Interest in I-PrEP and Willingness to Participate in Clinical Trials Among Men and Transfeminine Persons Who have Sex with Men in Sub-Saharan Africa: Quantitative and Qualitative Findings from HPTN 075

This study explored interest in injectable PrEP (I-PrEP) and willingness to participate in clinical trials testing new biomedical HIV prevention strategies among men and transfeminine persons who have sex with men (MSM & TGP), using data collected in the HIV Prevention Trials Network (HPTN) 075 study, which took place at sites in Kenya, Malawi, and South Africa. Data result from a survey among 267 18-44 years old HIV negative participants, complemented with semi-structured interviews with 80 purposively recruited persons. Correlations coefficients were calculated to identify demographic and psychosocial factors associated with interest in I-PrEP. Qualitative interviews were analyzed using concept-driven and subsequent data-driven coding. Most surveyed participants expressed an interest in I-PrEP. Quantitatively, only being interested in other HIV prevention measures was associated with interest in I-PrEP. Qualitatively, most participants preferred I-PrEP to O-PrEP and remained interested in I-PrEP despite barriers such as the somewhat invasive nature of the procedure and potential side effects of I-PrEP. Interest in I-PrEP was driven by the possibility of avoiding sexual or HIV stigma. Access to healthcare and altruism-such as assisting in the development of new HIV prevention methods-positively impacted willingness to participate in clinical trials. With I-PrEP favored by most participants, it is potentially a critical tool to prevent HIV infection among MSM & TGP in sub-Saharan Africa, with the mitigation of stigma as a major advance. Recruitment of MSM & TGP in biobehavioral clinical trials seems feasible, with altruistic reasons and receiving I-PrEP and free medical care as major motivators.

A Systematic Review of Intervention Studies That Address HIV-Related Stigmas Among US Healthcare Workers and Health Systems: Applying a Theory-Based Ontology to Link Intervention Types, Techniques, and Mechanisms of Action to Potential Effectiveness

BACKGROUND

To end the HIV epidemic, we need to better understand how to address HIV-related stigmas in healthcare settings, specifically the common theoretical bases across interventions so that we can generalize about their potential effectiveness.

PURPOSE

We describe theory-based components of stigma interventions by identifying their functions/types, techniques, and purported mechanisms of change.

METHODS

This systematic review examined studies published by April 2021. We applied a transtheoretical ontology developed by the Human Behaviour Change Project, consisting of 9 intervention types (ITs), 93 behavior change techniques (BCTs), and 26 mechanisms of action (MOAs). We coded the frequency and calculated the potential effectiveness of each IT, BCT, and MOA. We evaluated study quality with a 10-item adapted tool.

RESULTS

Among the nine highest quality studies, indicated by the use of an experimental design, the highest potentially effective IT was "Persuasion" (i.e. using communication to induce emotions and/or stimulate action; 66.7%, 4/6 studies). The highest potentially effective BCTs were "Behavioral practice/rehearsal" (i.e. to increase habit and skill) and "Salience of consequences" (i.e. to make consequences of behavior more memorable; each 100%, 3/3 studies). The highest potentially effective MOAs were "Knowledge" (i.e. awareness) and "Beliefs about capabilities" (i.e. self-efficacy; each 67%, 2/3 studies).

CONCLUSIONS

By applying a behavior change ontology across studies, we synthesized theory-based findings on stigma interventions. Interventions typically combined more than one IT, BCT, and MOA. Practitioners and researchers can use our findings to better understand and select theory-based components of interventions, including areas for further evaluation, to expedite ending the HIV epidemic.

HIV risk perception and sexual behavior among HIV-uninfected men and transgender women who have sex with men in sub-Saharan Africa: Findings from the HPTN 075 qualitative sub-study

There remains a limited understanding of how men who have sex with men (MSM) and transgender women (TGW) in sub-Saharan Africa (SSA) perceive their risk for HIV and how risk influences behavior during sexual interactions. We performed thematic analysis on in-depth interviews from the qualitative sub-study of HPTN 075 in Kenya, Malawi, and South Africa. Using the Integrated Behavioral Model (IBM) constructs, we found that most MSM and TGW perceived themselves to be at risk for HIV, leading them to regularly engage in safer sexual behaviors. Notably, even though these MSM and TGW perceived themselves to be at risk for HIV, some of them reported engaging in transactional sex, sex under the influence of alcohol, and intentional non-use of condoms. This indicates that HIV risk perception was not always associated with safer sexual behaviors or a reduction in risk behaviors. Attitudes (negative attitudes toward condom use), perceived norms (social pressures), and environment constraints (contextual barriers) were related to MSM and TGW not engaging in safe sexual behavior. Hearing the perspectives of MSM and TGW on their sexual behavior continues to be important for the development and implementation of effective prevention policies and interventions. Eliminating structural barriers such as stigma, discrimination, and criminalization of same-sex sexuality is a crucial prerequisite for the success of interventions to promote sexual health among MSM and TGW in SSA.

