MSM: resurgent epidemics

The effect of sexual behavior on HIV-1 seroconversion is mediated by the gut microbiome and proinflammatory cytokines

The association between HIV-1 seroconversion and gut dysbiosis is well documented, and its association with sexual activity is also widely recognized. However, it is not known whether the gut dysbiosis mediates the effects of high-risk sexual behavior on HIV-1 seroconversion. In this report we focused on men who engaged in high-risk sexual behavior where they had receptive anal intercourse with multiple men. We demonstrate that proinflammatory cytokines, sCD14 and sCD163, and gut microbiota mediate the effects of this high-risk sexual behavior on subsequent HIV seroconversion. We discovered changes in the gut microbial ecology, prior to seroconversion, both in terms of the composition as well as inter-relationships among the commensal species. Furthermore, these changes correlate with future HIV seroconversion. Specifically, as the number of sexual partners increased, we discovered in a "dose-response" manner, a decrease in the abundance of commensal and short-chain fatty acid-producing species, A. muciniphila, B. caccae, B. fragilis, B. uniformis, Bacteroides spp., Butyricimonas spp., and Odoribacter spp, and an increase in proinflammatory species Dehalobacterium spp. and Methanobrevibacter spp. These changes were also observed among subsequent HIV seroconverters. Interestingly, we also discovered a reduction in correlations among these commensal and short-chain fatty acid producing bacteria in a "dose-response" manner with the number of sexual partners. Our mediation analysis not only provides a conceptual model for the disease process but also provides clues for future clinical interventions that will manipulate the gut microbiota to treat high-risk subjects to prevent HIV seroconversion.

Exploring drivers of pre-exposure prophylaxis uptake among gay, bisexual, and other men who have sex with men in Malaysia

BACKGROUND

Pre-exposure prophylaxis (PrEP) is a valuable HIV prevention strategy, particularly among men who have sex with men (MSM); however, PrEP uptake is below the threshold needed to curb the HIV epidemic among this group, especially in settings like Malaysia, where same-sex sexual behavior is illegal.

METHODS

A sample of 355 participants completed an online survey between June and July 2020, recruited through geosocial networking apps for MSM and social networking websites (e.g. Facebook). We used descriptive and multivariable analyses to examine correlates of PrEP use within this population.

RESULTS

The sample was predominantly Malay (53.5%), had monthly incomes greater than RM 3000 (USD 730) (52.7%), and a tertiary level of education (84.5%). About 80% of participants heard of PrEP prior to the survey, with significantly less (18.3%) having ever taken PrEP. In the adjusted multivariable logistic model, using drugs before or during sexual intercourse ("chemsex") (AOR: 3.37; 95% CI: 1.44-7.89), being diagnosed with a sexually transmitted infection in the last 12 months (AOR: 2.08; 95% CI: 1.13-3.85), HIV testing in the previous 6 months (AOR: 3.23; 95% CI: 1.74-5.99), and disclosure of sexual orientation (AOR: 1.85; 95% CI: 1.02-3.34) were associated with having taken PrEP in the past.

CONCLUSIONS

This study revealed that PrEP use among Malaysian MSM is relatively low, despite high awareness, and is associated with healthcare engagement and high-risk behaviors. These results highlight the need to tailor outreach activities for individuals at increased risk for HIV and those disengaged with the health system.

First reported lymphogranuloma venereum cases in Russia discovered in men who have sex with men attending proctologists

BACKGROUND

Several lymphogranuloma venereum (LGV) outbreaks among men who have sex with men (MSM) have been reported throughout the world since 2003. Nevertheless, no LGV cases have been internationally reported from Russia. We evaluated the prevalence of LGV among MSM attending proctologists in Moscow, Russia, and compared the LGV and non-LGV rectal Chlamydia trachomatis (CT) infections.

METHODS

MSM (n = 534) attending for proctologic care were included. Rectal specimens were sampled for CT and Neisseria gonorrhoeae (NG) by nucleic acid amplification tests (NAATs). All CT-positive patients were tested with an LGV-specific NAAT.

RESULTS

In total, 37.3% (95% CI 33.3-41.5; 199/534) of MSM were CT positive. Of these, 68.8% (95% CI 62.1-74.9; 137/199) had LGV and 31.2% (95% CI 25.1-37.9; 62/199) a non-LGV rectal CT infection. Older age (34 years vs. 31 years, p = 0.035) and group-sex practices (67.2% (92/137) vs. 33.9% (21/62), p < 0.0001) were associated with LGV. The LGV-positive MSM were also more likely to be HIV-positive (67.2% (92/137) vs. 41.9% (26/62), p = 0.001). Proctoscopy revealed ulcerative proctitis/proctocolitis in 99.3% (136/137) of LGV-positive MSM. No ulcerative or erosive proctitis was found in the MSM with non-LGV CT infection, but 58.1% (36/62) of them had anorectal disorders. Finally, mild catarrhal or hemorrhagic proctitis was diagnosed in only 21.6% (8/37) of MSM with non-LGV CT infection lacking concomitant NG or syphilis (p < 0.0001).

