Reliability of Self-Report of HIV Status Among Men Who Have Sex With Men in Brazil

Stigmatizing Policies Interact with Mental Health and Sexual Behaviours to Structurally Induce HIV Diagnoses Among European Men Who Have Sex with Men

Structural stigma shapes men who have sex with men's (MSM's) mental health and sexual behaviours. The aim of this study was to examine how stigmatizing policies interact with downstream anxiety/depression and sexual behaviours to structurally pattern HIV disparities among European MSM. We conducted a secondary data analysis of the European Men-who-have-sex-with-men Internet Survey (EMIS) from 2017. We included a total of 98,600 participants living in 39 European countries. We used the Rainbow Index, a score given to countries based on their sexual and gender minority policies as the predictor of HIV diagnosis. We conducted adjusted random intercept and slope multi-level logistic regressions. In adjusted models, higher Rainbow Index scores was associated with lower predictive probabilities of diagnosed HIV, regardless of the number of condomless intercourse partners. The predictive probability of HIV diagnosis was also lower, regardless of severity of anxiety/depression, where the Rainbow Index score was better. Country-level policies interact with downstream sexual behaviours and anxiety/depression to structurally influence HIV diagnosis among MSM in Europe.

A Pilot RCT Evaluating InThistoGether, an mHealth HIV Prevention Program for Ugandan Youth

Despite data suggesting that older adolescence is an important period of risk for HIV acquisition in Uganda, tailored HIV prevention programming is lacking. To address this gap, we developed and tested nationally, InThistoGether (ITG), a text messaging-based HIV prevention program for 18-22 year-old Ugandan youth. To assess feasibility and acceptability, and preliminary indications of behavior change, a randomized controlled trial was conducted with 202 youth. Participants were assigned either to ITG or an attention-matched control group that promoted general health (e.g., self-esteem). They were recruited between December 2017 and April 2018 on Facebook and Instagram, and enrolled over the telephone. Between 5-10 text messages were sent daily for seven weeks. Twelve weeks later, the intervention ended with a one-week 'booster' that reviewed the main program topics. Measures were assessed at baseline and intervention end, 5 months post-randomization. Results suggest that ITG is feasible: The retention rate was 83%. Ratings for the content and program features met acceptability thresholds; program experience ratings were mixed. ITG also was associated with significantly higher rates of condom-protected sex (aIRR = 1.68, p < 0.001) and odds of HIV testing (aOR = 2.41, p = 0.03) compared to the control group. The odds of abstinence were similar by experimental arm however (aOR = 1.08, p = 0.86). Together, these data suggest reason for optimism that older adolescent Ugandans are willing to engage in an intensive, text messaging-based HIV prevention programming. Given its wide reach and low cost, text messaging should be better utilized as an intervention delivery tool in low-income settings like Uganda. Findings also suggest that ITG may be associated with behavior change in the short-term. (Trial registration: ClinicalTrials.gov ID# NCT02729337).

The Value of Assessing Self-Reported and Biological Indicators of Outcomes in Evaluating HIV Programs

PURPOSE OF REVIEW

In this manuscript, we present recent findings concerning concordance and discrepancy between biological measures and self-reports of these three outcomes of HIV programs: HIV status, adherence to antiretroviral medications (ARVs) and use of and adherence to pre-exposure prophylaxis medication (PrEP), and condom use/unprotected sex.

RECENT FINDINGS

Recent studies suggest that three successive rapid HIV tests (for those whose first test in positive) might be reasonably inexpensive and valid biological data to collect to combine with self-reports of HIV status, dried blood spots sufficiently affordable to combine with self-reports of adherence to ARVs and use of or adherence to PrEP, and that the discrepancy between self-reports of condom use and biomarkers of unprotected sex may be relatively small in high-income countries. Additional work on assessment of incorrect condom usage and breakage, standardized self-report measures of condom use, and more private data collection methodologies in low-income settings might reduce the recent observed discrepancies even further. Concordance between self-reports of HIV and biomarkers indicating HIV positive status has varied considerably, with much lower rates in low-income countries, where the stigma of HIV is still very high. Recommendation is for combining self-report data with the results of three successive rapid tests for those testing positive. For adherence, again agreement between self-reports and a variety of more objective and/or biological measures is only moderate. Dried blood spots (DBS) may be sufficiently inexpensive in low-resource settings that this may be the best biological method to combine with self-reports. In publications over the last 8 years, the discrepancy between self-reports of condom use and biomarkers for unprotected sex may be even lower than 20% after controlling for other features of the study, particularly in high-income countries. Our results suggest that more careful assessment of incorrect condom use and breakage as reasons other than intentional misreporting should be investigated more carefully and that more private data collection methods such as audio, computer-assisted self-interviewing (ACASI) might be employed more often in low-resource settings to reduce this discrepancy in those settings further. In addition, further analysis of the discrepancy between self-reports of condom use and biomarkers should be conducted of published studies using the correct calculation methods to be more certain of these findings.

