Sexual seroadaptation: lessons for prevention and sex research from a cohort of HIV-positive men who have sex with men

The HIV Environmental Riskscape: The Roles of HIV Sexual Risk and Resilience Factors among Black Men Who Have Sex with Men: Findings from the Real Talk Project

Black and African American men who have sex with men (Black MSM) experience the greatest proportion of new HIV infections in the United States. To address this challenge, a better understanding of the HIV environment riskscape including both risk and resilience factors is warranted among Black MSM. Research indicates that stress is associated with increased HIV sexual risk behaviors. Further, behavioral factors such as serosorting and community level factors including social support and community connection are resilience factors that protect against risk behaviors. The present study examines whether everyday stress is associated with HIV sexual risk behavior, as well as the role of risk and resilience factors among 125 Black MSM recruited in the Real Talk study. The Real Talk project examined the relationships between resilience, HIV risk behaviors, and HIV prevention strategy among a sample of Black MSM. Using generalized estimating equations, our results indicate a positive association between everyday stress and engaging in condomless anal intercourse only after adjusting for risk, resilience, and correlate variables. Similarly, having multiple sex partners and using substances during sex also show positive associations with condomless anal intercourse. Resilience factors of engaging in serosorting and being connected to both the Black and gay communities were negatively associated with condomless anal intercourse. Future prevention research and programming should focus on both risk and resilience factors to mitigate new HIV infections among Black MSM.

Longitudinal Effects of Syndemics on HIV-Positive Sexual Minority Men's Sexual Health Behaviors

This study examined the longitudinal effects of co-occurring psychosocial concerns, or syndemics, on HIV-positive sexual minority men's likelihood of engaging in serodiscordant condomless anal sex (CAS), a health behavior with implications for personal and public health. Participants included 390 HIV-positive sexual minority men from two prior secondary prevention trials. Over the course of the 1-year data collection period (up to 5 observations per participant), participants completed self-report measures of CAS, as well as six syndemic factors: post-traumatic stress disorder, childhood sexual abuse, depression, anxiety, alcohol abuse, and polysubstance/stimulant use. We employed multilevel modeling to examine the longitudinal additive effect of syndemics on serodiscordant CAS (binary) over the 1-year period. The number of syndemic conditions was a significant predictor of CAS, with each additional syndemic associated with 1.41 greater odds of CAS (p = .0004; 95% CI [1.16, 1.70]). Both the between-person (p = .0121, 95% CI [1.07, 1.69]) and within-person (p = .01, 95% CI [1.11, 2.10]) effects of syndemics were significant predictors, showing that an increase in the number of syndemic conditions across person and time both increased odds of CAS. Interventions addressing HIV-positive sexual minority men's sexual health behaviors should address the potential impact of co-occurring psychosocial concerns that affect these behaviors. This will benefit this population's personal sexual health and reduce transmission of HIV and STIs among sexual minority men.

"Losing the Phobia:" Understanding How HIV Pre-exposure Prophylaxis Facilitates Bridging the Serodivide Among Men Who Have Sex With Men

The use of HIV serostatus information has played a pivotal role in partner selection norms. A phenomenon known as serosorting is the practice of selecting a partner based on a perception that they are of the same HIV status in order to avoid transmission from one partner to the other. An understudied aspect of serosorting is that it has a divisive effect-one accepts or rejects a potential partner based on a singular characteristic, the partner's HIV status, and thus excludes all others. This division has been formally referred to as the HIV serodivide. In this study, we explored partner selection strategies among a group of HIV-negative, young men who have sex with men (n = 29) enrolled in a PrEP demonstration project in Northern California. We found that trends in serosorting were in fact shifting, and that a new and opposite phenomenon was emerging, something we labeled "seromixing" and that PrEP use played a part in why norms were changing. We present three orientations in this regard: (1) maintaining the phobia: in which men justified the continued vigilance and exclusion of people living with HIV as viable sex or romantic partners, (2) loosening/relaxation of phobia: among men who were reflecting on their stance on serosorting and its implications for future sexual and/or romantic partnerships, and (3) losing the phobia: among men letting go of serosorting practices and reducing sentiments of HIV-related stigma. The majority of participants spoke of changing or changed attitudes about intentionally accepting rather than rejecting a person living with HIV as a sex partner. For those who maintained strict serosorting practices, their understandings of HIV risk were not erased as a result of PrEP use. These overarching themes help explain how PrEP use is contributing to a closing of the HIV serodivide.

Prevalence of and Factors Associated with the Use of HIV Serosorting and Other Biomedical Prevention Strategies Among Men Who Have Sex with Men in a US Nationwide Survey

PrEP and treatment-as-prevention (TasP) are biomedical strategies to reduce HIV transmission. Some men who have sex with men (MSM) are combining biomedical strategies with HIV serosorting-termed "biomed matching" when both partners are either on PrEP or TasP, or "biomed sorting" when one partner is using PrEP and the other TasP. Nevertheless, there is limited data on the extent of biomed matching/sorting in large geographically diverse samples. In 2016-2017, 5021 MSM from across the US were surveyed about their HIV status and HIV viral load/PrEP use, as well as that of their recent casual male partners. For each participant, we calculated the proportion of his partners who were (1) HIV-positive and undetectable, (2) HIV-positive and detectable/unknown, (3) HIV unknown/undiscussed, (4) HIV-negative on PrEP, (5) HIV-negative, not on PrEP. In total, 66.6% (n = 3346) of participants were HIV-negative and not on PrEP, 11.9% (n = 599) on PrEP, 14.1% (n = 707) HIV-positive and undetectable, 1.1% (n = 55) HIV-positive and viral load detectable/unknown, and 6.2% (n = 313) HIV unsure/unknown. A participant's own HIV and PrEP status/was significantly associated with that of his partners (all p < 0.001), evincing evidence of both serosorting and biomed matching. Among men on PrEP and those who were HIV-undetectable, there was also some evidence to suggest these participants dually engaged in biomed matching as well as biomed sorting. We found evidence of biomed matching and sorting, which may compound its effectiveness for those using it (i.e., both partners bring biomedical protection). Unintended consequences of biomed matching/sorting include that men not using a biomedical strategy may be less likely to benefit from a partner's use of the strategy-potentially further driving disparities in HIV infections. Public health campaigns might be well served to highlight not only the benefits that biomedical HIV prevention strategies provide for their users (e.g., "being on PrEP protects me from getting HIV"), but also the benefits that a user brings to his partners (e.g., "my use of PrEP means my partners won't get HIV"), and the benefits of being with a partner who is using a biomedical strategy (e.g., "my partner's use of PrEP/TasP protects me from HIV").

