Implications for HIV prevention programs from a serobehavioural survey of men who have sex with men in Vancouver, British Columbia: the ManCount study

Evolving the gay, bisexual and other men who have sex with men time-based deferral to sexual risk screening for all donors: The contribution of Canadian research programmes

BACKGROUND AND OBJECTIVES

In Canada, the time deferral for gay, bisexual and other men who have sex with men (gbMSM) to donate blood has gradually decreased. In September 2022, this deferral was replaced with sexual behaviour-based screening for all donors. We investigate how data from targeted research programmes addressed knowledge gaps to support this change.

MATERIALS AND METHODS

We conducted a scoping review describing the Canadian literature available before the research programmes relating to (1) behavioural indicators of HIV risk and (2) attitudes to blood donation among gbMSM, current donors and the general population. We summarize the targeted research programmes, their outputs and impact to date.

RESULTS

For question 1, five projects met inclusion criteria. For question 2, three articles met inclusion criteria. Knowledge gaps identified were insufficient evidence of HIV incidence in gbMSM who met other donor eligibility criteria and scant data on opinions and views of blood donation and screening criteria for sexual risk behaviours. The research programmes funded 19 projects at 11 different research sites involving over 100 individual researchers/collaborators resulting in 19 peer-reviewed publications to date. Leveraging existing gbMSM cohorts yielded relevant HIV incidence data to inform safety modelling studies. Findings indicated that sexual behaviour-based screening was acceptable to gbMSM and donors, and donor discomfort around specific questions could be mitigated with clear explanations.

CONCLUSION

Targeted research programmes filled critical knowledge gaps and informed a change to gender-neutral, sexual behaviour-based screening for all donors. Findings supported successful implementation of these changes with research-informed staff training.

Examining differential success in recruitment using respondent driven sampling (RDS) in a multi-site study of gay, bisexual and other men who have sex with men

BACKGROUND

The Engage Study is a longitudinal biobehavioral cohort study of gay, bisexual and other men who have sex with men (GBM) in Toronto, Montreal, and Vancouver. Baseline data (2,449 participants) were collected from February 2017 - August 2019 using respondent-driven sampling (RDS). Recruitment in Montreal required fewer seeds, had a much shorter recruitment period, and recruited the largest sample.

METHODS

To better understand why RDS recruitment was more successful in Montreal compared to other sites, we conducted an analysis to examine RDS recruitment characteristics for GBM in each of the three study sites, explore demographic characteristics and measures of homophily, that is, the tendency of individuals to recruit other study participants who are like themselves, and compared motivations for study participation.

RESULTS

Montreal had the greatest proportion of participants over the age of 45 (29.1% in Montreal, 24.6% in Vancouver, and 21.0% in Toronto) and the highest homophily for this age group, but homophily was high across the three cities. Montreal also reported the lowest percentage of participants with an annual income greater or equal to $60,000 (7.9% in Montreal, 13.1% in Vancouver and 10.6% in Toronto), but homophily was similar across all three cities. The majority of participants indicated interest in sexual health and HIV as the main reason for participating (36.1% in Montreal, 34.7% in Vancouver, and 29.8% in Toronto). Financial interest as the main reason for participation was low (12.7% in Montreal, 10.6% in Vancouver, and 5.7% in Toronto).

CONCLUSION

Taken together, although we found some differences in study demographic characteristics and homophily scores, we were unable to fully explain the different recruitment success based on the data available. Our study underlines the fact that success of RDS implementation may vary by unknown factors, and that researchers should be proactive and flexible to account for variability.

Sexual Practice Changes Post-HIV Diagnosis Among Men Who Have Sex with Men in the United States: A Systematic Review and Meta-analysis

Men who have sex with men (MSM) often change sexual behaviors following HIV diagnosis. This systematic review examined such changes, including sero-adaptive behaviors (i.e., deliberate safer-sex practices to reduce transmission risk) to better understand the magnitude of their association with HIV diagnosis. We searched four databases (1996-2017) and reviewed references from other systematic reviews. We included studies conducted in the United States that compared sexual behavior among HIV-infected "aware" versus "unaware" MSM. We meta-analytically pooled RRs and associated 95% confidence intervals (CI) using random-effects models, and assessed risk of bias and evidence quality. Twenty studies reported k = 131 effect sizes on sexual practices outcomes, most of which reported changes in unprotected sex (k = 85), and on sex with at-risk partners (k = 76); 11 reported sero-adaptive behaviors. Unprotected anal intercourse with an HIV-uninfected/unknown-status partner was less likely among aware MSM (insertive position: k = 2, RR 0.26, 95% CI 0.17, 0.41; receptive position: k = 2, RR 0.53, 95% CI 0.37, 0.77). Risk of not always serosorting among aware MSM (k = 3) was RR = 0.92 (0.83, 1.02). Existing evidence, although low-quality, suggests that HIV-infected MSM tend to adopt safer sexual practices once aware of their diagnosis. Variation in reporting of outcomes limits their comparability. Sero-adaptive behavior data are sparse.

HIV diagnoses and testing patterns among young gay, bisexual and other men who have sex with men: an analysis of HIV surveillance data in British Columbia, 2008-2015

BACKGROUND

We examined changes in HIV testing indicators following a recent increase in diagnoses among young gay, bisexual and other men who have sex with men (GBMSM) in BC that accompanied implementation of a provincial HIV strategy.

