharan Africa has been obscured by repressive governmental policies, criminalisation, stigma and the lack of basic epidemiological data describing these epidemics. In this paper, we aim to explore healthcare access, experiences with HIV prevention services and structural barriers to using healthcare services in order to inform the acceptability of a combination HIV prevention package of services for men who have sex with men in Uganda. We held focus group discussions (FGDs) with both MSM and healthcare providers in Kampala, Uganda, to explore access to services and to inform prevention and care. Participants were recruited through theoretical sampling with criteria based on ability to answer the research questions. Descriptive thematic coding was used to analyse the FGD data. We described MSM experiences, both negative and positive, as they engaged with health services. Our findings showed that socio-structural factors, mediated by psychological and relational factors impacted MSM engagement in care. The socio-structural factors such as stigma, homophobia and policy issues emerged strongly as did the mediating factors such as relations with specific health staff and a social support structure. A combination intervention addressing structural, social and psychological barriers could have an impact even in the precarious policy environment where this study was conducted.

Gender differences in the relationship of sexual partnership characteristics and inconsistent condom use among people living with HIV in China

Few studies have examined the relationship between inconsistent condom use and sexual partnership characteristics among people living with HIV (PLWH). The current study focused on such association and its gender differences. The study was conducted in a large hospital in South China in 2013. A total of 320 dyads (PLWH indexes and their sexual partners) were recruited from an outpatient clinic using convenience sampling. The proportion of inconsistent condom use in the last six months among female indexes was higher than that among male indexes (52.4% vs. 43.6%). Of sexual partnership characteristics, HIV seropositive status was a risk factor for inconsistent condom use for both male and female indexes (aOR = 2.32, 95%CI = 1.15∼4.66, aOR = 3.09, 95%CI = 1.10∼8.67, respectively). For male indexes, lower educational level was also a risk factor (aOR = 2.39, 95%CI = 1.23∼4.67); while having had emotionally intimate relationships was a protective factor (aOR = 0.40, 95%CI = 0.21∼0.77). For female indexes, receiving material support was a risk factor (aOR = 10.17, 95%CI = 2.13∼48.61) and receiving health-related advice was a protective factor (aOR = 0.11, 95%CI = 0.02∼0.55). Future HIV interventions for PLWH need to be gender-sensitive and include their sexual partners.

Trust, Sexual Trust, and Sexual Health: An Interrogative Review

Trust is experienced almost constantly in all forms of social and interpersonal relationships, including sexual relationships, and may contribute both directly and indirectly to sexual health. The purpose of this review is to link three aspects of trust to sexual health: (1) the role of trust in sexual relationships; (2) the role of trust in sexually transmitted infection (STI) prevention, particularly condom use; and (3) the relevance of trust in sexual relationships outside of the traditional model of monogamy. The review ends with consideration of perspectives that could guide new research toward understanding the enigmas of trust in partnered sexual relations in the context of sexual and public health.

Gender identity and HIV risk among men who have sex with men in Cape Town, South Africa

Gender identity plays a potentially important role contributing to HIV risk among MSM in South Africa. Where studies have included a focus on gender identity, MSM reporting gender non-conformity have been found to have a higher risk of being HIV positive than other MSM. This article examines HIV risk among gender non-conforming MSM in a sample of 316 MSM in Cape Town, South Africa. Reporting gender non-conformity was associated with higher HIV prevalence and increased HIV risk behaviour. Gender non-conformity was also associated with a higher likelihood of being unemployed and reporting low household incomes. These findings highlight the importance of gender-identity as a factor affecting access to HIV treatment, care, and prevention in South Africa and this is an issue that needs to be addressed in interventions targeting MSM populations.

Intimate relationship characteristics as determinants of HIV risk among men who have sex with regular male sex partners: a cross-sectional study in Guangzhou, China

Background

China faces a serious HIV epidemic among men who have sex with men (MSM), and a large proportion of new infections are attributed to their regular male sex partners (RP). The objective of this study was to investigate the association between intimate relationship characteristics and HIV-related behaviors among MSM with RP in Guangzhou, China.

Methods

A convenience-sampling method was used in data collection. A total of 608 MSM were screened, of whom 406 HIV negative MSM with at least one RP in the past six months were used for data analysis. Three-step logistic regressions were used to analyze the data.

