Experiences with health care services and HIV testing after sexual assault in cisgender gay, bisexual and other men who have sex with men and transgender people

OBJECTIVES

This qualitative sub-study aimed to explore how cisgender gay, bisexual, and other men who have sex with men (cis-GBMSM) and transgender people who reported non-consensual sex (NCS) accessed health care services, what barriers they faced, and how this experience influenced subsequent HIV testing.

METHODS

SELPHI is an online randomized controlled trial evaluating both acceptability and efficiency of HIV-self testing among cis-GBMSM and transgender people. Semi-structured interviews were conducted, audio-recorded, transcribed, and analysed through a framework analysis, as a qualitative sub-study. We identified narratives of NCS from interviews and investigated experiences of cis-GBMSM and transgender people accessing health care services following sexual assault.

RESULTS

Of 95 participants, 15 (16%) spontaneously reported NCS. Participants reported a broad range of NCS, including partner's coercive behaviours, non-consensual removal of condoms, and rapes. All feared HIV transmission, leading them to test for HIV, underlining a marked lack of awareness of post-exposure prophylaxis (PEP). Most had negative experiences in communicating with reception staff in sexual health clinics following these incidents. A lack of confidentiality and empathy was described in these situations of psychological distress. Clinic visits were primarily focused on testing for HIV and sexually transmitted infection, and generally no specific psychological support was offered. Getting a negative HIV result was a key step in regaining control for people who experienced NCS.

CONCLUSIONS

Sexual health care providers should take care to more fully address the issue of NCS with cis-GBMSM and transgender people when it arises. Recognizing and managing the emotional impact of NCS on affected patients would prevent negative experiences and increase confidence in care.

Determinants of HIV Testing Among Migrant Men Who Have Sex With Men from Sub-Saharan Africa and Other Regions Residing in 10 European Countries

Migrant men who have sex with men (mMSM) from sub-Saharan Africa (SSA) and other regions outside Europe are highly vulnerable to HIV. However, research on the determinants of HIV testing among mMSM from SSA, and how these differ across the categories of mMSM living in Europe, is limited. Using data from the European MSM Internet Survey (EMIS-2017), we assessed HIV testing prevalence and recency in mMSM from SSA and other mMSM residing in ten European countries, as well as the determinants of HIV testing across different mMSM categories with logistic regression analyses. Ever-testing for HIV was slightly higher in mMSM from SSA (83%) compared to other mMSM categories (75-80%), except for mMSM from Latin America and Caribbean region (84%). Overall, 20% of mMSM had never tested. In multivariable analysis, higher age (adjusted odds ratio [AOR] 1.05, 95% confidence interval [CI] 1.01-1.10), higher HIV knowledge (AOR 1.45, 95%-CI 1.11-1.90), and residence in smaller settlements (AOR 0.45, 95%-CI 0.21-0.96) were significantly associated with ever testing for HIV in mMSM from SSA. Comparing mMSM from SSA to mMSM from other regions, we found varying significant similarities (higher age, residence in smaller settlements and HIV knowledge) and differences (lower educational attainment, not identifying as gay, being a student, and limited disclosure of homosexual attraction) in the determinants of ever-testing for HIV. Community-specific interventions addressing identified sociodemographic and behavioral determinants to increase HIV testing uptake in the different mMSM categories and better data for further research are warranted.

Understanding experiences of potential harm among MSM (cis and trans) using HIV self-testing in the SELPHI randomised controlled trial in England and Wales: a mixed-methods study

BACKGROUND

The potential of HIV self-testing (HIVST) to cause harm is a concern hindering widespread implementation. The aim of this paper is to understand the relationship between HIVST and harm in SELPHI (An HIV Self-testing Public Health Intervention), the largest randomised trial of HIVST in a high-income country to date.

METHODS

10 111 cis and trans men who have sex with men (MSM) recruited online (geolocation social/sexual networking apps, social media), aged 16+, reporting previous anal intercourse and resident in England or Wales were first randomised 60/40 to baseline HIVST (baseline testing, BT) or not (no baseline testing, nBT) (randomisation A). BT participants reporting negative baseline test, sexual risk at 3 months and interest in further HIVST were randomised to three-monthly HIVST (repeat testing, RT) or not (no repeat testing, nRT) (randomisation B). All received an exit survey collecting data on harms (to relationships, well-being, false results or being pressured/persuaded to test). Nine participants reporting harm were interviewed in-depth about their experiences in an exploratory substudy; qualitative data were analysed narratively.

RESULTS

Baseline: predominantly cis MSM, 90% white, 88% gay, 47% university educated and 7% current/former pre-exposure prophylaxis (PrEP) users. Final survey response rate was: nBT=26% (1056/4062), BT=45% (1674/3741), nRT=41% (471/1147), RT=50% (581/1161).Harms were rare and reported by 4% (n=138/3691) in exit surveys, with an additional two false positive results captured in other study surveys. 1% reported harm to relationships and to well-being in BT, nRT and RT combined. In all arms combined, being pressured or persuaded to test was reported by 1% (n=54/3678) and false positive results in 0.7% (n=34/4665).Qualitative analysis revealed harms arose from the kit itself (technological harms), the intervention (intervention harms) or from the social context of the participant (socially emergent harms). Intervention and socially emergent harms did not reduce HIVST acceptability, whereas technological harms did.

DISCUSSION

HIVST harms were rare but strategies to link individuals experiencing harms with psychosocial support should be considered for HIVST scale-up.

TRIAL REGISTRATION NUMBER

ISRCTN20312003.

Recreational and sexualised drug use among gay, bisexual, and other men who have sex with men (gbMSM) in Ireland-Findings from the European MSM internet survey (EMIS) 2017

BACKGROUND

Gay, bisexual, and other men who have sex with men (gbMSM) report a higher prevalence of drug use in comparison to the general male population. However, in Ireland, there is a paucity of literature regarding the prevalence of drug use and its determinants among gbMSM.

AIMS/OBJECTIVES

To quantify the prevalence of (i) recreational drug use (RDU) and (ii) sexualised drug use (SDU) among gbMSM in Ireland, and to identify the factors associated with these drug use practices.

METHODS

The European MSM Internet Survey (EMIS) 2017 was an online, anonymous, internationally-promoted questionnaire. Two binary outcomes were included in our analyses: (1) RDU and (2) SDU in the previous year. Multivariable-adjusted logistic regression explored factors associated with these outcomes, and all independent covariates were adjusted for one another.

RESULTS

Among gbMSM without HIV (n = 1,898), 40.9% and 13.1% engaged in RDU and SDU in the previous year, respectively. Among diagnosed-positive gbMSM (n = 141), the past-year respective prevalence estimates were 51.8% and 26.2%. Increased odds of RDU were observed among gbMSM who were younger (vs. 40+ years) (18-24 years; AOR 2.96, 95% CI 2.05-4.28, 25-39 years; AOR 1.66, 95% CI 1.27-2.16), lived in Dublin (vs. elsewhere) (AOR 1.47, 95% CI 1.17-1.83), and engaged in condomless anal intercourse (CAI) in the previous year (vs. none) (1-2 partners; AOR 1.79, 95% CI 1.34-2.38, 6+ partners; AOR 1.79, 95% CI 1.18-2.71). Greater odds of SDU were identified among those who lived in Dublin (vs. elsewhere) (AOR 1.50, 95% CI 1.07-2.10), and engaged in CAI (vs. none) (1-2 partners; AOR 3.16, 95% CI 2.05-4.88, 3-5 partners; AOR 2.50, 95% CI 1.47-4.26, and 6+ partners; AOR 3.79, 95% CI 2.23-6.43).

CONCLUSION

GbMSM report a high prevalence of drug use in Ireland. Targeted interventions, including harm reduction campaigns, may be needed to support healthier drug use choices among this community.

Free HIV self-test for identification and linkage to care of previously undetected HIV infection in men who have sex with men in England and Wales (SELPHI): an open-label, internet-based, randomised controlled trial

BACKGROUND

High levels of HIV testing in men who have sex with men remain key to reducing the incidence of HIV. We aimed to assess whether the offer of a single, free HIV self-testing kit led to increased HIV diagnoses with linkage to care.

METHODS

SELPHI was an internet-based, open-label, randomised controlled trial that recruited participants via sexual and social networking sites. Eligibility criteria included being a man or trans woman (although trans women are reported separately); being resident in England or Wales, UK; being aged 16 years or older; having had anal intercourse with a man; not having a positive HIV diagnosis; and being willing to provide name, email address, date of birth, and consent to link to national HIV databases. Participants were randomly allocated (3:2) by computer-generated number sequence to receive a free HIV self-test kit (BT group) or to not receive this free kit (nBT group). Online surveys collected data at baseline, 2 weeks after enrolment (BT group only), 3 months after enrolment, and at the end of the study. The primary outcome was confirmed (linked to care) new HIV diagnosis within 3 months of enrolment, analysed by intention to treat. Those assessing the primary outcome were masked to allocation. This study is registered with the ISRCTN Clinical Trials Register, number ISRCTN20312003.

FINDINGS

10 111 participants (6049 in BT group and 4062 in nBT group) enrolled between Feb 16, 2017, and March 1, 2018. The median age of participants was 33 years (IQR 26-44 years); 9000 (89%) participants were White; 8118 (80%) participants were born in the UK; 81 (1%) participants were transgender men; 4706 (47%) participants were university educated; 1537 (15%) participants had never been tested for HIV; and 389 (4%) participants were taking pre-exposure prophylaxis. At enrolment, 7282 (72%) participants reported condomless anal sex with at least one male partner in the previous 3 months. In the BT group, of the 4511 participants for whom HIV testing information was available, 4263 (95%) reported having used the free HIV self-test kit within 3 months.Within 3 months of enrolment there were 19 confirmed new HIV diagnoses (0·31%) in 6049 participants in the BT group and 15 (0·37%) of 4062 in the nBT group (p=0·64).

INTERPRETATION

The offer of a single, free HIV self-test did not lead to increased rates of new HIV diagnoses, which could reflect decreasing HIV incidence rates in the UK. Nonetheless, the offer of a free HIV self-testing kit resulted in high HIV testing rates, indicating that self-testing is an attractive testing option for a large group of men who have sex with men.

FUNDING

UK National Institute for Health and Care Research.

Structural stigma and sexual minority men’s depression and suicidality: A multi-level examination of mechanisms and mobility across 48 countries

Background

Sexual minority men are at greater risk of depression and suicidality than heterosexuals. Stigma, the most frequently hypothesized risk factor for this disparity, operates across socioecological levels-structural (e.g., laws), interpersonal (e.g., discrimination), and individual (e.g., self-stigma). However, there is limited data on whether changes in structural stigma, such as when a stigmatized person moves to a lower stigma context, affect mental health, and on the mechanisms underlying this association

Methods

The current study uses data from the 2017/18 European Men-who-have-sex-with-men Internet Survey (n = 123,428), which assessed mental health and psychosocial mediators. We linked these data to an objective indicator of structural stigma related to sexual orientation in respondents’ countries of origin (N = 178) and receiving (N = 48) countries

Results

Among respondents who moved from higher-to-lower structural stigma countries (n = 11,831), longer exposure to the lower structural stigma environments of their receiving countries was associated with a significantly: 1) lower risk of depression and suicidality; 2) lower odds of concealment, internalized homonegativity, and social isolation; and 3) smaller indirect effect of structural stigma on mental health through these mediators.

Conclusions

This study provides evidence that structural stigma is associated with the mental health of sexual minority men, both through proximal experiences and as a function of length of exposure to structurally diverse contexts, at least for those who move higher-to-lower structural stigma contexts. Findings suggest the importance of routinely assessing life-course structural influences on mental health and deploying interventions to address those influences.

Sexual happiness and satisfaction with sexual safety among German trans men who have sex with men: results from EMIS-2017

INTRODUCTION

The population of men-who-have-sex-with-men (MSM) includes people who are on the masculine spectrum but were assigned female at birth (AFAB), that is trans MSM. This study aims to identify current circumstances regarding sexual happiness and safety among German trans MSM. To date, there is no health information about trans MSM in Germany, limiting the ability of MSM sexual health programmes to meet their needs.

