Knowledge of sexual partner's HIV serostatus and serosorting practices in a California population-based sample of men who have sex with men

Sexual Practice Changes Post-HIV Diagnosis Among Men Who Have Sex with Men in the United States: A Systematic Review and Meta-analysis

Men who have sex with men (MSM) often change sexual behaviors following HIV diagnosis. This systematic review examined such changes, including sero-adaptive behaviors (i.e., deliberate safer-sex practices to reduce transmission risk) to better understand the magnitude of their association with HIV diagnosis. We searched four databases (1996-2017) and reviewed references from other systematic reviews. We included studies conducted in the United States that compared sexual behavior among HIV-infected "aware" versus "unaware" MSM. We meta-analytically pooled RRs and associated 95% confidence intervals (CI) using random-effects models, and assessed risk of bias and evidence quality. Twenty studies reported k = 131 effect sizes on sexual practices outcomes, most of which reported changes in unprotected sex (k = 85), and on sex with at-risk partners (k = 76); 11 reported sero-adaptive behaviors. Unprotected anal intercourse with an HIV-uninfected/unknown-status partner was less likely among aware MSM (insertive position: k = 2, RR 0.26, 95% CI 0.17, 0.41; receptive position: k = 2, RR 0.53, 95% CI 0.37, 0.77). Risk of not always serosorting among aware MSM (k = 3) was RR = 0.92 (0.83, 1.02). Existing evidence, although low-quality, suggests that HIV-infected MSM tend to adopt safer sexual practices once aware of their diagnosis. Variation in reporting of outcomes limits their comparability. Sero-adaptive behavior data are sparse.

Awareness of HIV serostatus by sex partners of women living with HIV in North-Central Nigeria: correlates and predictive analyses

Non-communication of HIV status among sex partners is a notable hurdle in halting transmission, largely due to socio-cultural factors. This study aimed to predict the determinants of male partners' awareness of women's serostatus. A total of 8825 women of reproductive age living with HIV who were clients at five comprehensive HIV treatment centres in Benue State, North-Central Nigeria were surveyed between June and December 2017, and 6655 reported having a sexual partner at the time of the survey selected for analysis. A regression model was used to estimate the determinants of male partner awareness of serostatus from the perspective of women. Conditional marginal analyses were conducted to evaluate the marginal effects of identified predictors on the probability of outcomes. Partners of married women were found to have greater odds of being aware of their spouse's serostatus (adjusted OR (aOR): 3.20; 95%CI: 2.13-4.81) than non-married partners. Similarly, the odds of male partner awareness increased with the years women had been on antiretroviral therapy (aOR: 1.13; 95%CI: 1.07-1.20). The probability of partners of married respondents being aware of their spouse's HIV serostatus was 97%. The conditional marginal effects of being educated to primary or higher level were 1.2 (95% CI: -0.2 to 2.7) and 1.8 (95% CI: 0.09-3.4) percentage points higher respectively when compared with women with no formal education. Being unemployed or being a trader significantly decreased the probability of partners being aware of respondents' serostatus when compared with farmers; conditional marginal effects of -6.7 (95% CI: -12.0 to -1.4) and -3.9 (95% CI: -5.7 to -2.2) percentage points, respectively. The study found that relationship status and girl-child education are factors that can improve communication of HIV status to sex partners. Policies and interventions aimed at improving the social determinants of health, and social support for healthy communications in relationships, are recommended to reduce HIV transmission between sex partners.

Multilevel elements associated with HIV serosorting for sexual encounters: a scoping literature review

A scoping literature review to identify the multilevel HIV serosorting related elements was developed. Articles from EBSCO, PubMed, PsyNET and Science Direct with serosort* or serosorting at the tittle or abstract, written in English or Spanish were included. No restriction in type of population or design were applied. 239 records were retrieved after duplicates removed, but 181 references were extracted for full-text review. Individual level: HIV knowledge, serostatus, risk perceptions, abilities to disclose and for condom use negotiation, motivations, use of drugs, stigma, attitudes toward condom use, and perceptions/beliefs about the HIV and related treatments, HIV infection rates/testing and behavioral factors. Interpersonal level: social networks, abilities (sexual behavior negotiation, and communication). Community level: stigma, social norms, access to HIV related services. Structural level: political context, HIV related funding and public policies. HIV Serosorting is not solely an interpersonal behavior it involves multilevel elements that must be acknowledged by professionals and stakeholders.

HIV Self-Testing to Promote Serostatus Disclosure Among Men Who Have Sex With Men in China: Protocol for a Stepped Wedge Randomized Controlled Trial

BACKGROUND

Disclosure of HIV serostatus is important for the prevention of HIV infection among men who have sex with men (MSM). However, knowledge of sexual partners' HIV status among MSM in China is low. As a complement to HIV testing services, HIV self-testing (HIVST) has considerable potential to promote serostatus disclosure.

OBJECTIVE

The primary objective of our trial is to evaluate the effect of HIVST on improving serostatus disclosure to sexual partners. We hypothesize that MSM in an intervention condition will have a higher awareness of the HIV status of their sexual partners compared with MSM in the control condition. The secondary aims are to evaluate (i) changes in sexual behaviors after disclosure of HIV status by sexual partners, (ii) promotion of the frequency of HIV and syphilis testing on participants and their sexual partners, and (iii) factors that restrict the disclosure of HIV infection to sexual partners. We hypothesize that MSM in the intervention condition will exhibit safer sexual decision making and a higher rate of HIV testing uptake compared with MSM in the control condition.

METHODS

A stepped wedge randomized controlled trial will be conducted throughout China. Study recruitment of 800 MSM will be promoted through advertisements released on WeChat public accounts. Individuals who are born biologically male, aged ≥18 years, HIV negative, and who have not undergone HIV testing in the past 3 months will be recruited. Eligible men will be randomly divided (1:1:1:1) into four groups and randomized. The group cluster will initiate the intervention so that participants will be provided with 2-4 free finger prick-based HIVST kits until trial completion. The intervention period for participants in each of the four groups will be initiated at 3-month intervals. Men in both groups will be required to complete a baseline and four follow-up surveys every 3 months. The primary intervention outcome will evaluate the effect of the distribution of HIVST kits on improvement in the disclosure of sexual partners' HIV status. The secondary outcomes will be changes in sexual behaviors after disclosure of HIV status from sexual partners, the promotion of the frequency of HIVST on participants and their sexual partners, and the factors that restrict disclosure of HIV status to sexual partners.

RESULTS

Subject recruitment began in August 2018. The first round of follow-up surveys post intervention is complete, with three rounds remaining to be done. Data analysis was scheduled for April 2020 and the results will be disseminated through conferences and peer-reviewed publications.

CONCLUSIONS

Few studies have evaluated interventions to increase knowledge of sexual partners' HIV status among MSM. Our trial will provide information on the link between HIVST and HIV serostatus disclosure. The findings of this trial will facilitate the implementation of HIVST services to help control the spread of HIV among MSM in China.

TRIAL REGISTRATION

Chinese Clinical Trial Registry ChiCTR1800019453; http://www.chictr.org.cn/showproj.aspx?proj=30158.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

DERR1-10.2196/17788.

Increasing Syphilis Detection Among Patients Assigned Male at Birth Screened at a Boston Community Health Center Specializing in Sexual and Gender Minority Health, 2005-2015

BACKGROUND

United States syphilis rates have increased to levels last seen in the 1990s. We examined syphilis epidemiology of patients attending a Boston community health center specializing in sexual and gender minority health.

METHODS

We performed a retrospective cohort study of all patients assigned male at birth screened with rapid plasma reagin from 2005 through 2015. We developed an algorithm to identify new infections and used repeat cross-sectional analysis to assess temporal trends in syphilis diagnoses. We also performed longitudinal analysis to calculate syphilis incidence using a Cox proportional hazards model that accounts for multiple infections over time.

