Sexually transmitted infections and infectiousness beliefs among people living with HIV/AIDS: implications for HIV treatment as prevention

Amplified HIV Transmission Risk Among People Living With HIV in Southeast Brazil

ABSTRACT

This study investigated the factors associated with amplified HIV transmission risk among people living with HIV from a city in southeast Brazil. A cross-sectional study was conducted with 397 people living with HIV recruited in infectious diseases clinics. Data on risk of HIV transmission, sociodemographic characteristics, sexual behaviors, professional counseling, serological HIV status, HIV-related clinical data, and beliefs about risk of HIV transmission were collected through interviews and medical records. Hierarchical ordered multinomial regression analyses were performed. Amplified HIV risk transmission was associated with lower age, alcohol consumption before having sex, illicit drug use before sexual intercourse, and not receiving professional counseling about HIV transmission. The belief that HIV can be transmitted to a partner not living with HIV was associated with lower likelihood of amplified risk for HIV transmission. Our findings suggest the importance of minimizing substance use before having sex, professional counseling, and beliefs about HIV transmission on amplified HIV risk transmission.

Temporal Changes in Sexually Transmitted Infections in a Cohort of Men Who Have Sex with Men Living with HIV: Sex Partner Seeking and Behavioral Correlates

With "undetectable equals untransmittable," continued engagement in condomless sex has prolonged STI risk in people living with HIV. This study examined the pattern and relationship between STI diagnosis and sex partner-seeking practice over time in a cohort of men who have sex with men (MSM) attending the HIV specialist clinic in Hong Kong. Participants' STI diagnosis record since HIV diagnosis was retrieved and their frequency of seeking sex partners (A) before, (B) after HIV diagnosis, and (C) following extended period (5-10 years), through eight different settings, was assessed in two rounds of survey, along with their risk behavioral profile. Multivariable regression models were employed to study the factors associated with STI diagnosis and partner-seeking frequency, while their temporal relationships over the three time points (A-C) were examined using cross-lagged panel model. Of 345 subjects recruited, STI incidence dropped from 252 to 187 cases/1000 person-years during 2015-2019. Totally 139/212 MSM (66%) had ≥ 1 episode of STI within the 10-year period after HIV diagnosis, giving an 11-20% annual prevalence. The reduced frequency of seeking sex partner was well preserved following diagnosis with a rebound specifically noted in the use of mobile application, the patrons of which were more likely to be co-infected with STI in 2019. Chemsex, concurrent partnership, and casual sex were risk factors shared between frequent partner-seeking practice and STI diagnosis. A robust autoregressive effect for partner-seeking frequency was also identified, and which significantly predicted STI risk in the long term. To enhance HIV care, the co-administration of STI/behavioral surveillance should be emphasized.

Factors Associated with Sexually Transmitted Infections among Users of Voluntary HIV Counseling and Testing Centers in Portugal

Objective: Users of publicly funded voluntary HIV Counseling and Testing Centers (VCT C) in the Portuguese National Service have been found to have higher rates of HIV risk behavior than the general population, but data concerning the relationship between socio-demographic, behavioral, and cognitive variables, and Sexually Transmitted Infections (ST Is) in this specific population are limited. This study tests the impact of socio-demographic, behavioral and cognitive variables on ST Is in a sample of 168 users of VCT C. Methods: A cross-sectional study using structured questionnaires was conducted. Results: Being older, being gay or bisexual, and having more barriers towards safer sex (e.g., negative attitudes toward safer sex behavior) were associated with increased odds of having had a ST I diagnosis. We found significant differences between heterosexual and gay men for number of sexual partners, frequency of anal sex, exchanging sex for money or drugs, history of ST Is, AIDS knowledge, and risk beliefs about the partner, with gay men showing higher rates. Conclusions: ST Is education should target older, gay or bisexual individuals, and focus on information as well as on changing barriers towards safer sex and associated health beliefs.

Predictors of Condomless Anal Intercourse in Young HIV-Positive Men Who Have Sex With Men With Detectable Viral Loads

PURPOSE

A minority of young, gay, bisexual, and other men who have sex with men (YGBMSM) living with HIV in the U.S. achieve viral suppression, thus increasing the likelihood of viral transmission during condomless anal intercourse (CAI). The purpose of this study was to explore potential risk factors for CAI and serodiscordant CAI (SD-CAI) among YGBMSM with detectable viremia.

