High HIV-1 incidence, correlates of HIV-1 acquisition, and high viral loads following seroconversion among MSM

Awareness and Acceptability of pre-exposure prophylaxis (PrEP) among gay, bisexual and other men who have sex with men (GBMSM) in Kenya

Kenyan gay, bisexual, and other men who have sex with men (GBMSM) are significantly affected by HIV. Pre-exposure prophylaxis (PrEP) is an effective biomedical approach to HIV prevention. We conducted a cross-sectional survey of 459 HIV-negative Kenyan GBMSM to assess individual and interpersonal correlates of PrEP awareness/acceptability using univariate and hierarchical logistic regression modeling. We found that 64.3% of participants had heard of PrEP and 44.9% were willing to use PrEP. In hierarchical logistic regression models for PrEP awareness, condom use with regular partners, higher condom use self-efficacy, higher perceived ability to use PrEP, history of STI, and membership in LGBT organization were significantly associated with being aware of PrEP (χ2 = 69.6, p < .001). In hierarchical logistic regression models for PrEP acceptability, higher self-esteem, higher condom use self-efficacy, depression/anxiety, higher perceived ability to use PrEP, willingness to engage in PrEP follow-up visits, coercion at sexual debut, and family exclusion were significantly associated with being acceptable to PrEP (χ2 = 231.8, p < .001). Individual and interpersonal factors were significantly associated with PrEP awareness and acceptability. Our findings underscore the need to promote awareness and understanding of PrEP as an effective HIV prevention tool in combination with other safer-sex methods that are appropriate given an individual's personal circumstances.

Trends and predictors of new HIV diagnosis and time since last test at testing encounters among adults in Kilifi, Kenya, 2006-2017

Background: Little is known about HIV retesting uptake among key populations (KP) and general populations (GP) in Kenya. We assessed trends and predictors of new HIV diagnosis, first-time testing (FTT), and late retesting (previous test more than one year ago for GP or three months for KP). Methods: Data was collected routinely at three voluntary counselling and testing (VCT) centres in Kilifi County between 2006 and 2017. We analysed test encounters among adults 18-39 years, categorized as GP men, GP women, men who have sex with men (MSM), and female sex workers (FSW).     Results: Based on 25,670 test encounters (32% FTT), we observed significant declines in HIV positivity (proportion of encounters with a new HIV diagnosis) among GP men, GP women, and first-time testers, but not among MSM and FSW. FTT and late retesting decreased for both GP and KP, but remained much higher in KP than GP. In 2017, less than 20% of KP were testing quarterly as recommended. HIV positivity was higher at FTT and late retesting encounters (relative to on-time retesting); at FSW and MSM encounters; and at encounters with clients reporting lower educational attainment, sexually transmitted infection (STI) symptoms, or no religious affiliation. HIV positivity was lower in GP men and younger clients. FTT was associated with town, risk group, age 18-24 years, never-married status, low educational attainment, and STI symptoms. Late retesting was less common among encounters with GP individuals who were never married, had Muslim or no religious affiliation, had lower educational attainment, or reported STI symptoms. Conclusions: New HIV diagnoses were most common among first-time testers and late re-testers. While late retesting decreased steadily over the period reviewed, achievement of the county's 90% HIV diagnosis target will require redoubled efforts to increase retesting among the most at risk populations.

Changes in risky sexual behaviours among West African MSM enrolled in a quarterly HIV testing and counselling prevention programme (CohMSM ANRS 12324 - Expertise France)

OBJECTIVES

Whether regular HIV testing and counselling reduce risky sexual behaviours in African men who have sex with men (MSM) is still a matter for debate. We aimed to identify behavioural trajectories based on HIV risk exposure (HRE) and factors affecting their evolution.

METHODS

Data were collected from 621 HIV-negative West African MSM (Mali, Cote d'Ivoire, Burkina Faso and Togo) included in a community-based cohort providing quarterly HIV testing and counselling. Sociobehavioural data were collected every 6 months. HRE was defined as reporting inconsistent condom use during receptive anal sex with male partners of unknown HIV status in the previous 6 months. Using 18-month follow-up data, group-based trajectory modelling helped identify behavioural trajectories and determine the factors associated with their evolution. HIV seroconversions (n=67) were specified in each group trajectory.

RESULTS

Two distinct group trajectories were identified: medium-risk exposure MSM (ME-MSM) (61%, 6.4% of whom having seroconverted) and high-risk exposure MSM (HE-MSM) (39%, 17.5% of whom having seroconverted). A significant declining trend in the probability of reporting HRE over time ((95% CI)) was observed for HE-MSM (from 0.59 (0.48 to 0.70) at M0 to 0.31 (0.22 to 0.41) at M18), while it remained constant for ME-MSM (0.034 (0.0 to 0.079)). This can be explained by a progressive use of risk reduction strategies (less receptive anal sex, better knowledge of their partners' status and increasing condom use). Being younger, living in Burkina Faso, self-considering both a man and a woman and reporting a higher level of depression were all associated with HE membership. Among HE-MSM, HRE was higher in those practising transactional or group sex and those experiencing psychological harassment.

CONCLUSIONS

Quarterly HIV testing and counselling seem to reduce risky sexual behaviours in HIV-negative MSM at greatest risk of infection. Specific support for young MSM, focusing on identity and mental health, is needed to strengthen HIV prevention in West African MSM.

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

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

Combining Viral Genetics and Statistical Modeling to Improve HIV-1 Time-of-infection Estimation towards Enhanced Vaccine Efficacy Assessment

Knowledge of the time of HIV-1 infection and the multiplicity of viruses that establish HIV-1 infection is crucial for the in-depth analysis of clinical prevention efficacy trial outcomes. Better estimation methods would improve the ability to characterize immunological and genetic sequence correlates of efficacy within preventive efficacy trials of HIV-1 vaccines and monoclonal antibodies. We developed new methods for infection timing and multiplicity estimation using maximum likelihood estimators that shift and scale (calibrate) estimates by fitting true infection times and founder virus multiplicities to a linear regression model with independent variables defined by data on HIV-1 sequences, viral load, diagnostics, and sequence alignment statistics. Using Poisson models of measured mutation counts and phylogenetic trees, we analyzed longitudinal HIV-1 sequence data together with diagnostic and viral load data from the RV217 and CAPRISA 002 acute HIV-1 infection cohort studies. We used leave-one-out cross validation to evaluate the prediction error of these calibrated estimators versus that of existing estimators and found that both infection time and founder multiplicity can be estimated with improved accuracy and precision by calibration. Calibration considerably improved all estimators of time since HIV-1 infection, in terms of reducing bias to near zero and reducing root mean squared error (RMSE) to 5-10 days for sequences collected 1-2 months after infection. The calibration of multiplicity assessments yielded strong improvements with accurate predictions (ROC-AUC above 0.85) in all cases. These results have not yet been validated on external data, and the best-fitting models are likely to be less robust than simpler models to variation in sequencing conditions. For all evaluated models, these results demonstrate the value of calibration for improved estimation of founder multiplicity and of time since HIV-1 infection.

PrEP interest and HIV-1 incidence among MSM and transgender women in coastal Kenya

INTRODUCTION

There is emerging data on HIV-1 incidence among MSM in sub-Saharan Africa (SSA), but no known estimate of HIV-1 incidence among transgender women (TGW) in the region has yet been reported. We assessed HIV-1 incidence and pre-exposure prophylaxis (PrEP) interest in men who have sex with men exclusively (MSME), men who have sex with men and women (MSMW) and TGW in coastal Kenya.

METHODS

HIV-1-seronegative individuals who had participated in an HIV testing study in 2016 were traced and retested in 2017 according to Kenyan guidelines. All participants were assigned male sex at birth and had male sex partners; additional data on gender identity and sexual orientation were obtained. We assessed the factors associated with HIV-1 acquisition using Poisson regression and calculated HIV-1 incidence in MSME, MSMW and TGW. PrEP interest was assessed through focus group discussions to characterize subcategories' perceived PrEP needs.

RESULTS

Of the 168 cohort participants, 42 were classified as MSME, 112 as MSMW and 14 as TGW. Overall, HIV-1 incidence was 5.1 (95% confidence interval (CI): 2.6 to 9.8) per 100 person-years (PY): 4.5 (95% CI: 1.1 to 17.8] per 100 PY among MSME, 3.4 (95% CI: 1.3 to 9.1) per 100 PY among MSMW and 20.6 (95% CI: 6.6 to 63.8] per 100 PY among TGW. HIV-1 acquisition was associated with exclusive receptive anal intercourse (aIRR 13.0, 95% CI 1.9 to 88.6), history of an STI in preceding six months (aIRR 10.3, 95% CI 2.2 to 49.4) and separated/divorced marital status (aIRR 8.2 (95%: 1.1 to 62.2). Almost all (98.8%) participants were interested in initiating PrEP. MSME and TGW felt that PrEP would lead to increases in condomless anal or group sex.

