A behavioral intervention reduces HIV transmission risk by promoting sustained serosorting practices among HIV-infected men who have sex with men

Promoting health equity in HIV prevention and treatment research: a practical guide to establishing, implementing, and sustaining community advisory boards

Over the last 25 years, community-based participatory research (CBPR) has emerged as an innovative methodological approach to break down the barriers toward health equity in biopsychosocial research. Although there are several methods one can use to conduct CBPR research, one widely used established tool that has shown to be effective for engaging community meaningfully in research is community advisory boards (CABs). CABs are formalized collaborative bodies consisting of community and research stakeholders and have been integral in engaging underserved groups experiencing HIV-related health inequities at the early stages of the AIDS crisis. Even though evidence suggests that CABs are an effective tool for conducting high-quality, rigorous, and community-centered HIV-related research, there are minimal guidelines summarizing the steps needed for developing and maintaining a CAB. Therefore, to fill this gap in the literature, this article offers a practical guide to help researchers with minimal experience, particularly graduate students and early-stage investigators, feel more comfortable with establishing a CAB for equity-focused HIV-related research. This article synthesizes already established guidelines and frameworks for CAB development while specifically outlining unique steps related to the three main stages of CAB formation - establishment, implementation, and sustainment. Throughout this article, the authors offer tension points, generated from the literature and with consultation from a CAB working alongside the authors, that researchers and community partners may need to navigate during each of these three stages. In addition, best practices from the literature are identified for each step in the guidelines so that readers can see firsthand how research groups have carried out these steps in their own practice.

Usability of dual HIV/syphilis self-testing among men who have sex with men in China: study protocol for a three-arm randomised controlled trial

INTRODUCTION

HIV self-testing (HIVST) provides a key measure for the early detection of HIV infection in men who have sex with men (MSM). However, dual HIV/syphilis self-testing in the MSM population has not been studied. We describe a randomised controlled trial to evaluate the effect of dual HIV/syphilis self-testing on the testing frequency among MSM in China.

METHODS AND ANALYSIS

This randomised controlled trial will be implemented in Guangxi, China. 330 MSM, including 255 frequent testers and 75 less frequent testers, will be recruited and randomly assigned in a 1:1:1 ratio into one of three arms: a site-based testing arm, a single HIVST arm and a dual HIV/syphilis self-testing arm. Participants in the single HIVST arm and dual HIV/syphilis self-testing arm will receive two free finger-prick-based HIVST or HIV/syphilis self-testing kits at enrolment. The data will be collected at five separate times: baseline, 3 months, 6 months, 9 months and 12 months. The primary outcome is the mean frequency of HIV testing used by MSM after intervention comparing each group during the study period. The secondary outcome includes changes in sex behaviours (eg, number of male sex partners and the proportion of consistent condom use) and the mean number of HIV tests used by the social network members over the study period.

ETHICS AND DISSEMINATION

The study protocol was reviewed and approved by the Medical Ethics Committee of Guangxi Medical University, China (20210173). The study results will be disseminated through conferences and academic journals.

TRIAL REGISTRATION NUMBER

ChiCTR2100050898.

Prevalence of and Factors Associated with the Use of HIV Serosorting and Other Biomedical Prevention Strategies Among Men Who Have Sex with Men in a US Nationwide Survey

PrEP and treatment-as-prevention (TasP) are biomedical strategies to reduce HIV transmission. Some men who have sex with men (MSM) are combining biomedical strategies with HIV serosorting-termed "biomed matching" when both partners are either on PrEP or TasP, or "biomed sorting" when one partner is using PrEP and the other TasP. Nevertheless, there is limited data on the extent of biomed matching/sorting in large geographically diverse samples. In 2016-2017, 5021 MSM from across the US were surveyed about their HIV status and HIV viral load/PrEP use, as well as that of their recent casual male partners. For each participant, we calculated the proportion of his partners who were (1) HIV-positive and undetectable, (2) HIV-positive and detectable/unknown, (3) HIV unknown/undiscussed, (4) HIV-negative on PrEP, (5) HIV-negative, not on PrEP. In total, 66.6% (n = 3346) of participants were HIV-negative and not on PrEP, 11.9% (n = 599) on PrEP, 14.1% (n = 707) HIV-positive and undetectable, 1.1% (n = 55) HIV-positive and viral load detectable/unknown, and 6.2% (n = 313) HIV unsure/unknown. A participant's own HIV and PrEP status/was significantly associated with that of his partners (all p < 0.001), evincing evidence of both serosorting and biomed matching. Among men on PrEP and those who were HIV-undetectable, there was also some evidence to suggest these participants dually engaged in biomed matching as well as biomed sorting. We found evidence of biomed matching and sorting, which may compound its effectiveness for those using it (i.e., both partners bring biomedical protection). Unintended consequences of biomed matching/sorting include that men not using a biomedical strategy may be less likely to benefit from a partner's use of the strategy-potentially further driving disparities in HIV infections. Public health campaigns might be well served to highlight not only the benefits that biomedical HIV prevention strategies provide for their users (e.g., "being on PrEP protects me from getting HIV"), but also the benefits that a user brings to his partners (e.g., "my use of PrEP means my partners won't get HIV"), and the benefits of being with a partner who is using a biomedical strategy (e.g., "my partner's use of PrEP/TasP protects me from HIV").

A Randomized Clinical Trial of a Brief Internet-based Group Intervention to Reduce Sexual Transmission Risk Behavior Among HIV-Positive Gay and Bisexual Men

Background

HIV disproportionately affects sexual minority men, and developing strategies to reduce transmission risk is a public health priority.

Purpose

The goal was to empirically test a newly developed, Information, Motivation, Behavioral skills (IMB) theoretically derived, online HIV sexual risk reduction intervention (called HINTS) among a sample of sexual minority men living with HIV.

