Negotiated safety - components, context and use: an integrative literature review

Physical and mental health of long-term users of HIV preexposure prophylaxis in Australia

INTRODUCTION

HIV preexposure prophylaxis (PrEP) is highly effective at preventing HIV. We aimed to assess mental and physical health among long-term PrEP users in Australia's X-PLORE cohort.

METHODS

In early 2021, 1485 X-PLORE participants were emailed a survey covering demographics, sexual practices, ongoing PrEP use, physical and psychological diagnoses received since commencing PrEP, substance use, and impacts of the COVID-19 pandemic. Current anxiety and depression were assessed using GAD-7 and PHQ-9 questionnaires.

RESULTS

Of 476 participants (completion rate 32.1%), 99.8% were cis-gender men. Median PrEP use duration was 48 months (2002 person-years), with 81.7% currently using PrEP. PrEP-related toxicity was uncommon: 2.9% reported bone fractures, 1.3% low bone density, and 4.0% reported kidney problems, largely not necessitating PrEP cessation. Most (92.0%) rated their health as 'good' to 'excellent', and 22.6% reported improved health since starting PrEP, often because of improved mental health. Only 6.2% reported deterioration in health since starting PrEP, largely unrelated to PrEP. The most common diagnoses were hypertension (9.9%), depression (13.2%) and anxiety (14.9%); 17% had PHQ-9 scores indicating current moderate-to-severe depression, which was associated with unemployment [adjusted odds ratio (aOR) 3.90], regular cannabis use (aOR 2.49), and having ceased PrEP (aOR 2.13).

CONCLUSION

Among long-term PrEP users, of which over 80% were currently using PrEP, self-reported PrEP toxicity was uncommon. With almost one in five PrEP users categorized as having depression, and with higher risk among those having ceased PrEP, we recommend routine screening for depression and anxiety in PrEP users and corresponding follow-up of patients no longer attending for PrEP.

Use of "Strengthening Our Vows" Video Intervention to Encourage Negotiated Explicit Sexual Agreements in Zambian Heterosexual HIV Seroconcordant-Negative Couples

Negotiating sexual agreements in combination with couples' voluntary HIV counseling and testing (CVCT) may help further reduce HIV transmission in Zambian concordant HIV-negative couples (CNC). Though CVCT has been shown to reduce HIV transmission in CNC by 47%, approximately half of residual infections occur in this group. We developed a "Strengthening Our Vows" video session to foster communication and negotiation of explicit sexual agreements to reduce concurrent sexual exposures and prevent HIV transmission to the spouse due to unprotected, extramarital sex. CNC were recruited through CVCT services at five clinics in Lusaka and Ndola in 2016. Enrolled CNC attending the facilitated group video sessions were encouraged to discuss sexual agreements at home and return 1-2 weeks later for follow-up assessment. One-fourth of the 580 CNC returning reported a history of extramarital partners and/or a sexually transmitted infection (STI) prior to enrollment. More than 95% reported a friendly, supportive 15-60 min negotiation culminating in an agreement to remain monogamous or disclose sexual contacts and use condoms together until a repeat HIV test 30 days after an outside sexual exposure. Two-thirds of participants identified at least one threat to adherence of their agreements including alcohol use, financial pressures, travel, discord in the home, and post-partum or menstrual abstinence. CNC negotiated explicit sexual agreements to avoid exposure to HIV through concurrent partnerships and protect the spouse in the event of an outside sexual contact. Open communication was a consistent theme to facilitate mutual protective efforts. Long-term follow-up of HIV/STI incidence is ongoing to assess the impact of these agreements.Trial registration This sub-study is part of a trial retrospectively registered on ClinicalTrials.gov (Identifier: NCT02744586) on April 20, 2016.