CONCLUSIONS

TGW had a very high HIV-1 incidence compared with MSME and MSMW. Subcategories of MSM anticipated different PrEP needs and post-PrEP risk behaviour. Further studies should assess if TGW may have been wrongly categorized as MSM in other HIV-1 incidence studies in the region.

HIV testing and the HIV care continuum among sub-Saharan African men who have sex with men and transgender women screened for participation in HPTN 075

Throughout the world, men who have sex with men (MSM) are at increased risk for HIV infection compared to heterosexual men. Little is known about awareness of HIV infection and other gaps in the HIV care continuum for MSM, especially in sub-Saharan Africa (SSA). This information is urgently needed to address the HIV epidemic in this population. This study assessed gaps in the HIV care continuum among persons screened for participation in a multi-country prospective study that evaluated the feasibility of recruiting and retaining MSM for HIV prevention studies in SSA (HIV Prevention Trials Network (HPTN) 075, conducted in four cities in Kenya, Malawi, and South Africa). Participants were recruited using site-specific strategies, that included outreach and informal networks. Transgender women (TW) were eligible to participate. During screening, 601 MSM and TW were tested for HIV infection and asked about prior HIV testing, HIV status, engagement in care, and HIV treatment. Viral load testing and retrospective antiretroviral (ARV) drug testing were performed for HIV-infected participants. Most participants (92.2%) had a prior HIV test; 42.1% were last tested >6 months earlier. HIV prevalence was 30.4%. HIV infection was associated with older age and identifying as female or transgender; 43.7% of the HIV-infected participants were newly diagnosed, especially younger persons and persons with a less recent HIV test. Almost a third of previously-diagnosed participants were not linked to care. Most participants (88.7%) in care were on ARV treatment (ART). Only about one-quarter of all HIV-infected participants were virally suppressed. These findings demonstrate substantial prevalence of undiagnosed HIV infection and sub-optimal HIV care engagement among MSM and TW in SSA. Increased HIV testing frequency and better linkage to care represent critical steps in preventing further HIV transmission in this population. Once in care, gaps in the HIV care continuum appear less critical.

Rectal gonorrhoea and chlamydia among men who have sex with men in coastal Kenya

Background: Men who have sex with men (MSM) experience a high burden of Chlamydia trachomatis (CT) and Neisseria gonorrhoea (NG) infections. These remain largely undiagnosed in the context of syndromic treatment. In Kenya, prevalence of rectal CT and NG infection and NG antimicrobial sensitivity are poorly described. Methods: MSM who reported receptive anal intercourse (RAI) were recruited from an ongoing human immunodeficiency virus acquisition and treatment study in coastal Kenya in 2016-2017. Rectal swabs were collected at two time points 6 months apart to estimate prevalence of CT/NG using a molecular point-of-care assay. Participants positive for CT or NG were treated according to national guidelines. NG culture and antimicrobial susceptibility testing was performed. Participant and risk behaviour characteristics were collected and association with baseline CT/NG prevalence was assessed by multivariable regression analysis. Results: Prevalence of CT/NG in 104 MSM was 21.2% (CT 13.5%, NG 9.6%, dual infection 1.9%) at baseline and 25% in 84 MSM at follow-up (CT 14.3%, NG 14.3%, dual infection 3.6%). Most CT/NG positive participants were asymptomatic: 95.5% at baseline and 100% at follow-up. CT/NG infection was associated with being paid for sex (aOR=6.2, 95%CI (1.7-22.9)) and being in formal employment (aOR=7.5, 95%CI (1.14-49.2)). Six NG isolates were obtained at follow-up; all isolates were susceptible to ceftriaxone and cefixime (1 st line treatment for NG) and all were resistant to penicillin, tetracycline and ciprofloxacin. Conclusions: The high prevalence of asymptomatic rectal CT and NG in MSM reporting RAI demonstrates the need for frequent screening or presumptive treatment. MSM who were paid for sex or had formal employment were more likely to be infected with CT/NG, suggesting increased risk behaviour during transactional sex. Antimicrobial susceptibility results suggest that current antibiotic choices in Kenya are appropriate for NG treatment.

HIV prevalence, spatial distribution and risk factors for HIV infection in the Kenyan fishing communities of Lake Victoria

INTRODUCTION

Global efforts to end HIV by 2030 focus on reducing and eventually eliminating new infections in priority populations. Identifying these populations and characterizing their vulnerability factors helps in guiding investment of scarce HIV prevention resources to achieve maximum impact. We sought to establish HIV prevalence, spatial distribution and risk factors for HIV infection in the Kenyan fishing communities of Lake Victoria.

METHODS

We conducted a cross-sectional survey of 2637 people from all the 308 fish-landing beaches on the Kenyan shore of Lake Victoria. The number of participants enrolled at each beach were weighted based on the size of the beach, determined by the number of functional registered boats. We used simple random sampling to select those to be approached for study participation. Consenting participants were privately interviewed about their socio-economic and demographic characteristics and sexual behavior, and were invited for HIV test using the Kenya rapid HIV testing protocol. We used descriptive statistics and multivariate logistic and linear regression for analysis.

RESULTS

We found high HIV prevalence of 32% with significant differences between men (29%) and women (38%). Among men, having an HIV negative sexual partner, being circumcised, increasing number of condom protected sex acts in the preceding month, being younger and being a resident of Homa Bay, Kisumu, Siaya and Busia counties compared to Migori County reduced the risk of HIV infection. For women, being married, having more children with the current spouse, having an HIV negative sexual partner and being a resident of Busia compared to Migori County reduced the risk of HIV infection. We also found that longer distance from the beaches to the nearest public health facilities was associated with increasing cumulative HIV prevalence at the beaches.

CONCLUSION

Fishing communities have high HIV prevalence and may greatly benefit from interventions such as wider ART coverage, couple HIV risk reduction counseling, PrEP use for HIV negative partner at substantial continuous risk, alongside other HIV prevention services that the Kenyan government is currently rolling out. This will additionally require adequate plans to synchronize the provision of these services with the population's routine schedules for all these options to be reasonably accessible to them.

Accuracy of Self-Reported HIV Status Among African Men and Transgender Women Who Have Sex with Men Who were Screened for Participation in a Research Study: HPTN 075

Some HIV-infected individuals in research studies may choose not to disclose knowledge of their HIV status to study staff. We evaluated the accuracy of self-reported HIV status among African men and transgender women who have sex with men and who were screened for a research study. Sixty-seven of 183 HIV-infected participants reported a prior HIV diagnosis. Samples from the remaining 116 participants were tested for antiretroviral (ARV) drugs. Thirty-six of the 116 participants had ARV drugs detected, indicating that they were on antiretroviral treatment; these participants were classified as previously diagnosed based on ARV drug testing. Among participants classified as previously diagnosed, disclosure of a prior HIV diagnosis varied among study sites (p = 0.006) and was more common among those who reported having sex with men only (p = 0.002). ARV drug testing in addition to self-report improves the accuracy for identifying individuals with a prior HIV diagnosis.

HIV-1 subtype diversity, transmission networks and transmitted drug resistance amongst acute and early infected MSM populations from Coastal Kenya

Background

HIV-1 molecular epidemiology amongst men who have sex with men (MSM) in sub-Saharan Africa remains not well characterized. We aimed to determine HIV-1 subtype distribution, transmission clusters and transmitted drug resistance (TDR) in acute and early infected MSM from Coastal Kenya.

Methods

Analysis of HIV-1 partial pol sequences from MSM recruited 2005–2017 and sampled within six months of the estimated date of infection. Volunteers were classified as men who have sex with men exclusively (MSME) or with both men and women (MSMW). HIV-1 subtype and transmission clusters were determined by maximum-likelihood phylogenetics. TDR mutations were determined using the Stanford HIV drug resistance database.

