The role of venues in structuring HIV, sexually transmitted infections, and risk networks among men who have sex with men

Characterising HIV acquisition risk, treatment gaps and populations reached through venue-based outreach and clinical services in Blantyre, Malawi: findings from a district-wide CLOVE Study

BACKGROUND

In 2017, Blantyre district had the highest adult HIV prevalence in Malawi (17.7%) and lowest viral suppression (60%). In response, the Ministry of Health expanded prevention and treatment services. We assessed whether outreach to social venues could identify individuals with increased HIV acquisition risk or with unsuppressed HIV not currently reached by clinic-based services.

METHODS

We conducted a cross-sectional bio-behavioral survey in Blantyre, Malawi, from January to March 2022. We visited social venues where people meet new sexual partners and government clinics providing HIV testing or STI screening. Participants aged > 15 years were interviewed, and tested for HIV infection if not on ART. HIV recency tests were performed on those testing positive, and dried blood spots (DBS) was collected to quantify viral load and also to identify acute infection in those with HIV- results.

RESULTS

HIV prevalence (18.5% vs 8.3%) and unsuppressed HIV infection (3.9% vs 1.7%) were higher among venue-recruited (n=1802) compared with clinic-recruited participants(n=2313). Among PLHIV at both clinics (n=199) and venues (n=289), 79% were virally suppressed. Few had acute(n=1) or recent infection(n=8). Among women, HIV prevalence was four times higher (38.9% venue vs 8.9% clinic). At clinics, PLHIV reporting visiting venues were less likely to be suppressed (54.6 vs 82.6%). More men at venues than at clinics reported paying for sex (49% vs 30%) or having multiple sex partners in the past 4 weeks (32% vs 16%).

CONCLUSIONS

Enhanced venue-based prevention and testing for men and women could reduce treatment lapses, HIV treatment outcomes and reduce onward transmission.

Between a Rock and a Hard Place: "I Decided to Keep Quiet": A Qualitative Inquiry Into the Coping Experiences of Young People (15-24) Working at High-Risk Venues for HIV in Uganda

Employment linked with social venues has long been described as permissive environments for excessive drinking, disruptive/aggressive behaviors, and overt sexual behaviors, which are known risk factors for HIV. Yet, our understanding of the extent to which workers in such high-risk work settings cope with the various risks therein is still limited. This study explored the coping strategies employed by workers at social venues. We interviewed 47 workers at 22 social venues through small group discussions (15) and in-depth interviews (10) in 2021 in Rakai district, Uganda. All discussions were audiorecorded and transcribed verbatim before analysis. Data were analyzed using thematic content analysis. We found two main categories of coping strategies used by workers: acceptance of sexual risks and keeping safe. Acceptance of risks such as transactional sex was the most used strategy, hence highlighting negative coping. This calls for interventions for improving workers' coping efficiency and adjustment as well as interventions ameliorating the conditions underpinning increased risk of HIV at the venues.

The unwritten rules and HIV: a qualitative study of informal institutions and HIV vulnerability among workers at social venues in Uganda

Introduction

There is increasing appreciation of the need to understand how social and structural factors shape HIV risk. The unwritten rules, also known as informal institutions or social norms, are increasingly recognized as important determinants of HIV transmission. Unfortunately, these informal institutions, especially among high-risk environments for HIV, such as social venues like bars, lodges, remain poorly understood. This study explored the informal institutions at social venues, and how these institutions influenced vulnerability for HIV for venue workers in Uganda.

Methods

We conducted a qualitative study in two districts of Kyotera and Rakai in Central Uganda. We purposively selected and interviewed 44 workers including, cleaners, waiters, and waitresses and 22 venue managers at 22 social venues to explore the informal institutions at these establishments and how the institutions shaped HIV vulnerabilities among the workers. 31.8% (14) of the participants were males, and 68.2% (30) females. Data were analyzed using thematic content analysis.

