Increase in the share of steady partners as a source of HIV infection: a 17-year study of seroconversion among gay men

A protocol for a randomized controlled trial of couples motivational interviewing to reduce drug use and HIV transmission risk among male couples in the US: the Couples Health Project

BACKGROUND

To reduce substance use and sexual HIV transmission risk among sexual minority men (SMM) requires the development of interventions tailored for those in relationships. In the past 5 years, there have been considerable advances in the development of motivational nterviewing (MI) with couples. The Couples Health Project (CHP) is the first multi-session risk reduction protocol built on this formative research. The purpose of this study is to evaluate the efficacy of CHP relative to a standard of care control - couples HIV testing and counseling (CHTC).

METHODS

Eligibility includes couples where both partners are aged 18 or older, identify as cisgender male (assigned male sex at birth and identify as male gender), live in the US, and can communicate in English. Additionally, at least one partner has to be aged 18-34, HIV-negative, report recent drug use (excluding cannabis) and report condomless anal sex during the past 30 days. Couples are randomized post-baseline assessment to either CHP or CHTC. Follow-up assessments are completed at 3, 6, and 9-months post-randomization.

DISCUSSION

Findings from this trial will inform the practice of MI with couples. If found efficacious, the CHP intervention would be the first multi-session MI with couples' risk reduction protocol designed for use by substance use treatment or HIV prevention service providers who wish to engage SMM and their relationship partners.

PROTOCOL VERSION

1.0; April 1, 2024.

TRIAL REGISTRATION

ClinicalTrials.gov Protocol Registration; NCT06307977; completed March 6, 2024; https://register.

CLINICALTRIALS

gov/ .

Comparing Repeated (Annual) Couples HIV Testing and Counseling to Individual HIV Testing and Counseling Among Male Couples at High Risk of HIV Infection: Protocol for a Randomized Control Trial

BACKGROUND

Couples HIV testing and counseling (CHTC) is now a standard of care prevention strategy recommended by the Centers for Disease Control and Prevention for sexual minority men (SMM) in relationships. Despite standard recommendations that couples complete CHTC every 6-12 months, no study has empirically evaluated the effects associated with CHTC retesting.

OBJECTIVE

This study aims to understand the benefits associated with continued dyadic engagement in the HIV prevention continuum through routine CHTC retesting, which is of particular importance for emerging-adult SMM in relationships who use drugs.

METHODS

Eligible couples for this CHTC retesting trial must already be enrolled in the 4Us trial, where they completed a CHTC session after their baseline survey. The purpose of the original 4Us trial was to test the efficacy of 2 intervention components for CHTC: a communication skills training video and a substance use module. Couples were eligible for the original 4Us trial if they identified as cisgender male, were in a relationship for 3 months or longer, were aged 17 years or older, and communicated in English. At least 1 partner had to be aged 17-29 years, report HIV negative or unknown serostatus, report use of at least 1 drug (cannabis, cocaine or crack, crystal methamphetamine, ketamine, gamma-hydroxybuterate [GHB], psychedelics, ecstasy, prescription medication misuse, opiates, and nitrates) use, and engage in condomless anal sex (CAS) acts with a casual partner or have a main partner who is nonmonogamous or serodiscordant. Those who complete the 4Us 12-month follow-up and remain in a relationship with the partner they participated in 4Us with are offered the opportunity to participate in this CHTC retesting trial. Those consenting are randomized to either CHTC retesting or individual HIV testing. Follow-up assessments are conducted 3 and 6 months after randomization to evaluate the effects of repeat CHTC on 2 primary outcomes: (1) CAS with a casual partner in the absence of preexposure prophylaxis (PrEP), and (2) CAS with a serodiscordant main partner who is not virally suppressed or concurrent CAS between main and casual partners in the absence of PrEP.

RESULTS

The CHTC retesting trial launched in January 2023, and enrollment is ongoing. As of February 2024, the study had enrolled 106 eligible participants (n=53 couples).

CONCLUSIONS

Findings from this CHTC retesting study will contribute to knowledge about the benefits associated with regular (repeated) CHTC testing versus routine individual HIV testing for SMM in relationships. The results of this trial will inform CHTC retesting guidance.

TRIAL REGISTRATION

ClinicalTrials.gov NCT05833074; htps://www.clinicaltrials.gov/study/NCT05833074.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

DERR1-10.2196/53023.

Use of "Strengthening Our Vows" Video Intervention to Encourage Negotiated Explicit Sexual Agreements in Zambian Heterosexual HIV Seroconcordant-Negative Couples

Negotiating sexual agreements in combination with couples' voluntary HIV counseling and testing (CVCT) may help further reduce HIV transmission in Zambian concordant HIV-negative couples (CNC). Though CVCT has been shown to reduce HIV transmission in CNC by 47%, approximately half of residual infections occur in this group. We developed a "Strengthening Our Vows" video session to foster communication and negotiation of explicit sexual agreements to reduce concurrent sexual exposures and prevent HIV transmission to the spouse due to unprotected, extramarital sex. CNC were recruited through CVCT services at five clinics in Lusaka and Ndola in 2016. Enrolled CNC attending the facilitated group video sessions were encouraged to discuss sexual agreements at home and return 1-2 weeks later for follow-up assessment. One-fourth of the 580 CNC returning reported a history of extramarital partners and/or a sexually transmitted infection (STI) prior to enrollment. More than 95% reported a friendly, supportive 15-60 min negotiation culminating in an agreement to remain monogamous or disclose sexual contacts and use condoms together until a repeat HIV test 30 days after an outside sexual exposure. Two-thirds of participants identified at least one threat to adherence of their agreements including alcohol use, financial pressures, travel, discord in the home, and post-partum or menstrual abstinence. CNC negotiated explicit sexual agreements to avoid exposure to HIV through concurrent partnerships and protect the spouse in the event of an outside sexual contact. Open communication was a consistent theme to facilitate mutual protective efforts. Long-term follow-up of HIV/STI incidence is ongoing to assess the impact of these agreements.Trial registration This sub-study is part of a trial retrospectively registered on ClinicalTrials.gov (Identifier: NCT02744586) on April 20, 2016.

A cluster randomized trial to reduce HIV risk from outside partnerships in Zambian HIV-Negative couples using a novel behavioral intervention, "Strengthening Our Vows": Study protocol and baseline data

BACKGROUND

Heterosexual couples contribute to most new HIV infections in areas of generalized HIV epidemics in sub-Saharan Africa. After Couples' Voluntary HIV Counseling and Testing (CVCT), heterosexual concordant HIV negative couples (CNC) in cohabiting unions contribute to approximately 47% of residual new infections in couples. These infections are attributed to concurrent sexual partners, a key driver of the HIV epidemic in Zambia.

METHODS/DESIGN

Ten Zambian government clinics in two of the largest cities were randomized in matched pairs to a Strengthening Our Vows (SOV) intervention or a Good Health Package (GHP) comparison arm. SOV addressed preventing HIV infection from concurrent partners and protecting spouses after exposures outside the relationship. GHP focused on handwashing; water chlorination; household deworming; and screening for hypertension, diabetes and schistosomiasis. CNC were referred from CVCT services in government clinics. Follow-up includes post-intervention questionnaires and outcome assessments through 60 months. Longitudinal outcomes of interest include self-report and laboratory markers of condomless sex with outside partners and reported sexual agreements. We present baseline characteristics and factors associated with study arm and reported risk using descriptive statistics.