METHOD

Surveillance and laboratory testing data were used to compare case counts and testing characteristics among GBMSM < 30 and ≥ 30 years diagnosed in 2008-2011 and 2012-2015. We tested differences in the proportion diagnosed on first testing episode, proportion diagnosed at late stage of infection and the median inter-test interval ((ITI) time in months between last negative test and first positive test) using χ² and Wilcoxon rank-sum tests.

RESULTS

In 2008-2011, 657 diagnoses were made among GBMSM: 24% among men < 30 years and 76% among men ≥ 30 years. In 2012-2015, 590 diagnoses were made: 28% among < 30 years and 28% among ≥ 30 years. Among men < 30 years, diagnoses made on first testing episode decreased (39.4% vs. 28.7% in 2012-2015; p = 0.042) and there were few late-stage diagnoses (5.1% in 2008-2011 vs. 9.1% in 2012-2015). The median ITI was 10 months in both periods. No changes were observed over time among men ≥ 30 years. However, in both periods, late-stage diagnosis was more common in men ≥ 30 years (2008-2011, 18.8%; 2012-2015, 18.6%; p < 0.01 for both). The ITI was also longer for men ≥ 30 years (2008-2011, 24.5 months; 2012-2015, 20 months; p < 0.001 for both).

CONCLUSION

Testing indicators suggested better testing practices among GBMSM diagnosed at < 30 years compared to those diagnosed at older ages. However, there are clear needs for additional prevention measures in both age groups.

HIV Testing Among a Representative Community Sample of Gay, Bisexual, and Other Men Who Have Sex with Men in Vancouver, Canada

Earlier HIV diagnosis allows for improved treatment outcomes and secondary prevention. It is recommended that all individuals know their HIV status and that those at higher risk test more frequently. Using a representative community sample of gay, bisexual, and other men who have sex with men (GBMSM), we aimed to: (1) determine the proportion of GBMSM who have tested in the past 2 years, (2) determine reasons for testing and never having tested, and (3) explore correlates of testing. Of 535 eligible participants, 80.0% reported having had an HIV test in the past 2 years, most commonly as part of a regular testing schedule. The most common reason for not testing was low perceived HIV risk. Bisexual and older GBMSM, as well as those who lived outside of Vancouver, were less likely to have tested in the past 2 years. Rapid point-of-care testing may help improve testing rates and was shown to effectively engage some hard-to-reach GBMSM (e.g., those who had not tested for other STIs) in this sample.

High prevalence of syndemic health problems in patients seeking post-exposure prophylaxis for sexual exposures to HIV

Introduction

The standard clinical approach to non-occupational HIV post-exposure prophylaxis (nPEP) focuses on biomedical aspects of the intervention, but may overlook co-occurring or ‘syndemic’ psychosocial problems that reinforce future vulnerability to HIV. We therefore sought to determine the prevalence of syndemic health problems in a cohort of Ontario nPEP patients, and explored the relationship between syndemic burden and HIV risk.

Methods

Between 07/2013-08/2016, we distributed a self-administered questionnaire to patients presenting to three clinics in Toronto and Ottawa seeking nPEP for sexual HIV exposures. We used validated screening tools to estimate the prevalence of depression (CES-D score ≥16), harmful alcohol use (AUDIT ≥8), problematic drug use (DUDIT ≥6 men/≥2 women), and sexual compulsivity (SCS ≥24) among men who have sex with men (MSM) respondents. In exploratory analyses, we examined the relationships between syndemic conditions using univariable logistic regression models, and the relationship between syndemic count (total number of syndemic conditions per participant) and HIV risk, as estimated by the HIRI-MSM score, using linear regression models.

Results

The 186 MSM included in the analysis had median age 31 (IQR = 26–36), including 87.6% having a college/undergraduate degree or higher. Overall, 53.8% screened positive for depression, 34.4% for harmful alcohol use, 30.1% for problematic drug use, and 16.1% for sexual compulsivity. Most participants (74.2%) had at least one syndemic condition and 46.8% had more than one. Exploratory analyses suggested positive associations between depression and harmful alcohol use (OR = 2.11, 95%CI = 1.13, 3.94) and between harmful alcohol use and problematic drug use (OR = 1.22, 95%CI = 0.65, 2.29). Syndemic count was associated with increased HIRI-MSM risk scores in univariable (2.2, 95%CI = 1.0, 3.3 per syndemic condition) and multivariable (2.1, 95%CI = 0.6, 3.6) linear regression models.

Conclusions

The prevalence of syndemic conditions in MSM seeking nPEP for sexual exposure is alarmingly high, and is associated with underlying HIV risk. Routine screening for these conditions may identify opportunities for intervention and could alleviate future vulnerability to HIV.

Trends in the awareness, acceptability, and usage of HIV pre-exposure prophylaxis among at-risk men who have sex with men in Toronto

OBJECTIVES

Pre-exposure prophylaxis (PrEP) with daily oral tenofovir/emtricitabine dramatically reduces HIV risk in men who have sex with men (MSM). However, uptake is slow worldwide.

METHODS

We administered anonymous cross-sectional questionnaires to MSM presenting for anonymous HIV testing at a Toronto sexual health clinic at four successive time points during the period 2013-2016. We assessed trends in PrEP awareness, acceptability, and use over time using the Cochran-Armitage Trend Test, and identified barriers to using PrEP by constructing "PrEP cascades" using 2016 data. We assumed that to use PrEP, MSM must (a) be at risk for HIV, (b) be at objectively high risk (HIRI-MSM score ≥ 10), (c) perceive themselves to be at medium-to-high risk, (d) be aware of PrEP, (e) be willing to use PrEP, (f) have a family doctor, (g) be comfortable discussing sexual health with that doctor, and (h) have drug coverage/be willing to pay out of pocket.