Results

We found that the informal institutions at the venues were both officially and socially created, communicated, and sanctioned. The most common institutions operated through; selective hiring, rigid reporting structures, and informal job contracting procedures. Meager salaries, varying and delayed payments as well as attractive benefits and bonuses from customers were also important forms of informal institutions at the venues. Drinking alcohol, and offering sexual services at the venues were acceptable, although excessive drinking, and committed sexual relationships with customers were disapproved. These informal institutions shaped a risk environment at the venues by creating risk exposure opportunities that influenced workers' engagement into sexual risk behaviors.

Conclusion

The risk environment at social venues is shaped by the informal institutions at these venues. Thus, the need for venue-based HIV programs that integrate social norms interventions to better address the contextual determinants of HIV risk behaviors at the venues.

Social venues and HIV vulnerability of young venue workers: a cluster analysis of data from a national-level cross-sectional survey of social venues in Uganda

OBJECTIVE

Venues where people socialize, such as bars, play a significant role in HIV transmission risk. However, little research has been done that identifies characteristics of high-risk venues, to inform HIV prevention efforts. This study identified clusters of social venues in Uganda and their relationship with HIV vulnerability of young venue workers (15-24 years). We also assessed availability of HIV prevention services at the venues.

DESIGN AND SETTING

This was a secondary analysis of data from a larger cross-sectional survey of social venues in 25 districts of Uganda.

PARTICIPANTS

A total of 480 venues that employed young workers were included in this study.

ANALYSIS

Hierarchical cluster and mixed-effects regression analyses were conducted.

RESULTS

Four clusters were adopted: cluster 1 represented 127 venues (mainly alcohol-serving sex work venues with a provision of on-site sex); cluster 2 represented 80 venues (mainly alcohol-serving sex work venues without a provision of on-site sex); cluster 3 represented 113 venues (mainly alcohol-serving venues without sex work or on-site sex); and cluster 4 represented 160 venues (non-alcohol-serving venues). We found a positive correlation between venue clusters and HIV vulnerability. Workers who belonged to cluster 1 (alcohol-serving sex work venues with a provision of on-site sex) had a 0.15 increase in HIV vulnerability compared with those in alcohol-serving venues without sex work or a provision of on-site sex (cluster 3) (coefficient: 0.15, 95% CI: 0.030 to 0.287) after adjusting for age, sex and marital status. Thirty-seven per cent of cluster 1 venues reported any HIV prevention services in the past 12 months.

CONCLUSION

Alcohol-serving sex work venues with a provision of on-site sex (cluster 1) appeared to reinforce vulnerability to HIV in this study and should be targeted with HIV prevention interventions. Such venues can amplify HIV transmission by facilitating sexual partner coupling and on-site sex.

Identifying influential neighbors in social networks and venue affiliations among young MSM: a data science approach to predict HIV infection

OBJECTIVE

Young MSM (YMSM) bear a disproportionate burden of HIV infection in the United States and their risks of acquiring HIV may be shaped by complex multilayer social networks. These networks are formed through not only direct contact with social/sex partners but also indirect anonymous contacts encountered when attending social venues. We introduced a new application of a state-of-the-art graph-based deep learning method to predict HIV infection that can identify influential neighbors within these multiple network contexts.

DESIGN AND METHODS

We used empirical network data among YMSM aged 16-29 years old collected from Houston and Chicago in the United States between 2014 and 2016. A computational framework GAT-HIV (Graph Attention Networks for HIV) was proposed to predict HIV infections by identifying influential neighbors within social networks. These networks were formed by multiple relations constituted of social/sex partners and shared venue attendances, and using individual-level variables. Further, GAT-HIV was extended to combine multiple social networks using multigraph GAT methods. A visualization tool was also developed to highlight influential network members for each individual within the multiple social networks.

RESULTS

The multigraph GAT-HIV models obtained average AUC values of 0.776 and 0.824 for Chicago and Houston, respectively, performing better than empirical predictive models (e.g. AUCs of random forest: 0.758 and 0.798). GAT-HIV on single networks also delivered promising prediction performances.

CONCLUSION

The proposed methods provide a comprehensive and interpretable framework for graph-based modeling that may inform effective HIV prevention intervention strategies among populations most vulnerable to HIV.

