Young, Online and in the Dark: Scaling Up HIV Testing among MSM in ASEAN

User preferences for an mHealth app to support HIV testing and pre-exposure prophylaxis uptake among men who have sex with men in Malaysia

Recent estimates report a high incidence and prevalence of HIV among men who have sex with men (MSM) in Malaysia. Mobile apps are a promising and cost-effective intervention modality to reach stigmatized and hard-to-reach populations to link them to HIV prevention services (e.g., HIV testing, pre-exposure prophylaxis, PrEP). This study assessed attitudes and preferences toward the format, content, and features of a mobile app designed to increase HIV testing and PrEP uptake among Malaysian MSM. We conducted six online focus groups between August and September 2021 with 20 MSM and 16 stakeholders (e.g., doctors, nurses, pharmacists, and NGO staff) to query. Transcripts were analyzed in Dedoose software to identify thematic content. Key themes in terms of app functions related to stylistic preferences (e.g., design, user interface), engagement strategies (e.g., reward systems, reminders), recommendations for new functions (e.g., enhanced communication options via chat, discussion forum), cost of services (e.g., PrEP), and legal considerations concerning certain features (e.g., telehealth, patient identification), minimizing privacy and confidentiality risks. Our data suggest that a tailored HIV prevention app would be acceptable among MSM in Malaysia. The findings further provide detailed recommendations for successfully developing a mobile app to improve access to HIV prevention services (e.g., HIV testing, PrEP) for optimal use among MSM in Malaysia.

Patterns of Chemsex Substance Use and Its Association with HIV Transmission Risk Among Men Who Have Sex with Men in Thailand: A Latent Class Analysis

Sexualized substance use or "chemsex" may contribute to the HIV epidemic among men who have sex with men (MSM) in Thailand. Specific patterns of chemsex use may be associated with different HIV/STI transmission risks. We examined typologies and correlates of sexualized substance use among a sample of high-risk MSM (n = 532) who had attended a private sex party or circuit party in the past three years using latent class analysis. Multinomial regression was used to adjust for variables associated with the 3-class latent class model. We identified a 3-class model as the best fitting model, which included: (1) "negligible sexualized substance users" (36.7%), who had never engaged in chemsex in the past six months; (2) "sexualized substance users" (13.9%), who had a high level of sexualized alcohol use and a wide range of other substances before or during sex in the past six months; and (3) "exclusive chemsex users" (49.4%), who predominantly used crystal methamphetamine, amyl nitrite, and erectile dysfunctional drugs before or during sex in the past six months. Compared to negligible sexualized substance users, exclusive chemsex users were more likely to be HIV-positive, more likely to have six or more sexual partners in the past six months, less likely to have condom use at last anal intercourse, and more likely to have provided sex work. Relative to negligible sexualized substance users, sexualized substance users reported more frequent online sex-seeking behaviors. These subgroups of Thai MSM have unique substance use patterns and HIV-related risk profiles, underscoring the importance of targeted HIV prevention strategies.

Partying in Thailand: Never Testing Among Men Who Have Sex With Men Who Attend Sexualized (Drug) Parties

BACKGROUND

Human immunodeficiency virus (HIV) testing for Thai men who have sex with men (MSM) is suboptimal, which undermines their linkage to care and subsequent HIV preexposure prophylaxis (PrEP) uptake.

METHODS

We analyzed a cross-sectional survey conducted in 2021 among Thai MSM who attended any private sex parties or circuit parties in the past 3 years ("sexualized parties").

RESULTS

Of the 424 men included in our analysis, 47.6% had been recently tested for HIV in the past 1 year, 30.2% had not recently been tested, and 22.2% had never been tested. In our multivariable analysis, relative to participants who had recently tested for HIV, those who have never tested were more likely to have lower education or to live outside of Bangkok, and to have attended both circuit and private sex parties (vs. private sex party only) but were less likely to report any sexually transmitted infection diagnosis or to have heard of PrEP. Participants who had an HIV test more than a year ago were more likely to have attended both circuit and private sex parties (vs. private sex parties only) but were less likely to have any sexually transmitted infection diagnosis, meet sexual partners online, or have heard of PrEP. Rates of condomless anal sex and willingness to use PrEP were similar across groups.

CONCLUSIONS

Despite the high rates of sexual risk-taking, sexualized party attendees reported suboptimal HIV testing uptake. The joint promotion of HIV testing and PrEP is warranted-especially on-premise HIV testing at circuit parties and outreach at online platforms to reach sexualized party attendees.

Correlates of never testing for HIV among men who have sex with men in Malaysia: A cross-sectional study

INTRODUCTION

HIV testing uptake remains very low among men who have sex with men (MSM) in Malaysia, a subgroup still bearing a disproportionate HIV burden. Therefore, we sought to identify and measure factors associated with never-testing for HIV among Malaysian MSM to further characterize this subgroup and inform future public health interventions addressing low testing rates in the country.

METHODS

We conducted a cross-sectional online survey among Malaysian MSM (August to September 2021). Participants completed questionnaires, including socio-demographic characteristics, HIV/STI testing practices, drug- and sex-related behaviors, and knowledge and attitudes toward HIV prevention services. Out of 1,799 completed surveys, 870 were included in the analysis after eliminating duplicates and incomplete surveys. We used logistic regression to determine factors associated with never-testing for HIV.

RESULTS

Overall, one-third of the study participants (33.8%) reported having never tested for HIV. Of those who reported to have tested for HIV (n = 576), half reported that they had tested for HIV in the past 6 months (50.3%). In multivariable logistic regression, MSM with HIV sero-concordant partner (aOR = 3.44, 95% CI = 1.56-7.60), without a prior diagnosis of a sexually transmitted infection (aOR = 2.83, 95% CI = 1.46-5.49), unaware of pre-exposure prophylaxis (PrEP; aOR = 2.71, 95% CI = 1.74-4.21), unaware of someone taking PrEP (aOR = 1.64, 95% CI = 1.15-2.35), and unwilling to use PrEP (aOR = 2.48, 95% CI = 1.43-4.30) had higher odds of never been tested for HIV. In contrast, MSM who were older (aOR = 0.95, 95% CI = 0.93-0.97) and of the Malaya ethnic group (aOR = 0.59, 95% CI = 0.37-0.95) had lower odds of never testing for HIV.

CONCLUSION

Our findings shed light on the characteristics of HIV never-testers among MSM in Malaysia. The results indicate the need for innovative strategies to increase the uptake of HIV testing services among members of the MSM community.

Polydrug Use, Sexual Risk, and HIV Testing Among Cisgender Gay, Bisexual, and Other Men and Transgender and Nonbinary Individuals Who Have Sex With Men in Kazakhstan

This study examined substance use and sexual risk correlates of HIV testing among cisgender gay, bisexual, and other men (MSM) and transgender and nonbinary individuals (TSM) who have sex with men in Kazakhstan. We analyzed baseline data from an HIV prevention trial collected prior to intervention deployment (N = 304). Multivariable logistic regression analyses revealed that lifetime HIV testing was positively associated with poly-drug use (AOR = 4.4, 95% CI [2.0, 9.9]) and negatively with sexual risk (AOR = 0.4, 95% CI [0.2, 1.0]). Similarly, recent HIV testing was positively associated with polydrug use (AOR = 2.7, 95% CI [1.4, 5.2]) and negatively with sexual risk (AOR = 0.5, 95% CI [0.3, 0.9]). Current HIV testing was negatively associated with sexual risk (AOR = 0.6, 95% CI [0.3. 0.9]). Findings support the value of integrating drug treatment with HIV testing among MSM and TSM in Kazakhstan.

Participatory Action Research to Co-Design Internet-Based HIV Prevention with Young Men Who Have Sex with Men in HIV Prevention in Bali, Indonesia

There is increasing awareness of the need to develop innovative and relevant methodologies to best capture the voices of Young Men Who Have Sex with Men (YMSM), which will inform HIV prevention. This article discusses the process of researching with YMSM in Bali, the solution to methodological gaps in research for Internet-based HIV prevention. This research endorsed the Habermas Communicative Action Theory which was then translated to Participatory Action Research (PAR) methodology. Nine YMSM aged 18-24 years old participated in this research through multiple research activities for four months. Data collection included structured group meetings, group workshops, informal participant observations, and after-hour conversations over afternoon tea and shared meals. Participants used a range of visual and digital media to share their collective ideas and different trial strategies. We argue for the opportunity for participatory action research to strengthen the roles of YMSM in HIV prevention.

