Situational, partner, and contextual factors associated with level of risk at most recent intercourse among Black men who have sex with men

Condomless Anal Sex Associated With Heterogeneous Profiles Of HIV Pre-Exposure Prophylaxis Use and Sexual Activities Among Men Who Have Sex With Men: A Latent Class Analysis Using Sex Diary Data on a Mobile App

BACKGROUND

New innovative technologies, such as mobile apps, have been developed to increase pre-exposure prophylaxis (PrEP) adherence and the use of log sex diaries. The contiguity of mobile apps reduces the recall bias that generally affects reported condom and PrEP use. However, none of the currently used mobile apps were designed for event-driven PrEP users, and few studies have demonstrated the potential usage of sex diary data to facilitate the understanding of the different HIV risks among heterogeneous profiles of sex diaries and PrEP use.

OBJECTIVE

We aim to discriminate the heterogeneous profiles of sex events and PrEP use and examine the risk of condomless anal sex among different types of sex events.

METHODS

We recruited 35 adult men who have sex with men from two medical centers in Taiwan since May 2020 and followed up for four months. Participants were on PrEP or willing to take PrEP. They were asked to log their sex events, PrEP use, and dosing regimens on a mobile app to improve their PrEP adherence. Latent class analysis was used to distinguish profiles of sex events and PrEP use. Indicators included correct intake of PrEP for each sex event, participants' sexual positioning, partner's HIV status, and age.

RESULTS

A total of 551 sex events were classified into three classes by latent class analysis: PrEP nonadherent flip-flopping (234/551, 42%), PrEP imperfect-adherent power bottoming (284/551, 52%), and PrEP adherent serodiscordant topping (33/551, 6%). "PrEP nonadherent flip-flopping" sex events were more likely to involve condomless anal sex than "PrEP imperfect-adherent power bottoming" (OR 1.83, 95% CI 1.03-3.25) after considering random intercepts for individuals, and this class needed to increase their PrEP adherence and use of condoms. "PrEP imperfect-adherent power bottoming" realized their own risk and packaged PrEP with condoms to protect themselves. Up to 99% (32/33) of sex events in "PrEP adherent serodiscordant topping" were protected by PrEP, but all of the sex events in this group were condomless.

CONCLUSIONS

Using the sex diary data could advance the capacity to identify high-risk groups. HIV prevention strategy should be more flexible and combine PrEP with condom use for future HIV prevention.

Classes of Sexual Identity, Homophobia, and Sexual Risk among Black Sexual Minorities in HPTN 061

Homophobia is associated with sexual risk among sexual minorities, including Black sexual minority men, though experienced homophobia may differ across sexual identities. We conducted latent class analysis of sexual identities and experienced homophobia associated with sexual risk, and tested mediators of this association. We used longitudinal data from the HIV Prevention Trials Network Study 061 (n = 1,553). We generated rate ratios between baseline latent classes of experienced homophobia and sexual identity and 12-month outcomes: Condomless receptive anal intercourse (CRAI), number of partners, and transactional sex. Mediators included 6-month internalized homophobia, depression, social support, and substance use. We selected the following 7-class model: "Bisexual, rare homophobia" (reference), "Mixed identities, mixed homophobia", "Bisexual, frequent homophobia", "Heterosexual/Same-gender loving, frequent homophobia", "Gay, frequent homophobia", " Gay/Same-gender loving, frequent homophobia," and "Gay, rare homophobia." All other classes had greater CRAI than the reference. For bisexual/mixed/heterosexual classes, approximately 20% of this association was positively mediated through our mediators (p < .05). The Heterosexual/Same-gender loving class had the largest proportion mediated through internalized homophobia. For gay-identifying classes, mediation was marginally significant (.05 < p < .10). Classes of sexual identity and experienced homophobia were associated with CRAI among Black sexual minority men, partially mediated through internalized homophobia, depression, social support, and substance use.