[From evidence to action: challenges for the Brazilian Unified National Health System in offering pre-exposure prophylaxis (PrEP) for HIV to persons with the greatest vulnerability]

Pre-exposure prophylaxis (PrEP) has been considered a promising strategy for controlling the global HIV epidemic. However, it is necessary to translate the knowledge accumulated from clinical trials and demosntration studies to the reality of health services and the groups most vulnerable to infection in order to achieve broad coverage with PrEP. The article proposes a reflection on this challenge, focusing on three dimensions: users of prophylaxis, with an emphasis on the contexts of sexual practices and the potential exposures to HIV; the advantages of prophylaxis as compared to other methods and the challenges for protective and safe use; and health services, considering the organizational principles to ensure greater success in the supply and incorporation of PrEP as part of combination prevention strategies. The following principles were analyzed: uniqueness of care, freedom of choice and non-hierarchization of prevention methods, sexual risk management, scheduling flexibility, and complementary and multidisciplinary care. These principles can foster organization of the health service and care, facilitating linkage and retention in care. Some comments were offered on the relative incompatibility between the existing structure of services and the Brazilian Ministry of Health guidelines for offering PrEP. The conclusion was that the success of PrEP as a public health policy depends on two essential factors: ensuring that health services are culturally diverse settings, free of discrimination, and the intensification of community-based interventions, including social networks, in order to reduce inequalities in access to PrEP and health services as a whole.

Unsafe Sexual Behavior Among Gay/Bisexual Men in the Era of Combination Antiretroviral Therapy (cART)

The aim of this study was to determine the association between psychosocial determinants of unprotected receptive anal intercourse (URAI) and unprotected insertive anal intercourse (UIAI). Data from 417 HIV positive men who have sex with men (MSM) in the Multicenter AIDS Cohort Study from April 1999 to March 2012 were analyzed and adjusted odds were calculated. It was found that 66% (n = 277) and 72% (n = 299) reported any UIAI or URAI over follow-up, respectively. Cumulative cART-years (median = 5.30 years) was associated with 33 and 47% increases in UIAI and URAI, respectively. Not having reduced concern about HIV transmission (UIAI: OR 0.37, p-value = 0.0004; URAI: OR 0.57, p-value = 0.04), increased safe sex fatigue (UIAI: OR 2.32, 95% p-value = 0.0002; URAI: OR 1.94, p-value = 0.003), and sexual sensation seeking (UIAI: OR 1.76, p-value = 0.002; URAI: OR 1.56, p-value = 0.02) were associated with UIAI and URAI. Serosorting was associated with UIAI (OR 6.11, p-value < 0.0001) and URAI (OR 6.80, p-value < 0.0001). Findings suggest that negative attitudes about HIV transmission are sustained among older men who have sex with men.

Revisiting the use of condoms in Brazil

INTRODUCTION

It is known that a single prevention strategy is not enough to control multiple HIV epidemics around the world and in Brazil. However, it is not only necessary to recognize the importance of condoms as part of the policy of HIV/AIDS prevention but also discuss its limits. In this article, we aim to investigate the use of condoms in Brazil, draw critical reflections, and understand how they can once again be highlighted in Brazil's prevention strategy going forward.

METHODS

A narrative review of literature was conducted using keywords in PubMed. Reports from national surveys that guide the epidemiological and behavioral surveillance of the Brazilian Ministry of Health were also included.

RESULTS

A total of 40 articles and 3 reports were included in the review and 11 intervention studies to promote the condom use; the main findings were as follows: 1) Despite the increase in national studies on sexual behavior, little attention is given to the role of condom use; 2) There are few studies examining the factors associated with condom use among key populations such as men who have sex with men (MSM), female sex workers (FSW), drug users (DU), and transvestites and transexuals (TT), while substantial studies focus on adolescents and women; 3) Evidence suggests that a combination of interventions is more effective.

DISCUSSION

new prevention technologies must not lose sight of the critical importance of condoms, and efforts to reintroduce them should focus on the role of pleasure in addition to their potential to minimize the risk of HIV.

The effect of prevention methods on reducing sexual risk for HIV and their potential impact on a large-scale: a literature review

A spectrum of diverse prevention methods that offer high protection against HIV has posed the following challenge: how can national AIDS policies with high coverage for prevention and treatment make the best use of new methods so as to reverse the current high, and even rising, incidence rates among specific social groups? We conducted a narrative review of the literature to examine the prevention methods and the structural interventions that can have a higher impact on incidence rates in the context of socially and geographically concentrated epidemics. Evidence on the protective effect of the methods against sexual exposure to HIV, as well as their limits and potential, is discussed. The availability and effectiveness of prevention methods have been hindered by structural and psychosocial barriers such as obstacles to adherence, inconsistent use over time, or only when individuals perceive themselves at higher risk. The most affected individuals and social groups have presented limited or absence of use of methods as this is moderated by values, prevention needs, and life circumstances. As a result, a substantial impact on the epidemic cannot be achieved by one method alone. Programs based on the complementarity of methods, the psychosocial aspects affecting their use and the mitigation of structural barriers may have the highest impact on incidence rates, especially if participation and community mobilization are part of their planning and implementation.