Mobile Health Technology Use and the Acceptability of an mHealth Platform for HIV Prevention Among Men Who Have Sex With Men in Malaysia: Cross-sectional Respondent-Driven Sampling Survey

BACKGROUND

The growth in mobile technology access, utilization, and services holds great promise in facilitating HIV prevention efforts through mobile health (mHealth) interventions in Malaysia. Despite these promising trends, there is a dearth of evidence on the use of mHealth platforms that addresses HIV prevention among Malaysian men who have sex with men.

OBJECTIVE

The goal of this study was to gain insight into (1) access and utilization of communication technology (eg, landline phone, internet, mobile phone), (2) acceptability of mHealth-based interventions for HIV prevention services, and (3) preferences regarding the format and frequency of mHealth interventions among Malaysian men who have sex with men.

METHODS

We conducted a cross-sectional survey with Malaysian men who have sex with men between July 2018 and March 2020. Participants were recruited using respondent-driven sampling in the Greater Kuala Lumpur region of Malaysia. We collected information on demographic characteristics, HIV risk-related behaviors, access to and the frequency of use of communication technology, and acceptability of using mHealth for HIV prevention using a self-administered questionnaire with a 5-point scale (1, never; 2, rarely; 3, sometimes; 4, often; 5, all the time).

RESULTS

A total of 376 men participated in the survey. Almost all respondents owned or had access to a smartphone with internet access (368/376, 97.9%) and accessed the internet daily (373/376, 99.2%), mainly on a smartphone (334/376, 88.8%). Participants on average used smartphones primarily for social networking (mean 4.5, SD 0.8), followed by sending or receiving emails (mean 4.0, SD 1.0), and searching for health-related information (mean 3.5, SD 0.9). There was high acceptance of the use of mHealth for HIV prevention (mean 4.1, SD 1.5), including for receiving HIV prevention information (345/376, 91.8%), receiving medication reminders (336/376, 89.4%), screening and monitoring sexual activity (306/376, 81.4%) or illicit drug use (281/376, 74.7%), and monitoring drug cravings (280/376, 74.5%). Participants overwhelmingly preferred a smartphone app over other modalities (eg, text, phone call, email) for engaging in mHealth HIV prevention tools. Preference for app notifications ranged from 186/336 (53.9%), for receiving HIV prevention information, to 212/336 (69.3%), for screening and monitoring sexual activity. Acceptance of mHealth was higher for those who were university graduates (P=.003), living in a relationship with a partner (P=.04), engaged in sexualized drug use (P=.01), and engaged in receptive anal sex (P=.006).

CONCLUSIONS

Findings from this study provide support for developing and deploying mHealth strategies for HIV prevention using a smartphone app in men who have sex with men-a key population with suboptimal engagement in HIV prevention and treatment.

Effect of a Popular Web Drama Video Series on HIV and Other Sexually Transmitted Infection Testing Among Gay, Bisexual, and Other Men Who Have Sex With Men in Singapore: Community-Based, Pragmatic, Randomized Controlled Trial

Background

Gay, bisexual, and other men who have sex with men (GBMSM) are at disproportionately higher risk of acquiring HIV and other sexually transmitted infections (STI). While HIV/STI testing rates among GBMSM are increasing worldwide, they remain suboptimal in a variety of settings. While many studies have attempted to evaluate the efficacy of a variety of community-based campaigns, including peer and reminder-based interventions on HIV/STI testing, however few have attempted to do so for a web drama series.

Objective

This study evaluates the effectiveness of a popular web drama video series developed by a community-based organization in Singapore for GBMSM on HIV and other STI testing behaviors.

Methods

The study is a pragmatic, randomized controlled trial to evaluate a popular web drama video series developed by a community-based organization in Singapore for GBMSM. A total of 300 HIV-negative, GBMSM men in Singapore aged 18 to 29 years old were recruited and block-randomized into the intervention (n=150) and control arms (n=150). Primary outcomes included changes in self-reported intention to test for, actual testing for, and regularity of testing for HIV, syphilis, chlamydia or gonorrhea, while secondary outcomes include changes in a variety of other knowledge-based and psychosocial measures at the end of the study period.

Results

Overall, 83.3% (125/150) of participants in the intervention arm completed the proof of completion survey, compared to 88.7% (133/150) in the control arm. We found improvements in self-reporting as a regular (at least yearly) tester for HIV (15.9% difference, 95% CI, 3.2% to 28.6%; P=.02), as well as chlamydia or gonorrhea (15.5% difference, 95% CI, 4.2% to 26.9%; P=.009), indicating that the intervention had positively impacted these outcomes compared to the control condition. We also found improvements in participants’ intentions to test for HIV (16.6% difference, 95% CI, 4.3% to 28.9%; P=.009), syphilis (14.8% difference, 95% CI, 3.2% to 26.4%; P=.01), as well as chlamydia or gonorrhea (15.4% difference, 95% CI, 4.2% to 26.6%; P=.008), in the next 3 months, indicating that the intervention was effective in positively impacting intention for HIV and other STI testing among participants.

Conclusions

There are clear benefits for promoting intentions to test regularly and prospectively on a broad scale through this intervention. This intervention also has potential to reach GBMSM who may not have access to conventional HIV and other STI prevention messaging, which have typically been implemented at sex-on-premises venues, bars, clubs, and in sexual health settings frequented by GBMSM. When coupled with community or population-wide structural interventions, the overall impact on testing will likely be significant.

Trial Registration

ClinicalTrials.gov NCT04021953; https://clinicaltrials.gov/ct2/show/NCT04021953

International Registered Report Identifier (IRRID)

RR2-10.1136/bmjopen-2019-033855

Adaptation of a Theory-Based Social Networking and Gamified App-Based Intervention to Improve Pre-Exposure Prophylaxis Adherence Among Young Men Who Have Sex With Men in Bangkok, Thailand: Qualitative Study

BACKGROUND

HIV disproportionately affects young Thai men who have sex with men (YMSM). Recent studies report a high incidence and prevalence of HIV among Thai YMSM. The Thai national guidelines have recommended pre-exposure prophylaxis (PrEP) since 2014 for key populations; free PrEP has been piloted since 2019. Smartphone-based mobile health (mHealth) interventions provide an optimal platform for innovative PrEP adherence interventions for Thai YMSM.

OBJECTIVE

This study aims to adapt the P3 (Prepared, Protected, emPowered) app, developed with YMSM and transwomen in the United States to improve PrEP adherence and persistence for YMSM in Thailand. The app aims to provide daily adherence support and addresses gaps in staff available for large-scale PrEP rollout needed to see population-level effects of HIV prevention.

METHODS

We conducted focus group discussions (FGDs) with YMSM and key informant interviews (KIIs) with PrEP care providers in Bangkok, Thailand, to investigate PrEP adherence facilitators and barriers, preferences for functions and features in mHealth apps among YMSM, and how to best adapt the P3 app to the Thai context. We conducted four FGDs with 4-8 participants per group and 15 KIIs.

RESULTS

For FGDs, 23 YMSM participated with a mean age of 20 years (range 18-21), 96% (22/23) enrolled in full-time education, and all owned smartphones. The mean age of KII participants was 40 (range 26-60) years; most were state health service providers, with the majority being counselors (6/15, 40%) and physicians (6/15, 40%). Overall, the facilitators and barriers for PrEP adherence identified were similar to those of MSM and YMSM globally including the United States. Key themes included general recommendations for improving mHealth apps in Thailand, such as presenting reliable information in an appealing format, minimizing privacy risks, and addressing connectivity challenges. Additional themes focused on P3 Thailand adaptations and were related to cultural and stylistic preferences, engagement strategies, and recommendations for new functions. To develop the adapted app, P3 Thailand, these findings were balanced with resource limitations resulting in the prioritization of minor modifications: changes in app esthetics (color scheme, iconography, and imagery) and changes in the presentation of information in two of the app's features. FGDs identified similar PrEP adherence facilitators and barriers to those already addressed within the app.