Results

Of the 97 volunteers, majority (69%) were MSMW; 74%, 16%, 9% and 1% had HIV-1 subtypes A1, D, C or G, respectively. Overall, 65% formed transmission clusters, with substantial mixing between MSME and MSMW. Majority of volunteer sequences were either not linked to any reference sequence (56%) or clustered exclusively with sequences of Kenyan origin (19%). Eight (8% [95% CI: 4–16]) had at least one TDR mutation against nucleoside (n = 2 [2%]) and/or non-nucleoside (n = 7 [7%]) reverse transcriptase inhibitors. The most prevalent TDR mutation was K103N (n = 5), with sequences forming transmission clusters of two and three taxa each. There were no significant differences in HIV-1 subtype distribution and TDR between MSME and MSMW.

Conclusions

This HIV-1 MSM epidemic was predominantly sub-subtype A1, of Kenyan origin, with many transmission clusters and having intermediate level of TDR. Targeted HIV-1 prevention, early identification and care interventions are warranted to break the transmission cycle amongst MSM from Coastal Kenya.

Correlates of Rectal Douching Practices Among Men Who Have Sex With Men in Kenya

BACKGROUND

Among men who have sex with men (MSM), rectal douching (RD) has been associated with increased prevalence of human immunodeficiency virus and other sexually transmitted infections. Substances commonly used for RD, especially water-based solutions, could disrupt the rectal epithelium and increase susceptibility to infection. The few existing reports on RD among MSM are primarily in middle- and high-income settings, and to date, no study has focused on RD among MSM in Africa.

METHODS

We conducted a secondary data analysis of programmatic data from key population service centers in western Kenya. Data were extracted from records of clients who identified as MSM and accessed services between January 1, 2014, and September 1, 2016. We compared demographic and behavioral characteristics of men who did and did not practice RD. Logistic regression assessed associations with RD.

RESULTS

Of the 202 MSM in this analysis, 63% engaged in RD. All who engaged in RD used water-based substances. Those who engaged in receptive anal intercourse in the last 3 months were more likely to report RD (odds ratio, 3.19; 95% confidence interval, 1.67-6.07). Among MSM who engaged in sex work, those who practiced RD reported more regular clients per week (2.8 clients vs. 1.3 clients, P = 0.01). Rectal douching practices did not vary by other sexual risk practices.

CONCLUSIONS

Rectal douching is common in this population of Kenyan MSM, especially among those who have recently engaged in receptive anal intercourse, suggesting that a rectal douche that delivers microbicides could be a potential intervention to reduce human immunodeficiency virus/sexually transmitted infection within this population.

South African Men Who Have Sex With Both Men and Women and How They Differ From Men Who Have Sex With Men Exclusively

The label "men who have sex with men" (MSM) is used to categorize a diverse population exclusively on the basis of its sexual behavior. Understanding the diversity that this label comprises is critical for the development of health interventions that effectively reach the various populations subsumed under this label. In this cross-sectional study of South African MSM (N = 480) recruited through respondent-driven sampling (RDS), we explored differences between men who had sex with both men and women (MSMW) and men who had sex with men exclusively (MSME). We found significant differences between these two groups in terms of sexual attraction, sexual identity, sexual preferences, sexual histories, and current sexual practices. MSMW were more likely to be confused about their same-sex attraction, to experience internalized homophobia, and to have paid for sex in the previous year, while MSME were more gender nonconforming and more likely to have been forced to have sex in the previous year. These findings underscore that the MSM label comprises a diverse population and that exclusive sexual engagement with other men is a critical distinction to take into account in understanding this diversity and fully grasping the lived experiences of men who have sex with men.

Prevalence and correlates of and a risk score to identify asymptomatic anorectal gonorrhoea and chlamydia infection among men who have sex with men in Kisumu, Kenya

OBJECTIVES

In settings where laboratory capacity is limited, the WHO recommends presumptive treatment for Neisseria gonorrhoeae (NG) and Chlamydia trachomatis (CT) in asymptomatic men who have sex with men (MSM) at high risk for these infections. However, little is known about how best to target this intervention. We aimed to identify correlates of anorectal NG/CT infection in Kenyan MSM with and without anorectal symptoms and evaluate the performance of an empirical, model-based risk score to identify cases in asymptomatic men.

METHODS

Anorectal NG/CT infections were diagnosed by the Abbott RealTime NG/CT nucleic acid amplification testamong 698 MSM at enrolment into the Anza Mapema study. Multivariable logistic regression was used to identify correlates of anorectal NG/CT infection in men with and without anorectal symptoms. Using coefficients from the final multivariable model for asymptomatic men, we calculated a risk score for each participant. Risk score performance was determined by calculating the sensitivity, specificity and number needed to treat (NNT) to identify one NG/CT infection.

RESULTS

Overall anorectal NG/CT infection prevalence was 5.2% (n=36), of which 58.3% (n=21) were asymptomatic. Factors associated with anorectal NG/CT infection in asymptomatic men were aged 18-24 years (aOR=7.6; 95% CI: 1.7 to 33.2), HIV positive serostatus (aOR=6.9; 95% CI: 2.2 to 21.6) and unprotected anal sex in the past 3 months (aOR=3.8; 95% CI: 1.2 to 11.9). Sensitivity and specificity were optimal (81.0% and 66.1%, respectively) at a model-derived risk score cut-point ≥3, and the NNT was 12.

CONCLUSIONS

A model-derived risk score based on correlates of anorectal NG/CT infection in asymptomatic participants would be sensitive and efficient (i.e, low NNT) for targeting presumptive treatment. If validated in other settings, this risk score could improve on the WHO algorithm and help reduce the burden of asymptomatic anorectal NG/CT infections among MSM in settings where diagnostic testing is not available.

Effect of opioid-substitution therapy and mental health counseling on HIV risk among hepatitis C-infected individuals

Background

Understanding differences in HIV incidence among people living with hepatitis C virus (HCV) can help inform strategies to prevent HIV infection. We estimated the time to HIV diagnosis among HCV-positive individuals and evaluated factors that could affect HIV-infection risk in this population.

Patients and methods

The British Columbia Hepatitis Testers Cohort includes all BC residents (~1.5 million: about a third of all residents) tested for HCV and HIV from 1990 to 2013 and is linked to administrative health care and mortality data. All HCV-positive and HIV-negative individuals were followed to measure time to HIV acquisition (positive test) and identify factors associated with HIV acquisition. Adjusted HRs (aHRs) were estimated using Cox proportional-hazard regression.

Results

Of 36,077 HCV-positive individuals, 2,169 (6%) acquired HIV over 266,883 years of follow-up (overall incidence of 8.1 per 1,000 person years). Overall median (IQR) time to HIV infection was 3.87 (6.06) years. In Cox regression, injection-drug use (aHR 1.47, 95% CI 1.33–1.63), HBV infection (aHR 1.34, 95% CI 1.16–1.55), and being a man who has sex with men (aHR 2.78, 95% CI 2.14–3.61) were associated with higher risk of HIV infection. Opioid-substitution therapy (OST) (aHR 0.59, 95% CI 0.52–0.67) and mental health counseling (aHR 0.48, 95% CI 0.43–0.53) were associated with lower risk of HIV infection.

Conclusion

Injection-drug use, HBV coinfection, and being a man who has sex with men were associated with increased HIV risk and engagement in OST and mental health counseling were associated with reduced HIV risk among HCV-positive individuals. Improving access to OST and mental health services could prevent transmission of HIV and other blood-borne infections, especially in settings where access is limited.

Bias Adjustment Techniques Are Underutilized in HIV Sexual Risk Estimation: A Systematic Review

Background: Valid measurement of determinants of HIV infection among men who have sex with men (MSM) is critical for intervention planning and resource allocation. However, sexual minority research concerning HIV risk often relies on proxy exposures of sexual behaviors such as sexual orientation and partner gender. Inferring high risk sexual behaviors (i.e., condomless anal intercourse) from these proxies inaccurately captures HIV risk, but few studies have attempted to correct for this bias. Methods: We performed a systematic review of methodological practices for estimating risk of HIV infection among MSM. Results: We identified 32 studies in which high risk sexual behavior was assessed: 82% (n = 26) measured and used sexual risk behaviors (e.g., condomless anal intercourse or sexual positioning) to assess risk of HIV infection; 9% (n = 3) used proxy measures; and 9% (n = 3) used both behavior and proxy variables. Various treatments of misclassification reported by investigators included the following: 82% (n = 26) discussed misclassification of sexual behavior as a potential limitation; however, among these studies, no attempts were made to correct misclassification; 12% (n = 4) did not report exposure misclassification, and 6% (n = 2) explicitly considered this information bias and conducted a Bayesian approach to correct for misclassification. Conclusions: Our systematic review indicates that a majority of studies engaging in collecting primary data have taken additional steps to acquire detailed information regarding sexual risk behaviors. However, reliance on population-based surveys may still lead to potentially biased estimates. Thus, bias analytic techniques are potential tools to control for any suspected biases.