RESULTS

MSM participants were mostly white (54-59.5%), with median age 31 years (IQR = 26-38). PrEP awareness and use increased significantly over time (both p < 0.0001), reaching 91.3% and 5.0%, respectively, in the most recent wave. Willingness to use PrEP rose to 56.5%, but this increase did not reach statistical significance (p = 0.06). The full cascade, ABCDEFGH, suggested few could readily use PrEP under current conditions (11/400 = 2.8%). The largest barriers, in descending order, were low self-perceived HIV risk, unwillingness to use PrEP, and access to PrEP providers.

CONCLUSION

To maximize its potential public health benefits, PrEP scale-up strategies must address self-perceived HIV risk and increase access to PrEP providers.

High HIV risk and syndemic burden regardless of referral source among MSM screening for a PrEP demonstration project in Toronto, Canada

Background

To maximize public health impact and cost-effectiveness, HIV pre-exposure prophylaxis (PrEP) must reach individuals at high HIV risk. Referrals for PrEP can be self- or provider-initiated, but there are several challenges to both. We assessed whether HIV risk differed by referral source among gay, bisexual and other men who have sex (gbMSM) screening for an HIV PrEP demonstration project.

Methods

PREPARATORY-5 was an open-label PrEP demonstration project enrolling gbMSM at high risk of HIV acquisition in Toronto, Canada. Study eligibility criteria related to high risk was defined as scoring ≥10 on the HIV Incidence Risk Index for MSM (HIRI-MSM) and engaging in at least 1 act of condomless receptive anal sex within the past 6 months. Recruitment was promoted through self-referrals (ads in a sexual networking app and gay newspaper/website) and provider-referrals (10 community-based organizations, CBOs). HIV risk score (HIRI-MSM) and syndemic health burden were measured among gbMSM screened for study participation and compared according to referral source.

Results

Between October 16 and December 30, 2014, online ads generated 1518 click-throughs and CBOs referred 115 individuals. Overall, 165 men inquired about the trial, of which 86 underwent screening. The majority of screened men were self-referrals (60.5%), scored ≥10 on HIRI-MSM (96.5%), and reported condomless receptive anal sex in the past 6 months (74.2%). Self- and provider-referrals had similarly high HIV risk profiles, with a median (IQR) HIRI-MSM score of 26.0 (19.0–32.5) and 28.5 (20.0–34.0) (p = 0.3), and 75.0% and 73.5% reporting condomless receptive anal sex (p = 0.9), respectively. The overall burden of syndemic health problems was also high, with approximately one-third overall identified as having depressive symptoms (39.5%), alcohol-related problems (39.5%), multiple drug use (31.4%), or sexual compulsivity (31.4%). There were no significant differences in syndemic health problems by referral source.

Conclusions

HIV risk and syndemic burden were high among gbMSM presenting for this PrEP demonstration project regardless of referral source. Self-referral may be a useful and efficient strategy for identifying individuals suitable for PrEP use. Online strategies and CBOs working in gay men’s health may play important roles in connecting individuals at high HIV risk to PrEP services.

Trial registration

ClinicalTrials.gov NCT02149888. Registered May 12th 2014.

Gay Men's Understanding and Education of New HIV Prevention Technologies in Vancouver, Canada

Effective rollout of HIV treatment-based prevention such as pre-exposure prophylaxis and treatment as prevention has been hampered by poor education, limited acceptability, and stigma among gay men. We undertook a thematic analysis regarding the education sources and acceptability of these New Prevention Technologies (NPTs) using 15 semistructured interviews with gay men in Vancouver, Canada, who were early adopters of NPTs. NPT education was derived from a variety of sources, including the Internet, health care providers, community organizations, sexual partners, and peers; participants also emphasized their own capacities as learners and educators. Acceptable forms of NPT education featured high-quality factual information, personal testimony, and easy access. Stigma was highlighted as a major barrier. For public health, policy makers, and gay communities to optimize the personal and population benefits of NPTs, there is a need for increased community support and dialogue, antistigma efforts, early NPT adopter testimony, and personalized implementation strategies.

Use of an HIV-risk screening tool to identify optimal candidates for PrEP scale-up among men who have sex with men in Toronto, Canada: disconnect between objective and subjective HIV risk

INTRODUCTION

Identifying appropriate pre-exposure prophylaxis (PrEP) candidates is a challenge in planning for the safe and effective roll-out of this strategy. We explored the use of a validated HIV risk screening tool, HIV Incidence Risk Index for Men who have Sex with Men (HIRI-MSM), to identify "optimal" candidates among MSM testing at a busy sexual health clinic's community testing sites in Toronto, Canada.

METHODS

Between November 2014 and April 2015, we surveyed MSM undergoing anonymous HIV testing at community testing sites in Toronto, Canada, to quantify "optimal" candidates for scaling up PrEP roll-out, defined as being at high objective HIV risk (scoring ≥10 on the HIRI-MSM), perceiving oneself at moderate-to-high HIV risk and being willing to use PrEP. Cascades were constructed to identify barriers to broader PrEP uptake. The association between HIRI-MSM score and both willingness to use PrEP and perceived HIV risk were explored in separate multivariable logistic regression analyses.