Methods

Participants were 167 men randomized to either the four-session online HINTS intervention or to a time-matched, online control condition. Participants were assessed at baseline and at 6-month follow-up for demographic, medical and psychosocial factors, and sexual risk behavior. Analyses examined group differences in incidence rates of condomless anal sex (CAS) at follow-up with all male sex partners and by partner serostatus, either seroconcordant or serodiscordant for HIV infection.

Results

Men assigned to the HINTS intervention reported decreased CAS with serodiscordant partners, a behavior that confers high risk of HIV transmission, compared to the control group. Men assigned to the HINTS intervention also reported increased CAS with seroconcordant partners, a behavior indicative of serosorting. Although the IMB model did not appear to mediate these intervention effects, some IMB components were associated with behavioral outcomes at 6-month follow-up.

Conclusions

A new group-based sexual risk reduction intervention conducted exclusively online was successful in reducing HIV transmission risk behavior in a sample of gay and bisexual men living with HIV. Future work should consider utilizing this intervention with other groups living with HIV, perhaps in combination with biomedical HIV prevention strategies.

Critical Review: When the Party is Over: A Systematic Review of Behavioral Interventions for Substance-Using Men Who Have Sex with Men

Because problematic patterns of alcohol and other substance use are prevalent drivers of the HIV/AIDS epidemic, comprehensive interventions are needed for substance-using men who have sex with men (SUMSM). We conducted a systematic review of 12 randomized controlled trials (RCTs) of behavioral interventions for reducing condomless anal intercourse (CAI) in SUMSM. Three RCTs observed that cognitive behavioral or motivational interviewing interventions achieved a 24% to 40% decrease in CAI. Interventions also tended to demonstrate greater efficacy for reducing CAI and substance use among those who had lower severity of substance use disorder symptoms. Although behavioral interventions for SUMSM are one potentially important component of biobehavioral HIV/AIDS prevention, further research is needed to examine whether integrative approaches that cultivate resilience and target co-occurring syndemic conditions demonstrate greater efficacy. Multilevel intervention approaches are also needed to optimize the effectiveness of pre-exposure prophylaxis and HIV treatment as prevention with SUMSM.

Intention to undergo HIV testing and associated factors among women in one high-HIV prevalence city

OBJECTIVE

The objective of this study is to understand the rate of intention to undergo HIV testing and associated factors among women in a city with high HIV prevalence.

METHODS

A cross-sectional study was conducted among 293 women HIV/AIDS patients who were newly examined with HIV infection and aged ≥18 years from September to December 2012. Multivariate logistic regression analyses were used to identify the factors associated with intention to undergo HIV testing.

RESULTS

The rate of intention to undergo HIV testing was 12.3%. Nearly 90% of participants had no intention of getting HIV tested, and the main reasons were "Never thought I would be HIV-infected" (78.2%) and "I did not feel sick, and it was impossible to be HIV-infected" (19.8%). The awareness rate of HIV knowledge was 67.8%, and 34.1% had casual heterosexual partners. Those who had casual heterosexual partners or had better HIV knowledge were more likely to have intention of getting HIV tested.

CONCLUSION

The rate of intention to undergo HIV testing among women is low. AIDS health education programmess and public information campaigns should be initiated to improve knowledge about HIV and the risk of HIV infection, to encourage women to take HIV testing more promptly. It is also vital to take measures to reduce stigma against AIDS patients.

Mediation Analysis of the Efficacy of the Eban HIV/STD Risk-Reduction Intervention for African American HIV Serodiscordant Couples

Targeting couples is a promising behavioral HIV risk-reduction strategy, but the mechanisms underlying the effects of such interventions are unknown. We report secondary analyses testing whether Social-Cognitive-Theory variables mediated the Eban HIV-risk-reduction intervention's effects on condom-use outcomes. In a multisite randomized controlled trial conducted in four US cities, 535 African American HIV-serodiscordant couples were randomized to the Eban HIV risk-reduction intervention or attention-matched control intervention. Outcomes were proportion condom-protected sex, consistent condom use, and frequency of unprotected sex measured pre-, immediately post-, and 6 and 12 months post-intervention. Potential mediators included Social-Cognitive-Theory variables: outcome expectancies and self-efficacy. Mediation analyses using the product-of-coefficients approach in a generalized-estimating-equations framework revealed that condom-use outcome expectancy, partner-reaction outcome expectancy, intention, self-efficacy, and safer-sex communication improved post-intervention and mediated intervention-induced improvements in condom-use outcomes. These findings underscore the importance of targeting outcome expectancies, self-efficacy, and safer-sex communication in couples-level HIV risk-reduction interventions.

Pilot randomized controlled trial of an integrative intervention with methamphetamine-using men who have sex with men

Contingency management (CM) is an evidence-based intervention that provides tangible rewards as positive reinforcement for biologically confirmed abstinence from substance use. Integrative approaches targeting positive affect regulation could boost the effectiveness of CM by sensitizing individuals to non-drug-related sources of reward and assisting them with effectively managing symptoms of withdrawal. This pilot randomized controlled trial with 21 methamphetamine-using men who have sex with men (MSM) examined the feasibility and acceptability of a 5-session, positive affect intervention delivered during CM-Affect Regulation Treatment to Enhance Methamphetamine Intervention Success (ARTEMIS). After completing 4 weeks of a 12-week CM program, participants were randomized to receive ARTEMIS+CM (n = 12) or CM-only (n = 9). Those randomized to receive the ARTEMIS positive affect intervention completed 98 % of sessions and reported marginally significant increases in positive affect over the five sessions. In exit interviews with ARTEMIS+CM participants, individuals noted that the positive affect regulation skills increased self-awareness and led to greater engagement in the recovery process. ARTEMIS+CM participants reported significant increases in positive affect and CM-only participants reported significant reductions in negative affect over a 2-month follow-up. These affective changes were not maintained, and no concurrent effects on stimulant use or sexual risk taking were observed over the 6-month follow-up. More definitive clinical research is necessary to examine the efficacy of ARTEMIS+CM with methamphetamine-using MSM.