An Empiric Risk Score to Guide PrEP Targeting Among MSM in Coastal Kenya

Men who have sex with men (MSM), who have heterogeneous HIV-acquisition risks are not specifically targeted in Kenyan pre-exposure prophylaxis (PrEP) guidelines. We used data from an open cohort, which followed 753 initially HIV-negative MSM participants for more than 1378.5 person-years, to develop an empiric risk score for targeting PrEP delivery. Independent predictors of incident HIV-1 infection in this cohort were an age of 18-24 years, having only male sex partners, having receptive anal intercourse, having any unprotected sex, and having group sex. Poisson model coefficients were used to assign a numeric score to each statistically significant predictor. A risk score of ≥ 1 corresponded to an HIV-1 incidence of ≥ 2.2 [95% confidence interval (CI) 1.2-4.1] and identified 81.3% of the cohort participants as being at high risk for HIV-1 acquisition. The area under the receiver operating characteristic curve was 0.76 (95% CI 0.71-0.80). This empiric risk score may help Kenyan health care providers to assess HIV-1 acquisition risk and encourage PrEP uptake by high-risk MSM.

Unusual and unique distribution of anal high-risk human papillomavirus (HR-HPV) among men who have sex with men living in the Central African Republic

Background

High-risk (HR) human papillomavirus (HPV) infection remains a great concern in relation to African men who have sex with men (MSM), especially those infected with HIV. The prevalence of HR-HPV and associated risk factors was estimated in a cross-sectional observational study covering MSM living in Bangui, Central African Republic.

Methods

MSM receiving care at the Centre National de Référence des Infections Sexuellement Transmissibles et de la Thérapie Antirétrovirale, Bangui, were included. HIV serostatus and socio-demographic and behavioral characteristics were collected. HPV DNA was detected and genotyped on anal swabs using Anyplex™ II HPV28 test (Seegene, South Korea), and HSV DNA by in-house real-time PCR. Logistic regression analyses were used to determine risk factors associated with HPV outcomes.

Results

42 MSM (mean age, 23.2 years; range, 14–39) including 69.1% HIV-1-positive and 30.9% HIV-negative were prospectively enrolled. The prevalence of anal HPV was 69.1%, including 82.7% of HR-HPV which were multiple in 52.0%. The most prevalent genotypes were HPV-35, HPV-58, HPV-59 and HPV-31. While, HPV-16 and HPV-18 were present in a minority of samples. Multiple HR-HPV infection was more frequent in HIV-positive MSM (41.4%) with 2.7 genotypes per anal samples than in HIV-negative (7.7%) with 1.5 genotypes per anal samples. HPV types included in the prophylactic Gardasil-9^® vaccine were detected in 68.9% of specimens and HPV-58 was the most frequently detected. MSM infected by HPV-16 and HPV-18 were all infected by HIV-1. Few anal swabs (11.9%) contained HSV-2 DNA without relationship with HPV detection. Condomless receptive anal intercourse was the main risk factor to being infected with any type of HPV and condomless insertive anal intercourse was significantly less associated with HPV contamination than receptive anal intercourse (Odd ratio = 0.02).

Conclusion

MSM in Bangui are at-risk of HIV and HR-HPV anal infections. The unusual distribution of HPV-35 as predominant HPV suggests possible geographic specificities in the molecular epidemiology of HR-HPV in sub-Saharan Africa. Scaling up prevention strategies against HPV infection and related cancers adapted for MSM in Africa should be prioritized. Innovative interventions should be conceived for the MSM population living in Bangui.

Engaging religious leaders to support HIV prevention and care for gays, bisexual men, and other men who have sex with men in coastal Kenya

In Kenyan communities, religious leaders are important gatekeepers in matters of health and public morality. In a context that is generally homophobic, religious leaders may aggravate or reduce stigmatization of sexual minorities such as gay and bisexual men, and other men who have sex with men (GBMSM). Literature indicates mixed results in efforts to encourage religious leaders to work effectively and sensitively with issues regarding HIV and sexuality. This paper describes the implementation of an engagement intervention with religious leaders from different denominations, which took place following a homophobic hate attack that was led by local religious leaders, at an HIV research clinic for GBMSM on the Kenyan coast. After the homophobic attack, tailored engagement activities, including a comprehensive four-day online sensitivity training course took place between June 2015 and October 2016 in the Kenyan coast. HIV researchers, together with trained GBMSM activists, organized the series of engagement activities for religious leaders which unfolded iteratively, with each subsequent activity informed by the results of the previous one. Facilitated conversations were used to explore differences and disagreements in relation to questions of scripture, mission, HIV, and human sexuality. As a result, researchers noted that many religious leaders, who initially expressed exceedingly negative attitudes towards GBMSM, started to express far more accepting and supportive views of sexuality, sexual identities, and same-sex relations. This paper describes the changes in religious leaders’ discourses relating to GBMSM, and highlights the possibility of using engagement interventions to build trust between research institutes, religious leaders, and GBMSM.

Persistent high-risk behavior and escalating HIV, syphilis and hepatitis B incidences among men who have sex with men living in Bangui, Central African Republic

Introduction

HIV in sub-Saharan Africa remains a great concern in men who have sex with men (MSM). Intervention on MSM is a key strategy to control the burden of HIV among this population. Herein we assessed the effect of 2 years of HIV testing and counseling on risk-tacking and HIV and STI incidences among MSM living in Bangui in the Central African Republic.

Methods

The incidences of HIV, syphilis and hepatitis B and the sexual behavior characteristics were assessed at inclusion and after 2 years of follow up in the prospective MSM cohort.

Results

99 MSM were included and followed up during 2 years. The mean age of study MSM was 24 years (range, 14-39); among those, the majority was single (84.8%) and unemployed (33.3%) or students (23.9%). The majority (up to 80%) were living in only 4 (out of 10) neighboring district of Bangui. Insertive anal intercourse showed significant decrease from 54% at inclusion to 46% after 2 years of follow up (P < 0.001). In contrast, we observed slight increase in receptive anal intercourse (60% versus 66%) and oral sex (70% versus 74%), but the difference did not reach statistical significance. Finally, the prevalences of HIV, syphilis and hepatitis B increased significantly from 29% to 41%, 12% to 21% and 14% to 23%, respectively.

Conclusion

These observations indicate that medical care and counseling on MSM does not provide significant changes in risk-taking, whereas the incidences of HIV, syphilis and hepatitis B remained high. Innovative interventions should be conceived for the MSM population living in Bangui.

2016 United Kingdom national guideline on the sexual health care of men who have sex with men

This guideline is intended for use in UK Genitourinary medicine clinics and sexual health services but is likely to be of relevance in all sexual health settings, including general practice and Contraception and Sexual Health (CASH) services, where men who have sex with men (MSM) seek sexual health care or where addressing the sexual health needs of MSM may have public health benefits. For the purposes of this document, MSM includes all gay, bisexual and all other males who have sex with other males and both cis and trans men. This document does not provide guidance on the treatment of particular conditions where this is covered in other British Association for Sexual Health and HIV (BASHH) Guidelines but outlines best practice in multiple aspects of the sexual health care of MSM. Where prevention of sexually transmitted infections including HIV can be addressed as an integral part of clinical care, this is consistent with the concept of combination prevention and is included. The document is designed primarily to provide guidance on the direct clinical care of MSM but also makes reference to the design and delivery of services with the aim of supporting clinicians and commissioners in providing effective services. Methodology This document was produced in accordance with the guidance set out in the BASHH CEG's document 'Framework for guideline development and assessment' published in 2010 at http://www.bashh.org/guidelines and with reference to the Agree II instrument. Following the production of the updated framework in April 2015, the GRADE system for assessing evidence was adopted and the draft recommendations were regraded. Search strategy (see also Appendix 1) Ovid Medline 1946 to December 2014, Medline daily update, Embase 1974 to December 2014, Pubmed NeLH Guidelines Database, Cochrane library from 2000 to December 2014. Search language English only. The search for Section 3 was conducted on PubMed to December 2014. Priority was given to peer-reviewed papers published in scientific journals, although for many issues evidence includes conference abstracts listed on the Embase database. In addition, for 'Identification of problematic recreational drug and alcohol use' section and 'Sexual problems and dysfunctions in MSM' section, searches included PsycINFO. Methods Article titles and abstracts were reviewed and if relevant the full text article was obtained. Priority was given to randomised controlled trial and systematic review evidence, and recommendations made and graded on the basis of best available evidence. Piloting and feedback The first draft of the guideline was circulated to the writing group and to a small group of relevant experts, third sector partners and patient representatives who were invited to comment on the whole document and specifically on particular sections. The revised draft was reviewed by the CEG and then reviewed by the BASHH patient/public panel and posted on the BASHH website for public consultation. The final draft was piloted before publication. Guideline update The guidelines will be reviewed and revised in five years' time, 2022.

