Importance of Sex Partner HIV Status in HIV Risk Assessment Among Men Who have Sex With Men

Psychosocial characteristics pattern correlated with HIV-related risky sexual behavior among HIV-negative men who have sex with men: a latent profile analysis

BACKGROUND

Men who have sex with men (MSM) have become a high risk population of HIV infection due to their risky sexual behaviors. The latent pattern of psychosocial characteristics plays an important effect in HIV-related risky behaviors among HIV-negative MSM.

METHOD

Participants were recruited from Wuhan, Nanchang, and Changsha city from September 2017 to January 2018. Social support was assessed by the multidimensional scale of social support, Connor-Davidson Resilience scale-10 items for reliance, the assessment of Stigma towards Homosexuality for sexual minority stigma, the Likert subscale of nondisclosure for identity concealment, the ACE questionnaire-Kaiser-CDC for adverse childhood experience, the Centers for Epidemiological Studies Depression Scale for depression. Latent profile analysis (LPA) and multivariate regression were used to analyze the data.

RESULTS

Three psychosocial characteristic patterns were revealed by the LPA. "Social support and resilience group" (SR group), "Identity concealment group" (IC group) and "Adverse childhood experience" (ACE group) were identified, respectively. In comparison with "SR group", "IC group" have a higher likelihood of one-night male partners (AOR = 2.74, 95%CI = [1.54, 4.90]), both fixed and one-night male partners (AOR = 2.01, 95%CI = [1.34, 3.01]) and HIV-unsure male partner (AOR = 2.12, 95%CI = [1.44, 3.13]). Similarly, "ACE group" were more likely having inconsistent condom use (AOR = 2.58, 95%CI = [1.41, 4.73]), and having sex with HIV-positive male partner (AOR = 4.90, 95%CI = [1.95, 12.30]) with comparison of "SR group". In addition, we further revealed that "ACE group" had a higher ratio (90.0%) of inconsistent condom use among MSM whose male partners were HIV-positive.

CONCLUSIONS

Six important psychosocial factors were divided into three latent pattern classes. Compared with "SR group", "IC group" and "ACE group" were more likely to engage in HIV-related risky sexual behaviors. Further research may pay more attention to "IC group" and "ACE group" for targeted intervention.

How PrEP users constitute a community in the MSM population through their specific experience and management of stigmatization. The example of the French ANRS-PREVENIR study

The ANRS-PREVENIR (2017-2020) prospective cohort study aims to reduce the number of new HIV infections in the "Ile-de-France" region in France, by enrolling individuals at high risk of HIV infection and proposing daily and on-demand pre-exposure prophylaxis (PrEP). The qualitative component of the ANRS-PREVENIR study aimed to investigate social and relational evolutions associated with PrEP use in men who have sex with men (MSM). In 2018, 12 focus groups with MSM (n = 68) were conducted by a social sciences researcher in Paris. A thematic analysis was performed. Results showed that stigma concerning PrEP use is a complex issue, with various kinds of stigmatization being practiced, sometimes even by the wider MSM population and PrEP users themselves. All types of stigma identified were expressed in forms of verbal abuse which made PrEP use taboo. Inside the wider MSM population a PrEP-user "community" was identified which shared a certain complicity in terms of values and a positive attitude towards PrEP. The emergence of new intragroup and intergroup social norms should be taken into account by policy makers to promote a more positive image of PrEP users.

Venue-Based HIV-Testing: An Effective Screening Strategy for High-Risk Populations in Lima, Peru

Venue-based testing may improve screening efforts for HIV and syphilis, thereby reducing transmission. We offered onsite rapid dual HIV and syphilis testing at venues popular among MSM and/or transgender women in Lima, Peru. We used Poisson regression to calculate adjusted prevalence ratios (aPRs) for factors associated with each infection. Most (90.4%) of the 303 participants would test more frequently if testing was available at alternative venues. New cases of HIV (69) and syphilis infection (84) were identified. HIV was associated with recent sex work (aPR 1.11; 95% CI 1.02-1.22), sex with a partner of unknown serostatus (aPR 1.18; 95% CI 1.09-1.27), exclusively receptive anal sex role (aPR 1.16; 95% CI 1.03-1.30) or versatile sex role (aPR 1.17; 95% CI 1.06-1.30) compared to insertive. Syphilis was associated with reporting role versatility (aPR = 2.69; 95% CI 1.52-5.74). Sex work venues had higher syphilis prevalence 47% versus 28% in other venues, p value = 0.012. Venue-based testing may improve case finding.

HIV transmission risk behaviors among people living with HIV/AIDS: the need to integrate HIV prevention interventions and public health strategies into HIV care

CONTEXT

People living with human immunodeficiency virus (HIV)/AIDS (PLWHA) who continue high-risk behaviors may represent an important source for transmitting HIV infections.

OBJECTIVE

To identify factors associated with high-risk behaviors among PLWHA and to plan better HIV prevention intervention strategies in HIV care.

DESIGN

A cross-sectional survey to assess HIV transmission risk behaviors including sexual practices, disclosure of HIV infection status to sexual partner(s), and injection drug use.

SETTING

Five HIV outpatient clinics serving diverse PLWHA in south central Pennsylvania.

PARTICIPANTS

A total of 519 HIV-infected patients.

MAIN OUTCOME MEASURES

Two high-risk behaviors that may increase HIV transmission risk: (1) any unsafe sexual behavior and (2) nondisclosure of HIV infection status to sexual partner(s). An unsafe sexual behavior was defined as inconsistent condom use, sex under the influence of alcohol or drugs, or exchange of sex for money. A subgroup analysis was performed to examine factors related to unprotected anal intercourse among sexually active men who have sex with men.

RESULTS

About two-thirds of 519 HIV patients (65.7%) were sexually active, and nearly 50% of sexually active patients reported at least 1 unsafe sexual behavior. Nondisclosure of HIV infection status was reported by about 15% of the patients. Partners' characteristics including HIV infection status and the perceived partner behavior (ie, partner may have sex with other people) were significantly associated with unsafe sexual behaviors and with nondisclosure of HIV infection status. Non-Hispanic black males were more likely to withhold their HIV infection status from their sexual partner(s) (adjusted odds ratio = 4.51) than their white counterparts. In addition, the perceived partner sexual behavior was significantly related to unprotected anal intercourse among men who have sex with men (adjusted odds ratio = 2.00).

CONCLUSIONS

High-risk sexual behaviors are commonly reported by PLWHA, and these behaviors may be influenced by their partners' characteristics. HIV prevention interventions and public health strategies need to be incorporated into HIV care.

Incidence of syphilis seroconversion among HIV-infected persons in Asia: results from the TREAT Asia HIV Observational Database

INTRODUCTION

Outbreaks of syphilis have been described among HIV-infected men who have sex with men (MSM) in Western communities, whereas reports in Asian countries are limited. We aimed to characterize the incidence and temporal trends of syphilis among HIV-infected MSM compared with HIV-infected non-MSM in Asian countries.

METHODS

Patients enrolled in the TREAT Asia HIV Observational Database cohort and with a negative non-treponemal test since enrolment were analyzed. Incidence of syphilis seroconversion, defined as a positive non-treponemal test after previously testing negative, was evaluated among patients at sites performing non-treponemal tests at least annually. Factors associated with syphilis seroconversion were investigated at sites doing non-treponemal testing in all new patients and subsequently testing routinely or when patients were suspected of having syphilis.

RESULTS

We included 1010 patients from five sites that performed non-treponemal tests in all new patients; those included had negative non-treponemal test results during enrolment and subsequent follow-ups. Among them, 657 patients were from three sites conducting regular non-treponemal testing. The incidence of syphilis seroconversion was 5.38/100 person-years (PY). Incidence was higher in MSM than non-MSM (7.64/100 PY vs. 2.44/100 PY, p<0.001). Among MSM, the incidence rate ratio (IRR) for every additional year from 2009 was 1.19 (p=0.051). MSM status (IRR 3.48, 95% confidence interval (CI) 1.88-6.47), past syphilis diagnosis (IRR 5.15, 95% CI 3.69-7.17) and younger age (IRR 0.84 for every additional 10 years, 95% CI 0.706-0.997) were significantly associated with syphilis seroconversion.