METHODS

Data were used from the European MSM Internet Survey (EMIS-2017), where people identifying as men and/or trans men were recruited through dating apps for MSM, community websites and social media to participate in an online survey. We analysed parameters on sexual happiness and satisfaction with sexual safety among Germany-based trans MSM and compared those to outcomes of MSM assigned male at birth (cis MSM) living in Germany using descriptive methods and logistic regression models adjusting for age.

RESULTS

In total, 23,001 participants from Germany were included, of which 122 (0.5%) indicated to be AFAB (i.e. trans MSM). Trans MSM were markedly younger than cis participants (median age: 28.5 vs. 39 years). Trans MSM more often reported being unhappy with their current sex life (adjusted odds ratio [aOR] = 1.82, 95% CI 1.24-2.67), had higher odds of disagreeing with the statements "the sex I have is always as safe as I want" ([aOR] = 1.82, 95% CI 1.24-2.67) and "I find it easy to say no to sex that I don't want" ([aOR] = 1.80, 95% CI 1.18-2.77). Trans MSM were more likely to not be living comfortably financially ([aOR] = 2.43, 95% CI 1.60-3.67) and to be living with severe anxiety and/or depression ([aOR] = 3.90, 95% CI 2.22-6.83). Trans MSM were less likely to have ever tested for HIV ([aOR] = 0.63, 95% CI 0.43-0.93).

CONCLUSIONS

Sexual happiness, control of sexual boundaries, satisfaction with sexual safety, financial security, mental wellbeing and HIV testing were all lower in German trans MSM compared with cis MSM. Tailored sexual health interventions, contextualized with regard to needs and vulnerabilities, could address this inequality.

Experiences of and attitudes towards HIV testing for Asian, Black and Latin American men who have sex with men (MSM) in the SELPHI (HIV Self-Testing Public Health Intervention) randomized controlled trial in England and Wales: implications for HIV self-testing

Background

HIV self-testing (HIVST) could play an important role in improving access to testing and therefore reducing inequalities related to late diagnosis of HIV, while also improving access to HIV prevention interventions such as HIV pre-exposure prophylaxis. This study sought to understand the potential role of HIVST by exploring the experiences of Asian, Black and Latin American men who have sex with men (MSM) accessing the gay scene and the circulation of HIV testing norms; experiences of accessing HIV testing services; HIVST acceptability and preferences for intervention adaptations.

Methods

Twenty-nine qualitative interviews were conducted with Asian, Black and Latin American MSM who had participated in SELPHI, an HIVST randomised controlled trial. Topics included HIV testing history, HIV testing patterns, experiences of accessing sexual health services, mental health, engagement with HIVST and SELPHI, and experiences of the gay scene. Interviews were audio recorded, transcribed and then analysed using a thematic framework.

Results

The gay scene was identified as an important site for learning about HIV and being exposed to norms reinforcing the importance of protective behaviours. However, experiences of discomfort due to perceptions of ‘whiteness’ on the scene or experiences of racism may hinder the protective function the scene could play in developing norms influencing HIV testing behaviour. Discomfort in clinic waiting rooms was identified as a substantial barrier to accessing clinical services and many interviewees expressed preferences regarding the personal characteristics of healthcare providers. HIVST was found to be acceptable and some interviewees suggested potential adaptations of the HIVST offer, such as packaging HIVST with at home sexually transmitted infections testing options.

Conclusions

HIVST responds to some service access barriers experienced by Asian, Black and Latin American MSM. The decoupling of HIV testing and clinic attendance may be particularly valuable for MSM of minority ethnic backgrounds who are likely to experience anxiety and discomfort in clinic waiting rooms more acutely than White MSM due to concerns around implied disclosure. This suggests that HIVST may have the potential to increase testing uptake and frequency, particularly for those with complex relationships with clinical services.

Trial Registration

SELPHI was prospectively registered with the ISRCTN (ref: ISRCTN 20312003).

eHealth Interventions to Address HIV and Other Sexually Transmitted Infections, Sexual Risk Behavior, Substance Use, and Mental Ill-health in Men Who Have Sex With Men: Systematic Review and Meta-analysis

Background

Men who have sex with men experience disproportionately high levels of HIV and other sexually transmitted infections (STIs), sexual risk behavior, substance use, and mental ill-health. These experiences are interrelated, and these interrelations are potentiated by structural conditions of discrimination, stigma, and unequal access to appropriate health services, and they magnify each other and have intersecting causal pathways, worsening both risk for each condition and risk for the negative sequelae of each condition. eHealth interventions could address these issues simultaneously and thus have wide-ranging and greater effects than would be for any 1 outcome alone.

Objective

We systematically reviewed the evidence for the effectiveness of eHealth interventions in addressing these outcomes separately or together.

Methods

We searched 19 databases for randomized trials of interactive or noninteractive eHealth interventions delivered via mobile phone apps, internet, or other electronic media to populations consisting entirely or principally of men who have sex with men to prevent HIV, STIs, sexual risk behavior, alcohol and drug use, or common mental illnesses. We extracted data and appraised each study, estimated meta-analyses where possible by using random effects and robust variance estimation, and assessed the certainty of our findings (closeness of the estimated effect to the true effect) by using GRADE (Grading of Recommendations, Assessment, Development and Evaluations).

Results

We included 14 trials, of which 13 included active versus control comparisons; none reported mental health outcomes, and all drew from 12 months or less of follow-up postintervention. Findings for STIs drew on low numbers of studies and did not suggest consistent short-term (<3 months postintervention; d=0.17, 95% CI –0.18 to 0.52; I²=0%; 2 studies) or midterm (3-12 months postintervention, no meta-analysis, 1 study) evidence of effectiveness. Eight studies considering sexual risk behavior outcomes suggested a short-term, nonsignificant reduction (d=–0.14, 95% CI –0.30 to 0.03) with very low certainty, but 6 studies reporting midterm follow-ups suggested a significant impact on reducing sexual risk behavior (d=–0.12, 95% CI –0.19 to –0.05) with low certainty. Meta-analyses could not be undertaken for alcohol and drug use (2 heterogeneous studies) or for HIV infections (1 study for each of short-term or midterm follow-up), and alcohol outcomes alone were not captured in the included studies. Certainty was graded as low to very low for most outcomes, including all meta-analyses.

Conclusions

To create a comprehensive eHealth intervention that targets multiple outcomes, intervention evaluations should seek to generalize both mechanisms and components that are successfully used to achieve change in 1 outcome over multiple outcomes. However, additional evaluations of interventions seeking to address outcomes other than sexual risk behavior are needed before development and evaluation of a joined-up intervention.

What is the empirical basis for converting banded ordinal data on numbers of sex partners among MSM into a continuous scale level variable? A secondary analysis of 13 surveys across 17 countries

Background

To provide empirically based guidance for substituting partner number categories in large MSM surveys with mean numbers of sexual and condomless anal intercourse (CAI) partners in a secondary analysis of survey data.

Methods

We collated data on numbers of sexual and CAI partners reported in a continuous scale (write-in number) in thirteen MSM surveys on sexual health and behaviour across 17 countries. Pooled descriptive statistics for the number of sexual and CAI partners during the last twelve (N = 55,180) and 6 months (N = 31,759) were calculated for two sets of categories commonly used in reporting numbers of sexual partners in sexual behaviour surveys.

Results

The pooled mean number of partners in the previous 12 months for the total sample was 15.8 partners (SD = 36.6), while the median number of partners was 5 (IQR = 2–15). Means for number of partners in the previous 12 months for the first set of categories were: 16.4 for 11–20 partners (SD = 3.3); 27.8 for 21–30 (SD = 2.8); 38.6 for 31–40 (SD = 2.4); 49.6 for 41–50 (SD = 1.5); and 128.2 for ‘more than 50’ (SD = 98.1). Alternative upper cut-offs: 43.4 for ‘more than 10’ (SD = 57.7); 65.3 for ‘more than 20’ (SD = 70.3). Self-reported partner numbers for both time frames consistently exceeded 200 or 300. While there was substantial variation of overall means across surveys, the means for all chosen categories were very similar. Partner numbers above nine mainly clustered at multiples of tens, regardless of the selected time frame. The overall means for CAI partners were lower than those for sexual partners; however, such difference was completely absent from all categories beyond ten sexual and CAI partners.

Conclusions

Clustering of reported partner numbers confirm common MSM sexual behaviour surveys’ questionnaire piloting feedback indicating that responses to numbers of sexual partners beyond 10 are best guesses rather than precise counts, but large partner numbers above typical upper cut-offs are common.

E-health interventions targeting STIs, sexual risk, substance use and mental health among men who have sex with men: four systematic reviews

Background

Human immunodeficiency virus/sexually transmitted infections, sexual risk, substance (alcohol and other legal and illegal drugs) use and mental ill health constitute a ‘syndemic’ of mutually reinforcing epidemics among men who have sex with men. Electronic health (e-health) interventions addressing these epidemics among men who have sex with men might have multiplicative effects. To our knowledge, no systematic review has examined the effectiveness of such interventions on these epidemics among men who have sex with men.

Objective

The objective was to synthesise evidence addressing the following: (1) What approaches and theories of change do existing e-health interventions employ to prevent human immunodeficiency virus/sexually transmitted infections, sexual risk, alcohol/drug use or mental ill health among men who have sex with men? (2) What factors influence implementation? (3) What are the effects of such interventions on the aforementioned epidemics? (4) Are such interventions cost-effective?

Data sources

A total of 24 information sources were searched initially (October–November 2018) [the following sources were searched: ProQuest Applied Social Sciences Index and Abstracts; Campbell Library; EBSCO Cumulative Index to Nursing and Allied Health Literature Plus, Wiley Online Library The Cochrane Library; Centre for Reviews and Dissemination databases (the Database of Abstracts of Reviews of Effects and the NHS Economic Evaluation Database); the Health Technology Assessment database; Evidence for Policy and Practice Information and Co-ordinating Centre (EPPI-Centre) database of health promotion research (Bibliomap); ProQuest Dissertations & Theses Global; OvidSP EconLit; OvidSP EMBASE; OvidSP Global Health; OvidSP Health Management Information Consortium; ProQuest International Bibliography of the Social Sciences; Ovid MEDLINE ALL; OvidSP PsycINFO; Web of Science Science Citation Index Expanded; Elsevier Scopus; OvidSP Social Policy & Practice; Web of Science Social Sciences Citation Index Expanded; ProQuest Sociological Abstracts; ClinicalTrials.gov; World Health Organization International Clinical Trials Registry Platform; EPPI-Centre Trials Register of Promoting Health Interventions; and the OpenGrey database], and an updated search of 19 of these was conducted in April 2020. Reference lists of included reports were searched and experts were contacted.

Review methods

Eligible reports presented theories of change and/or process, outcome and/or economic evaluations of e-health interventions offering ongoing support to men who have sex with men to prevent human immunodeficiency virus/sexually transmitted infections, sexual risk behaviour, alcohol/drug use and/or common mental illnesses. References were screened by title/abstract, then by full text. Data extraction and quality assessments used existing tools. Theory and process reports were synthesised using qualitative methods. Outcome and economic data were synthesised narratively; outcome data were meta-analysed.

Results

Original searches retrieved 27 eligible reports. Updated searches retrieved 10 eligible reports. Thirty-seven reports on 28 studies of 23 interventions were included: 33 on theories of change, 12 on process evaluations, 16 on outcome evaluations and one on an economic evaluation. Research question 1: five intervention types were identified – ‘online modular’, ‘computer games’ and ‘non-interactive’ time-limited/modular interventions, and open-ended interventions with ‘content organised by assessment’ and ‘general content’. Three broad types of intervention theories of change were identified, focusing on ‘cognitive/skills’, ‘self-monitoring’ and ‘cognitive therapy’. Research question 2: individual tailoring based on participant characteristics was particularly acceptable, and participants valued intervention content reflecting their experiences. Research question 3: little evidence was available of effects on human immunodeficiency virus or sexually transmitted infections. The analysis did not suggest that interventions were effective in reducing instances of human immunodeficiency virus or sexually transmitted infections. The overall meta-analysis for sexually transmitted infections reported a small non-significant increase in sexually transmitted infections in the intervention group, compared with the control group. Meta-analyses found a significant impact on sexual risk behaviour. The findings for drug use could not be meta-analysed because of study heterogeneity. Studies addressing this outcome did not present consistent evidence of effectiveness. Trials did not report effects on alcohol use or mental health. Research question 4: evidence on cost-effectiveness was limited.