Technologies for HIV prevention and care: challenges for health services

This article aims to consider some relevant challenges to the provision of "new prevention technologies" in health services in a scenario where the "advances" in the global response to AIDS control are visible. We take as material for analysis the information currently available on the HIV post-exposure prophylaxis (PEP) and pre-exposure prophylaxis (PrEP), treatment as prevention (TASP) and over the counter. The methodology consisted of the survey and analysis of the Biblioteca Virtual em Saúde (BVS: MEDLINE, LILACS, WHOLIS, PAHO, SciELO) articles that addressed the issue of HIV prevention and care in the context of so-called new prevention technologies. The results of the studies show that there is assistance on the ground of clinics for the treatment of disease responses, but there are several challenges related to the sphere of prevention. The articles list some challenges regarding to management, organization of services and the attention given by health professionals to users. The current context shows evidence of the effectiveness of antiretroviral therapy in reducing the risk of HIV transmission, but the challenges for the provision of preventive technologies in health services permeate health professionals and users in their individual dimensions and health services in organizational and structural dimension. Interventions should be made available in a context of community mobilization; there should be no pressure on people to make HIV testing, antiretroviral treatment or for prevention. In the management is responsible for the training of health professionals to inform, clarify and make available to users, partners and family information about the new antiretroviral use strategies.

A Systematic Review of Published Respondent-Driven Sampling Surveys Collecting Behavioral and Biologic Data

Reporting key details of respondent-driven sampling (RDS) survey implementation and analysis is essential for assessing the quality of RDS surveys. RDS is both a recruitment and analytic method and, as such, it is important to adequately describe both aspects in publications. We extracted data from peer-reviewed literature published through September, 2013 that reported collected biological specimens using RDS. We identified 151 eligible peer-reviewed articles describing 222 surveys conducted in seven regions throughout the world. Most published surveys reported basic implementation information such as survey city, country, year, population sampled, interview method, and final sample size. However, many surveys did not report essential methodological and analytical information for assessing RDS survey quality, including number of recruitment sites, seeds at start and end, maximum number of waves, and whether data were adjusted for network size. Understanding the quality of data collection and analysis in RDS is useful for effectively planning public health service delivery and funding priorities.

The Men Who Have Sex with Men HIV Care Cascade in Rio de Janeiro, Brazil

Brazil has a concentrated HIV epidemic and men who have sex with men (MSM) are disproportionately affected. Yet, no data is available on the HIV care cascade for this population. This study aimed to assess the HIV care cascade among MSM newly diagnosed through innovative testing strategies in Rio de Janeiro. Data from 793 MSM and travestites/transgender women (transwomen) tested for HIV at a non-governmental LGBT organization and a mobile testing unit located at a gay friendly venue were analyzed. A 12-month-after-HIV-diagnosis-censored cohort was established using CD4, viral load and combination antiretroviral therapy (cART) longitudinal data from those diagnosed with HIV. A cross-sectional HIV care cascade was built using this data. The relative risks of achieving each cascade-stage were estimated using generalized linear models according to age, self-declared skin-color, education, history of sexually transmitted diseases (STD), drug use and prior HIV testing. From Jan-2013 to Jan-2014, 793 MSM and transwomen were tested, 131 (16.5%) were HIV-infected. As of January 2015, 95 (72.5%) were linked to HIV care, 90 (68.7%) were retained in HIV care, 80 (61.1%) were on cART, and 50 (38.2%) were virally suppressed one year after HIV diagnosis. Being non-white (Relative risk [lower bound; upper bound of 95% confidence interval] = 1.709 [1.145; 2.549]) and having a prior HIV-test (1.954 [1.278; 2.986]) were associated with an HIV-positive diagnosis. A higher linkage (2.603 [1.091; 6.211]) and retention in care (4.510 [1.880; 10.822]) were observed among those who were older than 30 years of age. Using community-based testing strategies, we were able to access a high-risk MSM population and a small sample of transwomen. Despite universal care coverage and the test-and-treat policy adopted in Brazil, the MSM cascade of care indicates that strategies to increase linkage to care and prompt cART initiation targeted to these populations are critically needed. Interventions targeting non-white and young MSM should be prioritized.