RESULTS

The mean age of men was 32 and 26 for women. On average, couples cohabited for 6 years and had 2 children. Baseline analyses demonstrated some failures of randomization by study arm which will be considered in future primary analyses of longitudinal data. An HIV/STI risk factor composite was not different in the two study arms. Almost one-quarter of couples had an HIV risk factor at baseline.

DISCUSSION

In preparation for future biomedical and behavioral interventions in sub-Saharan Africa, it is critical to understand and decrease HIV risk within CNC.

The Rhythm of Risk: Sexual Behaviour, PrEP Use and HIV Risk Perception Between 1999 and 2018 Among Men Who Have Sex with Men in Amsterdam, The Netherlands

HIV risk perception plays a crucial role in the uptake of preventive strategies. We investigated how risk perception and its determinants changed between 1999 and 2018 in an open, prospective cohort of 1323 HIV-negative men who have sex with men (MSM). Risk perception, defined as the perceived likelihood of acquiring HIV in the past 6 months, changed over time: being relatively lower in 2008–2011, higher in 2012–2016, and again lower in 2017–2018. Irrespective of calendar year, condomless anal intercourse (AI) with casual partners and high numbers of partners were associated with higher risk perception. In 2017–2018, condomless receptive AI with a partner living with HIV was no longer associated with risk perception, while PrEP use and condomless AI with a steady partner were associated with lower risk perception. We showed that risk perception has fluctuated among MSM in the past 20 years. The Undetectable equals Untransmittable statement and PrEP coincided with lower perceived risk.

Communication Patterns Among Male Couples with Open and Monogamous Agreements

Male couples in open relationships tend to have as equally fulfilling relationships as monogamous male couples; however, less is known about communication differences between monogamous and open couples. Because couples with open agreements permit sex with outside partners, they must navigate different relationship issues than monogamous couples, and this can translate to differences in communication. We therefore examined differences between cisgender men in monogamous versus open relationships regarding communication about sexual agreements, safety agreements, breaking of sexual and safety agreements, the disclosure of broken sexual and safety agreements, and general relationship communication. Using a sample of 395 couples, we found that while certain aspects of communication are different for monogamous couples compared to open couples, similarities also exist. Specifically, we identified no differences in how explicitly couples discussed their sexual and safety agreements, attitudes toward communication about safety agreements, and mutual avoidance and withholding communication. However, monogamous couples had more positive attitudes toward communication about sexual agreements. The results were mixed on the perceived impact that broken safety agreements had on communication with the primary partner. Our results are interpreted with attention to relationship well-being and implications for safer sex practices.

Socio-Demographic Characteristics and Sexual Behavioral Factors of Patients with Sexually Transmitted Infections Attending a Hospital in Southern Italy

Sexually transmitted infections (STIs) are a serious global health problem. In Italy, data describing the vulnerability to STIs of specific sexual minorities and the influence of sociodemographic and behavioral determinants are limited, as most infections are not subject to mandatory notification. This retrospective study describes the sociodemographic profile and main sexual behaviors of patients attending a hospital in Palermo (Sicily, Italy) from January 2018 to March 2019 as predictors of STI risk. Patients were divided in subgroups: men-who-have-sex-with-men (MSM), men-who-have-sex-with-women (MSW), bisexual men and females. Data were obtained through an anonymous questionnaire. Patients were tested for chlamydia, syphilis, Mycoplasma genitalium infection, genital herpes and HPV infection. A total of 294 subjects with STIs (male/female ratio about 2:1) were screened. Of the total sample, 79.6% of patients were Italian. MSM accounted for 34.3%, MSW for 29.6%, bisexual men for 5.8% and females for 30.3%. A total of 44.5% of patients had a high education level, 42.5% reported irregular use of condoms, 20.7% reported having had 5-10 partners in the six months prior to the visit and 32.9% were HIV-positive. HPV infection and syphilis were the most prevalent STIs. Conclusions: The most common profile of patients attending our clinic was that of an adult, Italian man with a high level of education, poor use of condoms and a high number of partners. MSM had the highest sex-behavior-related risk for STIs. In addition, our results suggest that all STD teams need to implement counselling topics and recommendations to share with patients, as well as tips on how to approach sexual health education/counselling, thereby promoting patient-centered approaches and educational programs.

Exploring Diversity in HIV Research in the Sexual Partnerships of Australian Gay and Bisexual Men

Gay and bisexual men engage in a variety of sexual partnerships, but the most common distinction made in HIV research and behavioral surveillance is a binary between "regular" and "casual" partners. The "regular partner" category is often perceived as pertaining to ongoing coupled "boyfriend" relationships, with the literature to date rarely troubling what actually constitutes a "regular partner." Some emerging literature has identified "fuckbuddy" partnerships as a type of regular partnership requiring attention, but it is relatively new and not well understood. Currently, assumptions of the regular partner category do not capture how men perceive and conduct commitment in different sexual partnerships that could also be considered "regular," and the implications this has for HIV prevention. Drawing on in-depth interviews with a sample of 61 Australian gay-identified men, we explore a diversity of partnership types that represent unique ways of enacting commitment. We identify three sexual partnerships: "fuckbuddies," dating, and serial monogamy, each with specific issues for HIV risk and prevention. These partnerships suggest important differences in the way men conceive of and practice intimacy and sex.

Sexual Agreements: A Scoping Review of Measurement, Prevalence and Links to Health Outcomes

A sexual agreement is a mutual understanding between two partners regarding sexual and relational behaviors both within and outside of their relationship. Sexual agreements have been central to research and programming efforts around HIV prevention, primarily for male couples. A comprehensive scoping review of the primary literature on sexual agreements, including negotiated safety, was performed to identify what is known about sexual agreements among couples (n = 66). Results indicate a wide range of prevalence of agreements and measurements used to characterize sexual agreements. Findings also report associations between sexual agreements and health and relational outcomes. Several knowledge gaps were identified; specifically, the need to expand sexual agreements research beyond MSM populations and the need to better understand agreement breaks, break disclosure, and how variation in agreement categorization may impact reported prevalence. This review demonstrates the importance of broadening the evidence-base of sexual agreements research and programmatic focus.

Sexual risk behaviour trajectories among MSM at risk for HIV in Amsterdam, the Netherlands

OBJECTIVE

Sexual risk behaviour changes during a person's life course. Insights in sexual risk behaviour trajectories of MSM may provide starting points for the timing of HIV prevention methods. We aimed to study longitudinal trajectories of sexual risk behaviour predictive of HIV acquisition from sexual debut onwards.

DESIGN

A longitudinal study among 815 HIV-negative participants of the Amsterdam Cohort Studies (ACS) who completed extensive questionnaires about their sexual behaviour every 6 months between 2007 and 2017.