CONCLUSIONS

LGV is widely spread among MSM attending proctologists in Moscow. Clinically, acute LGV proctitis/proctocolitis can be difficult to distinguish from inflammatory bowel disease that leads to mismanaged LGV infections. LGV diagnostic laboratory testing is essential, however, currently mainly lacking for MSM in Russia. All MSM with CT-positive rectal specimens should be subsequently tested for LGV.

Correlates of concurrent partnerships and patterns of condom use among men who have sex with men and transgender women in Peru

Background

In Peru, there is an ongoing high-incidence HIV epidemic among men who have sex with men (MSM) and transgender women (TW). Sexual concurrency, or having sex with a partner in between two acts of sex with another partner, may be a key factor in onward HIV transmission. In this study, we quantify concurrency, evaluate factors associated with concurrency, and assess condom use with concurrent partners among MSM and TW in Peru.

Methods

We conducted a secondary analysis of data from the 2011 Peruvian Biobehavioral Survey. Pearson’s Chi-squared test was used to identify individual-level characteristics associated with concurrency. We estimated the association between participant characteristics, concurrent partnerships, partnership type (stable vs. non-stable), and CLAI within the context of concurrent partnerships using multivariate and repeated-measure Poisson regression.

Results

3-month cumulative prevalence of concurrency was higher among TW compared to MSM (30.7% vs 25.2%, p = 0.014). Among those with concurrent stable and non-stable partners, 45% used condoms with both partners (95% CI: 40%-50%) and 30% preferentially had CLAI with the stable partner only (95%CI: 26%-35%). Factors associated with CLAI within the context of concurrent partnerships varied between MSM and TW.

Conclusions

Although concurrency is common among TW and MSM in Peru, patterns of concurrency and differential condom use may vary between TW and MSM. Future research may explore differential condom use with stable and non-stable partners to better understand behavioral factors that may alter vulnerability to HIV in TW compared to MSM.

Rising HIV prevalence among men who have sex with men in Nigeria: a trend analysis

BACKGROUND

Men who have sex with men (MSM) are conservatively estimated to be less than 1% of the Nigerian population yet nationally account for about 20% of new HIV infection. We estimated the trend in HIV prevalence and determined correlates of HIV infection among MSM.

METHODS

This study used data from respondent-driven sampling in three rounds of integrated biological and behavioral surveillance survey (2007, 2010 and 2014) and covered three states in 2007, six states in 2010 and eight states in 2014. Each round used similar methodology and thus allows for comparison. Behavioral data were obtained using a structured pre-coded questionnaire. Differences in categorical variables were assessed with Chi Square. Logistic regression was used to identify factors associated with HIV.

RESULTS

A total of 879, 1545 and 3611 MSM were recruited in 2007, 2010 and 2014 respectively. Median age was 22 years for 2007 and 2014 while it was 24 years in 2010. About one-third of MSM in 2007 and 2014 and about two-fifths in 2010 had engaged in transactional sex. HIV prevalence increased from 14% in 2007 to 17% in 2010 to 23% in 2014 (p < 0.0001). Factors associated with HIV include older age ≥ 25 years (adjusted odds ratio {AOR}:2.41; 95% CI:1.84-3.16); receptive anal sex (AOR:1.92; 95% CI:1.54-2.40) and history of sexually transmitted infections (AOR:1.26; 95% CI:1.02-1.55).

CONCLUSION

There's been a consistent and significant increase in HIV prevalence among MSM with about 10-percentage points relative increase per year over 7 years. Older MSM were more likely to be HIV positive and this may reflect their prolonged exposure to high risk sexual activities. Evidence based interventions are urgently needed to mitigate intra-group HIV transmission and propagation of HIV epidemic between MSM and the general population.

Using HIV Sequence and Epidemiologic Data to Assess the Effect of Self-referral Testing for Acute HIV Infection on Incident Diagnoses in San Diego, California

BACKGROUND

Because recently infected individuals disproportionately contribute to the spread of human immunodeficiency virus (HIV), we evaluated the impact of a primary HIV screening program (the Early Test) implemented in San Diego.