CONCLUSIONS

The core elements of the P3 app address major PrEP facilitators and barriers for Thai YMSM; however, changes to the app features, including stylistic presentation, were needed to appropriately customize the app to the Thai context. Given the similarities of facilitators and barriers for PrEP adherence globally, adapting existing PrEP mHealth solutions based on input from end users and key informants provides a promising approach. However, partnerships with local app designers and developers can improve the adaptation process and final product.

TRIAL REGISTRATION

ClinicalTrials.gov NCT04413708; http://clinicaltrials.gov/ct2/show/NCT04413708.

Developing HIV prevention online using a habermasian 'lifeworld' approach with young men who have sex with men from Bali

The Internet is a promising medium to strengthen participation in Human Immunodeficiency Virus (HIV) prevention among young men who have sex with men (YMSM). This study engaged YMSM from Bali in codesigning online HIV prevention using a series of participatory action research focus groups. Further, this research utilized Habermasian critical theory of communicative action to interpret the findings. This was framed around the current mismatch between HIV prevention, the "systemworld", and the lived reality, or "lifeworld", of YMSM in Bali. Using a model of intervention called "So Us", YMSM aspired to HIV prevention which reflects their identity, language, and interaction style.

Assessing mobile technology use and mHealth acceptance among HIV-positive men who have sex with men and transgender women in Malaysia

Background

Mobile health (mHealth) can be beneficial in monitoring the complex healthcare regimen for people with HIV that includes adhering to medication and refraining from risky practices such as unsafe sex and injection drug use. Not only is mHealth often implemented without appropriate feasibility and acceptability research, but there is limited mHealth research among key HIV-positive populations such as men who have sex with men (MSM) and transgender women (TGW).

Methods

This study assessed access to and use of mobile technology and acceptability of mHealth among 150 HIV-positive MSM and TGW who were prescribed antiretroviral therapy (ART) in Malaysia–an emerging economy with rapid telecommunications growth and societal stigma against these groups.

Results

Findings among the 114 MSM and 36 TGW reveal high levels of depression (42%), stigma (2.53/4.00) and risky sexual behavior (30%), and suboptimal ART adherence (22%). On the other hand, the sample had excellent access to smartphones (75.3%) and the internet (78%), and had high acceptance of mHealth especially for those with suboptimal ART adherence.

Conclusion

In settings like Malaysia where homosexuality and cross-dressing are socially and legally stigmatized, HIV prevention and treatment strategies delivered using an mHealth platform have the potential to overcome in-person barriers.

Willingness to Use HIV Self-Testing With Online Supervision Among App-Using Young Men Who Have Sex With Men in Bangkok

ABSTRACT

An online assessment among social media-using young men who have sex with men found that 87% were willing to use HIV self-testing with online supervision. Correlates included never tested, having higher numbers of sexual partners, and seeking partners online. HIV self-testing with online supervision may be appropriate for young men who have sex with men who have high risks and may not access venue-based settings.

Correlates of lifetime and past one-year HIV-testing experience among men who have sex with men in Japan

This study aimed to examine correlates of lifetime and past-year HIV testing among men who have sex with men (MSM) in Japan. A unique, anonymous online self-report survey was conducted in 2015. A total of 776 participants completed the survey and answered questions on sociodemographic information, HIV-testing experience, history of syphilis, experience talking about HIV, recognition of AIDS-related community-based organization (CBO) materials, and sex behaviors. HIV-testing experience and related factors were assessed for two groups: regional cities and Tokyo and Osaka. A Poisson regression analysis revealed that higher lifetime HIV testing was associated with older age, previous syphilis diagnosis, and experience talking about HIV. Moreover, higher HIV testing in the past year was associated with experience talking about HIV with friends and recognition of HIV-related CBO materials. Increased dissemination of HIV-related information provided by CBOs may, therefore, be an effective prevention policy intervention targeted at Japanese MSM to promote regular testing and maintain their interest in HIV issues.

Potential interactions between the pathways to diagnosis of HIV and other STIs and HIV self-testing: insights from a qualitative study of gay, bisexual and other men who have sex with men in Singapore

Objectives

This study draws on qualitative insights on the barriers and facilitators to HIV testing, as well as perceptions of HIV self-testing (HIVST), to propose a framework to understand not only the benefits but also potential knock-on implications of introducing HIVST in the context of other STI testing.

Methods

We conducted semistructured, in-depth interviews with 30 gay, bisexual and other men who have sex with men aged 18 and 39 years old in Singapore. Interview topics included barriers and facilitators to HIV and other STI testing, as well as perceptions of HIVST. Interviews were audio-recorded, transcribed, coded and analysed using thematic analysis.

Results

For HIV testing, participants cited the perceived risk of acquiring, susceptibility to and symptoms of HIV as internal motivators, while social influence and accessibility of HIV testing services were external motivators. For STI testing, perceived symptoms and partner notification of STI were reported as internal and external motivators, respectively. Availability of bundle tests, starting a new relationship and instances of mandatory testing motivated both simultaneous HIV and other STI testing. The fear of a positive diagnosis and lack of confidentiality were cited as internal and external barriers to HIV testing, respectively, while low perceived severity of other STI and the cost of STI tests were cited as internal and external barriers to other STI testing, respectively. We identified pathways to HIV and other STI testing and discussed how the introduction of HIVST may reduce opportunities for other STI testing.

Conclusions

The findings of this study suggest that introducing HIVST might weaken linkages to other STI testing if alternative strategies of promoting other STI testing are not simultaneously implemented. We recommend that future interventions address both the risks of HIV and other STI simultaneously, and that structural interventions promoting HIV and other STI preventions be balanced accordingly.

A scoping review of sexual transmission related HIV research among key populations in Malaysia: Implications for interventions across the HIV care cascade

The Malaysian government has committed to 'Fast Tracking the HIV Response' to achieve UNAIDS 2030 targets to end AIDS. The epidemic is concentrated among key populations and has shifted from people who inject drugs to HIV infection through sexual transmission among men who have sex with men, sex workers and transgender people. The aim of this scoping review was to examine social and behavioural research published since 2005 that can inform understanding of each stage of the 90:90:90 treatment cascade (as proposed by UNAIDS), including HIV risk behaviours and testing practices that precede entry. We found a concentration of studies related to predictors or correlates of HIV infections (mostly among men who have sex with men) and a shortfall in literature pertaining to sex workers or transgender people. While several studies examined factors associated with HIV testing, only one examined uptake of antiretroviral therapy and two explored issues of treatment adherence. No study examined broader care and support of people living with HIV. To scale-up effective programmes and apprise investment to achieve the ambitious targets set-out in the Malaysian National HIV/AIDS Strategic Plan, a combination of comprehensive strategic information and evidence generated through primary research is critical.

Adherence of HIV Self-Testing Among Men Who Have Sex With Men in China: Longitudinal Study

BACKGROUND

The World Health Organization recommended HIV self-testing (HIVST) for individuals practicing unsafe sexual behaviors; however, the adherence to HIV testing has not been reported.

OBJECTIVE

In this study, we attempted to determine the adherence to HIVST among men who have sex with men (MSM), as well as the impact factors and potential effects of their adherence.

METHODS

We conducted a longitudinal study among MSM in Harbin, Heilongjiang province, China from July 1, 2017 to June 30, 2018. A mobile app system was used to provide the "Mailing rapid test reagent kit" for the HIVST service. The proportion of those who adhered to HIV testing every 3 months was calculated. Logistic regression was used to explore the impact factors related to adherence to HIVST. Rates of HIV infection between MSM who adhered to HIVST and those who did not were compared using Cox proportional hazards regression. Changes of condom use behaviors between the two groups were also compared using the chi-square test.

RESULTS

A total of 1315 MSM who received the HIVST service through the app were included in the study. Overall, 10% of the MSM adhered to HIVST, and the proportion of adhering tests was only 34.9%. Adherence of HIVST was associated with marital status (adjusted odds ratio [OR]_{unmarried vs married} 2.31, 95% CI 1.13-4.71) and the number of HIV tests they received (adjusted OR_{3 times vs 2 times or below} 3.36, 95% CI 2.01-5.63; adjusted OR_{4 times or above vs 2 times or below} 7.30, 95% CI 4.67-11.42). Twenty HIV seroconversions were observed during 1-year follow up. The rate of HIV infection in the adherence group (17.10 per 100 person years, 95% CI 8.80-30.84) was significantly higher than that in the nonadherence group (4.80 per 100 person years, 95% CI 2.77-7.88; adjusted hazard ratio 3.33, 95% CI 1.35-8.20). Those who adhered to HIV testing were more likely to improve condom use behaviors, although the difference was not statistically significant.