Results

The prevalence of unprotected anal intercourse (UAI) with regular male sex partners, non-regular male sex partners, and concurrent UAI in the past six months was 53.9%, 23.6%, 20.7%, respectively. Variables associated with UAI with regular male sex partners included expectations for this relationship (adjusted odds ratio in multiple forward stepwise logistic regression, OR_m = 1.66) and open communication about the sexual relationship (OR_m = 1.79), while expectations for the relationship (OR_m = 0.46 to 0.54) and conflicts of interest (OR_m = 5.46 to 5.97) were associated with concurrent UAI and UAI with non-regular male sex partners.

Conclusion

Intimate relationship characteristics were related to HIV-related risk behaviors. Future HIV prevention interventions should take MSM couples into consideration, include a focus on the quality of their intimate relationships, and encourage open communication about their sexual relationships.

Electronic supplementary material

The online version of this article (10.1186/s12879-018-3044-6) contains supplementary material, which is available to authorized users.

Predictors of HIV Testing and Their Influence on PrEP Acceptance in Men Who Have Sex with Men: A Cross-Sectional Study

HIV testing is the gateway to biomedical means of prevention and treatment. Identifying predictors of HIV testing is important to inform future preventive interventions. Of 444 men who have sex with men without known HIV infection enrolled in a study in Hong Kong, 64% had ever been HIV-tested. Testers were generally older, better educated, had a higher monthly income, and more likely self-identified as gay. Testers often used Internet and frequented saunas for sex networking, compared with non-testers attending bars, massage centres and public toilets. HIV testing habit also varied with the profile of body image type and preferred type in sex networking. Higher acceptance of pre-exposure prophylaxis (PrEP) was observed among testers. Overall, socioeconomic status played an important role in both HIV testing and access to PrEP. Interventions targeting sex networking venues and alternative means of testing provision are needed to increase coverage of HIV testing.

Determinants of hazardous drinking among black South African men who have sex with men

BACKGROUND

There is a known heavy burden of hazardous drinking and its associated health risks among black South African MSM; however, no study to date has identified risk factors for hazardous drinking among this nor any other African MSM population.

METHODS

A cross-sectional survey was conducted among 480 black South African MSM recruited using respondent-driven sampling. All analyses were adjusted using an RDS II estimator. Multivariable logistic regression was used to assess the relationship between demographic characteristics, psychosocial factors, behavioral attributes and hazardous drinking.

RESULTS

More than half of the men (62%, 95%CI=56%-68%) screened positive as hazardous drinkers. In multivariable analyses, living in a township (versus the city of Pretoria) (aOR=1.9, 95%CI=1.2-3.1, p<.01), more gender dysphoria (aOR=1.4, 95%CI=1.0-1.8, p=.03), having ever received money or other incentives in return for sex (aOR=2.4, 95%CI=1.3-4.3, p<.01), having been sexually abused as a child (aOR=2.6, 95%CI=1.1-6.4, p=.03), having anxiety (aOR=5.4, 95%CI=1.2-24.3, p=.03), and social network drinking behavior (aOR=5.4, 95%CI=1.2-24.3, p=.03) were positively associated with hazardous drinking. Being sexually attracted only to men (aOR=0.3, 95%CI=0.1-0.8, p=.01) was negatively associated with hazardous drinking.

DISCUSSION

Hazardous drinking is highly prevalent among black South African MSM. Multiple indicators of social vulnerability were identified as independent determinants of hazardous drinking. These findings are of heightened concern because these health problems often work synergistically to increase risk of HIV infection and should be taken into consideration by efforts aimed at reducing hazardous drinking among this critical population.

HIV risk and prevention among men who have sex with men in rural South Africa

Rural South African men who have sex with men (MSM) are likely to be underserved in terms of access to relevant healthcare and HIV prevention services. While research in urban and peri-urban MSM populations has identified a range of factors affecting HIV risk in South African MSM, very little research is available that examines HIV risk and prevention in rural MSM populations. This exploratory study begins to address this lack by assessing perceptions of HIV risk among MSM in rural Limpopo province. Using thematic analysis of interview and discussion data, two overarching global themes that encapsulated participants' understandings of HIV risk and the HIV risk environment in their communities were developed. In the first theme, "community experience and the rural social environment", factors affecting HIV risk within the broad risk environment were discussed. These included perceptions of traditional value systems and communities as homophobic; jealousy and competition between MSM; and the role of social media as a means of meeting other MSM. The second global theme, "HIV/AIDS knowledge, risk and experience", focused on factors more immediately affecting HIV transmission risk. These included: high levels of knowledge of heterosexual HIV risk, but limited knowledge of MSM-specific risk; inconsistent condom and lubricant use; difficulties in negotiating condom and lubricant use due to uneven power dynamics in relationships; competition for sexual partners; multiple concurrent sexual partnerships; and transactional sex. These exploratory results suggest that rural South African MSM, like their urban and peri-urban counterparts, are at high risk of contracting HIV, and that there is a need for more in-depth research into the interactions between the rural context and the specific HIV risk knowledge and behaviours that affect HIV risk in this population.