Psychological Problems Mediate the Relationship Between Minority Stress and HIV Sexual Risk Among Nigerian Men Who Have Sex with Men: Testing the Minority Stress Model

Gay, bisexual, and other men who have sex with men (GBMSM) in Nigeria bear a disproportionately higher burden of HIV. Meyer's minority stress theory posits that social stress due to the discrimination, violence, and stigma experienced by lesbian, gay, and bisexual men and women (LGBs)-due to their sexual orientation-may contribute to psychological problems, including mental health problems, substance use, and HIV sexual risk-taking. Between March and June 2019, we recruited 406 GBMSM from four states in Nigeria (Abuja, Delta, Lagos, and Plateau) to complete a cross-sectional survey at local community-based organizations. We utilized structural equation modeling to test whether psychological problems and substance use mediated the relationship between minority stress and HIV sexual risk-taking (condomless anal sex and number of sexual partners) among GBMSM in Nigeria. Minority stress (β = 0.60, 95% CI: 0.44-0.72, p ≤ .001), substance use (β = 0.43, 95% CI: 0.27-0.59, p = .004), and psychological problems (β = 0.35, 95% CI: 0.28-0.45 p = .012) had moderate associations with HIV sexual risk-taking. We found that psychological problems mediated the relationship between minority stress and HIV sexual risk-taking. Interventions focused on addressing psychological problems may help mitigate the effects of minority stress on HIV sexual risk-taking among GBMSM in Nigeria.

Human Immunodeficiency Virus (HIV) Drug Resistance, Phylogenetic Analysis, and Superinfection Among Men Who Have Sex with Men and Transgender Women in Sub-Saharan Africa: HIV Prevention Trials Network (HPTN) 075 Study

BACKGROUND

The HIV Prevention Trials Network (HPTN) 075 study evaluated the feasibility of enrolling and retaining men who have sex with men (MSM) and transgender women (TGW) from Kenya, Malawi, and South Africa. During the study follow-up, 21 participants acquired human immunodeficiency virus (HIV) (seroconverters). We analyzed HIV subtype diversity, drug resistance, transmission dynamics, and HIV superinfection data among MSM and TGW enrolled in HPTN 075.

METHODS

HIV genotyping and drug resistance testing were performed for participants living with HIV who had viral loads >400 copies/mL at screening (prevalent cases, n = 124) and seroconverters (n = 21). HIV pol clusters were identified using Cluster Picker. Superinfection was assessed by a longitudinal analysis of env and pol sequences generated by next-generation sequencing.

RESULTS

HIV genotyping was successful for 123/124 prevalent cases and all 21 seroconverters. The major HIV subtypes were A1 (Kenya) and C (Malawi and South Africa). Major drug resistance mutations were detected in samples from 21 (14.6%) of 144 participants; the most frequent mutations were K103N and M184V/I. Phylogenetic analyses identified 11 clusters (2-6 individuals). Clusters included seroconverters only (n = 1), prevalent cases and seroconverters (n = 4), and prevalent cases only (n = 6). Superinfections were identified in 1 prevalent case and 2 seroconverters. The annual incidence of superinfection was higher among seroconverters than among prevalent cases, and was higher than the rate of primary HIV infection in the cohort.

CONCLUSIONS

This report provides important insights into HIV genetic diversity, drug resistance, and superinfection among MSM and TGW in sub-Saharan Africa. These findings may help to inform future HIV prevention interventions in these high-risk groups.

HIV incidence in a multinational cohort of men and transgender women who have sex with men in sub-Saharan Africa: Findings from HPTN 075