METHODS

The Early Test program used combined nucleic acid and serology testing to screen for primary infection targeting local high-risk individuals. Epidemiologic, HIV sequence, and geographic data were obtained from the San Diego County Department of Public Health and the Early Test program. Poisson regression analysis was performed to determine whether the Early Test program was temporally and geographically associated with changes in incident HIV diagnoses. Transmission chains were inferred by phylogenetic analysis of sequence data.

RESULTS

Over time, a decrease in incident HIV diagnoses was observed proportional to the number primary HIV infections diagnosed in each San Diego region (P < .001). Molecular network analyses also showed that transmission chains were more likely to terminate in regions where the program was marketed (P = .002). Although, individuals in these zip codes had infection diagnosed earlier (P = .08), they were not treated earlier (P = .83).

CONCLUSIONS

These findings suggests that early HIV diagnoses by this primary infection screening program probably contributed to the observed decrease in new HIV diagnoses in San Diego, and they support the expansion and evaluation of similar programs.

Incident risk factors as predictors of HIV seroconversion in the Lisbon cohort of men who have sex with men: first results, 2011-2014

HIV incidence in men who have sex with men (MSM) is increasing in western countries, including Portugal. We aimed to estimate HIV incidence and to assess how individual short-term changes in exposures over time predict seroconversion. We evaluated participants of an open cohort of HIV-negative MSM enrolled after testing at a community-based voluntary HIV counselling and testing centre in Lisbon. At each evaluation a structured questionnaire was completed and HIV status was ascertained using rapid followed by confirmatory testing. Between April 2011 and February 2014, 804 MSM were followed for a total of 893 person-years. Predictors of HIV seroconversion were identified using Poisson generalised linear regression. The overall seroincidence was 2.80/100 person-years (95% confidence interval: 1.89-4.14). Men who seroconverted had a higher mean number of tests per year. Seroconversions were significantly associated with partner disclosure of HIV status during follow-up, newly-adopted unprotected anal intercourse (UAI) with a steady partner and being newly-diagnosed with syphilis during follow-up. Likewise, sexual intercourse with HIV-positive men, having an HIV-positive steady partner at least once during follow-up and persistent UAI with occasional partners were predictors of seroconversion. High HIV incidence in this cohort is likely driven by short-term contextual and behavioural changes during follow-up.

Effects of a social network HIV/STD prevention intervention for MSM in Russia and Hungary: a randomized controlled trial

OBJECTIVE

To test a novel social network HIV risk-reduction intervention for MSM in Russia and Hungary, where same-sex behavior is stigmatized and men may best be reached through their social network connections.

DESIGN

A two-arm trial with 18 sociocentric networks of MSM randomized to the social network intervention or standard HIV/STD testing/counseling.

SETTING

St. Petersburg, Russia and Budapest, Hungary.

PARTICIPANTS

Eighteen 'seeds' from community venues invited the participation of their MSM friends who, in turn, invited their own MSM friends into the study, a process that continued outward until eighteen three-ring sociocentric networks (mean size = 35 members, n = 626) were recruited.

INTERVENTION

Empirically identified network leaders were trained and guided to convey HIV prevention advice to other network members.

MAIN OUTCOME AND MEASURES

Changes in sexual behavior from baseline to 3-month and 12-month follow-up, with composite HIV/STD incidence, measured at 12 months to corroborate behavior changes.

RESULTS

There were significant reductions between baseline, first follow-up, and second follow-up in the intervention versus comparison arm for proportion of men engaging in any unprotected anal intercourse (UAI) (P = 0.04); UAI with a nonmain partner (P = 0.04); and UAI with multiple partners (P = 0.002). The mean percentage of unprotected anal intercourse acts significantly declined (P = 0.001), as well as the mean number of UAI acts among men who initially had multiple partners (P = 0.05). Biological HIV/STD incidence was 15% in comparison condition networks and 9% in intervention condition networks.

CONCLUSION

Even where same-sex behavior is stigmatized, it is possible to reach MSM and deliver HIV prevention through their social networks.

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.

Concurrent partnerships and HIV risk among men who have sex with men in New York City

BACKGROUND

Concurrent partnerships are a significant public health concern among men who have sex with men (MSM). This study describes the prevalence of concurrency and its association with serodiscordant/serostatus unknown unprotected anal or vaginal intercourse (SDUI) among MSM in New York City.

METHODS

A total of 1458 MSM completed a social and sexual network inventory about their male and female sex partners, including concurrency, in the last 3 months. Logistic regression identified factors associated with SDUI.

