Diversification of risk reduction strategies and reduced threat of HIV may explain increases in condomless sex

Condomless Anal Sex Between Male Sex Workers and Clients in the Age of Hookup Apps

Among men who have sex with men (MSM), those who also engage in the exchange of sex for money, drugs, shelter or other material goods (i.e., male sex workers-MSWs) have been found to have higher rates of condomless anal sex (CAS), HIV, and STIs than MSM who do not engage in exchange sex. To gain a better understanding of the factors that influence MSWs' engagement in CAS with male clients, we analyzed qualitative interview data from a diverse sample of 141 MSWs from 8 U.S. cities who met clients primarily through hookup or dating apps/websites and who reported having condomless anal sex with at least one of their exchange sex partners in the prior three months. While high client demand and financial incentives were the most frequently mentioned reasons for engaging in CAS with clients, other factors including drug and alcohol use, attraction to the client, the heat of the moment, concerns about sexual performance, and reliance on pre-exposure prophylaxis (PrEP) were also important. Participants who engaged in CAS generally felt that due to client characteristics or mitigating steps they had taken themselves, their chance of acquiring HIV/STIs was acceptably low. Hookup or dating apps/websites have provided an additional and increasingly popular venue for exchange sex to be arranged. These platforms also offer an opportunity for HIV/STI prevention through interventions and tailored messages delivered through these venues that address the motivations, misconceptions and/or situational factors that may lead to CAS.

Pleasure and PrEP: A Systematic Review of Studies Examining Pleasure, Sexual Satisfaction, and PrEP

Pre-exposure prophylaxis (PrEP) is an effective form of Human Immunodeficiency Virus (HIV) prevention for people at potential risk for exposure. Despite its demonstrated efficacy, PrEP uptake and adherence have been discouraging, especially among groups most vulnerable to HIV transmission. A primary message to persons who are at elevated risk for HIV has been to focus on risk reduction, sexual risk behaviors, and continued condom use, rarely capitalizing on the positive impact on sexuality, intimacy, and relationships that PrEP affords. This systematic review synthesizes the findings and themes from 16 quantitative, qualitative, and mixed methods studies examining PrEP motivations and outcomes focused on sexual satisfaction, sexual pleasure, sexual quality, and sexual intimacy. Significant themes emerged around PrEP as increasing emotional intimacy, closeness, and connectedness; PrEP as increasing sexual options and opportunities; PrEP as removing barriers to physical closeness and physical pleasure; and PrEP as reducing sexual anxiety and fears. It is argued that positive sexual pleasure motivations should be integrated into messaging to encourage PrEP uptake and adherence, as well as to destigmatize sexual pleasure and sexual activities of MSM.

Trends in Condomless Sex Among MSM Who Participated in CDC-Funded HIV Risk-Reduction Interventions in the United States, 2012-2017

Consistent and correct use of condoms can reduce the risk for sexually transmitted diseases, including HIV/AIDS. Studies have reported that condomless sex among men who have sex with men (MSM) has steadily increased in recent years. We analyzed data reported by 51 health departments regarding 82 556 HIV-positive and HIV-negative MSM 13 years or older and participated in Centers for Disease Control and Prevention-funded behavioral risk-reduction intervention programs during 2012-2017. The percentages of condomless sex increased from 56.3% to 72.0% (estimated annual percent change [EAPC] = 7.1%) among HIV-positive MSM and from 46.0% to 70.5% (EAPC = 4.1%) among HIV-negative MSM. Continued increases in condomless sex might disrupt progress in ending the HIV/AIDS epidemic. Transmission risk associated with condomless sex can be reduced by ensuring that HIV-positive persons know their status early and are linked to care to achieve viral suppression and those at risk for acquiring HIV/AIDS can readily access preexposure prophylaxis.