RESULTS

Eighteen thousand two hundred eighty-two patients had a total of 57,080 rapid plasma reagins, 1170 (2.0%) tests met criteria for syphilis. Adjusted syphilis diagnoses increased from 1.2% to 1.9%, recurrent syphilis diagnoses increased from 0.04% to 0.3% during the study period. Black and Hispanic/Latinx patients, patients aged 35 to 44 years, gay/bisexual patients, cisgender men, and human immunodeficiency virus (HIV)-infected patients and those who became HIV-infected during the study period were more likely to test positive for syphilitic infection in repeat cross-sectional analysis. Among 6199 patients screened more than 1 time over 21,745 person-years, there were 661 new syphilis cases (3.0% annual incidence; 95% confidence interval [CI], 2.8% to 3.2%). Compared with those aged 14 to 24 years, patients 45 years or older were less likely to experience syphilis. New HIV infection was associated with increased risk of incident syphilis (adjusted hazard ratio, 2.87; 95% CI, 1.61-5.13). Virally suppressed HIV-infected patients were less likely to experience incident syphilis (adjusted hazard ratio, 0.69; 95% CI, 0.55-0.87).

CONCLUSIONS

The high incidence of syphilis among patients assigned male at birth disproportionately affected young patients, black and Hispanic/Latinx patients, gay/bisexual patients, cisgender men, and those with new or chronic HIV infection. Syphilitic reinfection rates increased over time.

Relationship power and HIV risk among young Black men who have sex with men in the Southern United States

Background The purpose of this study was to examine the impact of relationship power on HIV risk behaviour among young Black men who have sex with men (MSM) in the Southern US.

METHODS

Data from 425 Black/African American males aged 18-29 years who reported recent anal intercourse with a male partner were analysed. Five selected measures of relationship power were tested for correlation and association with protected receptive anal intercourse using contingency tables and logistic regression analysis.

RESULTS

Acts of 100% protected receptive anal intercourse were common (n=277, 65.2%). Men who reported low barriers to condom negotiation were significantly more likely to report protected acts (P<0.001). Men who reported 100% protected acts were less likely to report financial dependence on male sexual partners and serosorting behaviour (12.0% vs 20.7%, P=0.02; 31.5% vs 49.8%, P<0.001 respectively).

CONCLUSION

Future efforts should further examine the role of relationship power in HIV risk among young Black MSM, including the intersection of individual, dyadic and social-structure risks.

Prevalence and Correlates of Point-of-sex Human Immunodeficiency Virus Self-testing Among Human Immunodeficiency Virus-negative Men Who Have Sex With Men in China

BACKGROUND

Human immunodeficiency virus (HIV) self-testing (HIVST) provides a promising tool to screen sex partners for men who have sex with men (MSM) who engage in condomless sex and want to avoid HIV infection. Although previous studies have demonstrated HIVST acceptability and increased testing uptake, limited data exist on its use between sex partners for point-of-sex HIV testing. This study examined prevalence and correlates of point-of-sex HIVST among Chinese MSM.

METHODS

A cross-sectional survey was conducted among 400 HIV-negative Chinese MSM in 2017. Participants were recruited through a multifaceted sampling approach and self-administered an electronic questionnaire. Point-of-sex HIVST was measured by asking participants if they had ever conducted HIVST with a sex partner before sex to ensure that they both knew their HIV statuses. Multivariable logistic regression was used to identify correlates of point-of-sex HIVST after controlling for age, education and sexual orientation.

RESULTS

Overall, 19.2% (77/400) men reported point-of-sex HIVST (51.3% among self-testers). Participants who had four or more HIV self-tests before had 7.57-fold greater odds (95% confidence interval, 3.75, 15.28) of reporting point-of-sex HIVST compared to those who had fewer HIVST experiences. Point-of-sex HIVST was otherwise not associated with most other socio-demographic or behavioral practices, suggesting that it may be broadly acceptable.

CONCLUSIONS

A substantial proportion of Chinese MSM had utilized HIVST with their partners before sex, especially among those who were more experienced with HIVST. Scale up and routine implementation of HIVST programs are further warranted to facilitate point-of-sex HIV testing.

Receiving HIV Serostatus Disclosure from Partners Before Sex: Results from an Online Survey of Chinese Men Who Have Sex with Men

HIV serostatus disclosure before sex can facilitate serosorting, condom use and potentially decrease the risk of HIV acquisition. However, few studies have evaluated HIV serostatus disclosure from partners before sex. We examined the rate and correlates of receiving HIV serostatus disclosure from regular and casual male partners before sex among an online sample of men who have sex with men (MSM) in China. An online cross-sectional study was conducted among MSM in eight Chinese cities in July 2016. Participants completed questions covering sociodemographic information, sexual behaviors, HIV testing (including HIV self-testing) history, self-reported HIV status, and post-test violence. In addition, participants were asked whether they received HIV serostatus disclosure from their most recent partners before sex. Overall, 2105 men completed the survey. Among them, 85.9% were never married, and 35.4% had high school or less education. A minority (20.6%, 346/1678; 17.8%, 287/1608) of men received HIV serostatus disclosure from their most recent regular and casual male partners, respectively. Multivariate analysis indicated that participants who ever self-tested for HIV were more likely to have received HIV status disclosure from regular [adjusted OR (aOR) = 1.92, 95% CI 1.50-2.44] and casual (aOR = 2.34, 95% CI 1.80-3.04) male partners compared to never self-tested participants. Compared to participants who had not received HIV status disclosure from regular partners, participants who received disclosure from regular male partners had higher likelihood in experiencing post-test violence (aOR = 5.18, 95% CI 1.53-17.58). Similar results were also found for receiving HIV serostatus disclosure from casual partners. This study showed that HIV serostatus disclosure from partners was uncommon among Chinese MSM. Interventions and further implementation research to facilitate safe disclosure are urgently needed for MSM.

Uncovering a Role for Electronic Personal Health Records in Reducing Disparities in Sexually Transmitted Infection Rates Among Students at a Predominantly African American University: Mixed-Methods Study

Background

Black youth continue to bear an overwhelming proportion of the United States sexually transmitted infection (STI) burden, including HIV. Several studies on web-based and mobile health (mHealth) STI interventions have focused on characterizing strategies to improve HIV-related prevention and treatment interventions, risk communication, and stigma among men who have sex with men (MSM), people who use substances, and adolescent populations. The Electronic Sexual Health Information Notification and Education (eSHINE) Study was an exploratory mixed-methods study among students at a historically black university exploring perceptions on facilitating STI testing conversations with partners using electronic personal health records (PHRs).

Objective

The purpose of this paper is to use eSHINE Study results to describe perceived impacts of electronic PHRs on facilitating STI testing discussions between sexual partners.

Methods

Semistructured focus groups and individual in-depth interviews were conducted on a heterogeneous sample of students (n=35) between May and July 2014. Qualitative phase findings guided development of an online survey instrument for quantitative phase data collection. Online surveys were conducted using a convenience sample of students (n=354) between January and May 2015. Online survey items collected demographic information, sexual behaviors, beliefs and practices surrounding STI testing communication between partners, and beliefs about the impact of electronic PHR access on facilitating these discussions with partners. Chi-square analysis was performed to assess gender differences across quantitative measures. A Wilcoxon signed rank sum test was used to test the null hypothesis that electronic PHRs are believed to have no effect on the timing of dyadic STI health communication.

Results

Participants described multiple individual and dyadic-level factors that inhibit initiating discussions about STI testing and test results with partners. Electronic PHRs were believed to improve ability to initiate conversations and confidence in STI screening information shared by partners. Among online survey participants, men were more likely to believe electronic PHRs make it easier to facilitate STI talks with potential partners (59.9% vs 51.9%; χ²=3.93, P=.05). The Wilcoxon signed-rank test results indicate significant increases in perceived discussion timing before sex with electronic PHR access (61.0% vs 40.4%; P<.001).