"Knowing Your Status and Knowing Your Partner's Status Is Really Where It Starts": A Qualitative Exploration of the Process by Which a Sexual Partner's HIV Status Can Influence Sexual Decision Making

Gay and bisexual men are at disproportionate risk for human immunodeficiency virus (HIV) infection. While prevention efforts often emphasize consistent condom use, there is growing evidence that men are using seroadaptive safer-sex strategies, such as serosorting and seropositioning. This qualitative analysis of 204 HIV-negative and HIV-positive gay and bisexual men explored the ways that a sexual partner's HIV status can influence safer-sex strategies and sexual decisions. The majority of the respondents reported that they were influenced by their partners' HIV status. Those respondents who reported no influence discussed adhering to safer-sex rules that were not dependent on partner status and a lack of concern about HIV. Conversely, respondents who reported influence identified three primary areas of influence: psychological impacts, partner preference and selection, and specific behavioral intentions and strategies. A conceptual model explicating a potential process by which respondents use partner serostatus information in shaping sexual decisions is presented.

Seroadaptive Strategies of Gay & Bisexual Men (GBM) with the Highest Quartile Number of Sexual Partners in Vancouver, Canada

Despite continued research among men with more sexual partners, little information exists on their seroadaptive behavior. Therefore, we examined seroadaptive anal sex strategies among 719 Vancouver gay and bisexual men (GBM) recruited using respondent-driven sampling. We provide descriptive, bivariable, and multivariable adjusted statistics, stratified by HIV status, for the covariates of having ≥7 male anal sex partners in the past 6 months (Population fourth quartile versus <7). Sensitivity Analysis were also performed to assess the robustness of this cut-off. Results suggest that GBM with more sexual partners are more likely to employ seroadaptive strategies than men with fewer partners. These strategies may be used in hopes of offsetting risk, assessing needs for subsequent HIV testing, and balancing personal health with sexual intimacy. Further research is needed to determine the efficacy of these strategies, assess how GBM perceive their efficacy, and understand the social and health impacts of their widespread uptake.

Sexual behavior and HIV risk among age-discrepant, same-sex male couples

Research has suggested that men who have sex with men and who have older sexual partners are at increased risk of HIV infection. However, while several studies have explored risk among men in age-discrepant non-primary partnerships, only two have explored age discrepancy and risk in primary same-sex male relationships. We used data from semi-structured in-depth interviews to explore sexual behaviour and HIV risk among 14 Black, white and interracial (Black/white) same-sex male couples with an age difference of 10 or more years. Most couples regularly used condoms, and sexual positioning tended to lead to lower risk for younger partners. Some serodiscordant couples abstained from anal sex, while others used seropositioning to avoid transmission within the relationship. Within some couples, older partners acted as mentors on HIV prevention and broader life lessons. Future studies should further explore the potential risks and benefits of large age differences in same-sex male primary relationships.

Effects of a Quasi-Randomized Web-Based Intervention on Risk Behaviors and Treatment Seeking Among HIV-Positive Men Who Have Sex With Men in Chengdu, China

The men who have sex with men (MSM) population in China has experienced a recent increase in HIV incidence. Due to the dual stigma and discrimination towards homosexuality and HIV infection, most MSM living with HIV/AIDS are hard to reach by offline intervention initiatives. We recruited HIV-positive MSM participants in Chengdu, China and assessed whether they disclosed their HIV status to partners, motivated a partner to receive testing, used condoms consistently, or initiated antiretroviral therapy. Participants were quasi-randomized to either the intervention or control arm. The intervention group was given instructions for an online program with four modules: an information exchange website, a bulletin board system, individualized online counseling with trained peer educators, and an animation game. All participants were re-assessed at 6 months. The study enrolled 202 HIV-positive MSM. The intervention group had significant increases in disclosing their HIV status to their partners (76.0% vs 61.2%, P=0.0388) and motivating partners to accept HIV testing (42.3% vs 25.5%, P=0.0156) compared with the control group, but there were no between-group differences in receiving early treatment or using condoms consistently. We found that a web-based intervention targeting HIV-positive MSM was an effective tool in increasing the uptake of HIV testing within this high-risk population.

Factors associated with unprotected anal sex with multiple non-steady partners in the past 12 months: results from the European Men-Who-Have-Sex-With-Men Internet Survey (EMIS 2010)

BACKGROUND

Practising unprotected anal intercourse (UAI) with high numbers of partners is associated with increased risk for acquiring and transmitting HIV and other sexually transmitted infections. Our aim was to describe factors associated with UAI with multiple partners in a large sample of MSM from 38 European countries recruited for an online survey in 2010.

METHODS

Data are from the European Men-Who-Have-Sex-With-Men Internet Survey (EMIS). The analysis was restricted to men who reported any anal sex with a non-steady partner in the past 12 months, and who were either never diagnosed with HIV, or who had been diagnosed with HIV more than 12 months ago, reported a detectable viral load and did not exclusively serosort (n = 91,477). Multivariable logistic regression was used to compare men reporting UAI with four or more (4+) non-steady partners to two comparison groups: a) no UAI with non-steady partners, and b) UAI with 1-3 non-steady partners.