CONCLUSIONS

Regular HIV testing is necessary for early detection of HIV infection among MSM. Given the poor adherence, a new internet-based management paradigm for MSM is needed to raise their health awareness to optimize the implementation of HIVST.

HIV Seroconversion and Types of Relationships Among Men Who Have Sex With Men: A Cohort Study in China

BACKGROUND

The role of partner types in modifying HIV seroconversion risk among men who have sex with men (MSM) is complex. We sought to understand the role of regular sexual partners and risky sexual behavior in contributing to incident HIV infection among MSM.

METHODS

From July 2011 to August 2017, we recruited HIV-negative men who reported having anal or oral homosexual encounters in the past 6 months and they were followed up every 3 months for 2 visits. We collected sociodemographic and behavioral characteristics by a self-administrated questionnaire. HIV status was confirmed by a sequential rapid test and confirmatory test. We used multivariable Cox regression to identify risk factors and interaction models to evaluate the relative excess risk between relevant variables.

RESULTS

Among 1218 participants, the HIV seroconversion rate was 3.66/100 person-years. HIV seroconversion was associated with lower educational attainment [adjusted hazards ratio (aHR)] = 1.73, 95% CI: 1.06 to 2.81), having had penetrative sex with male before age of 18 years (aHR = 2.44, 95% CI: 1.20 to 4.99), not using condoms in the last sexual encounter (aHR = 2.19, 95% CI: 1.29 to 3.71), and having regular but not committed partners (aHR = 3.33, 95% CI: 1.77 to 6.93). Among 890 (73%) of men reported having regular partners, HIV seroconversion was more frequent in men whose stable partners were not committed as boyfriends (aHR = 3.31, 95% CI: 1.73 to 6.36) and in men having unprotected anal sex (aHR = 2.61, 95% CI: 1.42 to 4.80). Interaction between these 2 factors was observed (relative excess risk of interaction = 4.53).

CONCLUSIONS

Incidence among MSM in China was high; unprotected sex with steady but not committed partners was associated with increased seroconversion risk. It is imperative to expand safer sex education and training for MSM to reduce unsafe sexual behaviors, including awareness that casual partners are not the only source of infection.

Willingness to Use HIV Self-Testing and Associated Factors Among Transgender Women in Malaysia

Background: While global research on the implementation of HIV self-testing (HIVST) has increased exponentially, few studies have assessed information on HIVST uptake factors (i.e., willingness, preferences) in transgender women (TW) and none in the Malaysian context. We therefore sought to assess willingness to use HIVST among this understudied key population. Methods: A cross-sectional survey was conducted among 361 HIV-negative Malaysian TW in 2017. Participants were recruited using flyers, announcements through social media, and direct referral from staff members of the community-based organizations serving the TW communities. Multivariable logistic regression was used to identify correlates of willingness to use HIVST. Results: Nearly half of the participants (47.6%) reported that they would be willing to use HIVST. Multivariable analysis showed that willingness to use HIVST was positively associated with having experienced sexual assault in childhood (adjusted odds ratio [aOR]=3.239, p<0.001), having ever used mobile phone or apps to find sex work clients (aOR=1.677, p=0.040), and having engaged in condomless sex in the past 6 months (aOR=1.886, p=0.018). In contrast, living in Kuala Lumpur (aOR=0.559, p=0.032), having higher number of sex work clients per day (aOR=0.927, p=0.004), and current depressive symptoms (aOR=0.576, p=0.026) were negatively associated with willingness to use HIVST. Conclusions: Findings in this study suggest that TW in our sample were moderately willing to use HIVST. Especially important here is the increased interest in HIVST among TW who are at higher risk for HIV infection. Overall, our findings underscore the need for additional research on how to most effectively implement HIVST for key populations, including TW, such that uptake and retention in regular HIV screening is sustained.

Fast-tracking the end of HIV in the Asia Pacific region: domestic funding of key population-led and civil society organisations

Ending AIDS in Asia Pacific by 2030 requires countries to give higher priority to financing community-based and key population-led service delivery. Mechanisms must be developed for civil society organisations to deliver health and HIV/AIDS services for key populations, especially men who have sex with men, and transgender people, within national health policy frameworks. Current investments in the HIV response in the Asia Pacific region reflect inadequate HIV financing for key populations, particularly for civil society and key population-led organisations that are optimally positioned to advance HIV epidemic control. These organisations are typically supported by international agencies whose investments are starting to decline. Domestic investments in key population-led organisations are often hampered by punitive laws against their communities, pervasive stigma and discrimination by policy makers, an insufficient understanding of the most effective HIV epidemic control strategies, and financing systems that limit access to funding for these organisations from the national budget. Countries in the Asia Pacific region are evolving their community-based and key population policies and programmes. We need accessible, disaggregated financial data and in-depth case studies that showcase effective key population-led programmes, to enable countries to learn from each other.

Spatial characteristics of men who have sex with men and transgender women attending HIV voluntary counselling and testing in Bangkok, Thailand, 2005-2015

Spatiotemporal analyses can support Human Immuno-deficiency Virus (HIV) prevention programmes by identifying locations of at-risk populations in space and time, and their proximity to HIV testing and prevention services. We assessed residential proximity to HIV testing venues for Men who have Sex with Men (MSM) and Transgender Women (TGW) attending Voluntary Counselling and Testing (VCT) at a large urban MSM clinic in Bangkok, Thailand in the period 2005-2015. We mapped clientprovided spatial data and HIV testing venues, calculating distance from residence to venues for VCT clients between i) September 2005-December 2009; ii) January 2010-September 2013; and iii) October 2013-May 2015. We assessed spatial characteristics across times, evaluating autocorrelation of HIV prevalence and visit density using Moran's I. Among 8,758 first-time VCT clients reporting geographic information from 2005-2015 (by period: 2737, 3917, 2104), 1329 (15.2%) lived in postal codes ≤5 km from the clinic. Over time, the proportion living in areas covered by Bangkok postal codes ≤2 km from any MSM HIV testing venue increased from 12.6% to 41.0% (p<0.01). The proportion living ≤5 km from the clinic decreased from 16.6% to 13.0% (p<0.01). HIV prevalence and clinic visit density demonstrated statistically significant non-random spatial patterning. Significant non-random patterning of prevalent infection and client visits highlighted Bangkok's urban HIV epidemic, clinic proximity to clients, and geographic reach. Clients lived closer to testing venues, yet farther from the urban MSM clinic, over time. Spatiotemporal characteristics of VCT clients can help assess service accessibility and guide targeted prevention planning.

Effect of a web drama video series on HIV and other sexually transmitted infection testing among gay, bisexual and queer men: study protocol for a community-based, pragmatic randomised controlled trial in Singapore: the People Like Us (PLU) Evaluation Study

INTRODUCTION

Gay, bisexual and queer (GBQ) men are at disproportionately higher risk of acquiring HIV and other sexually transmitted infections (STI). While HIV/STI testing rates among GBQ men are increasing worldwide, they remain suboptimal in a variety of settings.

METHODS AND ANALYSIS

The study is a pragmatic randomised controlled trial designed to evaluate an online video series developed by a community-based organisation in Singapore for GBQ men. A total of 300 HIV-negative GBQ men in Singapore aged 18-29 years old will be recruited for this study. Participants will subsequently be randomised into the intervention arm (n=150) and the control arm (n=150). The intervention arm (n=150) will be assigned the intervention along with sexual health information via a pamphlet, while the control group (n=150) will be assigned only the sexual health information via a pamphlet. Participants should also not have watched the video prior to their participation in this study, which will be ascertained through a questionnaire. Primary outcomes for this evaluation are changes in self-reported intention to test for, actual testing for and regularity of testing for HIV, syphilis, chlamydia and gonorrhoea at the 3 and 6 months after intervention. Secondary outcomes include changes in self-reported risk perception for HIV and other STIs, knowledge of HIV, knowledge of risks associated with acquiring STIs, knowledge of HIV pre-exposure prophylaxis, consistent condom use for anal sex with casual partners, incidence of STIs, connectedness to the lesbian, gay, bisexual and transgender community, self-concealment of sexual orientation, perceived homophobia, internalised homophobia, HIV testing self-efficacy and HIV testing social norms.