Types of Group Sex and Their Association with Different Sexual Risk Behaviors Among HIV-Negative Men Who Have Sex with Men

The current study sought to identify types of group sex acts among HIV-negative men who have sex with men (MSM) and assess their association with different sexual risk behaviors using cross-sectional data of group sex acts reported during 6 waves (2015-2018) of the Amsterdam MSM Cohort Study. Latent class analysis was performed to identify group sex types based on size, familiarity with partners, location, planning, and drug use. Associations between group sex types and sexual behaviors were evaluated using logistic regression with generalized estimating equations, employing the sample mean as a reference. Data at the level of group sex acts were analyzed, while correcting variance estimations for repeated measurements within MSM. A total of 392 MSM engaged in group sex ≥ 1 times, totaling 1033 group sex acts. Four types of group sex emerged: familiar (29%), intimate (27%), impromptu (36%), and party (8%). Familiar group sex (characterized by high proportions of mostly known partners, occurring in private places and involving drug use) had an increased adjusted odds of risky fingering (aOR 1.6, 95%CI 1.3-2.0) and of risky fisting and/or use of sex toys (aOR 2.3, 95%CI 1.6-3.1). Intimate group sex (characterized by high proportions of threesomes, occurring in private places, and not involving drug use) had a decreased adjusted odds of risky fisting and/or use of sex toys (aOR 0.6, 95%CI 0.4-0.9). Impromptu group sex (characterized by high proportions of spontaneity, mostly unknown partners, and taking place in public places) had a decreased adjusted odds of risky fisting and/or use of sex toys (aOR 0.5, 95%CI 0.3-0.7) and of condomless anal intercourse (CAI) (OR 0.6, 95%CI 0.5-0.8). Party group sex (characterized by high proportions of larger groups, mostly unknown partners, and being planned) had an increased adjusted odds of risky fisting and/or use of sex toys (aOR 1.6, 95%CI 1.0-2.7) and of CAI (aOR 1.5, 95%CI 1.1-2.1). The identified types of group sex reflect different dynamics and characteristics, with some types riskier for STIs and others riskier for HIV. HIV and STI prevention efforts could be tailored accordingly. For example, in certain type of public sex environments (e.g., cruising parks), traditional HIV and STI prevention efforts, such as promoting of condom use and PrEP, might be sufficient. However, in other settings (e.g., private parties), where group sex is more likely to be planned and where behaviors such as fisting, sharing of sex toys, and CAI are more likely to take place, which carry different levels of risk for HIV and STI transmission, including that of Hepatitis C, different approaches might be needed, such as broader HIV and STI prevention education efforts or targeting the organizers of group sex events.

Contextualizing condoms: a cross-sectional study mapping intersections of locations of sexual contact, partner type, and substance use as contexts for sexual risk behavior among MSM in Peru

Background

Condomless anal intercourse (CAI) appears to be increasing among men who have sex with men (MSM) globally, and is reported to be as high as 70% in recent studies in Peru. To improve understanding of the evolving context of CAI among MSM in Peru, we studied associations between partner type, substance use, and condomless anal intercourse (CAI) in locations where MSM commonly report having sexual encounters.

Methods

In a 2017 cross-sectional study of rectal STI screening and HIV prevention, a convenience sample of MSM recruited from community venues in Lima completed a survey of demographic characteristics and sexual risk behavior with their three most recent partners. Generalized estimating equations estimated correlations of CAI with location of last sexual contact, participant substance use prior to sex, and negotiation of condom use before or during sex. The network data integration application, Cytoscape, mapped intersections of partner type, sexual orientation, substance use, and CAI by four types of locations where sex occurred: 1) Home, 2) Hotel, 3) Sauna or Internet Cabin, and 4) Public Spaces.

Results

Of 447 MSM (median age 27 years), 76.9% reported CAI with ≥1 of their last three partners. Participants reported sex with casual partners most commonly in homes (64.6%) and hotels (60.4%), and with anonymous partners most often in saunas/Internet cabins (57.5%) and public spaces (52.6%). CAI was less commonly reported in hotels (aPR, 95% CI: 0.85, 0.75–0.97) compared to homes. Participants who used marijuana before sex at home were more likely to report CAI than MSM who did not use marijuana (1.36, 1.01–1.92). Partner alcohol use before sex was associated with CAI in saunas/Internet cabins (3.17, 1.45–6.91) and public spaces (2.65, 1.41–4.98). In the sexual network maps, almost all MSM who used drugs prior to their sexual encounters used drugs with more than one of their last three partners.