RESULTS

Overall, 9.6% of the study population reported UAI with 4+ partners in the past 12 months. In both models, factors consistently associated with this behaviour were: having been diagnosed with HIV, lower educational levels, use of nitrite inhalants, drugs associated with sex and parties, or erectile dysfunction drugs in the past 4 weeks, using sex-on-site venues in the past 4 weeks, buying or selling sex in the past 12 months, having experienced physical violence due to sexual attraction to men in the past 12 months, reporting sexual happiness, being out to all or almost all of one's acquaintances, and knowing that ART reduces HIV transmissibility.

CONCLUSIONS

Effective antiretroviral treatment drastically reduces HIV transmission for men diagnosed with HIV, irrespective of partner numbers. Apart from reducing partner numbers or increasing condom use no other recommendations are currently in place to reduce the risk of HIV acquisition and onward transmission for HIV-negative men practicing UAI with multiple partners. A range of factors were identified as associated with UAI with four or more partners which allow the strengthening and targeting of prevention strategies to reduce HIV transmission risks resulting from condomless anal intercourse with multiple partners.

What people want from sex and preexposure prophylaxis

PURPOSE OF REVIEW

As demand for preexposure prophylaxis (PrEP) increases, we are learning more about what people want from sex and PrEP.

RECENT FINDINGS

PrEP demand has reached a tipping point in the USA and is increasing rapidly. Although the primary benefit of PrEP use is biological, to reduce risk of HIV infection, PrEP users often express an alternative set of social and emotional benefits that are provided by PrEP. These collateral benefits of PrEP have salience, affect, and are experienced in the present, which are compelling drivers of human behavior. PrEP use has been associated with feeling safe during sex, usually in contrast to ruminations related to fear of HIV or intimate partner violence or control. PrEP can create empowerment, or agency, defined as the capacity and autonomy to act on one's own behalf, because it provides control over one's vulnerability to HIV and relief to women and men who may otherwise worry about whether their partners will use a condom, take antiretroviral therapy, or disclose their HIV status accurately. Planning for sexual and social goals in calm moments is also empowering. These highly desired collateral benefits of PrEP could be undermined, or eliminated, if PrEP is implemented in ways that are coercive or that foment fear of sexual risk compensation, drug resistance, toxicity, or moral judgment.

SUMMARY

Current PrEP implementation provides direct and indirect benefits that are highly desired.

Epidemiology of infections by HIV, Syphilis, Gonorrhea and Lymphogranuloma Venereum in Barcelona City: a population-based incidence study

BACKGROUND

The aim of this study was to determine the evolution of HIV infection, gonorrhea, syphilis and lymphogranuloma venereum (LGV), and their epidemiological characteristics in Barcelona city.

METHODS

Population-based incidence study of all newly occurring diagnoses of HIV infection, syphilis, gonorrhea and LGV detected in Barcelona between January 2007 and December 2011. A descriptive analysis was performed. The annual incidence rates per 100,000 inhabitants were calculated by sex, sexual conduct and educational level. To estimate global sex-specific rates we used the Barcelona city census; for the calculation of rates by sexual conduct and educational level we used estimates of the Barcelona Health Interview Survey. Trends were analysed using the chi-squared test for linear trend.

RESULTS

HIV. 66.8 % of the HIV cases were men who had sex with men (MSM). The incidence rates in MSM over the study period were from 692.67/100,000 to 909.88/100,000 inh. Syphilis. 74.2 % of the syphilis cases were MSM. The incidence rates in MSM were from 224.9/100,000 to 891.97/100,000 inh. and the MSM with a university education ranged from 196.3/100,000 to 1020.8/100,000. Gonorrhea. 45.5 % of the gonorrhea cases were MSM. The incidence rates in MSM were from 164.24/100,000 to 404.79/100,000 inh. and the MSM with university education ranged from 176.7/100,000 to 530.1/100,000 inh.. Lymphogranuloma venereum (LGV). 95.3 % of the LGV cases are MSM. The incidence rates in MSM were from 24.99/100,000 to 282.99/100,000 inh. and the MSM with university education ranged from 9.3/100,000 to 265/100,000 inh.

CONCLUSION

An increase in cases of STI was observed. These STI mainly affected MSM with a university education. Continuing to monitor changes in the epidemiology of STI, and identifying the most affected groups should permit redesigning preventive programs, with the goal of finding the most efficient way to reach these population groups.

Pre-exposure and postexposure prophylaxes and the combination HIV prevention methods (The Combine! Study): protocol for a pragmatic clinical trial at public healthcare clinics in Brazil

INTRODUCTION

Few results from programmes based on combination prevention methods are available. We propose to analyse the degree of protection provided by postexposure prophylaxis (PEP) for consensual sexual activity at healthcare clinics, its compensatory effects on sexual behaviour; and the effectiveness of combination prevention methods and pre-exposure prophylaxis (PrEP), compared with exclusively using traditional methods.

METHODS AND ANALYSIS

A total of 3200 individuals aged 16 years or older presenting for PEP at 5 sexually transmitted disease (STD)/HIV clinics in 3 regions of Brazil will be allocated to one of two groups: the PEP group-individuals who come to the clinic within 72 h after a sexual exposure and start PEP; and the non-PEP group-individuals who come after 72 h but within 30 days of exposure and do not start PEP. Clinical follow-up will be conducted initially for 6 months and comprise educational interventions based on information and counselling for using prevention methods, including PrEP. In the second study phase, individuals who remain HIV negative will be regrouped according to the reported use of prevention methods and observed for 18 months: only traditional methods; combined methods; and PrEP. Effectiveness will be analysed according to the incidence of HIV, syphilis and hepatitis B and C and protected sexual behaviour. A structured questionnaire will be administered to participants at baseline and every 6 months thereafter. Qualitative methods will be employed to provide a comprehensive understanding of PEP-seeking behaviour, preventive choices and exposure to HIV.