Conclusions

Findings suggest that electronic PHR access in STI screening settings among similar populations of Black youth may improve both motivation and personal agency for initiating dyadic STI health communication. Results from this study will likely inform novel interventions that use access to electronic PHRs to stimulate important health-related discussions between sexual partners. Moving forward requires studying strategies for implementing interventions that leverage electronic PHRs to create new sexual health communication channels with providers, peers, and family among black youth.

An Event-Level Analysis of Condomless Anal Intercourse with a HIV-Discordant or HIV Status-Unknown Partner Among Black Men Who Have Sex with Men from a Multi-site Study

Despite the high HIV incidence and prevalence among black men who have sex with men (BMSM), little research has examined partner characteristics, partner seeking venue, sexual position, substance use, and sexual risk behavior at the sex event-level among BMSM. Using the baseline data from a multi-site study of 807 BMSM stratified by their HIV status, the goal of this study was to conduct a detailed event-level analysis of 1577 male anal sex events to assess the factors associated with condomless anal intercourse (CLAI) with a HIV-discordant or HIV status-unknown partner. We found CLAI with an HIV-discordant or unknown HIV status partner among HIV-negative BMSM was negatively associated with having sex with a main partner, and was positively associated with taking both receptive and insertive sexual positions during sex. As compared to a sex partner met at bar, night club or dance club, HIV-positive BMSM were less likely to engage in CLAI with HIV-discordant and unknown HIV status partner met at party or friend's house or at community organizations. HIV-positive BMSM had lower odds of engaging in CLAI with HIV-discordant and unknown HIV status partner if they had insertive sexual position or both receptive and insertive sexual positions. These results underscore the importance of delineating unique sex event-level factors associated with sexual risk behavior depending on individuals' HIV status. Our findings suggest event-level partner characteristics, sexual position, and partner seeking venues may contribute to disparities in HIV incidence.

Prevalence of HIV infection, access to HIV care, and response to antiretroviral therapy among partners of HIV-infected individuals in Thailand

Background

Health care providers usually focus on index HIV-infected patients and seldom obtain information from their partners. We aimed to determine HIV-preventative measures among couples, the prevalence of HIV infection, and treatment outcomes of partners.

Methods

This cross-sectional study was conducted in two hospital settings, a university hospital in Bangkok and a general hospital in northeastern Thailand, from January 2011-October 2015. Factors associated with serodiscordant relationships were determined by logistic regression.

Results

A total of 393 couples were enrolled for analysis; 156 (39.7%) were serodiscordant. The median relationship duration of serodiscordant couples was shorter than that of seroconcordant couples (6.4 years vs 11.6 years, p < 0.001). Of 237 HIV-infected partners, 17.7% had AIDS-defining illness, the median nadir CD4 count (interquartile range) was 240 (96–427) cells/mm³, 83.5% received antiretroviral therapy (ART), 98.3% had adherence > 95%, 90.3% had undetectable HIV RNA, and 22.9% had a prior history of treatment failure. There was no significant difference in condom usage in the prior 30 days between serodiscordant and seroconcordant couples. Factors of index HIV-infected patients associated with serodiscordant relationships were younger age (odds ratio [OR] 1.04 per 5 years; 95% confidence interval [CI] 1.01–1.06), receiving care at the general hospital (OR 1.73; 95% CI 1.08–2.78), a shorter duration of relationship (OR 1.04 per year; 95% CI 1.01–1.07), a higher nadir CD4 count (OR 1.06 per 50 cells/mm³; 95% CI 1.1–1.13), and not receiving a protease inhibitor-based regimen (OR 2.04; 95% CI 1.06–3.96).

Conclusions

A high number of serodiscordant couples was determined. Partners’ information should be retrieved as a holistic approach. Interventions for minimizing HIV transmission within serodiscordant couples should be evaluated and implemented.

Perceived Cost Advantages and Disadvantages of Purchasing HIV Self-Testing Kits among Urban Tanzanian Men: An Inductive Content Analysis

Impoverished men have lower rates of facility-based HIV counseling and testing and higher unknown HIV-positive status than women. Economic theory suggests that individuals will obtain an HIV test if anticipated benefits are greater than anticipated costs. Yet, few studies have investigated the range of financial preferences of HIV self-testing (HIVST) among poor men who decline testing or do not test regularly. Twenty-three interviews were conducted to qualitatively assess perceived costs saved and costs incurred from use of HIVST kits in infrequently- or never-tested Tanzanian men. All men were shown an HIVST kit and video. They were then asked about the costs associated with provider-led HIV testing, financial benefits and concerns of HIVST and willingness to pay for HIVST. Data were transcribed, coded and analyzed using inductive content analyses. We then grouped codes into perceived cost advantages and disadvantages and tabulated the range of prices men were willing to pay for a self-test kit. Perceived cost advantages of HIVST were avoidance of spending money to test in facilities, omission of follow-up fees, affordability relative to private clinics, and increased time for earning income and other activities. Men also discussed the imbalance of the financial benefit of accessing free, public HIV testing with the resources spent for transport, purchasing meals away from home and long wait lines. Perceived cost disadvantages of HIVST were prohibitive kit costs, required prior savings to purchase kits, expenditures relating to death and preferences for free provider-performed testing. Men were also concerned about the psychological costs of inaccurate results. HIVST willingness to pay varied among men. Men's decisions to self-test for HIV takes into account expected financial gains and losses. Demand generation for HIVST among men should consider use of low fees or free HIVST, while emphasizing potential savings from reduced travel, clinical costs, or time way from work. Efforts are also needed to address anticipated emotional costs of HIVST, such as anxiety from kit errors, purchasing "death" or testing alone, which for some men was a substantial barrier.

Brief Report: HIV Prevalence and the Prevalence of Unsuppressed HIV in New York City, 2010-2014

BACKGROUND

The widespread use of antiretroviral treatment made HIV prevalence no longer a good measure of population-level transmission risk. The objective of this analysis was to use the prevalence of unsuppressed HIV to describe population-level HIV transmission risk.

METHODS

Using New York City (NYC) HIV surveillance data, we reported HIV prevalence and the prevalence of unsuppressed HIV, defined as the number of persons living with HIV with an unsuppressed viral load divided by population size.

RESULTS

The estimated number of persons living with HIV in NYC increased from 79,100 [95% confidence interval (CI): 78,200 to 80,000] in 2010 to 81,700 (95% CI: 80,500 to 82,900) in 2014. HIV prevalence (≥18 years old) remained unchanged at 1.22% (95% CI: 1.21% to 1.24%) in 2010 and 1.22% (95% CI: 1.20% to 1.24%) in 2014. The prevalence of unsuppressed HIV (≥18 years old) steadily decreased from 0.49% (95% CI: 0.48% to 0.51%) in 2010 to 0.34% (95% CI: 0.32% to 0.36%) in 2014. Men had both higher HIV prevalence (1.86% vs. 0.65% in 2014) and higher prevalence of unsuppressed HIV (0.51% vs. 0.18% in 2014) than women. In 2014, the black-white ratio of prevalence of unsuppressed HIV was 5.8 among men and 26.3 among women, and the Hispanic-white ratio was 2.7 among men and 10.0 among women.

CONCLUSIONS

The prevalence of unsuppressed HIV has been steadily decreasing in NYC. As antiretroviral treatment continues to expand, programs should consider using the prevalence of unsuppressed HIV to measure population-level transmission risk.

Event-level analysis of alcohol consumption and condom use in partnership contexts among men who have sex with men and transgender women in Lima, Peru

BACKGROUND

We explored the association between alcohol use and condomless receptive (CRAI) and insertive (CIAI) anal intercourse within partnership contexts of men who have sex with men (MSM) and transgender women (TGW) in Lima, Peru.

METHODS

From 2012-2014, we surveyed men and TGW (n=1607) who reported anal intercourse with ≥1 male or TGW. Alcohol use with up to 3 sexual partners during the prior 90days was evaluated. Bivariate and multivariate analyses used generalized estimating equations to assess event-level associations between alcohol use, CRAI, CIAI, and partnership characteristics while adjusting for participant clustering from multiple partners.

