Increasing risk behaviour can outweigh the benefits of antiretroviral drug treatment on the HIV incidence among men-having-sex-with-men in Amsterdam

The Effectiveness of Electronic Health Interventions for Promoting HIV-Preventive Behaviors Among Men Who Have Sex With Men: Meta-Analysis Based on an Integrative Framework of Design and Implementation Features

Background

The disproportionately high prevalence of HIV among men who have sex with men (MSM) is a global concern. Despite the increasing utilization of electronic health (eHealth) technology in the delivery of HIV prevention interventions, few studies have systematically explored its effectiveness and association with various intervention characteristics.

Objective

This study aimed to conduct a meta-analysis of the effectiveness of eHealth technology–based interventions for promoting HIV-preventive behaviors among MSM and to determine effectiveness predictors within a framework integrating design and implementation features.

Methods

A systematic literature search using terms related to eHealth technology, HIV, the MSM population, and an experimental study design was performed using 5 databases (ie, MEDLINE, PsycINFO, EMBASE, Web of Science, and ProQuest Dissertations & Theses) and other sources (eg, bibliographies of relevant reviews and JMIR Publications). First, primary meta-analyses were conducted to estimate the effectiveness of eHealth interventions (d₊) in changing 3 HIV-preventive behaviors among MSM: unprotected anal intercourse (UAI), HIV testing, and multiple sex partnership (MSP). Moderation analyses were then conducted to examine a priori effectiveness predictors including behavioral treatment components (eg, theory use, tailoring strategy use, navigation style, and treatment duration), eHealth technology components (eg, operation mode and modality type), and intervention adherence.

Results

A total of 46 studies were included. The overall effect sizes at end point were small but significant for all outcomes (UAI: d₊=−.21, P<.001; HIV testing: d₊=.38, P<.001; MSP: d₊=−.26, P=.02). The intervention effects on UAI were significantly larger when compared with preintervention groups than with concurrent groups. Greater UAI reductions were associated with the increased use of tailoring strategies, provision of feedback, and tunneling navigation in interventions with a concurrent group, whereas reductions were associated with the use of self-paced navigation in interventions with a preintervention group. Greater uptake of HIV testing was associated with longer treatment duration; computer-mediated communication; and the use of messaging, social media, or a combined technology modality. Higher intervention adherence consistently predicted larger effects on UAI and HIV testing.

Conclusions

This study provided empirical evidence for the effectiveness of eHealth interventions in promoting HIV-preventive behaviors among MSM. Features of treatment content and eHealth technology might best predict the intervention effects on UAI and HIV testing, respectively. Most importantly, intervention adherence tended to play an important role in achieving better effectiveness. The findings could help inform the development of efficacious interventions for HIV prevention in the future.

Does sexual behaviour of people with HIV reflect antiretroviral therapy as a preventive strategy? A cross-sectional study among outpatients in Kenya

Background

The World Health Organisation (WHO) advocates early initiation of HIV treatment as a prevention strategy among people living with HIV. There is strong evidence for the effectiveness of antiretroviral therapy (ART) as a preventive tool for HIV transmission. We aimed to determine the sexual behaviour of HIV outpatients and assess if it reflects the current preventive strategy for HIV transmission.

Methods

We conducted a cross-sectional study among adult (aged at least 18 years) patients with confirmed HIV diagnosis, and aware of their diagnosis, attending HIV outpatient care in Kenya. Data were gathered through self-report (using validated questionnaires) and file extraction. Multivariate logistic regression assessed the association between sexual risk taking behaviour controlling for gender, HIV clinical stage, HIV treatment status, Tuberculosis (TB) treatment status, and CD4 count.

Results

We recruited n = 400 participants (n = 280[70%] female gender). The mean age was 39.4 (SD = 9.9) years. The mean CD4 count was 393.7 (SD = 238.2) and ranged from 2 to 1470 cells/mm³. N = 61 (15.64%) were on TB treatment. The majority (n = 366, 91.5%) were on ART. Just over half (n = 202, 50.5%) reported having a sexual partner. Of these n = 33 (16.1%) reported having unprotected sexual intercourse with a person of unknown HIV status in the previous 3 months.

Multivariate analysis showed that participants not on ART (HIV treatment) were more likely to report unprotected sexual intercourse compared to those who were on ART (odds ratio .25, 95% CI .09 to .69; P = 0.007).

Participants at early stage of HIV infection (stages 1/2) were more likely to report unprotected sexual intercourse compared to participants at advanced HIV infection (stages 3/4) (odds ratio .34, 95% CI .13 to .92; P = 0.035). Males participants were more likely to be involved in sexual risk taking behaviours compared to female participants (odds ratio .36, 95% CI .16 to .82; P = 0.015). TB treatment status, and CD4 count were not significantly associated with sexual risk taking.

