Awareness and use of untested barrier methods by HIV-seropositive gay and bisexual men

Lifetime prevalence and correlates of female condom use for anal sex in a geographically diverse sample of Men who have sex with men (MSM) in the United States

OBJECTIVES

Examine use of the female condom (FC) for anal sex among Men who have sex with men (MSM) in the United States (US).

METHODS

An online survey among 3,837 MSM.

RESULTS

5.2% had used the FC for anal sex. Use was higher among those who had used the FC for vaginal sex (OR=14.39, p<0.001), those with multiple partners, (OR=2.68, p=0.004), and those who were HIV-positive (OR=2.07, p<0.001) or on PrEP (OR=2.66, p<0.001).

CONCLUSIONS

FC use for anal sex was associated with risk of HIV infection/transmission and may be a risk reduction strategy used by MSM in the US.

Stigma, access to healthcare, and HIV risks among men who sell sex to men in Nigeria

INTRODUCTION

Among men who have sex with men (MSM), men who sell sex (MSS) may be subject to increased sexual behaviour-related stigma that affects uptake of healthcare and risk of sexually transmitted infections (STIs). The objectives of this study were to characterize stigma, access to care, and prevalence of HIV among MSS in Nigeria.

METHODS

Respondent-driven sampling was used to recruit MSM in Abuja and Lagos into the ongoing TRUST/RV368 study, which provides HIV testing and treatment. Detailed behavioural data were collected by trained interviewers. MSS were identified by self-report of receiving goods or money in exchange for sex with men. Poisson regression with robust error variance was used to explore the impact of sex-selling on the risk of HIV.

RESULTS

From 12 initial seed participants, 1552 men were recruited from March 2013-March 2016. Of these, 735 (47.4%) reported sex-selling. Compared to other MSM, MSS were younger (median 22 vs. 24 years, p < 0.001) and more likely to identify as gay/homosexual (42.4% vs. 31.5%, p < 0.001). MSS were more likely to report perceived and experienced stigmas such as healthcare avoidance (27.6% vs. 21.5%, p = 0.005) and verbal harassment (39.2% vs. 26.8%, p < 0.001). Total HIV prevalence was 53.4%. After controlling for other factors, HIV prevalence among MSS was similar to that observed among other MSM (relative risk 0.94 [95% confidence interval 0.84-1.05]).

CONCLUSION

These data highlight increased sexual behaviour-related stigma affecting MSS, as compared with other MSM, that limits uptake of healthcare services. The distinct characteristics and risks among MSS suggest the need for specific interventions to optimize linkage to HIV prevention and treatment services in Nigeria.

Inconsistencies on U.S. Departments of Health Websites Regarding Anal Use of the Female Condom

The female condom (FC) is FDA approved to prevent pregnancy and sexually transmitted infections during vaginal intercourse, but not for use during anal intercourse. Studies suggest that a sizeable proportion of men who have sex with men use the FC for anal intercourse despite lack of safety and efficacy information. We reviewed Department of Health (DOH) websites for U.S. states (n = 50) and major municipalities (population >500,000; n = 29) regarding anal use of the FC. Forty-eight (60.8 %) websites mentioned the FC, of which only 21 (45.8 %) mentioned anal use. Of those that mention anal use, 8 (38.1 %) supported, 13 (61.9 %) were neutral, and 1 (4.8 %) discouraged this use. Ten websites (47.6 %) provided instructions for anal use of the FC-ranging from removal of the inner ring, leaving the inner ring in place, and either option. In the absence of safety and efficacy data, U.S. DOH websites are providing different and often contradictory messages about the FC for anal sex.

Comparisons of reported sexual behaviors from a retrospective survey versus a prospective diary in the Botswana Defence Force

This study compares self-reported sexual behaviors from a retrospective survey and a prospective diary among Botswana Defence Force (BDF) personnel. One hundred sixty-one male participants, aged 18-30, completed two weekly prospective diaries and a retrospective survey querying them about behaviors reported during the same time frame as the diaries. Most reported behaviors were similar between the two data collection methods. However, there was low agreement for reporting sex with a spouse and exchanging material goods for sex with a casual partner; frequency of sex and condom use rates (CURs) among married participants also differed. When comparing survey condom use frequencies to diary CURs, the level of agreement diminished from the always to occasionally condom use categories. Inconsistencies in reporting may be due to the frequency of the sexual behavior, question sensitivity, the data collection setting, and the interpretation of response categories. Further research is needed to improve accurate reporting of sexual behaviors.