Limitations

The quality of the eligible reports was variable and the economic synthesis was limited to one eligible study.

Conclusions

There is commonality in intervention theories of change and factors affecting receipt of e-health interventions. Evidence on effectiveness is limited.

Future work

Future trials should assess the impact of interventions on multiple syndemic factors, among them sexual risk, substance use and mental health; incorporate sufficient follow-up and sample sizes to detect the impact on human immunodeficiency virus/sexually transmitted infections; and incorporate rigorous process and economic evaluations.

Study registration

This study is registered as PROSPERO CRD42018110317.

Funding

This project was funded by the National Institute for Health Research (NIHR) Public Health Research programme and will be published in full in Public Health Research; Vol. 10, No. 4. See the NIHR Journals Library website for further project information.

Disparities in HIV/STI burden and care coverage among men and transgender persons who have sex with men in Nairobi, Kenya: a cross-sectional study

Objectives

The study aimed to estimate the prevalence of, and associations, with HIV and metrics of HIV care engagement in a representative population of gay, bisexual and other men who have sex with men (GBMSM) and transgender persons (TP) who have sex with men (GBMSM/TP)

Setting

Urban districts of Nairobi, Kenya.

Design

Cross-sectional.

Participants

608 eligible participants were identified through respondent-driven sampling over 19 waves of recruitment arising from ten seeds between May and December 2017. Inclusion criteria were: age >18 years; Nairobi residence; male sex assignment at birth or current identification as male, and recent consensual sex with male partners. Exclusion criteria were: missing or invalid recruitment coupon; repeat registration; intoxication at study visit.

Primary and secondary outcome measures

HIV status measured using Determine Alere HIV 1/2 and First Response HIV 1–2.0 and GeneXpert HIV-1 Qual. Self-reported metrics of HIV status awareness, antiretroviral use and objective quantification of viral suppression using GeneXpert HIV-1 VL.

Results

26.4% (286/618) were HIV positive of whom 76.6% were status aware, 65.3% were on antiretroviral therapy (ART), and 47.4% were virally suppressed (<50 copies/mL). Participants 18–22 years were less likely to be status aware, be receiving ART or to have achieved viral suppression. Mean log viral load was 3.14 log higher in 18–22 years compared with older participants. Bacterial sexually transmitted infections were common at both urethral and rectal sites and most infections were asymptomatic by self-report (rectal 82.2%, urethral 82.3%).

Conclusions

Engagement in the HIV diagnosis and care cascade among GBMSM/TP in Nairobi is markedly better than in most sub-Saharan African countries, yet falls short of achievements for the general population in Kenya and for GBMSM in high income settings. Young GBMSM/TP are least well served by the current configuration of adult key population services, and programmes should identify and address the sexual, social and developmental needs of adolescent and young key populations.

Structural stigma and sexual minority men's depression and suicidality: A multilevel examination of mechanisms and mobility across 48 countries

Sexual minority men are at greater risk of depression and suicidality than heterosexuals. Stigma, the most frequently hypothesized risk factor for this disparity, operates across socioecological levels-structural (e.g., laws), interpersonal (e.g., discrimination), and individual (e.g., self-stigma). Although the literature on stigma and mental health has focused on interpersonal and individual forms of stigma, emerging research has shown that structural stigma is also associated with adverse mental health outcomes. However, there is limited data on whether changes in structural stigma, such as when a stigmatized person moves to a lower stigma context, affect mental health, and on the mechanisms underlying this association. To address these questions, we use data from the 2017/18 European Men-who-have-sex-with-men Internet Survey (n = 123,428), which assessed mental health (i.e., Patient Health Questionnaire) and psychosocial mediators (i.e., sexual orientation concealment, internalized homonegativity, and social isolation). We linked these data to an objective indicator of structural stigma related to sexual orientation-including 15 laws and policies as well as aggregated social attitudes-in respondents' countries of origin (N = 178) and receiving countries (N = 48). Among respondents who still live in their country of birth (N = 106,883), structural stigma was related to depression and suicidality via internalized homonegativity and social isolation. Among respondents who moved from higher-to-lower structural stigma countries (n = 11,831), longer exposure to the lower structural stigma environments of their receiving countries was associated with a significantly: 1) lower risk of depression and suicidality; 2) lower odds of concealment, internalized homonegativity, and social isolation; and 3) smaller indirect effect of structural stigma on mental health through these mediators. This study provides additional evidence that stigma is a sociocultural determinant of mental health. (PsycInfo Database Record (c) 2021 APA, all rights reserved).

Potential alcohol use disorder (AUD) among men who have sex with men (MSM) in Ireland

Background

Alcohol consumption is a major public health concern in Ireland. Alcohol use disorder (AUD) appears to disproportionately affect men who have sex with men (MSM). However, little is known about the prevalence of AUD in this group in Ireland specifically, and the characteristics of MSM who may struggle with this.

Methods

The European MSM Internet Survey 2017 was an online, self-completed, anonymous questionnaire among MSM residing in Ireland. Standardised questions were used to explore a variety of topics. The validated CAGE-4 questionnaire was used to screen for potential AUD, defined as a CAGE-4 score of ≥ 2 out of 4. Multivariable-adjusted logistic regression analysis was used to identify factors associated with potential AUD.

Results

In total, 1,793 MSM met inclusion criteria, and 31% screened positive for AUD. We observed higher odds of possible AUD among MSM who were bisexual (vs. gay/homosexual) (aOR 1.48 95%CI 1.01-2.18), native to Ireland (vs. non-native) (aOR 1.49 95%CI 1.12-1.96), unemployed (vs. employed) (aOR 1.80 95%CI 1.02-3.16), had used illicit drugs in the previous year (vs. none) (cannabis only, aOR 1.74 95%CI 1.14-2.63) (other illicit drugs, aOR 2.28 95%CI 1.67-3.09), reported anxiety/depression (vs. none) (aOR 1.73 95%CI 1.12-2.66), and MSM who experienced homophobic abuse (vs. never) (aOR 1.55 95%CI 1.09-2.22). Student MSM were less likely to screen positive for AUD (vs. employed) (aOR 0.65 95%CI 0.46-0.93).

Conclusions

The prevalence of AUD appears to be higher in the MSM population compared to the general male population in Ireland. Targeted interventions may be warranted to reduce the burden of AUD among MSM.

Key messages

The prevalence of AUD appears to be higher in the MSM population compared to the general male population in Ireland. Targeted interventions may be warranted to reduce the burden of AUD among MSM.

Interventions to address loneliness and social isolation in young people: A systematic review of the evidence on acceptability and effectiveness

INTRODUCTION

Loneliness is prevalent and associated with negative health outcomes in young people. Our understanding of how it can be best addressed is limited. This systematic review aims to assess the acceptability and effectiveness of interventions to reduce and prevent loneliness and social isolation in young people.

METHODS

Six bibliographic databases were searched; references of included studies were screened for relevant literature. A pre-defined framework was used for data extraction. Quality appraisal was performed using the Mixed Method Appraisal Tool. Data were synthesised narratively.

RESULTS

9,358 unique references were identified; 28 publications from 16 interventions met the inclusion criteria. The majority of interventions were high intensity, individual or small group interventions, often targeted at specific 'at risk' populations. While 14 interventions were associated with a statistically significant reduction in loneliness or social isolation, the heterogeneous measures of loneliness, small sample sizes, short periods of follow-up and high attrition rates limit evidence on effectiveness. Interventions implemented in more general populations of young people appeared more acceptable than those in specific 'at risk' populations.

CONCLUSION

High intensity interventions are unlikely to be feasible at a population level. Further work is required to develop and evaluate theoretically-informed loneliness interventions for young people that reach wider audiences.

Experiences and challenges in sexual health service access among men who have sex with men in Kenya

Men who have sex with men (MSM) in Kenya bear a heavy burden of HIV/STIs and are a priority population in the national HIV/AIDS response, yet remain criminalised and stigmatised within society. HIV pre-exposure prophylaxis (PrEP) offers an opportunity to significantly impact the HIV epidemic, as does the concept of U = U, whereby those who are living with HIV and on treatment are uninfectious when their viral load has been suppressed so as to be undetectable. However, the value of such innovations will not be realised without sufficient understanding of, and respect for, the sexual health service provision needs of MSM. This paper describes findings from 30 in-depth interviews with MSM living in Nairobi that explored engagement with sexual health service providers, barriers to access and perceived opportunities to improve service design and delivery. Findings indicate concern relating to the professionalism of some staff working within public hospitals as well as feelings that many sexual health services were not considered safe spaces for the discussion of MSM-specific sexual behaviour. Diverse views were expressed relating to comfort in public, community and private sexual health services as well as how these are and should be organised.

'Stay at home …': exploring the impact of the COVID-19 public health response on sexual behaviour and health service use among men who have sex with men: findings from a large online survey in the UK

OBJECTIVES

The first UK national lockdown began on 23 March 2020, in response to the COVID-19 pandemic, and led to reduced STI/HIV service provision in the UK. We investigated sexual behaviour, use and need for sexual healthcare during the pandemic.

METHODS

Participants (N=2018), including men (cis/transgender), transwomen and gender-diverse people reporting sex with another man (cis/transgender) or non-binary person assigned male at birth, completed an online cross-sectional survey (23 June 2020-14 July 2020), in response to adverts on social media and dating apps.Sexual behaviour, service use and unmet need for STI testing (any new male and/or multiple condomless anal sex (CAS) partners without STI testing) in the 3 months since lockdown began were examined and compared using multivariable analyses with an equivalent 3-month period in a 2017 survey (N=1918), conducted by the same research team.

RESULTS

Since lockdown began, 36.7% of participants reported one or more new partners, 17.3% reported CAS with multiple partners, 29.7% HIV testing (among 1815 of unknown/negative status), 24.9% STI testing and 15.4% using pre-exposure prophylaxis (PrEP).Since lockdown began, 25.3% of participants had unmet need for STI testing. This was more likely among Asian versus white participants (adjusted OR (aOR)=1.76, (1.14 to 2.72), p=0.01); for participants living in Scotland (aOR=2.02, (1.40 to 2.91), p<0.001) or Northern Ireland (aOR=1.93, (1.02-3.63), p=0.04) versus England; and for those living with HIV (aOR=1.83, (1.32 to 2.53), p<0.001).Compared to 2017, the equivalent 2020 subsample were less likely to report new male partners (46.8% vs 71.1%, p<0.001), multiple CAS partners (20.3% vs 30.8%, p<0.001) and have unmet need for STI testing (32.8% vs 42.5%, p<0.001) in the past 3 months.

CONCLUSIONS

We found potential for ongoing STI/HIV transmission among men who have sex with men during the initial UK lockdown, despite reduced sexual activity, and inequalities in service access. These findings will support public health planning to mitigate health risks during and after the COVID-19 response.

Examining the effects of HIV self-testing compared to standard HIV testing services in the general population: A systematic review and meta-analysis

BACKGROUND

We updated a 2017 systematic review and compared the effects of HIV self-testing (HIVST) to standard HIV testing services to understand effective service delivery models among the general population.

METHODS

We included randomized controlled trials (RCTs) comparing testing outcomes with HIVST to standard testing in the general population and published between January 1, 2006 and June 4, 2019. Random effects meta-analysis was conducted and pooled risk ratios (RRs) were reported. The certainty of evidence was determined using the GRADE methodology.