CONCLUSIONS

We observed a higher incidence of syphilis seroconversion among HIV-infected MSM and a trend to increasing annual incidence. Regular screening for syphilis and targeted interventions to limit transmission are needed in this population.

HIV Serosorting, Status Disclosure, and Strategic Positioning Among Highly Sexually Active Gay and Bisexual Men

Researchers have identified harm reduction strategies that gay, bisexual, and other men who have sex with men (GBMSM) use to reduce HIV transmission--including serosorting, status disclosure, and strategic positioning. We report on patterns of these behaviors among 376 highly sexually active (i.e., 9+partners, <90 days) GBMSM: mean age of 37, 49.5% men of color, 87.8% gay identified, 57.5% college educated. We found evidence that many men engaged in serosorting, status disclosure, and strategic positioning; however, rates varied based on the participant's HIV status. HIV-positive and HIV-negative men both engaged in sex with men of similar status more often than they engaged in sex with men known to be a different HIV status (i.e., serosorting). However, HIV-negative men disclosed their HIV-status with about half of their partners, whereas HIV-positive participants disclosed with only about one-third. With regard to strategic positioning, HIV-positive participants were the receptive partner about half the time with their HIV-negative partners and with their HIV-positive partners. In contrast, strategic positioning was very common among HIV-negative participants-they rarely bottomed with HIV-positive partners, bottomed about one-third of the time with status-unknown partners, and 42% of the time (on average) with HIV-negative partners. Highly sexually active GBMSM are a critical population in which to both investigate HIV prevention strategies as well as develop effective intervention programs. Providers and clinicians might be well served to include a wide range of behavioral harm reduction strategies in addition to condom use and biomedical approaches to reduce onward HIV transmission.

Recency and frequency of HIV testing among men who have sex with men in Germany and socio-demographic factors associated with testing behaviour

Background

Testing for presence of HIV infection is a pre-requisite to qualify for antiretroviral treatment. A considerable proportion of German men who have sex with men (MSM) infected with HIV have a CD4 cell count below 350 cells/μl at time of diagnosis and are thus defined as “late presenters”. Late presentation increases the risk of adverse disease outcomes. In addition, knowledge and assessment of HIV status is often used for decisions about condom use and anal intercourse with steady and non-steady partners. Incorrect assumptions may result in high risk for HIV transmission.

Methods

Between 11/2013 and 01/2014 MSM were recruited to an online survey predominantly by personalized invitation messages from MSM social networking and dating websites. Respondents were asked about demographic characteristics, HIV testing history, reasons for testing decisions, and sexual behaviours. We describe reasons for not testing and analyse factors associated with not or infrequent testing using univariable and multivariable multinomial regression.

Results

Questions on HIV testing history were answered by 15,297 respondents. An HIV test within the last 12 months was reported by 38 %, a test more than 12 months ago by 27 % and 35 % had never been tested for HIV. Compared to recently tested, respondents who had never tested were more likely to be younger than 25 years (adjusted relative risk ratio (aRRR) 2.90, 95 % CI 2.11-3.99), living in a settlement with less than 100,000 inhabitants (aRRR 1.47, 95 % CI 1.18-1.83), being less open about their sexual orientation to their co-workers/classmates, and particularly to their primary care provider (aRRR 4.54, 95 % CI 4.02-5.11). Untested and less frequently tested respondents reported less sex partners and a lower proportion reported unprotected anal intercourse (UAI) with a non-steady partner (24 % compared to 38 % among those recently tested).

Conclusions

MSM who were younger, who did not live in large cities, and who were not out about their sexual orientation tested less frequently for HIV. Apart from strengthening protection from sexual orientation-related discrimination and empowering MSM who conceal their orientation, more opportunities to test anonymously and without revealing one’s sexual orientation should be provided.

Electronic supplementary material

The online version of this article (doi:10.1186/s12889-015-1945-5) contains supplementary material, which is available to authorized users.

Racial/Ethnic Differences in Sexual Network Mixing: A Log-Linear Analysis of HIV Status by Partnership and Sexual Behavior Among Most at-Risk MSM

Mixing patterns within sexual networks have been shown to have an effect on HIV transmission, both within and across groups. This study examined sexual mixing patterns involving HIV-unknown status and risky sexual behavior conditioned on assortative/dissortative mixing by race/ethnicity. The sample used for this study consisted of drug-using male sex workers and their male sex partners. A log-linear analysis of 257 most at-risk MSM and 3,072 sex partners was conducted. The analysis found two significant patterns. HIV-positive most at-risk Black MSM had a strong tendency to have HIV-unknown Black partners (relative risk, RR = 2.91, p < 0.001) and to engage in risky sexual behavior (RR = 2.22, p < 0.001). White most at-risk MSM with unknown HIV status also had a tendency to engage in risky sexual behavior with Whites (RR = 1.72, p < 0.001). The results suggest that interventions that target the most at-risk MSM and their sex partners should account for specific sexual network mixing patterns by HIV status.

Perceived HIV status is a key determinant of unprotected anal intercourse within partnerships of men who have sex with men in Amsterdam

The practice of unprotected anal intercourse (UAI) involves at least two partners. We examined the associations between insertive or receptive UAI and perceived HIV seroconcordance and partnership type in self-perceived HIV-negative and self-perceived HIV-positive men who have sex with men (MSM). MSM (age ≥ 18 years) were recruited for a cross-sectional survey at the sexually transmitted infections clinic in Amsterdam, the Netherlands, in 2008-2009. Participants completed a questionnaire concerning partnerships in the preceding 6 months. Associations were quantified via multinomial logistic regression models using generalized estimating equations. The outcomes were 'no, or safe anal intercourse', 'insertive UAI', and 'receptive UAI'. We included 5,456 partnerships from 1,890 self-perceived HIV-negative men and 1,861 partnerships from 558 self-perceived HIV-positive men. Within the partnerships, perceived HIV status of the partner was an important determinant of UAI (p < 0.001). Among HIV-negative men, perceived HIV discordance was negatively associated with receptive UAI compared with no or safe UAI (OR 0.57; 95 % CI 0.36-0.92); when the partners were more familiar with each other, the risk of receptive UAI was increased relative to no or safe anal intercourse. Among HIV-positive men, perceived HIV discordance was negatively associated with insertive UAI (OR 0.05; 95 % CI 0.03-0.08). Within partnerships, perceived HIV status of the partner was one of the strongest determinants of UAI among self-perceived HIV-negative and HIV-positive MSM, and discordant serostatus was negatively associated with UAI. The findings suggest that serosorting is one of the main strategies when engaging in UAI.

Racial differences in the accuracy of perceived partner HIV status among men who have sex with men (MSM) in Atlanta, Georgia

We compared perceptions of partner HIV status to HIV test results in a cross-sectional study of sexual networks of men who have sex with men (MSM) in Atlanta. We then examined differences between black and white MSM in the predictive value of perceived partner status. We recruited men ("seeds") using time-space venue sampling. These seeds then referred up to three partners, who could also refer partners. All participants reported sexual behavior and HIV status for recent partners and received HIV tests. For partners who enrolled, we compared laboratory diagnoses to their partner's perception of their status. Black MSM who perceived themselves to be HIV negative were more likely than perceived-negative white MSM to have a positive partner among those they perceived to be HIV negative or whose status was unknown to them (OR=6.6). Furthermore, although frequency of unprotected anal intercourse (UAI) was similar by race, black men were more likely to have had UAI with an unknown-positive partner (OR=9.3).