Influence of Partner Type on Acceptability and Likelihood of Use of a Rectal Microbicide Among Young Men Who Have Sex With Men in the United States and Puerto Rico

This study examined how acceptability of placebo gel with receptive anal intercourse (RAI) and likelihood of future rectal microbicide use varied across partner types. Because no rectal microbicide is available yet, use of placebo permitted the study of gel use behavior in real-life circumstances. A total of 87 men who have sex with men (MSM) aged 18 to 30 years inserted placebo gel rectally before RAI during 12 weeks. Using mixed-methods design, participants completed a behavioral questionnaire and in-depth interview. In all, 62 men (71.3%) reported gel use with a lover (i.e., spouse equivalent, boyfriend), 32 (36.8%) with a one-night stand (i.e., man with whom you had sex once), and 29 (33.3%) with an "other" male partner. While gel acceptability was high across partner types, use with lovers was facilitated by trust and familiarity; yet trust made participants believe protection was less necessary. Conversely, participants expressed high likelihood of using gel with one-night stands, whom they perceived as riskier; yet they felt less comfortable discussing gel with them, often resorting to covert use or forgoing gel. A successful microbicide will be positioned as a sexual pleasure enhancer so that men can present it to their lovers and other partners as a gel that improves sex and secondarily prevents human immunodeficiency virus (HIV).

Most at-risk populations: contextualising HIV prevention programmes targeting marginalised groups in Zanzibar, Tanzania

According to a 2009 UNAIDS report the HIV/AIDS prevalence rate in Zanzibar, Tanzania, is low in the general population (0.6%), but high among vulnerable groups, specifically sex workers (10.8%), injecting drug users (15.1%), and men who have sex with men (12.3%). In response to this concentrated epidemic, the Government of Zanzibar, international and local non-profit organisations have focused their prevention activities on these marginal populations. Although these efforts are beneficial in terms of disseminating information about HIV/AIDS and referring clients to health clinics, they fail to address how the socio-economic status of these groups places them at a greater risk for contracting and dying from the virus. Furthermore, there is an absence of qualitative research on these populations which is needed to understand the challenges these groups face and to improve the effectiveness of interventions. Through interviews with employees of government agencies and non-profit organisations, medical professionals, vulnerable populations and HIV/AIDS patients, this paper used a political economy of health and syndemic framework to examine how local realities inform and challenge HIV/AIDS programmes in Zanzibar.

Prevalence and associated factors of unprotected anal intercourse with regular male sex partners among HIV negative men who have sex with men in China: a cross-sectional survey

The HIV prevalence and incidence among men who have sex with men (MSM) in China are high. Unprotected anal intercourse (UAI) with a regular male sex partner (RP), a significant predictor of HIV sero-conversion, was high yet under-emphasized among MSM having RP (MSMRP). The present cross-sectional survey interviewed 307 HIV negative MSMRP recruited through convenient sampling from multiple sources, including venue-based outreaching, online recruitment, and referrals made by peers, in Beijing and Chengdu, China. Among MSMRP, the prevalence of UAI with RP in the last three months was 52.4%. The results of the multivariate analysis showed that trust and intimacy within the relationship with RP and presence of clinical depression symptoms were positively associated with UAI with RP in the last three months. Other associated scalar factors derived from the Theory of Planned Behavior were related to perceptions on condom use, including positive attitudes toward condom use (a negative association), subjective norm of the perception that MSM do not usually use condoms during anal intercourse with RP (a positive association), perceived behavioral control over condom use with RP (a negative association), and behavioral intention to use condoms with RP in the coming three months (a negative association). It is seen that MSMRP were at high risk of HIV/STD transmission. The associated factors hence involved those related to perceptions about condom use, mental health, and interpersonal relationship. Future interventions should take these multi-dimensional factors into account. In particular, future research to test the efficacy of couple-based interventions that include mental health elements needs to be conducted, as trust and intimacy within the relationship were associated with UAI among MSMRP, and mental health problems may exist for both the MSMRP and their RP.