METHODS

A comprehensive behavioural risk score predictive of HIV seroconversion was developed. On the basis of this risk score, linear trajectories of sexual risk behaviour and MSM group membership were estimated using latent class growth mixture modelling. Associations between longitudinal trajectories and demographic and psychosocial factors were examined.

RESULTS

Three trajectories of sexual risk behaviour were identified, which were labelled Low risk (90.3% of the sample), Falling high risk (6.5%) and Rising high risk (3.3%). MSM following the Falling high risk (20.5%) and Rising high risk (25.0%) trajectories were more likely to acquire HIV during follow-up. The Falling high risk trajectory was associated with younger age at sexual debut, fewer steady partnerships and high percentages of substance use. The Rising high-risk trajectory was associated with increasing percentages of substance use over time.

CONCLUSION

MSM follow different trajectories of changing sexual risk behaviour over time. Early identification of MSM following a trajectory of falling or rising high-risk behaviour and adequate timing of individual-based preventive interventions may reduce HIV transmission.

Factors associated with condom use and HIV testing among young men who have sex with men: a cross-sectional survey in a random online sample in Sweden

OBJECTIVES

The objectives are to analyse social determinants of sexual health behaviour (condom use and HIV testing) among young, internet-active, cis men who have sex with men (MSM) in a high-income country. The aspects of sexual health behaviour analysed here are condomless anal intercourse with one or more new or casual partner(s), condomless anal intercourse during the most recent sex with a man and HIV testing.

METHODS

A randomised sample of men active on Sweden's main online community for Lesbian, Gay, Bisexual and Trans people responded to an online survey (response rate 19%). A subsample of young people, aged 15-29, was analysed (effective sample 597-669) using multivariable logistic regression with respect to factors associated with condomless anal intercourse with one or more new or casual partner(s), condomless anal intercourse at most recent sex and not having had a test for HIV.

RESULTS

Low education, being single and living in a metropolitan area were found to be independently associated with condomless anal intercourse with new or casual partner(s). Sex with a steady partner was associated with condomless anal intercourse during the most recent sex. Knowledge of where to get tested, high education, being born outside Sweden and condomless anal intercourse with new or casual sex partner(s) were independently associated with having been tested for HIV.

CONCLUSIONS

The factors associated with sexual health behaviour among young MSM are complex, and preventive messages need to be tailored accordingly.

Factors Associated With Recent Human Immunodeficiency Virus Testing Among Men Who Have Sex With Men in Puerto Rico, National Human Immunodeficiency Virus Behavioral Surveillance System, 2011

BACKGROUND

Annual human immunodeficiency virus (HIV) testing is considered a key strategy for HIV prevention for men who have sex with men (MSM). In Puerto Rico, HIV research has primarily focused on injection drug use, yet male-to-male sexual transmission has been increasing in recent years.

METHODS

Cross-sectional data from the National HIV Behavioral Surveillance system collected in 2011 in San Juan, Puerto Rico, were analyzed to identify factors associated with HIV testing in the past 12 months (recent testing).

RESULTS

Overall, 50% of participants were tested recently. In the multivariate analysis, testing recently was associated with having multiple partners in the past 12 months (adjusted prevalence ratio [aPR] [≥4 vs 1 partner] = 1.5; 95% confidence interval [95% CI], 1.2-2.0), visiting a health care provider in the past 12 months (aPR, 1.4; 95% CI, 1.04-1.8), and disclosing male-male attraction/sex to a health care provider (aPR< 1.4; 95% CI, 1.1-1.7).

CONCLUSIONS

Human immunodeficiency virus testing was suboptimal among MSM in San Juan. Strategies to increase HIV testing among MSM may include promoting HIV testing for all sexually active MSM including those with fewer partners, increasing utilization of the healthcare system, and improving patient-provider communication.

In Australia, Most HIV Infections Among Gay and Bisexual Men are Attributable to Sex with 'New' Partners

It has been estimated that the majority of global HIV infections among gay and bisexual men (GBM) can be attributed to sex within a committed relationship. In Australia, however, negotiated safety, whereby HIV-negative regular partners agree to discard condoms with each other but commit to consistent condom use with other partners, has been promoted as a key component of the HIV prevention response. We asked GBM recently diagnosed with HIV to describe their relationship to the person they believed to be the source of their infection ('source person'). The majority (66.1%) ascribed their infection to a casual partner. A further 23.3% ascribed their infection to a non-committed and non-romantic partner (or 'fuckbuddy'). Only 10.6% believed they had acquired their HIV from a 'boyfriend' in the context of a committed romantic relationship, and 51.7% of these occurred within the first 3 months following their first sexual contact. Most men (61.5%) believed they had acquired their HIV infection on the first occasion they had sex with the source person. In the Australian context, negotiated safety appears to have minimised infections between regular partners. However, many HIV infections between regular partners may not be in the context of a romantic committed relationship, and yet this distinction between types of regular partners has been all but ignored. Furthermore, in this sample, most infections occurred on the occasion of first meeting, suggesting that the most useful indicators of risk may be the characteristics, contexts, and lengths of sexual partnerships and how sex is negotiated, rather than how GBM categorize their partner. Findings suggest more new HIV infections occur in new partnerships, than in established relationships.

Racial Differences in Partnership Attributes, Typologies, and Risk Behaviors Among Men Who Have Sex With Men in Atlanta, Georgia

The role of main partnerships in shaping HIV transmission dynamics among men who have sex with men (MSM) has gained recognition in recent studies, but there is little evidence that existing definitions of partnership type are accurate or have consistent meaning for all men. Using data collected from 2011 to 2013 on 693 partnerships described by 193 Black and White MSM in Atlanta, GA, partnership attributes and risk behaviors were examined and compared by race, stratified in two ways: (1) by commonly used definitions of partnerships as "main" or "casual" and (2) by a new data-driven partnership typology identified through latent class analysis (LCA). Racial differences were analyzed using chi-square, Fisher's exact, and Wilcoxon-Mann-Whitney tests. Black participants were less likely to report condomless anal sex (CAS) within partnerships they labeled as main, yet they were also less likely to describe these partnerships as "primary" on a parallel question. In contrast, within strata defined by the LCA-derived typology, most partnership attributes were comparable and the likelihood of CAS was equivalent by race. These findings suggest that classification of partnerships as main or casual does not accurately capture the partnership patterns of MSM, resulting in differential misclassification by race. Future studies and interventions should refine and utilize more evidence-based typologies.

Negotiated safety - components, context and use: an integrative literature review

AIM

The aim of this study was to examine the components and use of negotiated safety in the context of HIV prevention and to identify reported factors associated with the concept.

BACKGROUND

There is an emerging interest in dyadic approaches to address HIV transmission. Although there are theoretical foundations for how interpersonal relationships influence individual behaviour, how these dyadic processes influence on health is still not wholly understood.

DESIGN

Integrative review of empirical and theoretical literature.

DATA SOURCES

The Cumulative Index for Nursing and Allied Health Literature (CINAHL) MEDLINE and PsychINFO electronic databases were accessed.

REVIEW METHODS

Articles were read to gain a historical context of the term and identify varying interpretations of the concept. Factors warranting consideration in association with NS were identified and clinical and public health implications were noted.