HIV prevention in clinical care settings: 2014 recommendations of the International Antiviral Society-USA Panel

IMPORTANCE

Emerging data warrant the integration of biomedical and behavioral recommendations for human immunodeficiency virus (HIV) prevention in clinical care settings.

OBJECTIVE

To provide current recommendations for the prevention of HIV infection in adults and adolescents for integration in clinical care settings.

DATA SOURCES, STUDY SELECTION, AND DATA SYNTHESIS

Data published or presented as abstracts at scientific conferences (past 17 years) were systematically searched and reviewed by the International Antiviral (formerly AIDS) Society-USA HIV Prevention Recommendations Panel. Panel members supplied additional relevant publications, reviewed available data, and formed recommendations by full-panel consensus.

RESULTS

Testing for HIV is recommended at least once for all adults and adolescents, with repeated testing for those at increased risk of acquiring HIV. Clinicians should be alert to the possibility of acute HIV infection and promptly pursue diagnostic testing if suspected. At diagnosis of HIV, all individuals should be linked to care for timely initiation of antiretroviral therapy (ART). Support for adherence and retention in care, individualized risk assessment and counseling, assistance with partner notification, and periodic screening for common sexually transmitted infections (STIs) is recommended for HIV-infected individuals as part of care. In HIV-uninfected patients, those persons at high risk of HIV infection should be prioritized for delivery of interventions such as preexposure prophylaxis and individualized counseling on risk reduction. Daily emtricitabine/tenofovir disoproxil fumarate is recommended as preexposure prophylaxis for persons at high risk for HIV based on background incidence or recent diagnosis of incident STIs, use of injection drugs or shared needles, or recent use of nonoccupational postexposure prophylaxis; ongoing use of preexposure prophylaxis should be guided by regular risk assessment. For persons who inject drugs, harm reduction services should be provided (needle and syringe exchange programs, supervised injection, and available medically assisted therapies, including opioid agonists and antagonists); low-threshold detoxification and drug cessation programs should be made available. Postexposure prophylaxis is recommended for all persons who have sustained a mucosal or parenteral exposure to HIV from a known infected source and should be initiated as soon as possible.

CONCLUSIONS AND RELEVANCE

Data support the integration of biomedical and behavioral approaches for prevention of HIV infection in clinical care settings. A concerted effort to implement combination strategies for HIV prevention is needed to realize the goal of an AIDS-free generation.

Multi-dimensional factors associated with unprotected anal intercourse with regular partners among Chinese men who have sex with men in Hong Kong: a respondent-driven sampling survey

Background

The HIV prevalence and incidence among men who have sex with men (MSM) are high. Unprotected anal intercourse (UAI) with male regular partners (RP) is an important but under-emphasized risk behavior. The current study aimed to describe the prevalence of UAI with regular partner and the associated multi-dimensional factors with UAI among MSM in Hong Kong, China.

Methods

Respondent Driven Sampling method was used to recruit participants. A total of 285 participants were recruited, of whom 211 (75.1%) had had anal sex with RP in the last six months and their data were analyzed in this report. Weighed data were presented and logistic regression methods were fit.

Results

Participants’ high risk behaviors in the last six months included high prevalence of having had UAI with RP (45.8%), having had non-regular male sex partners (NRP: 27.3%) and UAI with such partners (18.9%). Adjusted for socio-demographic variables, factors associated with UAI with RP included: 1) substances use prior to having anal sex (65.7% versus 43.8%; AOR =2.36; 95% CI =1.07-5.18), 2) worry that condom use symbolizes mistrust (67.9% versus 44.3%; AOR = 2.91; 95% CI =1.19-7.10), 3) a lower perceived degree of the RP’s acceptance of condom use (91.7% versus 38.3%; AOR = 22.70; 95% CI =6.20-83.10), and 4) a higher level of impulsivity (61.1% versus 35.0%; AOR =4.02; 95% CI = 1.62-9.97). Two of these four variables, substances use (ORm = 2.28, 95% CI = 1.01-5.16) and perceived lower level of RP’s acceptance of condom use (ORm = 17.22; 95% CI = 5.06-58.62) were selected by the forward stepwise logistic regression model.

Conclusions

MSM with RP in Hong Kong is subjected to high risk of HIV transmission. Risk factors of UAI are multi-dimensional and interventions need to take into account factors of structural, interpersonal and individual levels.

Men who have sex with men's attitudes toward using color-coded wristbands to facilitate sexual communication at sex parties

Sex parties are environments where men who have sex with men (MSM) have the opportunity to have sex with multiple partners over a brief period of time. Dim lighting and non-verbal communication are characteristics of sex parties that make sexual communication more challenging. We report on qualitative data from 47 MSM who attended sex parties in New York City. Participants responded to distinct hypothetical scenarios involving the use of color-coded wristbands to communicate (1) condom use preferences, (2) sexual position (e.g., top, bottom) and (3) HIV status at sex parties. The majority had positive-to-neutral attitudes toward color-coded wristbands to indicate (1) condom use preference and (2) sexual position (70.8%, 75.0% HIV-positive; 63.6%, 81.8%, HIV-negative respectively). These men cited that wristbands would facilitate the process of pursuing partners with similar interests while also avoiding the discomforts of verbal communication. In contrast, 41.7% of HIV-positive and 50.0% of HIV-negative men expressed unfavorable attitudes to using wristbands to communicate HIV status. These men cited the potential for HIV-status discrimination as well as suspicions around dishonest disclosure. Although participants were receptive to utilizing color-coded wristbands at sex parties to convey certain information, it may be unfeasible to use wristbands to communicate HIV status.

Evidence for the long-term stability of HIV transmission-associated sexual behavior after HIV diagnosis

BACKGROUND

Most persons diagnosed as having HIV alter their sexual behavior in a way that reduces the risk of HIV transmission, but the durability of such behavior change is unknown.

METHODS

We conducted annual anonymous cross-sectional surveys in randomly selected patients with appointments at a large, public hospital HIV clinic in Seattle, Washington, from 2005 to 2009. We used logistic regression to assess the association between time since HIV diagnosis and self-report of unprotected anal or vaginal intercourse (UAVI) with partners of negative or unknown HIV status (nonconcordant UAVI), and quantile regression to evaluate the association between time since HIV diagnosis and number of anal or vaginal sex partners.

RESULTS

We analyzed 845 surveys collected for 5 years. Men who have sex with men (MSM) had been diagnosed as having HIV a mean (standard deviation) of 12 (7) years and non-MSM a mean of 11 (6) years. Among 597 MSM, longer time since HIV diagnosis was associated with lower age-adjusted odds of reporting nonconcordant UAVI (odds ratio, 0.96 [95% confidence interval, 0.92-0.99]) and a lower age-adjusted number of sex partners (β coefficient = -0.03, P = 0.007). Among 248 women and heterosexual men, time since HIV diagnosis was not significantly associated with age-adjusted odds of nonconcordant UAVI (odds ratio 0.99 [95% confidence interval, 0.93-1.04]) or number of sex partners (β coefficient = -0.01, P = 0.48).

CONCLUSIONS

These results indicate that HIV transmission-associated behavior is relatively stable following the first year after HIV diagnosis. Our findings suggest that behavior change in the first year after HIV diagnosis, reported in other studies, is durable.

Do Men who have Sex with Men (MSM) in the United States Understand that HIV Serodiscordance is Possible?

BACKGROUND

Little is currently known about the extent to which US MSM understand the possibility that a long-term sex partner can have an HIV status different than one's own status. This information is important in the adaptation of Couples Voluntary HIV Counseling and Testing (CVCT) for US MSM.

METHODS

428 US MSM completed an online survey using MySpace.com from March-April, 2009.

RESULTS

Of 426 MSM with complete data, 21.1% (90) were not definitively aware that serodiscordance is possible. Factors associated with a lack of understanding that serodiscordance is possible were: never having tested for HIV (OR: 2.0; CI: 1.1, 3.8), compared to testing 0-6 months previously and having a high school education or less (OR: 2.2; CI: 1.1, 4.5), compared to men who had completed at least some college.