FINDINGS

We identified 14 eligible RCTs, 13 of which were conducted in sub-Saharan Africa. Support provided to self-testers ranged from no/basic support to one-on-one in-person support. HIVST increased testing uptake overall (RR:2.09; 95% confidence interval: 1.69-2.58; p < 0.0001;13 RCTs; moderate certainty evidence) and by service delivery model including facility-based distribution, HIVST use at facilities, secondary distribution to partners, and community-based distribution. The number of persons diagnosed HIV-positive among those tested (RR:0.81, 0.45-1.47; p = 0.50; 8 RCTs; moderate certainty evidence) and number linked to HIV care/treatment among those diagnosed (RR:0.95, 0.79-1.13; p = 0.52; 6 RCTs; moderate certainty evidence) were similar between HIVST and standard testing. Reported harms/adverse events with HIVST were rare and appeared similar to standard testing (RR:2.52: 0.52-12.13; p = 0.25; 4 RCTs; very low certainty evidence).

INTERPRETATION

HIVST appears to be safe and effective among the general population in sub-Saharan Africa with a range of delivery models. It identified and linked additional people with HIV to care. These findings support the wider availability of HIVST to reach those who may not otherwise access testing.

Accessing and utilising gender-affirming healthcare in England and Wales: trans and non-binary people's accounts of navigating gender identity clinics

BACKGROUND

Transgender, or trans, people experience a number of barriers to accessing gender-affirming healthcare and have a range of barriers and facilitators to primary care and specialist services, commonly citing discrimination and cisgenderism playing a central role in shaping accessibility. The pathway through primary care to specialist services is a particularly precarious time for trans people, and misinformation and poorly applied protocols can have a detrimental impact on wellbeing.

METHOD

We recruited trans participants from an HIV Self-Testing Public Health Intervention (SELPHI) trial to interviews which explored contemporary gender-affirming service experiences, with an aim to examine the path from primary care services through to specialist gender services, in the UK.

RESULTS

A narrative synthesis of vignettes and thematic analysis of in-depth qualitative interviews were conducted with twenty trans individuals. We summarise positive and negative accounts of care under three broad categories: Experiences with primary care physicians, referrals to gender identity clinics (GICs), and experiences at GICs.

CONCLUSIONS

We discuss implications of this research in terms of how to improve best practice for trans people attempting to access gender-affirming healthcare in the UK. Here we highlight the importance of GP's access to knowledge around pathways and protocols and clinical practice which treats trans patients holistically.

Potential alcohol use disorder among MSM in Ireland - Findings from the European MSM internet survey (EMIS 2017)

BACKGROUND

Alcohol consumption is a major public health concern in Ireland. Alcohol use disorder (AUD) disproportionately affects men who have sex with men (MSM). However, little is known about the prevalence of AUD in this group in Ireland specifically, and the characteristics of MSM who may struggle with this.

METHODS

The European MSM Internet Survey 2017 was an online, self-completed, anonymous questionnaire among MSM in Ireland. Standardised questions were used to explore a variety of topics. The validated CAGE-4 questionnaire was used to screen for potential AUD, defined as a CAGE-4 score of ≥2 out of 4. Multivariable-adjusted logistic regression analysis was used to identify factors associated with potential AUD.

RESULTS

In total, 1793 MSM met inclusion criteria. 31 % screened positive for AUD. We observed higher odds of possible AUD among MSM who were bisexual (vs. gay/homosexual) (aOR 1.48 95 %CI 1.01-2.18), native to Ireland (vs. non-native) (aOR 1.49 95 %CI 1.12-1.96), unemployed (vs. employed) (aOR 1.80 95 %CI 1.02-3.16), had used illicit drugs in the previous year (vs. none) (cannabis only, aOR 1.74 95 %CI 1.14-2.63) (other illicit drugs, aOR 2.28 95 %CI 1.67-3.09), reported anxiety/depression (vs. none) (aOR 1.73 95 %CI 1.12-2.66), and MSM who experienced homophobic abuse (vs. never) (aOR 1.55 95 %CI 1.09-2.22). Student MSM were less likely to screen positive for AUD (vs. employed) (aOR 0.65 95 %CI 0.46-0.93).

CONCLUSIONS

The prevalence of AUD appears to be higher in the MSM population compared to the general male population in Ireland. Targeted interventions may be warranted to reduce the burden of AUD among MSM.

The cost-effectiveness of case-finding strategies for achieving hepatitis C elimination among men who have sex with men in the UK

Modelling suggests hepatitis C virus (HCV) elimination is possible among men who have sex with men (MSM), with key screening groups including HIV-diagnosed MSM and MSM using pre-exposure prophylaxis (PrEP). Mathematical modelling was used to determine the cost-effectiveness of HCV case-finding strategies among MSM from the provider perspective, and to determine which interventions could achieve a 90% reduction in HCV incidence over 2015-2030. At baseline, we assumed symptomatic screening in HIV-negative MSM (including PrEP users) and 12-monthly screening among HIV-diagnosed MSM. Improved case-finding strategies included screening alongside HIV testing in HIV-negative MSM not using PrEP (PrEP non-users); 12/6/3-monthly screening in PrEP users; and 6-monthly screening in HIV-diagnosed MSM, with the cost-effectiveness being compared incrementally. Costs (GBP) and quality-adjusted life years (QALYs) were assessed to estimate the mean incremental cost-effectiveness ratio (ICER) with a time horizon to 2050, compared to a willingness-to-pay threshold of £20,000/QALY. From the baseline, the most incrementally cost-effective strategy is to firstly undertake: (1) 12-monthly HCV screening of PrEP users (gaining 6715 QALYs with ICER £1760/QALY), followed by (2) HCV screening among PrEP non-users alongside HIV testing (gaining 7048 QALYs with ICER £4972/QALY). Compared to the baseline, this combined strategy would cost £46.9 (95%CrI £25.3-£66.9) million and achieve the HCV elimination target in 100% of model runs. Additional screening incurs ICERs >£20,000/QALY compared to this combined strategy. In conclusion, HCV elimination can be achieved cost-effectively among UK MSM. Policymakers should consider scaling-up HCV screening in HIV-negative MSM, especially PrEP users, for achieving this target.

HIV burden and correlates of infection among transfeminine people and cisgender men who have sex with men in Nairobi, Kenya: an observational study

BACKGROUND

Transgender people are disproportionately affected by HIV and other sexually transmitted infections (STIs) worldwide, and culturally competent prevention and treatment services are often unavailable or inaccessible. Despite recent improvements in national HIV responses for many key populations in east Africa, evidence of effective responses informed by transgender sexual health needs is sparse. We aimed to assess gender identity among men and transgender people who have sex with men in Kenya, and to explore its associations with sexual health-related outcomes, risk behaviours, and uptake of HIV prevention and care interventions.

METHODS

We did a cross-sectional study in Nairobi, Kenya, and recruited adult cisgender men and transfeminine people who reported having sex with men, through respondent-driven sampling. Inclusion criteria were possession of a valid study coupon, being aged 18 years or older, having male sex assignment at birth or male gender identification currently, living within 50 km of Nairobi, and having had consensual anal or oral sexual activity with a man in the previous 12 months. Seed participants were identified by three community organisations that provide targeted health-care services to gay, bisexual, or other men who have sex with men (MSM) communities in Nairobi. We assessed gender identity, sociodemographics, sexual behaviour, and HIV prevention and care uptake, by self-completed survey. Participants were tested for HIV, syphilis, and rectal and urethral gonorrhoea and chlamydia. We compared prevalence of sexual health outcomes, risk behaviour, and HIV prevention and care service uptake among transfeminine and cisgender participants, using multivariable robust Poisson regression models, with gender identity as the independent variable.

FINDINGS

Between May 4 and Dec 8, 2017, we enrolled 618 participants. Six participants did not answer the questions on sex assigned at birth and gender identity and so were excluded from the analyses. 522 (sample-weighted percentage 86%) of 612 participants were classified as cisgender men, 70 (11%) as transfeminine, and three (<1%) as transmasculine. 17 participants (2%) did not identify as male, female, or transgender. Compared with cisgender men, transfeminine people were more likely to be HIV-positive (28 [41%] of 70 transfeminine vs 151 [25%] of 521 cisgender men; p=0·0009) and to report current symptoms consistent with a rectal STI (eight [16%] of 67 vs 38 [7%] of 518; p=0·014). Transfeminine people reported higher numbers of recent male sexual partners (22 [27%] of 70 transfeminine people reported four or more male sexual partners in the past 3 months vs 112 [13%] of 522 cisgender men; p=0·042) and were more likely to report condomless anal intercourse with men (43 [62%] of 70 vs 208 [39%] of 522; p=0·0009) and receptive anal intercourse (54 [76%] of 70 vs 252 [46%] of 522; p<0·0001) in the past 3 months, and transactional sex with men (42 [57%] of 69 vs 240 [42%] of 518; p=0·023) and experience of sexual assault (16 [23%] of 69 vs 65 [11%] of 520; p=0·019) in the past 12 months. Use of pre-exposure prophylaxis and post-exposure prophylaxis was low in both groups.

INTERPRETATION

Transfeminine people who have sex with men have a higher burden of HIV and associated risk behaviours compared with cisgender MSM in the same context, yet their uptake of prevention and care services is poor. Policies should acknowledge the specific needs of transfeminine people as distinct from cisgender MSM, and support health-care providers to address these needs.

FUNDING

Evidence for HIV Prevention in Southern Africa (EHPSA), UK Aid.

eHealth Interventions to Address Sexual Health, Substance Use, and Mental Health Among Men Who Have Sex With Men: Systematic Review and Synthesis of Process Evaluations

Background

Men who have sex with men (MSM) face disproportionate risks concerning HIV and other sexually transmitted infections, substance use, and mental health. These outcomes constitute an interacting syndemic among MSM; interventions addressing all 3 together could have multiplicative effects. eHealth interventions can be accessed privately, and evidence from general populations suggests these can effectively address all 3 health outcomes. However, it is unclear how useable, accessible, or acceptable eHealth interventions are for MSM and what factors affect this.

Objective

We undertook a systematic review of eHealth interventions addressing sexual risk, substance use, and common mental illnesses among MSM and synthesized evidence from process evaluations.

Methods

We searched 19 databases, 3 trials registers, OpenGrey, and Google, and supplemented this by reference checks and requests to experts. Eligible reports were those that discussed eHealth interventions offering ongoing support to MSM aiming to prevent sexual risk, substance use, anxiety or depression; and assessed how intervention delivery or receipt varied with characteristics of interventions, providers, participants, or context. Reviewers screened citations on titles, abstracts, and then full text. Reviewers assessed quality of eligible studies, and extracted data on intervention, study characteristics, and process evaluation findings. The analysis used thematic synthesis.

Results

A total of 12 reports, addressing 10 studies of 8 interventions, were eligible for process synthesis. Most addressed sexual risk alone or with other outcomes. Studies were assessed as medium and high reliability (reflecting the trustworthiness of overall findings) but tended to lack depth and breadth in terms of the process issues explored. Intervention acceptability was enhanced by ease of use; privacy protection; use of diverse media; opportunities for self-reflection and to gain knowledge and skills; and content that was clear, interactive, tailored, reflective of MSM’s experiences, and affirming of sexual-minority identity. Technical issues and interventions that were too long detracted from acceptability. Some evidence suggested that acceptability varied by race or ethnicity and educational level; findings on variation by socioeconomic status were mixed. No studies explored how intervention delivery or receipt varied by provider characteristics.

Conclusions

Findings suggest that eHealth interventions targeting sexual risk, substance use, and mental health are acceptable for MSM across sociodemographic groups. We identified the factors shaping MSM’s receipt of such interventions, highlighting the importance of tailored content reflecting MSM’s experiences and of language affirming sexual-minority identities. Intervention developers can draw on these findings to increase the usability and acceptability of integrated eHealth interventions to address the syndemic of sexual risk, substance use, and mental ill health among MSM. Evaluators of these interventions can draw on our findings to plan evaluations that explore the factors shaping usability and acceptability.