The pleasure principle: the effect of perceived pleasure loss associated with condoms on unprotected anal intercourse among immigrant Latino men who have sex with men

Sexual pleasure has been identified as an important consideration in decision-making surrounding condom use. We examined the impact of perceived pleasure loss associated with condom use on recent history of insertive and receptive unprotected anal intercourse (UAI) among Latino men who have sex with men (MSM) living in the United States. A total of 482 Dominican, Colombian, and Brazilian immigrant MSM were surveyed regarding sexual attitudes and practices via computer-assisted self-interviewing technology with audio enhancement (ACASI). Participants rated the pleasure they derived from protected and unprotected anal intercourse in each position (insertive and receptive) and also reported their HIV status, relationship status, and recent sexual history. Men who had engaged in both positions, with and without condoms (n=268), perceived a greater pleasure loss associated with condoms during anal intercourse in the insertive versus receptive position. Logistic regression analyses controlling for HIV status, relationship status, and age revealed that men who perceived greater pleasure loss from condoms were more likely to have engaged in UAI over the past 3 months (n[insertive]=297; n[receptive]=284). Findings indicate that the pleasure loss associated with condoms may be a key deterrent for their use in either sex position among Latino MSM. Therefore, pleasure needs to be prioritized in the development of condoms and other sexual safety measures as well as in the promotion of their use.

Alcohol consumption patterns and sexual risk behavior among female sex workers in two South Indian communities

BACKGROUND

HIV transmission in India is primarily heterosexual and there is a concentrated HIV epidemic among female sex workers (FSWs). Earlier reports demonstrate that many FSWs consume alcohol regularly before sexual encounters. This qualitative study is part of a larger quantitative study designed to assess alcohol consumption patterns among female sex workers and their association with sexual risk taking. Here we investigate the environmental influence, reasons for and consequences of consuming alcohol in the FSW population.

METHODS

Trained staff from two Non-Governmental Organizations in Andhra Pradesh and Kerala conducted semi-structured interviews with 63 FSWs in Chirala, Andhra Pradesh (n = 35) and Calicut, Kerala (n = 28) following extensive formative research, including social mapping and key informant interviews, to assess drinking patterns and sexual risk behaviors.

RESULTS

FSWs reported consuming alcohol in multiple contexts: sexual, social, mental health and self-medication. Alcohol consumption during sexual encounters with clients was usually forced, but some women drank voluntarily. Social drinking took place in public locations such as bars and in private locations including deserted buildings, roads and inside autorickshaws (motorcycle taxis). Consequences of alcohol consumption included failure to use condoms and to collect payments from clients, violence, legal problems, gastrointestinal side effects, economic loss and interference with family responsibilities.

CONCLUSION

FSWs consume alcohol in multilevel contexts. Alcohol consumption during transactional sex is often forced and can lead to failure to use condoms. Social drinkers consume alcohol with other trusted FSWs for entertainment and to help cope with psychosocial stressors. There are multiple reasons for and consequences of alcohol consumption in this population and future interventions should target each specific aspect of alcohol use.

A review of the effectiveness and acceptability of the female condom for dual protection

The female condom remains the sole female-initiated method of dual protection against unintended pregnancy and sexually transmissible infections (STIs), including HIV. We reviewed published data on the effectiveness and acceptability of the female condom for protection against pregnancy and infection. Overall, use of the female condom is low and several barriers hinder the wider adoption of the use of the method. Research on effectiveness has focussed on pregnancy, STIs and biological markers of semen exposure. Although the data available suggest that female condoms (or a mixture of female and male condoms) may provide similar degrees of protection against pregnancy and STIs as do latex male condoms alone, this conclusion has not been demonstrated and thus comparative research is urgently needed.