CONCLUSIONS

A large proportion of young, internet-using MSM in the United States may not understand that HIV serodiscordance is possible within sexual partnerships. Based on these results, we recommend that CVCT provided to male couples in the United States should include education on HIV serodiscordance.

HIV-infected men who have sex with men who engage in very high levels of transmission risk behaviors: establishing a context for novel prevention interventions

Men who have sex with men (MSM) comprise the largest risk group of individuals living with HIV in the USA and have the highest rates of new infections. A minority of HIV-infected MSM engage in unprotected anal intercourse after learning about their infection, potentially transmitting the virus to others. The current study sought to generate self-generated descriptive themes, from a group of HIV-infected MSM who reported high rates of sexual transmission risk behavior that may be relevant for understanding sexual risk in this group. Five descriptive themes emerged during content analysis: (a) serostatus attribution, (b) assumption of sexual partner's responsibility for safer sex, (c) sexual sensation seeking, (d) ongoing substance use, and (e) dissatisfaction with current relationships. Traditional HIV transmission risk reduction interventions that have been known to have only modest effects should be augmented by developing HIV prevention strategies for this subgroup of MSM to address these salient themes.

Patterns of HIV disclosure and condom use among HIV-infected young racial/ethnic minority men who have sex with men

Recent findings highlight the continued rise in cases of HIV infection among racial/ethnic minority young men who have sex with men (YMSM). In adults, disclosure of HIV status has been associated with decreased sexual risk behaviors but this has not been explored among YMSM. In this study of 362 HIV-infected racial/ethnic minority YMSM, rates of disclosure were high, with almost all disclosing their status to at least one person at baseline. The majority had disclosed to a family member, with higher disclosure rates to female relatives compared with males. After adjustment for site, disclosure to sex partners and boyfriends was associated with an increase in condom use during both oral and anal sex. Future studies should consider skills training to assist youth in the disclosure process, facilitate how to determine who in their family and friend social network can be safely disclosed to and support family-based interventions.

HIV disclosure and sexual transmission behaviors among an Internet sample of HIV-positive men who have sex with men in Asia: implications for prevention with positives

The relationship between HIV disclosure and sexual transmission behaviors, and factors that influence disclosure are unknown among HIV-positive men who have sex with men (MSM) in Asia. We describe disclosure practices and sexual transmission behaviors, and correlates of disclosure among this group of MSM in Asia. A cross-sectional multi-country online survey was conducted among 416 HIV-positive MSM. Data on disclosure status, HIV-related risk behaviors, disease status, and other characteristics were collected. Multivariable logistic regression was used to identify significant correlates of disclosure. Only 7.0% reported having disclosed their HIV status to all partners while 67.3% did not disclose to any. The majority (86.5%) of non-disclosing participants had multiple partners and unprotected insertive or receptive anal intercourse with their partners (67.5%). Non-disclosure was significantly associated with non-disclosure from partners (AOR = 37.13, 95% CI: 17.22, 80.07), having casual partners only (AOR = 1.91, 95% CI: 1.03, 3.53), drug use before sex on a weekly basis (AOR: 6.48, 95% CI: 0.99, 42.50), being diagnosed with HIV between 1 and 5 years ago (AOR = 2.23, 95% CI: 1.05, 4.74), and not knowing one's viral load (AOR = 2.80, 95% CI: 1.00, 7.83). Given the high HIV prevalence and incidence among MSM in Asia, it is imperative to include Prevention with Positives for MSM. Interventions on disclosure should not solely focus on HIV-positive men but also need to include their sexual partners and HIV-negative men.

Behavioral factors in assessing impact of HIV treatment as prevention

The recent NIH HPTN 052 study of using HIV treatment to prevent HIV transmission in serostatus discordant heterosexual partnerships has garnered much attention. In subsequent discussions, however, the topic of HIV-related risk behavior has been nearly absent. Here, we identify the critical roles that HIV-related risk behavior plays in determining the unmet needs, optimal targeting, and ultimate impact of treatment as prevention. We describe the size of the population at risk of HIV and three subgroups of persons living with HIV (PLWH) based on awareness of serostatus and risk behavior, and the corresponding HIV transmission rates to seronegative partners. For each of the subgroups of PLWH, we identify which approach is most relevant ("testing and linkage to care," "treatment as prevention," and/or "treatment as clinical care"). We observe that the impact of "treatment as prevention" on HIV incidence will depend heavily on which subgroup of PLWH is targeted for services.

High and persistent HIV seroincidence in men who have sex with men across 47 U.S. cities

OBJECTIVE

To provide HIV seroincidence data among men who have sex with men (MSM) in the United States and to identify predictive factors for seroconversion.

METHODS

From 1998-2002, 4684 high-risk MSM, age 18-60 years, participated in a randomized, placebo-controlled HIV vaccine efficacy trial at 56 U.S. clinical trial sites. Demographics, behavioral data, and HIV status were assessed at baseline and 6 month intervals. Since no overall vaccine efficacy was detected, data were combined from both trial arms to calculate HIV incidence based on person-years (py) of follow-up. Predictors of seroconversion, adjusted hazards ratio (aHR), were evaluated using a Cox proportional hazard model with time-varying covariates.

RESULTS

Overall, HIV incidence was 2.7/100 py and was relatively uniform across study sites and study years. HIV incidence was highest among young men and men reporting unprotected sex, recreational drug use, and a history of a sexually transmitted infection. Independent predictors of HIV seroconversion included: age 18-30 years (aHR = 2.4; 95% CI 1.4,4.0), having >10 partners (aHR = 2.4; 95% CI 1.7,3.3), having a known HIV-positive male sex partner (aHR = 1.6; 95% CI 1.2, 2.0), unprotected anal intercourse with HIV positive/unknown male partners (aHR = 1.7; 95% CI 1.3, 2.3), and amphetamine (aHR = 1.6; 95% CI 1.1, 2.1) and popper (aHR = 1.7; 95% CI 1.3, 2.2) use.

CONCLUSIONS

HIV seroincidence was high among MSM despite repeated HIV counseling and reported declines in sexual risk behaviors. Continuing development of new HIV prevention strategies and intensification of existing efforts will be necessary to reduce the rate of new HIV infections, especially among young men.

Variations in patterns of sexual risk behavior among Seattle-area MSM based on their HIV status, the HIV status of their partner and partner type

We evaluated sexual risk behavior in 368 Seattle-area MSM recruited in the 2008 National HIV Behavioral Surveillance survey. We found significant concordance between participants' self-reported HIV status and that of their sexual partners. Persons unaware of partners' HIV status were more likely to report only oral sex. Those aware were less likely to report non-concordant unprotected anal intercourse (UAI). Participants reporting themselves HIV-positive were more likely than those self-reporting HIV-negative status to report non-concordant UAI and several other sexual risk behaviors. The level of non-concordant UAI did not materially differ by whether their partner was a main or casual partner.

'I've had unsafe sex so many times why bother being safe now?': the role of cognitions in sexual risk among American Indian/Alaska Native men who have sex with men

BACKGROUND

American Indian/Alaska Native (AI/AN) men who have sex with men (MSM) are at high risk of human immunodeficiency virus (HIV) acquisition and transmission.

PURPOSE

This study aimed to investigate a potential area of focus for HIV prevention interventions by assessing the impact of sexual risk cognitions on sexual risk-taking among AI/AN MSM.

METHODS

AI/AN MSM (N = 173) from a national cross-sectional survey were analyzed.

RESULTS

Reporting more frequent sexual risk cognitions overall (high sexual risk cognitions) was associated with multiple HIV risk factors including unprotected anal intercourse and serodiscordant unprotected anal intercourse. Participants with high sexual risk cognitions had a 2.3 (95% Confidence Interval: 1.1, 4.7) times greater odds of engaging in unprotected anal intercourse regardless of childhood sexual abuse, depression, and alcohol dependence. Most individual sexual risk cognitions were associated with unprotected anal intercourse, serodiscordant unprotected anal intercourse, or both.