Knowledge of HIV and willingness to conduct oral rapid HIV testing among dentists in Xi'an China

Introduction

China is considered a country of low HIV prevalence (780,000 people living with HIV), however, HIV infections among high-risk populations continue to grow at alarming rates. Voluntary Counseling and Testing services were first implemented in 2003, and oral rapid HIV testing (ORHT) began in 2012. Dentists, as oral health experts, would be well placed to conduct ORHT. We assessed willingness of dentists to undertake ORHT in their clinical practice.

Methods

A cross-sectional, paper-based survey of dentists from the Xi’an region of China was conducted from April to June 2013. Dentists were recruited from Shaanxi Stomatological Association using a stratified sampling methodology. A 40-item survey was used to measure knowledge of HIV, attitudes toward people living with HIV and willingness to conduct ORHT.

Results

477 dentists completed the survey with a mean HIV knowledge test score of 13.2/18 (SD 1.9). If made available in the dental setting, 276 (57.9%) preferred to use blood to diagnose HIV, only 190 (39.8%) preferred saliva or both. Four hundred and thirty-five (91.2%) thought that ORHT was needed in dental clinics. Female dentists felt more accepting of ORHT than males (93.8% vs. 87.8%; χ²=5.145; p<0.05). 42.6% of the participants who responded thought that lack of education on ORHT for dentists was the most urgent problem to solve for ORHT, 144 (31.3%) thought that lack of support for ORHT from patients was the most urgent problem. There was statistically significant difference among dental hospital, dentistry and department of dentistry (χ²=24.176; p<0.05).

Conclusions

The majority of Chinese dentists thought that ORHT was needed in the dental setting. Providing opportunities for dentists and dental students to learn about HIV testing guidelines and practices is needed as well as feasibility and implementation science research.

Motivational interviewing targeting risky sex in HIV-positive young Thai men who have sex with men

Motivational interviewing (MI) has been shown to reduce sexual risks among HIV-positive men who have sex with men (HMSM) in the US. We conducted a randomized trial of Healthy Choices, a 4-session MI intervention, targeting sexual risks among 110 HIV-positive youth ages 16-25 years in Thailand. Risk assessments were conducted at baseline, 1 month, and 6 months post-intervention. This report presents the analysis of 74 HMSM in the study. There were 37 HMSM in the Intervention group and 37 in the control group. The proportions of participants having anal sex and having sex with either HIV-uninfected or unknown partners in past 30 days were significantly lower in Intervention group than in Control group at 6 months post-intervention (38 vs. 65 %, p = .04; and 27 vs. 62 %, p < .01, respectively). There were no significant differences in general mental health scores and HIV stigma scores between the two groups at any study visit. Thirty-five (95 %) HMSM in the Intervention group vs. 31 (84 %) in control group attended ≥ 3 sessions. Loss to follow-up was 8 and 30 %, respectively (p = .04). Healthy Choices for young Thai HMSM was associated with sexual risk reduction. Improvements in mental health were noted in Intervention group. Healthy Choices is a promising behavioral intervention and should be further developed to serve the needs of young HMSM in resource-limited countries.

Developing a conceptual framework of seroadaptive behaviors in HIV-diagnosed men who have sex with men

BACKGROUND

Seroadaptive behaviors are strategies employed by men who have sex with men (MSM) to reduce the transmission risk for human immunodeficiency virus (HIV). It has been suggested that they contribute to the increasing diagnoses of sexually transmitted infections in HIV-diagnosed MSM. To understand the context in which the reemerging sexually transmitted infections appear, we developed a social epidemiological model incorporating the multiple factors influencing seroadaptive behaviors.

METHODS

A literature review of seroadaptive behaviors in HIV-diagnosed MSM was conducted. The literature was synthesized using a social epidemiological perspective.

RESULTS

Seroadaptive behaviors are adopted by MSM in high-income countries and are a way for HIV-diagnosed men to manage and enjoy their sexual lives. Influences are apparent at structural, community, interpersonal, and intrapersonal levels. There is little evidence of whether and when the behavior forms part of a premeditated strategy; it seems dependent on the social context and on time since HIV diagnosis. Social rules of HIV disclosure and perception of risk depend on the setting where partners are encountered.

CONCLUSIONS

Seroadaptive behaviors are strongly context dependent and can reduce or increase transmission risk for different infectious diseases. Further data collection and mathematical modeling can help us explore the specific conditions in more detail.

Risk factors associated with prevalent and incident syphilis among an HIV-infected cohort in Northeast China

Background

Sexually transmitted infections (STIs) increase HIV infectivity through local inflammatory processes. Prevalent and incident STIs among people who live with HIV/AIDS (PLWHA) are indicators of high-risk sexual behaviors and imply potential spread of HIV. Little is known about the prevalence and incidence of concurrent syphilis and associated risk behaviors among PLWHA in China.

Methods

A retrospective cohort study was conducted among PLWHA who attended the outpatient clinic of a designated AIDS treatment hospital in Shenyang, China, between March 2009 and May 2013. Physical examinations and syphilis serology were conducted at each visit. A questionnaire on demographic characteristics was also collected.