RESULTS

Of 420 respondents, 64.4% were objectively at high risk, 52.5% were willing to use PrEP and 27.2% perceived themselves at moderate-to-high HIV risk. Only 16.4% were "optimal" candidates. Higher HIRI-MSM scores were positively associated with both willingness to use PrEP (aOR=1.7 per 10 score increase, 95%CI=1.3-2.2) and moderate-to-high perceived HIV risk (aOR=1.7 per 10 score increase, 95%CI=1.2-2.3). The proportion of men who were "optimal" candidates increased to 42.9% when the objective HIV risk cut-off was changed to top quartile of HIRI-MSM scores (≥26). In our full cascade, a very low proportion (5.3%) of MSM surveyed could potentially benefit from PrEP under current conditions. The greatest barrier in the cascade was low perception of HIV risk among high-risk men, but considerable numbers were also lost in downstream cascade steps. Of men at high objective HIV risk, 68.3% did not perceive themselves to be at moderate-to-high HIV risk, 23.6% were unaware of PrEP, 40.1% were not willing to use PrEP, 47.6% lacked a family physician with whom they felt comfortable discussing sexual health, and 31.6% had no means to cover the cost of PrEP.

CONCLUSIONS

A higher HIRI-MSM cut-off may be helpful for identifying candidates for PrEP scale-up. Improving engagement in the PrEP cascade will require interventions to simultaneously address multiple barriers.

HIV Community Viral Load and Factors Associated With Elevated Viremia Among a Community-Based Sample of Men Who Have Sex With Men in Vancouver, Canada

BACKGROUND

We developed estimates of community viral load (VL) and risk factors for unsuppressed VL from a cross-sectional study of men who have sex with men (MSM) in Vancouver, Canada.

METHODS

MSM were recruited from February 25, 2012 to February 28, 2014 using respondent-driven sampling (RDS). Participants completed a computer-assisted self-interview questionnaire and a nurse-administered point-of-care HIV test. For HIV-positive participants, we conducted VL and CD4 cell counts. We used RDS-weighted analysis to obtain population estimates of key variables and multivariable logistic regression to examine factors associated with having a VL of ≥200 copies per milliliter among HIV-positive participants.

RESULTS

We recruited 719 participants, of whom 119 (16.6%) were seeds. Our estimate of the population prevalence of HIV was 23.4% [95% confidence interval (CI): 15.8% to 31.0%] after RDS adjustments. We estimated that 18.6% (95% CI: 8.8% to 30.4%) of HIV-positive MSM in Vancouver had a VL of ≥200 copies per milliliter. Having an unsuppressed VL was associated with non-white ethnicity [adjusted odds ratio (AOR) = 4.34; 95% CI: 1.67 to 11.1], an annual income of <$15,000 CAD (AOR = 6.43; 95% CI: 2.08 to 19.9), using gamma-hydroxy butyrate in the previous 6 months (AOR = 4.85; 95% CI: 1.79 to 13.2), unprotected anal intercourse with a known HIV-negative or an unknown serostatus partner (AOR = 3.13; 95% CI: 1.10 to 8.90), and disclosing one's HIV serostatus ≥50% of the time (AOR = 7.04; 95% CI: 1.01 to 49.1).

CONCLUSION

Despite a high prevalence of HIV, we estimated that a small proportion of HIV-positive MSM have undiagnosed HIV and unsuppressed VL. Our results highlight the importance of continued work to address health inequities using a framework based on social determinants of health.

Factors Associated with Productive Recruiting in a Respondent-Driven Sample of Men who Have Sex with Men in Vancouver, Canada

Respondent-driven sampling (RDS) has become a preferred sampling strategy for HIV research and surveillance in many global settings. Methodological investigation into the validity of RDS-generated samples has helped improve theoretical components of design. However, the operational challenges of implementing RDS remain underreported. We sought to identify factors independently associated with productive recruiting in an urban RDS-generated sample of gay, bisexual, and other men who have sex with men (MSM). Data were collected from the Momentum Health Study, a cohort of MSM recruited by RDS in Vancouver, Canada. Eligible men were given up to six RDS coupons to recruit their peers. The primary outcome was a count variable of each participant's number of eligible recruits. Multivariable Poisson regression identified independent predictors of productive recruitment. In total, 719 individuals comprised this analysis, of which 119 were seeds. The distribution of eligible recruits was right skewed, with 391 (54.4 %) having never recruited another participant and only eight participants (1.1 %) having recruited five. Significant, independent predictors of recruiting one additional participant included network size per ten unit increase (adjusted risk ratio [aRR] 1.03), being of Aboriginal race/ethnicity compared with White (aRR 1.51), being HIV-positive (aRR 1.31), being sexually active with only males (aRR 2.48), being single compared with common law/married (aRR 1.37), having recently read gay newspapers (aRR 1.58), having recently sought sex partners online (aRR 1.33) and being out to a male parent (aRR 1.30). This analysis demonstrates the importance of social network size in RDS adjustment, but also identifies other socio-demographic and behavioral variables that increased RDS coupon return, which may help researchers better operationalize the implementation of RDS.