CONCLUSIONS

Results suggest that sexual risk cognitions may be a productive area for further work on HIV prevention among AI/AN MSM.

Exposure to HIV partner counseling and referral services and notification of sexual partners among persons recently diagnosed with HIV

OBJECTIVE

Among HIV-infected persons, we evaluated use of client partner notification (CPN) and health-department partner notification strategies to inform sex partners of possible HIV exposure, and prior exposure to partner counseling and referral services.

METHODS

We conducted a cross-sectional, observational study of 590 persons diagnosed with HIV in the prior 6 months at 51 HIV test, medical, and research providers in Chicago and Los Angeles in 2003 and 2004. Logistic regression was used to identify independent correlates of using CPN to notify all locatable partners.

RESULTS

Participants reported a total of 5091 sex partners in the 6 months preceding HIV diagnosis; 1253 (24.6%) partners were locatable and not known to be HIV-positive. Of 439 participants with ≥1 locatable partners, 332 (75.6%) reported notifying 696 (55.5%) partners by CPN (585, 84.1%), health-department partner notification (94, 13.5%), or other means (17, 2.4%); 208 (47.4%) used CPN to notify all locatable partners. Independent correlates of CPN included having fewer locatable partners and discussing the need to notify partners with an HIV medical-care provider (black and Hispanic participants only). Many participants reported that their HIV test or medical-care provider did not discuss the need to notify partners (48.8%, 33.7%, respectively) and did not offer health-department partner-notification services (60.8%, 52.8%).

CONCLUSION

Many locatable sex partners who might benefit from being notified of potential HIV exposure are not notified. In accordance with national policies, HIV test and medical-care providers should routinely provide partner counseling and referral services to HIV-infected clients so that all locatable partners are notified and provided an opportunity to learn their HIV status.

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.

Is injection serosorting occurring among HIV-positive injection drug users? Comparison by injection partner's HIV status

Research needs to build evidence for the roles that HIV status of injection partners may or may not play in injection risk behaviors of injection drug users (IDUs). Using baseline data collected from a randomized controlled study (INSPIRE) conducted in four cities (Baltimore, Miami, New York, and San Francisco) from 2001 to 2005, we categorized 759 primarily heterosexual HIV-positive IDUs into four groups based on HIV serostatus of drug injection partners. Thirty-two percent of the sample injected exclusively with HIV-positive partners in the past 3 months and more than 60% had risky injection behavior with these partners. Eight percent injected exclusively with HIV-negative partners and 49% injected with any unknown status partners. The remaining 11% reported having both HIV-positive and -negative injection partners, but no partners of unknown HIV status. Riskier injection behavior was found among the group with mixed status partners. The risk among the group with any unknown status partners appeared to be driven by the greater number of injection partners. No major group differences were observed in socio-demographic and psychosocial factors. Our analysis suggests that serosorting appeared to be occurring among some, but not an overwhelming majority of HIV-positive IDUs, and knowledge of HIV status of all injection partners per se did not appear to be as important as knowledge of sexual partner's HIV status in its association with risk behavior.

Indeterminate and discrepant rapid HIV test results in couples' HIV testing and counselling centres in Africa

Background

Many HIV voluntary testing and counselling centres in Africa use rapid antibody tests, in parallel or in sequence, to establish same-day HIV status. The interpretation of indeterminate or discrepant results between different rapid tests on one sample poses a challenge. We investigated the use of an algorithm using three serial rapid HIV tests in cohabiting couples to resolve unclear serostatuses.

Methods

Heterosexual couples visited the Rwanda Zambia HIV Research Group testing centres in Kigali, Rwanda, and Lusaka, Zambia, to assess HIV infection status. Individuals with unclear HIV rapid antibody test results (indeterminate) or discrepant results were asked to return for repeat testing to resolve HIV status. If either partner of a couple tested positive or indeterminate with the screening test, both partners were tested with a confirmatory test. Individuals with indeterminate or discrepant results were further tested with a tie-breaker and monthly retesting. HIV-RNA viral load was determined when HIV status was not resolved by follow-up rapid testing. Individuals were classified based on two of three initial tests as "Positive", "Negative" or "Other". Follow-up testing and/or HIV-RNA viral load testing determined them as "Infected", "Uninfected" or "Unresolved".

Results

Of 45,820 individuals tested as couples, 2.3% (4.1% of couples) had at least one discrepant or indeterminate rapid result. A total of 65% of those individuals had follow-up testing and of those individuals initially classified as "Negative" by three initial rapid tests, less than 1% were resolved as "Infected". In contrast, of those individuals with at least one discrepant or indeterminate result who were initially classified as "Positive", only 46% were resolved as "Infected", while the remainder was resolved as "Uninfected" (46%) or "Unresolved" (8%). A positive HIV serostatus of one of the partners was a strong predictor of infection in the other partner as 48% of individuals who resolved as "Infected" had an HIV-infected spouse.

Conclusions

In more than 45,000 individuals counselled and tested as couples, only 5% of individuals with indeterminate or discrepant rapid HIV test results were HIV infected. This represented only 0.1% of all individuals tested. Thus, algorithms using screening, confirmatory and tie-breaker rapid tests are reliable with two of three tests negative, but not when two of three tests are positive. False positive antibody tests may persist. HIV-positive partner serostatus should prompt repeat testing.

Contingency management to reduce methamphetamine use and sexual risk among men who have sex with men: a randomized controlled trial

BACKGROUND

Methamphetamine use is associated with HIV acquisition and transmission among men who have sex with men (MSM). Contingency management (CM), providing positive reinforcement for drug abstinence and withholding reinforcement when abstinence is not demonstrated, may facilitate reduced methamphetamine use and sexual risk. We compared CM as a stand-alone intervention to a minimal intervention control to assess the feasibility of conducting a larger, more definitive trial of CM; to define the frequency of behavioral outcomes to power such a trial; and, to compute preliminary estimates of CM's effectiveness.

METHODS

We randomly assigned 127 MSM from Seattle, WA who use methamphetamine to receive a 12-week CM intervention (n = 70) or referral to community resources (n = 57).

RESULTS

Retention at 24 weeks was 84%. Comparing consecutive study visits, non-concordant UAI declined significantly in both study arms. During the intervention, CM and control participants were comparably likely to provide urine samples containing methamphetamine (adjusted relative risk [aRR] = 1.09; 95%CI: 0.71, 1.56) and to report non-concordant UAI (aRR = 0.80; 95%CI: 0.47, 1.35). However, during post-intervention follow-up, CM participants were somewhat more likely to provide urine samples containing methamphetamine than control participants (aRR = 1.21; 95%CI: 0.95, 1.54, P = 0.11). Compared to control participants, CM participants were significantly more likely to report weekly or more frequent methamphetamine use and use of more than eight quarters of methamphetamine during the intervention and post-intervention periods.

CONCLUSIONS

While it is possible to enroll and retain MSM who use methamphetamine in a trial of CM conducted outside drug treatment, our data suggest that CM is not likely to have a large, sustained effect on methamphetamine use.

HIV among people who use drugs: a global perspective of populations at risk

This article examines the epidemiology of HIV among selected subgroups of drug users around the world who are "most at risk"--men who have sex with men, female sex workers, prisoners, and mobile populations. The underlying determinants of HIV infection among these populations include stigma, physical and sexual violence, mental illness, social marginalization, and economic vulnerability. HIV interventions must reach beyond specific risk groups and individuals to address the micro-level and macro-level determinants that shape their risk environments. Public health interventions that focus on the physical, social, and health policy environments that influence HIV risk-taking in various settings are significantly more likely to impact the incidence of HIV and other blood-borne and sexually transmitted infections across larger population groups.