METHODS

A total of 146 YGBMSM (aged 16-24 years) with a detectable viremia enrolled in a mobile health adherence intervention. Baseline characteristics, stratified by any CAI and any SD-CAI (past 3 months), were computed. Random Forests and regression methods were used to assess factors associated with each type of CAI. Adjusted prevalence rate ratios (aPRR) and 95% confidence intervals (CIs) were calculated.

RESULTS

Half (51.9%) reported engaging in CAI; 57.1% of those reported SD-CAI. There was strong agreement between the Random Forests and regression methods. Significant risk factors of CAI included marijuana use (aPRR = 1.97, 95% CI: 1.21-3.21), problematic substance use (aPRR = 1.56, 95% CI: 1.11-2.20), and being in a committed relationship (aPRR = 1.66, 95% CI: 1.21-2.27). Only 47% believed they were less likely to transmit HIV through CAI when virally suppressed.

CONCLUSION

High rates of CAI, including engagement in SD-CAI in a population of YGBMSM with detectable viral loads, pose significant concerns for onward transmission. Individual, dyadic, and structural predictors of CAI were associated with engagement in risk in this priority population. Addressing these factors in concert with ensuring viral suppression will be key to ending the epidemic among youth.

Risk Factors Associated with HIV, Sexually Transmitted Infections (STI), and HIV/STI Co-infection Among Youth Living in the Slums of Kampala, Uganda

The purpose of this analysis was to examine the associated factors of self-reported HIV/STI co-infection among youth living in the slums of Kampala. The study sample consists of a cross-sectional survey. Participants comprised a convenience sample (N = 1134) of youth living on the streets or in the slums (age 12-18). Multinomial logistic regression analyses were used to determine the association between hypothesized risk factors and levels of HIV/STI co-infection, adjusting for sociodemographic variables. Among the sample of youth who were sexually active (n = 586), 9.9% (n = 58) of youth reported HIV/STI co-infection. Among youth with HIV (13.8%), 71.6% reported a co-infection with another STI. In the multivariable analysis, youth with HIV/STI co-infection were more likely to engage in problem drinking (OR 2.55; 95% CI 1.08, 6.02) and drinking alcohol without problematic alcohol behavior (OR 3.43; 95% CI 1.60, 7.36). HIV/STI co-infection rates are high among youth living in the slums of Kampala and warrant urgent attention.

Contrasting HIV prevalence trends among young women and men in Zambia in the past 12 years: data from demographic and health surveys 2002-2014

BACKGROUND

The HIV epidemic remains a concern on the global health agenda, despite progress made in reducing incidence. Investigation of trends among young people is important for monitoring HIV incidence and informing programming. The study examined geographical and sub-population differences in HIV prevalence trends among young people aged 15-24 years in Zambia.

METHODS

This study analysed data from Zambia Demographic and Health Surveys (ZDHSs) that were conducted in 2001-2, 2007, and 2013-14. A two-stage cluster stratified sampling procedure was used to select samples of 8050, 7969, and 18,052 for the three surveys, respectively. Young people (15-24 years) with known HIV status were selected for analysis. The outcome variable was HIV status. Log binomial regression analysis of generalised linear models was used to test for trends.

RESULTS

Overall HIV prevalence declined over the period 2001-2 to 2013-14 among women and men aged 15-49 years (17.8 and 12.9% to 15.1 and 11.3%, respectively). There was, however, an increase in HIV prevalence among urban young men over this period, from 3.7% in 2001-2 to 7.3% in 2013-14 (aRR 2.17, 95% CI 0.99-4.75), and, in rural areas, from 2.6 to 3.6% (aRR 1.46, 95% CI 0.78-2.75). In contrast, HIV prevalence among women declined over the same period of time. In urban areas, HIV prevalence among women declined from 15.2 to 10.7% (aRR 0.66, 95% CI 0.53-0.93), while in rural areas it declined from 8.2 to 4.8% (aRR 0.41, 95% CI 0.59-0.85). In addition, there was a narrowing gender gap in terms of HIV infection, as the prevalence ratio of females to males declined from 4.2 and 3.1 to 1.5 and 1.3, in urban and rural areas, respectively.