ETHICS AND DISSEMINATION

This study will be conducted in accordance with the resolution of the School of Medicine Research Ethics Commission of Universidade de São Paulo (protocol no. 251/14). The databases will be available for specific studies, after management committee approval. Findings will be presented to researchers, health managers and civil society members by means of newspapers, electronic media and scientific journals and meetings.

Developing a conceptual framework of seroadaptive behaviors in HIV-diagnosed men who have sex with men

BACKGROUND

Seroadaptive behaviors are strategies employed by men who have sex with men (MSM) to reduce the transmission risk for human immunodeficiency virus (HIV). It has been suggested that they contribute to the increasing diagnoses of sexually transmitted infections in HIV-diagnosed MSM. To understand the context in which the reemerging sexually transmitted infections appear, we developed a social epidemiological model incorporating the multiple factors influencing seroadaptive behaviors.

METHODS

A literature review of seroadaptive behaviors in HIV-diagnosed MSM was conducted. The literature was synthesized using a social epidemiological perspective.

RESULTS

Seroadaptive behaviors are adopted by MSM in high-income countries and are a way for HIV-diagnosed men to manage and enjoy their sexual lives. Influences are apparent at structural, community, interpersonal, and intrapersonal levels. There is little evidence of whether and when the behavior forms part of a premeditated strategy; it seems dependent on the social context and on time since HIV diagnosis. Social rules of HIV disclosure and perception of risk depend on the setting where partners are encountered.

CONCLUSIONS

Seroadaptive behaviors are strongly context dependent and can reduce or increase transmission risk for different infectious diseases. Further data collection and mathematical modeling can help us explore the specific conditions in more detail.

Providers caring for adolescents with perinatally-acquired HIV: Current practices and barriers to communication about sexual and reproductive health

The population of adolescents and young adults (AYA) with perinatally-acquired HIV (PHIV) present challenges to HIV healthcare providers (HHCPs). Originally not expected to survive childhood, they are now living well into young adulthood. Little is known about the type of sexual and reproductive (SRH) information/services offered to AYA with PHIV by HHCPs. HHCPs (n=67) were recruited using snowball sampling, and completed an online survey. Providers' most frequently endorsed SRH topics discussed with both male and female patients included condom use (77.3%), STD prevention (73.1%), and screening (62.1%). Providers' reports indicated that females received significantly more education about SRH topics overall. The most frequently noted barriers to SRH communication included more pressing health concerns (53.0%), parent/guardian not receptive (43.9%), and lack of time during appointment (43.9%). Provider-reported SRH conversations with HHCPs were highly focused on horizontal transmission and pregnancy prevention. Salient social aspects of SRH promotion for AYAs with PHIV (e.g., managing disclosure and romantic relationships) were less commonly discussed, though such conversations may serve to reduce secondary transmission and enhance the overall well-being of AYA with PHIV. Findings indicated that further work must be done to identify strategies to address unmet SRH needs of the aging population of AYA with PHIV.

Social networks, sexual networks and HIV risk in men who have sex with men

Worldwide, men who have sex with men (MSM) remain one of the most HIV-vulnerable community populations. A global public health priority is developing new methods of reaching MSM, understanding HIV transmission patterns, and intervening to reduce their risk. Increased attention is being given to the role that MSM networks play in HIV epidemiology. This review of MSM network research studies demonstrates that: (1) Members of the same social network often share similar norms, attitudes, and HIV risk behavior levels; (2) Network interventions are feasible and powerful for reducing unprotected sex and potentially for increasing HIV testing uptake; (3) HIV vulnerability among African American MSM increases when an individual enters a high-risk sexual network characterized by high density and racial homogeneity; and (4) Networks are primary sources of social support for MSM, particularly for those living with HIV, with greater support predicting higher care uptake and adherence.

Comparison of HIV behavioral indicators among men who have sex with men across two survey methodologies, San Francisco, 2004 and 2008

BACKGROUND

Our goal was to examine whether community-based behavioral surveys can augment data collected for the National HIV Behavioral Surveillance System (NHBS) among men who have sex with men (MSM) in San Francisco.

METHODS

We compared estimates of sexual risk behaviors among MSM using data from two cycles of NHBS (2004 and 2008) and outreach surveys conducted by STOP AIDS Project (SAP) during the same years. We compared estimates of unprotected anal intercourse (UAI) and other indicators to assess concordance of estimates across methodologies.

RESULTS

Of the 3248 interviews conducted, the NHBS sample included more nonwhite and older MSM, more self-reported HIV positive, and less sexually active men than the SAP sample. Estimates of UAI in the last 6 months were slightly higher in the NHBS survey than in the SAP surveys (2004: 40% vs. 36%, P = 0.03; 2008: 44% vs. 38%, P = 0.08). In 2008, where respondent-partner HIV-discordant status could be measured, estimates of UAI with a potentially discordant partner were similar (12% vs. 12%, P = 0.87). Also, the NHBS and SAP surveys observed similar estimates of UAI by high-risk positioning with potentially discordant partners (HIV-positive men reporting insertive UAI with a potentially HIV-negative partner: 13% vs. 11%, P = 0.45; HIV-negative men reporting receptive UAI with a potentially HIV-positive person: 5% vs. 4%, P = 0.85).

CONCLUSIONS

Behavioral estimates drawn from convenience sampling methods can provide informative surveillance estimates of key behavioral indictors that can augment data from more rigorous national HIV behavioral surveillance surveys.