Vil NM, Bond KT, Mitchell JW, Juarez AC, Lambert F, Muheriwa SR, McMahon J. Dimensions of Sexual Health Conversations among U.S. Black Heterosexual Couples

Sexual health communication is an important feature of healthy intimate relationships; however, some couples may avoid discussing difficult matters (e.g., HIV/STI testing, sexual satisfaction) to minimize interpersonal conflict. From October 2018 to May 2019 in New York State, we conducted a multi-method descriptive pilot study to characterize Black heterosexual couples' (N = 28) sexual health conversations. Partners individually completed an online sexual health/relationship survey before engaging in-person for a joint dyadic qualitative in-depth interview. Quantitative descriptive statistics demonstrated that most absolute score differences among couple's preferences for sexual health outcomes, communal coping and sexual relationship power were mainly small, but greatest regarding extra-dyadic sexual behaviors. A qualitative descriptive approach discerned, motivation and norms for sexual health conversations, and communication patterns. Thematic and content analysis revealed two central themes: initiating and sustaining sexual health conversations, and leveraging features of the couples to promote sexual health. Integrated findings indicate that couples possess varied communication patterns that operate with motivations for sexual health conversations toward subsequent sexual health promotion. Equitable and skewed communication patterns emerged as relationship assets that can be leveraged to optimize sexual health. There is also opportunity for future work to address communication regarding extra-dyadic behavior and preferences. Asset-based considerations are discussed.

Eligibility criteria vs. need for pre-exposure prophylaxis: a reappraisal among men who have sex with men in Amsterdam, the Netherlands

To reappraise pre-exposure prophylaxis (PrEP) eligibility criteria towards the men who have sex with men (MSM) with highest HIV-risk, we assessed PrEP need (i.e. HIV-risk) using Amsterdam Cohort Studies data from 2011-2017 for all non-PrEP using MSM. Outcomes were incident HIV-infection and newly-diagnosed anal STI. Determinants were current PrEP eligibility criteria (anal STI and condomless sex (CAS)) and additional determinants (age, education, group sex, alcohol use during sex and chemsex). We used targeted maximum likelihood estimation (TMLE) to estimate the relative risk (RR) and 95% confidence intervals (CI) of determinants on outcomes, and calculated population attributable fractions (PAFs) with 95% CI using RRs from TMLE. Among 810 included MSM, 22 HIV-infections and 436 anal STIs (n = 229) were diagnosed during follow-up. Chemsex (RR = 5.8 (95% CI 2.0-17.0); PAF = 55.3% (95% CI 43.3-83.4)), CAS with a casual partner (RR = 3.3 (95% CI 1.3-8.7); PAF = 38.0% (95% CI 18.3-93.6)) and anal STI (RR = 5.3 (95% CI 1.7-16.7); PAF = 22.0 (95% CI -16.8 to 100.0)) were significantly (P < 0.05) associated with and had highest attributable risk fractions for HIV. Chemsex (RR = 2.0 (95% CI 1.6-2.4); PAF = 19.5 (95% CI 10.6-30.6)) and CAS with a casual partner (RR = 2.5 (95% CI 2.0-3.0); PAF = 28.0 (95% CI 21.0-36.4)) were also significantly associated with anal STI, as was younger age (16-34/≥35; RR = 1.7 (95% CI 1.4-2.1); PAF = 15.5 (95% CI 6.4-27.6)) and group sex (RR = 1.3 (95% CI 1.1-1.6); PAF = 9.0 (95% CI -2.3 to 23.7)). Chemsex should be an additional PrEP eligibility criterion.

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

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

Perspectives on a Couples-Based, e-Health HIV Prevention Toolkit Intervention: A Qualitative Dyadic Study with Black, Heterosexual Couples in New York State

Web-based technology provides an unparalleled opportunity to increase access and uptake of couples-based HIV prevention interventions. e-Health HIV prevention interventions for US Black heterosexual couples have largely been understudied. To address this gap, we applied the Assessment Phase of the ADAPT-ITT Framework to investigate Black heterosexual couples' perspectives on an existing e-Health, couples-based HIV prevention intervention. Applying a qualitative descriptive approach, joint dyadic interviews were conducted with 28 Black heterosexual couples from three jurisdictions in New York State. Content dyadic analysis revealed three descriptive categories: perspectives of the toolkit intervention (sub-codes: perceived relevance, reactions to core components), recommendations to enhance intervention relevancy (sub-codes: tailoring to relationship type, adding new content), and lasting intervention considerations (sub-codes: toolkit usability and language use). Overall, couples found the toolkit intervention content and usability acceptable and reflected on its potential to build sexual and relationship health. Couples recommended to enhance toolkit adaptability for varied couple's motivation and types re-consider terms like sexual agreements, and include content to facilitate communication regarding sensitive topics (e.g., childhood sexual trauma, co-parenting, family planning) and other issues that may have more relevance to the experience of US Black persons (i.e., wealth building).