CONCLUSIONS

The increase in HIV prevalence among urban young men over the past 12 years, contrasting declining trends among young women in both urban and rural populations, suggests differential effects of prevention efforts. Furthermore, findings that Zambia's overall national HIV prevalence decline masks some striking sex and rural/urban differentials, indicate the need for reconsidering the prevention efforts for young urban men.

Incidence rate of sexually transmitted infections among HIV infected patients on long-term ART in an urban and a rural clinic in Uganda

BACKGROUND

HIV immunosuppression increases susceptibility to other STIs and STIs can enhance HIV transmission, reduce CD4 cell count and increase viral load. Co-infections of HIV and STIs may thus reduce the preventive benefits of ART. Little is known about the incidence rate of STIs among long-term patients on ART.

METHOD

We conducted a secondary data analysis of all patients enrolled in a rural and an urban longitudinal cohort studies who initiated ART between April 2003 and July 2007 followed up to 2016. Patients were screened for STI every three months using "a syndromic and case management approaches". STI incidence rate, was defined as the number of new cases per population at risk over the follow-up review period. We performed a time-to-event and Kaplan Meier analysis. We used a multivariable Cox proportional hazards regression model to assess for factors associated with STI incidence.

RESULT

Of 1012 participants, 402 (39.8%) were urban and 610 (60.2%) rural residents. Mean age was 42.8 years (SD 8.5). The total number of follow up time was 44,304 person years. We observed STI incidence rate of 2.1 per 1000 person-years after follow-up. Rural residence (adjusted hazard ratio [aHR] 3.53, 95% CI: 1.95-6.39), younger age (aHR 2.05, 95% CI: 1.02-4.12 for 18-34 years and aHR 1.65, 95% CI: 1.00-2.72 for 35-44 years) were factors associated with higher incidence of STIs. Being male (aHR 0.51, 95% CI: 0.27-0.93) was associated with a lower incidence of STIs.

CONCLUSION

We found STIs incidence rate of approximately 3 per 1000 person-years among patients on long-term (≥ 4 years) ART followed up-to 3.5 years. Rural and younger persons on ART should be routinely screened for STIs because high incidence of STIs may undo the preventative effects of ART for all.

Sexually Transmitted Infections Among HIV-Infected Individuals in the District of Columbia and Estimated HIV Transmission Risk: Data From the DC Cohort

Background

Washington, DC, has one of the highest rates of HIV infection in the United States. Sexual intercourse is the leading mode of HIV transmission, and sexually transmitted infections (STIs) are a risk factor for HIV acquisition and transmission.

Methods

We evaluated the incidence and demographic factors associated with chlamydia, gonorrhea, and syphilis among HIV-infected persons enrolled at 13 DC Cohort sites from 2011 to 2015. Using Poisson regression, we assessed covariates of risk for incident STIs. We also examined HIV viral loads (VLs) at the time of STI diagnosis as a proxy for HIV transmission risk.

Results

Six point seven percent (451/6672) developed an incident STI during a median follow-up of 32.5 months (4% chlamydia, 3% gonorrhea, 2% syphilis); 30% of participants had 2 or more STI episodes. The incidence rate of any STIs was 3.8 cases per 100 person-years (95% confidence interval [CI], 3.5-4.1); age 18-34 years, 10.8 (95% CI, 9.7-12.0); transgender women, 9.9 (95% CI, 6.9-14.0); Hispanics, 9.2 (95% CI, 7.2-11.8); and men who have sex with men (MSM), 7.7 (95% CI, 7.1-8.4). Multivariate Poisson regression showed younger age, Hispanic ethnicity, MSM risk, and higher nadir CD4 counts to be strongly associated with STIs. Among those with an STI, 41.8% had a detectable VL within 1 month of STI diagnosis, and 14.6% had a VL ≥1500 copies/mL.

Conclusions

STIs are highly prevalent among HIV-infected persons receiving care in DC. HIV transmission risk is considerable at the time of STI diagnosis. Interventions toward risk reduction, antiretroviral therapy adherence, and HIV virologic suppression are critical at the time of STI evaluation.