RESULTS

Of 4774 sexual partnerships reported, 48% were casual, 34% primary, 10% anonymous, and 8% commercial. Alcohol use preceding sex was significantly (p<0.05) associated with CRAI (PR=1.26) and CIAI (PR=1.37). Partnership characteristics significantly associated with alcohol use included commercial sex work (PR=2.21) and trended (p<0.10) towards alcohol use with casual (PR=1.16), transgender (PR=1.48), and moderno ("versatile"; PR=1.17) partners. CRAI and CIAI were more common among participants who reported knowing they (PR=1.52; PR=1.41, respectively) or their partner (PR=1.47; PR=1.44, respectively) was HIV-uninfected. Yet, only CIAI (PR=1.42) was more commonly reported with known HIV-infected partners. Participants who drank alcohol prior to sex were less likely to know their partner's HIV serostatus.

CONCLUSIONS

Alcohol use prior to intercourse was associated with CRAI and CIAI, varied by partnership type, and may impair knowledge of partner HIV serostatus. Detailed knowledge of alcohol use within partner-specific contexts is essential for informing condom-based and alternative HIV prevention strategies for MSM and TGW in Peru.

Systematic review of mobile health behavioural interventions to improve uptake of HIV testing for vulnerable and key populations

Introduction This systematic narrative review examined the empirical evidence on the effectiveness of mobile health (mHealth) behavioural interventions designed to increase the uptake of HIV testing among vulnerable and key populations. Methods MEDLINE/PubMed, Embase, Web of Science, and Global Health electronic databases were searched. Studies were eligible for inclusion if they were published between 2005 and 2015, evaluated an mHealth intervention, and reported an outcome relating to HIV testing. We also reviewed the bibliographies of retrieved studies for other relevant citations. The methodological rigor of selected articles was assessed, and narrative analyses were used to synthesize findings from mixed methodologies. Results A total of seven articles met the inclusion criteria. Most mHealth interventions employed a text-messaging feature and were conducted in middle- and high-income countries. The methodological rigor was moderate among studies. The current literature suggests that mHealth interventions can have significant positive effects on HIV testing initiation among vulnerable and key populations, as well as the general public. In some cases, null results were observed. Qualitative themes relating to the use of mobile technologies to increase HIV testing included the benefits of having low-cost, confidential, and motivational communication. Reported barriers included cellular network restrictions, poor linkages with physical testing services, and limited knowledge of appropriate text-messaging dose. Discussion MHealth interventions may prove beneficial in reducing the proportion of undiagnosed persons living with HIV, particularly among vulnerable and key populations. However, more rigorous and tailored interventions are needed to assess the effectiveness of widespread use.

HIV Testing and Awareness of Partner's HIV Status Among Chinese Men Who Have Sex with Men in Main Partnerships

Many men who have sex with men (MSM) do not use condoms with their main partners, especially if both parties are of the same HIV status. However, significant proportions of MSM have never tested or recently tested and are unaware of their main partners' HIV status. A cross-sectional survey was conducted among 524 MSM in Jiangsu, China in 2013-2014. Time-location sampling and online convenience sampling were used to recruit participants. We compared awareness of HIV status and recent HIV testing between participants who had main partners versus those who did not, and identified factors associated with recent HIV testing among men in main partnerships. Participants in main partnerships were significantly more likely to report recent HIV testing and being HIV-negative instead of HIV-unknown compared to participants in casual partnerships only. Overall, 74.5 % of participants were aware of their main partners' HIV status. Among participants in main partnerships, those who had 2-5 male anal sex partners in the past 6 months and those who reported that their partners were HIV-negative had 2.36 (95 % CI 1.12, 4.97) and 4.20 (95 % CI 2.03, 8.70) fold greater odds of being tested in the past year compared to those who had main partners only and those whose partners were HIV-positive/unknown, respectively. Chinese MSM in main partnerships might be practicing serosorting and may be at lower risk for HIV infection due to increased awareness of main partners' HIV status and higher uptake of recent testing.

Relationship Dynamics and Sexual Risk Reduction Strategies Among Heterosexual Young Adults: A Qualitative Study of Sexually Transmitted Infection Clinic Attendees at an Urban Chicago Health Center

Few studies have examined risk-reduction alternatives to consistent condom use for HIV prevention among heterosexual young adults. We used qualitative methodology to explore risk reduction strategies and contextual factors influencing attempts to reduce risk in an urban, high morbidity sexually transmitted infection (STI) clinic. Focus groups were conducted October-December 2014 with heterosexually identified men (n = 13) and women (n = 20) aged 18-29 seeking STI screening at an urban clinic. Groups were audio recorded, transcribed verbatim, and analyzed for thematic content using Atlas.ti software. Quantitative information included sociodemographics, HIV/STI testing history, and 6-month sexual behaviors. Among 33 predominantly African-American participants with a median age of 22, risk-reduction strategies included monogamy agreements, selective condom use with casual and high-risk partners, and frequent HIV/STI testing, though testing was commonly used as a post-hoc reassurance after risk exposure. Many men and women used implicit risk assessment strategies due to mistrust or difficulty communicating. Concurrency was common but rarely discussed within partnerships. Despite attempts to reduce risk, monogamy agreements were often poorly adhered to and not openly discussed. Alcohol and substance use frequently interfered with safer sexual decisions. Participants were aware of HIV/STI risk and commonly practiced risk-reduction strategies, but acknowledged faulty assumptions and poor adherence. This work provides insights into risk-reduction approaches that are already used and may be strengthened as part of effective HIV/STI prevention interventions.

HIV-Negative Partnered Men's Willingness to Use Non-Occupational Post-Exposure Prophylaxis and Associated Factors in a U.S. Sample of HIV-Negative and HIV-Discordant Male Couples

PURPOSE

Non-occupational post-exposure prophylaxis (nPEP) is an underutilized biomedical option for HIV prevention. Few studies have assessed male couples' knowledge of and willingness to use nPEP.

METHODS

Cross-sectional dyadic data from 275 HIV-negative and 58 HIV-discordant male couples were used to describe HIV-negative, partnered men's awareness and willingness to use nPEP, and factors associated with their willingness to use nPEP. Data were analyzed with the use of multivariate multilevel modeling.

RESULTS

Less than a third of the men were aware of nPEP, yet 73% were very-to-extremely likely to use nPEP. Partnered men's willingness to use nPEP was positively associated with having an individual income less than $30,000 USD and serosorting within the relationship. Willingness to use nPEP was negatively associated with greater age difference between primary partners and with higher scores on measures of couples' investment in their relationship.

CONCLUSION

Efforts should be made to increase male couples' awareness of nPEP and how to access nPEP. Uptake of nPEP has the potential to help avert new HIV infections among male couples.

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.

Disassortative Age-Mixing Does Not Explain Differences in HIV Prevalence between Young White and Black MSM: Findings from Four Studies

OBJECTIVE

Age disassortativity is one hypothesis for HIV disparities between Black and White MSM. We examined differences in age mixing by race and the effect of partner age difference on the association between race and HIV status.

DESIGN

We used data from four studies of MSM. Participants reported information about recent sexual partners, including age, race, and sexual behavior. Two studies were online with a US sample and two focused on MSM in Atlanta.

METHODS

We computed concordance correlation coefficients (CCCs) by race across strata of partner type, participant HIV status, condom use, and number of partners. We used Wilcoxon rank-sum tests to compare Black and White MSM on partner age differences across five age groups. Finally, we used logistic regression models using race, age, and partner age difference to determine the odds ratio of HIV-positive serostatus.

RESULTS

Of 48 CCC comparisons, Black MSM were more age-disassortative than White MSM in only two. Furthermore, of 20 comparisons of median partner age, Black and White MSM differed in two age groups. One indicated larger age gaps among the Black MSM (18-19). Prevalent HIV infection was associated with race and age. Including partner age difference in the model resulted in a 2% change in the relative odds of infection among Black MSM.