Differences in acute retroviral syndrome by HIV-1 subtype in a multicentre cohort study in Africa

OBJECTIVE

Symptoms of acute retroviral syndrome (ARS) may be used to identify patients with acute HIV-1 infection who seek care. ARS symptoms in African adults differ by region. We assessed whether reporting of ARS was associated with HIV-1 subtype in a multicentre African cohort study representing countries with predominant HIV-1 subtypes A, C, and D.

METHODS

ARS symptoms were assessed in adults enrolling within 6 weeks after the estimated date of infection in an acute and early HIV-1 infection cohort study. HIV-1 subtype was determined by POL genotyping. We used log-binomial regression to compare ARS symptom prevalence among those with subtype A vs. C or D, adjusting for sex, time since enrolment, and enrolment viral load.

RESULTS

Among 183 volunteers ascertained within 6 weeks after estimated date of infection, 77 (42.0%) had subtype A, 83 (45.4%) subtype C, and 23 (12.6%) subtype D infection. Individuals with subtype A were 1.40 (95% confidence interval: 1.17, 1.68) times as likely as individuals with subtypes C or D to report any ARS symptoms; each individual symptom other than rash was also more prevalent in subtype A than in subtype C or D, with prevalence ratios ranging from 1.94 (1.40, 2.70) for headache to 4.92 (2.24, 10.78) for lymphadenopathy.

CONCLUSION

Individuals with subtype A were significantly more likely than individuals with subtypes C or D to report any ARS symptoms. HIV-1 subtypes may help explain differences in ARS that have been observed across regions in Africa, and may impact the yield of symptom-based screening strategies for acute HIV infection detection.

Substance Use and HIV Risk Among Men Who Have Sex With Men in Africa: A Systematic Review

BACKGROUND

Substance use and its relation to HIV risk among men who have sex in Africa, a population at high risk for HIV, has received little attention.

METHODS

This systematic review summarizes and discusses findings from 68 empirical studies, published between 1980 and 2016 that included data about substance use in men who have sex with men (MSM) in Africa.

RESULTS

Substance use has rarely been the primary focus of studies in African MSM. In general, measurement of substance use was suboptimal. Whereas prevalence of alcohol use varied across studies, partly resulting from variety in assessment strategies, it seemed higher than in the general male population across countries. Alcohol use was associated with sexual risk practices, but not with HIV infection. The most frequently reported drug used by African MSM was cannabis. The use of other drugs, such as cocaine and heroin seemed relatively rare, although injection drug use was exceptionally high in a few studies. As alcohol, drugs were regularly used in conjunction with sex. Both alcohol and drug use were often associated with other risk factors for HIV infection, including violence and transactional sex. No interventions were found addressing substance use among African MSM.

CONCLUSIONS

Given high HIV risk and prevalence in this population, substance use should be studied more in-depth, taking into account the specific social and cultural context. Assessment of substance use practices in this population has to be improved. The available information suggests, though, that there is an urgent need for interventions addressing substance use tailored to the needs of this critical population.

Assessing the Feasibility of Smartphone Apps for HIV-Care Research with MSM and Transgender Individuals in Mpumalanga, South Africa

There is an urgent need to develop the HIV treatment cascade for men who have sex with men (MSM) and transgender individuals in rural Mpumalanga, South Africa. Mhealth tools such as smartphone applications have the potential to support HIV self-care behaviors. We conducted an exploratory study with HIV-positive community leaders to understand their current uses of cell phones and smartphones and to assess their interest in an HIV research study that utilized a smartphone application for HIV care support. A total of 18 community leaders were recruited to complete a questionnaire and focus group. We found that a large proportion of participants had smartphone access and were interested in a research study that utilized a smartphone application with secure access measures. We conclude that smartphone applications for HIV care research are feasible based on access and interest by MSM and transgender individuals in this rural setting.

Brief Report: High HIV Incidence in a South African Community of Men Who Have Sex With Men: Results From the Mpumalanga Men's Study, 2012-2015

Cross-sectional studies among African men who have sex with men (MSM) populations demonstrate high HIV prevalence, but few incidence estimates exist. The Mpumalanga Men's Study in Gert Sibande, Mpumalanga province, South Africa, involved 3 serial cross-sectional surveys of MSM recruited through respondent-driven sampling between 2012 and 2015. Successive surveys recaptured a nested cohort of 179, contributing 144.3 person-years (PY) of observation. We observed 18 seroconversions, or incidence of 12.5/100 (PY) (95% confidence interval CI: 8.1 to 19.2/100 PY). Presumptions of high incidence among MSM were confirmed and demonstrate an urgent need for biomedical prevention and treatment programming for MSM in South Africa.

Sexual Assault and HIV Postexposure Prophylaxis at an Urban African Hospital

Antiretroviral postexposure prophylaxis (PEP) may be underutilized in sexual assault cases in Kenya. This study evaluated the characteristics of survivors of sexual violence attending the Gender-Based Violence Recovery Center (GBVRC) at the Kenyatta National Hospital and reviewed the uptake, adherence, and outcomes of those initiated on PEP. In a retrospective cohort, data from charts of the assaulted seen at the GBVRC from 2009 to 2012 were abstracted. Data were collected describing sociodemographic characteristics, nature of sexual assault, HIV serostatus, and aspects of the PEP care cascade. Characteristics of participants who received PEP were compared with those who did not receive PEP. We enrolled 385 assaulted persons; 331 (86%) were female; the median age of the assaulted persons was 21 (interquartile range 14-28) years; and 61 (15.8%) were children aged 10 years and younger. Of 379 assaults with descriptions, 330 (85.7%) were vaginal assaults and 40 (10.3%) were penile-anal assaults. Most perpetrators were unknown to the assaulted 220 of 384 (57.3%). All assaulted persons were offered HIV testing and 359 (93%) accepted testing; 346 (96.4%) of 359 assaulted persons tested HIV negative. In total, 207 (53.8%) of 385 sexual assault survivors initiated PEP. Only 70 (34%) completed 28 days of PEP, and only 21 (10.1%) returned for repeat HIV test at 3 months. In conclusion, PEP was only initiated in 54% of sexual assault cases. The care cascade showed that late presentation and poor adherence were the greatest gaps in PEP provision. Earlier presentation for PEP should be promoted among sexual assault in areas of high HIV prevalence.

"Facing Our Fears": Using facilitated film viewings to engage communities in HIV research involving MSM in Kenya

Kenya is a generally homophobic country where homosexuality is criminalised and people who engage in same sex sexuality face stigma and discrimination. In 2013, we developed a 16 min documentary entitled "Facing Our Fears" that aimed at sharing information on how and why men who have sex with men (MSM) are involved in on-going KEMRI HIV prevention research, and associated community engagement. To consider the film's usefulness as a communication tool, and its perceived security risks in case the film was publicly released, we conducted nine facilitated viewings with 122 individuals representing seven different stakeholder groups. The documentary was seen as a strong visual communication tool with potential to reduce stigma related to homosexuality, and facilitated film viewings were identified as platforms with potential to support open dialogue about HIV research involving MSM. Despite the potential, there were concerns over possible risks to LGBT communities and those working with them following public release. We opted-giving emphasis to the "do no harm" principle-to use the film only in facilitated settings where audience knowledge and attitudes can be carefully considered and discussed. The results highlight the importance of carefully assessing the range of possible impacts when using visuals in community engagement.

Learning to Live With HIV in the Rural Townships: A Photovoice Study of Men Who Have Sex With Men Living With HIV in Mpumalanga, South Africa

There is limited understanding about the health and well-being of men who have sex with men (MSM) with HIV infection living in rural African areas. We present the results of an adapted photovoice project with 35 MSM with HIV infection who live in townships in Mpumalanga, South Africa. The project was designed to explore the social factors that influenced HIV care. Twenty-four photo essays were developed by participants in focus group discussions that were audio-recorded and transcribed for analysis. Transcripts and photo essays were coded using a constant comparison approach combining researcher observation notes and reflection on participant-identified themes. Participants identified (a) a shared experience of illness and coming to terms with having HIV infection and (b) family and taverns as necessary support systems. The findings suggested that family- and tavern-based interventions might improve health outcomes for MSM newly diagnosed with HIV infection living in rural and semi-rural African communities.