Condom-Associated Erectile Function, But Not Other Domains of Sexual Functioning, Predicts Condomless Insertive Anal Sex Among Young Men Who Have Sex with Men

Condoms effectively prevent against HIV, especially when used in conjunction with biomedical strategies such as PrEP and viral suppression. However, consistent use of condoms in the real world has been a continual health promotion challenge, even among populations at highest risk, such as young men who have sex with men (YMSM). Inconsistent condom use may be related to poor sexual functioning, but limited research exists. The analytic sample comprised 688 racially diverse YMSM aged 16-29 (M = 22.9 years) living in Chicago, IL (19.2% living with HIV). Using multivariable logistic regression, we examined longitudinal associations between condom-associated sexual functioning (erectile function, orgasm satisfaction, global satisfaction, and anal discomfort) and condomless insertive anal sex (CIAS) and condomless receptive anal sex (CRAS) 6 months later. CIAS at Time 2 was associated with condom-associated erectile function at the bivariate and multivariable levels, even after controlling for CIAS at Time 1 (p < .05). Condom-associated erectile function, orgasm satisfaction, and global satisfaction predicted Time 2 CRAS in bivariate models, but none remained significant in the multivariable models. Age, having had a serious partner in the past 6 months, and HIV/PrEP status at Time 2 were significant predictors of CIAS/CRAS in some but not all models. Future interventions to improve consistent condom use should specifically highlight information and skills on how to use condoms within real-world contexts rather than from a clinical perspective. Our results also support the importance of biomedical strategies for those who have continued problems with sexual functioning when using condoms.

Brief Report: Changes in Behavior After PrEP Initiation Among Australian Gay and Bisexual Men

INTRODUCTION

HIV pre-exposure prophylaxis (PrEP) has been increasingly adopted by gay and bisexual men (GBM). Little is known about whether individual GBM change their sexual behavior after PrEP initiation.

METHODS

Following Lives Undergoing Change (Flux) is a national, online, prospective observational study among Australian GBM. Using McNemar statistics, we compare rates of sexual behaviors before and coincident with PrEP initiation among 1518 non-HIV-positive men recruited between August 2014 and July 2017 who had not commenced PrEP at baseline and who completed at least one 6-monthly follow-up surveys by July 2018.

RESULTS

The proportion of men using PrEP rose to 24.2% over time. In total, 348 men initiated PrEP during follow-up. PrEP initiators were more likely to report particular sexual behaviors during the follow-up period that they commenced PrEP compared with the period immediately prior: receptive condomless anal intercourse with casual partners increased from 31.0% to 48.9% (McNemar < 0.001); mean partner number increased from 21.96 partners to 34.55 partners (p-trend < 0.001). Among the 1170 men who did not initiate PrEP, prevalence of these behaviors remained lower and stable. Sexual sensation-seeking and gay social engagement were both higher among men who commenced PrEP.

CONCLUSIONS

GBM tended to increase their engagement in "adventurous" sexual behaviors after PrEP initiation. Sexual behaviors among men who did not initiate PrEP were less common and did not change over time.

Pleasure and HIV biomedical discourse: The structuring of sexual and drug-related risks for gay and bisexual men who Party-n-Play

Party-n-Play (PNP) is a social practice that refers to sex that occurs under the influence of drugs. This study critically examined the risk and pleasure discourses of gay and bisexual men who PNP to explore how epistemic shifts associated with advancements in HIV biomedical sciences influence gay and bisexual men's perceptions of HIV risks and their sexual and drug-related practices. This study also aims to provide a more nuanced understanding of how sexual and drug-related risk practices of gay and bisexual men are entangled with their search for pleasure. The study was framed within poststructural Critical Discourse Analysis (CDA) methodology. In-depth one-hour interviews were conducted with 44 self-identified gay, bisexual, queer, or Two-Spirit men, who lived in Toronto, and who reported using drugs before or during sex with another man. The findings from this study demonstrated the capacity of biomedical discourses to affect respondents' HIV risk perceptions and practices. The transition from condom-centered prevention to today's context where new highly effective biomedical tools for HIV prevention are available created possibilities for greater intimacy, increased pleasure, and less anxiety about HIV tranmission, while challenging many years of preventive socialization among gay and bisexual men. However, this new context also rekindled deep-seated fears about HIV risk and viral load verifiability, reinforced unequal forms of biomedical self-governance and citizenship, and reproduced practices of biopolitics. While discourses on risk and pleasure were interwoven within complex PNP assemblages, the notion of pleasure was mobilized as a discursive tactic of self-control, and the division between normative and non-normative pleasures highlighted the consequence of biopolitical forces governing the production of discourses on sex and drugs. Future HIV social science research needs to attend to the fluid nature of the discursive environments of HIV prevention science, and consider how both the material context of PNP and its social/discursive elements operate together.