ETHICS AND DISSEMINATION

The study has been approved by the National University of Singapore Institutional Review Board (S-19-059) and registered at ClinicalTrials.gov. The results will be published in peer-reviewed academic journals and disseminated to community-based organisations and policymakers.

TRIAL REGISTRATION NUMBER

NCT04021953.

Developing a Typology of HIV/STI Testing Patterns Among Gay, Bisexual, and Queer Men: A Framework to Guide Interventions

Although factors associated with HIV/sexually transmitted infection (STI) testing among gay, bisexual, and queer (GBQ) men are well-established in the literature, few studies have attempted to delineate the processes underlying different patterns of testing. We conducted a qualitative study involving 35 semistructured interviews with a purposive sample of GBQ men in Singapore from October 2017 to July 2018. Topics explored included formative sexual experiences, relationships, and experiences of HIV/STI testing. Interviews were audio-recorded, transcribed, coded, and analyzed through inductive thematic analysis. A typology comprising four distinct HIV/STI testing patterns was identified from the data, categorized based on the regularity of testing, relative to internal or external factors that motivate testing behaviors. These include triggered episodic testing, influenced episodic testing, institutionalized regular testing, and value-based regular testing. The typology highlights the preconditions that underlie different testing patterns and provides a framework for developing interventions that promote HIV/STI testing among GBQ men.

High levels of engagement with testing for HIV and sexually transmissible infection among gay Asian men in Sydney and Melbourne: an observational study

Background Gay and other men who have sex with men of Asian background (GAM) have been identified as a key population in efforts to eradicate HIV in New South Wales. The aims of the present study were to evaluate current levels of engagement with HIV and sexually transmissible infection (STI) testing services, assess knowledge of pre- and post-exposure prophylaxis and to identify factors associated with service engagement in this group.

METHODS

A survey of 604 GAM residing in Sydney and Melbourne was undertaken.

RESULTS

The data identified that a significant proportion of non-HIV-positive men (i.e. HIV-negative men and men whose HIV status was unknown) surveyed (n = 567; 93.9%) had engaged in frequent HIV testing and comprehensive STI testing in the 12 months prior to the survey (n = 180; 31.7%). There were significant differences (P < 0.05) in sexual practices at the bivariate level between those who reported frequent and comprehensive HIV/STI testing and those who did not. Those who tested regularly were substantially more sexually active, were more likely to have multiple partners (P = 0.001) and were more likely to engage in condomless anal intercourse with both casual (P < 0.001) and regular (P = 0.002) partners. Those who engaged with testing initiatives were more likely to discuss HIV status with both regular (P = 0.008) and casual (P < 0.001) partners, and identified more reasons to test than their counterparts (P < 0.001). The data also highlighted key service venues, with gay men most likely to have used public sexual health clinics (46.9%) as their most recent testing venue.

CONCLUSIONS

The data demonstrate an association between high levels of male-to-male sexual activity and engagement in frequent and comprehensive HIV and STI testing. This likely derives from both self-perceived notions of risk and current reliance on established gay community organisations to convey information around testing. Increasing engagement with testing initiatives beyond GAM who self-identify as being at high HIV and STI risk will require the use of novel routes by which to disseminate this information.

Linkages to HIV confirmatory testing and antiretroviral therapy after online, supervised, HIV self-testing among Thai men who have sex with men and transgender women

INTRODUCTION

Online, supervised, HIV self-testing has potential to reach men who have sex with men (MSM) and transgender women (TGW) who never tested before and who had high HIV-positive yield. We studied linkages to HIV confirmatory test and antiretroviral therapy (ART) initiation among Thai MSM and TGW who chose online and/or offline platforms for HIV testing and factors associated with unsuccessful linkages.

METHODS

MSM and TGW were enrolled from Bangkok Metropolitan Region and Pattaya during December 2015 to June 2017 and followed for 12 months. Participants could choose between: 1) offline HIV counselling and testing (Offline group), 2) online pre-test counselling and offline HIV testing (Mixed group) and 3) online counselling and online, supervised, HIV self-testing (Online group). Sociodemographic data, risk behaviour and social network use characteristics were collected by self-administered questionnaires. Linkages to HIV confirmatory testing and/or ART initiation were collected from participants who tested reactive/positive at baseline and during study follow-up. Modified Poisson regression models identified covariates for poor retention and unsuccessful ART initiation.

RESULTS

Of 465 MSM and 99 TGW, 200 self-selected the Offline group, 156 the Mixed group and 208 the Online group. The Online group demonstrated highest HIV prevalence (15.0% vs. 13.0% vs. 3.4%) and high HIV incidence (5.1 vs. 8.3 vs. 3.2 per 100 person-years), compared to the Offline and Mixed groups. Among 60 baseline HIV positive and 18 seroconversion participants, successful ART initiation in the Online group (52.8%) was lower than the Offline (84.8%) and Mixed groups (77.8%). Factors associated with unsuccessful ART initiation included choosing to be in the Online group (aRR 3.94, 95% CI 1.07 to 14.52), <17 years old at first sex (aRR 3.02, 95% CI 1.15 to 7.92), amphetamine-type stimulants use in the past six months (aRR 3.6, 95% CI 1.22 to 10.64) and no/single sex partner (aRR 3.84, 95%CI 1.36 to 10.83) in the past six months.

CONCLUSIONS

Online, supervised, HIV self-testing allowed more MSM and TGW to know their HIV status. However, linkages to confirmatory test and ART initiation once tested HIV-reactive are key challenges. Alternative options to bring HIV test confirmation, prevention and ART services to these individuals after HIV self-testing are needed.

Cost and anonymity as factors for the effective implementation of pre-exposure prophylaxis: an observational study among gay, bisexual and other men who have sex with men in Singapore

Background HIV pre-exposure prophylaxis (PrEP) is currently offered by several public and private clinics at unsubsidised prices in Singapore, but to date, no information is available on the effect of these services. This study sought to assess the knowledge and uptake of, and willingness to use PrEP among gay, bisexual and other men who have sex with men (GBMSM) in Singapore.

METHODS

Recruitment was conducted through Grindr®, a geosocial networking application for GBMSM. Results were quantitatively analysed through descriptive statistics and multivariate Poisson regression models, while open-ended responses were qualitatively coded and categorised.

RESULTS

Of the 1339 participants who responded, 1098 participants who indicated their knowledge and use of PrEP were included in the analytic sample. Overall, 15.0% (n=154) had taken PrEP, 66.2% (n=678) had heard of but not taken PrEP, while 18.8% (n=193) had never heard of PrEP. Of those who had ever taken PrEP, 59.6% (n=90) had obtained PrEP from overseas or other unofficial sources. Of those who had heard of but never taken PrEP, 73.3% (n=486) reported that they would consider taking PrEP. Those who had taken PrEP were older and had higher educational attainment.

CONCLUSIONS

The gap between the willingness to use PrEP and its uptake may be attributed to the cost of PrEP and issues of anonymity at healthcare settings in Singapore. National financing schemes are needed to expand access to PrEP if it is to make a meaningful effect to the Singapore HIV/AIDS response.

What would you choose: Online or Offline or Mixed services? Feasibility of online HIV counselling and testing among Thai men who have sex with men and transgender women and factors associated with service uptake

Introduction

HIV testing coverage remains low among men who have sex with men (MSM) and transgender women (TGW). We studied characteristics of Thai MSM and TGW who chose online and/or offline platforms for HIV counselling and testing and the feasibility of integrating online technologies and HIV self‐testing to create service options.

Methods

From December 2015 to June 2017, MSM and TGW enrolled from Bangkok Metropolitan Region and Pattaya could choose between: 1 offline HIV counselling and testing (Offline group), 2 online pre‐test counselling and offline HIV testing (Mixed group), and 3 online counselling and online, supervised, HIV self‐testing (Online group). Sociodemographic data, risk behaviour and social network use characteristics were collected by self‐administered questionnaires. Logistic regression models identified covariates for service preferences.