Barriers and Motives for Complying With "Sexual Distancing" Among Men Who Have Sex With Men During the First COVID-19 Pandemic Lockdown in Amsterdam: A Qualitative Study

BACKGROUND

Between March 15 and May 31, 2020, the Dutch government imposed lockdown and health measures to curb the coronavirus disease 2019 (COVID-19) pandemic. As part of social distancing, sexual distancing was one of these measures. Sexual distancing implied refraining from sex with partners outside of one's household. We aimed to elucidate barriers and motives for complying with sexual distancing and related factors that could have led to (non)compliance among men who have sex with men.

METHODS

In this exploratory qualitative study, we interviewed men who have sex with men who visited the center for sexual health in Amsterdam during the first COVID-19 lockdown using a semistructured interview guide from March to May 2020. We interviewed both men who complied and did not comply with sexual distancing. The interviews were transcribed verbatim and analyzed using an open-coding process in MAXQDA.

RESULTS

We included 18 noncompliers and 4 compliers to COVID-19 sexual distancing. Barriers to compliance were the following: lack of information on, or understanding of, the need for sexual distancing; being single; having had an active sex life before COVID-19; a high perceived importance of the social aspect of sex; a strong urge for sex; using sex to cope with the negative impact of the pandemic; being under the influence of alcohol or drugs; and not perceiving COVID-19 as a serious health threat. Motives for compliance were the following: perceiving COVID-19 as a serious health threat, direct confrontation with critically ill COVID-19 patients, protecting someone dear from COVID-19, and being convinced of the importance of social and/or sexual distancing measures.

CONCLUSIONS

Information on sexual distancing needs to be made more explicit, accessible, understandable, inclusive, customized to individual barriers, and relatable to the key populations. This may improve the effectiveness of measures and health recommendations in both the current COVID-19 pandemic and future respiratory outbreaks.

A cluster randomized trial to reduce HIV risk from outside partnerships in Zambian HIV-Negative couples using a novel behavioral intervention, "Strengthening Our Vows": Study protocol and baseline data

BACKGROUND

Heterosexual couples contribute to most new HIV infections in areas of generalized HIV epidemics in sub-Saharan Africa. After Couples' Voluntary HIV Counseling and Testing (CVCT), heterosexual concordant HIV negative couples (CNC) in cohabiting unions contribute to approximately 47% of residual new infections in couples. These infections are attributed to concurrent sexual partners, a key driver of the HIV epidemic in Zambia.

METHODS/DESIGN

Ten Zambian government clinics in two of the largest cities were randomized in matched pairs to a Strengthening Our Vows (SOV) intervention or a Good Health Package (GHP) comparison arm. SOV addressed preventing HIV infection from concurrent partners and protecting spouses after exposures outside the relationship. GHP focused on handwashing; water chlorination; household deworming; and screening for hypertension, diabetes and schistosomiasis. CNC were referred from CVCT services in government clinics. Follow-up includes post-intervention questionnaires and outcome assessments through 60 months. Longitudinal outcomes of interest include self-report and laboratory markers of condomless sex with outside partners and reported sexual agreements. We present baseline characteristics and factors associated with study arm and reported risk using descriptive statistics.

RESULTS

The mean age of men was 32 and 26 for women. On average, couples cohabited for 6 years and had 2 children. Baseline analyses demonstrated some failures of randomization by study arm which will be considered in future primary analyses of longitudinal data. An HIV/STI risk factor composite was not different in the two study arms. Almost one-quarter of couples had an HIV risk factor at baseline.