Impact and acceptability of HIV self-testing for trans men and trans women: A mixed-methods subgroup analysis of the SELPHI randomised controlled trial and process evaluation in England and Wales

BACKGROUND

Globally, trans people are disproportionately affected by HIV, but research on strategies to increase testing are limited. SELPHI is a randomised-controlled-trial (RCT) of 10,135 cis men, trans men, and trans women reporting lifetime anal intercourse with male partners (cis or trans), evaluating whether the offer of free HIV self-testing (HIVST) increases diagnosis. This subgroup analysis from the SELPHI RCT aims to describe key HIVST outcomes and HIVST acceptability for trans people.

METHODS

SELPHI recruited using social networking and trans focused social media. Participants were randomised 60/40 to baseline HIVST (Biosure™) (BT) vs no baseline HIVST (nBT); and at 3-months (if completed the survey and reported recent CAI) 50/50 to 3-monthly HIVST (RT) vs no repeat HIVST (nRT). Outcomes were self-reported through online surveys. We conducted a qualitative study of semi-structured peer-led participant interviews (n = 20) exploring HIVST motivations and experiences. These were analysed using a framework approach.

FINDINGS

SELPHI recruited and randomised 118 trans men and trans women (94 trans men, 24 trans women), of whom 20 (16 trans men, 4 trans women) underwent the second randomisation. Median age at baseline was 29 (IQR: 22, 37), 79% were white, 79% were UK born, 37% had degree level education, and 31% had never tested for HIV. 62% (n = 59) of trans men completed the 3-month survey, but survey completion by trans women in nBT was too low (1/11) for randomised comparison. In trans men HIV testing uptake by 3 months was significantly higher in BT (95% 36/38) vs nBT (29%, 6/21) (RR=3.32 (1.68, 6.55) p<0.001). Trans people randomised to RT reported 3 times higher rate of HIV testing compared to nRT during the two-year follow-up (IRR 3.66 (1.86, 8.01) p<0.0001). STI testing frequency (mean number of tests during each 13 week period/ 2-year follow-up) was not significantly different across interventions: RT (0.03) and nRT (0.01) (IRR=1.86 95%CI; 0.77, 5.15; p = 0.15). Social harms were rare. Acceptability was very high in BT: 97% (38/39) found instructions easy to understand, 97% (37/38) found the HIVST simple to use and 100% (39/39) reported good overall experience. In interviews, reported HIVST benefits included increased autonomy, privacy, convenience and avoidance of health care providers perceived to be discriminatory and services that increased dysphoria. Minor lancet and test processing issues were reported.

INTERPRETATION

HIVST significantly increased testing uptake and frequency in trans men and trans people overall, although recruitment and retention of trans women was low. HIVST acceptability was high and indicates easy access to this novel technology may increase HIV testing access for this key population.

Chemsex and diagnoses of syphilis, gonorrhoea and chlamydia among men who have sex with men in the UK: a multivariable prediction model using causal inference methodology

INTRODUCTION

In the last decade diagnoses of most STIs have risen among men who have sex with men (MSM). Although a significant proportion of this is likely due to increased STI screening, understanding the role of behavioural drivers remains critical. We measure the associations between stimulant use to enhance and prolong sexual experiences (chemsex) and bacterial STI diagnoses in UK MSM, individually considering HIV-diagnosed MSM, pre-exposure prophylaxis (PrEP) users and other MSM.

METHODS

We used the UK 2017-2018 European MSM Internet Survey data (n=9375). We constructed causal inference models using multivariable logistic regression, calculating adjusted OR (aOR) and 95% CI of the associations between participation in recent (≤12 months) exclusively dyadic or multipartner chemsex versus no chemsex and recent self-reported diagnoses of syphilis, gonorrhoea and chlamydia.

RESULTS

Among MSM with an HIV diagnosis, 25% of users indicated recent multipartner chemsex, vs 28% of PrEP users and 5% of other MSM. Adjusting for age, ethnicity, UK birth, cis-trans status, sexual identity, education, settlement size and relationship status, participation in recent multipartner chemsex versus no chemsex was associated with greater odds of recent syphilis, gonorrhoea and chlamydia diagnosis. aORs for recent syphilis, gonorrhoea and chlamydia diagnoses were 2.6 (95% CI 1.7 to 4.1), 3.9 (95% CI 2.6 to 5.8) and 2.9 (95% CI 1.9 to 4.3), respectively, in HIV-diagnosed MSM; 1.9 (95% CI 1.1 to 3.3), 2.9 (95% CI 2.0 to 4.2) and 1.9 (95% CI 1.3 to 2.8), respectively, in PrEP users; and 4.0 (95% CI 2.3 to 6.9), 2.7 (95% CI 1.9 to 3.8) and 2.3 (95% CI 1.6 to 3.4), respectively, in other MSM. Conversely, exclusively dyadic chemsex had no significant associations with bacterial STI diagnoses among HIV-diagnosed MSM, only gonorrhoea (aOR 2.4, 95% CI 1.2 to 4.7) among PrEP users and syphilis (aOR 2.8, 95% CI 1.4 to 5.6) among other MSM.

DISCUSSION

Multipartner chemsex may drive the association between chemsex and bacterial STI diagnoses and thus should be the focus of future tailored chemsex interventions. Additionally, PrEP acceptability among MSM and particularly chemsex participants has generated an emergent group suitable for such interventions.

Theories of change for e-health interventions targeting HIV/STIs and sexual risk, substance use and mental ill health amongst men who have sex with men: systematic review and synthesis

BACKGROUND

Sexual risk, substance use, and mental ill health constitute a syndemic of co-occurring, mutually reinforcing epidemics amongst men who have sex with men (MSM). Developed since 1995, e-health interventions offer accessible, anonymous support and can be effective in addressing these outcomes, suggesting the potential value of developing e-health interventions that address these simultaneously amongst MSM. We conducted a systematic review of e-health interventions addressing one or more of these outcomes amongst MSM and in this paper describe the theories of change underpinning relevant interventions, what these offer and how they might complement each other.

METHODS

We identified eligible reports via expert requests, reference-checking and database and Google searches. Results were screened for reports published in 1995 or later; focused on MSM; reporting on e-health interventions providing ongoing support to prevent HIV/STIs, sexual risk behaviour, substance use, anxiety or depression; and describing intervention theories of change. Reviewers assessed report quality, extracted intervention and theory of change data, and developed a novel method of synthesis using diagrammatic representations of theories of change.

RESULTS

Thirty-three reports on 22 intervention theories of change were included, largely of low/medium-quality. Inductively grouping these theories according to their core constructs, we identified three distinct groupings of theorised pathways. In the largest, the 'cognitive/skills' grouping, interventions provide information and activities which are theorised to influence behaviour via motivation/intention and self-efficacy/perceived control. In the 'self-monitoring' grouping, interventions are theorised to trigger reflection, self-reward/critique and self-regulation. In the 'cognitive therapy' grouping, the theory of change is rooted in cognitive therapy techniques, aiming to reframe negative emotions to improve mental health.

CONCLUSIONS

The synthesised theories of change provide a framework for developing e-health interventions that might holistically address syndemic health problems amongst MSM. Improving reporting on theories of change in primary studies of e-health interventions would enable a better understanding of how they are intended to work and the evidence supporting this. The novel diagrammatic method of theory of change synthesis used here could be used for future reviews where interventions are driven by existing well-defined behaviour and behaviour change theories.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO CRD42018110317.

Comparing the effects of HIV self-testing to standard HIV testing for key populations: a systematic review and meta-analysis

BACKGROUND

We update a previous systematic review to inform new World Health Organization HIV self-testing (HIVST) recommendations. We compared the effects of HIVST to standard HIV testing services to understand which service delivery models are effective for key populations.

METHODS

We did a systematic review of randomised controlled trials (RCTs) which compared HIVST to standard HIV testing in key populations, published from 1 January 2006 to 4 June 2019 in PubMed, Embase, Global Index Medicus, Social Policy and Practice, PsycINFO, Health Management Information Consortium, EBSCO CINAHL Plus, Cochrane Library and Web of Science. We extracted study characteristic and outcome data and conducted risk of bias assessments using the Cochrane ROB tool version 1. Random effects meta-analyses were conducted, and pooled effect estimates were assessed along with other evidence characteristics to determine the overall strength of the evidence using GRADE methodology.

RESULTS

After screening 5909 titles and abstracts, we identified 10 RCTs which reported on testing outcomes. These included 9679 participants, of whom 5486 were men who have sex with men (MSM), 72 were trans people and 4121 were female sex workers. Service delivery models included facility-based, online/mail and peer distribution. Support components were highly diverse and ranged from helplines to training and supervision. HIVST increased testing uptake by 1.45 times (RR=1.45 95% CI 1.20, 1.75). For MSM and small numbers of trans people, HIVST increased the mean number of HIV tests by 2.56 over follow-up (mean difference = 2.56; 95% CI 1.24, 3.88). There was no difference between HIVST and SoC in regard to positivity among tested overall (RR = 0.91; 95% CI 0.73, 1.15); in sensitivity analysis of positivity among randomised HIVST identified significantly more HIV infections among MSM and trans people (RR = 2.21; 95% CI 1.20, 4.08) and in online/mail distribution systems (RR = 2.21; 95% CI 1.14, 4.32). Yield of positive results in FSW was not significantly different between HIVST and SoC. HIVST reduced linkage to care by 17% compared to SoC overall (RR = 0.83; 95% CI 0.74, 0.92). Impacts on STI testing were mixed; two RCTs showed no decreases in STI testing while one showed significantly lower STI testing in the intervention arm. There were no negative impacts on condom use (RR = 0.95; 95% CI 0.83, 1.08), and social harm was very rare.

CONCLUSIONS

HIVST is safe and increases testing uptake and frequency as well as yield of positive results for MSM and trans people without negative effects on linkage to HIV care, STI testing, condom use or social harm. Testing uptake was increased for FSW, yield of positive results were not and linkage to HIV care was worse. Strategies to improve linkage to care outcomes for both groups are crucial for effective roll-out.

An update on the performance of STI services for gay and bisexual men across European cities: results from the 2017 European MSM Internet Survey

OBJECTIVES

Rectal STIs compromise health and are common in men who have sex with men (MSM). However, the European-MSM-Internet-Survey (EMIS-2010) showed that in 2010, the prevalence of anal swabbing during STI screening by MSM varied widely across 40 European cities. In this paper, we replicate a variety of measures of STI testing performance using 2017-18 data and extending the geographic spread of the analysis.

METHODS

Data were analysed from the EMIS-2017, a 33-language online sexual health survey accessible from 18 October 2017 to 31 January 2018. We focus on a subsample of 38 439 respondents living in the same 40 European cities we reported on in 2010. For a broader perspective, we also included an additional 65 cities in the analysis (combined n=56 661). We compared the prevalence of STI screening in MSM and disclosure of same-sex sexual contacts to the healthcare provider. We applied multivariable logistic regression models to compare the odds of MSM receiving each of four diagnostic procedures, including anal swabbing in the previous 12 months, controlling for age, HIV diagnosis, pre-exposure prophylaxis use and number of sexual partners.

RESULTS

In 2017, across 40 European cities, the proportion of respondents screened for STIs ranged from under 19% in Belgrade to over 59% in London. At an individual level, in comparison to London, the adjusted OR (AOR) of having received anal swabbing ranged from 0.03 in Belgrade, Bucharest and Istanbul to 0.80 in Oslo, with little evidence for a difference in Amsterdam and Dublin. Since 2010, most cities in West and South-west Europe have substantially narrowed their performance gap with London, but some in East and South-east Europe have seen the gap increase.

CONCLUSIONS

Although comprehensive STI screening in MSM has expanded across many European cities, the low prevalence of anal swabbing indicates that rectal STIs continue to be underdiagnosed, particularly in East/South-east Europe.