HIV Disclosure and Transmission Risks to Sex Partners Among HIV-Positive Men

Disclosure of HIV-positive status to sex partners is critical to protecting uninfected partners. In addition, people living with HIV often risk criminal prosecution when they do not inform sex partners of their HIV status. The current study examined factors associated with nondisclosure of HIV status by men living with HIV in Atlanta, GA (92% African African, mean age = 43.8), who engage in condomless sex with uninfected sex partners. Sexually active HIV-positive men (N = 538) completed daily electronic sexual behavior assessments over the course of 28 days and completed computerized interviews, drug testing, medication adherence assessments, and HIV viral load retrieved from medical records. Results showed that 166 (30%) men had engaged in condomless vaginal or anal intercourse with an HIV-uninfected or unknown HIV status sex partner to whom they had not disclosed their HIV status. Men who engaged in nondisclosed condomless sex were less adherent to their HIV treatment, more likely to have unsuppressed HIV, demonstrated poorer disclosure self-efficacy, enacted fewer risk reduction communication skills, and held more beliefs that people with HIV are less infectious when treated with antiretroviral therapy. We conclude that undisclosed HIV status is common and related to condomless sex with uninfected partners. Men who engage in nondisclosed condomless sex may also be more infectious given their nonadherence and viral load. Interventions are needed in HIV treatment as prevention contexts that attend to disclosure laws and enhance disclosure self-efficacy, improve risk reduction communication skills, and increase understanding of HIV infectiousness.

Diminishing Perceived Threat of AIDS and Increasing Sexual Risks of HIV Among Men Who Have Sex with Men, 1997-2015

Community-wide awareness that antiretroviral therapies (ART) provides protection against HIV has the potential to increase perceived safety and thereby increase condomless anal sex among men who have sex with men (MSM). Furthermore, reductions in condom use can increase exposure to sexually transmitted infections, which in turn can reduce the protective effects of ART on HIV transmission. The current study extends previous community-based behavioral surveillance research on beliefs regarding use of ART for HIV prevention and sexual practices among MSM. Anonymous cross-sectional community surveys were collected from 1831 men at the same gay pride event in Atlanta, GA four times over nearly two decades; 1997, 2005-2006 (the 2006 survey over-sampled African-Americans to diversify the study), and 2015. Results indicate clear and consistent trends of increasing beliefs that HIV treatments reduce HIV transmission risks, reflecting the dissemination of HIV prevention research findings. Changes in treatment beliefs coincide with increased rates of condomless anal intercourse. Increased beliefs that treatments prevent HIV and increased condomless anal sex were observed for both HIV positive men and men who had not tested HIV positive. Results illustrate the emergence of an era where ART is the focus of HIV prevention and community-held beliefs and behaviors regarding definitions of risk create a new and potentially problematic environment for HIV transmission.

The association between symptoms of mental disorders and health risk behaviours in Vietnamese HIV positive outpatients: a cross-sectional study

Background

A high prevalence of symptoms of mental disorders (SOMD) has been found among people living with HIV/AIDS (PLHIV). Additionally, SOMD may impact on the prevalence of high-risk health behaviours (HRB). This study investigates the relationship between SOMD and HRB in a large sample of Vietnamese HIV positive outpatients.

Methods

A cross-sectional study was conducted with 400 outpatients at two HIV/AIDS clinics in Ho Chi Minh City, Vietnam, selected using a systematic sampling technique. Validated scales were used to measure SOMD, specifically symptoms of depression, anxiety, alcohol use disorder (AUD), substance use disorder (SUD) and HIV associated dementia (HAD). Participants completed a self-report questionnaire assessing HRB during the preceding 12 months including unsafe sexual practices and illicit drug use. Multivariable logistic regression models were used to evaluate associations between SOMD and HRB.

Results

The majority of participants (63.5%) were male and the median age was 34.0 years. Unsafe sexual practices and illicit drug use were reported by 13.8 and 5.5% of participants. The prevalences of HAD, depression, AUD, anxiety and SUD symptoms were 39.8, 36.5, 13.3 10.5, 3.3% respectively. There was no association between SOMD and HRB either with or without adjusting for correlates of HRB, except between symptoms of SUD and illicit drug use. PLHIV who had symptoms of SUD were more likely to use illicit drugs (adjusted Odds Ratio 81.14, 95% CI 12.55–524.47).

