Estimating Prevalent Diagnoses and Rates of New Diagnoses of HIV at the State Level by Age Group Among Men who Have Sex With Men in the United States

Daily Marijuana Use Predicts HIV Seroconversion Among Black Men Who Have Sex with Men and Transgender Women in Atlanta, GA

We evaluated whether different types of substance use predicted HIV seroconversion among a cohort of 449 Black men who have sex with men (MSM) and transgender women (TGW). A community-based sample was recruited in Atlanta, GA between December 2012 and November 2014. Participants completed a survey and were tested for STIs (Chlamydia and gonorrhoeae using urine samples and rectal swabs) at baseline. HIV testing was conducted at 12-months post enrollment. Multivariable binary logistic regression was used to estimate adjusted odds ratios (aORs) and 95% confidence intervals (CI) for associations between substance use and HIV seroconversion. By 12-month follow-up, 5.3% (n = 24) of participants seroconverted. In multivariable analyses, daily marijuana use was positively associated with HIV seroconversion (aOR 3.07, 95% CI 1.11-8.48, P = 0.030). HIV incidence was high and daily marijuana use was associated with a more than threefold increased odds of HIV seroconversion among a community-based cohort of Black MSM and TGW.

Comparing recruitment strategies to engage hard-to-reach men who have sex with men living with HIV with unsuppressed viral loads in four US cities: Results from HPTN 078

Introduction

There is an urgent need to identify men who have sex with men (MSM) living with HIV with unsuppressed viral loads to prevent transmission. Though respondent‐driven sampling (RDS) is traditionally used for hard‐to‐reach populations, we compare how RDS and direct recruitment (DR) perform in identifying MSM living with HIV with unsuppressed viral loads and identifying MSM with socio‐demographics characteristic of hard‐to‐reach populations.

Methods

This is a cross‐sectional analysis among 1305 MSM who were recruited from March 2016 to December 2017 for a case management intervention trial (HPTN 078). We recruited participants across four cities using RDS and DR methods: Birmingham, AL; Atlanta, GA; Baltimore, MD; and Boston, MA. Participants completed a socio‐demographic questionnaire and underwent HIV testing. We compare the proportion of MSM with HIV and unsuppressed viral loads (HIV RNA ≥ 1000 copies/ml) based on recruitment method using Pearson chi‐square tests. We also compare differences in race, income, healthcare coverage, education, sexual orientation, hidden sexuality and comfort with participating in the LGBT community between recruitment methods and perform non‐parametric trend tests to see how demographics change across RDS recruitment waves.

Results

RDS recruited 721 men (55.2%) and DR yielded 584 men (44.8%). Overall, 69% were living with HIV, of whom 18% were not virally suppressed. HIV prevalence was higher among those recruited via DR (84%) compared to RDS (58%), p < 0.0001. Twenty per cent of DR recruits were not virally suppressed compared to 15% of RDS, though this was not significant. DR yielded a significantly higher proportion of Black participants and those with less than a high school diploma. The prevalence of low income, no healthcare coverage, bisexuality and hidden sexuality increased across RDS waves.

Conclusions

DR was more efficient in identifying MSM living with HIV with unsuppressed viral loads; however, there was a higher proportion of hard‐to‐reach MSM who were low income, lacked health coverage, were bisexual and were not open with their sexuality in deeper waves of RDS. Researchers should consider supplementing RDS recruitment with DR efforts if aiming to identify MSM with unsuppressed viral loads via RDS.

Are spatial models advantageous for predicting county-level HIV epidemiology across the United States?

Predicting human immunodeficiency virus (HIV) epidemiology is vital for achieving public health milestones. Incorporating spatial dependence when data varies by region can often provide better prediction results, at the cost of computational efficiency. However, with the growing number of covariates available that capture the data variability, the benefit of a spatial model could be less crucial. We investigate this conjecture by considering both non-spatial and spatial models for county-level HIV prediction over the US. Due to many counties with zero HIV incidences, we utilize a two-part model, with one part estimating the probability of positive HIV rates and the other estimating HIV rates of counties not classified as zero. Based on our data, the compound of logistic regression and a generalized estimating equation outperforms the candidate models in making predictions. The results suggest that considering spatial correlation for our data is not necessarily advantageous when the purpose is making predictions.