CONCLUSIONS

Partner age disassortativity and partner age differences do not differ by race. Partner age difference offers little predictive value in understanding prevalent HIV infection among Black and White MSM, including diagnosis of HIV-positive status among self-reported HIV-negative individuals.

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.

Prevalence and correlates of knowledge of male partner HIV testing and serostatus among African-American women living in high poverty, high HIV prevalence communities (HPTN 064)

Knowledge of sexual partners' HIV infection can reduce risky sexual behaviors. Yet, there are no published studies to-date examining prevalence and characteristics associated with knowledge among African-American women living in high poverty communities disproportionately affected by HIV. Using the HIV Prevention Trial Network's (HPTN) 064 Study data, multivariable logistic regression was used to examine individual, partner, and partnership-level determinants of women's knowledge (n = 1,768 women). Results showed that women's demographic characteristics alone did not account for the variation in serostatus awareness. Rather, lower knowledge of partner serostatus was associated with having two or more sex partners (OR = 0.49, 95 % CI 0.37-0.65), food insecurity (OR = 0.68, 95 % CI 0.49-0.94), partner age >35 years (OR = 0.68, 95 % CI 0.49-0.94), and partner concurrency (OR = 0.63, 95 % CI 0.49-0.83). Access to financial support (OR = 1.42, 95 % CI 1.05-1.92) and coresidence (OR = 1.43, 95 % CI 1.05-1.95) were associated with higher knowledge of partner serostatus. HIV prevention efforts addressing African-American women's vulnerabilities should employ integrated behavioral, economic, and empowerment approaches.

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.

Factors influencing HIV serodisclosure among men who have sex with men in the US: an examination of online versus offline meeting environments and risk behaviors

One key component in HIV prevention is serostatus disclosure. Until recently, many studies have focused on interpersonal factors and minimally considered meeting venues as they pertain to disclosure. Using data (N = 3,309) from an online survey conducted across 16 U.S. metropolitan statistical areas, we examined whether HIV serodisclosure varies by online/offline meeting venues in both protected and unprotected anal intercourse encounters. Most of the sample (76.9 %) reported meeting men for sex (last 90 days) both online and offline, versus 12.7 % offline only and 10.4 % online only. After controlling for other variables, we found that the men who meet partners in both online and offline were 20~30 % more likely to report disclosing their HIV status prior to sex than men who met their partners exclusively either offline or online. While previous studies have identified the Internet as a risk environment, our findings suggest bi-environmental partner seeking may also have beneficial effects.

Dating, marriage, and parenthood for HIV-positive heterosexual Puerto Rican men: normalizing perspectives on everyday life with HIV

HIV-positive men are living long and healthier lives while managing HIV as a chronic illness. Although research has extensively documented the experiences of illness of people living with HIV, dating, marriage, and fatherhood among heterosexual Latino men has not been examined. To address this gap, this study used a qualitative study design to examine patterns and strategies for dating, marriage, and parenthood among 24 HIV-positive heterosexual Puerto Rican men living in Boston. The findings in our study indicate that an HIV diagnosis does not necessarily deter men from having an active sexual life, marrying, or having children. In fact, for some of the men, engaging in these social and life-changing events is part of moving on and normalizing life with HIV; these men planned for, achieved, and interpreted these events in the context of establishing normalcy with HIV. Although the HIV diagnosis discouraged some men from engaging in sexual relations, getting married, or having children, others fulfilled these desires with strategies aimed to reconciling their HIV status in their personal life, including dating or marrying HIV-positive women only. Additional important themes identified in this study include the decision to disclose HIV status to new sexual partners as well as the decision to accept the risk of HIV transmission to a child or partner in order to fulfill desires of fatherhood. Understanding the personal struggles, decision-making patterns, and needs of HIV-positive heterosexual men can aid in designing interventions that support healthy living with HIV.

Unprotected sex among men who have sex with men living with HIV in Brazil: a cross-sectional study in Rio de Janeiro

Background

Many countries are facing concentrated HIV epidemics among vulnerable populations, including men who have sex with men (MSM). Unprotected anal intercourse (UAI) is the main HIV transmission route among them and its understanding in the different cultures and how it relates to HIV transmission, re-infection and development of HIV antiretroviral resistance has important public health implications. Data on UAI among Brazilian MSM are scarce. This study aims to evaluate the prevalence and associated factors of UAI among HIV-infected MSM who had sex with seronegative or male partners with an unknown serostatus.

Method

A cross-sectional study nested in a cohort was conducted in Rio de Janeiro, Brazil. The one hundred and fifty five MSM included in the study answered an ACASI interview and provided biological samples. Generalized linear models were used to identify variables associated with UAI.

Results

Overall, UAI with an HIV-negative or unknown serostatus male partner was reported by 40.6% (63/155) of MSM. Lifetime sexual abuse or domestic violence was reported by 35.9%, being more frequent among MSM who reported UAI compared to those who did not (P = 0.001). Use of stimulants before sex was reported by 20% of the MSM, being slightly higher among those who reported UAI (27.0% vs. 15.2%; P = 0.072). Commercial sex was frequent among all MSM (48.4%). After multivariate modeling, the report of sexual abuse or domestic violence (OR = 2.70; 95% CI: 1.08-7.01), commercial sex (OR = 2.28; 95% CI: 1.04- 5.10), the number of male sexual partners (p = 0.039) and exclusively receptive anal intercourse (OR = 0.21; 95% CI: 0.06-0.75) remained associated with UAI. CD4 levels, HIV viral load and antiretroviral therapy were not associated with UAI.

Conclusion

The UAI prevalence found with negative or unknown HIV status partners points out that other interventions are needed as additional prevention tools to vulnerable MSM. The main factors associated with UAI were a lifetime history of violence, commercial sex and the number of male sexual partners. This clustering of different behavioral, health and social problems in this population reinforce the need of a comprehensive approach on treating and preventing HIV among MSM.

Factors associated with high transmission risk and detectable plasma HIV RNA in HIV-infected MSM on ART

Summary HIV transmission risk is increased during antiretroviral therapy (ART) use if individuals are not virologically suppressed and engage in high risk transmission behaviour. Baseline data of HIV-infected men who have sex with men (MSM) with recent history of risky behaviour on ART for ≥3 months (n = 139) were evaluated to assess predictors of detectable viraemia and HIV transmission risk-taking behaviour. Twenty-four subjects had viral load (VL) >75 copies/mL and 12 had VL >1000 copies/mL. In multivariable regression analyses, subjects with VL >75 copies/mL were more likely to be Black (OR = 4.48, p = 0.007), have lower CD4 cell counts (OR = 0.727, p = 0.005) and have used methamphetamines in the last month (OR = 6.64, p = 0.019). Subjects with VL >1000 copies/mL were more likely to have lower CD4 cell counts (OR = 0.494, p = 0.004), report <90% adherence (OR = 7.94; p = 0.046) and have used methamphetamines in the last month (OR = 10.01, p = 0.034). Subjects with VL >75 copies/mL with the greatest transmission risk behaviour (n = 14) were more likely to be Black (OR = 8.00, p = 0.006), have lower CD4 cell counts (OR = 0.657, p = 0.009) and have used methamphetamines in the last month (OR = 5.20, p = 0.042). High risk HIV transmission behaviour with viraemia occurred in 10% of the cohort. Future efforts to reduce HIV transmission among MSM on ART will require combined interventions that target risk-taking behaviours and substance use.

Social network characteristics and HIV risk among African American, Asian/Pacific Islander, and Latino men who have sex with men

OBJECTIVES

To examine how social networks influence HIV risk among US racial/ethnic minority men who have sex with men (MSM) and whether the associations of social network characteristics with risk vary by race/ethnicity.

METHODS

A chain-referral sample of 403 African American, 393 Asian/Pacific Islander, and 400 Latino MSM recruited in Los Angeles County, California, completed a questionnaire, which asked about their egocentric social networks, safer sex peer norms, and male anal intercourse partners. HIV-nonconcordant partnerships were those reported by respondents as serodisconcordant or where self and/or partner serostatus was unknown.