Conclusions

While the prevalence of SOMD among HIV positive outpatients was high, most SOMD were not associated with increased HRB. Only illicit drug use was predicted by symptoms of SUD. Screening PLHIV for symptoms of SUD may be useful for detecting people likely to be engaging in illicit drug use to reduce the risk of secondary disease transmission.

PEP and TasP Awareness among Italian MSM, PLWHA, and High-Risk Heterosexuals and Demographic, Behavioral, and Social Correlates

Post-exposure prophylaxis (PEP) has been proposed as a strategy to prevent the acquisition of HIV infection after certain high-risk exposures, and treatment as prevention (TasP) is also being advocated as a means to reduce sexual transmission of HIV. The aim of this study was to investigate the prevalence of PEP and TasP awareness and their demographic, behavioral, and social correlates in Italy. We conducted a cross-sectional survey of 1,028 high-risk heterosexual men and women, 1,874 non-HIV positive MSM (men who have sex with men), and 694 people living with HIV/AIDS (PLWHA). The majority of the participants was aware of PEP and unaware of TasP. MSM were less knowledgeable about PEP and TasP than were PLWHA and more knowledgeable about PEP and TasP than were high-risk heterosexual participants. The variables most consistently associated with PEP and TasP awareness were contact with HIV/AIDS organizations, HIV testing, and HIV stigma. A positive relationship between unprotected sexual intercourse and PEP and TasP awareness was found among high risk heterosexual participants, while this association was not significant among MSM and PLWHA. Because PEP and TasP are currently recommended, effective educational and dissemination strategies are needed to increase the level of knowledge about PEP and TasP.

Implementation challenges and opportunities for HIV Treatment as Prevention (TasP) among young men in Vancouver, Canada: a qualitative study

BACKGROUND

Despite evidence supporting the preventative potential of HIV Treatment as Prevention (TasP), scientific experts and community stakeholders have suggested that the success of TasP at the population level will require overcoming a set of complex and population-specific implementation challenges. For example, the factors that might influence decisions to initiate 'early' treatment have yet to be thoroughly understood; neither have questions about the factors that enhance or impede their ability to achieve long-term adherence to ARVs or the social norms regarding various treatment regimens been examined in detail. This knowledge gap may hamper opportunities to effectively develop public health practices that are informed by the various challenges and opportunities related to TasP implementation and scale up.

METHODS

Drawing on 50 in-depth, individual interviews with young men ages 18-24 in Vancouver, Canada, this study examines young men's perspectives regarding factors that might affect their engagement with TasP.

RESULTS

While findings from the current study indicate young men generally have a high receptiveness to TasP, our findings also identify key social and structural forces that will warrant ongoing consideration for TasP implementation. For example, participants described how an enhanced awareness regarding treatment (including awareness of the universal availability of treatment in Vancouver) would be a necessary, but not sufficient, condition to decide to endorse TasP. Their decisions about engaging in HIV care in the context of TasP (e.g., HIV testing, treatment initiation, long-term adherence) also appear to be contingent on their ability to negotiate or 'balance' the risks and benefits to themselves and others. The findings also offer insight into the complex and sometimes controversial narratives that continue to emerge regarding risk compensation practices in the context of TasP.

CONCLUSION

Based on the results of this study, we identify several areas that hold promise for informing the effective scale up of TasP, including new information regarding implementation adaptation strategies.

Willingness to Act upon Beliefs about 'Treatment as Prevention' among Australian Gay and Bisexual Men

HIV ‘treatment as prevention’ (TasP) is highly effective in reducing HIV transmission in serodiscordant couples. There has been little examination of gay and bisexual men’s attitudes towards TasP, particularly regarding men’s willingness to act on beliefs about TasP. We conducted an online cross-sectional survey of Australian men in late 2012 to investigate knowledge and beliefs about new developments in HIV prevention. Amongst 839 men (mean age 39.5 years), men tended to disagree that TasP was sufficiently effective to justify reduced condom use, although HIV-positive men had more favourable attitudes. Only a minority of men were aware of any evidence for TasP; and one-quarter incorrectly believed that evidence for the effectiveness of TasP already existed for the homosexual population. One-fifth (20.5%) of men reported that they would be willing to have condomless anal intercourse with an opposite-status sexual partner when the HIV-positive partner was taking HIV treatments. Factors independently associated with such willingness were: HIV-positive serostatus, reporting any serodiscordant or serononconcordant condomless anal intercourse with a regular male partner in the previous six months, reporting any condomless anal intercourse with a casual male partner in the previous six months, and having greater beliefs in the effectiveness of TasP. This indicated that the men most willing to rely on TasP to prevent transmission were already engaging in higher risk practices. Biomedical HIV prevention represents a rapidly changing environment with new research as well as community and policy responses emerging at a fast pace. For men with serodiscordant sexual partners to successfully apply TasP to reducing transmission risk, more support and education is needed to enable better utilisation of TasP in specific relational and sexual contexts.