Exploring the role of LGBT-affirming churches in health promotion for Black sexual minority men

In the USA, Black sexual minority men (BSMM) remain disproportionately impacted upon by HIV and other sexual health issues. Individuals who attend church have lower rates of morbidity and mortality than those that do not; however, church attendance presents a paradox of being protective for some health outcomes and a risk for others among this population. Lesbian, gay, bisexual, and transgender (LGBT) affirming churches may offer support, but little is known about the role of LGBT-affirming churches in the lives of BSMM and how they may impact HIV and other health outcomes. This study explored the role of LGBT-affirming churches in the lives of BSMM. Nine focus groups (N = 52) were conducted in Baltimore City, Maryland between December 2017 and April 2018. Thematic analysis evaluated domains related to how men perceived, experienced, and engaged with LGBT-affirming churches. Three primary themes identified: (1) preferring traditional church environments over LGBT-affirming churches; (2) experiencing the LGBT-affirming church as a space of acceptance, emotional healing, and modelling loving same-sex relationships; and (3) perceiving LGBT-affirming churches as opportunities to engage community members to promote the well-being of BSMM. A secondary theme identified involvement in the house and ballroom community as an LGBT-affirming religious experience.

Characteristics of Sex Events, Partners, and Motivations and Their Associations with HIV-Risk Behavior in a Daily Diary Study of High-Risk Men Who Have Sex with Men (MSM)

In the United States, men who have sex with men (MSM) continue to be at high-risk for HIV and other STIs, and condoms represent the most popular, affordable, and accessible method of prevention. Although a vast body of research has explored various factors associated with condom use in MSM, fewer studies have explored situation-level characteristics that affect their decisions about sex partners and condom use. Daily diary studies are well-suited to help improve our understanding of these event-level factors in detail, including the sex events themselves, partner characteristics, and motivations. As part of a larger study using ecological momentary assessment methods, high-risk MSM completed daily diary surveys about their sexual behavior on their smartphones each day for 30 days. This study explored detailed descriptive characteristics of sex events, partner characteristics, and motivations for sex and condom use, and examined whether specific aspects of these characteristics were associated with having condomless anal sex (CAS) with high-risk partners. High-risk CAS was common among MSM, with the majority of participants having met their partners online and many reporting sex the same day they met. Results showed that the odds of CAS were not higher with partners met online versus those met in other ways, but MSM were more likely to have asked online partners about their HIV status and testing history before sex. The odds of engaging in high-risk CAS was higher when MSM reported intimacy or self-assurance motives. Not having condoms readily available was a CAS motivation reported more commonly when MSM had sex with high-risk partners. Findings suggest that interventions should incorporate strategies that help MSM be safer specifically when meeting partners online and when having sex for intimacy or re-assurance. Interventions that remind MSM to carry condoms at opportune moments may also help reduce some HIV risk.

A New Era of HIV Risk: It's Not What You Know, It's Who You Know (and How Infectious)

HIV is transmitted in social and sexual relationships, and HIV transmission risks, as well as protective actions, are evolving as HIV epidemics unfold. The current focus of HIV prevention is centered on antiretroviral medications used to reduce HIV infectiousness in persons already infected with HIV [treatment as prevention (TasP)]. The same medications used to treat infected persons can also be used by uninfected persons as pre-exposure prophylaxis (PrEP) to reduce the infectivity of HIV. Both PrEP and TasP are effective when adherence is high and individuals do not have co-occurring sexually transmitted infections. HIV prevention is most effective and efficient when delivered within sexual networks with high HIV prevalence. Specific network characteristics are recognized as important facilitators of HIV transmission; these characteristics include the degree of similarity among network members (homophily), gender role norms, and belief systems. Since 2011, HIV risk has been redefined based on infectiousness and infectivity, ushering in a new era of HIV prevention with the potential to end HIV epidemics.

An Event-Level Analysis of Condomless Anal Intercourse with a HIV-Discordant or HIV Status-Unknown Partner Among Black Men Who Have Sex with Men from a Multi-site Study

Despite the high HIV incidence and prevalence among black men who have sex with men (BMSM), little research has examined partner characteristics, partner seeking venue, sexual position, substance use, and sexual risk behavior at the sex event-level among BMSM. Using the baseline data from a multi-site study of 807 BMSM stratified by their HIV status, the goal of this study was to conduct a detailed event-level analysis of 1577 male anal sex events to assess the factors associated with condomless anal intercourse (CLAI) with a HIV-discordant or HIV status-unknown partner. We found CLAI with an HIV-discordant or unknown HIV status partner among HIV-negative BMSM was negatively associated with having sex with a main partner, and was positively associated with taking both receptive and insertive sexual positions during sex. As compared to a sex partner met at bar, night club or dance club, HIV-positive BMSM were less likely to engage in CLAI with HIV-discordant and unknown HIV status partner met at party or friend's house or at community organizations. HIV-positive BMSM had lower odds of engaging in CLAI with HIV-discordant and unknown HIV status partner if they had insertive sexual position or both receptive and insertive sexual positions. These results underscore the importance of delineating unique sex event-level factors associated with sexual risk behavior depending on individuals' HIV status. Our findings suggest event-level partner characteristics, sexual position, and partner seeking venues may contribute to disparities in HIV incidence.