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

HIV diagnosis is an important step in the HIV cascade of prevention and treatment. However, men who have sex with men in low- and middle-income countries have limited access to HIV care services. We examined factors associated with prior HIV testing among men who have sex with men in western Kenya. We recruited 95 men who have sex with men aged 18 years and older, and who reported at least one sexual contact with a man in the past 6 months; however, this analysis is restricted to 89 participants who completed questions on HIV testing. Logistic regression model was used to determine factors associated with HIV testing in the past one year. Results indicate that 23 (26%) had not been tested in the past 12 months. Bivariate analyses demonstrated that condomless anal sex (odds ratio = 3.29, 95% confidence interval = 1.18-9.17) and comfort with healthcare providers (odds ratio = 1.15, 95 % CI = 1.05-1.26) were associated with higher odds of HIV testing in the past 12 months. Experiencing social stigma was associated with lower odds of HIV testing in the last 12 months (odds ratio = 0.91, 95% confidence interval = 0.84-0.94). In multivariable models, social stigma remained significantly associated with lower odds of HIV testing in the last 12 months odds ratio = 0.90, 95% confidence interval = 0.82-0.99) after inclusion of sexual risk and individual level variables. Development of men who have sex with men-sensitive HIV-testing services, addressing stigma, and training healthcare workers to provide culturally sensitive services may assist in effectively engaging men who have sex with men in the HIV treatment cascade.

Hepatitis B Virus Incidence and Risk Factors Among Human Immunodeficiency Virus-1 Negative Men Who Have Sex With Men in Kenya

No data exist on hepatitis B virus (HBV) incidence among African men who have sex with men (MSM). We tested plasma samples archived between 2005 and 2014 for HBV core antibody or surface antigen seroconversion in a cohort of 312 initially human immunodeficiency virus (HIV)-1-negative MSM with no evidence of prior HBV infection. Hepatitis B virus incidence was 6.0/100 person-years (95% confidence interval [CI], 3.9–9.1). Hepatitis B virus acquisition was associated with being uncircumcised (adjusted incidence rate ratio [aIRR], 5.0; 95% CI, 1.5–16.8), recent HIV-1 acquisition (aIRR, 2.9; 95% CI, 1.1–7.7), rape (aIRR, 5.0; 95% CI, 1.2–20.4), and any tertiary education (aIRR, 3.2; 95% CI, 1.1–9.7). African MSM have a substantial risk of HBV acquisition and require vaccination urgently.

Investigating HIV Infection and HIV Incidence Among Chinese Men Who Have Sex with Men with Recent Sexual Debut, Chongqing, China, 2011

HIV among men who have sex with men (MSM) with recent male-male sexual debut, such as within the past 5 years, may be a proxy for recent HIV infection. Using this definition, we explored factors associated with HIV infection in this group to understand the evolving HIV epidemic among MSM in Chongqing. We conducted a cross-sectional respondent-driven sampling survey among Chongqing MSM in 2011. Computer-assisted, self-administered questionnaires were used and blood specimens were collected for HIV and syphilis testing. Three hundred and ninety-one unique MSM were recruited of which 65.7 % (257) had their sexual debut with another man in the past 5 years. HIV prevalence among men with recent sexual debut was 18.7 % suggesting a possible HIV incidence of 3.7 %. Multivariable analysis among men with recent sexual debut suggests that lower education, having more than one male partner, and currently being infected with syphilis are associated with HIV among men with recent sexual debut. HIV prevalence is high among MSM with recent sexual debut in Chongqing, which may be a proxy a high incidence rate. HIV prevention efforts should focus on STD reduction among those MSM with lower educational attainment.

Engagement of Gay Men and Other Men Who Have Sex with Men (MSM) in the Response to HIV: A Critical Step in Achieving an AIDS-Free Generation

Men who have sex with men (MSM) continue to be at elevated risk for HIV acquisition and transmission secondary to biological and behavioral characteristics, social and sexual network characteristics, community environmental factors, and structural factors. HIV incidence rates remain high among MSM in both low- and high-income settings, and in both concentrated and more generalized HIV epidemic settings. While data quality tends to be poorer, the best estimates collectively suggest that MSM have up to 20 times the odds of living with HIV as compared to other reproductive aged adults across low- and middle-income countries. Recent prevention strategies to lower biological HIV transmission and acquisition risks, including the early use of antiretrovirals to decrease infectiousness for those living with HIV, and pre-exposure prophylaxis for those at significant risk of HIV acquisition, have demonstrated the potential to change the trajectory of the HIV epidemics among MSM. However, the coverage and effectiveness of these approaches is limited by structural factors including the punitive legal frameworks and institutional discrimination that contribute to limited uptake, challenges to adherence, and suboptimal health-seeking behaviors among MSM. More intensive efforts will be required to reach MSM who do not currently have access to relevant and effective prevention and treatment services or elect not to access these services given enacted and/or perceived stigma. Respect for human rights, including efforts to aggressively confront and combat the forms of stigma that are preventing us from achieving an AIDS-Free generation, are needed for all people including gay men and other MSM.

PrEP implementation research in Africa: what is new?

INTRODUCTION

Of the two million new HIV infections in adults in 2014, 70% occurred in sub-Saharan Africa. Several African countries have already approved guidelines for pre-exposure prophylaxis (PrEP) for individuals at substantial risk of HIV as part of combination HIV prevention but key questions remain about how to identify and deliver PrEP to those at greatest need. Throughout the continent, individuals in sero-discordant relationships, and members of key populations (sex workers, men who have sex with men (MSM), transgender women and injection drug users) are likely to benefit from the availability of PrEP. In addition, adolescent girls and young women (AGYW) are at substantial risk in some parts of the continent. It has been estimated that at least three million individuals in Africa are likely to be eligible for PrEP according to WHO's criteria. Tens of demonstration projects are planned or underway across the continent among a range of countries, populations and delivery settings.

DISCUSSION

In each of the target populations, there are overarching issues related to (i) creating demand for PrEP, (ii) addressing supply-side issues and (iii) providing appropriate and tailored adherence support. Critical for creating demand for PrEP is the normalization of HIV prevention. Community-level interventions which engage opinion leaders as well as empowerment interventions for those at highest risk will be key. Critical to supply of PrEP is that services are accessible for all, including for stigmatized populations. Establishing accessible integrated services provides the opportunity to address other public health priorities including the unmet need for HIV testing, contraception and sexually transmitted infections treatment. National policies need to include minimum standards for training and quality assurance for PrEP implementation and to address supply chain issues. Adherence support needs to recognize that social and structural factors are likely to have an important influence. Combining interventions that build self-efficacy, empowerment and social cohesion, with evidence-based individualized adherence support for PrEP, are most likely to be effective.

CONCLUSIONS

Efficacy of tenfovir-based PrEP is proven but many issues related to implementation remain unclear. Here, we have summarized some of the important implementation questions that need to be assessed as PrEP is rolled out across Africa.

PrEP as a feature in the optimal landscape of combination HIV prevention in sub-Saharan Africa

Introduction

The new WHO guidelines recommend offering pre-exposure prophylaxis (PrEP) to people who are at substantial risk of HIV infection. However, where PrEP should be prioritised, and for which population groups, remains an open question. The HIV landscape in sub-Saharan Africa features limited prevention resources, multiple options for achieving cost saving, and epidemic heterogeneity. This paper examines what role PrEP should play in optimal prevention in this complex and dynamic landscape.

Methods

We use a model that was previously developed to capture subnational HIV transmission in sub-Saharan Africa. With this model, we can consider how prevention funds could be distributed across and within countries throughout sub-Saharan Africa to enable optimal HIV prevention (that is, avert the greatest number of infections for the lowest cost). Here, we focus on PrEP to elucidate where, and to whom, it would optimally be offered in portfolios of interventions (alongside voluntary medical male circumcision, treatment as prevention, and behaviour change communication). Over a range of continental expenditure levels, we use our model to explore prevention patterns that incorporate PrEP, exclude PrEP, or implement PrEP according to a fixed incidence threshold.