Conclusions

CAI was common and associated with different risk factors, like partner type and substance use, based on location where sex occurred. Novel combination HIV, STI, and substance use prevention interventions must consider how the social environments of MSM influence condom use and other sexual risk behaviors.

Trial registration

ClinicalTrials.gov Identifier NCT03010020, January 4, 2017.

The burden of HIV among female sex workers, men who have sex with men and transgender women in Haiti: results from the 2016 Priorities for Local AIDS Control Efforts (PLACE) study

INTRODUCTION

Despite the higher risk of HIV among female sex workers (FSWs), men who have sex with men (MSM) and transgender women (TGW), these populations are under-represented in the literature on HIV in Haiti. Here, we present the first nationally representative estimates of HIV prevalence and the first care and treatment cascade for FSWs, MSM and TGW in Haiti. We also examine the social determinants of HIV prevalence in these groups and estimate FSW and MSM population size in Haiti.

METHODS

Data were collected between April 2016 and February 2017 throughout the 10 geographical departments of Haiti. The Priorities for Local AIDS Control Efforts (PLACE) method was used to: (1) recruit participants for a behavioural survey; (2) provide rapid testing, counselling and linkage to care for syphilis and HIV; and (3) measure viral load using dried blood spots for participants testing HIV positive.

RESULTS

Study participants included 990 FSWs, 520 MSM and 109 TGW. HIV prevalence was estimated at 7.7% (95% CI 6.2%, 9.6%) among FSWs, 2.2% (0.9%, 5.3%) among MSM and 27.6% (5.0%, 73.5%) among TGW. Of participants who tested positive for syphilis, 17% of FSWs, 19% of MSM and 74% of TGW were co-infected with HIV. Economic instability and intimate partner violence (IPV) were significantly associated with HIV among MSM; food insecurity, economic instability and history of rape were significantly associated with HIV among TGW. Fewer than one-third of participants living with HIV knew their status, and more than a quarter of those who knew their status were not on treatment. While approximately four in five FSW and MSM participants on treatment for HIV were virally suppressed, viral suppression was less common among TGW participants at only 46%.

CONCLUSIONS

This study demonstrates a need for targeted interventions to prevent and treat HIV among key populations in Haiti. Potential high-impact interventions may include venue-based, peer navigator-led outreach and testing for HIV and syphilis and improving screening and case management for structural violence and IPV. TGW are in urgent need of such interventions due to our observations of alarmingly high HIV prevalence and low frequency of HIV viral suppression among TGW.

Factors Associated with Recent HIV Testing among Men Who Have Sex with Men in Philadelphia: a Cross-Sectional Analysis of the National Behavioral Surveillance System Survey

The main objective of this study was to determine the demographic, geographic and socioeconomic characteristics of men who have sex with men (MSM) in Philadelphia that were associated with having a recent HIV test. We used data from the National HIV Behavioral Surveillance System (NHBS) surveys from 2011 and 2014 among MSM in Philadelphia, with the outcome of interest of having received an HIV test in the past twelve months. Of 1043 HIV-negative MSM, 70.2% had an HIV test. Multivariable analysis showed that seeing a medical provider (aOR: 1.73; p = .0039) or having heard of PrEP (aOR: 2.24; p < .0001) was associated with recent HIV testing. Those participants forty-five years of age or older (aOR 0.40, p = .0001) and those with Medicaid had lower rates of HIV testing (aOR 0.48, p = .002). Although over 80% of participants had seen a medical provider in the past year, only 50% had been offered an HIV test by a provider. Optimizing HIV testing through the expansion and increased awareness of PrEP, especially among older MSM, is critical. Further research is needed to delineate barriers that prevent MSM from utilizing medical providers for HIV testing and for those with Medicaid from receiving HIV testing.