DISCUSSION

In preparation for future biomedical and behavioral interventions in sub-Saharan Africa, it is critical to understand and decrease HIV risk within CNC.

An Analysis of Sex Practices and Behaviors Among African Americans in Sexually Concurrent and Sexually Exclusive Relationships

Historically, sexually concurrent relationships have been associated with increased risk for sexually transmitted infections (STIs), including HIV. Due to socio-structural factors, African Americans (AAs) have higher rates of STIs compared to other racial groups and are more likely to engage in sexually concurrent (SC) relationships. Current research has challenged the assumption that SC is the only risky relationship type, suggesting that both SC and sexually exclusive (SE) relationships are at equal risk of STI and HIV acquisition and that both relationship types should engage in safer sex practices. This study aimed to compare sex practices and behaviors among AA men and women in SC and SE relationships (N = 652). Results demonstrate differences in sexual practices and behaviors between SC and SE men and women. Overall, SC and SE women report condom use with male partners less frequently than SC and SE men. SC men were more likely to report substance use during sex compared to SC and SE women. Pre-exposure prophylaxis (PrEP) use did not differ across groups. SE men were less likely to report STI testing and diagnosis compared to SC women. Findings support the need to focus on culturally and gender-specific safer sex interventions among AAs.

The Who and Why of Consensual Nonmonogamy Among African Americans

Prevalence rates of consensual nonmonogamy (CNM) demonstrate little difference across race. Yet, not much is known about CNM among African Americans. Through an online survey study, we examined the correlates of CNM among African Americans as well as the reasons why they engage. A total of 1050 African Americans between the ages of 18-40 years participated in this study. Binomial logistic regression was utilized to determine the correlates of CNM. Sexual orientation was the only significant predictor of CNM. The following variables were nonsignificant predictors of CNM: age, gender, household income, religiosity, and education. Qualitative analysis revealed several reasons for CNM engagement: (1) belief that it is natural; (2) excitement; (3) not meant for each other; (4) scared of losing partner; (5) bisexuality; (6) does not want commitment; and (7) maintain honesty, trust, and integrity. This study adds to the sparse knowledge base of CNM among African Americans.

Correlates of concurrent partnerships and patterns of condom use among men who have sex with men and transgender women in Peru

Background

In Peru, there is an ongoing high-incidence HIV epidemic among men who have sex with men (MSM) and transgender women (TW). Sexual concurrency, or having sex with a partner in between two acts of sex with another partner, may be a key factor in onward HIV transmission. In this study, we quantify concurrency, evaluate factors associated with concurrency, and assess condom use with concurrent partners among MSM and TW in Peru.

Methods

We conducted a secondary analysis of data from the 2011 Peruvian Biobehavioral Survey. Pearson’s Chi-squared test was used to identify individual-level characteristics associated with concurrency. We estimated the association between participant characteristics, concurrent partnerships, partnership type (stable vs. non-stable), and CLAI within the context of concurrent partnerships using multivariate and repeated-measure Poisson regression.

Results

3-month cumulative prevalence of concurrency was higher among TW compared to MSM (30.7% vs 25.2%, p = 0.014). Among those with concurrent stable and non-stable partners, 45% used condoms with both partners (95% CI: 40%-50%) and 30% preferentially had CLAI with the stable partner only (95%CI: 26%-35%). Factors associated with CLAI within the context of concurrent partnerships varied between MSM and TW.

Conclusions

Although concurrency is common among TW and MSM in Peru, patterns of concurrency and differential condom use may vary between TW and MSM. Future research may explore differential condom use with stable and non-stable partners to better understand behavioral factors that may alter vulnerability to HIV in TW compared to MSM.

Population size and self-reported characteristics and sexual preferences of men-who-have-sex-with-men (MSM) in Germany based on social network data

Background

In the absence of detailed information about the population size and behaviour data of men-who-have-sex-with-men (MSM), the estimation of prevalence rates of sexually transmitted infections (STIs) and the design of public health interventions become difficult. The aim of the present study is to estimate the lower boundary of age-specific population sizes and retrieve self-reported information from this population.