Conclusion

Participants not on ART have more unprotected sexual intercourse than those who are on ART. This calls for the need to scale up coverage and early ART initiation in order to reduce transmission of HIV.

Community acceptance and HIV sexual risk among gay and bisexual men in a ‘typical’ Canadian city

Included in Statistics Canada's largest geographical “peer group,” London, Ontario is typical of many mid-size Canadian cities. A local health forum identified community acceptance and homophobia as key factors impacting LGBTQ health; we studied these with regard to HIV-related sexual risk in gay and bisexual men. Survey data were collected from 201 gay and bisexual men in Middlesex-London, Ontario; 173 reported their HIV status as negative/unknown and were included in this analysis. Unadjusted and adjusted prevalence risk ratios (PRRs) were modelled using modified Poisson regression. First, a model was fit for non-modifiable sociodemographic and background factors. Community factors were then added: social support; internalized homonegativity; perceptions of community acceptance of people like oneself (based on orientation, racialization, gender identity). Older age was associated with decreased risk; other sociodemographic and background factors were not. For each 10-year increase in age, prevalence of high-risk sex decreased by 24% (PRR=0.76; 95% CI: 0.60, 0.95). Controlling for age, we found an interaction between perception of broader community acceptance and gay community acceptance of people like oneself. As broader community acceptance increased, high-risk sex decreased; however, this effect varied depending upon perceptions of gay community acceptance, with men feeling most accepted within the gay community having the smallest reductions in high-risk sex. This interaction raises a series of questions. Among these: How do community norms and availability of partners shape sexual risk-taking? Are conventional “contextualized” measures of sexual risk sufficient, or do they miss important risk-mitigation strategies used within gay communities?

Implementation and Operational Research: Computer-Assisted Intervention for Safer Sex in HIV-Positive Men Having Sex With Men: Findings of a European Randomized Multi-Center Trial

OBJECTIVE

Men who have sex with men (MSM) are the key population most affected by HIV in Europe. We performed the first European multicenter, simple-randomized parallel-group study to test the effectiveness of a theory-guided computer-assisted intervention to improve safer sex among HIV-positive men who have sex with men.

METHODS

Between February, 2011 and February, 2013, 112 participants were enrolled in 8 different European HIV-care settings. Intervention participants received 3 individual counseling sessions facilitated by trained service providers using computer-assisted tools. The control-group received sexual health advice delivered as part of regular HIV care. Outcome behavior (self-reported condom use at last intercourse; combined HIV transmission risk score), its influencing factors, and mediating variables were assessed at baseline, and at 3 and 6 months follow-up. Mixed effects models were used to compare primary outcomes (condom use at last intercourse, HIV transmission risk score), and mediation analysis to explore intervention effects.

RESULTS

Condom use at last intercourse increased more among intervention than control participants at 3 months follow-up (odds ratio of 3.83; P = 0.03), but not significantly at 6 months follow-up. Intervention participants reported a lower transmission risk at 3 months follow-up than controls (odds ratio compared with baseline of 11.53 and 1.28, respectively; P = 0.008), but this effect became nonsignificant at 6 months. Intervention effects were mediated by the proximal variables, self-efficacy to negotiate condom use and condom attitudes.

CONCLUSIONS

This intervention showed short-term effectiveness. The intervention should be replicated in other settings, eventually investigating if booster-counseling sessions would yield a longer lasting effect.

The diminishing role of hubs in dynamical processes on complex networks

It is notoriously difficult to predict the behaviour of a complex self-organizing system, where the interactions among dynamical units form a heterogeneous topology. Even if the dynamics of each microscopic unit is known, a real understanding of their contributions to the macroscopic system behaviour is still lacking. Here, we develop information-theoretical methods to distinguish the contribution of each individual unit to the collective out-of-equilibrium dynamics. We show that for a system of units connected by a network of interaction potentials with an arbitrary degree distribution, highly connected units have less impact on the system dynamics when compared with intermediately connected units. In an equilibrium setting, the hubs are often found to dictate the long-term behaviour. However, we find both analytically and experimentally that the instantaneous states of these units have a short-lasting effect on the state trajectory of the entire system. We present qualitative evidence of this phenomenon from empirical findings about a social network of product recommendations, a protein–protein interaction network and a neural network, suggesting that it might indeed be a widespread property in nature.

The need to reemphasize behavior change for HIV prevention in Uganda: a qualitative study

Uganda has long been considered an AIDS success story, although in recent years declines in prevalence and incidence appear to have stalled or even reversed. During the early stages of Uganda's AIDS prevention program, health messages emphasized behavior change, especially fidelity. Ugandans were made to fear AIDS and feel personally at risk of dying from a new, poorly understood disease. In this research, six focus group discussions with 64 participants in peri-urban and rural areas outside Kampala suggest that HIV prevention messages have shifted in the direction of risk reduction: condoms, testing, and drugs. Ugandans now seem less afraid of becoming infected with HIV, at least in part because antiretroviral therapy is available, and this diminished fear may be having a disinhibiting effect on sexual behavior. Participants believe that HIV rates are on the rise, that more individuals are engaged in multiple and concurrent sexual partnerships, and that sexual behavior is less restrained than a generation ago. These findings suggest that AIDS-prevention programs in Uganda would benefit from refocusing on the content that yielded success previously-sexual behavior change strategies.