The impact of criminalization of HIV non-disclosure on the healthcare engagement of women living with HIV in Canada: a comprehensive review of the evidence

Introduction

In 2012, the Supreme Court of Canada ruled that people living with HIV (PLWH) must disclose their HIV status to sexual partners prior to sexual activity that poses a “realistic possibility” of HIV transmission for consent to sex to be valid. The Supreme Court deemed that the duty to disclose could be averted if a person living with HIV both uses a condom and has a low plasma HIV-1 RNA viral load during vaginal sex. This is one of the strictest legal standards criminalizing HIV non-disclosure worldwide and has resulted in a high rate of prosecutions of PLWH in Canada. Public health advocates argue that the overly broad use of the criminal law against PLWH undermines efforts to engage individuals in healthcare and complicates gendered barriers to linkage and retention in care experienced by women living with HIV (WLWH).

Methods

We conducted a comprehensive review of peer-reviewed and non-peer-reviewed evidence published between 1998 and 2015 evaluating the impact of the criminalization of HIV non-disclosure on healthcare engagement of WLWH in Canada across key stages of the cascade of HIV care, specifically: HIV testing and diagnosis, linkage and retention in care, and adherence to antiretroviral therapy. Where available, evidence pertaining specifically to women was examined. Where these data were lacking, evidence relating to all PLWH in Canada or other international jurisdictions were included.

Results and discussion

Evidence suggests that criminalization of HIV non-disclosure may create barriers to engagement and retention within the cascade of HIV care for PLWH in Canada, discouraging access to HIV testing for some people due to fears of legal implications following a positive diagnosis, and compromising linkage and retention in healthcare through concerns of exposure of confidential medical information. There is a lack of published empirical evidence focused specifically on women, which is a concern given the growing population of WLWH in Canada, among whom marginalized and vulnerable women are overrepresented.

Conclusions

The threat of HIV non-disclosure prosecution combined with a heightened perception of surveillance may alter the environment within which women engage with healthcare services. Fully exploring the extent to which HIV criminalization represents a barrier to the healthcare engagement of WLWH is a public health priority.

Rationale and design of FORTH: a randomised controlled trial assessing the effectiveness of HIV self-testing in increasing HIV testing frequency among gay and bisexual men

BACKGROUND

Gay and bisexual men (GBM) are a major risk group for HIV acquisition, yet the majority of higher-risk GBM test for HIV less often than recommended (3-6 monthly). HIV self-testing has the potential to increase testing frequency and improve awareness of personal HIV status. HIV self-tests have been approved in some countries, however there are concerns whether self-testing would increase HIV testing frequency enough to compensate for the reduced sensitivity of self-tests in early infection. We describe here a randomised controlled trial to assess the effectiveness of self-testing in increasing HIV testing frequency among higher-risk GBM, and its acceptability.

METHODS/DESIGN

Participants are higher-risk HIV negative GBM (>5 partners or condomless anal intercourse in previous 3 months; n = 350), including 50 GBM who tested for HIV over two years ago or never tested before ('infrequent-testers'). Participants are recruited from sexual health clinics and community-based organisations, and randomised 1:1 to either self-testing or standard-care (routine clinic-based testing) arms. The trial employs a wait-list control design: participants in the standard-care arm switch to self-testing arm in the second year, and gain access to self-test kits. Participants in the self-testing arm receive four oral-fluid self-test kits at enrolment, with additional kits provided on request. Demographics, sexual behaviour and HIV testing preferences are collected at baseline, and the frequency and pattern of HIV and sexually transmissible infection (STI) testing is collected via online 3-monthly questionnaires. The acceptability of self-testing is assessed at 12 months via an online questionnaire and in-depth interviews. A 24-h telephone support is provided, with expedited follow-up of those with reactive self-test results. The primary outcome is HIV testing frequency (mean number of HIV tests per person) over 12 months, and the secondary outcomes are: mean number of STI tests (chlamydia, gonorrhoea, syphilis) per person; reasons for HIV testing; and acceptability of HIV self-testing.

DISCUSSION

This is the first trial to evaluate the use of self-testing among GBM in Australia, and the first internationally among infrequent testers. The study will provide evidence on whether self-testing increases HIV testing frequency, and its acceptability among GBM. The findings will improve our understanding of self-testing patterns, and whether GBM supplement or replace their existing testing routine.

TRIAL REGISTRATION

Australian and New Zealand Clinical Trial Registration number: ACTRN12613001236785 , registered on November 12, 2013.

The prevalence and correlates of undiagnosed HIV among Australian gay and bisexual men: results of a national, community-based, bio-behavioural survey

Introduction

Gay and bisexual men (GBM) with undiagnosed HIV are believed to contribute disproportionately to HIV transmission in Australia but national prevalence estimates have been lacking.

Methods

From November 2013 to November 2014, we recruited men at gay venues and events in six Australian states and territories. Of 7291 survey participants, 3071 men also provided an oral fluid sample for testing and decided whether to receive their test results or not. We calculated raw and population-weighted prevalence estimates and identified associations with undiagnosed infection using logistic regression.

Results

Of 3071 participants, 213 men tested HIV-positive (6.9%, 95% confidence interval [CI] 6.0 to 7.8%), of whom 19 (8.9%, 95% CI 5.8 to 13.5%) were previously undiagnosed. After weighting for the size of the gay and bisexual male population in each state or territory, national HIV prevalence was estimated to be 7.2% (95% CI 6.3 to 8.1), of which 9.1% (95% CI 6.0 to 13.6%) were estimated to be undiagnosed. Compared with HIV-negative participants, men with undiagnosed HIV were more likely to report meeting partners at sex venues, using antiretroviral drugs as pre-exposure prophylaxis, condomless anal intercourse with casual partners, using party drugs for sex, injecting drugs and using amyl nitrite, crystal methamphetamine or gamma hydroxybutyrate in the six months prior to the survey.