The Mpumalanga Men's Study (MPMS): results of a baseline biological and behavioral HIV surveillance survey in two MSM communities in South Africa

The Mpumalanga Men's Study (MPMS) is the assessment of the Project Boithato HIV prevention intervention for South African MSM. Boithato aims to increase consistent condom use, regular testing for HIV-negative MSM, and linkage to care for HIV-positive MSM. The MPMS baseline examined HIV prevalence and associated risk behaviors, and testing, care, and treatment behaviors among MSM in Gert Sibande and Ehlanzeni districts in Mpumalanga province, South Africa in order to effectively target intervention activities. We recruited 307 MSM in Gert Sibande and 298 in Ehlanzeni through respondent-driven sampling (RDS) between September 2012-March 2013. RDS-adjusted HIV prevalence estimates are 28.3% (95% CI 21.1%–35.3%) in Gert Sibande, and 13.7% (95% CI 9.1%–19.6%) in Ehlanzeni. Prevalence is significantly higher among MSM over age 25 [57.8% (95% CI 43.1%–72.9%) vs. 17.9% (95% CI 10.6%–23.9%), P<0.001 in Gert Sibande; 34.5% (95%CI 20.5%–56.0%) vs. 9.1% (95% CI 4.6%–13.9%), P<0.001 in Ehlanzeni]. In Gert Sibande, prevalence is higher among self-identified gay and transgender MSM vs. other MSM [39.3% (95%CI, 28.3%–47.9%), P<0.01], inconsistent condom users [38.1% (18.1%–64.2%), P<0.05], those with a current regular male partner [35.0% (27.1%–46.4%), P<0.05], and those with lifetime experience of intimate partner violence with men [40.4%, (95%CI 28.9%–50.9%), P<0.05]. Prevalence of previous HIV testing was 65.8% (95%CI 58.8%–74.0%) in Gert Sibande, and 69.3% (95%CI 61.9%–76.8%) in Ehlanzeni. Regular HIV testing was uncommon [(34.6%, (95%CI 27.9%–41.4%) in Gert Sibande; 31.0% (95%CI 24.9%–37.8%) in Ehlanzeni]. Among HIV-positive participants, few knew their status (28.1% in Gert Sibande and 14.5% in Ehlanzeni), or were appropriately linked to care (18.2% and 11.3%, respectively), or taking antiretroviral therapy (13.6% and 9.6% respectively). MPMS results demonstrate the importance of implementing interventions for MSM to increase consistent condom use, regular HIV testing, and linkage and engagement in care for HIV-infected MSM.

Os jovens homossexuais masculinos e sua saúde: uma revisão sistemática

Com o objetivo de analisar a literatura acadêmica de abordagem sociocultural acerca da relação entre os temas homossexualidade masculina, homem jovem e saúde, realizou-se uma revisão baseada na análise de conteúdo temática de 37 artigos selecionados, nas bases de dados Medline e Lilacs, entre 2004 e 2013. A escassez de literatura na perspectiva sociocultural apontou para obstáculos e desafios, relacionados à promoção de saúde, que vão desde a qualidade da informação, passando por valores simbólicos inconscientes, até a efetivação de propostas de gestores de saúde. Concluiu-se que a hegemonia heterossexual encontra-se presente nas estruturas inconscientes da construção da homossexualidade, contribuindo para a perpetuação do habitus heteronormativo. Estudos que valorizam o encontro do saber técnico com o conhecimento que cada um produz, referido a seus valores pessoais e culturais, podem servir de subsídio para o maior aprofundamento dessa discussão.

Types of female partners reported by black men who have sex with men and women (MSMW) and associations with intercourse frequency, unprotected sex and HIV and STI prevalence

We used baseline data from a study of Black MSM/MSMW in 6 US cities to examine the association of female partnership types with disease prevalence and sexual behaviors among the 555 MSMW participants. MSMW reported more than three times as many total and unprotected sex acts with each primary as they did with each non-primary female partner. We compared MSMW whose recent female partners were: (1) all primary ("PF only", n = 156), (2) both primary and non-primary ("PF & NPF", n = 186), and (3) all non-primary ("NPF only", n = 213). HIV/STI prevalence did not differ significantly across groups but sexual behaviors did. The PF only group had the fewest male partners and was the most likely to have only primary male partners; the PF & NPF group was the most likely to have transgender partners. PF & NPF men reported the most sex acts (total and unprotected) with females; NPF only men reported the fewest. Implications for HIV risk and prevention are discussed.