RESULTS

Overall, 26% of the sample reported HIV-nonconcordant unprotected anal intercourse (UAI) with a nonprimary male partner in the previous 6 months. In a generalized estimating equation (GEE) logistic model that controlled for race/ethnicity, age, nativity, incarceration history, and HIV status, being in a more dense network was associated with less HIV-nonconcordant UAI [adjusted odds ratio (AOR) = 0.92, 95% confidence interval (CI): 0.86 to 0.99, P = 0.0467]. In addition, the effect of safer sex peer norms on HIV-nonconcordant UAI was moderated by ego-alter closeness (P = 0.0021). Safer sex peer norms were protective among those reporting "medium" or "high" ego-alter closeness (AOR = 0.70, 95% CI: 0.52 to 0.95, P = 0.0213 and AOR = 0.48, 95% CI: 0.35 to 0.66, P < 0.0001, respectively), but not among those reporting "low" ego-alter closeness (AOR = 0.96, 95% CI: 0.63 to 1.46, P = 0.8333). The effects of density, closeness, and norms on HIV-nonconcordant UAI did not differ by race/ethnicity.

CONCLUSIONS

The significant association of social network characteristics with UAI point to network-level factors as important loci for both ongoing research and HIV prevention interventions among US MSM of color.

The effects of sexual partnership and relationship characteristics on three sexual risk variables in young men who have sex with men

Young men who have sex with men (YMSM) in the United States are experiencing an alarming increase in HIV incidence. Recent evidence suggests that the majority of new HIV infections in YMSM occur in the context of serious relationships, which underscores the importance of examining predictors of sexual risk behavior in the context of sexual partnerships, including relationship type, sexual partner characteristics, and relationship dynamics. The current study aimed to evaluate relationship and sexual partnership influences on sexual risk behavior in YMSM, including differentiating between multiple sexual risk variables (i.e., any unprotected anal or vaginal intercourse, unprotected insertive anal or vaginal intercourse, and unprotected receptive anal intercourse). More serious/familiar partnerships were associated with more sexual risk across all three risk variables, while wanting a relationship to last was protective against risk across all three risk variables. Some variables were differentially linked to unprotected insertive sex (partner gender) or unprotected receptive sex (partner age, partner race, believing a partner was having sex with others, and partners repeated across waves). Sexual risk behavior in YMSM is inconsistent across sexual partnerships and appears to be determined in no small part by sexual partner characteristics, relationship dynamics, and sexual role (i.e., insertive or receptive partner). These influences are critical in understanding sexual risk in YMSM and provide important targets for intervention.

Anal sex role segregation and versatility among men who have sex with men: EXPLORE Study

Anal sex role patterns and correlates during unprotected anal sex were examined longitudinally among HIV-negative men who have sex with men. Nearly 9.6% were exclusively receptive, 16.7% exclusively insertive, and 63.0% versatile. Versatility was more likely with primary and HIV-negative/unknown status partners and among younger men and substance users but less likely among Blacks and with higher number of partners. Exclusively receptive role was more likely with HIV-negative/unknown status partners and among younger men and substance users but less likely with higher number of partners. Examining anal sex role patterns helps understand the factors that drive the epidemic among men who have sex with men.

Men having sex with men serosorting with casual partners: who, how much, and what risk factors in Switzerland, 2007-2009

Background

Serosorting is practiced by men who have sex with men (MSM) to reduce human immunodeficiency virus (HIV) transmission. This study evaluates the prevalence of serosorting with casual partners, and analyses the characteristics and estimated numbers of serosorters in Switzerland 2007-2009.

Methods

Data were extracted from cross-sectional surveys conducted in 2007 and 2009 among self-selected MSM recruited online, through gay newspapers, and through gay organizations. Nested models were fitted to ascertain the appropriateness of pooling the datasets. Multiple logistic regression analysis was performed on pooled data to determine the association between serosorting and demographic, lifestyle-related, and health-related factors. Extrapolations were performed by applying proportions of various types of serosorters to Swiss population data collected in 2007.

Results

A significant and stable number of MSM (approximately 39% in 2007 and 2009) intentionally engage in serosorting with casual partners in Switzerland. Variables significantly associated with serosorting were: gay organization membership (aOR = 1.67), frequent internet use for sexual encounters (aOR = 1.71), having had a sexually transmitted infection (STI) at any time in the past 12 months (aOR = 1.70), HIV-positive status (aOR = 0.52), regularly frequenting sex-on-premises venues (aOR = 0.42), and unprotected anal intercourse (UAI) with partners of different or unknown HIV status in the past 12 months (aOR = 0.22). Approximately one-fifth of serosorters declared HIV negativity without being tested in the past 12 months; 15.8% reported not knowing their own HIV status.

Conclusion

The particular risk profile of serosorters having UAI with casual partners (multiple partners, STI history, and inadequate testing frequency) requires specific preventive interventions tailored to HIV status.

HIV-negative and HIV-discordant gay male couples' use of HIV risk-reduction strategies: differences by partner type and couples' HIV-status

Previous research has found that gay men and other men who have sex with men have adopted a variety of HIV risk-reduction strategies to engage in unprotected anal intercourse (UAI). However, whether gay male couples' use these strategies within and out of their relationships remains unknown. The present national cross-sectional study collected dyadic data from an online sample of 275 HIV-negative and 58 discordant gay male couples to assess their use of these strategies, and whether their use of these strategies had differed by partner type and couples' HIV-status. The sample used a variety of risk-reduction strategies for UAI. Some differences and patterns by partner type and couples' HIV-status were detected about men's use of these strategies. Findings indicate the need to bolster HIV prevention and education with gay male couples about their use of these strategies within and outside of their relationships.

A cross-sectional study of knowledge of sex partner serostatus among high-risk Peruvian men who have sex with men and transgender women: implications for HIV prevention

Background

Knowledge of a sex partner’s HIV serostatus can influence sexual behavior and inform harm-reduction strategies. We sought to determine how often Peruvian men who have sex with men (MSM) and transgender women (TW) knew the HIV serostatus of their sex partners, if this knowledge was associated with any predictive factors or unprotected anal intercourse (UAI), and if UAI was associated with partner serostatus.

Methods

We analyzed data from the 2008 Peruvian MSM Sentinel Surveillance Survey. Data were collected by CASI about each participant’s three most recent male sex partners. Primary outcome was knowledge of a partner's HIV test result. Multivariate analysis assessed the effect of age, education, sexual identity, number of male partners, alcohol use during intercourse, type of partnership and length of partnership using logistic regression.

Results

735 participants provided data on 1,643 of their most recent sex partners from the last 3 months. 179/735 (24.4%) of all participants knew HIV test results for at least one of their 3 most recent partners, corresponding to 230/1643 (14.0%) of all sexual partnerships in the last 3 months. In multivariate analysis, casual (OR: 0.27, 95% CI: 0.17-0.42) and exchange sex (OR: 0.31, 95% CI: 0.11-0.88) partners, compared to stable partners, were negatively associated with knowledge of partner serostatus, whereas relationships lasting longer than one night (<3 months OR: 2.20, 95% CI: 1.39-3.51; 3 months to 1 year OR: 3.00, 95% CI: 1.80-5.01; ≥ 1 year OR: 4.13, 95% CI: 2.40-7.10) were positively associated with knowledge of partner serostatus. Knowledge of partner serostatus was not associated with unprotected anal intercourse with that partner.

Conclusions

Few MSM and TW in Peru know their partners’ HIV serostatus. Our findings suggest that the type and length of partnership influence the likelihood of knowing a partner’s serostatus. Further research should explore the contexts and practices of partner communication, their effect on sexual behavior, and interventions to promote discussion of HIV testing and serostatus as an HIV prevention strategy in this population.