Discussion

The results indicate that the prevalence of undiagnosed HIV is relatively low among Australian GBM but is higher among men who report riskier sex and drug practices.

Conclusions

The results underline the importance of targeted HIV prevention and frequent testing for men at increased risk of infection.

High HIV Prevalence among Men who have Sex with Men in a Time-Location Sampling Survey, São Paulo, Brazil

We conducted a time-location sampling sero-behavioral surveillance survey of men who have sex with men (MSM) in São Paulo, Brazil, the largest city in Latin America and the Southern Hemisphere (N = 1,217 interviewed with serological results for 771). HIV prevalence was 15.4 % (95 % CI 11.6-20.1), with only 45.8 % previously aware of their infection. HIV prevalence achieved 6.4 % among youth 18-24 years and was higher among MSM with lower socio-economic status. In multivariate analysis, correlates of HIV were older age, gay identity, lower socio-economic status, social networks with HIV-positive MSM, receptive anal sex, and internet sex partners. Policy change towards increasing avenues for HIV testing coupled with antiretroviral treatment regardless of CD4 count or stage of disease stand to benefit the MSM community if scaled up fast enough.

Gay and bisexual men's awareness and knowledge of treatment as prevention: findings from the Momentum Health Study in Vancouver, Canada

Introduction

Awareness and knowledge of treatment as prevention (TasP) was assessed among HIV-positive and HIV-negative gay, bisexual and other men who have sex with men (GBMSM) in Vancouver, Canada.

Methods

Baseline cross-sectional survey data were analyzed for GBMSM enrolled, via respondent-driven sampling (RDS), in the Momentum Health Study. TasP awareness was defined as ever versus never heard of the term “TasP.” Multivariable logistic regression identified covariates of TasP awareness. Among those aware of TasP, men's level of knowledge of TasP was explored through an examination of self-perceived knowledge levels, risk perceptions and short-answer definitions of TasP which were coded as “complete” if three TasP-related components were identified (i.e. HIV treatment, viral suppression and prevention of transmission). Information source was also assessed. Analyses were stratified by HIV status and RDS adjusted.

Results

Of 719 participants, 23% were HIV-positive, 68% Caucasian and median age was 33 (Interquartile range (IQR) 26,47). Overall, 46% heard of TasP with differences by HIV status [69% HIV-positive vs. 41% HIV-negative GBMSM (p<0.0001)]. In adjusted models: HIV-positive GBMSM were more likely to have heard of TasP if they were Canadian born, unemployed, not using party drugs and had higher CD4 counts; HIV-negative GBMSM were more likely to have heard of TasP if they were Caucasian (vs. Aboriginal), students, had higher education, a regular partner and multiple sexual partners. Among those aware of TasP 91% of HIV-positive and 69% of HIV-negative GBMSM (p<0.0001) felt they knew “a lot” or “a bit in general” about TasP; 64 and 41% (p=0.002) felt HIV treatment made the risk of transmission “a lot lower”; and 21 and 13% (p<0.0001) demonstrated “complete” TasP definitions. The leading information source was doctors (44%) for HIV-positive GBMSM and community agencies (38%) for HIV-negative GBMSM, followed by gay media for both populations (34%).

Conclusions

Nearly half of GBMSM in this study reported having heard of TasP, yet only 14% demonstrated complete understanding of the concept. Variations in TasP awareness and knowledge by HIV status, and key socio-demographic, behavioural and clinical factors, highlight a need for health communication strategies relevant to diverse communities of GBMSM in order to advance overall TasP health literacy.

Becoming "Undetectable": Longitudinal Narratives of Gay Men's Sex Lives After a Recent HIV Diagnosis

We explore gay men's sex life narratives following their diagnosis with an acute or recent HIV infection. All participants received an acute (n = 13) or recent (n = 12) HIV diagnosis and completed a series of self-administered questionnaires and in-depth qualitative interviews over a one-year period or longer. Over the course of four qualitative interviews, participants frequently spoke of the role of medications (e.g., decisions to start treatment) and changing viral loads (e.g., discourses of becoming "undetectable") in relation to their sex lives since being diagnosed with HIV. Many men talked about milestones relating to initiating medication and viral load as informing their shifting sexual behaviors and identities as HIV-positive--or "undetectable"--gay men. The narratives of our participants provide insight regarding complex negotiations and processes of decision-making over time related to sex, counseling needs, treatment initiation, viral load, and the significance of undetectability as an emergent identity.

Seroprevalence of hepatitis C and correlates of seropositivity among men who have sex with men in Vancouver, Canada: a cross-sectional survey

OBJECTIVES

We sought to determine the prevalence of hepatitis C virus (HCV) infection among men who have sex with men (MSM) in Vancouver, Canada, and associations of risk behaviours with HCV serostatus.

METHODS

We used data from the ManCount Study, a cross-sectional survey of MSM selected through a venue-based, time-location sampling method. Bivariate analyses and multivariate logistic regression modelling were used to determine correlates of HCV seropositivity. Bivariate analyses of participants who reported no history of injection drug use (IDU) were used to explore sexual behaviours associated with HCV seropositivity.