Results

Of 472 MSM and 99 TGW enrolled, 202 self‐selected the Offline group, 158 preferred the Mixed group, and 211 chose the Online group. The Online group had the highest proportion of first‐time testers (47.3% vs. 42.4% vs. 18.1%, p < 0.001) and reported highest HIV prevalence (15.9% vs. 13.0% vs. 3.4%, p = 0.001) as compared to Offline and Mixed groups, respectively. Having tested for HIV twice or more (OR 2.57, 95% CI 1.03 to 6.41, p = 0.04) increased the likelihood to choose online pre‐test counselling. Being TGW (OR 6.66, 95% CI 2.91 to 15.25, p < 0.001) and using social media from four to eight hours (OR 2.82, 95% CI 1.48 to 5.37, p = 0.002) or >8 hours (OR 2.33, 95% CI 1.05 to 5.16, p = 0.04) increased selection of online, supervised, HIV self‐testing. Providers primarily used smartphones (79.2%) and laptops (37.5%) to deliver online services. Self‐testing strip image sharpness and colour quality were rated “good” to “excellent” by all providers. Most participants (95.1%) agreed that online supervision and HIV self‐testing guidance offered were satisfactory and well delivered.

Conclusions

Online HIV services among MSM and TGW are feasible in Thailand and have the potential to engage high proportions of first‐time testers and those with high HIV prevalence. When designing public health interventions, integrating varied levels of online HIV services are vital to engage specific sections of MSM and TGW populations in HIV services.

Clinical Trial Number

NCT03203265

Using a HIV registry to develop accurate estimates for the HIV care cascade - the Singapore experience

INTRODUCTION

Achieving UNAIDS 90-90-90 targets is a crucial step towards ending the AIDS epidemic. Many countries have published estimates of care cascades, although often with methodological limitations. We describe an approach that used the national HIV registry as a starting-point to determine the HIV care cascade and resulting UNAIDS 90-90-90 estimates for Singapore in 2014.

METHODS

HIV is a legally notifiable disease in Singapore. The anonymized HIV registry data provided for a back-calculation model from the European Centre for Disease Prevention and Control to obtain 2014 estimates for the total number of persons living with HIV (PLHIV), and the count in the registry for proportions diagnosed with HIV and linked to care. Using additional data collected for a simple random sample from the registry, outcomes in 2015 and 2016 were ascertained retrospectively to derive proportions for those retained in care, on antiretroviral therapy, and achieved viral suppression. Findings were extrapolated to derive national estimates and UN90-90-90 estimates. Bootstrapped samples from the model and sample were used to derive 95% confidence intervals.

RESULTS

An estimated 6900 (95% CI 6650, 7050) persons were living with HIV and AIDS in 2014. Of these, 4948 were diagnosed with HIV, and 4820 had been linked to care. The random sample of 500 persons was further analysed, and of these, 87.2% were retained in care, 84.6% on antiretroviral therapy, and 79.6% had suppressed viral loads. The proportions of HIV-infected individuals on antiretroviral therapy and achieving viral suppression were 60.7% (95% CI 58.4, 63.6) and 57.1% (95% CI 55.0, 60.5) respectively. The corresponding UNAIDS 90-90-90 estimates were 71.7% (95% CI 70.0, 74.2) of all persons diagnosed; 84.6% (95% CI 81.6, 87.4) of diagnosed persons being on antiretroviral therapy, and 94.1% (95% CI 91.6, 96.2) of persons on therapy having achieved viral suppression.

CONCLUSIONS

A national HIV registry, alongside back-calculation and additional data from a sample, can be used to estimate attainment of UNAIDS 90-90-90 targets and identify system gaps. The registry had advantages of providing a well-established, comprehensive capture of diagnosed persons and easily accessible data. The same approach can be used elsewhere if similar data are available.

Extent and selectivity of sexual orientation disclosure and its association with HIV and other STI testing patterns among gay, bisexual and other men who have sex with men

Objectives

Gay, bisexual and other men who have sex with men (GBMSM) in Singapore may fear disclosing their sexual orientation to others due to negative societal attitudes, and the law that criminalises sexual relations between men, which may, in turn, impede access to HIV/sexually transmitted infection (STI)-related health services. This study attempts to determine how selective disclosure to varying social groups, and the extent of disclosure, may serve to impact HIV/STI testing patterns among GBMSM.

Methods

In this observational study, we recruited GBMSM in Singapore through an online cross-sectional survey disseminated via the smartphone app Grindr from 14 January to 11 February 2018. Respondents provided information on their sociodemographic characteristics, disclosure of sexual orientation towards other lesbian, gay, bisexual, transgender and questioning (LGBTQ) individuals, non-LGBTQ family members, non-LGBTQ friends and non-LGBTQ colleagues, along with their HIV/STI testing patterns. Extent of disclosure was defined as the number of social groups that a participant had disclosed his sexual orientation to. Statistical analyses were conducted through descriptive statistics, multivariable binary, ordinal, and multinomial logistic regression models.

Results

We recruited 1339 respondents, of which 1098 who had provided their response to questions on HIV/STI testing were included in the analytic sample. Multivariable analyses indicated that disclosure towards non-LGBTQ family members (adjusted OR [aOR] 1.85, 95% CI 1.12 to 3.07) and other LGBTQ individuals (aOR 1.63, 95% CI 1.12 to 2.37) were positively associated with recent HIV testing, whereas disclosure towards non-LGBTQ colleagues (aOR 1.56, 95% CI 1.09 to 2.22) was positively associated with regular HIV testing. Extent of disclosure exhibited a positive, dose–response relationship with all testing outcomes.

Conclusions

Results indicate how the fear of being identified as an LGBTQ individual may deter GBMSM from getting tested for HIV and other STIs. Health services should bridge the gaps to accessing healthcare among individuals who fear being stigmatised for attending sexual health-specific clinics or being identified as GBMSM.

Acceptability of Peer-Delivered HIV Testing and Counselling Among Men Who Have Sex with Men (MSM) and Transgender Women (TW) in Myanmar

Men who have sex with men (MSM) and transgender women (TW) are a priority population for HIV prevention in Myanmar but report sub-optimal HIV testing frequency. Previous studies have shown that peer involvement in HIV testing can normalize stigmatized sexualities and reduce barriers to testing. We explored the acceptability of peer-delivered HIV testing among 425 undiagnosed MSM and TW in Yangon and Mandalay. An overwhelming majority of participants (86%) reported being 'comfortable/very comfortable' with peer-delivered HIV testing. Logistic regression identified reporting sexual identity as Apone [adjusted odds ratio (aOR) 3.8; 95% CI 1.2-11.7], recent HIV testing (aOR 3.1; 95% CI 1.4-6.5), reporting a high likelihood of HIV acquisition (aOR 3.6; 95% CI 1.7-7.6), and reporting ≥ 5 casual partners in the past 3 months (aOR 0.2; 95% CI 0.1-0.6) as associated with peer-delivered HIV testing acceptability. Given ongoing HIV vulnerability among MSM and TW in Myanmar, peer-delivered testing may offer prevention benefits by increasing testing rates and identifying undiagnosed infection earlier.

Playing and Never Testing: Human Immunodeficiency Virus and Sexually Transmitted Infection Testing Among App-Using MSM in Southeast Asia

Little is known about mobile application (app)-based behavior of men who have sex with men (MSM) in Thailand. A cross-sectional online assessment of app users in Bangkok found that more than a quarter have never tested for human immunodeficiency virus (HIV) and 1 in 3 never tested for sexually transmitted infections (STI). STI testing patterns and HIV testing frequency were highly associated with each other in multinomial logistic regression. In the midst of an escalating epidemic where HIV incidence among MSM is highest in Asia, apps can serve to engage those least likely to be reached by traditional methods of recruitment and outreach in Thailand.

Ice parties among young men who have sex with men in Thailand: Pleasures, secrecy and risks

BACKGROUND

Crystal methamphetamine (ice) has become the substance of choice among young men who have sex with men (YMSM) in urban Thailand. Yet, there is scarce data on this phenomenon, partly due to the difficulty in accessing men who will disclose and openly discuss the social contexts, meanings and risks surrounding ice practice. We present an ethnography of ice parties, critically discussing the in-depth social meanings of ice; the sexual socialities and the secrecy surrounding its use; the transactions between older and younger men; and the role of the Internet and mobile technology.