Key factors in the acceptability of treatment as prevention (TasP) in Scotland: a qualitative study with communities affected by HIV

OBJECTIVES

There is a clear need to understand the factors that might prevent and/or facilitate the effective use of HIV treatment as prevention (TasP) at an individual level. This paper reports on findings from the first qualitative study in the UK exploring the acceptability of TasP among gay, bisexual and/or men who have sex with men (MSM) and migrant African communities in Scotland.

METHODS

We conducted seven exploratory focus group discussions (FGDs) with convenience samples of MSM (five FGDs, n=22) and mixed-gender African (two FGDs, n=11) participants. Of these, three FGDs were conducted with HIV-positive MSM (n=14) and one FGD with HIV-positive Africans (n=8). We then conducted 34 in-depth interviews (IDIs) with a purposive sample of MSM (n=20) and Africans (n=14, women=10). Half were HIV-positive (MSM, n=10; African, n=7). FGD and IDI data were analysed thematically drawing on predetermined and emergent themes.

RESULTS

We found that inequalities in HIV literacy could be a barrier to TasP, as could social constraints, such as criminalisation of transmission, increased risk of sexually transmitted infection and increased burden of treatment. We also identified psychological barriers such as perceptions of risk. However, relationships and shared decision making were identified as potential facilitators for TasP.

CONCLUSIONS

Our results suggest that potential use and management of TasP may not be straightforward. It could be contingent on reducing inequalities in HIV literacy, minimising the perceived burden of treatment and other potential risks, and addressing the dynamics of existing and socially acceptable risk management strategies, especially in relation to long-term serodiscordant relationships.

Australian gay and bisexual men's attitudes to HIV treatment as prevention in repeated, national surveys, 2011-2013

Objective

Assess the acceptability of HIV treatment as prevention and early antiretroviral treatment among gay and bisexual men in Australia and any changes in attitudes over time.

Methods

National, online, cross-sectional surveys of gay and bisexual men were repeated in 2011 and 2013. Changes in attitudes to HIV treatment over time were assessed with multivariate analysis of variance. The characteristics of men who agreed that HIV treatment prevented transmission and thought that early treatment was necessary were identified with multivariate logistic regression.

Results

In total, 2599 HIV-negative, untested and HIV-positive men participated (n = 1283 in 2011 and n = 1316 in 2013). Attitudes changed little between 2011 and 2013; most participants remained sceptical about the preventative benefits of HIV treatment. In 2013, only 2.6% of men agreed that HIV treatment prevented transmission; agreement was associated with being HIV-positive, having an HIV-positive regular partner, and having received HIV post-exposure prophylaxis. In contrast, 71.8% agreed that early antiretroviral treatment is necessary; younger men were more likely and HIV-positive men and participants with HIV-positive partners were much less likely to agree with this.

Conclusions

Promoting the individual health benefits of HIV treatment rather than its preventative benefits remains more acceptable to Australian gay and bisexual men.

Age, race/ethnicity, and behavioral risk factors associated with per contact risk of HIV infection among men who have sex with men in the United States

OBJECTIVE

Young men who have sex with men (MSM) and MSM of color have the highest HIV incidence in the United States. To explore possible explanations for these disparities and known individual risk factors, we analyzed the per contact risk (PCR) of HIV seroconversion in the early highly active antiretroviral therapy era.

METHODS

Data from 3 longitudinal studies of MSM (HIV Network for Prevention Trials Vaccine Preparedness Study, EXPLORE behavioral efficacy trial, and VAX004 vaccine efficacy trial) were pooled. The analysis included visits where participants reported unprotected receptive anal intercourse (URA), protected receptive anal intercourse, or unprotected insertive anal intercourse (UIA) with an HIV seropositive, unknown HIV serostatus, or an HIV seronegative partner. We used regression standardization to estimate average PCRs for each type of contact, with bootstrap confidence intervals.