The risk of stable partnerships: associations between partnership characteristics and unprotected anal intercourse among men who have sex with men and transgender women recently diagnosed with HIV and/or STI in Lima, Peru

BACKGROUND

Partnership type is an important factor associated with unprotected anal intercourse (UAI) and subsequent risk for HIV and sexually transmitted infections (STI). We examined the association of partnership type with UAI among men who have sex with men (MSM) and male-to-female transgender women (TGW) in Lima, Peru, recently diagnosed with HIV and/or STI.

METHODS

We report data from a cross-sectional analysis of MSM and TGW recently diagnosed with HIV and/or STI in Lima, Peru between 2011 and 2012. We surveyed participants regarding UAI with up to their three most recent sexual partners according to partner type. Multivariable Generalized Estimate Equating (GEE) models with Poisson distribution were used to estimate prevalence ratios (PR) for UAI according to partner type.

RESULTS

Among 339 MSM and TGW recently diagnosed with HIV and/or STI (mean age: 30.6 years, SD 9.0), 65.5% self-identified as homosexual/gay, 16.0% as bisexual, 15.2% as male-to-female transgender, and 3.3% as heterosexual. Participants provided information on 893 recent male or TGW partners with whom they had engaged in insertive or receptive anal intercourse: 28.9% stable partners, 56.4% non-stable/non-transactional partners (i.e. casual or anonymous), and 14.7% transactional partners (i.e. transactional sex client or sex worker). Unprotected anal intercourse was reported with 41.3% of all partners. In multivariable analysis, factors associated with UAI included partnership type (non-stable/non-transactional partner APR 0.73, [95% CI 0.59-0.91], transactional partner APR 0.53 [0.36-0.78], p<0.05) and the number of previous sexual encounters with the partner (>10 encounters APR 1.43 [1.06-1.92], p<0.05).

CONCLUSION

UAI was more commonly reported for stable partners and in partnerships with >10 sexual encounters, suggesting UAI is more prevalent in partnerships with a greater degree of interpersonal commitment. Further research assessing partner-level factors and behavior is critical for improving HIV and/or STI prevention efforts among Peruvian MSM and TGW.

Elements of Condom-Use Decision Making among South African Men Who Have Sex with Men

South African men who have sex with men (MSM) are at increased risk for HIV infection, and male condoms are fundamental to HIV prevention programs. We explored condom use experiences through in-depth interviews with 34 South African MSM from Cape Town and Port Elizabeth. For data analysis, we generated a codebook and used the constant comparison method. Condom use reinforcing elements included use of alternative sexual strategies, having a high level of self-worth that was linked to protective behaviors, and use of ready-made condom negotiation scripts. Elements inhibiting condom use included perceiving substantial declines in sexual pleasure/performance, experiences of condom failure (possibly related to petroleum-based lubricant), and being in trusted relationships. Our findings suggest nuanced HIV prevention approaches such as bolstering condom negotiation skills based on successful tactics already in use. Further research is needed to address how to mitigate perceptions and experiences that condoms negatively impact sexual pleasure and performance.

Male clients' behaviours with and perspectives about their last male escort encounter: comparing repeat versus first-time hires

Research on men who have sex with men suggests that condomless anal intercourse occurs more frequently in established sexual relationships. While comparable data regarding male-for-male escorting is unavailable, research implies that many clients seek emotional as well as physical connections with the men they hire. In 2012, 495 male clients, recruited via daddysreviews.com completed an online survey about their last hiring experience. Most participants were from the USA (85.7%), the UK and Canada (3.2% each). In total, 75% of encounters involved an escort hired for the first time; 25% were with a previously hired escort ('repeat encounter'). The client's age, lifetime number of escorts hired and number hired in the past year were positively associated with the last encounter being a repeat encounter. Cuddling, sharing a meal, drinking alcohol, taking a walk, watching a show and shopping were also positively associated with repeat encounters. Conversely, none of the sexual behaviours were significantly associated with repeat encounters. Repeat encounters were significantly more likely to include non-sexual behaviours alongside sexual activities, but no more likely to involve condomless anal intercourse. Moreover, clients' knowledge of escorts' HIV status was not significantly associated with engaging in condomless anal intercourse with repeat encounters.