RESULTS

Forty-eight studies were reviewed. Negotiated safety included the following components: (i) HIV sero-negative concordant men within a primary relationship; (ii) joint HIV screening and mutual disclosure of their HIV status; (iii) explicit relationship boundaries which establish either nonexclusively that allows for the dispensing of condoms within the primary relationship and consistent condom use for extra-dyadic sex; or dispensing of condoms within a primary partnership and exclusivity; and (iv) a breach clause that allows communication to re-establish the agreement if needed.

CONCLUSION

Negotiated safety is a prescriptive approach to HIV risk reduction among couples. Researchers and practitioners could benefit from promoting this approach to HIV prevention.

Relationship-Based Predictors of Sexual Risk for HIV Among MSM Couples: A Systematic Review of the Literature

Behavioral and epidemiological studies report high risk for HIV among MSM couples. Over the last decade, studies have examined relationship dynamics associated with sexual risk for HIV. It is important to examine the impact this research has had on HIV prevention and what is still needed. We conducted a review of the literature focusing on relationship dynamics associated with sexual risk for HIV among MSM couples. Procedures used for this review were guided by the Preferred Reporting Items for Systematic Reviews and Meta-Analyses established to provide a framework for collecting, reviewing and reporting studies systematically (Mohler et al. in Ann Intern Med 151(4):264-269, 2009). We found that positive relationship dynamics are associated with less risk with partners outside the relationship, but were associated with greater odds of unprotected anal intercourse with primary partners. We also discuss other factors including sexual agreements about outside partners and make recommendations for next steps in HIV prevention research among MSM couples.

A Dyadic Behavioral Intervention to Optimize Same Sex Male Couples' Engagement Across the HIV Care Continuum: Development of and Protocol for an Innovative Couples-based Approach (Partner Steps)

Background

An estimated one- to two-thirds of new human immunodeficiency virus (HIV) infections among US men who have sex with men (MSM) occur within the context of primary partnerships. Thus, HIV interventions that recognize and harness the power of relationships are needed. Increasingly, HIV prevention efforts are being directed toward improving engagement across the HIV care continuum from testing to linkage to care, antiretroviral therapy (ART) adherence, engagement in care, and viral suppression. However, to our knowledge, no behavioral interventions have attempted to address the HIV care continuum using a dyadic approach.

Objective

The objective of this paper is to describe the development of and protocol for an innovative couples-based approach to improving treatment adherence and engagement in care among HIV serodiscordant and concordant HIV-positive same sex male couples in the United States.

Methods

We developed the Partner Steps intervention by drawing from relationship-oriented theory, existing efficacious individual-level ART adherence interventions, couple-focused HIV prevention interventions, and expert consultation. We incorporated new content to address all aspects of the HIV care continuum (eg, linkage to and retention in care) and to draw on relationship strengths through interactive activities.

Results

The resulting theory-based Partner Steps intervention is delivered by a trained bachelors-level counselor (interventionist) over 2 in-person sessions with male-male dyads in which at least 1 partner has recent suboptimal engagement in HIV care. Each session is designed to use relationship strengths to increase motivation for HIV care and treatment, and cover sequential intervention “steps” relating to specific challenges in HIV care engagement and barriers to ART adherence. For each step, couples work with a trained interventionist to identify their unique challenges, actively problem-solve with the interventionist, and articulate and commit to working together to implement a plan in which each partner agrees to complete specific tasks.

Conclusions

We drew on theory and evidence to develop novel intervention strategies that leverage strengths of relationships to address engagement across the entire HIV care continuum. We provide details on intervention development and content that may be of use to researchers as well as medical and mental health professionals for whom a dyadic approach to HIV prevention and care may best suit their patient population.

Reduced Sexual Risk Behaviors Among Young Men of Color Who Have Sex with Men: Findings from the Community-Based Organization Behavioral Outcomes of Many Men, Many Voices (CBOP-3MV) Project

In 2006, the Centers for Disease Control and Prevention (CDC) funded community-based organizations (CBOs) to deliver Many Men, Many Voices (3MV) to young men of color who have sex with men. Although 3MV, a group-level behavioral intervention designed to reduce human immunodeficiency virus (HIV) risk behaviors of black men who have sex with men (MSM), has shown effectiveness when delivered in a controlled research environment, there is limited evidence that the intervention is associated with similar outcomes in "real world" settings. For the current project, CDC funded three CBOs to conduct outcome monitoring of the 3MV intervention to determine if young MSM of color report changes in HIV risk behaviors postintervention. Using a repeated measures design, risk behaviors were collected at baseline and again at 3 and 6 months postintervention. Changes in risk behaviors were assessed using generalized estimating equations. Participants (n = 337) reported decreases in sexual risk behaviors at both follow-up time points, such as sex without a condom, sex without a condom and multiple partners, and sex without a condom with serodiscordant or status unknown partners. Results suggest that 3MV may be an effective tool for reducing HIV risk behaviors in this critical target population.

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.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

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

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

Health, trust, or "just understood": explicit and implicit condom decision-making processes among black, white, and interracial same-sex male couples

Among gay and bisexual men, primary partners are a leading source of HIV infection. Trust, intimacy, and advancements in HIV treatment may impact same-sex male (SSM) couples' decisions to engage in unprotected anal intercourse (UAI). This qualitative study explored how Black, White and interracial couples discussed, and made decisions regarding condoms. Qualitative interviews were conducted with 48 SSM couples in the New York and San Francisco metropolitan areas. Stratified purposive sampling was used to include Black (n = 16), White (n = 17), and interracial (Black-White) (n = 15) couples. Twenty-six couples were concordant HIV-negative and 22 were HIV-discordant. Interviews were recorded, transcribed, coded, and analyzed using a grounded theory approach. Some couples described explicit processes, which involved active discussion, while others described implicit processes, where condom-use decisions occurred without any explicit discussion. These processes also differed by race and HIV status. Black couples tended to report condom-use as "just understood." White, HIV-discordant couples decided not to use condoms, with some identifying the HIV-positive partner's suppressed viral load and high CD4 count as deciding factors. After an unplanned episode of UAI, White, HIV-negative couples tended to discontinue condom use while Black HIV-negative couples decided to revert to using condoms. HIV prevention efforts focused on same-sex, male couples must consider the explicit/implicit nature of condom decision-making processes. Understanding differences in these processes and considering relationship dynamics, across race and HIV status, can promote the development of innovative couple-level, HIV prevention interventions.

Incorporating couples-based approaches into HIV prevention for gay and bisexual men: opportunities and challenges

Thirty years after the beginning of the HIV epidemic, gay, bisexual, and other men who have sex with men (collectively called MSM) bear a disproportionate burden of HIV in the United States and continue to acquire a distressingly high number and proportion of new infections. Historically, HIV prevention for MSM has been focused on individual-level behavior change, rarely intervening with MSM as part of a couple. Yet, an estimated 33–67% of HIV infections among MSM are acquired from primary sexual partners, suggesting that work with MSM as couples could be an important contributor to prevention. Given the emergence of high impact combination HIV prevention, it is timely to consider how work with the broad variety of male couples can improve both personal and community health. Couples HIV testing and counseling for MSM is an important advance for identifying men who are unaware that they are HIV-positive, identifying HIV-discordant couples, and supporting men who want to learn their HIV status with their partner. Once men know their HIV status, new advances in biomedical prevention, which can dramatically reduce risk of HIV transmission or acquisition, allow men to make prevention decisions that can protect themselves and their partners. This paper highlights the present-day challenges and benefits of using a couples-based approach with MSM in the era of combination prevention to increase knowledge of HIV status, increase identification of HIV discordant couples to improve targeting prevention services,and support mutual disclosure of HIV status.