Disclosure of newly diagnosed HIV infection and condom use at first sex after diagnosis: a study of young Black men who have sex with men

Background The first purpose of the present study was to determine whether young Black men who have sex with men (YBMSM) disclose their newly diagnosed HIV infection to a male or female partner, and to determine whether this disclosure is related to condom use; the second was to identify correlates of disclosing newly diagnosed HIV infection to male sex partners, including a measure of partner-related barriers to condom use.

METHODS

A sample of 125 HIV-infected YBMSM (age 15-29 years) provided cross-sectional data used for both study purposes. Recruitment occurred in a mid-size city in the southern US experiencing inordinately high prevalence and incidence rates of HIV among YBMSM. Significance was defined by an α level of <0.05.

RESULTS

Eighty-eight YBMSM (70.4%) indicated disclosing their newly diagnosed HIV status to the first male partner they had sex with after being diagnosed. Of these, nine (9.1%) reported that condoms were not used during ensuing sex with that partner. However, of the men not disclosing, 27.0% reported not using condoms for ensuing sex (P=0.009). Similar findings were observed relative to sex with females (P=0.057). Regarding the second study purpose, in addition to a protective effect of advancing age, men scoring at or above the median on a measure of partner-related barriers to condom use were 2.4-fold more likely to not disclose compared with men scoring below the median (P=0.04).

CONCLUSION

For YBMSM, a beneficial counselling objective relative to disclosing newly diagnosed HIV may be to help men resolve perceptions of partner-related barriers to condom use.

Partner-level substance use associated with increased sexual risk behaviors among men who have sex with men in San Francisco, CA

BACKGROUND

Substance use is highly prevalent among men who have sex with men (MSM) and is associated with individual-level sexual risk behaviors. However, few studies have explored the relationship between substance use and HIV risk behaviors within partnerships.

METHODS

We examined partner-level data between MSM participants (n=23) and their sexual partners (n=52). We used multivariable generalized estimating equations (GEE) logistic regression to assess the relationship between partner-level substance use during their last sexual encounter with each partner, and engaging in condomless anal intercourse (CAI) and serodiscordant CAI.

RESULTS

In multivariable analyses, participants had significantly higher adjusted odds ratio (AOR) of CAI when the participant (AOR=22.2, 95%CI=2.5-199.5) or their partners used any drugs (AOR=21.8, 95%CI=3.3-144.3); their partners (AOR=5.7, 95%CI=1.7-19.3) or both participant and partner had concordant use of methamphetamine (AOR=10.5, 95%CI=2.2-50.6); or when both used poppers (AOR=11.4, 95%CI=1.5-87). There were higher odds of SDCAI if the participant binge drank (AOR=4, 95%CI=1.01-15.8), used more than one substance (AOR=15.8, 95%CI=1.9-133), or used other drugs (AOR=4.8, 95%CI=1.3-18.4); if their partner used poppers (AOR=7.6, 95%CI=1.5-37.6), or used more than one substance (AOR=7.9, 95%CI=1.9-34.1); and when both participant and partner had concordant use of poppers (AOR=4.4, 95%CI=1.2-16.8).

CONCLUSIONS

This study observed significant relationship between substance use and HIV risk behaviors within partnerships. Specifically, when either the participant, the partner, or both used any drugs there was an increased odds of sexual risk behaviors. Findings suggest that partner-level substance use behaviors should be taken in account when developing sexual risk reduction interventions.

Qualitative Perspectives about Living with HIV from Seropositive African American MSM Aged 50 years and Older

It has nearly been more than three decades; yet, the research on aging seropositive African American men who have sex with men (MSM) is scarce. Exploring issues for an aging population of seropositive MSM is critical given that earlier epidemiological data suggested that by 2015, half of the AIDS cases will be in adults aged 50 years and older. A qualitative approach with the aim to examine perspectives about HIV risk from a group of seropositive African American MSM 50 years of age and older was conducted. Two separate focus groups with a total N  =  30 were conducted. Four themes emerged: feeling left out, no place to call home, not a priority, and no one to grow older with.