Behavioral and serologic survey of men who have sex with men in Beijing, China: implication for HIV intervention

We assessed HIV prevalence and associated behaviors and risk factors among men who have sex with men (MSM) in Beijing, China. Five hundred MSM were recruited for a biological and behavioral survey using respondent-driven sampling (RDS) in 2009. Serologic specimens were tested for markers of HIV and syphilis infection. A computer-assisted personal interview (CAPI) administered questionnaire gathered information including demographic characteristics, sexual behaviors, HIV testing, and social norms concerning condom use. The adjusted HIV prevalence was 8.0%, syphilis 22.0%. HIV testing and disclosure was low; only 39.3% had HIV tested in the past 12 months, 49.7% knew their own HIV status and 22.8% knew their last male partner's HIV status. HIV infection was associated with syphilis, ever having sex with a woman, not knowing the HIV status of the most recent male partner, and never buying condoms in the past 12 months. Stronger endorsement of positive social norms around condom use strongly and predicted lower prevalence of HIV infection. Compared to surveys of similar design in the recent past, HIV continues to spread rapidly among Beijing's MSM. Our results identify points of intervention that, if addressed in time, may still alter the course of the epidemic including the promotion of HIV testing and partner disclosure, syphilis control and particularly changing social norms around condom use.

Predictors of HIV Sexual Risk Behavior among Men Who Have Sex with Men, Men Who Have Sex with Men and Women, and Transgender Women

Men who have sex with men, men who have sex with men and women, and transgender women are at high risk for HIV infection. This study seeks to clarify which known HIV risk factors (partner type, sex location, serodiscordance, multiple sex partners, substance use during sex) contribute to engagement in high-risk (unprotected receptive anal) sex in each population. Data collected from June 2005 through June 2008 indicate all three populations display different HIV sexual risk profiles. The data suggest that HIV-prevention interventions should be individually tailored to address the specific needs of these three highly vulnerable and impacted populations.

Repeat syphilis among men who have sex with men in California, 2002-2006: implications for syphilis elimination efforts

OBJECTIVES

We examined rates of and risk factors for repeat syphilis infection among men who have sex with men (MSM) in California.

METHODS

We analyzed 2002 to 2006 California syphilis surveillance system data.

RESULTS

During the study period, a mean of 5.9% (range: 4.9%-7.1% per year) of MSM had a repeat primary or secondary (PS) syphilis infection within 2 years of an initial infection. There was no significant increase in the annual proportion of MSM with a repeat syphilis infection (P = .42). In a multivariable model, factors associated with repeat syphilis infection were HIV infection (odds ratio [OR] = 1.65; 95% confidence interval [CI] = 1.14, 2.37), Black race (OR = 1.84; 95% CI = 1.12, 3.04), and 10 or more recent sex partners (OR = 1.99; 95% CI = 1.12, 3.50).

CONCLUSIONS

Approximately 6% of MSM in California have a repeat PS syphilis infection within 2 years of an initial infection. HIV infection, Black race, and having multiple sex partners are associated with increased odds of repeat infection. Syphilis elimination efforts should include messages about the risk for repeat infection and the importance of follow-up testing. Public health attention to individuals repeatedly infected with syphilis may help reduce local disease burdens.

Characteristics of HIV epidemics driven by men who have sex with men and people who inject drugs

PURPOSE OF REVIEW

To highlight the latest developments in mathematical transmission modelling of HIV epidemics among men who have sex with men (MSM) and people who inject drugs (PWID).

RECENT FINDINGS

Mathematical approaches have been applied to a wide range of topics in recent HIV research. Epidemiological models have evaluated past and forecasted future trends in prevalence and incidence, evaluated innovative behaviour modification strategies and public health programmes aimed at minimizing risk, and explored the potential impact of various biomedical interventions. MSM have developed new risk reduction strategies which models have deemed to be effective at a population level only in certain settings, such as when there are high rates of HIV testing. Modelling has also indicated that persistent circulation of drug-resistant HIV strains is likely to become an inevitable public health issue in the near future in resource-rich settings among MSM. Models have also recently been used to demonstrate that needle and syringe programmes for harm reduction among PWID are effective and cost-effective.

SUMMARY

Mathematical modelling is particularly amenable to single population groups of concentrated HIV epidemics, such as among MSM and PWID. Models have been utilized to evaluate innovative areas in clinical, biomedical and public health research that cannot be conducted in other population groups. Future directions are likely to include evaluation of specific public health programmes and providing understanding of the importance of specific treatment regimens and incidence and interaction of comorbid conditions associated with HIV.

Sexual contexts and the process of risk reduction

Understanding the dynamics of sexual risks for HIV among men who have sex with men has been one of the ongoing challenges of HIV prevention. While the majority of HIV-prevention interventions target individual behaviour and decision making, multiple studies point to the importance of social context in shaping risk behaviour. Analysis of qualitative data from a study of men who have sex with men, drug use and sex found that sexual encounters were made up multiple contextual and interpersonal elements, which interacted to shape sexual practices and risk reduction strategies. Semi-structured interviews were conducted with 60 racially diverse men who have sex with men in NYC, recruited from multiple venues. The majority of respondents were gay-identified and half were 40 or older. Respondents described risk assessment and risk-reduction processes that develop throughout a sexual encounter, embedded in ongoing negotiations of sexual practices. Strategies of risk assessment and reduction draw on probability-based approaches to HIV prevention, presenting a challenge to health education.

Predictors of HIV disclosure among untested, HIV-negative and HIV-positive Australian men who had anal intercourse with their most recent casual male sex partner

We analysed HIV disclosure between Australian men who have sex with men (MSM) who reported anal intercourse with their last casual male partner. Of 804 MSM included in the analysis, 413 reported HIV disclosure and 391 reported no disclosure. After identifying bivariate associations with HIV disclosure, we developed three models of HIV disclosure (one for untested, one for HIV-negative and one for HIV-positive MSM). A range of factors was found to be associated with HIV disclosure. Having previously had sex with the last casual male partner and expecting HIV-negative and HIV-positive men to disclose before sex were predictors of HIV disclosure shared by more than one serostatus group. As unprotected anal intercourse was more common among MSM who disclosed (across all serostatus groups), we suggest caution should be exercised before encouraging HIV disclosure as a prevention strategy. Nondisclosure remains more strongly associated with safe sex among Australian MSM.

Sexual partner characteristics, serodiscordant/serostatus unknown unprotected anal intercourse and disclosure among human immunodeficiency virus-infected and uninfected black men who have sex with men in New York City

OBJECTIVES

Black men who have sex with men (MSM) are disproportionately infected with human immunodeficiency virus (HIV) in the United States. This study describes sexual partner characteristics and disclosure of HIV serostatus and evaluates factors associated with sexual risk behaviors during last sex among black MSM.

DESIGN AND METHODS

Between 2008 and 2009, 328 black MSM who reported recent unprotected anal intercourse were enrolled in an HIV behavioral intervention study in New York City. Factors associated with serodiscordant/serostatus unknown UAI (defined as having UAI with a partner of different or unknown HIV serostatus) with a male partner during last sex were assessed using logistic regression.

RESULTS

A total of 205 HIV-infected and 123 uninfected men were enrolled in this study. Almost all men (91.6%) reported having a black male partner during last sex. About half (47.3%) of men used alcohol and 38.7% used other substances before or during last sex. About two-thirds (68.8%) of participants disclosed their HIV status to their last sex partner, while 57.2% of partners disclosed. In multivariate analysis, meeting a partner on the internet or chat line was associated with serodiscordant/serostatus unknown UAI during last sex among HIV-infected men. The only factor associated with serodiscordant/serostatus unknown UAI during last sex among HIV-uninfected men was the partner being a non-main partner.

CONCLUSIONS

A significant proportion of black MSM in this study did not disclose their HIV status. Our data highlight the need for more data on dyadic variables and sexual risk behaviors among black MSM, as well as interventions to encourage communication between partners.