RESULTS

HCV seroprevalence was 4.9% (56/1132). Among HCV-seropositive participants who responded to the question, 22.4% (11/49) were unaware of their HCV-seropositive status, 84.9% (45/53) reported a history of IDU and 60.7% (34/56) were HIV positive by dried blood spot. Multivariate modelling found previous IDU (adjusted OR (AOR): 26.30, 95% CI 11.15 to 62.03), receiving goods, drugs or money for sex (AOR 4.98, 95% CI 2.43 to 10.20) and current smoking (AOR 3.46, 95% CI 1.47 to 8.16) were associated with HCV seropositivity. Among MSM who reported no history of IDU, HCV seropositivity was associated with bleeding after receptive anal sex (p=0.001) and a previous diagnosis of gonorrhoea (p=0.007).

CONCLUSIONS

HCV seroprevalence among a sample of MSM is higher than the general population and associated with a history of IDU. Among those who did not report IDU, we found evidence that suggests sexual exposure could be the route of transmission.

HIV testing behaviour and use of risk reduction strategies by HIV risk category among MSM in Vancouver

We carried out an analysis of a serobehavioural study of men who have sex with men >19 years of age in Vancouver, Canada to examine HIV testing behaviour and use of risk reduction strategies by HIV risk category, as defined by routinely gathered clinical data. We restricted our analysis to those who self-identified as HIV-negative, completed a questionnaire, and provided a dried blood spot sample. Of 842 participants, 365 (43.3%) were categorised as lower-risk, 245 (29.1%) as medium-risk and 232 (27.6%) as higher-risk. The prevalence of undiagnosed HIV infection was low (lower 0.8%, medium 3.3%, higher 3.9%; p = 0.032). Participants differed by risk category in terms of having had an HIV test in the previous year (lower 46.5%, medium 54.6%, higher 67.0%; p < 0.001) and in their use of serosorting (lower 23.3%, medium 48.3%, higher 43.1%; p < 0.001) and only having sex with HIV-positive men if those men had low viral loads or were taking HIV medication (lower 5.1%, medium 4.8%, higher 10.9%; p = 0.021) as risk reduction strategies. These findings speak to the need to consider segmented health promotion services for men who have sex with men with differing risk profiles. Risk stratification could be used to determine who might benefit from tailored multiple health promotion interventions, including HIV pre-exposure prophylaxis.

Eradicating syphilis, hepatitis C and HIV in MSM through frequent testing strategies

PURPOSE OF REVIEW

The rates of sexual transmission of HIV, syphilis and hepatitis C in MSM are rising in most countries. Recent research has raised the question of whether increasing testing and treatment of these infections could substantially reduce their transmission.

RECENT FINDINGS

Although mathematical models suggest this strategy could be potentially effective in reducing transmission, there is currently very limited evidence that community-wide incidence has been curtailed by this strategy.

SUMMARY

If increasing in testing is to substantially reduce the incidence of these infections then significant increases in testing are required together with innovative approaches to testing and healthcare delivery. Notwithstanding this, relatively simple approaches to increasing testing are currently underutilized.

Relationship between disclosure of same-sex sexual activity to providers, HIV diagnosis and sexual health services for men who have sex with men in Vancouver, Canada

OBJECTIVES

Men who have sex with men (MSM) report challenges to accessing appropriate health care. We sought to understand the relationship between disclosure of same-sex sexual activity to a health care practitioner (HCP), sexual behaviour and measures of sexual health care.

METHODS

Participants recruited through community venues and events completed a questionnaire and provided a blood sample. This analysis includes only individuals with self-reported HIV negative or unknown serostatus. We compared participants who had disclosed having same-sex partners with those who had not using chi-square, Wilcoxon Rank Sum and Fisher's exact tests and used logistic regression to examine those variables associated with receiving an HIV test.

RESULTS

Participants who had disclosed were more likely to have a higher level of education (p&lt;0.001) and higher income (p&lt;0.001), and to define themselves as "gay" or "queer" (p&lt;0.001). Those who had not disclosed were less likely to report having risky sex (p=0.023) and to have been tested for HIV in the previous two years (adjusted odds ratio 0.23, 95% confidence interval: 0.16-0.34). There was no difference in undiagnosed HIV infection (3.9% versus 2.6%, p=0.34). Individuals who had disclosed were also more likely to have been tested for gonorrhea and syphilis, and more likely to have ever been vaccinated against hepatitis A and hepatitis B (p&lt;0.001 for all).

CONCLUSIONS

While generally reporting lower risk behaviour, MSM who did not disclose same-sex sexual activity to their HCP did have undiagnosed HIV infections and were less likely to have been tested or vaccinated. Strategies to improve access to appropriate sexual health care for MSM are needed.

Time since last negative HIV test among men who have sex with men and people who use injection drugs in British Columbia, 2006-2011

OBJECTIVES

Canadian surveys of men who have sex with men (MSM) and people using injection drugs (IDU) demonstrate that most have tested for HIV at least once, but that half or fewer have done so in the previous year. To better inform targeted HIV testing guidelines for these populations, we derived estimates of inter-test interval (ITI) for persons newly diagnosed with HIV in British Columbia (BC) between 2006 and 2011, and assessed variables associated with longer ITI among MSM and IDU.

METHODS

Provincial HIV case report and testing data were linked by deterministic and probabilistic matching (based on unique personal health number, name, and date of birth). ITI was defined as time from last recorded negative to first positive HIV result; those with ITI ≤30 days were excluded.

RESULTS

Of 2,004 eligible individuals, 1,116 (55.7%) had a recorded negative HIV test result in the previous ten years. Overall median ITI was 20 months with a skewed distribution (inter-quartile range 8-46); median ITI was 15 months for MSM and 21 months for IDU with 41.2% and 33.1% testing in the past year, respectively. Longer ITI was associated with older age for both groups, and among MSM with residence outside Vancouver and not known to have an HIV-positive partner.