Gay male couples' attitudes toward using couples-based voluntary HIV counseling and testing

Many men who have sex with men acquire HIV from their primary male partners while in a relationship. Studies with gay couples have demonstrated that relationship characteristics and testing behaviors are important to examine for HIV prevention. Recently, couples-based voluntary HIV counseling and testing (CVCT) has become available to male couples throughout the U.S. However, HIV-negative couples' attitudes toward using CVCT and how their relationship characteristics may affect their use of CVCT remain largely unknown. This information is particularly relevant for organizations that offer CVCT. To assess couples' attitudes, and associated factors toward using CVCT, a cross-sectional study design was used with a novel Internet-based recruitment method to collect dyadic data from a national sample of 275 HIV-negative gay couples. Multivariate multilevel modeling was used to identify factors associated with differences between and within couples about their attitudes towards using CVCT. Findings revealed that couples were "somewhat" to "very likely" to use CVCT. More positive attitudes toward using CVCT were associated with couples who had higher levels of relationship satisfaction and commitment toward their sexual agreement and among those who had at least one partner having had sex outside of the relationship. Less positive attitude toward using CVCT was associated with couples who had higher levels of trust toward their partners being dependable. Differences within couples, including age between partners, whether sex had occurred outside of the relationship, and value toward a sexual agreement also affected their attitudes toward using CVCT. Providing additional testing methods may help HIV-negative gay couples better manage their HIV risk.

Relationship characteristics and HIV transmission risk in same-sex male couples in HIV serodiscordant relationships

Unprotected anal intercourse (UAI) remains a main risk factor for HIV among men who have sex with men (MSM) and this is of particular concern for partners of HIV serodiscordant status. However, HIV transmission risk has been demonstrated to vary by the sexual position adopted among partners. Guided by interdependence theory, this study examined how relational factors were differentially associated with risk taking (HIV-positive/insertive and HIV-negative/receptive) and strategic positioning (HIV-positive/receptive and HIV-negative/insertive) UAI within serodiscordant same-sex male couples. HIV-positive men and their HIV-negative partners (n couples = 91; n individuals = 182) simultaneously but independently completed computerized questionnaires and HIV-positive men had blood drawn for viral load. A minority of couples (30 %) engaged in risk taking and/or strategic positioning unprotected anal sex. Results of multinomial logistic regression indicated that HIV-negative partners' levels of relationship commitment were positively associated with the odds of engaging in strategic positioning sexual behaviors. For HIV-negative partners, reports of relationship intimacy, and sexual satisfaction were negatively associated with odds of reporting risk taking behavior. In contrast, HIV-positive partners' reported sexual satisfaction was positively associated with odds of engaging in risk taking behavior. Findings suggested that aspects of relational quality may be differentially associated with sexual decision making for same-sex male couples in serodiscordant relationships. Study findings lend support for the incorporation of discussions of HIV risk reduction strategies, enhancing communication between partners, and support for general relationship functioning in HIV care.

Personal or relational? Examining sexual health in the context of HIV serodiscordant same-sex male couples

Couples' ability to adopt a "we" orientation has been associated with optimal health outcomes. This study examined how personal and relational motivations are uniquely associated with unprotected anal intercourse (UAI), protected anal intercourse (PAI), and the absence of sexual activity within HIV-serodiscordant same-sex male couples. HIV-positive men and their HIV-negative partners (N = 116 couples, 232 men) completed questionnaires and HIV-positive men had blood drawn for viral load. Results of a multinomial logistic regression illustrated that sexual satisfaction was positively associated with PAI among HIV-negative partners and negatively associated with PAI among HIV-positive partners. Endorsing a "we" orientation was positively associated with PAI among HIV-positive partners. Findings suggest that HIV-positive partners who espouse a "we" orientation may be willing to forgo their personal interests to protect their HIV-negative partners from HIV transmission. Couples-based interventions are warranted to help strengthen relationship dynamics to enhance the sexual health of serodiscordant couples.

Intergenerational sex as a risk factor for HIV among young men who have sex with men: a scoping review

An emerging body of evidence suggests that intergenerational sexual partnerships may increase risk of HIV acquisition among young men who have sex with men (YMSM). However, no studies have comprehensively evaluated literature in this area. We applied a scoping review methodology to explore the relationships between age mixing, HIV risk behavior, and HIV seroconversion among YMSM. This study identified several individual, micro-, and meso-system factors influencing HIV risk among YMSM in the context of intergenerational relationships: childhood maltreatment, coming of age and sexual identity, and substance use (individual-level factors); family and social support, partner characteristics, intimate partner violence, connectedness to gay community (micro-system factors); and race/ethnicity, economic disparity, and use of the Internet (meso-system factors). These thematic groups can be used to frame future research on the role of age-discrepant relationships on HIV risk among YMSM, and to enhance public health HIV education and prevention strategies targeting this vulnerable population.

Actor-partner effects of demographic and relationship factors associated with HIV risk within gay male couples

Recent research has investigated the association of relationship factors and dynamics with sexual behaviors and HIV risk among gay male couples. However, few studies with gay male couples have used the Actor-Partner Interdependence Model framework to examine whether factors influence an individual and his partner's sexual risk behaviors. None of these studies analyzed whether relationship factors had influenced the sexual risk behaviors of both partners within the couple. Our cross-sectional study used dyadic data from 142 gay male couples to assess actor-partner effects of relationship commitment, trust, and investment in one's sexual agreement for HIV risk. Multilevel modeling was used to examine which actor-partner effects of these factors were predictive of individuals and their partners having had UAI within and outside the relationship. Results indicated that participants' likelihood of having had UAI within and outside of the relationship significantly decreased with: (1) actor effects of value in and commitment to a sexual agreement, and quality of alternatives to the relationship and (2) partner effects of participant's age, dependability of trust, quality of alternatives to the relationship, and investment of relationship commitment. No significant actor-partner effects were detected for having had UAI within the relationship. Our findings suggest that future HIV prevention strategies should take into account how relationship factors influence an individual and his main partners' sexual risk behaviors and in turn, the couple's risk for HIV. However, more research is needed to examine how actor-partner effects of relationship factors influence a variety of sexual risk behaviors within gay male couples.

Seroadaptation in a sample of very poor Los Angeles area men who have sex with men

Data from 635 very poor men who have sex with men (MSM) were used to identify seroadaptation with 1,102 male partners reported between 2005 and 2007 in Los Angeles as part of the Sexual Acquisition and Transmission of HIV Cooperative Agreement Program. The mean age of the sample was 41.7 years; 53 % had experienced homelessness in the past year. Condoms were reported in 51 % of sexual events involving anal intercourse. HIV seroconcordance was reported in 41 % of sexual partnerships among HIV-positive participants. HIV-positive men were more likely to have oral-only or unprotected receptive anal intercourse and less likely to have unprotected insertive anal intercourse with HIV-negative or unknown partners compared to HIV-positive partners. Even in the face of poverty, HIV-positive MSM report mitigating risks of HIV-transmission though seroadaptation in the context of modest rates of condom use.