Methods

We used publicly accessible data from a large online dating and social network website for MSM in Germany to retrieve data on the age and regional distribution of profiles. The profiles were also stratified by their information on the preferred position during anal intercourse, safer sex, and sexual identity.

Results

A total of 464,873 user profiles correspond to an average 15.2 profiles per 1,000 male inhabitants in Germany, varying between 7.6 and 45.6 across federal states. Although the information on the absolute numbers for different age groups is limited by the search engine, age-specific relative frequencies were found to increase from 12.9 in the age group of 18 to 20 year olds to 24.6 profiles per 1,000 male inhabitants in the 28 to 30 year olds. The data shows age-specific trends for safer sex with an increasing easiness of reporting “never” engaging in safer sex or stating that safer sex “needs discussion” with increasing age. Around one third of profile owners stated to be versatile with respect to the preferred position in anal intercourse. All other options (“only bottom”, “more bottom”, “only top”, “more top”) were preferred equally likely by roughly 10% of profile owners, respectively.

Conclusions

Online social network or dating sites can provide some information about specific populations in the absence of other data sources. The presented results are the first to report age-specific rates of MSM per 1,000 male inhabitants in Germany and may be useful to estimate age-specific prevalence or incidence rates as well as to inform health promotion activities and modelling studies for MSM in Germany.

Sexual Agreements: A Scoping Review of Measurement, Prevalence and Links to Health Outcomes

A sexual agreement is a mutual understanding between two partners regarding sexual and relational behaviors both within and outside of their relationship. Sexual agreements have been central to research and programming efforts around HIV prevention, primarily for male couples. A comprehensive scoping review of the primary literature on sexual agreements, including negotiated safety, was performed to identify what is known about sexual agreements among couples (n = 66). Results indicate a wide range of prevalence of agreements and measurements used to characterize sexual agreements. Findings also report associations between sexual agreements and health and relational outcomes. Several knowledge gaps were identified; specifically, the need to expand sexual agreements research beyond MSM populations and the need to better understand agreement breaks, break disclosure, and how variation in agreement categorization may impact reported prevalence. This review demonstrates the importance of broadening the evidence-base of sexual agreements research and programmatic focus.

Differences in knowledge, attitudes and behaviors of Israeli HIV-uninfected gay men in HIV-discordant vs. concordant steady relationships

HIV-discordant gay male couples may play an important role in HIV-transmissions. This cross-sectional study compared the knowledge, attitudes and sexual behaviors of HIV-uninfected gay men, between those in HIV-discordant and those in HIV-concordant steady relationships. Anonymous questionnaires were distributed electronically in designated gay-related internet sites and in AIDS-clinics in 2015. The dependent variable was defined as a steady relationship of an HIV-uninfected man with an HIV-infected partner. Risky sexual behavior was defined as unprotected anal intercourse (UAI) with a sex partner whose HIV-status was either positive or unknown. Of 2,319 responders, 460 (20%) were HIV-uninfected gay men in steady relationships, of whom 72 were in HIV-discordant relationships and 388 were in HIV-concordant relationships. Those in HIV-discordant relationships presented better established knowledge regarding HIV-transmission, more lenient attitudes regarding UAI, and reported being involved in riskier sexual behavior, both within and outside their steady relationship compared to men in HIV-concordant relationships. UAI was performed by 48% of the HIV-discordant couples and was associated with the use of sero-positioning strategy and with achieving undetectable viral-load. These findings reflect the complexity of constant use of condoms during long-term sero-discordant relationships. Targeted interventions for HIV-prevention in HIV-discordant couples should be employed for balancing the partners' desire for intimacy and sexual pleasure in the relationship, while reducing the risk for acquiring HIV.

ABBREVIATIONS

ART: Antiretroviral therapy; PEP: Post exposure prophylaxis; PrEP: Pre exposure prophylaxis; STI: Sexually transmitted infections; UAI: Unprotected anal intercourse.