Results

A total of 1010 PLWHA were enrolled, of whom 77.0% were men who have sex with men (MSM). The baseline syphilis prevalence among PLWHA was 19.8% (95% confidence interval [CI]:17.3–22.3%). During follow-up, 78.3% retained in the cohort, and contributed a median follow-up of 9.4 months (interquartile range: 5.9-18.7 months). Syphilis incidence among PLWHA was 18.7 (95% CI: 15.5–21.8) per 100 person years. Mulitvariate logistic analysis showed that receiving antiretroviral therapy (ART) (adjusted OR [aOR] = 0.48), older age (≥40 years vs. ≤24 years, aOR = 2.43), being MSM (aOR = 2.30) and having higher baseline HIV viral load (>100000 copies/mL vs. ≤100000 copies/mL, aOR = 1.56) were independent predictors for syphilis infection among PLWHA at enrollment (p < 0.05 for all). Mulivariate Cox regression found that receiving ART (adjusted hazard ratio [aHR] = 1.81), older age (≥40 years vs. ≤24 years, aHR: 5.17) and MSM status (aHR = 2.68) were independent risk factors for syphilis seroconversion (each p < 0.05).

Conclusions

Syphilis prevalence and incidence were high among PLWHA in Shenyang. A campaign focusing on detection and treatment of syphilis among PLWHA is urgently needed, especially one with a focus on MSM who are at a higher risk for syphilis.

Electronic supplementary material

The online version of this article (doi:10.1186/s12879-014-0658-1) contains supplementary material, which is available to authorized users.

A systematic review of sexual health interventions for adults: narrative evidence

Recent work has explored the intersection between sexual health (as construed by the World Health Organization and others) and public health domains of action in the United States of America. This article reports the narrative results of a systematic review of sexual health intervention effects on public health-relevant outcomes. To qualify, interventions had to be based on the principles (1) that sexual health is intrinsic to individuals and their overall health and (2) that relationships reflecting sexual health must be positive for all parties concerned. Outcomes were classed in domains: knowledge, attitudes, communication, health care use, sexual behavior, and adverse events. We summarized data from 58 studies (English language, adult populations, 1996-2011) by population (adults, parents, sexual minorities, vulnerable populations) across domains. Interventions were predominantly individual and small-group designs that addressed sexual behaviors (72%) and attitudes/norms (55%). They yielded positive effects in that 98% reported a positive finding in at least one domain; 50% also reported null effects. The most consistently positive effects on behaviors and adverse events were found for sexual minorities, vulnerable populations, and parental communication. Whether via direct action or through partnerships, incorporating principles from existing sexual health definitions in public health efforts may help improve sexual health.

Positive choices: outcomes of a brief risk reduction intervention for newly HIV-diagnosed men who have sex with men

Positive choices (PC), a brief sexual risk reduction intervention conducted with newly HIV-diagnosed men who have sex with men (MSM), was evaluated for preliminary efficacy. Participants were enrolled if they reported unprotected anal intercourse (UAI) in the three months prior to HIV diagnosis (n = 102). Three months after diagnosis, participants completed baseline assessments and were randomly assigned to receive the 3-session PC intervention or the comprehensive standard of care (C-SoC) at a community health center. Participants completed assessments at 3- (post intervention), 6-, and 9- months after baseline. Compared to C-SoC participants, PC participants significantly reduced the frequency of UAI with HIV serodiscordant (HIV negative or status unknown) partners over the 9-month follow-up period. No differences by condition were found in the frequency of UAI with all partners. The findings from this trial suggest that brief risk reduction approaches for newly-diagnosed MSM integrated into HIV care can benefit secondary HIV prevention efforts.

Setting the bar high or setting up to fail? Interpretations and implications of the EXPLORE Study (HPTN 015)

Controlled studies show that HIV risk reduction counseling significantly increases condom use, reduces unprotected sex and prevents sexually transmitted infections. Nevertheless, without evidence of reducing HIV incidence, these interventions are generally discarded. One trial, the EXPLORE study, was designed to test whether ten sessions of risk reduction counseling could impact HIV incidence among men who have sex with men in six US cities. Based on epidemiologic models to define effective HIV vaccines, a 35 % reduction in HIV incidence was set a priori as the benchmark of success in this behavioral intervention trial. Results demonstrated a significant effect of the intervention, with more than a 35 % reduction in HIV incidence observed during the initial 12-18 months following counseling. Over an unprecedented 48-month follow-up, however, the effect of counseling on HIV incidence declined to 18 %. The current review examined how the scientific literature has thus far judged the outcomes of the EXPLORE study as well as the policy implications of these judgments. We identified 127 articles that cited the EXPLORE study since its publication. Among articles that discuss the HIV incidence outcomes, 20 % judged the intervention effective and 80 % judged the intervention ineffective. The overwhelmingly negative interpretation of the EXPLORE study outcomes is reflected in public policies and prevention planning. We conclude that using a vaccine standard to define success led to a broad discrediting of the benefits of behavioral counseling and, ultimately, adversely impacted policies critical to the field of HIV prevention.

Meta-Analysis of Interventions for Reducing Number of Sexual Partners and Drug and Alcohol Abuse among People Living with HIV/AIDS

OBJECTIVE

To perform a systematic review and meta-analysis of the efficacy of risk reduction interventions on HIV-related risk behaviors among people living with HIV/AIDS (PLWHA).

METHODS

Studies included in the meta-analysis were randomized clinical trials (RCTs) of risk reduction interventions, which targeted PLWHA aged 18 year or older and assessed the changes of number of sexual partners, drug use, needle sharing, and/or alcohol abuse between pre- and post-intervention. The standardized mean differences (SMD) between study arms as well as between baseline and post-intervention, defined as the effect sizes (ES), were calculated in random effects models. Heterogeneity of studies was estimated by the I2 statistic.