Predictors of day-level sexual risk for young gay and bisexual men

As HIV infection rates remain high among young gay and bisexual men, investigations into determinants of sexual risk are paramount. This study examined independent and interactive effects of substance use, mental health, perceived benefits of unprotected sex, and type of sex partner on odds of not using condoms. Analyses included 188 high-risk substance using HIV-negative and unknown status young gay and bisexual men (ages 18-29). Substance use and endorsing favorable attitudes towards unprotected sex strongly predicted sexual risk. Mental health moderated the relationship between partner type (main vs. casual) and condom use such that increased anxiety and depression were associated with increased odds of using condoms with main partners and not using condoms with casual partners. Understanding how these determinants of HIV risk converge to predict unprotected anal sex can identify essential risk relationships for prevention, obtain effects sizes of greater magnitude and prolonged sustainability, and build robust couples-based interventions.

Patterns of HIV and sexually transmitted infection testing among men who have sex with men couples in the United States

BACKGROUND

Most men who have sex with men (MSM) within the United States acquire human immunodeficiency virus (HIV) while in a same-sex relationship. Few studies have examined HIV and sexually transmitted infection (STI) testing rates among MSM couples. Interestingly, the patterns that MSM test for HIV while in their relationships remain largely unknown. The current study helps fill this gap in knowledge by assessing HIV testing patterns and HIV and STI testing rates from a large convenience sample of Internet-using MSM couples.

METHODS

The current study used a cross-sectional study design to collect dyadic data from 361 MSM couples who lived throughout the United States. A novel recruitment strategy that included placing paid targeted advertisements on Facebook enrolled both men in the couple to independently complete the confidential electronic survey.

RESULTS

Nearly half of the HIV-negative men indicated either not having been tested for HIV since their relationship started or only testing if they believed they were at risk. Few men reported testing every 3 to 4 months. HIV/STI testing rates varied among the sample of couples. Few men reported having been diagnosed with a recent STI. Testing patterns and rates were mostly similar, irrespective of whether unprotected anal intercourse was practiced within and/or outside the relationship.

CONCLUSIONS

HIV testing and prevention services must target men who are at risk for acquiring HIV within MSM couples. To help accomplish this goal, additional research is needed to examine the specific barriers and facilitators to HIV and STI testing among MSM in couples.

High HIV incidence and prevalence and associated factors among young MSM, 2008

OBJECTIVE

To estimate HIV prevalence, annual HIV incidence density, and factors associated with HIV infection among young MSM in the United States.

DESIGN

The 2008 National HIV Behavioral Surveillance System (NHBS), a cross-sectional survey conducted in 21 US cities.

METHODS

NHBS respondents included in the analysis were MSM aged 18-24 with a valid HIV test who reported at least one male sex partner in the past year. We calculated HIV prevalence and estimated annual incidence density (number of HIV infections/total number of person-years at risk). Generalized estimating equations were used to determine factors associated with testing positive for HIV.

RESULTS

Of 1889 young MSM, 198 (10%) had a positive HIV test; of these, 136 (69%) did not report previously testing HIV positive when interviewed. Estimated annual HIV incidence density was 2.9%; incidence was highest for blacks. Among young MSM who did not report being HIV infected, factors associated with testing HIV positive included black race; less than high school education; using both alcohol and drugs before or during last sex; having an HIV test more than 12 months ago; and reporting a visit to a medical provider in the past year.

CONCLUSION

HIV prevalence and estimated incidence density for young MSM were high. Individual risk behaviors did not fully explain HIV risk, emphasizing the need to address sociodemographic and structural-level factors in public health interventions targeted toward young MSM.

Frequency of sexual activity with most recent male partner among young, Internet-using men who have sex with men in the United States

Sex frequency, defined here as the number of oral or anal sex acts with the most recent partner in the past year, is a potential driver of risk for sexually transmitted infections. However, few data on sex frequency have been reported for men who have sex with men (MSM). Data from an Internet survey of MSM were used to describe sex frequency with most recent main and casual male partners and to estimate factors associated with higher sex frequency. Among 5,193 MSM, higher sex frequency was associated with younger age, shorter relationship duration, and reporting a main (vs. casual) partner; and lower sex frequency with male partners was associated with heterosexual or bisexual (vs. homosexual) identity or Black race (vs. non-Hispanic White). Secondary analyses of estimates of sex frequency from 2 publicly available nationally representative datasets comprised of primarily heterosexual survey respondents (the 2008 General Social Survey and the 1992 National Health and Social Life Survey) were performed. Sex frequency among MSM respondents was similar to that reported by heterosexuals.

Relationship characteristics associated with sexual risk behavior among MSM in committed relationships

Understanding situations that increase HIV risk among men who have sex with men (MSM) requires consideration of the context in which risky behaviors occur. Relationships are one such context. This study examines the presence and predictors of unprotected anal intercourse (UAI) in the past 3 months among 566 MSM couples. A majority of couples allowed sex with outside partners. Overall, 65% of the sample engaged in UAI with primary partner, including nearly half of discordant couples. Positive relationship factors, such as attachment and intimacy, were associated with an increased likelihood of UAI with primary partner. Meanwhile, 22% of the sample engaged in at least one episode of UAI with an outside partner, half of whom were discordant or unknown HIV status outside partners. Higher levels of HIV-specific social support, equality, and sexual agreement investment were significantly associated with a decreased likelihood of engaging in UAI with a discordant or unknown HIV status outside partner. HIV-positive men in discordant relationships had two and one half times the odds of having UAI with a discordant or unknown HIV status outside partner as their HIV-negative partners. Many MSM in relationships, including some in serodiscordant ones, engage in UAI with primary partners. Potential explanations include relationship closeness, relationship length, and agreement type. In addition, relationship context appears to have a differential impact upon UAI with primary and outside partners, implying that prevention messages may need to be tailored for different types of couples. Prevention efforts involving MSM couples must take into account relationship characteristics as couples balance safer sex and HIV risk with intimacy and pleasure.

What drives the US and Peruvian HIV epidemics in men who have sex with men (MSM)?