A conceptual model of HIV disclosure in casual sexual encounters among men who have sex with men

HIV/AIDS continues to disproportionately impact men who have sex with men (MSM). Advances in highly active antiretroviral therapies (HAART) have successfully helped HIV-infected individuals lead longer, healthier, and presumably more sexually active lives. Consequently, secondary prevention approaches aimed at reducing the rate of HIV transmission have raised important questions about the role of sexual communication, namely HIV disclosure, as a primary target for intervention. This paper proposes a conceptual model of HIV disclosure in casual sexual encounters among MSM informed by Goffman's work on stigma and based on existing empirical research. The article concludes with an agenda for research based in this integrative model.

A strategy for selecting sexual partners believed to pose little/no risks for HIV: serosorting and its implications for HIV transmission

A common HIV/AIDS risk reduction strategy among men who have sex with men (MSM) is to limit their unprotected sex partners to those who are of the same HIV status, a practice referred to as serosorting. Decisions to serosort for HIV risk reduction are based on personal impressions and beliefs, and there is limited guidance offered on this community derived strategy from public health services. This paper reviews research on serosorting for HIV risk reduction and offers an evidence-based approach to serosorting guidance. Following a comprehensive electronic and manual literature search, we reviewed 51 studies relating to the implications of serosorting. Studies showed that HIV negative MSM who select partners based on HIV status are inadvertently placing themselves at risk for HIV. Infrequent HIV testing, lack of HIV status disclosure, co-occurring sexually transmitted infections, and acute HIV infection impede the potential protective benefits of serosorting. Public health messages should continue to encourage reductions in numbers of sexual partners and increases in condom use. Risk reduction messages should also highlight the limitations of relying on one's own and partner's HIV status in making sexual risk decisions.

Is sexual serosorting occurring among HIV-positive injection drug users? Comparison between those with HIV-positive partners only, HIV-negative partners only, and those with any partners of unknown status

Using baseline data from a multi-site, randomized controlled study (INSPIRE), we categorized 999 HIV-positive IDUs into three groups based on serostatus of their sex partners. Our data provide some evidence for serosorting occurring in our sample; about 40% of the sample had sex exclusively with HIV-positive partners, and about half of them reported having unprotected sex with these partners. Twenty per cent had sex exclusively with HIV-negative partners; their sexual behaviors tended to be least risky with about two-thirds reporting their sex was protected. However, we also found that another 40% had at least one partner of unknown HIV status and sexual and drug risk was the highest among them. They were also least empowered, showing attributes that may undermine HIV prevention. Some of these findings are consistent with findings from MSM studies, suggesting that partner selection practices are similar between primarily heterosexual IDUs and MSM.

Effects of a behavioral intervention to reduce serodiscordant unsafe sex among HIV positive men who have sex with men: the Positive Connections randomized controlled trial study

Few behavioral interventions have been conducted to reduce high-risk sexual behavior among HIV-positive Men who have Sex with Men (HIV+ MSM). Hence, we lack well-proven interventions for this population. Positive Connections is a randomized controlled trial (n = 675 HIV+ MSM) comparing the effects of two sexual health seminars--for HIV+ MSM and all MSM--with a contrast prevention video arm. Baseline, 6-, 12- and 18-month follow-up surveys assessed psychosexual variables and frequency of serodiscordant unprotected anal intercourse (SDUAI). At post-test, intentions to avoid transmission were significantly higher in the sexual health arms. However, SDUAI frequency decreased equally across arms. HIV+ MSM engaging in SDUAI at baseline were more likely to leave the study. Tailoring interventions to HIV+ MSM did not increase their effectiveness in this study. A sexual health approach appeared as effective as an untailored video-based HIV prevention intervention in reducing SDUAI among HIV+ MSM.

Measuring sexual risk for HIV: a Rasch scaling approach

In this study, we developed an HIV transmission risk scale and examined its psychometric properties using data on sexual behavior obtained from a probability sample of adult men who have sex with men living in Chicago. We used Messick's (Am Psychol 50:741-749, 1995) conceptualization of unified validity theory to organize the psychometric properties of data. Evidence related to scale content was investigated via Rasch item fit statistics, point-measure correlations, and expert evaluation. The substantive aspect of validity was addressed by interpreting the meaningfulness of the item difficulty hierarchy (continuum of risky behaviors) and assessment of person fit. The structural aspect of validity was assessed using Rasch item fit statistics, principal component analysis of standardized residuals, and other residual analyses. The generalizability aspect of validity was investigated via internal consistency reliability estimates for both items and persons, and aspects of external validity were addressed by examining between-group differences with respect to levels of risky behavior. Applications and suggested future studies are discussed.

HIV serosorting as a harm reduction strategy: evidence from Seattle, Washington

OBJECTIVE

We sought to estimate how serosorting may affect HIV prevalence and individual risk among men who have sex with men in Seattle, Washington, and how the results vary under different assumptions of HIV testing frequency, heterogeneity in sexual behavior, and condom use.

METHODS

We developed a deterministic mathematical model of HIV transmission dynamics. Data from the 2003 random digit dial study of men who have sex with men conducted in Seattle, Washington (n = 400) are used to parameterize the model.

RESULTS

Predicted population-level HIV prevalence as well as an individual's risk of HIV acquisition decreases when the odds of serosorting are increased in the mathematical model. In our model based on observed levels of serosorting, we predict an HIV prevalence of 16%. In contrast, if serosorting were eliminated in the population, we predict that HIV prevalence would increase to 24.5%. However, our findings depend on rates of condom use, mean anal sex contact rates, and HIV testing in the population.

CONCLUSION

Under realistic scenarios of sexual behavior and testing frequency for men who have sex with men in the United States, serosorting can be an effective harm reduction strategy.

Prediction of HIV acquisition among men who have sex with men

OBJECTIVE

To develop and validate an easy-to-use prediction model for HIV acquisition among men who have sex with men (MSM).

METHODS

We developed prediction models using medical records data from an STD clinic (2001-2008) and validated these models using data from the control arm of Project Explore, an HIV prevention trial (1999-2003).

RESULTS

Of 1903 MSM who tested for HIV more than once in the development sample, 101 acquired HIV over 6.7 years of follow-up. Annual HIV incidence was 2.57% (95% confidence interval [CI]: 2.09%, 3.12%). During 4 years of follow-up of 2081 Project Explore control arm participants, 144 acquired HIV for an incidence of 2.32% (95% CI: 1.96%, 2.73%). A prediction model that included variables indicating use of methamphetamine or inhaled nitrites in the prior 6 months, unprotected anal intercourse with a partner of positive or unknown HIV status in the prior year, > or =10 male sex partners in the prior year, and current diagnosis or history of bacterial sexually transmitted infection was well calibrated overall (expected-observed ratio = 1.01; 95% CI: 0.97, 1.05) and had modest discriminatory accuracy at 1 year (area under the receiver-operator characteristic curve = 0.67; 95% CI: 0.60, 0.75) and at 4 years (area under the receiver-operator characteristic curve = 0.66; 95% CI: 0.61, 0.71). Over 4 years, cumulative incidence ranged from 3.9% to 14.3% for groups of men defined by the prediction model.

CONCLUSIONS

A new risk score was predictive of HIV acquisition and could assist providers in counseling MSM and in targeting intensified prevention to MSM at greatest risk for HIV infection. Its accuracy requires further evaluation.

HIV testing in a high-incidence population: is antibody testing alone good enough?

BACKGROUND

The Centers for Disease Control and Prevention recently recommended the expansion of human immunodeficiency virus (HIV) antibody testing. However, antibody tests have longer "window periods" after HIV acquisition than do nucleic acid amplification tests (NAATs).

METHODS

Public Health-Seattle & King County offered HIV antibody testing to men who have sex with men (MSM) using the OraQuick Advance Rapid HIV-1/2 Antibody Test (OraQuick; OraSure Technologies) on oral fluid or finger-stick blood specimens or using a first- or second-generation enzyme immunoassay. The enzyme immunoassay was also used to confirm reactive rapid test results and to screen specimens from OraQuick-negative MSM prior to pooling for HIV NAAT. Serum specimens obtained from subsets of HIV-infected persons were retrospectively evaluated by use of other HIV tests, including a fourth-generation antigen-antibody combination assay.

