The Continuum of HIV Care in the Urban United States: Black Men Who Have Sex With Men (MSM) Are Less Likely Than White MSM to Receive Antiretroviral Therapy

Sexual Risk Behavior and Lifetime HIV Testing: The Role of Adverse Childhood Experiences

Despite the success of HIV prevention drugs such as PrEP, HIV incident transmission rates remain a significant problem in the United States. A life-course perspective, including experiences of childhood adversity, may be useful in addressing the HIV epidemic. This paper used 2019 BRFSS data to elucidate the role that childhood adversity plays in the relationship between HIV risk and HIV testing. Participants (n = 58,258) completed self-report measures of HIV risk behaviors, HIV testing, and adverse childhood experiences (ACEs). The median number ACEs in the sample was 1, with verbal abuse (33.9%), and parental separation (31.3%) being the most common ACEs reported. Bivariate findings showed that all ACEs were associated with increased HIV risk and testing. However, increased risk was not correlated with increased HIV testing, with the highest incongruence related to mental health problems of household member (53.48%). While both self-reported HIV risk and ACEs were positively associated with HIV testing, their interaction had a negative association with testing (aPR = 0.51, 95%CI 0.42, 0.62). The results highlight the need for targeted HIV prevention strategies for at-risk individuals with a history of childhood adversity.

HIV Treatment Cascade and PrEP Care Continuum Among Serodiscordant Male Couples in the United States

A large proportion of HIV infections among men who have sex with men occur within primary partnerships, however, there is a lack of research focused on serodiscordant male couples. We used baseline data collected as part of Project Stronger Together-a randomized controlled trial to improve treatment outcomes among 155 serodiscordant male couples. We described engagement in HIV care/prevention using the HIV treatment cascade and PrEP care continuum. Among partners living with HIV, 86.5% were linked to care, 77.4% retained in care, 81.3% prescribed ART, 60.7% adherent, and 67.7%virally suppressed. Among HIV-negative partners, 62.6% were willing to take PrEP, 48.4% had ever taken PrEP, and 26.5% were adherent to PrEP. Black partners living with HIV had lower odds of being virally suppressed compared to White partners. Our findings provide evidence to suggest designing programs to address the racial disparities in viral suppression, addressing barriers to HIV prevention/treatment, and improving PrEP education.

Pre-exposure prophylaxis initiation and adherence among Black men who have sex with men (MSM) in three US cities: results from the HPTN 073 study

INTRODUCTION

Randomized clinical trials have demonstrated the efficacy of antiretroviral pre-exposure prophylaxis (PrEP) in preventing HIV acquisition among men who have sex with men (MSM). However, limited research has examined initiation and adherence to PrEP among Black MSM (BMSM) in the United States (US) who are disproportionately represented among newly HIV infected and late to care individuals. This research reports on the HIV Prevention Trials Network 073 (HPTN 073) study aimed to examine PrEP initiation, utilization and adherence among Black MSM utilizing the theoretically principled, culturally informed and client-centered care coordination (C4) model.

METHODS

The HPTN 073 study enrolled and followed 226 HIV-uninfected Black MSM in three US cities (Los Angeles, CA; Washington DC; and Chapel Hill, NC) from February 2013 through September 2015. Study participants were offered once daily oral emtricitabine/tenofovir (FTC/TDF) PrEP combined with C4 and followed up for 52 weeks. Participants received HIV testing, risk reduction education and clinical monitoring.

RESULTS

Of the 226 men enrolled, 178 participants initiated PrEP (79%), and of these 64% demonstrated PrEP utilization at week 26 (mid-point of the study) based on pharmacokinetic testing. Condomless anal sex with an HIV-infected or unknown status casual male partner was statistically significantly associated with a greater likelihood of PrEP initiation (adjusted odds ratio (OR) 4.4, 95% confidence interval (CI) 1.7, 11.7). Greater age (≥25 vs. <25, OR 2.95, 95% CI 1.37 -6.37), perception of having enough money (OR 3.6, 95% CI 1.7 to 7.7) and knowledge of male partner taking PrEP before sex (OR 2.22, 95% CI 1.03 to 4.79) were statistically significantly associated with increased likelihood of PrEP adherence at week 26. Annualized HIV incidence was 2.9 (95% CI 1.2 to 7.9) among those who initiated PrEP, compared to 7.7 (95% CI 2.5 to 24.1) among those who did not initiate PrEP (p = 0.18).

CONCLUSIONS

Results suggest a high level of PrEP initiation among at-risk Black MSM, a group historically characterized as hard to reach. The data support the importance of addressing contextual factors that affect PrEP initiation and adherence, and of additional research on the ultimate benefit of PrEP in HIV prevention among Black MSM.

Social Network Support and Decreased Risk of Seroconversion in Black MSM: Results of the BROTHERS (HPTN 061) Study

BACKGROUND AND SETTING

Black men who have sex with men (BMSM) in the United States have disproportionately high HIV infection rates. Social networks have been shown to influence HIV risk behavior; however, little is known about whether they affect the risk of HIV seroconversion. This study uses data from the BROTHERS (HPTN 061) study to test whether contextual factors related to social networks are associated with HIV seroconversion among BMSM.