RESULTS

Median age was 29 years. The proportion of participants who reported being HIV+ was 23.5%. The men reported a mean of 3.2 male partners in the last 3 months. The proportion of MSM who reported having recent SDUI was 16.6%. More than half (63.2%) described having concurrent sex partners (individual concurrency based on overlapping dates of relationships); 71.5% reported having partners whom they believed had concurrent partners (perceived partner concurrency); and 56.1% reported that both they and their partners had concurrent partners (reciprocal concurrency). Among HIV+ men by self-report, having SDUI was positively associated with individual concurrency, any alcohol use during sex, having more male sex partners, and not having a main partner. Among self-reported HIV- men, having SDUI was positively associated with perceived partner concurrency, lower education level, any alcohol and drug use during sex, having more male sex partners, and having an anonymous partner.

CONCLUSIONS

Concurrency was common among MSM. The association of SDUI with individual and perceived partner concurrency, along with substance use during sex, having an anonymous partner, and having many sex partners likely further increases HIV acquisition and transmission risk among MSM. HIV prevention interventions should address concurrency among MSM.

Examining the correspondence between relationship identity and actual sexual risk behavior among HIV-positive men who have sex with men

Sexual behavior of men who have sex with men (MSM), within and outside of one's primary relationship, may contribute to increased risk of HIV transmission among those living with HIV. The current study sought to understand how HIV-infected MSM report their relationship status and the degree to which this corresponds with their sexual behavior. Further, we examined rates and psychosocial associations with sexual HIV transmission risk behavior (TRB) across relationship categories. In a sample of 503 HIV-infected MSM in HIV care, 200 (39.8 %) reported having a primary partner. Of these, 115 reported that their relationship was open and 85 reported that it was monogamous. Of the 85 who reported a monogamous relationship, 23 (27 %) reported more than one sexual partner in the prior 3 months, 53 (62 %) reported only one partner, and nine did not report on the number of partners in the past 3 months. Hence, there were three categories of relationships: (1) "monogamous with one sexual partner," (2) "monogamous with more than one sexual partner," and (3) "open relationship." The "monogamous with more than one sexual partner" group reported higher TRB and crystal methamphetamine use compared to the "monogamous with one sexual partner" group and different patterns of relationships with TRB emerged across the three groups. Couples-based HIV prevention interventions for MSM may be enhanced by considering that there may be different definitions of monogamy among MSM, and that the context of relationship status may require tailoring interventions to meet the needs of specific subgroups of MSM couples.

Associations between the legal context of HIV, perceived social capital, and HIV antiretroviral adherence in North America

BACKGROUND

Human rights approaches to manage HIV and efforts to decriminalize HIV exposure/transmission globally offer hope to persons living with HIV (PLWH). However, among vulnerable populations of PLWH, substantial human rights and structural challenges (disadvantage and injustice that results from everyday practices of a well-intentioned liberal society) must be addressed. These challenges span all ecosocial context levels and in North America (Canada and the United States) can include prosecution for HIV nondisclosure and HIV exposure/transmission. Our aims were to: 1) Determine if there were associations between the social structural factor of criminalization of HIV exposure/transmission, the individual factor of perceived social capital (resources to support one's life chances and overcome life's challenges), and HIV antiretroviral therapy (ART) adherence among PLWH and 2) describe the nature of associations between the social structural factor of criminalization of HIV exposure/transmission, the individual factor of perceived social capital, and HIV ART adherence among PLWH.

METHODS

We used ecosocial theory and social epidemiology to guide our study. HIV related criminal law data were obtained from published literature. Perceived social capital and HIV ART adherence data were collected from adult PLWH. Correlation and logistic regression were used to identify and characterize observed associations.

RESULTS

Among a sample of adult PLWH (n = 1873), significant positive associations were observed between perceived social capital, HIV disclosure required by law, and self-reported HIV ART adherence. We observed that PLWH who have higher levels of perceived social capital and who live in areas where HIV disclosure is required by law reported better average adherence. In contrast, PLWH who live in areas where HIV transmission/exposure is a crime reported lower 30-day medication adherence. Among our North American participants, being of older age, of White or Hispanic ancestry, and having higher perceived social capital, were significant predictors of better HIV ART adherence.

CONCLUSIONS

Treatment approaches offer clear advantages in controlling HIV and reducing HIV transmission at the population level. These advantages, however, will have limited benefit for adherence to treatments without also addressing the social and structural challenges that allow HIV to continue to spread among society's most vulnerable populations.