HIV seroadaptation among individuals, within sexual dyads, and by sexual episodes, men who have sex with men, San Francisco, 2008

"Seroadaptation" comprises sexual behaviors to reduce the risk of HIV acquisition and transmission based on knowing one's own and one's sexual partners' serostatus. We measured the prevalence of seroadaptive behaviors among men who have sex with men (MSM) recruited through time-location sampling (TLS) across three perspectives: by individuals (N = 1207 MSM), among sexual dyads (N = 3746 partnerships), and for sexual episodes (N = 63,789 episodes) in the preceding six months. Seroadaptation was more common than 100% condom use when considering the consistent behavioral pattern of individuals (adopted by 39.1% vs. 25.0% of men, respectively). Among sexual dyads 100% condom use was more common than seroadaptation (33.1% vs. 26.4%, respectively). Considering episodes of sex, not having anal intercourse (65.0%) and condom use (16.0%) were the most common risk reduction behaviors. Sex of highest acquisition and transmission risks (unprotected anal intercourse with a HIV serodiscordant or unknown status partner in the riskier position) occurred in only 1.6% of sexual episodes. In aggregate, MSM achieve a high level of sexual harm reduction through multiple strategies. Detailed measures of seroadaptive behaviors are needed to effectively target HIV risk and gauge the potential of serosorting and related sexual harm reduction strategies on the HIV epidemic.

Cultural beliefs, partner characteristics, communication, and sexual risk among Latino MSM

This study examined factors associated with communication about condom use and unprotected anal intercourse (UAI) in a U.S. sample of immigrant Latino MSM (N = 356), with a focus on culturally based beliefs. Logistic regression analysis revealed that communication about condom use at participants' most recent encounter was associated with a lower likelihood of UAI during that encounter. UAI was more likely when the partner was a main partner and there was seroconcordance. A separate logistic regression indicated that communication about condom use was less likely when the most recent encounter involved a main partner, greater sexual desire, and intoxication due to substance use. Although cultural beliefs were not predictive of communication about condom use or UAI at the most recent encounter, they were related to the occurrence of UAI in the previous three months. There is a need for more research on the interplay of culture, safer sex communication, and sexual risk.

Correlates of unprotected anal sex at last sexual episode: analysis from a surveillance study of men who have sex with men in Montreal

Recent increases in rates of unprotected anal sex (UAS) among men who have sex with men (MSM) signal the need to continually refine our understanding of factors associated with risky sexual behavior. Data were collected using a questionnaire eliciting information about the last sexual episode (LSE) with another man in the past 6 months. Logistic regression was used to identify both event-level and background correlates of UAS at LSE. 965 participants who reported having sex with a partner with whom they were not in a couple relationship at LSE were studied. Several event-level variables were significantly associated with UAS after adjusting for background factors, including finding the partner at LSE sexually attractive and using alcohol or cocaine at LSE. Our findings parallel the results of other HIV prevention studies which have highlighted the importance of interpersonal factors that influence risk-taking at the moment of a sexual act among MSM.

A novel approach to prevention for at-risk HIV-negative men who have sex with men: creating a teachable moment to promote informed sexual decision-making

OBJECTIVES

As a result of the impact of HIV among men who have sex with men (MSM), multiple strategies for reducing HIV risks have emerged from within the gay community. One common HIV risk reduction strategy limits unprotected sex partners to those who are of the same HIV status (serosorting). We tested a novel, brief, one-on-one intervention, based on informed decision-making and delivered by peer counselors, designed to address the limitations of serosorting (e.g., risk for HIV transmission).

METHODS

In 2009, we recruited a group of 149 at-risk men living in Atlanta, Georgia, and randomly assigned them to an intervention condition addressing serosorting or a standard-of-care control condition.

RESULTS

Men in the serosorting intervention reported fewer sexual partners (Wald χ(2) = 8.79, P < .01) at the study follow-ups. Behavioral results were also consistent with changes in psychosocial variables, including condom use self-efficacy and perceptions of risk for HIV transmission.

CONCLUSIONS

With the current intervention, service providers can offer risk reduction for men arguably at the highest risk for HIV infection in the United States. Addressing risks associated with serosorting in a feasible, low-cost intervention has the potential to significantly affect the HIV epidemic.

Racial/Ethnic differences in seroadaptive and serodisclosure behaviors among men who have sex with men

We examined racial/ethnic differences in reported seroadaptive and serodisclosure behaviors among the partnerships of MSM recruited for a cross-sectional survey using time-location sampling (TLS) in San Francisco during 2007-2008. The sample (N = 1,199) consisted of 12.2% Asian/Pacific Islander (API), 52.4% White, 6.8% Black, 20.2% Latino, and 8.5% of "other" race/ethnicity. Pure serosorting was most common (about 20%) among HIV-negative men while seropositioning was most used (about 15%) by HIV-positive men. Reported seroadaptive behaviors did not differ significantly across races/ethnicities among both HIV-negative and HIV-positive men. However, HIV-positive Black and Latino men were significantly more likely to report no preventive, seroadaptive behavioral strategy (i.e., unprotected insertive anal intercourse with unknown status or serodiscordant partners). Among men who reported engaging in seroadaptive behaviors, they reported not discussing HIV status with a third of their partners-a major concern in that lack of disclosure undermines the effectiveness and means to practice serosorting. Partnerships of API and Black men were least likely to involve serodisclosure behaviors. Our study confirms that seroadaptive behaviors are common preventive strategies reported by MSM of all races/ethnicities, and does not find strong evidence that racial/ethnic differences in seroadaptive behaviors are enhancing disparities in HIV prevalence. The implications are that condom promotion and safe sex messages are not the only prevention measures adopted by MSM and that public health professionals should be well aware of current trends within the MSM community in order to better assist HIV prevention efforts.

Sexual serosorting among women with or at risk of HIV infection

Serosorting, the practice of selectively engaging in unprotected sex with partners of the same HIV serostatus, has been proposed as a strategy for reducing HIV transmission risk among men who have sex with men (MSM). However, there is a paucity of scientific evidence regarding whether women engage in serosorting. We analyzed longitudinal data on women's sexual behavior with male partners collected in the Women's Interagency HIV Study from 2001 to 2005. Serosorting was defined as an increasing trend of unprotected anal or vaginal sex (UAVI) within seroconcordant partnerships over time, more frequent UAVI within seroconcordant partnerships compared to non-concordant partnerships, or having UAVI only with seroconcordant partners. Repeated measures Poisson regression models were used to examine the associations between serostatus partnerships and UAVI among HIV-infected and HIV-uninfected women. The study sample consisted of 1,602 HIV-infected and 664 HIV-uninfected women. Over the follow-up period, the frequency of seroconcordant partnerships increased for HIV-uninfected women but the prevalence of UAVI within seroconcordant partnerships remained stable. UAVI was reported more frequently within HIV seroconcordant partnerships than among serodiscordant or unknown serostatus partnerships, regardless of the participant's HIV status or types of partners. Among women with both HIV-infected and HIV-uninfected partners, 41% (63 HIV-infected and 9 HIV-uninfected) were having UAVI only with seroconcordant partners. Our analyses suggest that serosorting is occurring among both HIV-infected and HIV-uninfected women in this cohort.

An overview of the relative risks of different sexual behaviours on HIV transmission

PURPOSE OF REVIEW

Sexual intercourse represents the majority of HIV transmission and is preventable. Overall, the risk of HIV transmission following a single sexual exposure is low especially in comparison with other sexually transmitted infections (STIs), with estimates of the average probability of male-to-female HIV transmission only 0.0005-0.0026 per coital act. The risk of acquiring HIV from a single contact varies enormously and is dependant upon the infectiousness of the HIV-positive individual and the susceptibility to HIV of their sexual partner.

RECENT FINDINGS

Of concern, unprotected sex among men who have sex with men (MSM) has increased in recent years and HIV incidence in both MSM and heterosexuals remains a considerable public health concern. Sexual practices and health optimism about HIV have changed, which have significantly impacted HIV risk behaviour.

SUMMARY

In this review article we summarize the current evidence regarding the observed relative risks of HIV transmission for each different types of sex act, relationship type and the strategies that have been tested to interrupt transmission.