Sexual mixing and the risk environment of sexually active transgender women: data from a respondent-driven sampling study of HIV risk among transwomen in San Francisco, 2010

Background

Research on the sexual networks of transwomen is central to explaining higher HIV risk for this population. This study examined HIV risk behaviors and sexual mixing patterns of transwomen by demographic and HIV-related risk behaviors.

Methods

Data were obtained from a 2010 study of HIV risk for transwomen in San Francisco. Assortativity by race, partner type, HIV serostatus, and IDU across sexual networks was calculated using Newman’s assortativity coefficient (NC). Multivariable generalized estimating equations (GEE) logistic regression models were used to evaluate associations between unprotected anal intercourse with race and HIV serostatus, partner-IDU status and relationship type discordance while adjusting for the HIV status of transwomen.

Results

There were 235 sexually active transwomen in this study, of whom 104 (44.3%) were HIV-positive and 73 (31.1%) had a history of injection drug use. Within the 575 partnerships, African American/black and Latina transwomen were the most racially assortative (NC 0.40, 95% CI 0.34-0.45, and NC 0.43, 95% CI 0.38-0.49, respectively). In partnerships where the partner’s HIV status was known (n = 309, 53.7%), most transwomen were in sexual partnerships with people of their same known serostatus (71.8%, n = 222). In multivariable analyses, unprotected anal intercourse was significantly associated with primary partners, having a sexual partner who was an injection drug user, and sexual partner seroconcordance.

Conclusions

Public health efforts to reduce transwomen’s HIV risk would likely benefit from prioritizing prevention efforts to risk reduction within IDU-discordant and primary partnerships, determining risks attributable to sexual network characteristics, and actively addressing injection drug use among transwomen.

Lymphogranuloma venereum in Barcelona, 2007–2012: the role of seroadaptation in men who have sex with men

This study describes the incidence rate of reported lymphogranuloma venereum (LGV) in men who have sex with men (MSM) in Barcelona from 2007 to 2012. Epidemiological, clinical and sexual behaviour characteristics of LGV cases are described. Seroadaptive behaviours as a transmission risk factor were assessed by a telephone questionnaire during 2012. Data were handled on a strictly confidential basis. LGV annual rate ratios in MSM were compared with cases from 2007. Differences were statistically analysed with a Poisson test. The incidence rate of LGV in MSM aged 15–69 years ranged from 32·1/105MSM per year in 2007 to 182·7/105MSM per year in 2012. In 2012, 31/51 LGV cases (61%) answered the telephone questionnaire, of which 84% (26/31) were HIV positive, 39% (12/31) reported having sex according to their partners’ serostatus and 7% (2/31) used strategic positioning. The incidence of LGV has increased since 2007 and mainly affects HIV-positive MSM. It is probable that seroadaptation has facilitated LGV transmission.

The role of intent in serosorting behaviors among men who have sex with men sexual partnerships

BACKGROUND

Serosorting is increasingly assessed in studies of men who have sex with men (MSM). Most research studies have measured serosorting by combining reported unprotected anal intercourse (UAI) and the occurrence of participant and partner same HIV status (seroconcordance). The Centers for Disease Control and Prevention's definition of serosorting also incorporates intent to be in such a partnership, although few studies incorporate both intent and behavior into their measures.

METHODS

Using data from a national, online survey of 3519 US MSM, we assessed the role of intention in seroconcordant partnerships, as measured by participant rating of the importance of shared serostatus when selecting a sex partner.

RESULTS

For HIV+ men, 30% partnerships were seroconcordant; of these, 48% reported intent to be in such a partnership (intentional seroconcordance). For HIV- men, 64% partnerships were seroconcordant; of these, 80% reported intentional seroconcordance. Intentional seroconcordance was associated with UAI for HIV+ partnerships [odds ratio (OR): 1.9; 95% confidence interval (CI): 1.3 to 2.9] but not significant for HIV- partnerships (OR: 1.1; CI: 0.99 to 1.3). In separate models where intent was not considered, seroconcordance was associated with UAI for HIV+ partnerships (OR: 3.2; 95% CI: 2.2 to 4.6) and for HIV- partnerships (OR: 1.2; 95% CI: 1.0 to 1.3; P = 0.03).

CONCLUSIONS

Regardless of intentionality, seroconcordance was strongly associated with UAI for HIV+ men and weakly associated with UAI for HIV- men. Intentional seroconcordance was not associated with UAI more strongly than was seroconcordance in absence of consideration of intent. Intentionality may not be a critical element of the relationship between seroconcordance and UAI.

Seroadaptation among men who have sex with men: emerging research themes

Seroadaptation describes a diverse set of potentially harm-reducing behaviors that use HIV status to inform sexual decision making. Men who have sex with men (MSM) in many settings adopt these practices, but their effectiveness at preventing HIV transmission is debated. Past modeling studies have demonstrated that serosorting is only effective at preventing HIV transmission when most men accurately know their HIV status, but additional modeling is needed to address the effectiveness of broader seroadaptive behaviors. The types of information withwhichMSMmake seroadaptive decisions is expanding to include viral load, treatment status, and HIV status based on home-use tests, and recent research has begun to examine the entire seroadaptive process, from an individual's intentions to seroadapt to their behaviors to their risk of acquiring or transmitting HIV and other STIs. More research is needed to craft clear public health messages about the risks and benefits of seroadaptive practices.