RESULTS

From September 2003 through June 2008, a total of 328 (2.3%) of 14,005 specimens were HIV antibody positive, and 36 (0.3%) of 13,677 antibody-negative specimens were NAAT positive (indicating acute HIV infection). Among 6811 specimens obtained from MSM who were initially screened by rapid testing, OraQuick detected only 153 (91%) of 169 antibody-positive MSM and 80% of the 192 HIV-infected MSM detected by the HIV NAAT program. HIV was detected in serum samples obtained from 15 of 16 MSM with acute HIV infection that were retrospectively tested using the antigen-antibody combination assay.

CONCLUSIONS

OraQuick may be less sensitive than enzyme immunoassays during early HIV infection. NAAT should be integrated into HIV testing programs that serve populations that undergo frequent testing and that have high rates of HIV acquisition, particularly if rapid HIV antibody testing is employed. Antigen-antibody combination assays may be a reasonably sensitive alternative to HIV NAAT.

Prevalence of unprotected anal intercourse among HIV-diagnosed MSM in the United States: a meta-analysis

OBJECTIVE

To integrate the empirical findings on the prevalence of unprotected anal intercourse (UAI) among HIV-diagnosed men who have sex with men (MSM) in the United States.

METHODS

Comprehensively searching MEDLINE, EMBASE, PsycINFO (2000-2007), hand searching bibliographic lists, and contacting researchers. Thirty US studies (n = 18,121) met selection criteria. Analyses were conducted using random-effects models and meta-regression.

RESULTS

The prevalence of UAI was considerably higher with HIV-seropositive partners (30%; 95% confidence interval 25-36) than with serostatus unknown (16%; 95% confidence interval 13-21) or HIV-seronegative partners (13%; 95% confidence interval 10-16). The prevalence of UAI with either a serostatus unknown or HIV-seronegative partner was 26%. The UAI prevalence did not differ by the length of the behavioral recall window but did vary by the type of anal intercourse (insertive vs. receptive). Studies with the following features had a lower UAI prevalence: recruiting participants before 2000, MSM of color being the majority of study sample, recruiting participants from medical settings, using random or systematic sampling methods, and having interviewers administer the questionnaire. Being on antiretroviral therapy, having an undetectable viral load, and reporting more than 90% medication adherence were not associated with UAI.

CONCLUSION

Most HIV-diagnosed MSM protect partners during sexual activity, but a sizeable percentage continues to engage in sexual behaviors that place others at risk for HIV infection and place themselves at risk for other sexually transmitted infections. Prevention with positives programs continues to be urgently needed for MSM in the United States.

Increases in unprotected anal intercourse with serodiscordant casual partners among HIV-negative gay men in Sydney

Prevalence of unprotected anal intercourse between casual male partners (UAIC) has been increasing worldwide. We explored trends in serodiscordant UAIC and the associated factors among gay men in Sydney. Proportions of HIV-positive and negative men with serodiscordant casual partners increased during 2003-2006. Prevalence of serodiscordant UAIC increased among HIV-negative men. Age, number of partners, seeking partners online, drug use and esoteric practices were associated with serodiscordant UAIC. Increases in serodiscordant UAIC may be related to growing disclosure. These findings do not indicate a core group of high-risk men. More research is needed about the context in which serodiscordant UAIC happens.

HIV testing frequency among men who have sex with men attending sexually transmitted disease clinics: implications for HIV prevention and surveillance

OBJECTIVES

To describe trends in the occurrence and frequency of HIV testing among men who have sex with men (MSM) receiving care in 4 US sexually transmitted disease (STD) clinics and to define factors associated with HIV testing frequency and positivity.

STUDY DESIGN

Routine clinical encounters during 57,131 visits by MSM to STD clinics in 4 cities (Seattle-King County, San Francisco, Denver, and District of columbia), 2002-2006, were examined.

RESULTS

From 2002 to 2006, a city-specific median of 69.1% of presumptive HIV-uninfected MSM were tested for HIV, of which, a median of 86.7% had previously tested (4.5% unknown) and a median of 3.9% were newly diagnosed with HIV. Between 2002 and 2006, the median percentage of tested MSM who reported no previous HIV testing decreased from 9.4% to 5.4% (P = 0.01) and the city-specific median intertest interval decreased from 302 to 243 days (P = 0.03). Among MSM with newly diagnosed HIV, the median intertest interval decreased from 531 days in 2002 to 287 days in 2006 (P = 0.001). Predictors of newly diagnosed HIV infection included the following: younger age, longer intertest interval, black or Hispanic race/ethnicity, clinic in San Francisco, and concurrent diagnosis with a bacterial STD.

CONCLUSIONS

In MSM seen at 4 STD clinics, the percentage of never previously HIV tested is decreasing and MSM are testing more frequently.

Predictors of HIV disclosure to secondary partners and sexual risk behavior among a high-risk sample of HIV-positive MSM: results from six epicenters in the US

This study sought to identify predictors of HIV disclosure and serodiscordant unprotected anal intercourse (SDUAI) among HIV-positive men who have sex with men (MSM). Between January 2005 and April 2006, 675 HIV-positive MSM were recruited into the Positive Connections intervention trial held in six US cities with intentional over-sampling of HIV-positive MSM of Color (74%) and men engaging in unprotected anal intercourse (UAI) in the previous year. Baseline survey data showed 30 and 31%, respectively, of participants disclosed to none or some of their secondary sex partners in the last 90 days. Greater disclosure to secondary partners was associated with having fewer sexual partners, being extremely out as MSM, longer HIV diagnosis, knowledge of CD4 count, detectable viral load and being white. Disclosure to all secondary partners was associated with lower SDUAI. Recommendations for prevention for HIV-positive MSM include the promotion of serodisclosure to all secondary partners and increasing comfort with, and outness about, one's sexuality.

Peptide inhibition of HIV-1: current status and future potential

More than 2 decades of intensive research has focused on defining replication mechanisms of HIV type 1 (HIV-1), the etiologic agent of AIDS. The delineation of strategies for combating this viral infection has yielded many innovative approaches toward this end. HIV-1 is a lentivirus in the family retroviridae that is relatively small with regard to both structure and genome size, having a diploid RNA genome of approximately 9 kb, with only three major genes and several gene products resulting from alternate splicing and translational frameshifting. Most marketed drugs for treating AIDS are inhibitors of HIV-1 reverse transcriptase or protease enzymes, but new targets include the integrase enzyme, cell surface interactions that facilitate viral entry, and also virus particle maturation and assembly. The emergence of drug-resistant variants of HIV-1 has been the main impediment to successful treatment of AIDS. Thus, there is a pressing need to develop novel treatment strategies targeting multiple stages of the virus life-cycle. Research efforts aimed at developing successful means for combating HIV-1 infection have included development of peptide inhibitors of HIV-1. This article summarizes past and current endeavors in the development of peptides that inhibit replication of HIV-1 and the role of peptide inhibitors in the search for new anti-HIV drugs.

Ongoing risk behavior among persons with HIV in medical care

We surveyed randomly selected patients in the largest HIV clinic in Seattle, WA in 2005 and 2006. A total of 397 patients completed usable surveys. Twenty-seven percent of men who have sex with men (MSM) and 22% of women or heterosexual men reported having non-concordant unprotected anal or vaginal intercourse in the preceding year. Compared to 2005, more MSM in 2006 reported meeting a sex partner via the Internet (15% vs. 33%), and fewer met partners in bathhouses (23% vs. 13%). Twenty-four percent of MSM reported deciding not to have sex with a potential partner because he was HIV negative, and 31% of MSM reported that another man had decided not to have sex with them because they were HIV positive. Among all participants, 22% had told a sex partner they were HIV negative since their HIV diagnosis. These findings demonstrate the persistence of high-risk behavior among persons with HIV, a rapid increase in the use of the Internet among MSM to find sex partners, and provide direct evidence for serosorting among MSM.