RESULTS

The estimated PCR was highest for URA with an HIV seropositive partner (0.73%; 95% bootstrap confidence interval [BCI]: 0.45% to 0.98%) followed by URA with a partner of unknown HIV serostatus (0.49%; 95% BCI: 0.32% to 0.62%). The estimated PCR for protected receptive anal intercourse and UIA with an HIV seropositive partner was 0.08% (95% BCI: 0.0% to 0.19%) and 0.22% (95% BCI: 0.05% to 0.39%), respectively. Average PCRs for URA and UIA with HIV seropositive partners were higher by 0.14%-0.34% among younger participants and higher by 0.08% for UIA among Latino participants compared with white participants. Estimated PCRs increased with the increasing number of sexual partners, use of methamphetamines or poppers, and history of sexually transmitted infection.

CONCLUSIONS

Susceptibility or partner factors may explain the higher HIV conversion risk for younger MSM, some MSM of color, and those reporting individual risk factors.

How acceptable are antiretrovirals for the prevention of sexually transmitted HIV?: A review of research on the acceptability of oral pre-exposure prophylaxis and treatment as prevention

Recent research has demonstrated how antiretrovirals (ARVs) could be effective in the prevention of sexually transmitted HIV. We review research on the acceptability of oral pre-exposure prophylaxis (PrEP) and treatment as prevention (TasP) for HIV prevention amongst potential users. We consider with whom, where and in what context this research has been conducted, how acceptability has been approached, and what research gaps remain. Findings from 33 studies show a lack of TasP research, PrEP studies which have focused largely on men who have sex with men (MSM) in a US context, and varied measures of acceptability. In order to identify when, where and for whom PrEP and TasP would be most appropriate and effective, research is needed in five areas: acceptability of TasP to people living with HIV; motivation for PrEP use and adherence; current perceptions and management of risk; the impact of broader social and structural factors; and consistent definition and operationalisation of acceptability which moves beyond adherence.

Incorporating couples-based approaches into HIV prevention for gay and bisexual men: opportunities and challenges

Thirty years after the beginning of the HIV epidemic, gay, bisexual, and other men who have sex with men (collectively called MSM) bear a disproportionate burden of HIV in the United States and continue to acquire a distressingly high number and proportion of new infections. Historically, HIV prevention for MSM has been focused on individual-level behavior change, rarely intervening with MSM as part of a couple. Yet, an estimated 33–67% of HIV infections among MSM are acquired from primary sexual partners, suggesting that work with MSM as couples could be an important contributor to prevention. Given the emergence of high impact combination HIV prevention, it is timely to consider how work with the broad variety of male couples can improve both personal and community health. Couples HIV testing and counseling for MSM is an important advance for identifying men who are unaware that they are HIV-positive, identifying HIV-discordant couples, and supporting men who want to learn their HIV status with their partner. Once men know their HIV status, new advances in biomedical prevention, which can dramatically reduce risk of HIV transmission or acquisition, allow men to make prevention decisions that can protect themselves and their partners. This paper highlights the present-day challenges and benefits of using a couples-based approach with MSM in the era of combination prevention to increase knowledge of HIV status, increase identification of HIV discordant couples to improve targeting prevention services,and support mutual disclosure of HIV status.

Treatment-related optimistic beliefs and risk of HIV transmission: a review of recent findings (2009-2012) in an era of treatment as prevention

The promising outlook for HIV treatment as prevention (TasP) offered by the recent success in clinical trials has highlighted the need for effort against over-optimism toward anti-retroviral therapy (ART). It has been of a central concern that such optimistic beliefs may fuel an increase in risk behaviors to counter the protective effect of ART on reducing overall transmissibility of HIV. The current review was conducted to provide an updated look at the potential impact of treatment-related optimistic beliefs on the risk of HIV transmission. The review yielded a total of 14 studies published during the past 4 years that have examined the role of treatment-related optimistic beliefs in changing people's adoption of sexual risk behaviors. Findings from quantitative studies were largely in support of an association between optimistic beliefs and risk of HIV transmission. Results from qualitative studies discovered additional information concealed under the numerical associations, and pointed to the need of more rigorous and comprehensive examination of the relationship between optimistic beliefs and HIV transmission risk. Gaps in the current literature were identified and suggestions for future research were provided.