METHODS

We analyzed data from the BROTHERS study (2009-2011), which examined a multicomponent intervention for BMSM in 6 US cities. We ran a series of Cox regression analyses to examine associations between time-dependent measures of network support (personal/emotional, financial, medical, and social participation) and time to HIV seroconversion. We ran unadjusted models followed by models adjusted for participant age at enrollment and study location.

RESULTS

A total of 1000 BMSM tested HIV negative at baseline and were followed at 6- and 12-month study visits. Twenty-eight men tested HIV positive. In adjusted hazard ratio models, study participants who remained HIV negative had higher proportions of social network members who provided personal/emotional {0.92 [95% confidence interval (CI): 0.85 to 0.99]}, medical [0.92 (95% CI: 0.85 to 0.99)], or social participation [0.91 (95% CI: 0.86 to 0.97)] support.

CONCLUSION

Findings suggest that the increased presence of social network support can be protective against HIV acquisition. Future research should explore the processes that link social network support with sexual and other transmission risk behaviors as a basis to inform HIV prevention efforts.

HIV and Sexuality Stigma Reduction Through Engagement in Online Forums: Results from the HealthMPowerment Intervention

HIV and sexuality stigma impede HIV prevention and care efforts. HealthMpowerment.org (HMP) is an interactive mobile phone- and web-based HIV prevention and care intervention for young Black men who have sex with men (YBMSM; ages 18-30) in the United States. HMP included three forums where participants could share their experiences. In this study, we explored whether engaging in stigma-related discussions was associated with changes in YBMSM's stigma-related scores throughout the trial. YBMSM (ages 18-30; N = 238) participating in HMP completed surveys at baseline, and 3 and 6 month follow-ups that included a series of scales focused on HIV and sexuality (internalized homophobia; sexual prejudice) stigma. Sixty-two participants contributed to the forums (1497 posts). We coded instances where YBMSM's conversations were stigma related (915 posts, 61.1%), including discussions of anticipated (74/915, 8.1%), experienced (125/915, 13.7%), internalized (410/915, 44.8%), and/or challenged (639/915, 69.8%) stigma regarding sexuality and HIV. Using a mixed methods approach, we examined whether changes in YBMSM's stigma scores were associated with stigma-related discussions within the forum. We controlled for age, HIV status, income, and educational attainment in these multivariable models. YBMSM who discussed experiencing HIV stigma in the forums reported decreases in perceived HIV stigma over time (b = - 0.37, p ≤ 0.05). YBMSM whose forum posts indicated anticipated HIV stigma reported increases in HIV stigma over time (b = 0.46, p ≤ 0.01). Participants who challenged sexuality-related stigma in forums had lower internalized homophobia (b = - 0.68, p ≤ 0.01) at baseline. YBMSM whose discussions focused on experiencing sexuality-related stigma reported increases in internalized homophobia (b = 0.39, p ≤ 0.01) and sexual prejudice (b = 0.87, p ≤ 0.05) over time. Developing strategies to combat stigma remains a key priority. HMP created an online space where YBMSM could discuss HIV and sexuality stigma. Although a limited number of HMP participants authored the majority of these forum discussions, the discussions were associated with changes in the sample's stigma scores over time. Online interventions (e.g., social media, apps) should consider the inclusion of forums to address stigma and test the efficacy of forums to improve YBMSM's HIV prevention and care continuum outcomes.

Composite Risk for HIV: A New Approach Towards Integrating Biomedical and Behavioral Strategies in Couples-Based HIV Prevention Research

A substantial number of new HIV infections among gay, bisexual, and other men who have sex with men and transgender women occurs in the context of primary partnerships. Given the diversity of risk reduction needs and various approaches available for reducing risk within couples, condomless sex is no longer the gold standard HIV outcome. We present a novel, comprehensive, and flexible Composite Risk for HIV (CR-HIV) approach for integrating evolving biomedical and behavioral HIV prevention strategies into couples-based HIV prevention intervention and survey research. We provide illustrative examples of the utility of the CR-HIV approach based on couples' HIV status.

Characterizing the HIV care continuum among a community sample of black men who have sex with men in the United States

Black men who have sex with men (BMSM) have the highest HIV incidence rates among all men who have sex with men (MSM) and have been less likely than other MSM to be diagnosed, linked or retained in care for HIV. The Promoting Our Worth, Equality, and Resilience (POWER) study administered a behavioral health survey and HIV test to BMSM to estimate the HIV continuum of care among a community-derived sample. Of the N = 1,680 BMSM living with HIV, n = 956 (56.9%) were aware of their HIV-positive status. BMSM who had been previously diagnosed reported progression through the care continuum at greater than 80% for linkage to medical care (97.6%), retention in medical care (97.3%), prescription of antiretroviral therapy (93.6%) and viral suppression (86.4%). Results of this analysis reveal the urgent need to ensure BMSM are being screened and diagnosed. Additionally, community-driven samples are a promising method offering the opportunity to build on the resilience of BMSM progressing though the continuum as well as engage BMSM not yet in care. Lastly, such methods can assist in communicating with those lost to retention.