Calendar trends in sexual behaviours in a cohort of HIV-infected MSM at the era of treatment as prevention of HIV infection

BACKGROUND

With the advent of treatment as prevention of HIV infection (TasP), we assessed trends in sexual behaviours between 2000 and 2017 among HIV-infected MSM enrolled in the French ANRS PRIMO cohort.

METHODS

At each cohort visit, a clinical questionnaire including laboratory values was completed and a self-administered questionnaire was used to collect sexual behaviours, that is, the number, type (steady/casual) and HIV status (positive or negative/unknown) of partners, and condom use. The possible influence of viral load (undetectable/detectable) measured at the preceding visit on the evolution over time of sexual behaviour was assessed with logistic regression models fitted by generalized estimating equations (GEE), taking into account longitudinal data.

RESULTS

We analyzed data from 10657 follow-up visits by 1364 MSM. Overall, whatever the considered behavioural variable: at least one sexual partner, steady and/or casual, condomless sex with steady, casual partners, serodiscordant or not, we observed a calendar increase with a particularly more marked rise from 2010 (P < 0.0001). Inconsistent condom use did not differ according to the viral load status (detectable vs. undetectable). Trends in inconsistent condom use increased across different generations of MSM, as defined by the year they were diagnosed with HIV infection.

CONCLUSIONS

'Having a sexual partner' and condomless sex, both increased in frequency between 2000 and 2017. Viral load status did not influence condom use as could have been expected from the 2008 Swiss Statement.

Criminalization of HIV non-disclosure: Narratives from young men living in Vancouver, Canada

Background

Previous research has identified the impacts of legal frameworks that criminalize HIV non-disclosure among people living with HIV (e.g., elevated stigma and violence). However, far less is known about the perspectives or experiences of people–particularly, men–who are HIV-seronegative or who are unaware of their status. The objective of this paper is to describe the health and social risks that young men perceive to be associated with an HIV diagnosis in the context of Canada’s current legal framework pertaining to HIV non-disclosure.

Methods

We analyzed data from 100 in-depth interviews (2013–2016) conducted with 85 young men ages 18–30 in Vancouver on the topic of the criminalization of HIV non-disclosure.

Results

Our analysis revealed two dominant narratives in relation to HIV criminalization: (a) interrogation and (b) justification. An interrogation narrative problematized the moral permissibility of criminalizing HIV non-disclosure. In this narrative, Canada’s HIV non-disclosure legal framework was characterized as creating unjust barriers to HIV testing uptake, as well as impeding access to and reducing retention in care for those living with HIV. Conversely, a justification narrative featured a surprising number of references to HIV as a “death sentence”, despite effective treatments being universally available in Canada. However, most of those who presented the justification narrative asserted that the criminalization of HIV non-disclosure was morally justified in light of the perceived negative stigma-related impacts of HIV (e.g., discrimination; being ostracized from sex or romantic partners, friends, family). The justification narrative often reflected a belief that the legal framework provides both punishment and deterrence, which were perceived to supersede any barriers to care for both HIV-positive and -negative individuals.

Conclusion

Public education regarding contemporary medical advances in HIV may help contest lay understandings of HIV as a “death sentence”, which is particularly relevant to destabilizing justification narratives. However, significant strengthening of HIV stigma-reduction efforts will be needed to move society away from narratives that attempt to justify Canada’s current HIV non-disclosure legal framework.

Trends in Sexual Behavior Among Men Who have Sex with Men (MSM) in High-Income Countries, 1990-2013: A Systematic Review

HIV diagnoses among men who have sex with men (MSM) have been increasing in several high-income countries. A better understanding of the sexual behavior trends among MSM can be useful for informing HIV prevention. We conducted a systematic review of studies that examined behavioral trends (1990-2013) in any condomless anal sex, condomless anal sex with an HIV-discordant partner, and number of partners. Studies included come from the United States, Europe, and Australia. We found increasing trends in condomless anal sex and condomless anal sex with an HIV-discordant partner, and a decreasing trend in number of partners. The increase in condomless anal sex may help to explain the increase in HIV infections. More explanatory research is needed to provide insight into factors that contribute to these behavior trends. Continuous monitoring of HIV, risk behaviors, and use of prevention and treatment is needed to evaluate prevention efforts and monitor HIV transmission risk.