Results

At low-to-moderate levels of total prevention expenditure, we find that the optimal intervention portfolios would include PrEP in only a few regions and primarily for female sex workers (FSW). Prioritisation of PrEP would expand with increasing total expenditure, such that the optimal prevention portfolios would offer PrEP in more subnational regions and increasingly for men who have sex with men (MSM) and the lower incidence general population. The marginal benefit of including PrEP among the available interventions increases with overall expenditure by up to 14% (relative to excluding PrEP). The minimum baseline incidence for the optimal offer of PrEP declines for all population groups as expenditure increases. We find that using a fixed incidence benchmark to guide PrEP decisions would incur considerable losses in impact (up to 7%) compared with an approach that uses PrEP more flexibly in light of prevailing budget conditions.

Conclusions

Our findings suggest that, for an optimal distribution of prevention resources, choices of whether to implement PrEP in subnational regions should depend on the scope for impact of other possible interventions, local incidence in population groups, and total resources available. If prevention funding were to become restricted in the future, it may be suboptimal to use PrEP according to a fixed incidence benchmark, and other prevention modalities may be more cost-effective. In contrast, expansions in funding could permit PrEP to be used to its full potential in epidemiologically driven prevention portfolios and thereby enable a more cost-effective HIV response across Africa.

Risk Factors Associated with HIV Among Men Who Have Sex Only with Men and Men Who Have Sex with Both Men and Women in Three Urban Areas in Mozambique

Using respondent-driven sampling (RDS), an integrated biological behavioral survey among men that have sex with men (MSM) enrolled 457 participants in Maputo [63.0 % were MSM who had sex with women (MSMW)], 538 in Beira (36.2 % MSMW) and 330 in Nampula-Nacala (54.8 % MSMW) in 2011. Analysis suggests that MSM who have sex only with men (MSMO) had increased odds of having HIV (aOR 2.7) compared to MSMW. HIV among MSMO associated with age, self-reported STI (aOR 4.2), having a single male anal partner (aOR 3.8) and having transactional sex with a man (aOR 3.5) in the past year. Among MSMW, HIV associated with age, lower education (aOR 32.5), being uncircumcised (aOR 3.1) and having transactional sex with a woman (aOR 6.0) in the past year. Findings confirm that MSMO and MSMW have distinct HIV risks in Mozambique; HIV programs for MSM in Southern Africa should take such differences into consideration.

Sociodemographic Factors, Sexual Behaviors, and Alcohol and Recreational Drug Use Associated with HIV Among Men Who Have Sex with Men in Southern Vietnam

A total of 2768 MSM participated in a survey in southern Vietnam. Univariate and multivariate logistic regression analyses were performed to determine predictors of HIV infection. The prevalence of HIV among MSM was 2.6 %. HIV infection was more likely in MSM who were older, had a religion, had engaged in anal sex with a foreigner in the past 12 months, previously or currently used recreational drugs, perceived themselves as likely or very likely to be infected with HIV, and/or were syphilis seropositive. MSM who had ever married, were exclusively or frequently receptive, sometimes consumed alcohol before sex, and/or frequently used condoms during anal sex in the past 3 months were less likely to be infected with HIV. Recreational drug use is strongly associated with HIV infection among MSM in southern Vietnam. HIV interventions among MSM should incorporate health promotion, condom promotion, harm reduction, sexually transmitted infection treatment, and address risk behaviors.

Incidence of and temporal relationships between HIV, herpes simplex II virus, and syphilis among men who have sex with men in Bangkok, Thailand: an observational cohort

Background

High HIV incidence has been detected among men who have sex with men (MSM) in Thailand, but the relationship and timing of HIV, herpes simplex virus 2 (HSV-2), and syphilis is unknown. This analysis measures incidence, temporal relationships, and risk factors for HIV, HSV-2, and syphilis among at-risk MSM in the Bangkok MSM Cohort Study.

Methods

Between April 2006 and December 2010, 960 men negative for HIV, HSV-2, and syphilis at entry enrolled and contributed 12–60 months of follow-up data. Behavioral questionnaires were administered at each visit; testing for HIV antibody was performed at each visit, while testing for syphilis and HSV-2 were performed at 12 month intervals. We calculated HIV, HSV-2, and syphilis incidence, assessed risk factors with complementary log-log regression, and among co-infected men, measured temporal relationships between infections with Kaplan-Meier survival analysis and paired t-test.

Results

The total number of infections and incidence density for HIV, HSV-2, and syphilis were 159 infections and 4.7 cases/100 PY (95 % Confidence Interval (CI): 4.0–5.4), 128 infections and 4.5/100 PY (95 % CI: 3.9–5.5), and 65 infections and 1.9/100 PY (95 % CI: 1.5–2.5), respectively. Among men acquiring >1 infection during the cohort period, mean time to HIV and HSV-2 infection was similar (2.5 vs. 2.9 years; p = 0.24), while syphilis occurred significantly later following HIV (4.0 vs. 2.8 years, p < 0.01) or HSV-2 (3.8 vs. 2.8 years, p = 0.04) infection. The strongest independent predictor of any single infection in adjusted analysis was acquisition of another infection; risk of syphilis (Adjusted Hazards Ratio (AHR) = 3.49, 95 % CI: 1.89–6.42) or HIV (AHR = 2.26, 95 % CI: 1.47–3.48) acquisition during the cohort was significantly higher among men with incident HSV-2 infection. No single independent behavioral factor was common to HIV, HSV-2, and syphilis acquisition.

Conclusion

HIV and HSV-2 incidence was high among this Thai MSM cohort. However, acquisition of HIV and co-infection with either HSV-2 or syphilis was low during the time frame men were in the cohort. Evaluation of behavioral risk factors for these infections suggests different risks and possible different networks.

HIV Infection and AIDS in Sub-Saharan Africa: Current Status, Challenges and Opportunities

Global trends in HIV infection demonstrate an overall increase in HIV prevalence and substantial declines in AIDS related deaths largely attributable to the survival benefits of antiretroviral treatment. Sub-Saharan Africa carries a disproportionate burden of HIV, accounting for more than 70% of the global burden of infection. Success in HIV prevention in sub-Saharan Africa has the potential to impact on the global burden of HIV. Notwithstanding substantial progress in scaling up antiretroviral therapy (ART), sub-Saharan Africa accounted for 74% of the 1.5 million AIDS related deaths in 2013. Of the estimated 6000 new infections that occur globally each day, two out of three are in sub-Saharan Africa with young women continuing to bear a disproportionate burden. Adolescent girls and young women aged 15-24 years have up to eight fold higher rates of HIV infection compared to their male peers. There remains a gap in women initiated HIV prevention technologies especially for women who are unable to negotiate the current HIV prevention options of abstinence, behavior change, condoms and medical male circumcision or early treatment initiation in their relationships. The possibility of an AIDS free generation cannot be realized unless we are able to prevent HIV infection in young women. This review will focus on the epidemiology of HIV infection in sub-Saharan Africa, key drivers of the continued high incidence, mortality rates and priorities for altering current epidemic trajectory in the region. Strategies for optimizing the use of existing and increasingly limited resources are included.

How intersectional constructions of sexuality, culture, and masculinity shape identities and sexual decision-making among men who have sex with men in coastal Kenya

Men who have sex with men are increasingly recognised as one of the most vulnerable HIV risk groups in Kenya. Sex between men is highly stigmatised in Kenya, and efforts to provide sexual health services to men who have sex with men require a deeper understanding of their lived experiences; this includes how such men in Kenya construct their sexual identities and how these constructions affect sexual decision-making. Adult self-identified men who have sex with men (n = 26) in Malindi, Kenya, participated in individual interviews to examine sociocultural processes influencing sexual identity construction and decision-making. Four key themes were identified: (1) tensions between perceptions of 'homosexuality' versus being 'African', (2) gender-stereotyped beliefs about sexual positioning, (3) socioeconomic status and limitations to personal agency and (4) objectification and commodification of non-normative sexualities. Findings from this analysis emphasise the need to conceive of same-sex sexuality and HIV risk as context-dependent social phenomena. Multiple sociocultural axes were found to converge and shape sexual identity and sexual decision-making among this population. These axes and their interactive effects should be considered in the design of future interventions and other public health programmes for men who have sex with men in this region.

Changes in sexual risk behavior among MSM participating in a research cohort in coastal Kenya

OBJECTIVE

To describe changes in sexual risk behavior among Kenyan MSM who received regular risk reduction counseling (RRC).

DESIGN

Data were derived from two cohorts of HIV-1-negative and HIV-1-positive MSM in Kenya. Behavioral data were collected at enrollment and at monthly or quarterly scheduled follow-up visits. At each visit, RRC was provided to all men and HIV-1 testing to seronegative men.