HIV intervention for providers study: a randomized controlled trial of a clinician-delivered HIV risk-reduction intervention for HIV-positive people

Clinician-delivered prevention interventions offer an opportunity to integrate risk-reduction counseling as a routine part of medical care. The HIV Intervention for Providers study, a randomized controlled trial, developed and tested a medical provider HIV prevention training intervention in 4 northern California HIV care clinics. Providers were assigned to either the intervention or control condition (usual care). The intervention arm received a 4-hour training on assessing sexual risk behavior with HIV-positive patients and delivering risk-reduction-oriented prevention messages to patients who reported risk behaviors with HIV-uninfected or unknown-status partners. To compare the efficacy of the intervention versus control on transmission risk behavior, 386 patients of the randomized providers were enrolled. Over six-months of follow-up, patients whose providers were assigned the intervention reported a relative increase in provider-patient discussions of safer sex (OR = 1.49; 95% CI = 1.06 to 2.09), assessment of sexual activity (OR = 1.60; 95% CI = 1.05 to 2.45), and a significant decrease in the number of sexual partners (OR = 0.49, 95% CI = 0.26 to 0.92). These findings show that a brief intervention to train HIV providers to identify risk and provide a prevention message results in increased prevention conversations and significantly reduced the mean number of sexual partners reported by HIV-positive patients.

Off-label use of the female condom for anal intercourse among men in New York City

We surveyed 111 male clients of an HIV/AIDS service organization in New York City in 2008 and 2009. Seventeen percent had used the female condom for anal intercourse; of these, 89.3% had used the female condom with male partners, 21.4% with female partners, and 10.7% with both. Users of the female condom for vaginal intercourse were more likely to use it for anal intercourse (odds ratio = 12.7; 95% confidence interval = 2.5, 64.9; P = .002). The safety and efficacy of the female condom for anal intercourse are unknown and should be evaluated.

Anal use of the female condom: does uncertainty justify provider inaction?

Despite limited safety data and the absence of efficacy data, several studies have reported that the female condom is being used for anal sex by men who have sex with men. We describe providers' awareness of female condom use during anal sex among their clients and their experiences in counseling clients. We conducted semi-structured interviews with 78 health-care providers recruited from various health-care delivery systems in New York City: a family planning agency, a sexually transmitted infection agency, a hospital-based obstetrics and gynecology clinic, and two community-based AIDS service organizations. While two-thirds of providers reported that they were uncertain as to whether the female condom could or should be used for anal intercourse, nearly one-third believed that anything is better than nothing to prevent HIV/sexually transmitted infections during anal sex. Few providers had actually talked with clients about anal use of the female condom, and clients themselves had seldom mentioned nor asked for information about such use. Our findings highlight providers' uncertainty about anal use of the female condom. Lacking guidelines regarding the safety and efficacy of female condom use during anal sex, health-care providers are left to make their own well-intentioned recommendations (or not) to potential users. The dearth of information on female condom use during anal sex could encourage individuals to use the female condom for anal sex, which may increase HIV transmission risk or represent a missed opportunity for protecting non-condom users. There is a need for a series of harm-reduction, acceptability, and efficacy studies and, in the interim, for the development of a carefully qualified safety set of guidelines regarding anal use of the female condom for health-care providers.

Adding the female condom to the public health agenda on prevention of HIV and other sexually transmitted infections among men and women during anal intercourse

Legal barriers to conducting public health research on methods of protection for anal intercourse were lifted in the United States in 2003 when the US Supreme Court invalidated all state antisodomy laws. Although research funding has been available for the development of rectal microbicides, the female condom, which has already been approved for vaginal use, has not been evaluated for anal use. Although there is no evidence that the female condom is safe for anal intercourse, it has already been taken up for off-label use by some men who have sex with men. This demonstrates the urgent need for more protection options for anal intercourse and, more immediately, the need to evaluate the safety and efficacy of the female condom for anal intercourse.