Over-the-counter human immunodeficiency virus self-test kits: time to explore their use for men who have sex with men in Brazil

Increasing access and frequency of human immunodeficiency virus testing are critical to stemming the epidemic. In Brazil's concentrated epidemic, human immunodeficiency virus prevalence in the men who have sex with men/transgender population far exceeds that in the general population, but testing rates fall below what is needed to ensure early detection and treatment. Over-the-counter human immunodeficiency virus self-testing kits, now available in stores in the U.S., have enormous potential to increase testing access and frequency and to facilitate early detection and treatment. With the advent of human immunodeficiency virus self-testing upon us, it is timely to engage the scientific community, government, and civil society in a dialog around how to best utilize this technology in Brazil. We summarize recent research on over-the-counter testing among men who have sex with men, raise potential questions and challenges to using self-tests, suggest implementation strategies, and outline a research agenda moving forward.

HIV risk behaviors in the U.S. transgender population: prevalence and predictors in a large internet sample

To study the influence of gender on HIV risk, a sample of the U.S. transgender population (N = 1,229) was recruited via the Internet. HIV risk and prevalence were lower than reported in prior studies of localized, urban samples but higher than the overall U.S. population. Findings suggest that gender nonconformity alone does not itself result in markedly higher HIV risk. Sex with nontransgender men emerged as the strongest independent predictor of unsafe sex for both male-to-female (MtF) and female-to-male (FtM) participants. These sexual relationships constitute a process that may either affirm or problematize gender identity and sexual orientation, with different emphases for MtFs and FtMs, respectively.

Respondent driven sampling for HIV biological and behavioral surveillance in Latin America and the Caribbean

Since 2005, respondent driven sampling (RDS) has been widely used for HIV biological and behavioral surveillance surveys (BBSS) in Latin America and the Caribbean (LAC). In this manuscript, we provide a focused review of RDS among hard-to-reach high-risk populations in LAC and describe their principal operational, design, and analytical considerations. We reviewed published and unpublished reports, protocols, and manuscripts for RDS studies conducted in LAC between January 1, 2005 and December 31, 2011. We abstracted key operational information and generated summary statistics across all studies. Between 2005 and 2011, 87 RDS studies were conducted in 15 countries in LAC (68 % in South America, 18 % in Mexico and Central America, and 14 % in the Caribbean). The target populations were primarily men who have sex with men (43 %), sex workers (29 %), and drug users (26 %). Study considerations included establishing clear eligibility criteria, measuring social network sizes, collecting specimens for biological testing, among others. Most of the reviewed studies are the first in their respective countries to collect data on hard-to-reach populations and the first attempt to use a probability-based sampling method. These RDS studies allowed researchers and public health practitioners in LAC to access hard-to-reach HIV high-risk populations and collect valuable data on the prevalence of HIV and other infections, as well as related risk behaviors.

Prevalence, correlates, and risk perception of HIV infection among heroin users in Central Taiwan

We investigated the prevalence and correlated factors of human immunodeficiency virus (HIV) among heroin users attending methadone maintenance treatment (MMT) programs in Central Taiwan, and explored the degree of risk perception of HIV infection among the participants. Our study participants were 781 heroin users seeking treatment at the MMT program at Tsaotun Psychiatric Center in Taiwan. The presence of HIV antibodies was identified by microparticle enzyme immunoassay and confirmed by western blot. Multivariate logistic regression was used to identify the independent correlates of HIV infection. The mean age of the sample was 36.1 years [standard deviation (SD) = 7.6]; of the patients, 710 (90.9%) were men. The prevalence of HIV infection among our study population was 20.7%. Multivariate logistic regression analysis revealed that HIV infection was independently associated with the age of the patients of initial heroin use, heroin injection use, nondrug-related criminal convictions, needle-sharing behaviors, and sharing injection paraphernalia. A strong agreement existed between self-reported HIV serostatus and the results of laboratory analyses, with 88.8% of patients reporting their condition correctly. We found a high rate of HIV infection among patients in the MMT program. Factors associated with HIV infection were mostly related to drug-use behaviors. These findings stress the importance of education regarding drug-risk behaviors.