METHODS

Forty repeated narrative interviews (life stories), ten focus group discussions, as well as systematic online and offline observations were conducted over a three-year period. Purposive sampling was used to recruit study participants in a variety of online and offline spaces and through working closely with local Thai community-based organizations serving MSM. To be eligible, participants had to be between 18 and 29 years, able to converse in Thai, had used ice, and had anal sex with another man in the past 6 months. We also strived for sample variability with respects to socio-demographic characteristics (e.g., age, educational attainment and living situation). Data analysis was conducted in Thai by two researchers using the constant comparative method based on grounded theory.

RESULTS

On surface, participants described ice parties as exclusive, in trend, luxurious, fun and pleasurable-a kind of modern camaraderie among beautiful men. In reality, however, this group phenomenon was a social hierarchy containing several important players with relational power to one another, to the ice itself and to the physical space where ice was being consumed. These players included ice suppliers, party hosts, party guests and "icetenders." The paper also discusses the sociality of secrecy that surrounds ice parties as well as the power relations between older relatively rich men who provide ice and the younger men who crave for the chemical, pointing to the risks associated with engagement at ice parties, including instances of rape, violence and unsafe sex. For some participants, ice use was part of their "everyday life," or even believed to be a "rites of passage." For others, it involved sexual silence in cases where they were forced to have (unprotected) sex with certain persons or engage in high-risk activities against their will.

CONCLUSIONS

Ice parties, where high-risk practices were common, power and agency quickly became relational and negotiable. This paper illuminated the secret sociality of ice so that public health efforts will be better equipped with understanding and reaching out to young men who may be at heightened risk for HIV, STI, violence and other health concerns. Ice parties can, for example, be seen as opportunities for harm-reduction strategies whereby young men are not judged for the activities they engage, but are instead respected and approached in a contextualized, non-judgmental way. Finally, icetenders and party hosts may be individuals where public health practitioners can target and include in the development of novel harm-reduction programs.

Factors associated with HIV testing among young men who have sex with men in Myanmar: a cross-sectional study

Introduction

In Myanmar, men who have sex with men (MSM) experience high risk of HIV infection. However, access to HIV testing and prevention services remains a challenge among this marginalized population. The objective of this study was to estimate population prevalence and correlates of prior HIV testing among young MSM (YMSM) and informs the development of HIV testing and intervention programmes that respond to the specific needs of this population.

Methods

Five hundred and eighty‐five YMSM aged 18 to 24 years were recruited using respondent‐driven sampling (RDS) in a cross‐sectional survey conducted in six townships of Myanmar. RDS‐adjusted population estimates were calculated to estimate prevalence of HIV testing; RDS‐weighted logistic regression was used to examine correlates of HIV testing in the past 6 months and in a lifetime.

Results

There were 12 participants who reported receiving a HIV‐positive test; of those, five were tested in the past 6 months. The RDS‐weighted prevalence estimates of lifetime (any prior) HIV testing was 60.6% (95% CI: 53.3% to 66.4%) and of recent (≤ 6 months) HIV testing was 50.1% (95% CI: 44.1% to 55.5%). In multivariable analysis, sexual identity was associated with lifetime but not recent HIV testing. Lifetime and recent HIV testing were associated with having three or more male sexual partners in the past 12 months (adjusted ORs (aORs) = 2.28, 95% CIs: 1.21 to 4.32 and 2.69, 95% CI: 1.59 to 4.56), having good HIV‐related knowledge (aORs = 1.96, 95% CIs: 1.11 to 3.44 and 1.77, 95% CI: 1.08 to 2.89), reporting high HIV testing self‐efficacy (aORs = 13.5, 95% CIs: 6.0 to 30.1 and 9.81, 95% CI: 4.27 to 22.6) and having access to and use of non‐HIV health‐related services in the past 12 months (aORs = 13.2, 95% CIs: 6.85 to 25.6 and 7.15, 95% CI: 4.08 to 12.5) respectively.

Conclusions

HIV testing coverage among YMSM aged 18 to 24 years old in Myanmar is still suboptimal. Integrated HIV testing and prevention services in existing health service provision systems with tailored HIV information and education programmes targeting YMSM to improve HIV‐related knowledge and self‐efficacy may help to promote regular HIV testing behaviour and contribute to sustainable control of the HIV epidemic among this marginalized population in Myanmar.

Socio-demographic Characteristics, Sexual and Test-Seeking Behaviours Amongst Men Who have Sex with Both Men and Women: Results from a Bio-behavioural Survey in 13 European Cities

Within the MSM population, men who have sex with both men and women (MSMW) are identified as a high-risk group both worldwide and in Europe. In a multi-centred bio-behavioural cross-sectional study, we aimed to assess the relationship(s) between socio-demographic factors, stigma, sexual behavioural patterns, test seeking behaviour and sero-status amongst MSMW. A multi-level analysis was conducted to identify factors associated with being MSMW versus Men who have Sex with Men Only (MSMO). A total of 4901 MSM were enrolled across the 13 study sites. Participants were categorised as MSMW in the 12.64% of the cases. Factors such as educational status, perceived homonegativity, testing facilities knowledge and HIV testing lifetime seem to be relevant factors when characterising the MSMW group. The results highlight the vulnerability of MSMW and the wide spectrum of risky behavioural and psycho-social patterns, particularly in terms of HIV testing, 'outness', and perceived stigma.

A novel Online-to-Offline (O2O) model for pre-exposure prophylaxis and HIV testing scale up

Introduction: PrEP awareness and uptake among men who have sex with men (MSM) and transgender women (TG) in Thailand remains low. Finding ways to increase HIV testing and PrEP uptake among high-risk groups is a critical priority. This study evaluates the effect of a novel Adam’s Love Online-to-Offline (O2O) model on PrEP and HIV testing uptake among Thai MSM and TG and identifies factors associated with PrEP uptake.

Methods: The O2O model was piloted by Adam’s Love (www.adamslove.org) HIV educational and counselling website. MSM and TG reached online by PrEP promotions and interested in free PrEP and/or HIV testing services contacted Adam’s Love online staff, received real-time PrEP eCounseling, and completed online bookings for receiving services at one of the four sites in Bangkok based on their preference. Auto-generated site- and service-specific e-tickets and Quick Response (QR) codes were sent to their mobile devices enabling monitoring and check-in by offline site staff. Service uptake and participant’s socio-demographic and risk behaviour characteristics were analyzed. Factors associated with PrEP uptake were assessed using multiple logistic regression.

Results: Between January 10th and April 11th, 2016, Adam’s Love reached 272,568 people online via the PrEP O2O promotions. 425 MSM and TG received eCounseling and e-tickets. There were 325 (76.5%) MSM and TG who checked-in at clinics and received HIV testing. Nine (2.8%) were diagnosed with HIV infection. Median (IQR) time between receiving the e-ticket and checking-in was 3 (0–7) days. Of 316 HIV-negative MSM and TG, 168 (53.2%) started PrEP. In a multivariate model, higher education (OR 2.30, 95%CI 1.14–4.66; p = 0.02), seeking sex partners online (OR 2.05, 95%CI 1.19–3.54; p = 0.009), being aware of sexual partners’ HIV status (OR 2.37, 95%CI 1.29–4.35; p = 0.008), ever previously using post-exposure prophylaxis (PEP) (OR 2.46, 95%CI 1.19–5.09; p = 0.01), and enrolment at Adam’s Love clinic compared to the other three sites (OR 3.79, 95%CI 2.06–6.95; p < 0.001) were independently associated with PrEP uptake.

Conclusions: Adam’s Love O2O model is highly effective in linking online at-risk MSM and TG to PrEP and HIV testing services, and has high potential to be replicated and scaled up in other settings with high Internet penetration among key populations.