Sexual and Mental Health Inequalities across Gender Identity and Sex-Assigned-at-Birth among Men-Who-Have-Sex-with-Men in Europe: Findings from EMIS-2017

Some men who have sex with men (MSM) were assigned female at birth (AFB) and/or identify as trans men. Little is known about how these men differ from other MSM. We compared sexual and mental health indicators from the European MSM Internet Survey (EMIS-2017), comparing men AFB and/or currently identifying as trans men with those assigned male at birth (AMB) who identified as men. EMIS-2017 was an opportunistic 33-language online sexual health survey for MSM recruiting throughout Europe. We used regression models adjusting for age, country of residence and employment status to examine differences across groups. An analytic sample of 125,720 men living in 45 countries was used, of which 674 (0.5%) were AFB and 871 (0.7%) identified as trans men. The two sub-groups were not coterminous, forming three minority groups: AFB men, AFB trans men and AMB trans men. Minority groups were younger and more likely unemployed. Anxiety, depression, alcohol dependence and sexual unhappiness were more prevalent in sex/gender minority men. Conversely HIV and STI diagnoses were less common. AMB trans men were most likely to have sexual risk behavior with steady partners and to have unmet health promotion needs, and were least likely to be reached by interventions. Sex assigned at birth and trans identification were associated with different sexual and mental health needs. To facilitate service planning and to foster inclusion, sex-assigned-at-birth and current gender identity should be routinely collected in health surveys.

Online socializing among men who have sex with men and transgender people in Nairobi and Johannesburg and implications for public health-related research and health promotion: an analysis of qualitative and respondent-driven sampling survey data

INTRODUCTION

There is little published literature about gay, bisexual and other men who have sex with men and transgender individuals (MSM and TG)'s use of social media in sub-Saharan Africa, despite repressive social and/or criminalizing contexts that limit access to physical HIV prevention. We sought to describe MSM and TG's online socializing in Nairobi and Johannesburg, identifying the characteristics of those socializing online and those not, in order to inform the development of research and health promotion in online environments.

METHODS

Respondent-driven sampling surveys were conducted in 2017 in Nairobi (n = 618) and Johannesburg (n = 301) with those reporting current male gender identity or male sex assigned at birth and sex with a man in the last 12 months. Online socializing patterns, sociodemographic, sexual behaviour and HIV-testing data were collected. We examined associations between social media use and sociodemographic characteristics and sexual behaviours among all, and only those HIV-uninfected, using logistic regression. Analyses were RDS-II weighted. Thirty qualitative interviews were conducted with MSM and TG in each city, which examined the broader context of and motivations for social media use.

RESULTS

Most MSM and TG had used social media to socialize with MSM in the last month (60% Johannesburg, 71% Nairobi), mostly using generic platforms (e.g. Facebook), but also gay-specific (e.g. Grindr). HIV-uninfected MSM and TG reporting riskier recent sexual behaviours had raised odds of social media use in Nairobi, including receptive anal intercourse (adjusted OR = 2.15, p = 0.006), buying (aOR = 2.24, p = 0.015) and selling sex with men (aOR = 2.17, p = 0.004). Evidence for these associations was weaker in Johannesburg, though socializing online was associated with condomless anal intercourse (aOR = 3.67, p = 0.003) and active syphilis (aOR = 13.50, p = 0.016). Qualitative findings indicated that while online socializing can limit risk of harm inherent in face-to-face interactions, novel challenges were introduced, including context collapse and a fear of blackmail.

CONCLUSIONS

Most MSM and TG in these cities socialize online regularly. Users reported HIV acquisition risk behaviours, yet this space is not fully utilized for sexual health promotion and research engagement. Effective, safe and acceptable means of using online channels to engage with MSM/TG that account for MSM and TG's strategies and concerns for managing online security should now be explored, as complements or alternatives to existing outreach.

Cross-sectional analysis of chemsex drug use and gonorrhoea diagnosis among men who have sex with men in the UK

Background Illicit drug use among men who have sex with men (MSM) has been associated with sexual risk and HIV. Less is documented about associations with other sexually transmissible infections (STIs). The aim of the present study was to determine whether the use of drugs commonly associated with chemsex is associated with increased risk of gonorrhoea among MSM.

METHODS

Using data from 16065 UK-based respondents to the European MSM Internet Survey (2010), we examined associations between a recent diagnosis of gonorrhoea and three chemsex drugs (crystal methamphetamine, γ-hydroxybutyric acid (GHB)/γ-butyrolactone (GBL) and mephedrone). Univariate logistic regression identified determinants of gonorrhoea diagnosis and multivariate logistic regression models calculated adjusted odds ratios (aORs) for independent associations between chemsex drugs and gonorrhoea.

RESULTS

MSM who reported using crystal methamphetamine and GHB/GBL in the previous year had 1.92- and 2.23-fold higher odds of gonorrhoea respectively over the same period (P=0.0001 and P<0.0001; n=15137) after adjusting for age, recruitment website, HIV status, residence and use of other chemsex drugs. MSM reporting the use of all three chemsex drugs had the highest increased odds (aOR 3.58; P<0.0001; n=15174). Mephedrone alone was not associated with gonorrhoea in multivariate models.

CONCLUSIONS

Use of chemsex drugs is associated with a higher risk of gonorrhoea. The results of this study complement existing research about crystal methamphetamine and indicate a role for GHB/GBL in adverse sexual health outcomes. The use of mephedrone alongside other chemsex drugs may account for its lack of association with gonorrhoea in multivariate models. Future research should use encounter-level data, examine other STIs and attribute pathways through which chemsex leads to infection.

Estimating the 'PrEP Gap': how implementation and access to PrEP differ between countries in Europe and Central Asia in 2019

In 2019, only 14 European and Central Asian countries provided reimbursed HIV pre-exposure prophylaxis (PrEP). Using EMIS-2017 data, we present the difference between self-reported use and expressed need for PrEP in individual countries and the European Union (EU). We estimate that 500,000 men who have sex with men in the EU cannot access PrEP, although they would be very likely to use it. PrEP’s potential to eliminate HIV is currently unrealised by national healthcare systems.

Sexual risk and HIV testing disconnect in men who have sex with men (MSM) recruited to an online HIV self-testing trial

OBJECTIVES

We report the frequency of previous HIV testing at baseline in men who have sex with men (MSM) who enrolled in an HIV self-testing (HIVST) randomized controlled trial [an HIV self-testing public health intervention (SELPHI)].

METHODS

Criteria for enrolment were age ≥ 16 years, being a man (including trans men) who ever had anal intercourse (AI) with a man, not being known to be HIV positive and having consented to national HIV database linkage. Using online survey baseline data (2017-2018), we assessed associations with never having tested for HIV and not testing in the previous 6 months, among men who reported at least two recent condomless AI (CAI) partners.

RESULTS

A total of 10 111 men were randomized; the median age was 33 years [interquartile range (IQR) 26-44 years], 89% were white, 20% were born outside the UK, 0.8% were trans men, 47% were degree educated, and 8% and 4% had ever used and were currently using pre-exposure prophylaxis (PrEP), respectively. In the previous 3 months, 89% reported AI and 72% reported CAI with at least one male partner. Overall, 17%, 33%, 54%, and 72% had tested for HIV in the last 3 months, 6 months, 12 months and 2 years, respectively; 13% had tested more than 2 years ago and 15% had never tested. Among 3972 men reporting at least two recent CAI partners, only 22% had tested in the previous 3 months. Region of residence and education level were independently associated with recent HIV testing. Among current PrEP users, 15% had not tested in the previous 6 months.

CONCLUSIONS

Most men in SELPHI, particularly those reporting at least two CAI partners and current PrEP users, were not testing in line with current UK recommendations. The results of the trial will inform whether online promotion of HIVST addresses ongoing testing barriers.

HIV testing, care and viral suppression among men who have sex with men and transgender individuals in Johannesburg, South Africa

INTRODUCTION

Men who have sex with men and transgender individuals (MSM/TG) carry a disproportionately high burden of HIV, including in South Africa. However, there are few empirical population-representative estimates of viral suppression and the HIV care cascade including HIV testing among this population, nor of factors associated with these outcomes.

METHODS

We conducted a respondent driven sampling (RDS) survey among 301 MSM/TG in Johannesburg in 2017. Participants gave blood samples for HIV testing and viral load. Participants self-completed a survey including sociodemographics, HIV testing history, and engagement in care. We calculated RDS-II weighted estimates of the percentage of HIV-negative MSM/TG reporting HIV testing in the previous 6 months, their testing experience and preferences. Among those HIV-positive, we estimated the percentage status-aware, on ART, and virally suppressed (<50 viral copies/ml plasma). We conducted RDS-weighted robust Poisson regression to obtain weighted prevalence ratios of factors associated with 1) HIV testing among those HIV-negative; and 2) viral suppression among those HIV-positive.

RESULTS

There were 118/300 HIV-positive MSM/TG, (37.5%). Of the HIV-negative MSM/TG, 61.5% reported that they had tested for HIV in the previous 6 months, which was associated with selling sex to men (Prevalence Ratio = 1.67, 95% CI 1.36-2.05). There were 76/118 HIV-positive MSM/TG (56.5%) who reported having previously tested positive for HIV and 39/118 (30.0%) who reported current ART. There were 58/118 HIV-positive MSM/TG with viral loads <50 copies/ml plasma (46.9%). Viral suppression was associated with older age (adjusted PR = 1.03, 95% CI 1.00-1.06 for each year), neighbourhood, and having bought sex from men (adjusted PR = 1.53, 95% CI 1.12-2.08).

CONCLUSIONS

HIV prevalence was very high. Viral suppression among those HIV-positive was similar to the general male population in South Africa, but remains far short of national and international targets. A majority of HIV-negative MSM/TG had HIV tested in the previous 6 months, though there is room for improvement.

Characteristics and sexual health service use of MSM engaging in chemsex: results from a large online survey in England

Background

Chemsex, the use of select psychoactive drugs to enhance sexual experience, typically among men who have sex with men (MSM), is associated with sexual behaviours with higher STI risk. Understanding patterns of chemsex among MSM as well as the characteristics and sexual health service engagement of chemsex participants is important for developing interventions.

Methods

Between 5/2016 to 5/2017, 3933 MSM completed an online survey, recruited in sexual health clinics (SHCs) in England (n=421) and via four social networking/dating apps (n=3512). We described patterns of chemsex in the past year and used multivariable logistic regression to investigate differences in demographics and sexual behaviours by chemsex history. We described history of SHC attendance and STI test in the past year among app-recruited chemsex participants.

Results

Chemsex in the past year was reported by 10% of respondents; 19% of SHC-recruited and 9% of app-recruited. Among chemsex participants, 74% had used ≥2 chemsex drugs. In the multivariable model, MSM engaging in chemsex had a raised odds of being HIV-positive (adjusted OR (aOR): 3.6; 95% CI 2.1 to 6.1), aged 30–44 (aOR 1.5 vs <30 years; 95% CI 1.0 to 2.1), being born outside the UK and having engaged in higher risk sexual behaviours in the past 3 months. Chemsex participants also had higher odds of condomless anal sex with partners of different or unknown HIV status, but only among HIV-negative/untested. In the past year, 66% of app-recruited chemsex participants had attended a SHC and 81% had had an STI test.

Conclusion

One in 10 MSM recruited through community and clinical settings across England had engaged in chemsex in the past year. Those that did appear to be at greater STI risk but engaged more actively with sexual health services. This highlights the need and opportunity for chemsex-related services in SHCs and robust referral pathways to drug treatment services.

A qualitative study of attitudes towards, typologies, and drivers of concurrent partnerships among people of black Caribbean ethnicity in England and their implications for STI prevention

BACKGROUND

Partner concurrency, (having sexual partnerships overlapping in time), especially when condoms are not used, can facilitate sexually transmitted infections (STI) transmission. In Britain, STI diagnoses rates and the reporting of concurrency are higher among black Caribbeans than other ethnic groups. We explored attitudes towards, drivers, characteristics, and contexts of concurrent partnerships, and their implications for STI risk among black Caribbeans in England.

METHODS

Purposive sampling, by sex and age-groups, was used to recruit participants (overall n = 59) from five sexual health clinics and community settings in London and Birmingham, England. Audio-recorded four focus group discussions (n = 28 participants), and in-depth interviews (n = 31) were conducted (June 2014-December 2015). Transcribed data were thematically analysed using Framework Analysis.