HIV-negative and HIV-discordant gay male couples' use of HIV risk-reduction strategies: differences by partner type and couples' HIV-status

Previous research has found that gay men and other men who have sex with men have adopted a variety of HIV risk-reduction strategies to engage in unprotected anal intercourse (UAI). However, whether gay male couples' use these strategies within and out of their relationships remains unknown. The present national cross-sectional study collected dyadic data from an online sample of 275 HIV-negative and 58 discordant gay male couples to assess their use of these strategies, and whether their use of these strategies had differed by partner type and couples' HIV-status. The sample used a variety of risk-reduction strategies for UAI. Some differences and patterns by partner type and couples' HIV-status were detected about men's use of these strategies. Findings indicate the need to bolster HIV prevention and education with gay male couples about their use of these strategies within and outside of their relationships.

Changes in seroadaptive practices from before to after diagnosis of recent HIV infection among men who have sex with men

OBJECTIVE

We assessed changes in sexual behavior among men who have sex with men (MSM), before and for several years after HIV diagnosis, accounting for adoption of a variety of seroadaptive practices.

METHODS

We collected self-reported sexual behavior data every 3 months from HIV-positive MSM at various stages of HIV infection. To establish population level trends in sexual behavior, we used negative binomial regression to model the relationship between time since diagnosis and several sexual behavior variables: numbers of (a) total partners, (b) potentially discordant partners (PDP; i.e., HIV-negative or unknown-status partners), (c) PDPs with whom unprotected anal intercourse (UAI) occurred, and (d) PDPs with whom unprotected insertive anal intercourse (uIAI) occurred.

RESULTS

A total of 237 HIV-positive MSM contributed 502 interviews. UAI with PDPs occurred with a mean of 4.2 partners in the 3 months before diagnosis. This declined to 0.9 partners/3 months at 12 months after diagnosis, and subsequently rose to 1.7 partners/3 months at 48 months, before falling again to 1.0 partners/3 months at 60 months. The number of PDPs with whom uIAI occurred dropped from 2.4 in the pre-diagnosis period to 0.3 partners/3 months (an 87.5% reduction) by 12 months after enrollment, and continued to decline over time.

CONCLUSION

Within months after being diagnosed with HIV, MSM adopted seroadaptive practices, especially seropositioning, where the HIV-positive partner was not in the insertive position during UAI, resulting in a sustained decline in the sexual activity associated with the highest risk of HIV transmission.

A cautionary tale: risk reduction strategies among urban American Indian/Alaska Native men who have sex with men

American Indian and Alaska Native (AIAN) men who have sex with men (MSM) are considered particularly high risk for HIV transmission and acquisition. In a multi-site cross-sectional survey, 174 AIAN men reported having sex with a man in the past 12 months. We describe harm reduction strategies and sexual behavior by HIV serostatus and seroconcordant partnerships. About half (51.3%) of the respondents reported no anal sex or 100% condom use and 8% were in seroconcordant monogamous partnership. Of the 65 men who reported any sero-adaptive strategy (e.g., 100% seroconcordant partnership, strategic positioning or engaging in any strategy half or most of the time), only 35 (54.7%) disclosed their serostatus to their partners and 27 (41.5%) tested for HIV in the past 3 months. Public health messages directed towards AIAN MSM should continue to encourage risk reduction practices, including condom use and sero-adaptive behaviors. However, messages should emphasize the importance of HIV testing and HIV serostatus disclosure when relying solely on sero-adaptive practices.

Network mixing and network influences most linked to HIV infection and risk behavior in the HIV epidemic among black men who have sex with men

OBJECTIVES

We evaluated network mixing and influences by network members upon Black men who have sex with men.

METHODS

We conducted separate social and sexual network mixing analyses to determine the degree of mixing on risk behaviors (e.g., unprotected anal intercourse [UAI]). We used logistic regression to assess the association between a network "enabler" (would not disapprove of the respondent's behavior) and respondent behavior.

RESULTS

Across the sample (n = 1187) network mixing on risk behaviors was more assortative (like with like) in the sexual network (r(sex), 0.37-0.54) than in the social network (r(social), 0.21-0.24). Minimal assortativity (heterogeneous mixing) among HIV-infected men on UAI was evident. Black men who have sex with men reporting a social network enabler were more likely to practice UAI (adjusted odds ratio = 4.06; 95% confidence interval = 1.64, 10.05) a finding not observed in the sexual network (adjusted odds ratio = 1.31; 95% confidence interval = 0.44, 3.91).

CONCLUSIONS

Different mixing on risk behavior was evident with more disassortativity among social than sexual networks. Enabling effects of social network members may affect risky behavior. Attention to of high-risk populations' social networks is needed for effective and sustained HIV prevention.

People living with HIV are receptive to HIV prevention interventions in clinical settings: a qualitative evaluation

In the United States, HIV prevention services are increasingly being offered in the context of healthcare settings. This includes prioritizing prevention services for people living with HIV (PLWH), otherwise known as "prevention with positives." We conducted sixty in-depth interviews to explore patients' perceptions of clinic-based HIV prevention interventions targeting people living with HIV. The majority of patients were receptive to the prevention interventions. Patients described experiencing feeling fulfilled by communicating about issues related to HIV prevention when the conversations were specific to their situation and with an interventionist who was objective, yet empathic and non-judgmental. Provider-delivered interventions opened up new areas of prevention discussions with patients. Specialist-delivered interventions, specifically group-level interventions, provided opportunities to integrate participants into social networks that in turn provided social support and a reduction in social isolation. HIV prevention counseling benefited patients regardless of risk status.