Community-Based Surveys for Determining the Prevalence of HIV, Chlamydia, and Gonorrhoea in Men Having Sex with Men in Hong Kong

Background. Community sampling of men having sex with men (MSM) for human immunodeficiency virus (HIV) and sexually transmitted infections prevalence studies poses challenges in view of problems in logistics and the hidden nature of MSM population. Methods. MSM in Hong Kong were recruited through social venues and the Internet. All participants were invited to complete a behavioural questionnaire and submit a urine specimen for HIV, Chlamydia, and gonorrhoea testing. Results. Totally, 994 MSM were recruited. No differences between venue and online-recruited respondents were identified regarding their demographics and infection status. The prevalence of HIV, Chlamydia, and gonorrhoea was 3.6% (95% CI: 2.6–5.0%), 4.7% (95% CI: 3.6–6.2%), and 0.2% (95% CI: 0.1–0.7%), respectively. Of all HIV cases, only 8.3% were aware of the infection; reflecting newly infected MSM were probably overrepresented. Some 58.3% had had HIV test within the past year, and 11.1% had CT/NG coinfection. HIV infection was associated with group sex [aOR: 2.67 (1.03–6.92)], receiving money for anal sex [aOR: 4.63 (1.12–19.18)], and unprotected anal sex with nonregular partners [aOR: 3.047 (1.16–8.01)]. Conclusion. Difference between venue- and online-recruited MSM was observed. A combination of sampling methods is complementary for epidemiology purpose. Overall, risk behaviours practised by undiagnosed HIV-positive MSM remains a cause for concern.

Forced sexual experiences as risk factor for self-reported HIV infection among southern African lesbian and bisexual women

Even though women who have sex with women are usually understood to be at no or very low risk for HIV infection, we explored whether lesbian and bisexual women in a geographical area with high HIV prevalence (Southern Africa) get tested for HIV and whether, among those women who get tested, there are women who live with HIV/AIDS. The study was conducted in collaboration with community-based organizations in Botswana, Namibia, South Africa and Zimbabwe. Data were collected via written surveys of women who in the preceding year had had sex with a woman (18 years and older; N = 591). Most participating women identified as lesbian and black. Almost half of the women (47.2%) reported ever having had consensual heterosexual sex. Engagement in transactional sex (lifetime) was reported by 18.6% of all women. Forced sex by men or women was reported by 31.1% of all women. A large proportion of the women reported to ever have been tested for HIV (78.3%); number of lifetime female and male partners was independently associated with having been tested; women who had engaged in transactional sex with women only or with women and men were less likely to have been tested. Self-reported HIV prevalence among tested women who knew their serostatus was 9.6%. Besides age, the sole independent predictor of a positive serostatus was having experienced forced sex by men, by women, or by both men and women. Study findings indicate that despite the image of invulnerability, HIV/AIDS is a reality for lesbian and bisexual women in Southern Africa. Surprisingly, it is not sex with men per se, but rather forced sex that is the important risk factor for self-reported HIV infection among the participating women. HIV/AIDS policy should also address the needs of lesbian, bisexual and other women who have sex with women.

Travestis, an unexplored population at risk of HIV in a large metropolis of northeast Brazil: a respondent-driven sampling survey

Travestis are highly vulnerable to HIV infection in Brazil. We conducted a survey among 304 travestis using Respondent-Driven Sampling from August to December 2008. Travestis are young (49% <24 years), poorly educated (55% just elementary school), low social class (62% Class C-E), reside with families (49%) or friends/madam (22%), are victims of homophobia (91%) and violence (61%). They report early sexual debut (75% <14), many sexual partners, drug use during sex (43%), and unprotected sex (male partner, 47%, both male and female partners, 50%). Sex work is common (82%, 59% >10 partners last six months) and relatively low cost (median=US$24). A majority report testing for HIV (69%), and report high prevalence (12% disclosed a positive result). Almost all the respondents refused to test in the study. Interventions, targeted to both travestis and to the general community about sexual discrimination, are necessary.