Estimated Number of Men Who Have Sex With Men With Indications for HIV Pre-exposure Prophylaxis in a National Sexual Network Study

BACKGROUND

A 2015 CDC analysis estimated that 24.7% of sexually active men who have sex with men (MSM) had indications for HIV pre-exposure prophylaxis (PrEP) based on 2014 US Public Health Service (USPHS) clinical practice guidelines. Given that the USPHS revised these guidelines in 2017, updated estimates of the fraction of MSM indicated for PrEP overall and stratified by demographic factors and geography are needed to scale-up PrEP for MSM in the US.

METHODS

We conducted a national web-based study of 4904 MSM aged 15-65 who had ever had sex with another man between July 2017 and January 2019. We estimated the percentage of HIV-negative, sexually active MSM meeting USPHS indications for PrEP by demographic category.

RESULTS

Of 3511 sexually active, HIV-negative MSM, 34.0% (95% confidence interval: 32.4 to 35.6) met USPHS indications for PrEP, with percentages consistent across US census region and varying slightly by race/ethnicity (Black: 32.2%, White: 33.7%, Hispanic: 36.4%, Other: 33.6%). Among individuals meeting USPHS PrEP indications, 93.5% reported condomless anal intercourse in the prior 6 months. Among all survey respondents, PrEP eligibility was lowest among non-Hispanic black (18.4%) and younger respondents (15-17: 4.1%; 18-24: 18.1%).

CONCLUSIONS

Estimated percentages of MSM meeting indications for PrEP exceeded the previous CDC estimate across race/ethnicity, age, and census regions, with one-third of adult, sexually active, HIV-negative MSM exhibiting indications for PrEP. This study suggests, given current guidelines for PrEP indications, that a different fraction of eligible MSM could be receiving PrEP than previously estimated.

Does Stigma Toward Anal Sexuality Impede HIV Prevention Among Men Who Have Sex With Men in the United States? A Structural Equation Modeling Assessment

INTRODUCTION

Men who have sex with men (MSM) are suboptimally engaged in efficacious HIV interventions, due in part to stigma.

AIM

We sought to validate the Anal Health Stigma Model, developed based on theory and prior qualitative data, by testing the magnitude of associations between measures of anal sex stigma and engagement in HIV prevention practices, while adjusting for covariates.

METHODS

We conducted a cross-sectional online survey of 1,263 cisgender MSM living in the United States and analyzed data with structural equation modeling. We tested a direct path from Anal Sex Stigma to Engagement in HIV Prevention alongside 2 indirect paths, 1 through Anal Sex Concerns and another through Comfort Discussing Anal Sexuality with Health Workers. The model adjusted for Social Support, Everyday Discrimination, and Sociodemographics.

MAIN OUTCOME MEASURE

Engagement in HIV Prevention comprised an ad hoc measure of (i) lifetime exposure to a behavioral intervention, (ii) current adherence to biomedical intervention, and (iii) consistent use of a prevention strategy during recent penile-anal intercourse.

RESULTS

In the final model, anal sex stigma was associated with less engagement (β = -0.22, P < .001), mediated by participants' comfort talking about anal sex practices with health workers (β = -0.52; β = 0.44; both P < .001), adjusting for covariates (R² = 67%; χ²/df = 2.98, root mean square error of approximation = 0.040, comparative fit index = 0.99 and Tucker-Lewis index = 0.99). Sex-related concerns partially mediated the association between stigma and comfort (β = 0.55; β = 0.14, both P < .001). Modification indices also supported total effects of social support on increased comfort discussing anal sex (β = 0.35, P < .001) and, to a lesser degree, on decreased sex-related concerns (β = -0.10; P < .001).

CLINICAL IMPLICATIONS

Higher stigma toward anal sexuality is associated with less engagement in HIV prevention, largely due to discomfort discussing anal sex practices with health workers.

STRENGTH & LIMITATIONS

Adjustment for mediation in a cross-sectional design cannot establish temporal causality. Self-report is vulnerable to social desirability and recall bias. Online samples may not represent cisgender MSM in general. However, findings place HIV- and health-related behaviors within a social and relational context and may suggest points for intervention in health-care settings.

CONCLUSION

Providers' willingness to engage in discussion about anal sexuality, for example, by responding to questions related to sexual well-being, may function as social support and thereby bolster comfort and improve engagement in HIV prevention. Kutner BA, Simoni JM, King KM, et al. Does Stigma Toward Anal Sexuality Impede HIV Prevention Among Men Who Have Sex With Men in the United States? A Structural Equation Modeling Assessment. J Sex Med 2020;17:477-490.