Personal and contextual factors related to delayed HIV diagnosis among men who have sex with men

Medical-Legal Partnerships: a promising approach for addressing health-harming legal needs among people with HIV

Introduction

People with HIV (PWH), particularly those at the intersection of sexual and gender identities, face enduring obstacles to accessing HIV care, including structural stigma, structural racism and discrimination, housing instability, and limited access to health insurance. To address these challenges, Medical-Legal Partnerships (MLPs) in HIV care offer an innovative approach that integrates medical and legal services. By targeting health-harming legal needs (HHLN), MLPs aim to enhance the HIV care continuum outcomes for PWH.

Methods

This study examines the benefits and challenges of MLPs within organizations serving PWH through the social-ecological model. MLP providers (n=111) identified organizational-level challenges such as funding limitations, resource integration issues, and staffing constraints.

Results

MLPs demonstrated numerous benefits, including patient impact and benefits, comprehensive service provision, enhanced staff support and capacity, and potential for policy influence.

Discussion

These results underscore the feasibility of MLPs while offering valuable insights into their efficacy and challenges, guiding the implementation of MLPs to address health-harming legal needs, including discrimination, and thereby improving HIV care outcomes.

"We in This Fight Together…": HIV Treatment and Prevention Among Couples of HIV-Discordant Black and Latino Men Who Have Sex with Men

HIV-positive Black and Latino men who have sex with men (MSM) have substantial challenges accessing and engaging in HIV care. Findings presented here are an analysis of 14 HIV-discordant couples (N = 28) from Atlanta, GA; Baltimore, MD; Chicago, IL; Los Angeles, CA; and Washington, DC. One-hour in-depth interviews were conducted. Interviews were analyzed using a qualitative content analysis approach. Most couples reported relationship fears associated with delayed disclosure, HIV care engagement instigated by the HIV-uninfected partner, and varying knowledge and concern about the impacts of HIV infection and risk reduction. Findings suggest an opportunity to jointly educate and treat MSM of color in HIV-discordant relationships to improve engagement in ART and PrEP care and adherence.

A realist evaluation of the continuum of HIV services for men who have sex with men

Background

Men who have Sex with Men (MSM) represent the risk group that are disproportionately most affected by the human immunodeficiency virus (HIV) and continue to drop-off from the steps of the continuum of HIV services that have been adopted to overcome poor engagement and retention in care. This realist evaluation aimed at: (1) describing the evaluation carried out in Haiti aiming to ascertain why, how and under which circumstances MSM are linked and retained along the continuum, (2) assessing the outcomes of this approach and (3) exploring the motivators and facilitators for the HIV continuum of services through mechanisms and pathways.

Methods

Guided by a realist approach, first, an initial program theory (IPT) was developed based on literature and frameworks review, participant observations and discussions with stakeholders. Then, the IPT was tested using a mixed method explanatory study: a quantitative phase to build the continuum from a cross-sectional analysis, and a qualitative phase to explore the motivators and facilitators related to proper linkages along the continuum. Finally, the IPT was refined by eliciting the mechanisms and pathways for outcomes improvement.

Results

The results showed that the current service delivery model is suboptimal in identifying, engaging, linking and retaining MSM, resulting in loss to follow-up at every step of the continuum and failure to fully realize the health and prevention benefits of antiretroviral. However, the mechanisms through which linkages across the continuum can be improved are: self-acceptance, sense of community support and sense of comprehensive and tailored HIV services. These mechanisms are based on 10 different pathways: self-esteem, awareness and pride, perception of HIV risk, pcceptance and HIV status, addressing community stigma, strengthening of MSM organizations and community networks, societal acceptation and tolerance, stigma reduction training for healthcare providers, engagement of peers as educators and navigators and, adapted services delivery through drug dispensing points and mobile technology and financial assistance.

Conclusions

The study findings show that engagement, adherence and retention to the continuum of HIV service for MSM are affected by a multi-layer of factors, thus highlighting the importance of taking a comprehensive approach to improve the program.