CONCLUSIONS

These findings highlight potential missed opportunities for earlier detection of HIV and prevention of secondary transmission among newly diagnosed MSM and IDU, and provide evidence to inform recommendations for HIV test frequency and testing strategies for these populations in BC.

A systematic review of HIV testing among Canadian populations

OBJECTIVE

Regular HIV testing and early detection leads to timely treatment. Appropriate treatment and care can prevent disease progression in the individual and prevent onwards transmission within the community. This review describes HIV testing coverage in populations disproportionately affected by HIV and in the general population in Canada.

METHODS

A search of published and grey literature on HIV testing uptake in Canada was conducted. Studies reporting quantitative data on testing practices (ever tested, recent testing, and regular testing), published in either English or French from 2008-2012, were included. Studies that involved testing for immigration or prenatal purposes, and post-intervention studies, were excluded. Included studies were assessed using a modified version of the Public Health Agency of Canada's Descriptive Study Critical Appraisal Tool. Pooled prevalence for percent ever tested was calculated for subpopulations and heterogeneity was estimated using the I2 statistic.

SYNTHESIS

A total of 26 studies were included in the review. The highest rates of ever having been tested were among people who inject drugs (90.6%) and inmates (90.4%); followed by men who have sex with men (83.0%); Aboriginal peoples (55.5%); and the general population (32.8%). Limited information was available on regular and recent testing.

CONCLUSION

HIV testing can reduce the number of undiagnosed cases in Canada. Future research should focus on testing coverage in certain populations, and on the extent to which populations engage in regular testing.

Intergenerational sex as a risk factor for HIV among young men who have sex with men: a scoping review

An emerging body of evidence suggests that intergenerational sexual partnerships may increase risk of HIV acquisition among young men who have sex with men (YMSM). However, no studies have comprehensively evaluated literature in this area. We applied a scoping review methodology to explore the relationships between age mixing, HIV risk behavior, and HIV seroconversion among YMSM. This study identified several individual, micro-, and meso-system factors influencing HIV risk among YMSM in the context of intergenerational relationships: childhood maltreatment, coming of age and sexual identity, and substance use (individual-level factors); family and social support, partner characteristics, intimate partner violence, connectedness to gay community (micro-system factors); and race/ethnicity, economic disparity, and use of the Internet (meso-system factors). These thematic groups can be used to frame future research on the role of age-discrepant relationships on HIV risk among YMSM, and to enhance public health HIV education and prevention strategies targeting this vulnerable population.

Risks for HIV and other sexually transmitted infections among Asian men who have sex with men in Vancouver, British Columbia: a cross-sectional survey

BACKGROUND

Individuals of Asian heritage represent the largest ethnic minority in Canada. Approximately 10% of the new HIV diagnoses in men in British Columbia occur among Asian-Canadians. However, the HIV risk patterns of Asian men who have sex with men (MSM) have not been extensively studied.

METHODS

Participants aged ≥ 19 years were enrolled in a venue-based HIV serobehavioural survey of MSM in Vancouver, Canada. We compared the demographic characteristics, risk behaviours, and prevalence of HIV and other sexual and blood borne infections between Asian and non-Asian MSM using bivariate analysis and logistic regression confounder modelling.

RESULTS

Amongst 1132 participants, 110 (9.7%) self-identified as Asian. Asian participants were younger than non-Asian participants (median age 29 vs. 32 years; p < 0.001), but otherwise did not differ from other study participants. HIV prevalence was lower among Asian MSM compared to Non-Asian MSM (3.7% vs 19.0%, p <0.001). Among men who self-reported as HIV negative or unknown we found no differences in unprotected anal intercourse (UAI) with a discordant or unknown serostatus partner in the previous six months (11 vs. 13%; p = 0.503). However, Asian MSM were less likely to report ever using injection drugs (10.8% vs. 19.2%; p = 0.043) or using alcohol before having sex (52% vs. 64.4%; p = 0.017).

CONCLUSIONS

Asian MSM in our study reported similar rates of UAI as non-Asian MSM, but had a lower prevalence of HIV infection. Other factors, such as the use of drugs and alcohol, in relation to sex, may partly explain these differences. However this requires further investigation.

Impact of statistical adjustment for frequency of venue attendance in a venue-based survey of men who have sex with men

Venue sampling is a common sampling method for populations of men who have sex with men (MSM); however, men who visit venues frequently are more likely to be recruited. While statistical adjustment methods are recommended, these have received scant attention in the literature. We developed a novel approach to adjust for frequency of venue attendance (FVA) and assess the impact of associated bias in the ManCount Study, a venue-based survey of MSM conducted in Vancouver, British Columbia, Canada, in 2008-2009 to measure the prevalence of human immunodeficiency virus and other infections and associated behaviors. Sampling weights were determined from an abbreviated list of questions on venue attendance and were used to adjust estimates of prevalence for health and behavioral indicators using a Bayesian, model-based approach. We found little effect of FVA adjustment on biological or sexual behavior indicators (primary outcomes); however, adjustment for FVA did result in differences in the prevalence of demographic indicators, testing behaviors, and a small number of additional variables. While these findings are reassuring and lend credence to unadjusted prevalence estimates from this venue-based survey, adjustment for FVA did shed important insights on MSM subpopulations that were not well represented in the sample.