Risk patterns preceding diagnosis among newly HIV-diagnosed men who have sex with men in New York City

Men who have sex with men (MSM) are at high risk for contracting and transmitting HIV. They are increasingly encouraged to get tested, but understanding of the interplay between HIV testing and risk behavior is limited. One hundred fifty newly HIV-diagnosed (within past 3 months) MSM were recruited from a community clinic in New York City. Participants completed an interview assessing sexual behavior and substance use during the 3 months pre-diagnosis, current depressive symptoms, and prior HIV testing. HIV-related health characteristics at diagnosis were abstracted from medical records. Analyses examined factors associated with unprotected anal intercourse (UAI) in the 3 months pre-diagnosis, and with a negative HIV test in the 12 months pre-diagnosis. The sample was young (mean age=32.5, SD=8.8), ethnically diverse (62% racial/ethnic minority), low-income (71%≤$30,000/year), and educated (48% college/advanced degree). Most (95%) had a prior negative HIV test, 55% within the last 12 months. Significant risk behavior was reported, with 79% reporting UAI. UAI was associated with recent testing and use of substances during sexual behavior. Recent testing was associated with being employed/a student, having had UAI, and higher CD4 count. Implications for future research addressing perceived HIV risk, HIV testing utilization, and risk behavior are discussed.

Factors associated with men in HIV-negative gay couples who practiced UAI within and outside of their relationship

Despite recent advances in research with gay male couples, less data exists about men who have had UAI within and outside of their HIV-negative seroconcordant relationship. Multilevel modeling with dyadic data from 142 couples was used to identify the characteristics associated with men who have had UAI with both their main partner and a casual MSM partner within the same timeframe. Analyses revealed that men were more likely to have had UAI within and outside of their relationship if they perceived their main partner has had a recent HIV test. Men were less likely to have had UAI within and outside of their relationship if they valued their sexual agreement and reported having a sexual agreement that does not allow sex outside of their relationship. Research with a more diverse sample of couples is warranted. Future interventions must consider the complexity of relationships and sexual behaviors among gay male couples.

Sexual behavior and HIV testing among bisexual men: a nationwide comparison of Australian bisexual-identifying and gay-identifying men

Men who have sex with men (MSM) are typically studied as though they were a homogeneous population. This has resulted in a lack of knowledge about the sexual health and behavior of bisexual men as distinct from gay men. In this study, patterns of sexual behavior and rates of HIV testing were compared between 854 gay-identifying and 164 bisexual-identifying men who participated in an Australian nationwide online survey. Approximately half of both groups engaged in unprotected anal intercourse (UAI) at their most recent sexual encounter, but bisexual-identifying men were more likely to have had sex with a partner who was either serodiscordant or with whom their seroconcordance was unknown. Despite these patterns, only 62% of bisexual-identifying men had ever been tested for HIV compared to 84% of gay-identifying men. Multivariate logistic regression focused on rates of UAI and HIV testing among bisexual-identifying men. Patterns were similar across all age groups and educational backgrounds. However, bisexual-identifying men were less likely to engage in UAI with a casual partner and were more likely to have been tested for HIV if they had multiple partners or had disclosed their sexual orientation to their social networks. In all, these data reveal important differences between gay- and bisexual-identifying men, particularly with regard to HIV testing, and highlight a need for HIV prevention strategies to focus more strategically on finding ways of promoting safer sex and HIV testing among all MSM.

Controlling the HIV/AIDS epidemic: current status and global challenges

This review provides an overview of the current status of the global HIV pandemic and strategies to bring it under control. It updates numerous preventive approaches including behavioral interventions, male circumcision (MC), pre- and post-exposure prophylaxis (PREP and PEP), vaccines, and microbicides. The manuscript summarizes current anti-retroviral treatment options, their impact in the western world, and difficulties faced by emerging and resource-limited nations in providing and maintaining appropriate treatment regimens. Current clinical and pre-clinical approaches toward a cure for HIV are described, including new drug compounds that target viral reservoirs and gene therapy approaches aimed at altering susceptibility to HIV infection. Recent progress in vaccine development is summarized, including novel approaches and new discoveries.

HIV treatment as prevention: natural experiments highlight limits of antiretroviral treatment as HIV prevention

There is growing enthusiasm for increasing coverage of antiretroviral treatment among HIV-infected people for the purposes of preventing ongoing transmission. Treatment as prevention will face a number of barriers when implemented in real world populations, which will likely lead to the effectiveness of this strategy being lower than proposed by optimistic modelling scenarios or ideal clinical trial settings. Some settings, as part of their prevention and treatment strategies, have already attained rates of HIV testing and use of antiretroviral therapy--with high levels of viral suppression--that many countries would aspire to as targets for a treatment-as-prevention strategy. This review examines a number of these "natural experiments", namely, British Columbia, San Francisco, France, and Australia, to provide commentary on whether treatment as prevention has worked in real world populations. This review suggests that the population-level impact of this strategy is likely to be considerably less than as inferred from ideal conditions.