Racial Differences in Partnership Attributes, Typologies, and Risk Behaviors Among Men Who Have Sex With Men in Atlanta, Georgia

The role of main partnerships in shaping HIV transmission dynamics among men who have sex with men (MSM) has gained recognition in recent studies, but there is little evidence that existing definitions of partnership type are accurate or have consistent meaning for all men. Using data collected from 2011 to 2013 on 693 partnerships described by 193 Black and White MSM in Atlanta, GA, partnership attributes and risk behaviors were examined and compared by race, stratified in two ways: (1) by commonly used definitions of partnerships as "main" or "casual" and (2) by a new data-driven partnership typology identified through latent class analysis (LCA). Racial differences were analyzed using chi-square, Fisher's exact, and Wilcoxon-Mann-Whitney tests. Black participants were less likely to report condomless anal sex (CAS) within partnerships they labeled as main, yet they were also less likely to describe these partnerships as "primary" on a parallel question. In contrast, within strata defined by the LCA-derived typology, most partnership attributes were comparable and the likelihood of CAS was equivalent by race. These findings suggest that classification of partnerships as main or casual does not accurately capture the partnership patterns of MSM, resulting in differential misclassification by race. Future studies and interventions should refine and utilize more evidence-based typologies.

Preferences for Condomless Sex in Sexually Explicit Media Among Black/African American Men Who Have Sex with Men: Implications for HIV Prevention

Accumulating evidence suggests that viewing sexually explicit media (SEM; i.e., pornography) may be related to the sexual behaviors of men who have sex with men (MSM). Furthermore, stereotypical depictions of Black/African American MSM engaging in sexual risk behaviors in SEM may serve to normalize condomless sex, reinforce low peer norms around condom use, and facilitate HIV risk taking among Black/African American MSM. Despite this evidence, very little is known about the correlates of SEM consumption among Black/African American MSM, including HIV risk behaviors and their relation to preferences for viewing condomless sex in SEM. Participants were 653 HIV-seronegative Black-identified MSM ages 18-62 (M 33.58, SD 11.01) who completed a cross-sectional survey as a part of a HIV prevention trial in Atlanta, Georgia. Over three-quarters of the men (n = 514) reported a preference for condomless sex in SEM. In multivariate models, engaging in serodiscordant condomless sex was not significantly associated with preferences for condomless sex in SEM; however, men who self-identified as bisexual, engaged in transactional sex, and reported greater agreement with sexual risk cognitions (i.e., heat-of-the-moment thoughts about condom use) had significantly greater odds of reporting a preference for condomless sex in SEM. Study findings highlight the need for future research exploring the role of SEM in the sexual health of Black/African American MSM, including the extent to which SEM exposure alters norms and expectations about sexual behaviors among Black/African American MSM and how this might be addressed in HIV prevention programs.

Sexual Networks, Dyadic Characteristics, and HIV Acquisition and Transmission Behaviors Among Black Men Who Have Sex With Men in 6 US Cities

The role of sexual networks in the epidemiology of human immunodeficiency virus (HIV) among black men who have sex with men (MSM) is poorly understood. Using data from 1,306 black MSM in the BROTHERS Study (2009-2010) in the United States, we examined the relationships between multiple sexual dyadic characteristics and serodiscordant/serostatus-unknown condomless sex (SDCS). HIV-infected participants had higher odds of SDCS when having sex at least weekly (odds ratio (OR) = 2.41, 95% confidence interval (CI): 1.37, 4.23) or monthly (OR = 1.94, 95% CI: 1.17, 3.24) versus once to a few times a year. HIV-uninfected participants had higher odds of SDCS with partners met offline at sex-focused venues (OR = 1.79, 95% CI: 1.15, 2.78) versus partners met online. In addition, having sex upon first meeting was associated with higher odds of SDCS (OR = 1.49, 95% CI: 1.21, 1.83) than was not having sex on first meeting, while living/continued communication with sexual partner(s) was associated with lower odds of SDCS (weekly: OR = 0.64, 95% CI: 0.47, 0.85; monthly: OR = 0.60, 95% CI: 0.44, 0.81; yearly: OR = 0.58, 95% CI: 0.39, 0.85) versus discontinued communication. Persons with primary/steady nonprimary partners versus commercial partners had lower odds of SDCS regardless of HIV serostatus. This suggests the need for culturally relevant HIV prevention efforts for black MSM that facilitate communication with sexual partners especially about risk reduction strategies, including preexposure prophylaxis.