Understanding Reasons for HIV Late Diagnosis: A Qualitative Study Among HIV-Positive Individuals in Amsterdam, The Netherlands

Since the introduction of effective anti-retroviral therapy, early diagnosis and treatment of HIV have become increasingly important from individual and public health perspectives. People who are diagnosed with a CD4 count below 350 cells/µL blood are today considered to be “late” diagnoses. In an effort to understand the reasons for late diagnosis, we conducted in-depth interviews (n = 14) in Amsterdam, the Netherlands. Two main factors were identified: psychosocial factors and health-system factors. Psychosocial factors relate to people’s personal relationship with health professionals, low risk perception, fear related to the outcome of testing, and trauma from observed past experiences of living with HIV. Health-system factors relate to institutional barriers and missed opportunities during client-provider interactions. We conclude that in order to mitigate late diagnosis, the social and institutional context within which HIV testing is conducted should be addressed.

Factors Associated with Never Testing for HIV: Directions for Targeted Testing Interventions Among Men Who Have Sex with Men

Men who have sex with men (MSM) and who are unaware of their HIV infection contribute to onward HIV transmission and are more likely to progress to severe illness. We therefore assessed determinants of never testing for HIV among MSM living in the Netherlands. Between April and July 2019, 950 HIV-negative and 122 never-tested MSM completed a cross-sectional survey on sociodemographics, HIV testing behavior, and sexual risk taking, which was distributed through gay networking sites/apps. In never-tested MSM, median age was 37 (interquartile range = 22-51) years and 37 (30%) reported recent sexual risk behavior. Never testing was associated with younger age [adjusted odds ratio (aOR) per year increase = 0.98, 95% confidence interval (CI) = 0.97-1.00, p = 0.015], having sex with men and women (aOR = 2.85, 95% CI = 1.57-5.62, p = 0.001), and not knowing others living with HIV (aOR = 3.85, 95% CI = 2.35-6.32, p < 0.001) in multi-variable logistic regression analysis. A significant interaction effect between education level and residential area was observed (p = 0.001). Among higher-educated MSM, those living outside a large urban area had higher odds of never testing compared to those living in an urban area (aOR = 6.26, 95% CI = 2.42-16.24, p < 0.001). Lower-educated MSM had higher odds of never testing irrespective of residential area (large urban area: aOR = 12.06, 95% CI = 4.00-36.38; outside large urban area: aOR 9.29, 95% CI = 3.64-23.76; p < 0.001 for both). Among MSM recently exposed to sexual risk, never testing was associated with having sex with men and women (aOR = 2.80, 95% CI = 1.09-7.18, p = 0.032) and not knowing others with HIV (aOR = 4.91, 95% CI = 1.97-12.24, p = 0.001). To conclude, testing interventions for those never tested should be tailored to residential area and education level, and inclusive of bisexuality.

Factors associated with sexually transmissible infection testing practices among men who have sex with men in Jamaica: results from a cross-sectional, tablet-based survey

Background Men who have sex with men (MSM) are at elevated risk for sexually transmissible infection (STI) acquisition globally. Yet, limited research has explored STI testing practices among MSM in contexts where same-sex practices are criminalised, such as in Jamaica.

METHODS

A cross-sectional, tablet-based survey with MSM in Kingston, Ocho Rios and Montego Bay, Jamaica, was conducted. Multivariable logistic regression analyses were conducted to determine the adjusted risk ratio for lifetime STI testing and lifetime STI diagnosis. Multinomial logistic regression analyses were conducted to determine the relative odds of having had an STI test 3-5 months ago and 6-12 months ago in comparison with <3 months ago.

RESULTS

Three-quarters (74.8%) of the 556 participants reported receiving an STI test (44% <3 months ago; 32% 3-5 months ago; 13% 6-12 months ago; 10% >12 months ago); 12.1% reported ever receiving an STI diagnosis. In adjusted multivariable analyses, STI testing was associated with sociodemographic (education, location), individual (depression, perceived risk), social (relationship status, sexual stigma) and structural (healthcare provider access) factors. In multinomial analysis, reporting a less recent STI test (>3 months ago) versus <3 months ago was associated with increased likelihood of sexual stigma and food insecurity. Lifetime STI diagnosis was associated with sociodemographic (location), individual (HIV infection) and social (lower social support) factors.

CONCLUSIONS

Findings document associations between structural factors and delayed timing of STI testing. Further research is necessary to explore how to address social ecological factors in sexual health interventions with MSM in Jamaica.

HIV incidence among gay men and other men who have sex with men in 2020: where is the epidemic heading?