RESULTS

Twelve RCTs involving 3993 PLWHA were included in our analysis: seven reported impacts on the number of sexual partners, and three reported impacts on drug use, needle sharing, and alcohol abuse, respectively. There were no statistically significant impacts of risk reduction interventions on the number of total sexual partners (mean ES, -0.10; 95% confidence interval [CI], -0.26, 0.06; P=0.22) or on the subset of HIV-negative or unknown-status sexual partners (mean ES, 0.003; 95% CI, -0.54, 0.54; P=0.99). Overall, risk reduction intervention studies documented a reduction of drug abuse (mean ES: -0.26; 95% CI: -0.51, -0.01; P=0.04) among HIV-infected drug users, but this impact was mainly attributable to one study. Risk reduction interventions did not show a reduction of needle sharing (mean ES, -0.15; 95% CI, -0.43, 0.13; P=0.29) or of alcohol abuse (mean ES, -0.10; 95% CI, -0.36, 0.17; P=0.47). No heterogeneity or publication bias was found across individual studies.

CONCLUSIONS

Our meta-analysis did not find a positive impacts of risk reduction interventions on number of sexual partners, drug use, needle sharing, or alcohol abuse among PLWHA, but the small number of studies meeting our review criteria limits these findings.

Willingness to use the oral fluid HIV rapid test among men who have sex with men in Beijing, China

Background

Early detection of HIV infection enables timely care and treatment. However, many men who have sex with men (MSM) remain unaware of their HIV status because they do not or are unable to access HIV testing services. Oral fluid HIV rapid tests have the potential to increase HIV testing. This study is the first to evaluate willingness to use the oral fluid test among MSM in China.

Methods

A cross-sectional study was conducted in Beijing from July to October, 2012. Data were collected by self-administered questionnaires.

Results

Of 262 who participated in the survey, 223(85.1%) reported that they were willing to use the oral fluid HIV rapid test. Willingness to use the oral fluid test was associated with higher education (adjusted odds ratio (AOR): 2.40, 95% confidence interval (CI): 1.13–5.10), lack of unprotected anal intercourse (UAI) with male partners in the past one month (AOR: 2.38; 95% 95%CI: 1.15–4.95), having taken more than 4 HIV tests (AOR: 3.54; 95%CI:1.52–8.28), and having ever heard of the oral fluid HIV rapid test from gay friends or gay organizations (AOR: 3.24, 95%CI: 1.40–7.51). Among those who expressed willingness to use the oral fluid HIV rapid test, the median amount of money they were willing to pay was 8 dollars. Among the 39 participants who were unwilling to use the oral fluid test, 79.5% (31/39) expressed concerns about the accuracy of the oral fluid HIV rapid test results and 17.9%(7/39) reported that they were not familiar with the oral fluid test and did not know how to use such a test.

Conclusions

A high proportion of MSM in Beijing appear to be willing to use the oral fluid HIV rapid test. Appropriate cost and education measures could help improve acceptance of the oral fluid test.

A systematic review to identify challenges of demonstrating efficacy of HIV behavioral interventions for gay, bisexual, and other men who have sex with men (MSM)

Gay, bisexual, and other men who have sex with men (MSM) are disproportionately affected by HIV but few MSM-specific evidence-based interventions (EBIs) have been identified for this vulnerable group. We conducted a systematic review to identify reasons for the small number of EBIs for MSM. We also compared study, intervention and sample characteristics of EBIs versus non-EBIs to better understand the challenges of demonstrating efficacy evidence. Thirty-three MSM-specific studies were evaluated: Nine (27 %) were considered EBIs while 24 (73 %) were non-EBIs. Non-EBIs had multiple methodological limitations; the most common was not finding a significant positive effect. Compared to EBIs, non-EBIs were less likely to use peer intervention deliverers, include sexual communication in their interventions, and intervene at the community level. Incorporating characteristics associated with EBIs may strengthen behavioral interventions for MSM. More EBIs are needed for substance-using MSM, MSM of color, MSM residing in the south and MSM in couples.

Exploring the venue's role in risky sexual behavior among gay and bisexual men: an event-level analysis from a national online survey in the U.S

Venue-based characteristics (e.g., alcohol in bars, anonymous chat online, dark/quiet spaces in bathhouses) can impact how men who have sex with men (MSM) negotiate sex and HIV-associated risk behavior. We sought to determine the association between HIV-associated risk factors and the venues where MSM met their most recent new (first-time) male sex partner, using data from a 2004 to 2005 national online anonymous survey of MSM in the U.S. (n = 2,865). Most men (62%) met their partner through the Internet. Among those reporting anal sex during their last encounter (n = 1,550), half had not used a condom. In multivariate modeling, and among men reporting anal sex during their last encounter, venue where partner was met was not significantly associated with unprotected anal intercourse (UAI). Nevertheless, venue was related to other factors that contextualized men's sexual encounters. For example, HIV status disclosure was lowest among men who met their most recent partner in a park, outdoors, or other public place and highest among men who met their most recent partner online. Alcohol use prior to/during the last sexual encounter was highest among men who met their most recent partner in a bathhouse or a bar/club/party/event. These data suggest it is possible to reach men online who seek sex in many different venues, thus potentially broadening the impact of prevention messages delivered in virtual environments. Although not associated with UAI, venues are connected to social-behavioral facets of corresponding sexual encounters, and may be important arenas for differential HIV and STI education, treatment, and prevention.

Project enhance: a randomized controlled trial of an individualized HIV prevention intervention for HIV-infected men who have sex with men conducted in a primary care setting

OBJECTIVE

Men who have sex with men (MSM) are the largest group of individuals in the U.S. living with HIV and have the greatest number of new infections. This study was designed to test a brief, culturally relevant prevention intervention for HIV-infected MSM, which could be integrated into HIV care.