Sexual risk behavior has decreased among men who have sex with men in Los Angeles but remains greater than that among heterosexual men and women

We examined changes and correlates of sexual risk behavior of men who have sex with men (MSM) compared with heterosexual men and women over three time periods. Data from the 1997, 1999, and 2003 Los Angeles County Health Surveys, a population-based telephone survey, were analyzed to examine the association of sociodemographic and health-related factors with sexual risk behaviors among the three groups. In each time period, MSM reported a significantly greater percentage of sexual risk (i.e., both inconsistent condom use and multiple sex partners in the past 12 months) compared with heterosexual men and women. Multivariate analyses indicated that MSM and heterosexual men reported greater sexual risk than heterosexual women. Respondents who were younger, U.S. born, reported heavy alcohol consumption, or had been tested for HIV in the past 24 months were more likely to report sexual risk behavior. The findings suggest the need for continued targeted prevention for MSM and prevention efforts for segments of the general population at elevated risk for HIV.

Immune dysfunction in Atlantic bottlenose dolphins (Tursiops truncatus) with lobomycosis

Lobomycosis (Lacaziosis) occurs only in humans and dolphins under natural conditions. We evaluated the immune status of eight dolphins with lobomycosis and 40 healthy dolphins from the Indian River Lagoon (IRL), Florida. Lobomycosis cases had multiple abnormalities in their immunologic parameters when compared to healthy dolphins. The absolute number of circulating lymphocytes and serum albumin concentration were reduced (P<0.05) while the segmented neutrophils, alpha 1, total beta, total gamma and total globulins were increased (P<0.05). Although innate immunity was relatively intact and phagocytosis and natural killer cell activity were not affected, the plasma lysozyme concentrations were elevated in dolphins with lobomycosis (P<0.05). Adaptive immunity was depressed with statistically significant decreases found in the absolute numbers of CD4(+) helper T cells and CD19(+) and CD21(+) B cells. The ratios of CD2(+) T cells to CD4(+) cells and CD2(+) to CD21(+) cells were increased (P=0.05 and P<0.05, respectively) and the numbers of lymphocytes expressing MHC class II molecules was decreased in dolphins with lobomycosis (P<0.05). Lymphocyte proliferation was reduced in response to stimulation with lipopolysaccharide and concanavalin A (P<0.05). Antibody titers to Erysipelas rhusiopathiae, a common marine micro-organism, were decreased (P<0.05). In summary, dolphins with lobomycosis exhibit significant impairment in adaptive immunity.

Simultaneous Use of Multiple Condoms Among Male Cambodian Military Personnel Visiting Female Sex Workers

OBJECTIVES

To estimate the prevalence of simultaneous use of multiple condoms (SUMC) and identify the characteristics of the multiple condoms users.

STUDY DESIGN

Cross-sectional survey among military men from a purposively selected Cambodian military region. Military men were interviewed face to face.

RESULTS

From the 1638 respondents, 40% never had sex with female sex workers (FSWs), 55% had used condom(s), and 5% had unprotected sex at their last encounter with a FSW. Among those reporting sex with FSWs, 21% had used multiple condoms simultaneously at their last sex with a FSW.

CONCLUSION

Compared with single condom users, multiple condom users were younger, had lower rank, had first sex more recently, had lower knowledge of HIV transmission, had received less HIV peer-education sessions, were more likely to have visited multiple FSWs, and were more likely to have sought their HIV serostatus. As it is unknown if SUMC increases or decreases condom effectiveness, more research is needed to investigate the effect of SUMC on condom failure rates.

Examining the role of partner status in an HIV prevention trial targeting HIV-positive gay and bisexual men: the seropositive urban men's intervention trial (SUMIT)

The goal of this analysis was to examine whether partner status impacted behavioral outcomes from the Seropositive Urban Men's Intervention Trial (SUMIT). We contrasted sample characteristics of HIV-positive gay and bisexual men with and without main partners and then examined differences in sexual behaviors among men participating in an enhanced HIV prevention intervention compared to those in a standard condition. Logistic regression analyses were performed to differentiate characteristics of men with and without main partners and mixed-model logistic regression analyses were performed to test for intervention effects. Men with main partners showed a greater likelihood of having unprotected anal sex with any partner, although the number of male sexual partners was higher for men without a main partner. SUMIT generally produced few differences in sexual risk behaviors and did not affect several potential mediator variables of the relationship between the intervention and sexual behaviors with main and nonmain partners.