The goal to effectively prevent new HIV infections among gay, bisexual, and other men who have sex with men (MSM) is more challenging now than ever before. Despite declines in the late 1990s and early 2000s, HIV incidence among MSM is now increasing in many low- and high-income settings including the US, with young, adolescent, and racial/ethnic minority MSM being among those at highest risk. Potentiating HIV risks across all settings are individual-, network-, and structural-level factors such as stigma and lack of access to pre-exposure prophylaxis (PrEP) and antiretroviral treatment as prevention. To make a sustained impact on the epidemic, a concerted effort must integrate all evidence-based interventions that will most proximally decrease HIV acquisition and transmission risks, together with structural interventions that will support improved coverage and retention in care. Universal HIV treatment, increased access to HIV testing, and daily oral PrEP have emerged as integral to the prevention of HIV transmission, and such efforts should be immediately expanded for MSM and other populations disproportionately affected by HIV. Respect for human rights and efforts to combat stigma and improve access to prevention services are needed to change the trajectory of the HIV pandemic among MSM.

The use of social marketing campaigns to increase HIV testing uptake: a systematic review

Social marketing campaigns have been increasingly used in HIV prevention efforts to address barriers to HIV testing. The purpose of this review is to evaluate the social marketing campaigns in the past ten years (2008-2017) that have targeted HIV testing or intent to test as an outcome, and synthesize the results to determine which campaigns work or do not work. The search was conducted using PubMed, Scopus, PsycINFO, EMBASE, and ABI/Inform. The quality assessment tool for quantitative studies developed by the Effective Public Health Practice Project was used to assess study quality. The search generated 373 articles, of which 13 articles met the inclusion criteria. These articles were from 13 distinct campaigns carried out in 9 countries, twelve of which were in high income countries. Sixty-nine percent (n = 9) of the campaigns targeted MSM, gay men, or MSMW, 23% (n = 3) targeted the general population, while 8% (n = 1) focused on African-American women. The study designs for evaluating the campaigns were predominantly cross-sectional, with 4 of the articles combining two or three study designs to evaluate their campaign. Overall, 38% (n = 5) of the campaigns had an increase in HIV testing outcomes, 23% (n = 3) reported no change in HIV testing outcomes, and the remaining 38% (n = 5) of the studies reported mixed outcomes. The results of the quality rating showed that 69% (n = 9) of the papers had weak global ratings, while 31% (n = 4) had moderate rating. None of the articles had a strong rating. This review displayed that social marketing campaigns intended to increase HIV testing uptake were effective in some context. Social marketing practitioners will need to come up with a standardized way of communicating the results of campaign exposure and impact so as to enhance comparison among the multitude of campaigns.

Quality of life among men who have sex with men in China measured using the 36-item Short-Form Health Survey: A cross-sectional study

The present study was conducted to assess the quality of life (QOL) of Chinese men who have sex with men (MSM) and to explore possible factors associated with QOL among them.A cross-sectional study of 370 MSM in Dalian and Huludao city was conducted to evaluate QOL in MSM using the Chinese version of the 36-item Short-Form Health Survey (SF-36). A t test was used to compare the QOL score of our sample with the Chinese norm. ANOVA, t test, and multivariate linear regression analysis were used to assess the association of QOL with basic characteristics.The QOL score of MSM was lower than the Chinese norm (P < .05). Multivariate analysis showed that marital status and monthly income were factors associated with physical component summary (PCS) and mental component summary (MCS) among MSM population (P < .05). Married MSM had poorer QOL, and respondents with higher income levels had better QOL.The government may need to develop more effective prevention strategies to improve the mental component of QOL in the Chinese MSM population, especially the married MSM population.

Determinants of HIV Incidence Disparities Among Young and Older Men Who Have Sex with Men in the United States

This study sought to determine why young men who have sex with men (MSM) have higher HIV incidence rates than older MSM in the United States. We developed hypotheses that may explain this disparity. Data came from peer-reviewed studies published during 1996-2016. We compared young and older MSM with respect to behavioral, clinical, psychosocial, and structural factors that promote HIV vulnerability. Compared with older MSM, young MSM were more likely to have HIV-discordant condomless receptive intercourse. Young MSM also were more likely to have "any" sexually transmitted infection and gonorrhea. Among HIV-positive MSM, young MSM were less likely to be virally suppressed, use antiretroviral therapy, and be aware of their infection. Moreover, young MSM were more likely than older MSM to experience depression, polysubstance use, low income, decreased health care access, and early ages of sexual expression. These factors likely converge to exacerbate age-associated HIV incidence disparities among MSM.