Clinical uncertainties, health service challenges, and ethical complexities of HIV "test-and-treat": a systematic review

Despite the HIV "test-and-treat" strategy's promise, questions about its clinical rationale, operational feasibility, and ethical appropriateness have led to vigorous debate in the global HIV community. We performed a systematic review of the literature published between January 2009 and May 2012 using PubMed, SCOPUS, Global Health, Web of Science, BIOSIS, Cochrane CENTRAL, EBSCO Africa-Wide Information, and EBSCO CINAHL Plus databases to summarize clinical uncertainties, health service challenges, and ethical complexities that may affect the test-and-treat strategy's success. A thoughtful approach to research and implementation to address clinical and health service questions and meaningful community engagement regarding ethical complexities may bring us closer to safe, feasible, and effective test-and-treat implementation.

Sexual HIV transmission and antiretroviral therapy: a prospective cohort study of behavioral risk factors among men and women living with HIV/AIDS

BACKGROUND

Using antiretroviral therapies for HIV prevention relies on patient adherence and avoidance of co-occurring sexually transmitted infections.

PURPOSE

The objective of this study is to simultaneously examine HIV treatment adherence and sexual risks for HIV transmission.

METHODS

This study is a prospective cohort of 201 men and 55 women diagnosed with HIV/AIDS infection.

RESULTS

A total of 32% men and 39% women engaged in unprotected intercourse with at least one HIV negative or unknown HIV status sex partner over 12 months. Nearly half (46%) of participants with HIV negative or unknown HIV status unprotected sex partners had detectable HIV viral load and were significantly more likely to have contracted a sexually transmitted infection since their HIV diagnosis. Individuals at higher risk for transmitting HIV were also less adherent to antiretroviral therapies.

CONCLUSIONS

Programs that aim to use antiretroviral therapies for HIV prevention require careful attention to adherence, sexually transmitted co-infections, and substance use.

Antiretroviral-based HIV prevention strategies for women

Almost three decades have elapsed since researchers identified HIV as the cause of AIDS, with current estimates from UNAIDS that 33.4 million adults were living with HIV/AIDS in 2008. Two-thirds of this burden of disease is in Sub-Saharan Africa, and 60% of those infected are women. The disease still remains incurable and current prevention strategies including abstinence, male/female condom use and male circumcision are only partially effective. New strategies to curb the epidemic are urgently needed. Scientists are diligently exploring HIV prevention methods that are safe, effective and affordable. These new biological interventions include oral pre-exposure prophylaxis using oral antiretroviral (ARV) drugs, ARV treatment in HIV-infected persons to reduce transmission and topical ARV-based microbicide formulations.

Prevalence of sexually transmitted co-infections in people living with HIV/AIDS: systematic review with implications for using HIV treatments for prevention

Sexually transmitted co-infections increase HIV infectiousness through local inflammatory processes. The prevalence of STI among people living with HIV/AIDS has implications for containing the spread of HIV in general and the effectiveness of HIV treatments for prevention in particular. Here we report a systematic review of STI co-infections in people living with HIV/AIDS. We focus on STI contracted after becoming HIV infected. Electronic database and manual searches located 37 clinical and epidemiological studies of STI that increase HIV infectiousness. Studies of adults living with HIV/AIDS from developed and developing countries reported STI rates for 46 different samples (33 samples had clinical/laboratory confirmed STI). The overall mean point-prevalence for confirmed STI was 16.3% (SD=16.4), and median 12.4% STI prevalence in people living with HIV/AIDS. The most common STI studied were Syphilis with median 9.5% prevalence, Gonorrhea 9.5%, Chlamydia 5%, and Trichamoniasis 18.8% prevalence. STI prevalence was greatest at the time of HIV diagnosis, reflecting the role of STI in HIV transmission. Prevalence of STI among individuals receiving HIV treatment was not appreciably different from untreated persons. The prevalence of STI in people infected with HIV suggests that STI co-infections could undermine efforts to use HIV treatments for prevention by increasing genital secretion infectiousness.