Prevention with HIV-seropositive men who have sex with men: lessons from the Seropositive Urban Men's Study (SUMS) and the Seropositive Urban Men's Intervention Trial (SUMIT)

SUMMARY

Men who have sex with men (MSM) are disproportionately affected by HIV, and HIV-seropositive (HIV-positive) MSM are an especially important group for prevention efforts. This article describes findings from the Seropositive Urban Men's Study (SUMS, N = 456) and the Seropositive Urban Men's Intervention Trial (SUMIT, N = 1168). These studies were conducted from 1996 to 2002 with racially diverse samples from New York and San Francisco. Patterns of sexual behavior often reflected an understanding of the relative risks of specific sexual practices and were generally consistent with harm reduction strategies to reduce the risk of HIV transmission to uninfected partners. Some men, however, continued to engage in behaviors that placed themselves and their partners at risk for exposure to HIV and other sexually transmitted infections. Correlates of unprotected sex included self-efficacy, personal responsibility, substance use, mental health, and contextual influences. Disclosure of HIV status was a difficult issue for many HIV-positive MSM. Most participants had disclosed to their main partner, but they disclosed to less than half of their non-main partners before first sex. The interest of HIV-positive MSM in prevention efforts, the design of the SUMIT intervention trial, and implications for future research and programmatic efforts are discussed.

Building an HIV/STI prevention program in a gay bathhouse: a case study

Gay bathhouses have long been subject to community and public health pressures owing to the perceived link between the behaviors associated with these settings and various sexually transmitted infections. The straightforward solution of closing gay bathhouses has not worked for long when it has been tried. The more complex approach of working with management to develop holistic prevention programs can be problematic also, because developing successful HIV/STD prevention programs requires the collaboration of multiple stake-holders. Furthermore, to overcome the stigma associated with disease, the population, and bathhouse environments places significant, and sometimes awkward, demands on those who undertake such prevention programs. Nevertheless, a number of U.S. cities now have had years of experience with such efforts. This article provides an example of a collaboration of multiple stakeholders to develop a holistic prevention program. We examine our own process of building a collaborative team of bathhouse managers, health department officials, and academics to provide HIV/STD prevention programs in a bathhouse. We describe the process of developing the collaboration and offer recommendations for establishing mutually beneficial relationships among stakeholders.

Partner awareness of the serostatus of HIV-seropositive men who have sex with men: impact on unprotected sexual behavior

Prior research has provided conflicting evidence about the association between partner awareness of an HIV-seropositive person's serostatus and HIV transmission behavior via unprotected intercourse. The current study examined partner awareness of participant HIV-seropositive status and sexual behavior in a multiethnic sample of HIV-seropositive men who have sex with men. Most HIV-seropositive men reported that their primary partners are aware, and most reported that at least some non-primary partners are aware the participant was HIV-seropositive before first having sex. Partner awareness of participant HIV-serostatus was related to unprotected sexual behavior during the past 3 months in a non-linear fashion, as men with partners who were inconsistently aware had higher rates of unprotected receptive anal intercourse than men with partners who were consistently aware or consistently unaware. Men with partners who were inconsistently aware also had higher rates of insertive oral intercourse than men with partners who were consistently aware. However, there were no differences in HIV transmission risk behavior between men with partners who were consistently aware and men with partners who were consistently unaware a participant was HIV-seropositive.

Prevention with gay and bisexual men living with HIV: rationale and methods of the Seropositive Urban Men's Intervention Trial (SUMIT)

OBJECTIVES

To provide a public health rationale for prevention with HIV-seropositive gay and bisexual men and to describe the methods of the Seropositive Urban Men's Intervention Trial (SUMIT).

DESIGN

A randomized intervention trial.