HIV Testing in Men who have Sex with Men: A Follow-up Review of the Qualitative Literature since 2010

The landscape of HIV testing has changed significantly in recent years following the rise in importance of the 'treatment as prevention' strategy and advancements in new HIV testing and prevention technologies. This review provides a synthesis of qualitative research findings published since 2010 on preferences and practices of men who have sex with men (MSM) surrounding HIV testing in high-income settings. MSM are one of the hardest groups to reach with standard or conventional HIV testing approaches. To develop innovative testing strategies for this particular group, a good understanding of their concerns, barriers and facilitators of accessing HIV testing is needed. This updated review provides valuable information for improving existing programs and designing new testing services for MSM.

Social networks and social support among ball-attending African American men who have sex with men and transgender women are associated with HIV-related outcomes

The House Ball Community (HBC) is an understudied network of African American men who have sex with men and transgender women, who join family-like houses that compete in elaborate balls in cities across the United States. From 2011 to 2012, we surveyed 274 recent attendees of balls in the San Francisco Bay Area, focusing on social networks, social support, and HIV-related behaviours. Participants with a high percentage of alters who were supportive of HIV testing were significantly more likely to have tested in the past six months (p = .02), and less likely to have engaged in unprotected anal intercourse (UAI) in the past three months (p = .003). Multivariate regression analyses of social network characteristics, and social support, revealed that testing in the past six months was significantly associated with social support for safer sex, instrumental social support, and age. Similarly, UAI in the past three months was significantly associated with social support for safer sex, homophily based on sexual identity and HIV status. HIV-related social support provided through the HBC networks was correlated with recent HIV testing and reduced UAI. Approaches utilising networks within alternative kinship systems, may increase HIV-related social support and improve HIV-related outcomes.

HIV Testing Behavior and Social Network Characteristics and Functions Among Young Men Who have Sex with Men (YMSM) in Metropolitan Detroit

HIV testing promotion is a critical HIV prevention strategy, especially among at-risk groups such as young men who have sex with men (YMSM). Based on a web survey of 194 YMSM (18-24), we examine the association of social network characteristics and functions, and of individual-level characteristics, with three HIV testing behaviors (ever, repeat, and recent testing). Network homophily was associated with recent testing in multivariable models. The network function of information acquisition was associated with ever testing and repeat testing. Perceived stigma regarding HIV-related help-seeking was negatively related to recent testing. Individual characteristics were associated with testing outcomes in all models; age, perceived behavioral control, and positive attitudes had the greatest influence. Individual characteristics had a stronger association with ever testing and repeat testing than network characteristics and functions; however, this relationship was reversed for recent testing. Findings support the value of multi-level and network-focused interventions for promoting HIV testing among YMSM.

Racial/ethnic disparities in delayed HIV diagnosis among men who have sex with men, Florida, 2000-2014

Only about 85% of men who have sex with men (MSM) with human immunodeficiency virus (HIV) have been tested for and diagnosed with HIV. Racial/ethnic disparities in HIV risk and HIV care outcomes exist within MSM. We examined racial/ethnic disparities in delayed HIV diagnosis among MSM. Males aged ≥13 reported to the Florida Enhanced HIV/AIDS Reporting System 2000-2014 with a reported HIV transmission mode of MSM were analyzed. We defined delayed HIV diagnosis as an AIDS diagnosis within three months of the HIV diagnosis. Multilevel logistic regressions were used to estimate adjusted odds ratios (aOR). Of 39,301 MSM, 27% were diagnosed late. After controlling for individual factors, neighborhood socioeconomic status, and rural-urban residence, non-Latino Black MSM had higher odds of delayed diagnosis compared with non-Latino White MSM (aOR 1.15, 95% confidence interval [CI] 1.08-1.23). Foreign birth compared with US birth was a risk factor for Black MSM (aOR 1.27, 95% CI 1.12-1.44), but a protective factor for White MSM (aOR 0.77, 95% CI 0.68-0.87). Rural residence was a risk for Black MSM (aOR 1.79, 95% CI 1.36-2.35) and Latino MSM (aOR 1.87, 95% CI 1.24-2.84), but not for White MSM (aOR 1.26, 95% CI 0.99-1.60). HIV testing barriers particularly affect non-Latino Black MSM. Social and/or structural barriers to testing in rural communities may be significantly contributing to delayed HIV diagnosis among minority MSM.