Factors associated with intention to be tested for HIV among men who have sex with men in a country with a very low HIV prevalence

This study examined factors associated with the intention to take an HIV test among men who have sex with men (MSM) in South Korea. An internet website-based survey was conducted among users of the only and largest online MSM website between 20 July 2016, and 20 August 2016. A total of 2915 participants completed the survey and answered questions related to sociodemographic information, health behaviors, sexual behaviors, and HIV testing history. Of these, 2587 (88.7%) participants responded as having an intention to take an HIV test. A multivariable logistic regression analysis revealed the following as having reduced the intention to undergo HIV testing: very good subjective health status and no sexual interactions during the last 6 months (Adjusted odds ratios [AOR] 0.45 and 0.54, respectively). In contrast, increased intention to take an HIV test was associated with being 20-29 years old, 30-39 years old, not paying or receiving money for sex, having a history of HIV testing, and taking an HIV test once per 12 months (AOR 2.64, 2.13, 1.54, 1.81, and 2.17, respectively). In conclusion, HIV testing among MSM in this study was associated with age, subjective health status, sex(es) of one's sexual partner(s) during the last 6 months, sexual risk behaviors, HIV testing history, and undergoing regular HIV testing.

Challenges and emerging opportunities for the HIV prevention, treatment and care cascade in men who have sex with men in Asia Pacific

In Asia Pacific, most countries have expanded HIV treatment guidelines to include all those with HIV infection and adopted antiretroviral treatment for prevention (TFP) as a blanket strategy for HIV control. Although the overall epidemic development associated with this focus is positive, the HIV epidemic in men who have sex with men (MSM) is continuing unperturbed without any signs of decline or reversal. This raises doubt about whether TFP as a blanket HIV prevention policy is the right approach. This paper reviews currently available biomedical HIV prevention strategies, national HIV prevention policies and guidelines from selected countries and published data on the HIV cascade in MSM. No evidence for efficacy of TFP in protecting MSM from HIV infection was found. The rationale for this approach is based on assumptions about biological plausibility and external validity of latency-based efficacy found in heterosexual couples. This is different from the route and timing of HIV transmission in MSM. New HIV infections in MSM principally occur in chains of acutely HIV-infected highly sexually active young men, in whom acquisition and transmission are correlated in space and time. By the time TFP renders its effects, most new HIV infections in MSM will have already occurred. On a global level, less than 6% of all reports regarding the HIV care cascade from 1990 to 2016 included MSM, and only 2.3% concerned MSM in low/middle-income countries. Only one report originated from Asia Pacific. Generally, HIV cascade data in MSM show a sobering picture of TFP in engaging and retaining MSM along the continuum. Widening the cascade with a preventive extension, including pre-exposure prophylaxis, the first proven efficacious and only biomedical HIV prevention strategy in MSM, will be instrumental in achieving HIV epidemic control in this group.

MSM HIV testing following an online testing intervention in China

BACKGROUND

Scaling up HIV testing is the first step in the HIV treatment continuum which is important for controlling the HIV epidemic among men who have sex with men (MSM). Following an online HIV testing intervention among MSM, we aim to examine sociodemographic and spatial factors associated with HIV testing.

METHODS

We conducted a secondary analysis on data from an online HIV testing intervention among MSM who had never-tested for HIV. The survey was distributed through online networks connected to all provinces and regions of China. Univariate and multivariable analyses were performed to examine factors associated with testing three weeks post-intervention.

RESULTS

At three weeks after the intervention, 36% of 624 followed-up MSM underwent HIV testing, 69 men reported positive HIV test results. Having money for sex, ever tested for sexually transmitted infections and intimate partner violence experience were significant factors of post-intervention HIV testing. Students were less likely to undergo HIV testing at follow-up compared to others (adjusted odds ratio=0.69, 95% C.I.=0.47-0.99), adjusted by age and type of intervention. Moderate provincial spatial variation of testing was observed.

CONCLUSIONS

While high risk men generally had higher HIV testing rates, some MSM like students had lower testing rates, suggesting the need for further ways to enhance HIV testing in specific MSM communities.

Sexual identity and behavior in an online sample of Indian men who have sex with men

Indian men who have sex with men are disproportionately impacted by HIV. While prevention efforts to date have focused on men who visit drop-in centers or physical cruising sites, little is known about men who are meeting sexual partners on virtual platforms. This paper explores issues related to sexual identity and sexual behaviors in an online sample of men who identified as gay (n = 279) or bisexual (n = 123). There were significant differences in outedness between the two groups, with 48% of bisexually identified men reporting that they were out to "no one" and 82% stating that they present themselves as heterosexual to family and friends. Corresponding rates for gay-identified men were 15% and 41%, respectively (both p < .001). Twenty-nine percent of bisexually identified men reported being married, compared to only 3% of the gay-identified men (p < .001). Bisexually identified men were also more likely to report having exclusively insertive anal sex (49% vs 30% p < .001), while gay-identified men were more likely to report exclusively receptive anal sex (41% vs 13% p < .0001). Rates of unprotected anal sex (UAS) in the two groups were similar; however, married men were significantly more likely to report unprotected vaginal sex (76% vs 35%, p < .012). Positive attitudes toward UAS and lower self-efficacy were associated with sexual risk in both groups; however, substance use was associated with sexual risk only among bisexually identified men. These findings show that a large proportion of Indian bisexually identified men lead closeted lives, especially in their interactions with friends and family, with the vast majority presenting as heterosexual. The lower condom use with wives may be due to societal pressures to have children. The results suggest that bisexually identified men may benefit from targeted programs and non-directive, non-judgmental individual or couples counseling which emphasizes condom use with both male and female partners.

HIV and Sexual Risk Among Men Who Have Sex With Men and Women in Asia: A Systematic Review and Meta-Analysis

We performed a systematic review to estimate the proportion of men who have sex with men (MSM) in Asia who are bisexual and compare prevalence of HIV and sexual risk between men who have sex with men and women (MSMW) and men who have sex with men only (MSMO). Forty-eight articles based on 55 unique samples were identified from nine countries in Asia. Bisexual behaviour was common among MSM (pooled prevalence 32.8 %). Prevalence of HIV (pooled OR 0.90; 95 % CI 0.77-1.05), recent syphilis infection (pooled OR 0.99; 95 % CI 0.93-1.06) and unprotected anal intercourse (pooled OR 0.80; 95 % CI 0.57-1.11) were similar between MSMW and MSMO, but heterogeneity was high. MSMW had lower odds of reporting a prior HIV test than MSMO (OR 0.82; 95 % CI 0.70-0.95; p = 0.01, I(2) = 0 %). Targeted interventions are needed to increase uptake of HIV testing among MSMW. Increased reporting of disaggregated data in surveillance and research will help improve understanding of risk in MSMW and inform targeted interventions.

HIV testing among men who have sex with men in Tijuana, Mexico: a cross-sectional study

OBJECTIVES

HIV testing is critical to the delivery of comprehensive HIV prevention and care services, yet coverage of sexual minorities by HIV testing programmes remains insufficient in many low- and middle-income countries, including Mexico. The objective of this study was to identify the prevalence and correlates of HIV testing among men who have sex with men (MSM) in Tijuana, Mexico.

METHODS

We conducted a cross-sectional study (2012-2013) among 189 MSM recruited via respondent-driven sampling (RDS). RDS-weighted logistic regression was used to identify correlates of prior HIV testing.

RESULTS

RDS-adjusted prevalence of prior and recent (≤ 12 months) HIV testing was 63.5% (95% CI 51.9% to 73.5%) and 36.8% (95% CI 25.4% to 46.4%), respectively. Prior HIV testing was positively associated with older age (adjusted OR (AOR)=1.09, 95% CI 1.04 to 1.15), being born in Tijuana (AOR=2.68, 95% CI 1.05 to 6.86), higher levels of education (AOR=2.65, 95% CI 1.08 to 6.53), identifying as homosexual or gay (AOR=3.73, 95% CI 1.48 to 9.42), being more 'out' about having sex with men (AOR=1.28, 95% CI:1.02 to 1.62), and a history of sexual abuse (AOR=3.24, 95% CI 1.06 to 9.86). Prior HIV testing was negatively associated with reporting more condomless anal intercourse acts (past 2 months) (AOR=0.95, 95% CI 0.92 to 0.98) and greater internalised homophobia (AOR=0.92, 95% CI 0.86 to 0.99).

CONCLUSIONS

Our findings indicate an urgent need for expanded HIV testing services for MSM in Tijuana. Innovative, non-stigmatising, confidential HIV testing interventions targeted at young, less educated, migrant and non-gay identifying MSM may facilitate HIV testing and timely linkage to HIV care and treatment within this population.