METHOD

HIV-infected MSM who received HIV care in a community health center (N = 201), and who reported HIV sexual transmission-risk behavior (TRB) in the prior 6 months, were randomized to receive the intervention or treatment as usual. The intervention, provided by a medical social worker, included proactive case management for psychosocial problems, counseling about living with HIV, and HIV TRB risk reduction. Participants were followed every 3 months for one year.

RESULTS

Participants, regardless of study condition, reported reductions in HIV TRB, with no significant differential effect by condition in primary intent-to-treat analyses. When examining moderators, the intervention was differentially effective in reducing HIV TRB for those who screened in for baseline depression, but this was not the case for those who did not screen in for depression.

CONCLUSIONS

The similar level of reduction in HIV TRB in the intervention and control groups, consistent with other recent secondary prevention interventions, speaks to the need for new, creative designs, or more potent interventions in secondary HIV prevention trials, as the control group seemed to benefit from risk assessment, study contact, and referrals provided by study staff. The differential finding for those with depression may suggest that those without depression could reap benefits from limited interventions, but those with a comorbid psychiatric diagnosis may require additional interventions to modify their sexual risk behaviors.

Are HIV-negative men who have sex with men and who bareback concerned about HIV infection? Implications for HIV risk reduction interventions

The emergence of barebacking (intentional unprotected anal intercourse in situations where there is risk of HIV infection) among men who have sex with men (MSM) has been partially attributed to a decrease in HIV-related concerns due to improved anti-retroviral treatment. It is important to understand the level of concern these men have regarding HIV infection because it can affect their interest in risk reduction behaviors as well as their possible engagement in risk reduction interventions. As part of a study on MSM who use the Internet to seek sexual partners, 89 ethnic and racially diverse men who reported never having an HIV-positive test result completed an in-depth qualitative interview and a computer-based quantitative assessment. Of the 82 men who were asked about concerns of HIV infection during the qualitative interviews, 30 expressed "significant concern" about acquiring HIV, 42 expressed "moderate concern," and 10 expressed "minimal concern." Themes that emerged across the different levels of concern were their perceptions of the severity of HIV infection, having friends who were HIV positive, and their own vulnerability to HIV infection. However, these themes differed depending on the level of concern. Among the most frequently mentioned approaches to decrease risk of HIV infection, participants mentioned avoiding HIV-positive sex partners, limiting the number of partners with whom they barebacked, and not allowing partners to ejaculate inside their rectum. Findings suggest that many MSM who bareback would be amenable to HIV prevention efforts that do not depend solely on condom use.

What HIV-positive MSM want from sexual risk reduction interventions: findings from a qualitative study

To facilitate the development of a tailored intervention that meets the needs of HIV-positive men who have sex with men (HIV-positive MSM), we conducted formative research with 52 HIV-positive MSM. We sought to (a) identify major barriers to consistent condom use, (b) characterize their interest in sexual risk reduction interventions, and (c) elicit feedback regarding optimal intervention format. Men identified several key barriers to consistent condom use, including treatment optimism, lessened support for safer sex in the broader gay community, challenges communicating with partners, and concerns about stigmatization following serostatus disclosure. Many men expressed an interest in health promotion programming, but did not want to participate in an intervention focusing exclusively on safer sex. Instead, they preferred a supportive group intervention that addresses other coping challenges as well as sexual risk reduction. Study results reveal important considerations for the development of appealing and efficacious risk reduction interventions for HIV-positive MSM.

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

BACKGROUND

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

PURPOSE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Syphilis resurgence in Dublin, Ireland

A large outbreak of syphilis was reported in Dublin, Ireland, in 2001. The mean age of patients in 2001 was 35 years and 22.5% of patients were HIV-positive. The number of new cases decreased from 2003 on, however, new diagnoses have again increased. All positive syphilis serology results from 2007-09 were identified. Patients were included if they had a newly positive syphilis serology or, in the case of patients with previously treated syphilis, had a four-fold rise in rapid plasma reagin titre. Four hundred and thirty-nine new diagnoses of syphilis were made. The mean age of patients at diagnosis was 35.7 years (range 17-73 years). Four hundred and twelve (93.8%) cases occurred in men. Three hundred and eighty-one (86.8%) cases occurred in men who have sex with men (MSM). The estimated crude incidence rate among MSM is 378.16 per 100,000 population. Where known, 126/421 (28.7%) occurred in HIV-positive patients. Sixty-eight (15.5%) episodes of syphilis infection were diagnosed in patients who had had previously been diagnosed and treated for syphilis; 43/68 (63.2%) cases of re-infection occurred in HIV-positive patients. The rising number of syphilis diagnoses and high associated HIV co-infection rate is concerning and prevention efforts must continue to decrease the number of new syphilis cases.

Behavior, intention or chance? A longitudinal study of HIV seroadaptive behaviors, abstinence and condom use

Seroadaptive behaviors have been widely described as preventive strategies among men who have sex with men (MSM) and other populations worldwide. However, causal links between intentions to adopt seroadaptive behaviors and subsequent behavior have not been established. We conducted a longitudinal study of 732 MSM in San Francisco to assess consistency and adherence to multiple seroadaptive behaviors, abstinence and condom use, whether prior intentions predict future seroadaptive behaviors and the likelihood that observed behavioral patterns are the result of chance. Pure serosorting (i.e., having only HIV-negative partners) among HIV-negative MSM and seropositioning (i.e., assuming the receptive position during unprotected anal sex) among HIV-positive MSM were more common, more successfully adhered to and more strongly associated with prior intentions than consistent condom use. Seroconcordant partnerships occurred significantly more often than expected by chance, reducing the prevalence of serodiscordant partnerships. Having no sex was intended by the fewest MSM, yet half of HIV-positive MSM who abstained from sex at baseline also did so at 12 month follow-up. Nonetheless, no preventive strategy was consistently used by more than one-third of MSM overall and none was adhered to by more than half from baseline to follow-up. The effectiveness of seroadaptive strategies should be improved and used as efficacy endpoints in trials of behavioral prevention interventions.