Men at risk; a qualitative study on HIV risk, gender identity and violence among men who have sex with men who report high risk behavior in Kampala, Uganda

In Uganda, men who have sex with men (MSM) are at high risk for HIV. Between May 2008 and February 2009 in Kampala, Uganda, we used respondent driven sampling (RDS) to recruit 295 MSM≥18 years who reported having had sex with another man in the preceding three months. The parent study conducted HIV and STI testing and collected demographic and HIV-related behavioral data through audio computer-assisted self-administered interviews. We conducted a nested qualitative sub-study with 16 men purposively sampled from among the survey participants based on responses to behavioral variables indicating higher risk for HIV infection. Sub-study participants were interviewed face-to-face. Domains of inquiry included sexual orientation, gender identity, condom use, stigma, discrimination, violence and health seeking behavior. Emergent themes included a description of sexual orientation/gender identity categories. All groups of men described conflicting feelings related to their sexual orientation and contextual issues that do not accept same-sex identities or behaviors and non-normative gender presentation. The emerging domains for facilitating condom use included: lack of trust in partner and fear of HIV infection. We discuss themes in the context of social and policy issues surrounding homosexuality and HIV prevention in Uganda that directly affect men's lives, risk and health-promoting behaviors.

Factors associated with regular HIV testing among a sample of US MSM with HIV-negative main partners

: HIV transmission is common within men who have sex with men (MSM) couples; despite recommendations that MSM who engage in risky sexual behaviors get tested biannually/annually, little is known about the testing patterns of MSM while in a current primary relationship. This study compared demographic and relationship characteristics of groups of MSM with different testing patterns while in their primary relationships and assessed which factors were associated with regular or irregular testing. Two hundred seventy-five HIV-negative male couples/550 MSM were recruited online to complete a survey in 2011. Since the start of their relationship, 21% of MSM tested for HIV every 3, 4, or 6 months; 29% tested once a year; 30% tested only when they felt at risk for HIV; and 20% never tested for HIV. Bivariate analyses indicated that men who had never been tested while in their relationship were younger, less educated, had greater trust in their partner, and were less likely to be in a couple that had 1 or both men having had sex with someone else. In the multivariate analyses, testing at regular intervals was associated with higher education, having a sexual agreement, being in a couple that had 1 or both men having had sex with someone else, and having lower faith in trust toward the main partner. Findings suggest that many MSM's testing behaviors while in their primary relationship do not align with their risk profile. Trust seems to be a barrier to regular HIV testing, which may be addressed by encouraging MSM to negotiate clear sexual agreements with their primary partner.

Communicating HIV status in sexual interactions: assessing social cognitive constructs, situational factors, and individual characteristics among South African MSM

This study assessed whether social cognitive constructs, situational factors, and individual characteristics were associated with communicating HIV status and whether communication was related to sexual risk behavior. A quota-sampling method stratified by age, race, and township was used to recruit 300 men who have sex with men to participate in a community-based survey in Pretoria in 2008. Participants reported characteristics of their last sexual encounter involving anal sex, including whether they or their partner had communicated their HIV status. Fifty-nine percent of participants reported that they or their partner had communicated their HIV status. HIV communication self-efficacy (aOR = 1.2, 95 % CI: 1.04-1.68), being with a steady partner (aOR = 0.36, 95 % CI: 0.19-0.67), and being Black (versus White; aOR = 0.08, 95 % CI: 0.03-0.27) were independently associated with communicating HIV status. Communicating HIV status was not associated with unprotected anal intercourse. HIV communication self-efficacy increases men's likelihood of communicating HIV status. Being with a steady partner and being Black reduces that likelihood. Communication about HIV status did not lead to safer sex.

Progress and challenges to male and female condom use in South Africa

South Africa has responded to the sexually transmissible infection and HIV epidemic with a rapid expansion of its national-level public sector condom program. Male condoms are available widely at no cost in the public sector, with expanded access via social marketing and the private sector. The female condom program is one of the largest and best established globally. National surveys show progressive increases in rates of condom use at last sex. However, inconsistent and incorrect condom use and the likelihood that condoms are discontinued in longer-term partnerships are some of the challenges impeding the condom program's successes in the fight against sexually transmissible infections and HIV. This article reviews the current condom program, related guidelines and policies, and the existing data on male and female condom use, including distribution and uptake. We discuss the main challenges to condom use, including both user and service-related issues and finally how these challenges could be addressed.