RESULTS

'Main plus' and 'non-main' concurrency were identified in this population. Main plus concurrency involves an individual having a main partner with whom s/he has a "relationship" with, and the individual and/or their partner secretly or explicitly have other non-main partners. In contrast, non-main concurrency entails having multiple, non-committed partners overlapping in time, where concurrency is usually taken as a given, making disclosure to partners irrelevant. While main partnerships were usually long-term, non-main partnerships ranged in duration from a single event through to encounters lasting several months/years. Condomless sex was common with ex/long-term/married/cohabiting partners; whereas condoms were typically used with non-main partners. However, condom use declined with partnership duration and familiarity with partners. Awareness of partners' concurrency facilitated condom use, STI-testing, and partner notification. While unresolved feelings, or sharing children with ex-partners, usually facilitated main plus concurrency; non-main concurrency was common among young, and single people. Gender norms, notions of masculinity, and sexual desires influenced concurrency. Black Caribbean popular music, social media, peer pressure, and relationship norms among black Caribbeans were also perceived to encourage concurrency, especially among men and young people.

CONCLUSIONS

Concurrency among black Caribbeans is shaped by a complex interaction between emotional/psychological, interpersonal, sociocultural, and structural factors. Concurrency type, its duration, and awareness influence sexual health choices, and thus STI risk in this population. Collecting these data during clinic consultations could facilitate offering partner notification methods tailored to concurrency type. Gender- and age-specific, culturally-sensitive interventions addressing STI risks associated with concurrency are needed.

Scaling up screening and treatment for elimination of hepatitis C among men who have sex with men in the era of HIV pre-exposure prophylaxis

BACKGROUND

Routine HIV pre-exposure prophylaxis (PrEP) and HIV care appointments provide opportunities for screening men who have sex with men (MSM) for hepatitis C virus infection (HCV). However, levels of screening required for achieving the WHO elimination target of reducing HCV incidence by 90% by 2030 among all MSM are unknown.

METHODS

An HCV/HIV transmission model was calibrated to UK prevalence of HIV among MSM (4·7%) and chronic HCV infection among HIV-positive MSM (9·9%) and HIV-negative MSM (1.2%). Assuming 12·5% coverage of PrEP among HIV-negative MSM, we evaluated the relative reduction in overall HCV incidence by 2030 (compared to 2018 levels) of HCV screening every 12/6-months (alongside completing direct acting antiviral treatment within 6-months of diagnosis) in PrEP users and/or HIV-diagnosed MSM. We estimated the additional screening required among HIV-negative non-PrEP users to reduce overall incidence by 90% by 2030. The effect of 50% reduction in condom use among PrEP users (risk compensation) was estimated.

RESULTS

Screening and treating PrEP users for HCV every 12 or 6-months decreases HCV incidence by 67·3% (uncertainty range 52·7-79·2%) or 70·2% (57·1-80·8%), respectively, increasing to 75·4% (59·0-88·6%) or 78·8% (63·9-90·4%) if HIV-diagnosed MSM are also screened at same frequencies. Risk compensation reduces these latter projections by <10%. To reduce HCV incidence by 90% by 2030 without risk compensation, HIV-negative non-PrEP users require screening every 5·6 (3·8-9·2) years if MSM on PrEP and HIV-diagnosed MSM are screened every 6-months, shortening to 4·4 (3·1-6·6) years with risk compensation. For 25·0% PrEP coverage, the HCV elimination target can be reached without screening HIV-negative MSM not on PrEP, irrespective of risk compensation.

INTERPRETATION

At low PrEP coverage, increased screening of all MSM is required to achieve the WHO HCV-elimination targets for MSM in the UK, whereas at higher PrEP coverage this is possible through just screening HIV-diagnosed MSM and PrEP users.

Exploring Mechanisms of Action: Using a Testing Typology to Understand Intervention Performance in an HIV Self-Testing RCT in England and Wales

SELPHI involves two interventions: A provides one HIV self-testing (HIVST) kit; B offers 3-monthly repeat HIVST kits if participants report ongoing risk. A logic model underpinned by the Behaviour Change Wheel informed the design of the intervention. SELPHI recruited 10,135 cis-men and trans people in England and Wales, all reporting anal sex with a man. This paper explores how the interventions were experienced and the mechanisms of action leading to impact for different groups of trial participants. In-depth interviews with 37 cis-men who have sex with men (MSM) were used to inductively categorise participants based on sexual and HIV testing histories. Themes relating to intervention experiences and impacts were mapped onto SELPHI-hypothesised intermediate outcomes to consider intervention impacts. Three groups were identified: ‘inexperienced testers’ engaged with SELPHI to overcome motivational and social and physical opportunity testing barriers. For ‘pro self-testers’, testing frequency was constrained by psychological and social barriers and lack of opportunity. ‘Opportunistic adopters’ engaged in HIVST for novelty and convenience. Perceived impacts for inexperienced testers were most closely aligned with the logic model, but for opportunistic adopters there was little evidence of impact. Distinctive groups were discernible with divergent intervention experiences. Using COM-B as a model for understanding behaviour change in relation to HIVST, our results indicate how HIVST interventions could be adapted to respond to different needs based on the target population’s demographic and behavioural features.

HIV self-testing intervention experiences and kit usability: results from a qualitative study among men who have sex with men in the SELPHI (Self-Testing Public Health Intervention) randomized controlled trial in England and Wales

Objectives

SELPHI (HIV Self‐Testing Public Health Intervention) is the largest randomized controlled trial (RCT) of HIV self‐testing (HIVST) in a high‐income setting to date, and has recruited 10 000 men who have sex with men (cis‐ and transgender) and transgender women who have sex with men. This qualitative substudy aimed to explore how those utilizing self‐tests experience HIVST and the implications for further intervention development and scale‐up. This is the first qualitative study in Europe investigating experiences of HIVST among intervention users, and the first globally examining the experience of using blood‐based HIVST.

Methods

Thirty‐seven cisgender MSM SELPHI participants from across England and Wales were purposively recruited to the substudy, in which semi‐structured interviews were used to explore testing history, HIVST experiences and intervention preferences. Interviews were audio‐recorded, transcribed and analysed through a framework analysis.

Results

Men accessed the intervention because HIVST reduced barriers related to convenience, stigma and privacy concerns. Emotional responses had direct links to acceptability. Supportive intervention components increased engagement with testing and addressed supportive concerns. HIVST facilitated more frequent testing, with the potential to reduce sexually transmitted infection (STI) screening frequency. Substudy participants with an HIV‐positive result (n = 2) linked to care promptly and reported very high acceptability. Minor adverse outcomes (n = 2; relationship discord and fainting) did not reduce acceptability. Ease of use difficulties were with the lancet and the test processing stage.

Conclusions

Intervention components shaped acceptability, particularly in relation to overcoming a perceived lack of support. The intervention was broadly acceptable and usable; participants expressed an unexpected degree of enthusiasm for HIVST, including those with HIV‐positive results and individuals with minor adverse outcomes.

Acceptability and potential impact of delivering sexual health promotion information through social media and dating apps to MSM in England: a qualitative study

Background

Increasing rates of sexually transmitted infections (STIs) in men-who-have-sex-with-men (MSM) in England is a pressing public health concern. Interventions targeting MSM, including information provision that effectively promotes sexual health, are needed. To support such intervention development, it is necessary to understand acceptable ways of delivering sexual health information. We explored the acceptability and potential uses and impacts of delivering sexual health information to MSM through social media and geosocial networking apps or dating apps.

Methods

Semi-structured interviews were conducted in person or by telephone with 25 MSM resident in England recruited via dating apps and social media advertisements. Interviews explored sexual health information sources, perceptions and uses. Attitudes towards sexual health promotion through social media and dating apps were then discussed. The data were analysed using thematic analysis.

Results

Sexual health information delivery through social media and dating apps was considered acceptable. Receiving information when browsing social media was viewed positively by most, as people have time to absorb information. In contrast, concerns were expressed that sharing or commenting on social media sexual health information may lead to judgements and discrimination. While social media reaches a high proportion of the population, dating apps can easily target MSM. However, tensions exist between the ability to provide information at an opportune time through dating apps, when users are connecting with new sexual partners, with the potential to adversely affect the app user’s experience. Hypothetical and actual uses and impacts of sexual health information ranged from no impact to reading information, sharing with peers, and increased awareness, to influencing healthcare-seeking, decision-making and risk-taking behaviours. Ensuring that information is engaging, positive in tone, not too clinical, focused on building social norms and delivered by trusted organisations were viewed as important for supporting its use.

Conclusions

Overall, these findings support the development of new interventions that use dating apps and social media for sexual health promotion.

Electronic supplementary material

The online version of this article (10.1186/s12889-019-7558-7) contains supplementary material, which is available to authorized users.

Pilot phase of an internet-based RCT of HIVST targeting MSM and transgender people in England and Wales: advertising strategies and acceptability of the intervention

BACKGROUND

The SELPHI study (An HIV Self-Testing Public Health Intervention) is an online randomised controlled trial (RCT) of HIV self-testing (HIVST). The aim of this study was to assess the feasibility of recruiting UK men who have sex with men (cis and trans) and trans women who have sex with men to the SELPHI pilot, and the acceptability of the HIVST intervention used among those randomised to receive a kit.

METHODS

A mixed-methods approach to assessing trial feasibility and intervention acceptability was taken, using quantitative data from advertising sources and RCT surveys alongside qualitative data from a nested sub-study.

RESULTS

Online recruitment and intervention delivery was feasible. The recruitment strategy led to the registration of 1370 participants of whom 76% (1035) successfully enrolled and were randomised 60/40 to baseline testing vs no baseline testing. Advertising platforms performed variably. Reported HIVST kit use increased from 83% at two weeks to 96% at three months. Acceptability was very high across all quantitative measures. Participants described the instructions as easy to use, and the testing process as simple. The support structures in SELPHI were felt to be adequate. Described emotional responses to HIVST varied.

CONCLUSIONS

Recruiting to a modest sized HIVST pilot RCT is feasible, and the recruitment, intervention and HIVST kit were acceptable. Research on support needs of individuals with reactive results is warranted.

Links between transactional sex and HIV/STI-risk and substance use among a large sample of European men who have sex with men

BACKGROUND

In Europe, the highest proportion of HIV diagnoses are in gay men and other men who have sex with men (MSM). Globally, HIV prevalence is particularly high among males who report selling sex, but rates among men who buy sex from other men are less clear. This study analyzed the association of transactional sex (TS) and HIV diagnosis, sexually transmitted infection (STI) diagnoses, and various drug use; and examined the variations in TS by payment direction.

METHODS

We conducted a cross-sectional, non-randomized, observational study. This European MSM Internet Survey recruited MSM from 38 European countries. For descriptive purposes we stratified according to TS behavior (frequently selling sex, frequently buying sex, neither frequently selling nor buying sex in the previous 12 months), and we constructed separate multivariable logistic regression models to investigate whether engaging in TS accounted for some of the HIV- and STI diagnoses and drug use in this population.

RESULTS

Of almost 161,000 sexually active MSM, 12.2% engaged in TS. The multivariable logistic regression results showed that relative to not frequently engaging in TS, frequently selling sex was independently associated with a higher odds of reporting diagnosed HIV (ever, adjusted odds ratio [aOR] 1.60, confidence interval [CI] 95% 1.39 to 1.85), bacterial STIs (past 12 months, aOR 1.75 CI 95% 1.54 to 2.00), using heroin or crack cocaine or injecting drugs (aOR 3.17, CI 95% 2.70 to 3.73), and using benzodiazepines (aOR 2.13, CI 95% 1.88 to 2.41). Compared to men not engaging in frequent TS, frequently buying sex was associated with a higher odds of using benzodiazepines (aOR 2.13, CI 95% 1.88 to 2.41).

CONCLUSIONS

MSM who frequently sell sex suffer greater sexual- and substance use risks than other MSM, but both men who frequently sell and those who buy sex are more likely to use benzodiazepines. MSM who sell sex to other men constitute an important at-risk population who must be offered targeted health services.