METHODS

Random effects logistic and Poisson regression models with time since study entry as main variable of interest were used to evaluate changes in number of sex partners and unprotected sex in the past week, and insertive, receptive, and unprotected anal intercourse in the past 3 months. Analyses were adjusted for HIV-1-status, calendar year of follow-up, and several baseline characteristics. Trends over follow-up time were allowed to differ by HIV-1-status. Men were censored when they seroconverted for HIV.

RESULTS

Number of regular and casual sex partners and unprotected anal intercourse decreased in both HIV-1-negative and HIV-1-positive men. Unprotected sex with both regular and casual sex partners decreased more strongly early in follow-up in HIV-1-positive men than in HIV-1-negative men. Decreases in insertive anal intercourse were found for HIV-1-positive men only, whereas decreases in receptive anal intercourse were found for HIV-1-negative men only.

CONCLUSION

MSM who were regularly exposed to RRC showed some reductions in sexual risk behavior, but it is uncertain if these reductions are sustained over time. As HIV-1 incidences in Kenyan MSM are very high, RRC should be supported by comprehensive biomedical interventions.

Risk of sexual, physical and verbal assaults on men who have sex with men and female sex workers in coastal Kenya

BACKGROUND

Violence toward MSM and female sex workers (FSW) is associated with HIV risk, and its prevention is prioritized in international HIV/AIDS policy.

METHODS

Sociodemographic and behavioural data derived from HIV risk and follow-up cohorts including MSM and FSW in coastal Kenya between 2005 and 2014 was used to estimate the risk of rape, physical assault and verbal abuse, and to assess associations between first occurrence of assault with individual and recent behavioural factors.

RESULTS

Incidence of first reported rape was similar for MSM [3.9, confidence interval (CI) 3.1-5.0 per 100 person-years (pyrs)] and FSW (4.8 CI 3.5-6.4 per 100 pyrs), P = 0.22. Incidence of first reported physical and verbal assault was higher for FSW than MSM (21.1 versus 12.9 per 100 pyrs, P = 0.14 and 51.3 versus 30.9 per 100 pyrs, P = 0.03 respectively). Recent alcohol use was associated with reporting of all forms of assault by MSM [adjusted odds ratio (AOR) 1.8, CI 0.9-3.5] and FSW (AOR 4.4, CI 1.41-14.0), as was recent sale of sex for MSM (AOR 2.0, CI 1.1-3.8). Exclusive sex with men, active sex work, and group sex were also specifically associated with reporting rape for MSM. Perpetrators of sexual and verbal assault were usually unknown, whilst perpetrators of physical violence toward FSW were usually regular sexual partners.

CONCLUSION

MSM and FSW experienced a similarly high incidence of sexual assault in coastal Kenya, in addition to physical and verbal assault. Current national policies focus heavily on gender-based violence against women and young girls, but need to be inclusive of MSM and FSW.

Gender Expression and Risk of HIV Infection Among Black South African Men Who Have Sex with Men

To explore demographic, behavioral and psychosocial risk factors for HIV infection in South African MSM we recruited 480 MSM (aged 18 and 44 years) using respondent-driven sampling. Data were collected through individual computer-assisted face-to-face interviews. Participants were tested for HIV. RDS-adjusted HIV prevalence is 30.1 % (unadjusted 35.6 %). Few participants had ever engaged in both receptive and insertive anal sex; sex with women was frequently reported. Independent demographic and behavioral correlates of HIV infection include age, education, number of male sexual partners, ever having been forced to have sex, and ever having engaged in transactional sex; engagement in sex with women was a protective factor. Psychosocial risk factors independently associated with HIV infection were feminine identification, internalized homophobia, and hazardous drinking. Our findings confirm what has been found in other studies, but also suggest that the dynamics and context of sexual transmission among MSM in South Africa differ from those among MSM in Western countries.

Heterosexual behaviours among men who sell sex to men in coastal Kenya

OBJECTIVE

African men who have sex with men often sell sex to men, and MSM who sell sex (MSM-SW) often also have female partners. We compared sexual risk behaviour of MSM-SW who were sexually active with female partners (bisexual MSW) to MSM-SW with only male partners (exclusive MSW).

DESIGN

Descriptive behavioural study

METHODS

: A novel, validated daily event and partner diary self-completed by 82 MSM who sold sex over a follow-up period of 42 days with weekly review. Cumulative individual counts of sex and condomless sex were compiled by partner characteristics. The incidence of specific partnerships and sex acts were compared within and between bisexual and exclusive MSW.

RESULTS

Most (59%) MSM-SW reported female partners during follow-up. The majority of both male and female partners were cash-paying clients originating locally. Bisexual MSW reported a similar rate of condomless sex with male and female partners, but significantly fewer male partners than exclusive MSW. Bisexual MSW had lower HIV prevalence, were more likely to only report insertive anal sex roles, and reported lower frequencies of condomless receptive anal sex than exclusive MSW.

CONCLUSION

Bisexually active male sex workers in coastal Kenya create HIV and other sexually transmitted infection transmission pathways to partners and clients in both MSM and heterosexual networks, but differed from exclusive MSW in having lower HIV acquisition and transmission risks. Epidemiological projection methods are liable to overestimate bridging potential of MSM-SW and MSM populations without account for systematic differences in risk within these populations.

Development and pilot testing of an intervention to promote care engagement and adherence among HIV-positive Kenyan MSM

OBJECTIVES

In many African settings, MSM are a stigmatized group whose access to and engagement in HIV care may be challenging. Our aim was to design a targeted, culturally appropriate intervention to promote care engagement and antiretroviral therapy (ART) adherence for MSM in coastal Kenya, and describe intervention safety, feasibility, and acceptability based upon a small pilot study.

DESIGN

Based on qualitative work including in-depth interviews with HIV-positive MSM and focus groups with providers, we developed a tailored intervention and conducted a pilot test to refine intervention materials and procedures.

METHODS

The Shikamana intervention combines modified Next-Step Counseling by trained providers, support from a trained peer navigator, and tailored use of SMS messaging, phone calls, and discrete pill carriers. Providers, including counselors and clinicians, work together with peer navigators as a case management team.

RESULTS

Forty HIV-positive MSM aged 19-51 participated in intervention development and testing. Six counselors, three clinical officers, and four MSM peers were trained in intervention procedures. Of 10 ART-naïve participants who enrolled in the pilot, eight completed follow-up with no adverse events reported. One participant was lost to follow-up after 2 months and another failed to initiate ART despite ongoing counseling. No adverse events were reported. Staff feedback and exit interviews rated the intervention as feasible and acceptable.

CONCLUSION

This adherence support intervention tailored for Kenyan MSM was well tolerated, feasible, and acceptable in the pilot phase. A randomized controlled trial of a scaled-up programme to estimate intervention efficacy is ongoing.

The green shoots of a novel training programme: progress and identified key actions to providing services to MSM at Kenyan health facilities

Introduction

Although men who have sex with men (MSM) in sub-Saharan Africa are at high risk for HIV acquisition, access to and quality of health and HIV services within this population are negatively affected by stigma and capacity within the health sector. A recently developed online MSM training programme (www.marps-africa.org) was shown to contribute to reductions in MSM prejudice among healthcare providers (HCPs) in coastal Kenya. In this study, we used qualitative methods to explore the provision of MSM healthcare services two years post-training in coastal Kenya.

Methods

From February to July 2014, we held 10 focus group discussions (FGD) with 63 participants, including HCP from 25 facilities, county AIDS coordinators and MSM from local support groups. Participants discussed availability, acceptability and accessibility of HIV healthcare for MSM. HCP also discussed changes in their health service practices after completing the training. FGD were recorded, transcribed verbatim and analyzed using Ritchie and Spencer's “framework approach” for qualitative data.

Results

HCPs described continued improvements in their ability to provide service in a non-stigmatizing way to MSM patients since completing the training programme and expressed comfort engaging MSM patients in care. Four additional recommendations for improving MSM healthcare services were identified: 1) expanding the reach of MSM sensitivity training across the medical education continuum; 2) establishing guidelines to manage sexually transmitted anal infections; 3) promoting legal and policy reforms to support integration of MSM-appropriate services into healthcare; and 4) including MSM information in national reporting tools for HIV services.

Conclusions

Positive impacts of this sensitivity and skills training programme were reflected in HCP attitudes two years post-intervention. Scaling-up of efforts will rely on continued policies to include MSM in healthcare programmes to reduce stigma in health settings and guidelines for MSM STI service delivery.