Sexual health, HIV risk, and retention in an adolescent HIV-prevention trial preparatory cohort

PURPOSE

Although adolescents are at high risk for human immunodeficiency virus (HIV) infection, they have not been, included in HIV vaccine trials.

METHODS

In preparation for enrollment in HIV vaccine trials, 100 HIV-negative adolescents aged 14-17 years from Cape Town were recruited into a cohort. HIV, syphilis, pregnancy testing, and sexual risk questionnaires were conducted at varying intervals for a year.

RESULTS

The mean age of the participants was 15 years, and 70% of them were female. Recruitment was completed within 3 months. Retention was found to be 82% at 1-year follow-up. The main reasons for dropout were as follows: relocation to other communities, phlebotomy, and visit frequency. In a Cox proportional hazards model, only female gender was significantly associated with retention. No change in reported sexual risk occurred, but the proportion of individuals who were aware of their partner's HIV status was significantly higher (17% at baseline, 83% at 1-year follow-up; p < .001). Five pregnancies were reported during follow-up.

CONCLUSIONS

To our knowledge, this is the first prospective adolescent HIV-prevention cohort in Southern Africa. Despite reports of risky sexual behaviors and high pregnancy rates, HIV seroconversions did not occur in the retained cohort. HIV-prevention trials with high-risk adolescents will require rigorous efforts to prevent future pregnancies, and may require risk eligibility criteria. Retention may improve with transport provision, visits with incentives, and efforts to retain males.

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.

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.

Neurocognitive impairment and HIV risk factors: a reciprocal relationship

Cognitive impairment among populations at risk for HIV poses a significant barrier to managing risk behaviors. The impact of HIV and several cofactors, including substance abuse and mental illness, on cognitive function is discussed in the context of HIV risk behaviors, medication adherence, and risk-reduction interventions. Literature suggests that cognitive impairment is intertwined in a close, reciprocal relationship with both risk behaviors and medication adherence. Not only do increased risk behaviors and suboptimal adherence exacerbate cognitive impairment, but cognitive impairment also reduces the effectiveness of interventions aimed at optimizing medication adherence and reducing risk. In order to be effective, risk-reduction interventions must therefore take into account the impact of cognitive impairment on learning and behavior.

Sexual risk behaviour for transmission of HIV in men who have sex with men: recent findings and potential interventions

PURPOSE OF REVIEW

Men who have sex with men (MSM) remain one of the groups most at risk of HIV, particularly in countries with concentrated epidemics. Here, we review findings from behavioural research with MSM and discuss the potential of behavioural interventions.

RECENT FINDINGS

Increasing sexual risk behaviour and HIV transmission among MSM is apparent. Although risk reduction strategies, including serosorting and strategic positioning, are being widely reported, these appear to offer limited protection to HIV-negative MSM. There are emerging HIV epidemics among MSM in low-income and middle-income countries, with reported high levels of HIV and sexual risk behaviour. Studies of African MSM report higher HIV prevalence than that in the adult male general population. Evidence of effective behavioural interventions is growing. However, further trials, incorporating biological endpoints, are required.

SUMMARY

Reducing HIV transmission among MSM remains a significant challenge. Risk reduction strategies, other than condom use, could reduce the risk, but their efficacy is questionable, particularly when knowledge of HIV status may be inaccurate. Behaviour change alone is unlikely to produce the sustained reductions in HIV transmission necessary to change the course of the epidemic. 'Combination prevention', which incorporates biomedical, behavioural, social and structural interventions, should be explored further.

Reducing HIV risk behavior of men who have sex with men through persuasive computing: results of the Men's INTernet Study-II

OBJECTIVE

The primary objective of this study was to develop and test a highly interactive Internet-based HIV prevention intervention for men who have sex with men (MSM). MSM remain the group at highest risk for HIV/AIDS in the United States and similar countries. As the Internet becomes popular for seeking sex, online interventions to reduce sexual risk are critical. Given previous studies, a secondary objective was to demonstrate that good retention is possible in online trials.

DESIGN

A randomized controlled trial with 3-month, 6-month, 9-month, and 12-month follow-up design was employed.

METHODS

In 2008, 650 participants were randomized to an online, interactive sexual risk reduction intervention or to a waitlist null control.

RESULTS

Retention was 76-89% over 12 months. At 3-month follow-up, results showed a 16% reduction in reported unprotected anal intercourse risk among those in the treatment condition versus control [95% confidence interval (95% CI) of rate ratio: 0.70-1.01]. No meaningful differences were observed at 12-month follow-up.

CONCLUSION

Internet-based, persuasive computing programs hold promise as an effective new approach to HIV prevention for MSM, at least in the short term. Further, online trials can be conducted with acceptable retention provided strong retention protocols are employed. Four directions for future research are identified.

Hepatitis C virus risk behaviors within the partnerships of young injecting drug users

AIMS

Young injection drug users (IDU) are at high risk for hepatitis C virus (HCV). We sought to determine whether perceiving one's injecting partner to be HCV positive was associated with decreased odds of engaging in receptive needle/syringe sharing (RNS) or ancillary equipment sharing (AES) with that partner.

DESIGN

Cross sectional study.

SETTING

2003 to 2007 in San Francisco.

PARTICIPANTS

212 young (under age 30) IDU who were HCV antibody negative reported on 492 injecting partnerships.

MEASUREMENTS

Self-reported RNS and AES within injecting partnerships.