In this work, we estimate the proportions of transmissions occurring in main vs. casual partnerships, and by the sexual role, infection stage, and testing and treatment history of the infected partner, for men who have sex with men (MSM) in the US and Peru. We use dynamic, stochastic models based in exponential random graph models (ERGMs), obtaining inputs from multiple large-scale MSM surveys. Parallel main partnership and casual sexual networks are simulated. Each man is characterized by age, race, circumcision status, sexual role behavior, and propensity for unprotected anal intercourse (UAI); his history is modeled from entry into the adult population, with potential transitions including HIV infection, detection, treatment, AIDS diagnosis, and death. We implemented two model variants differing in assumptions about acute infectiousness, and assessed sensitivity to other key inputs. Our two models suggested that only 4–5% (Model 1) or 22–29% (Model 2) of HIV transmission results from contacts with acute-stage partners; the plurality (80–81% and 49%, respectively) stem from chronic-stage partners and the remainder (14–16% and 27–35%, respectively) from AIDS-stage partners. Similar proportions of infections stem from partners whose infection is undiagnosed (24–31%), diagnosed but untreated (36–46%), and currently being treated (30–36%). Roughly one-third of infections (32–39%) occur within main partnerships. Results by country were qualitatively similar, despite key behavioral differences; one exception was that transmission from the receptive to insertive partner appears more important in Peru (34%) than the US (21%). The broad balance in transmission contexts suggests that education about risk, careful assessment, pre-exposure prophylaxis, more frequent testing, earlier treatment, and risk-reduction, disclosure, and adherence counseling may all contribute substantially to reducing the HIV incidence among MSM in the US and Peru.

Rates of testing for HIV in the presence of serodiscordant UAI among HIV-negative gay men in committed relationships

We examined testing rates for HIV-negative men (N = 752) from a sample of gay male couples. Approximately half (52 %) tested in the past year. Among men who had engaged in sexual risk behavior in the past 3 months, 27 % tested within that period and 65 % within the past year. For men in concordant relationships these rates were 25 and 60 %, for men in serodiscordant relationships they were 34 and 72 %. MSM in primary relationships are testing at lower rates than the general MSM population, even after potential exposure to HIV. Testing and prevention messages for MSM should factor in relationship status.

Willingness of US men who have sex with men (MSM) to participate in Couples HIV Voluntary Counseling and Testing (CVCT)

Background

We evaluated willingness to participate in CVCT and associated factors among MSM in the United States.

Methods

5,980 MSM in the US, recruited through MySpace.com, completed an online survey March-April, 2009. A multivariable logistic regression model was built using being “willing” or “unwilling” to participate in CVCT in the next 12 months as the outcome.

Results

Overall, 81.5% of respondents expressed willingness to participate in CVCT in the next year. Factors positively associated with willingness were: being of non-Hispanic Black (adjusted odds ratio [aOR]: 1.5, 95% confidence interval [CI]: 1.2–1.8), Hispanic (aOR: 1.3, CI: 1.1–1.6), or other (aOR: 1.4, CI: 1.1–1.8) race/ethnicity compared to non-Hispanic White; being aged 18–24 (aOR: 2.5, CI: 1.7–3.8), 25–29 (aOR: 2.3, CI: 1.5–3.6), 30–34 (aOR: 1.9, CI: 1.2–3.1), and 35–45 (aOR: 2.3, CI: 1.4–3.7) years, all compared to those over 45 years of age; and having had a main male sex partner in the last 12 months (aOR: 1.9, CI: 1.6–2.2). Factors negatively associated with willingness were: not knowing most recent male sex partner’s HIV status (aOR: 0.81, CI: 0.69–0.95) compared to knowing that the partner was HIV-negative; having had 4–7 (aOR: 0.75, CI: 0.61–0.92) or >7 male sex partners in the last 12 months (aOR: 0.62, CI: 0.50–0.78) compared to 1 partner; and never testing for HIV (aOR: 0.38, CI: 0.31–0.46), having been tested over 12 months ago (aOR: 0.63, CI: 0.50–0.79), or not knowing when last HIV tested (aOR: 0.67, CI: 0.51–0.89), all compared to having tested 0–6 months previously.

Conclusions

Young MSM, men of color, and those with main sex partners expressed a high level of willingness to participate in couples HIV counseling and testing with a male partner in the next year. Given this willingness, it is likely feasible to scale up and evaluate CVCT interventions for US MSM.

Sexual agreements in the partnerships of internet-using men who have sex with men

Recent studies among men who have sex with men (MSM) have found that the majority of HIV transmission results from sex with a main partner. One factor likely to affect the risk of transmission is the type of agreements the couple has regarding sexual behaviour within and outside the relationship. This study recruited 732 Internet-using MSM through Facebook banner ads. Participants completed an online questionnaire regarding demographic characteristics of the respondent and their main partner, the sexual behaviour of the couple, the existence of a sexual agreement, and the strength of investment in that agreement. The Pearson chi-square test was used to assess the association between sexual agreements (categorized as open, closed, or none) and the predictive variables. Respondents' investment in their sexual agreement was measured using the sexual agreement investment scale (a composite score ranging from 0 to 52). Ninety-one percent of respondents had some form of sexual agreement in place with their main partner. The presence and type of sexual agreement was found to be strongly associated with many characteristics of the individual and couple, including the respondent's HIV status, length of time with the main partner, having unprotected anal intercourse with a man other than their main partner, and happiness in the relationship. Increases in the strength of respondents' investment in their sexual agreement were found to be associated with newness of the relationship, relationship happiness, having a closed relationship, and decreases in risky sexual behaviour. This study offers further evidence of the important role that sexual agreements play in male couples. The overwhelming prevalence of sexual agreements and their association with relationship happiness and risky sexual behaviours has important implications for future HIV prevention and control strategies, including the implementation of couples voluntary counseling and testing.

Relationship factors associated with HIV risk among a sample of gay male couples

More HIV prevention research is needed to better understand how relationship factors may affect sexual risk behaviors among gay male couples. Our cross-sectional study collected dyadic data from 144 gay male couples to examine which relationship factors and characteristics were associated with men having UAI with a secondary sex partner. We targeted male couples by using a variety of recruitment strategies. Multilevel random-effects logistic regression modeling was used to examine which factors were predictive of men in gay couples who had UAI with a secondary sex partner. Analyses revealed that men were less likely to have had UAI with a secondary sex partner if they reported being in a strictly monogamous relationship, receiving an HIV test within the previous 3 months, and being committed to their sexual agreement. Future HIV prevention interventions must consider how relationship factors may influence sexual risk behaviors among gay male couples.

Risks worth taking: safety agreements among discordant gay couples

As HIV research and prevention efforts increasingly target gay men in relationships, situational factors such as couple serostatus and agreements about sex become central to examinations of risk. Discordant gay couples are of particular interest because the risk of HIV infection is seemingly near-at-hand. Yet, little is known about their sexual behaviors, agreements about sex, and safer sex efforts. The present study utilized longitudinal semi-structured, qualitative interviews to explore these issues among 12 discordant couples. Findings show that nearly every couple had agreements about reducing the likelihood of HIV transmission from one partner to the other. Negotiating these agreements involved establishing a level of acceptable risk, determining condom use, and employing other risk-reduction techniques, such as seropositioning and withdrawal. For half of the couples, these agreements did not involve using condoms; only two couples reported consistent condom use. Despite forgoing condoms, however, none reported seroconversion over the course of data collection. Additional issues are raised where long-term HIV prevention is concerned. Future prevention efforts with discordant couples should work with, rather than fight against, the couple's decision to use condoms and endeavor to complement and accentuate their other safer sex efforts.