METHODS

Self-identified HIV-positive gay and bisexual men were recruited from community-based venues in New York City and San Francisco. Eligible participants completed an A-CASI baseline assessment, were asked to provide samples for sexually transmitted infection (STI) testing, and were randomly assigned to either a single-session intervention or a six-session enhanced intervention designed to reduce HIV transmission risk and promote serostatus disclosure. Participants who attended the first intervention session were assessed 3 and 6 months post-intervention. STI testing was offered at the 6-month assessment.

RESULTS

A total of 1168 self-identified HIV-seropositive gay and bisexual men completed the baseline assessment, and 1110 of these (95%) opted for STI testing. A total of 811 attended the first intervention session, of which 85% were assessed at 3 months and 90% were assessed at 6 months. Of those assessed at 6 months, 92% (670/729) provided a blood or urine sample for STI testing.

CONCLUSION

SUMIT demonstrates the feasibility and acceptability of prevention research with HIV-seropositive gay and bisexual men. The study provides new information about the sexual behavior, serostatus disclosure practices, and the efficacy of an intervention to reduce HIV transmission risk.

Sexual diversity among black men who have sex with men in an inner-city community

Dramatic increases in HIV-incidence rates have been documented for Black men who have sex with men (MSM). Moreover, MSM has become a more visible HIV-transmission route in the Black community, in part due to public interest in the "down low" (i.e., "straight" men who also have sex with men). Interviews were conducted with 21 Black MSM in central Brooklyn, New York City, in efforts to understand the diversity of MSM experience in a low income, high HIV-prevalence community. Two thirds of the men identified as either heterosexual (43%) or bisexual (24%) and 15 (71%) MSM reported recent sex with women. Conformity to masculine social role expectations made it difficult to identify sex partners in the community; therefore, men relied on private sex clubs and the Internet. The findings suggest that stigma surrounding both HIV and homosexuality may effectively insure that nonheterosexual preferences and practices remain hidden in the Black community. A focus on sexual orientation and bisexuality has obscured the issue of race in the HIV/AIDS epidemic among Black MSM. In the long term, public health promotion and HIV prevention will require greater tolerance and acceptance of sexual diversity in the Black community.

Correlates of sexual risk behaviors among HIV-positive men who have sex with men

This study examines correlates of unprotected sexual risk practices of an ethnically diverse sample of HIV-seropositive men who have sex with men (MSM) from the New York City and San Francisco metropolitan areas. Participants completed a self-report survey that assessed sexual risk behaviors and potential correlates. A total of 367 men reported sex with a casual male partner in the previous 3 months. Participants were divided into three groups based on level of HIV-transmission risk with HIV negative or unknown-status partners: no unprotected anal sex (58.9%), unprotected receptive anal sex only (14.2%), and unprotected insertive anal sex (22.6%). Multivariate logistic regression analyses indicated that men reporting unprotected anal insertive sex perceived less responsibility to protect their partners from HIV. Men reporting no unprotected anal sex also reported less use of nitrate inhalants, lower temptation for unsafe sex, and fewer HIV-negative and unknown-status partners. Men reporting unprotected receptive anal sex were less anxious than the other two groups but also reported greater depression than those not reporting unprotected anal sex and greater loneliness than those reporting unprotected anal insertive sex. Implications for interventions with HIV-positive MSM are presented.

Interests in HIV prevention topics of HIV-seropositive men who have sex with men

As improved medical treatments have extended the lives of persons with HIV, prevention programs increasingly address these persons' ability to adopt and sustain HIV risk reduction behavior. Little is known about which HIV-seropositive persons would most likely use prevention programs or what program topics would best meet the needs of this population. A diverse sample of HIV-seropositive men who have sex with men (MSM, N = 206) rated their interest in a variety of program topics addressing physical and mental health issues. Topics specific to HIV prevention were of interest to most MSM, but the level of interest was generally lower than for other topics. Compared with White MSM, African American MSM had higher overall interest in programs addressing safer sex and programs addressing serostatus disclosure. Higher active coping was related to more interest in a broad range of program topics for HIV-seropositive men, programs addressing safer sex, and programs addressing serostatus disclosure. Risk behavior was not associated with program interests. Gaining a better understanding of interest in a variety of program topics among persons living with HIV is an important step in enhancing HIV transmission prevention programs.