Network effects of risk behavior change following prophylactic interventions

We formulated a network-based model to understand how risk behavior change in conjunction with failure of prophylactic interventions can lead to unintended outcomes where "less (intervention) is more (effective)." Our model captures the distinction between one- and two-sided risk behavior change. In one-sided situations (e.g. influenza/H1N1) it is sufficient for either individual in an interaction to exhibit risk behavior change whereas in two-sided situations (e.g. AIDS/HIV) it is necessary for both individuals in the interaction to exhibit risk behavior change, for a potential transmission of the disease. A central discovery is that this phenomenon occurs at differing levels of intervention coverage depending upon the "sidedness" of the interaction. We find that for one-sided interactions, sufficiently high vaccination coverage is necessary for mitigating the effects of risk behavior; for two-sided interactions, it is essential to combine prophylactic treatments with programs aimed at reducing risky behavior. Furthermore, again dependent on the "sidedness," targeting highly connected nodes can be strictly worse than uniformly random interventions at the same level of coverage.

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.

Noise enhances information transfer in hierarchical networks

We study the influence of noise on information transmission in the form of packages shipped between nodes of hierarchical networks. Numerical simulations are performed for artificial tree networks, scale-free Ravasz-Barabási networks as well for a real network formed by email addresses of former Enron employees. Two types of noise are considered. One is related to packet dynamics and is responsible for a random part of packets paths. The second one originates from random changes in initial network topology. We find that the information transfer can be enhanced by the noise. The system possesses optimal performance when both kinds of noise are tuned to specific values, this corresponds to the Stochastic Resonance phenomenon. There is a non-trivial synergy present for both noisy components. We found also that hierarchical networks built of nodes of various degrees are more efficient in information transfer than trees with a fixed branching factor.

Is the Sexual Behaviour of HIV Patients on Antiretroviral therapy safe or risky in Sub-Saharan Africa? Meta-Analysis and Meta-Regression

Background

Reports on the sexual behavior of people on antiretroviral therapy (ART) are inconsistent. We selected 14 articles that compared the sexual behavior of people with and without ART for this analysis.

Methods

We included both cross-sectional studies that compared different ART-naïve and ART-experienced participants and longitudinal studies examining the behavior of the same individuals pre- and post-ART start. Meta-analyses were performed both stratified by type of study and combined. Outcome variables assessed for association with ART experience were any sexual activity, unprotected sex and having multiple sexual partners. Random-effect models were applied to determine the overall odds ratios. Sub-group analyses and meta-regression analyses were performed to examine sources of heterogeneity among the studies. Sensitivity analysis was also conducted to evaluate the stability of the overall odds ratio in the presence of outliers.

Results

The meta-analysis failed to show a statistically significant association of any sexual activity with ART experience. It did, however, show an overall statistically significant reduction of any unprotected sex, having multiple sexual partners and unprotected sex with HIV negative or unknown HIV status with ART experience. Meta-regression showed no interaction between duration of ART use or recall period of sexual behavior with the sexual activity variables. However, there was an association between the percentage of married or cohabiting participants included in a study and reductions in the practice of unprotected sex with ART.

Conclusion

In general, this meta-analysis demonstrated a significant reduction in risky sexual behavior among people on ART in sub-Saharan Africa. Future studies should investigate the reproducibility and continuity of the observed positive behavioural changes as the duration of ART lasts a decade or more.

HIV reservoirs and immune surveillance evasion cause the failure of structured treatment interruptions: a computational study

Continuous antiretroviral therapy is currently the most effective way to treat HIV infection. Unstructured interruptions are quite common due to side effects and toxicity, among others, and cannot be prevented. Several attempts to structure these interruptions failed due to an increased morbidity compared to continuous treatment. The cause of this failure is poorly understood and often attributed to drug resistance. Here we show that structured treatment interruptions would fail regardless of the emergence of drug resistance. Our computational model of the HIV infection dynamics in lymphoid tissue inside lymph nodes, demonstrates that HIV reservoirs and evasion from immune surveillance themselves are sufficient to cause the failure of structured interruptions. We validate our model with data from a clinical trial and show that it is possible to optimize the schedule of interruptions to perform as well as the continuous treatment in the absence of drug resistance. Our methodology enables studying the problem of treatment optimization without having impact on human beings. We anticipate that it is feasible to steer new clinical trials using computational models.