FINDINGS

RNS and AES (in the absence of RNS) occurred in 23% and 64% of injecting partnerships in the prior month. The odds of engaging in RNS were significantly lower for relationships in which the participant reported that his/her partner was HCV positive (odds ratio [OR] 0.49; 95% confidence interval [CI] 0.25-0.95). This association was attenuated when adjusted for reusing one's own needle/syringe (adjusted OR 0.57; 95% CI 0.28-1.15). The odds of engaging in AES were lower for participants who did not know the HCV status of their partner, only among non-sexual partnerships (OR 0.47; 95% CI 0.29-0.76).

CONCLUSIONS

Because perceiving one's partner to be HCV positive was associated with decreased RNS, increased HCV testing and partner disclosure may be warranted. AES was common and was decreased only among non-sexual partnerships in which the HCV status of the partner was not known. This suggests that interventions to reduce AES in young IDU must be widespread.

Methods for recruiting men of color who have sex with men in prevention-for-positives interventions

Men who have sex with men (MSM), especially MSM of color, are disproportionately impacted by HIV/AIDS compared to heterosexuals and Caucasians. Nonetheless, fewer sexual and ethnic minorities participate in prevention interventions for people with HIV. We consider recruitment for Positive Connections, a randomized controlled trial comparing unsafe sex prevention interventions primarily for HIV-positive (HIV+) MSM in six US epicenters. One community-based organization (CBO) in each city recruited adult MSM, particularly men of color and HIV+. Recruitment methods included on-line and print advertising, outreach events, health professionals, and social networks. Data on demographics, HIV status, and recruitment method were collected at registration. We tested for differences in registration proportions and attendance rates by recruitment strategy, stratified on race/ethnicity and serostatus. Of the 1,119 registrants, 889 attended the intervention. The sample comprised 41% African American, 18% Latino/Hispanic, and 77% HIV+. Friend referral was reported by the greatest proportion of registrants, particularly among African American (33%) and HIV+ men (25%). Print advertising yielded the largest proportions of non-Hispanic white (27%) and HIV-negative registrants (25%). Registrants recruited on-line were the least likely to attend (45% versus 69% average); this effect was strongest among Latino/Hispanic (27% attendance) and non-Hispanic white men (36%). Retention during the follow-up period did not differ by serostatus, race/ethnicity, or recruitment method. Differential attendance and retention according to recruitment strategy, serostatus, and racial/ethnic group can inform planning for intervention sample size goals.

Sexual risk behaviour of men who have sex with men: emerging patterns and new challenges

PURPOSE OF REVIEW

Antiretroviral treatment means that an increasing number of men who have sex with men (MSM) are living with HIV. The present review focuses on continuing transmission of HIV, risk factors for HIV infection in HIV-negative MSM, risk behaviour and risk reduction interventions among HIV-positive MSM, sexually transmitted infections, HIV and ageing and new and emerging populations of MSM communities.

RECENT FINDINGS

Transmission of HIV infection continues in populations of MSM; transmission may be particularly high from main partners. Serosorting offers limited protection against HIV infection for HIV-negative MSM; negotiated safety and strategic positioning may be partially protective. For HIV-positive men, serosorting is a strategy to prevent HIV transmission, but has contributed to high rates of new non-HIV sexually transmitted infections. Sexual networks are important to the understanding of emerging sexually transmitted infections; ageing brings a new dimension to research on HIV.

SUMMARY

Strategies other than exclusive condom use have emerged in communities of MSM to reduce the risk of HIV transmission, including serosorting and strategic positioning. 'Combination prevention' - using social structural, behavioural and biomedical approaches in tandem - could reduce the risk of HIV transmission, and may be particularly suited to HIV-positive MSM.

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

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

The potential role of biomarkers in HIV preventive vaccine trials

BACKGROUND

Successful conduct of HIV vaccine efficacy trials entails identification and enrollment of at-risk populations, assessment of appropriate end points as measures of vaccine efficacy for prevention of HIV acquisition, and amelioration of disease course among infected vaccinees, as well as identification of potential confounders or effect modifiers. Although not invariably useful and bringing their own cost in terms of measurement and validation, a variety of biomarkers may aid at each stage of trial conduct.

METHODS

A review of selected articles, chosen based on quality, relevance of the biomarker to HIV vaccine trials, and availability of the publication, was conducted. The authors also drew experience from current trials and other planned or ongoing trials.

CONCLUSIONS

Biomarkers are available to assess HIV incidence in potential study populations, but care is needed in interpreting results of these assays. During trial conduct, sexually transmitted infections such as herpes simplex virus type 2 may act as effect modifiers on primary and secondary end points, including HIV incidence and set point viral load. The utility of sexually transmitted infection biomarkers will likely depend heavily on local epidemiology at clinical trial sites. Analyses from recent large HIV vaccine efficacy trials point to the complexities in interpreting trial results and underscore the potential utility of biomarkers in evaluating confounding and effect modification.

Formation of personal HIV disclosure policies among HIV-positive men who have sex with men

Given the increasing emphasis on "prevention with positives" programs designed to promote HIV transmission risk reduction among people living with HIV/AIDS, better understanding of influences upon serostatus disclosure in sexual situations is needed. Based on grounded theory analyses of individual interviews, this exploratory research hypothesizes and interprets how 15 HIV-positive men who have sex with men (MSM) formed personal HIV disclosure policies for sexual situations. Participants described five elements influencing development of their personal policies, including: (1) making sense of having been infected, (2) envisioning sex as an HIV-positive man, (3) sorting through feelings of responsibility for others, (4) responding to views of friends and the gay community, and (5) anticipating reactions and consequences of disclosure. The article concludes with implications for current initiatives for prevention with positives.