Out of the closet and into public health focus: HIV and STDs in men who have sex with men in middle income and resource-limited countries

Intimate Partner Violence and Social Pressure among Gay Men in Six Countries

Introduction

Recent research suggests that men who have sex with men (MSM) experience intimate partner violence (IPV) at significantly higher rates than heterosexual men. Few studies, however, have investigated implications of heterosexist social pressures – namely, homophobic discrimination, internalized homophobia, and heterosexism – on risk for IPV among MSM, and no previous studies have examined cross-national variations in the relationship between IPV and social pressure. This paper examines reporting of IPV and associations with social pressure among a sample of internet-recruited MSM in the United States (U.S.), Canada, Australia, the United Kingdom, South Africa, and Brazil.

Methods

We recruited internet-using MSM from 6 countries through selective banner advertisements placed on Facebook. Eligibility criteria were men age over 18 reporting sex with a man in the past year. Of the 2,771 eligible respondents, 2,368 had complete data and were included in the analysis. Three outcomes were examined: reporting recent experience of physical violence, sexual violence, and recent perpetration of physical violence. The analysis focused on associations between reporting of IPV and experiences of homophobic discrimination, internalized homophobia, and heteronormativity.

Results

Reporting of experiencing physical IPV ranged from 5.75% in the U.S. to 11.75% in South Africa, while experiencing sexual violence was less commonly reported and ranged from 2.54% in Australia to 4.52% in the U.S. Perpetration of physical violence ranged from 2.47% in the U.S. to 5.76% in South Africa. Experiences of homophobic discrimination, internalized homophobia, and heteronormativity were found to increase odds of reporting IPV in all countries.

Conclusion

There has been little data on IPV among MSM, particularly MSM living in low- and middle-income countries. Despite the lack of consensus in demographic correlates of violence reporting, heterosexist social pressures were found to significantly increase odds of reporting IPV in all countries. These findings show the universality of violence reporting among MSM across countries, and highlight the unique role of heteronormativity as a risk factor for violence reporting among MSM. The results demonstrate that using internet-based surveys to reach MSM is feasible for certain areas, although modified efforts may be required to reach diverse samples of MSM.

Is expanded HIV treatment preventing new infections? Impact of antiretroviral therapy on sexual risk behaviors in the developing world

There have been dramatic increases in access to antiretroviral therapy (ART) across the developing world, and growing public health attention has focused on the possibility of utilizing ART as a means of slowing the global HIV epidemic. The preventive impact of ART will likely depend on decreasing levels of sexual risk behaviors following treatment initiation. The current review study examines the impact of wider access to ART on sexual risk behaviors among HIV-infected individuals in the developing world. The observational studies to date demonstrate that ART is associated with a significant reduction in unprotected sex following treatment initiation. Although data on the impact of ART on possible risk compensation are rapidly expanding across the developing world, more evidence is still needed before we can safely conclude expanded treatment will result in durable decreases in sexual risk behaviors.

Packaging PrEP to Prevent HIV: An Integrated Framework to Plan for Pre-Exposure Prophylaxis Implementation in Clinical Practice

Antiretroviral pre-exposure prophylaxis (PrEP) drugs may be partially effective for preventing HIV transmission. In anticipation of clinical trial results, behavioral HIV prevention scientists have begun examining possible challenges in the implementation of PrEP in clinical practice or community settings. These efforts have acknowledged the need to supplement PrEP drug delivery with risk-reduction counseling and ongoing HIV testing, and we suggest that an even wider range of clinical, diagnostic, behavioral, and monitoring services will be necessary to support PrEP as a population-level HIV prevention strategy. This Commentary offers an integrated structure for optimizing PrEP delivery in clinical practice, which includes five components: 1) PrEP drugs; 2) safety screening and repeated HIV testing; 3) behavioral interventions to facilitate PrEP initiation, maintain adherence, and minimize risk compensation; 4) the development of strategies to engage PrEP users and the healthcare system over the long term; and 5) population-level monitoring. We provide a brief overview of each component and highlight implications of this five-part package for implementation. Attempts to plan for scale-up without explicitly addressing non-pharmaceutical elements may overlook critical implementation needs, barriers, and facilitators.