Understanding user perspectives of and preferences for oral PrEP for HIV prevention in the context of intervention scale-up: a synthesis of evidence from sub-Saharan Africa

INTRODUCTION

Oral pre-exposure prophylaxis (PrEP) for HIV prevention has been proven to significantly reduce new HIV infections yet scale-up has been slow. As contexts continue to adjust to make space for PrEP, it is crucial to understand the perspectives and experiences of potential end-users. In order to inform PrEP and demand creation interventions, this paper examines personal perspectives on adopting and using PrEP among HIV at-risk populations in sub-Saharan Africa.

METHODS

Using the principles of a scoping review in July 2018, we explored the extent, range, and nature of published literature regarding PrEP uptake and use among; men who have sex with men, HIV serodiscordant couples, adolescent girls and young women, pregnant and breastfeeding women, women partners of migrant workers; and people who use drugs. Steps included: identification of the research question; identification of relevant studies; study selection; charting the data; and collation - summarizing and reporting results. PubMed and PsycInfo were searched for papers relating to PrEP uptake and use in sub-Saharan Africa. Resulting papers were reviewed with data extracted and compiled in Excel for analysis. A broad content analysis was conducted and organized into high-level themes.

RESULTS AND DISCUSSION

Thirty-five papers were included in this review. There was little opposition in general to oral PrEP; however, there were significant nuances in its broader acceptability, applicability, and usability. We identified five themes within which these are discussed. These relate to balancing complexities of personal empowerment and stigma; navigating complex risk environments; influences of relationships and partners; efficacy and side effects; and practicalities of use. This body of research suggests that while product attributes and the logistics of PrEP delivery and use are important topics, it is vital to consider stigma, the interactions of PrEP use with relationships, and the need for broader understanding of ARVs for prevention versus treatment.

CONCLUSIONS

Planning for, programming and promoting the adoption of oral PrEP necessitates a deeper understanding of end-user priorities in order to ensure successful interventions. This review illustrates the nuances facilitating or deterring PrEP use that may affect the larger effort of PrEP scale-up.

Association between knowledge, risk behaviours, and testing for sexually transmitted infections among men who have sex with men: findings from a large online survey in the United Kingdom

Objectives

In the UK, men who have sex with men (MSM) bear a disproportionate sexually transmitted infection (STI) burden. We investigated MSM's STI knowledge; whether their STI testing behaviour met national guidelines (annually if sexually active; 3‐monthly if engaging in STI risk behaviours); and the relationship between STI testing in the last 3 months, STI knowledge and STI risk behaviours by HIV status.

Methods

Sexually active (in the last year) men aged > 15 years who were UK residents and were recruited from gay‐orientated online dating platforms completed an anonymous online survey about STI knowledge, STI risk behaviours, and STI testing (March–May 2017). This included 11 true statements about STIs. Respondents scored 1 for each statement they ‘knew’, with those scoring < 6 overall treated as having ‘poor’ STI knowledge. Descriptive and multivariable analyses were conducted, separately by HIV status, to test our hypothesis and calculate adjusted odds ratios (AORs) with 95% confidence intervals (CIs).

Results

Compared to HIV‐positive men (n = 489), the proportion of HIV‐negative/unknown‐status men (n = 3157) with ‘poor’ STI knowledge was significantly higher (46.4% versus 22.9% for HIV‐positive men) and the proportion with STI testing in the last 12 months was lower (71.6% versus 87.2%, respectively). In the last 3 months, 56.9% of HIV‐negative/unknown‐status and 74.1% of HIV‐positive men reported STI risk behaviours, of whom 45.8% and 55.1%, respectively, had been tested for STIs during this time. Among HIV‐negative/unknown‐status men, those reporting STI risk behaviours were more likely (AOR 1.52; 95% CI 1.26–1.84) and those with poor STI knowledge less likely (AOR 0.73; 95% CI 0.61–0.89) to have been tested during the last 3 months. However, neither factor was independently associated with 3‐monthly testing among HIV‐positive men.

Conclusions

Improving STI knowledge, especially among HIV‐negative/unknown‐status men, and promoting frequent STI testing among men engaging in STI risk behaviours are vital to address the poor sexual health of MSM.

Self-sampling kits to increase HIV testing among black Africans in the UK: the HAUS mixed-methods study

BACKGROUND

Timely diagnosis of human immunodeficiency virus (HIV) enables access to antiretroviral treatment, which reduces mortality, morbidity and further transmission in people living with HIV. In the UK, late diagnosis among black African people persists. Novel methods to enhance HIV testing in this population are needed.

OBJECTIVES

To develop a self-sampling kit (SSK) intervention to increase HIV testing among black Africans, using existing community and health-care settings (stage 1) and to assess the feasibility for a Phase III evaluation (stage 2).

DESIGN

A two-stage, mixed-methods design. Stage 1 involved a systematic literature review, focus groups and interviews with key stakeholders and black Africans. Data obtained provided the theoretical base for intervention development and operationalisation. Stage 2 was a prospective, non-randomised study of a provider-initiated, HIV SSK distribution intervention targeted at black Africans. The intervention was assessed for cost-effectiveness. A process evaluation explored feasibility, acceptability and fidelity.

SETTING

Twelve general practices and three community settings in London.

MAIN OUTCOME MEASURE

HIV SSK return rate.

RESULTS

Stage 1 - the systematic review revealed support for HIV SSKs, but with scant evidence on their use and clinical effectiveness among black Africans. Although the qualitative findings supported SSK distribution in settings already used by black Africans, concerns were raised about the complexity of the SSK and the acceptability of targeting. These findings were used to develop a theoretically informed intervention. Stage 2 - of the 349 eligible people approached, 125 (35.8%) agreed to participate. Data from 119 were included in the analysis; 54.5% (65/119) of those who took a kit returned a sample; 83.1% of tests returned were HIV negative; and 16.9% were not processed, because of insufficient samples. Process evaluation showed the time pressures of the research process to be a significant barrier to feasibility. Other major barriers were difficulties with the SSK itself and ethnic targeting in general practice settings. The convenience and privacy associated with the SSK were described as beneficial aspects, and those who used the kit mostly found the intervention to be acceptable. Research governance delays prevented implementation in Glasgow.

LIMITATIONS

Owing to the study failing to recruit adequate numbers (the intended sample was 1200 participants), we were unable to evaluate the clinical effectiveness of SSKs in increasing HIV testing in black African people. No samples were reactive, so we were unable to assess pathways to confirmatory testing and linkage to care.

CONCLUSIONS

Our findings indicate that, although aspects of the intervention were acceptable, ethnic targeting and the SSK itself were problematic, and scale-up of the intervention to a Phase III trial was not feasible. The preliminary economic model suggests that, for the acceptance rate and test return seen in the trial, the SSK is potentially a cost-effective way to identify new infections of HIV.

FUTURE WORK

Sexual and public health services are increasingly utilising self-sampling technologies. However, alternative, user-friendly SSKs that meet user and provider preferences and UK regulatory requirements are needed, and additional research is required to understand clinical effectiveness and cost-effectiveness for black African communities.

STUDY REGISTRATION

This study is registered as PROSPERO CRD42014010698 and Integrated Research Application System project identification 184223.

FUNDING

The National Institute for Health Research Health Technology Assessment programme and the BHA for Equality in Health and Social Care.

Awareness of and attitudes to sexually transmissible infections among gay men and other men who have sex with men in England: a qualitative study

Background Rates of sexually transmissible infections (STIs) have increased over recent years among gay men and other men who have sex with men (MSM) in England and Wales. HIV diagnoses remain high in this group and men with diagnosed HIV are disproportionally affected by STIs. MSM are therefore a priority for health promotion efforts to reduce STIs. Understanding awareness of and attitudes towards STIs is essential in developing health promotion interventions to reduce prevalence. Methods: Eight focus group discussions (FGDs) with a total of 61 MSM in four English cities included a ranking exercise to gauge how ‘scary’ participants thought 11 STIs are. The exercise sought insights into participants’ awareness of, knowledge about and attitudes towards STIs and blood-borne viruses (BBVs). FGDs were audio-recorded, transcribed and data analysed thematically. Results: All groups ranked HIV and Hepatitis C virus (HCV) as the scariest infections, and the majority ranked syphilis and herpes as highly scary. Scabies was ranked as the least scary by most groups. Rankings were dependent on how well informed participants felt about an infection, its transmission mechanisms, health affect and the availability of vaccines and treatment. Personal experience or that of friends influenced perceptions of particular infections, as did their prevalence, treatment options, visibility of symptoms and whether an STI could be cleared from the body. Conclusions: The study findings suggest that, although some MSM are well informed, there is widespread lack of knowledge about the prevalence, modes of transmission, health implications and treatment regimens of particular STIs.

Protocol, rationale and design of SELPHI: a randomised controlled trial assessing whether offering free HIV self-testing kits via the internet increases the rate of HIV diagnosis

BACKGROUND

Among men who have sex with men (MSM) in the UK, an estimated 28% have never tested for HIV and only 27% of those at higher risk test at least every 6 months. HIV self-testing (HIVST), where the person takes their own blood/saliva sample and processes it themselves, offers the opportunity to remove many structural and social barriers to testing. Although several randomised controlled trials are assessing the impact of providing HIVST on rates of HIV testing, none are addressing whether this results in increased rates of HIV diagnoses that link to clinical care. Linking to care is the critical outcome because it is the only way to access antiretroviral treatment (ART). We describe here the design of a large, internet-based randomised controlled trial of HIVST, called SELPHI, which aims to inform this key question.

METHODS/DESIGN

The SELPHI study, which is ongoing is promoted via social networking website and app advertising, and aims to enroll HIV negative men, trans men and trans women, aged over 16 years, who are living in England and Wales. Apart from the physical delivery of the test kits, all trial processes, including recruitment, take place online. In a two-stage randomisation, participants are first randomised (3:2) to receive a free baseline HIVST or no free baseline HIVST. At 3 months, participants allocated to receive a baseline HIVST (and meeting further eligibility criteria) are subsequently randomised (1:1) to receive the offer of regular (every 3 months) free HIVST, with testing reminders, versus no such offer. The primary outcome from both randomisations is a laboratory-confirmed HIV diagnosis, ascertained via linkage to a national HIV surveillance database.

DISCUSSION

SELPHI will provide the first reliable evidence on whether offering free HIVST via the internet increases rates of confirmed HIV diagnoses and linkage to clinical care. The two randomisations reflect the dual objectives of detecting prevalent infections (possibly long-standing) and the more rapid diagnosis of incident HIV infections. It is anticipated that the results of SELPHI will inform future access to HIV self-testing provision in the UK.

TRIAL REGISTRATION

DOI 10.1186/ISRCTN20312003 registered 24/10/2016.

An initial typology of contexts of dyadic sexual encounters between men and associations with sexual risk and pleasure: findings from an observational study

Background Although many within-subjects comparisons conducted on samples of men who have sex with men have sought to understand the association between specific situational characteristics (e.g. drug use or location of sex) and sexual risk behaviour, none have considered the 'clustering' of patterns of situational characteristics. An initial typology of sexual encounters is derived and the relationship of this typology to condomless anal intercourse (CAI) and pleasure is tested.

METHODS

Data from a longitudinal survey of men who have sex with men living in England were used. Multilevel latent class analyses were estimated to determine an optimal class solution on the situational characteristics, and then pseudo-imputation was used to estimate the association between class and both CAI and pleasure.

RESULTS

A three-class solution fit the data best, with a scaled relative entropy of 92.4%. Classes were characterised as featuring: regular steady partners in private locations with low drug use (class 1), casual partners with increased probability of sex occurring in a sex-on-premises venue (class 2), and high levels of polydrug use together with increased probability of casual partners (class 3). Encounters were different both in pairwise comparisons and overall on probability of CAI. They were different overall but not necessarily pairwise on pleasure.

CONCLUSIONS

These initial findings demonstrate the possibility of understanding sexual encounters in terms of the contexts, or classes, within which they occur. This may have implications for tailoring HIV prevention to specific encounter types. Future research should seek to extend encounter-level typologies to specific drug use variables.