Condom Use Rather Than Serosorting Explains Differences in HIV Incidence Among Men Who Have Sex With Men

BACKGROUND

HIV incidence is high and increasing among men who have sex with men (MSM) attending the Sexually Transmitted Infection (STI) Outpatient Clinic in Amsterdam but remains low among MSM in the Amsterdam Cohort Studies (ACS). We studied whether sexual behaviors in these 2 groups are consistent with serosorting and if serosorting explains the difference in HIV incidence.

METHODS

In 2004 to 2006, a survey of sexual behaviors and HIV status regarding up to 4 traceable partners in the prior 6 months was performed in MSM attending the STI Outpatient Clinic (high-risk) and in MSM in the ACS (lower risk). Moreover, pooled information was collected on anonymous partners. We used logistic regression to test whether sexual behaviors are consistent with serosorting and to test whether risk group is associated with having concordant traceable partners among men reporting unprotected anal intercourse (UAI).

RESULTS

We included 513 MSM (54% lower risk and 75% HIV-negative). Lower risk and high-risk MSM with concordant traceable partners were more likely to have UAI than MSM with discordant partners or partners of unknown HIV status (P < 0.001). Risk group was not associated with having concordant UAI. Compared with lower risk MSM, however, high-risk MSM frequently had UAI with nonconcordant traceable partners and with anonymous partners.

CONCLUSIONS

Sexual risk behaviors with traceable partners are consistent with serosorting. Nonetheless, the higher level of UAI with anonymous or nonconcordant traceable partners more likely explains the increasing HIV incidence seen among STI Outpatient Clinic attendees than a difference in serosorting behavior.

Differences between HIV-positive gay men who 'frequently', 'sometimes' or 'never' engage in unprotected anal intercourse with serononconcordant casual partners: positive Health cohort, Australia

By measuring the actual number of risk acts engaged in by HIV-positive men participating in the Positive Health (PH) cohort study, this paper sets out to document the distribution of risk acts, to report on the proportion of acts of unprotected anal intercourse with casual (UAIC) partners that occurred between HIV-positive men (i.e. seroconcordant positive) and to examine the factors that differentiated men who 'frequently' compared with 'sometimes' or 'never' engaged in unsafe UAIC (i.e. UAIC with serononconcordant partners: partners who have not tested positive for HIV). The findings show that 42.6% of all UAIC acts occurred between seroconcordant HIV-positive partners, posing no risk of HIV infection to an HIV-negative person. A minority of participants (10%) accounted for the majority (70.7%) of the unsafe acts of UAIC. The HIV-positive men who 'sometimes' engaged in unsafe UAIC had higher treatment optimism scores and were more likely to use Viagra in comparison with those who did not engage in such risk. Those who reported 'frequent' engagement in unsafe UAIC were more likely to engage in a range of esoteric sexual practices, be slightly less well educated and be taking antiretroviral therapy compared with HIV-positive men who 'sometimes' engaged in unsafe UAIC. As such, taking ART but not viral load, predicted frequent unsafe UAIC. When considered alongside earlier studies, these results suggest that HIV-negative men who engage in esoteric sexual practices may be at increased risk of HIV transmission, not necessarily because they engage in esoteric sex practices but because of the sub-cultural milieu in which esoteric sex is occurring. The findings from this study also endorse the measurement of UAIC acts as a useful gauge of risk.

Discussing HIV Serostatus With Prospective Sex Partners: A Potential HIV Prevention Strategy Among High-Risk Men Who Have Sex With Men

OBJECTIVE

To study factors associated with HIV serostatus discussions among men who have sex with men (MSM).

DESIGN

The authors conducted a cross-sectional survey among MSM visiting an urban sexually transmitted infection (STI) clinic.

METHODS

MSM were asked about sex partner recruitment, serostatus of partners, condom use, drugs use, and HIV serostatus discussions with sex partners.

RESULTS

Among 1,400 MSM reporting occasional sex partners, serostatus discussion with 100% of partners was reported by 509 (36.3%), with 50% to 99% of partners by 263 (18.8%), and with <50% of partners by 628 (44.9%). Factors associated with serostatus discussion included lower number of sex partners, anal sex with an occasional partner, and sex partner recruitment through the Internet. Partner recruitment in bathhouses and having sex with both men and women were negatively associated.

CONCLUSIONS

Discussion of HIV serostatus was common among MSM studied. Although this strategy has limitations, interventions should address HIV status discussions. Because the Internet may facilitate these discussions, web-based interventions should be evaluated.

Unprotected intercourse among people living with HIV/AIDS: The importance of partnership characteristics

The purpose of this study was to determine the relative importance and interactive effects of partnership characteristics in unprotected intercourse among people living with HIV/AIDS (PLWHA). An interview study was conducted among a convenience sample of PLWHA in care. Of all the demographic, health status, risk history and behaviors and partnership covariates explored, only the partnership covariates were significantly associated with unprotected intercourse. Significant covariates included having a steady partner (OR and 95%CI = 4.2; 1.3, 13.5), HIV-positive (OR and 95%CI = 2.7; 1.0, 6.9 versus HIV-negative partner) or unknown serostatus partner (OR and 95%CI = 4.6; 1.1, 18.3 versus HIV-negative partner) and men who have sex with men (MSM) partnerships (OR and 95%CI = 3.0; 1.2, 7.3). Partnership covariates explained 23% of the variance in unprotected intercourse; other groups of covariates did not significantly improve model fit. Significant interaction terms between reported partner HIV status, partnership type and sexual orientation revealed the greatest likelihood of unprotected intercourse in two groups of individuals: those in steady relationships with HIV-positive partners and MSM in relationships with partners of unknown serostatus. Prevention interventions for PLWHA should focus on partnership characteristics.

Case-Control Study of Shigellosis in San Francisco: The Role of Sexual Transmission and HIV Infection

BACKGROUND

Shigella species infect approximately 450,000 persons annually in the United States. Person-to-person transmission of Shigella species, which have a low infectious dose, occurs frequently, particularly in areas with poor sanitation and hygiene. Sexual transmission of Shigella species among men who have sex with men (MSM) has been inferred from outbreaks of shigellosis among that population, and limited studies have suggested the importance of human immunodeficiency virus (HIV) infection as a risk factor for shigellosis. No population-based study of sporadic shigellosis has evaluated the role of sexual practices (especially among MSM) and HIV infection along with other established risk factors for shigellosis.

METHODS

We conducted a population-based case-control study of shigellosis in adults in San Francisco, California, during the period 1998-1999. Cases of Shigella infection were identified through laboratory-based active surveillance conducted by the California Emerging Infections Program. Seventy-six case patients were matched by sex with 146 control subjects. Exposure data were collected on established risk factors, sexual practices, and HIV infection status. Bivariable and multivariable analyses were conducted. Population-attributable fractions were calculated.

RESULTS

From the multivariable analysis, for men, shigellosis was associated with MSM (odds ratio [OR], 8.24; 95% confidence interval [CI], 2.70-25.2), HIV infection (OR, 8.17; 95% CI, 2.71-24.6), direct oral-anal contact (OR, 7.50; 95% CI, 1.74-32.3), and foreign travel (OR, 20.0; 95% CI, 5.26-76.3), with population-attributable fractions of 0.72, 0.42, 0.31, and 0.18, respectively. For women, shigellosis was associated only with foreign travel (OR, 21.0; 95% CI, 2.52-899), with a population-attributable fraction of 0.37.

CONCLUSIONS

Among MSM, shigellosis is predominantly a sexually transmitted disease, with direct oral-anal contact conferring the highest risk and HIV infection likely contributing to increased host susceptibility.