Resilience, syndemic factors, and serosorting behaviors among HIV-positive and HIV-negative substance-using MSM

Serosorting is commonly employed by MSM to reduce HIV risk. We hypothesize that MSM perceive serosorting to be effective, and that serosorting is predicted by resilience and inversely related to syndemic characteristics. Surveys included 504 substance-using MSM. Logistic regression models examined syndemic and resilience predictors of serosorting, separately by serostatus. For HIV-positive men, positive coping behaviors (P = .015) and coping self-efficacy (P = .014) predicted higher odds, and cognitive escape behaviors (P = .003) lower odds, of serosorting. For HIV-negative men, social engagement (P = .03) and coping self-efficacy (P = .01) predicted higher odds, and severe mental distress (P = .001), victimization history (P = .007) and cognitive escape behaviors (P = .006) lower odds, of serosorting. HIV-negative serosorters reported lower perceptions of risk for infection than non-serosorters (P < .000). Although high risk HIV-negative men may perceive serosorting to be effective, their high rates of UAI and partner change render this an ineffective risk reduction approach. Relevant public health messages are urgently needed.

Behavioral and serologic survey of men who have sex with men in Beijing, China: implication for HIV intervention

We assessed HIV prevalence and associated behaviors and risk factors among men who have sex with men (MSM) in Beijing, China. Five hundred MSM were recruited for a biological and behavioral survey using respondent-driven sampling (RDS) in 2009. Serologic specimens were tested for markers of HIV and syphilis infection. A computer-assisted personal interview (CAPI) administered questionnaire gathered information including demographic characteristics, sexual behaviors, HIV testing, and social norms concerning condom use. The adjusted HIV prevalence was 8.0%, syphilis 22.0%. HIV testing and disclosure was low; only 39.3% had HIV tested in the past 12 months, 49.7% knew their own HIV status and 22.8% knew their last male partner's HIV status. HIV infection was associated with syphilis, ever having sex with a woman, not knowing the HIV status of the most recent male partner, and never buying condoms in the past 12 months. Stronger endorsement of positive social norms around condom use strongly and predicted lower prevalence of HIV infection. Compared to surveys of similar design in the recent past, HIV continues to spread rapidly among Beijing's MSM. Our results identify points of intervention that, if addressed in time, may still alter the course of the epidemic including the promotion of HIV testing and partner disclosure, syphilis control and particularly changing social norms around condom use.

Repeat syphilis among men who have sex with men in California, 2002-2006: implications for syphilis elimination efforts

OBJECTIVES

We examined rates of and risk factors for repeat syphilis infection among men who have sex with men (MSM) in California.

METHODS

We analyzed 2002 to 2006 California syphilis surveillance system data.

RESULTS

During the study period, a mean of 5.9% (range: 4.9%-7.1% per year) of MSM had a repeat primary or secondary (PS) syphilis infection within 2 years of an initial infection. There was no significant increase in the annual proportion of MSM with a repeat syphilis infection (P = .42). In a multivariable model, factors associated with repeat syphilis infection were HIV infection (odds ratio [OR] = 1.65; 95% confidence interval [CI] = 1.14, 2.37), Black race (OR = 1.84; 95% CI = 1.12, 3.04), and 10 or more recent sex partners (OR = 1.99; 95% CI = 1.12, 3.50).

CONCLUSIONS

Approximately 6% of MSM in California have a repeat PS syphilis infection within 2 years of an initial infection. HIV infection, Black race, and having multiple sex partners are associated with increased odds of repeat infection. Syphilis elimination efforts should include messages about the risk for repeat infection and the importance of follow-up testing. Public health attention to individuals repeatedly infected with syphilis may help reduce local disease burdens.

MSM: resurgent epidemics

PURPOSE OF REVIEW

The present review discusses the recent finding on behavioral risk factors for HIV transmission from cohort studies in MSM.

RECENT FINDINGS

HIV incidence among MSM has been increasing in many countries around the world. Some data support early detection and widespread use of antiretroviral treatment (ART) to decrease HIV incidence. However, suboptimal ART adherence could lead to relapse of viremia and new transmission events. Condom use for unprotected anal sex among MSM remains an important prevention tool, but use remains low in many parts of the world. Seroadaptive behaviors by MSM, such as serosorting, may also decrease condom use. However, when serosorting is practiced by MSM who receive frequent HIV testing, the risk of HIV acquisition is reduced. Serosorting and other characteristics of sexual networks, such as concurrency, may be major determinants of transmission for HIV and sexually transmitted infections among MSM. Worldwide, detailed evaluation of the factors related to rising MSM HIV incidence, as well as access to testing and care, is limited by stigma and criminalization of HIV and homosexuality.

SUMMARY

Cohort studies of MSM remain an important strategy to characterize the behavioral factors that drive HIV transmission and how use of ART for prevention and treatment may affect both the risk of HIV transmission and acquisition by MSM.

The association between lymphogranuloma venereum and HIV among men who have sex with men: systematic review and meta-analysis

BACKGROUND

Lymphogranuloma venereum (LGV) is an important re-emerging sexually transmitted infection which is reported to affect particularly HIV-positive men who have sex with men (MSM). The aim of this study is to quantify the association between LGV and HIV in the context of the current emergence of LGV.

METHODS

A systematic review was performed on the emergence of LGV among MSM since 2000. We report the prevalence of HIV infection from descriptive studies of MSM with LGV, and conduct a meta-analysis to produce a summary estimate of the association between LGV and HIV from case-control studies where cases were MSM with LGV and controls were MSM with rectal chlamydia caused by non-LGV serovars.

RESULTS

The prevalence of HIV among LGV cases ranges from 67% to 100% in 13 descriptive studies. There is a significant association between HIV and LGV (odds ratio 8.19, 95% CI 4.68-14.33).

CONCLUSIONS

HIV-positive MSM are disproportionately affected by LGV highlighting the importance of prevention efforts to be targeted to this group. Further research is needed to determine whether the association is due to biological or behavioural factors.