Few studies have assessed HIV incidence in men who have sex with men (MSM) and transgender women (TGW) in sub-Saharan Africa (SSA). We assessed HIV incidence and its correlates among MSM and TGW in SSA enrolled in the prospective, multi-country HIV Prevention Trials Network (HPTN) 075 study, conducted from 2015 to 2017. Participants were enrolled at four sites in SSA (Kisumu, Kenya; Blantyre, Malawi; Cape Town and Soweto, South Africa). Eligible participants reported male sex assignment at birth, were 18 to 44 years of age, and had engaged in anal intercourse with a man in the preceding three months. Participation involved five study visits over 12 months. Visits included behavioral assessments and testing for HIV and sexually transmitted infections. Twenty-one of 329 persons acquired HIV during the study [incidence rate: 6.96/100 person-years (PY) (95% CI: 4.3, 10.6)]. Among TGW, HIV incidence was estimated to be 8.4/100 PY (95% CI: 2.3, 21.5). Four participants were found to have acute HIV infection at their first HIV-positive visit. HIV incidence varied among the four study sites, ranging from 1.3/100 PY to 14.4/100 PY. In multivariate longitudinal analysis, factors significantly associated with HIV acquisition were engagement in unprotected receptive anal intercourse [adjusted hazard ratio (AHR) 5.8, 95% confidence interval (CI): 2.4, 14.4] and incident rectal gonorrhea and/or chlamydia (AHR: 2.7, 95% CI: 1.1, 6.8). The higher HIV incidence in Cape Town compared to Blantyre could be explained by the higher prevalence of several risk factors for HIV infection among participants in Cape Town. Annual HIV incidence observed in this study is substantially higher than reported HIV incidence in the general populations in the respective countries and among MSM in the United States. Intensification of HIV prevention efforts for MSM and TGW in SSA is urgently needed.

Uptake of antiretroviral treatment and viral suppression among men who have sex with men and transgender women in sub-Saharan Africa in an observational cohort study: HPTN 075

Objectives:

HPTN 075 enrolled men who have sex with men (MSM) and transgender women (TGW) in sub-Saharan Africa. Persons in HIV care or on antiretroviral treatment (ART) were not eligible to enroll. We evaluated antiretroviral (ARV) drug use, viral suppression, and drug resistance in this cohort over a 12-month follow-up period.

Methods:

Assessments included 64 participants with HIV (39 MSM, 24 TGW, and one gender not specified). ARV drugs were detected using a qualitative assay. Viral load (VL) and drug resistance testing were performed using commercial assays.

Results:

Over 12 months, the proportion of participants using ARV drugs increased from 28.1% to 59.4% and the proportion with VLs <400 copies/mL increased from 21.9% to 57.8%. The rate of ART failure (detection of drugs without viral suppression) was similar at screening and 12 months (12.0% and 11.1%, respectively) and was similar among MSM and TGW. Two participants developed HIV drug resistance during follow-up.

Conclusions:

Over 12 months, ARV drug use in the cohort more than doubled and viral suppression increased nearly threefold without a significant increase in ART failure or drug resistance. These results suggest that ART can be successfully scaled up for HIV prevention and treatment in this high-risk population.

Experiences of minority stress among gay, bisexual, and other men who have sex with men (GBMSM) in Nigeria, Africa: The intersection of mental health, substance use, and HIV sexual risk behavior

Nigerian gay, bisexual, and other men who have sex with men (GBMSM) experience social marginalisation, discrimination and violence due to their sexual orientation and same-sex attraction, which may affect mental health, substance use, and HIV sexual risk behavior. The goal of the current study was to conduct formative qualitative research to gain better understanding of these issues among GBMSM in Lagos, Nigeria. Face-to-face, semi-structured, in-depth interviews were conducted with 30 GBMSM in Lagos, Nigeria. Data were analysed using a deductive content analysis approach. We found that Nigerian GBMSM experienced both general life stressors as well as proximal and distal sexual minority identity stressors, including rejection by family members, harassment, and physical violence perpetrated by the general public and police officers. Participants described dealing with mental health problems within the context of family rejection, experienced stigma due to sexual orientation, and feelings of social isolation. Substance use was described as occurring within the context of social settings. Lastly, some participants mentioned that they engaged in risky sexual behaviour while under the influence of alcohol and drugs. These findings call for comprehensive and innovative, GBMSM-affirming behavioural healthcare, substance cessation services, and innovative HIV prevention interventions specifically designed and tailored for Nigerian GBMSM.

Validation of depressive symptoms, social support, and minority stress scales among gay, bisexual, and other men who have with men (GBMSM) in Nigeria, Africa: a mixed methods approach

BACKGROUND

Gay, bisexual, and other men who have sex with men (GBMSM) in Nigeria experience social marginalization, discrimination and violence due to their sexual identity, which may negatively impact physical, mental, and sexual health outcomes. Studies on GBMSM in Africa utilize measurement scales developed largely for populations in the Global North. The validity and reliability of these instruments-to our knowledge-have never been thoroughly investigated among GBMSM in Nigeria. The aim of the current study was to determine the validity and reliability of the English versions of the Center for Epidemiologic Studies Depression Scale (CESD-R), Multidimensional Scale of Perceived Social Support (MSPSS), and LGBT Minority Stress Measure among a large multi-state sample of GBMSM Nigeria.