Partner-provided social support influences choice of risk reduction strategies in gay male couples

We investigated the influence of partner-provided HIV-specific and general social support on the sexual risk behavior of gay male couples with concordant, discordant, or serostatus-unknown outside partners. Participants were 566 gay male couples from the San Francisco Bay Area. HIV-specific social support was a consistent predictor for reduced unprotected anal intercourse (UAI) with both concordant outside partners (all couple types) and outside partners of discordant or unknown serostatus (concordant negative and discordant couples). General social support was associated with increased UAI with concordant outside partners for concordant negative and concordant positive couples (i.e., serosorting). Our findings suggest that prevention efforts should target couples and identify the level of HIV-specific support that partners provide. Partner-provided support for HIV-related behaviors could be an additional construct to consider in gay male relationships, akin to relationship satisfaction and commitment, as well as an important component of future HIV prevention interventions.

Serosorting and sexual risk behaviour according to different casual partnership types among MSM: the study of one-night stands and sex buddies

Among HIV-negative men who have sex with men (MSM), any incident of unprotected anal intercourse (UAI) between casual partners is usually regarded as risky for HIV transmission. However, men are increasingly using knowledge of their casual partner's HIV-status to reduce HIV risk during UAI (i.e., serosorting). Since familiarity between casual partners may lead to higher levels of UAI and serosorting, we examined how often men have UAI and practice serosorting with three types of casual partnerships that differ in their degree of familiarity. We included 240 HIV-negative men of the Amsterdam Cohort Study among MSM. We distinguished three types of casual partnerships: one-night stand ("met by chance and had sex only once"); multiple-time casual partner ("met and had sex with several times") and the "regular" casual partner ("sex buddy"). Serosorting was defined as UAI with an HIV-concordant partner. Generalised estimating equations analyses were used to examine the association between type of casual partnership and sexual risk behaviour. Analyses revealed that men with a sex buddy were more likely to have UAI than men with a one-night stand (OR [95%CI] 2.39 [1.39-4.09]). However, men with a sex buddy were also more likely to practice serosorting than men with a one-night stand (OR [95%CI] 5.20 [1.20-22.52]). Men with a sex buddy had more UAI but also reported more serosorting than men with a one-night stand. As a result, the proportion of UAI without serosorting is lower for men with a sex buddy, and therefore men might have less UAI at risk for HIV with this partner type. However, the protective value of serosorting with a sex buddy against HIV transmission needs to be further established. At this time, we suggest that a distinction between the one-night stand and the sex buddy should be incorporated in future studies as men behave significantly different with the two partner types.

Increasing risk behaviour can outweigh the benefits of antiretroviral drug treatment on the HIV incidence among men-having-sex-with-men in Amsterdam

Background

The transmission through contacts among MSM (men who have sex with men) is one of the dominating contributors to HIV prevalence in industrialized countries. In Amsterdam, the capital of the Netherlands, the MSM risk group has been traced for decades. This has motivated studies which provide detailed information about MSM's risk behavior statistically, psychologically and sociologically. Despite the era of potent antiretroviral therapy, the incidence of HIV among MSM increases. In the long term the contradictory effects of risk behavior and effective therapy are still poorly understood.

Methods

Using a previously presented Complex Agent Network model, we describe steady and casual partnerships to predict the HIV spreading among MSM. Behavior-related parameters and values, inferred from studies on Amsterdam MSM, are fed into the model; we validate the model using historical yearly incidence data. Subsequently, we study scenarios to assess the contradictory effects of risk behavior and effective therapy, by varying corresponding values of parameters. Finally, we conduct quantitative analysis based on the resulting incidence data.

Results

The simulated incidence reproduces the ACS historical incidence well and helps to predict the HIV epidemic among MSM in Amsterdam. Our results show that in the long run the positive influence of effective therapy can be outweighed by an increase in risk behavior of at least 30% for MSM.

Conclusion

We recommend, based on the model predictions, that lowering risk behavior is the prominent control mechanism of HIV incidence even in the presence of effective therapy.

Casual sexual encounters among gay men: familiarity, trust and unprotected anal intercourse

Familiarity with and a history of prior sex with casual partners is associated with unprotected anal intercourse and may increase the risk of HIV transmission among gay men. Using data from the Sydney Gay Community Periodic Survey 2007, we explored the relationship between familiarity and unprotected anal intercourse with the last casual partner (UAI-LC). 51% of the men knew their last casual partner and 49% had previously had sex with him. Men were more inclined to engage in UAI-LC if they had previously had sex with this partner. HIV-negative men were more likely to have UAI-LC with a more familiar partner independent of his serostatus. Familiarity with and a previous history of sex between casual partners may result in a false sense of trust and may increase the risk of HIV transmission. HIV prevention services should address this issue and develop programs to improve men's skills in negotiating safer sex.

HIV in young men who have sex with men: a review of epidemiology, risk and protective factors, and interventions

Epidemiological studies have found that young men who have sex with men (YMSM) represent the majority of young people infected with HIV annually in the United States. Further, they are one of the few risk groups to show an increase in the rate of infections in recent years. In addition to these disparities in prevalence and infection rates, there is an inequity in prevention and intervention research on this population. The purpose of this article is to review the existing YMSM literature on HIV epidemiology, correlates of risk, and intervention research. The article concludes that promising future directions for basic research include a focus on multiple clustering health issues, processes that promote resiliency, the role of family influences, and the development of parsimonious models of risk. In terms of intervention research, the article suggests that promising future directions include Internet-based intervention delivery, integration of biomedical and behavioral approaches, and interventions that go beyond the individual level to address partnership, structural, community, and network factors.

Ongoing HIV-1 transmission among men who have sex with men in Amsterdam: a 25-year prospective cohort study

BACKGROUND

To examine the suggested resurgence of the HIV epidemic among men who have sex with men (MSM), we studied trends in HIV-1 incidence rates, sexual risk behaviour, risk factors for HIV-1 seroconversion, and source of HIV-1 infection among MSM in the Amsterdam Cohort Studies from 1984 to 2009.

METHODS

Trends in HIV-1 incidence and risk factors for HIV-1 infection were studied using Poisson regression. Trends in sexual risk behaviour were evaluated using logistic regression, correcting for intra-individual correlation via generalized estimating equations. Trends in the source of HIV-1 infection were modelled via logistic regression.

RESULTS

Of 1642 HIV-1-negative individuals, 217 seroconverted during follow-up. HIV-1 incidence rates strongly decreased from 8.6/100 person-years in 1985 to 1.3/100 person-years in 1992; remained relatively stable around 1.0/100 person-years between 1992 and 1996, and slowly increased to 2.0/100 person-years in 2009 (P = 0.14; linear trend 1996-2009). Reports of unprotected anal intercourse (UAI) increased significantly from 1996 onwards. HIV-1 seroconversion was associated with receptive UAI with casual partners, more than five sexual partners, a history of gonorrhoea (all in the preceding 6 months), and a lower educational level. Currently, MSM are more likely to have contracted HIV-1 from casual partners than from steady partners, but trends of recent years suggest that steady partners became a growing source with increasing age.

CONCLUSIONS

Following increases in sexual risk behaviour from 1996 onwards, HIV-1 continues to spread among MSM. Targeted prevention messages should continue to focus on sexual behaviour with casual partners, but also on sexual behaviour within steady relationships.