METHODS

Between January and June 2019, we conducted cognitive interviews (N = 30) and quantitative assessments (N = 406) with GBMSM in Nigeria. The cognitive interviews assessed comprehension of scale items and elicited suggestions for scale modifications. The quantitative assessment was used to gather psychosocial health data and to evaluate psychometric properties and construct validity of the modified scales. We utilized confirmatory factor analysis to assess factor structure, correlation coefficients, and Cronbach's alpha to examine scale validity and internal consistency.

RESULTS

Based on participant feedback from the cognitive interviews, we made slight modifications (i.e., culturally appropriate word substitutions) to all three scales. Results of quantitative analyses indicated good psychometric properties including high factor loadings, internal consistency and construct validity among the CESD-R, MSPSS, and LGBT Minority Stress Measure among GBMSM in Nigeria.

CONCLUSION

These results suggests that modifying research scales to be more culturally relevant likely do not jeopardize their validity and reliability. We found that modified scales measuring depressive symptoms, perceived social support, and minority stress among GBMSM in Nigeria remained valid. More research is needed to explore whether the psychometric properties remain if the scales are translated into broken English (Pidgin) and other traditional Nigerian languages (Yoruba, Igbo and Hausa).

Substance Use and Depression Among Recently Migrated African Gay and Bisexual Men Living in the United States

Immigrant African gay and bisexual men (GBM) are at risk for substance use and adverse mental health outcomes due to negative experiences in home and host countries. Little is known about correlates of substance use and mental health outcomes in this population. We explored pre- and post-migratory factors associated with substance use and depression in recently migrated African GBM. Participants (N = 70) were recruited between July and November 2015 in NYC. Eligible participants were administered a structured questionnaire. Correlates of substance use and depression were identified using bivariate and multivariable analyses. Factors independently associated with current substance use were age, openness about sexual orientation, homophobic experiences in home country, forced sex in home country, current housing instability, and internalized homophobia. Factors independently associated with depression were post-traumatic stress disorder symptoms and alcohol use. Substance use and depression were associated with negative experiences in home and host country.

HIV testing and self-reported HIV status in South African men who have sex with men: results from a community-based survey

OBJECTIVE

To investigate the characteristics of South African men who have sex with men (MSM) who (1) have been tested for HIV and (2) are HIV positive.

METHODS

Data were collected from 1045 MSM in community surveys using questionnaires that were administered either face-to-face, by mail or on the internet. The mean age of the men was 29.9 years. The race distribution was 35.3% black, 17.0% coloured, 5.3% Indian and 41.1% white.

RESULTS

The proportion of MSM tested for HIV was 69.7%; having been tested was independently associated with being older, being more open about one's homosexuality and being homosexually instead of bisexually attracted; black MSM, students and MSM living in KwaZulu-Natal were less likely to have been tested. Of the 728 MSM who had been tested, 14.1% (n = 103) reported to be HIV positive (9.9% of the total sample). Being HIV positive is independently associated with two factors: men who were positive were more likely to have a lower level of education and to know other people who had HIV/AIDS; race was not independently associated with HIV status among those who had been tested.

CONCLUSIONS

The likelihood of having been tested for HIV seems to decrease with increasing social vulnerability. Racially, the distribution of HIV among MSM seems to differ from that of the general South African population, suggesting that while intertwined with the heterosexual epidemic there is also an epidemic among South African MSM with specific dynamics. These findings suggest that in-depth research is urgently needed to address the lack of understanding of HIV testing practices and HIV prevalence in South African MSM.

Same-sex sexuality and quality of life: findings from the Netherlands Mental Health Survey and Incidence Study

This study assessed differences in quality of life (QL) between homosexual and heterosexual people and attempted to identify factors accounting for observed differences. Data were collected in a representative sample of the Dutch population aged 18-64 (N = 7,076). Classification as heterosexual or homosexual was based upon reported sexual behavior in the preceding year; 84.8% of the total sample (N = 5,998) could be classified: 2.8% of 2,878 sexually active men and 1.4% of 3,120 sexually active women had had same-sex partners. Differences in QL were tested by analysis of variance. Factors accounting for observed differences in QL were identified by selecting determinants of QL on which homosexual and heterosexual people differed and including them with same-sex sexuality in multiple regression analyses. Homosexual men, but not women, differed from their heterosexual counterparts on various dimensions of QL. Lesser QL in homosexual men was predominantly explained by self-esteem and mastery. Same-sex sexuality contributed independently to some of the observed differences. Although same-sex sexuality is related to QL in men, the lack of association in women suggests that the link is mediated by other factors, indicating the need to explore in what respect the situation of homosexual men and women differs. This study also suggests the importance of finding out how lower sense of self-esteem and of mastery come about in homosexual men.