Toward Development of Enhanced Preventive Interventions for HIV Sexual Risk among Alcohol-Using Populations: Confronting the 'Mere Pause from Thinking'

The papers in this issue detail state-of-the science knowledge regarding the role of alcohol use in HIV/AIDS risk, as well as offer suggestions for ways forward for behavioral HIV prevention for at-risk alcohol-using populations. In light of recent evidence suggesting that the anticipated uptake of the newer biomedical HIV prevention approaches, prominently including pre-exposure prophylaxis, has been stalled owing to a host of barriers, it has become ever more clear that behavioral prevention avenues must continue to receive due consideration as a viable HIV/AIDS prevention approach. The papers collected here make a valuable contribution to "combination prevention" efforts to curb HIV spread.

Optimization of Multicomponent Behavioral and Biobehavioral Interventions for the Prevention and Treatment of HIV/AIDS

To move society toward an AIDS-free generation, behavioral interventions for prevention and treatment of HIV/AIDS must be not only effective, but also cost-effective, efficient, and readily scalable. The purpose of this article is to introduce to the HIV/AIDS research community the multiphase optimization strategy (MOST), a new methodological framework inspired by engineering principles and designed to develop behavioral interventions that have these important characteristics. Many behavioral interventions comprise multiple components. In MOST, randomized experimentation is conducted to assess the individual performance of each intervention component, and whether its presence/absence/setting has an impact on the performance of other components. This information is used to engineer an intervention that meets a specific optimization criterion, defined a priori in terms of effectiveness, cost, cost-effectiveness, and/or scalability. MOST will enable intervention science to develop a coherent knowledge base about what works and does not work. Ultimately this will improve behavioral interventions systematically and incrementally.

Correlates of Seroadaptation Strategies Among Black Men Who have Sex with Men (MSM) in 4 US Cities

We assessed associations of demographic, psychosocial, and substance use factors with seroadaptation strategies among 835 BMSM in four US cities. Seroadaptation strategies were practiced by 59.8 % of men, with 10.5 % practicing 100 % condom use, 26.5 % serosorting, 7.2 % condom serosorting, and 15.6 % seropositioning. In multivariable analyses, compared to men who used no seroadaptation strategies, serosorters were older, were less likely to be HIV infected, had fewer male sex partners, and had higher levels of social support and sexual self-efficacy. Condom serosorters had less psychological distress, were more likely to use methamphetamine, and had higher levels of sexual self-efficacy. Seropositioners were older, were less likely to be HIV infected, to have a main partner, and report alcohol/drug use with sex, while having higher levels of sexual self-efficacy. Seroadaptation practices among BMSM need to be considered to address perceived safer sex strategies and strengthen access to a broader reach of culturally-relevant prevention efforts.

Correlates of Sexual HIV Risk Among African American Men Who Have Sex With Men

OBJECTIVES

We examined correlates of condomless anal intercourse with nonmain sexual partners among African American men who have sex with men (MSM).

METHODS

We recruited social networks composed of 445 Black MSM from 2012 to 2014 in Milwaukee, Wisconsin; Cleveland, Ohio; and Miami Beach, Florida. Participants reported past-3-month sexual behavior, substance use, and background, psychosocial, and HIV-related characteristics.

RESULTS

Condomless anal intercourse outside main concordant partnerships, reported by 34.4% of MSM, was less likely in the case of no alcohol and marijuana use in the past 30 days, and higher risk-reduction behavioral intentions. High frequency of condomless anal intercourse acts with nonmain partners was associated with high gay community participation, weak risk-reduction intentions, safer sex not being perceived as a peer norm, low condom-use self-efficacy, and longer time since most recent HIV testing.

CONCLUSIONS

Condomless anal intercourse with nonmain partners among Black MSM was primarily associated with gay community participation, alcohol and marijuana use, and risk-reduction behavioral intentions.

Tensions between the epidemiology and psychology of HIV risk: implications for pre-exposure prophylaxis

This study focuses on psychological differences in risk-taking patterns and their association with risk compensation motivations in the context of pre-exposure prophylaxis (PrEP). Participants were 257 HIV-negative MSM and transgender women recruited in New York City. The majority of participants (89.5 %, n = 230), could be classified as either: Intimates (40 %), who report unprotected anal intercourse (UAI) only with a main partner believed to be HIV-negative; Trusters (34 %), who engaged in UAI only with casual partners believed to be HIV-negative; and Gamblers (26 %) who report UAI with partners of unknown serostatus. Partner-based classifications were better predictors of HIV risk perception and other traditional correlates of risk-taking (e.g. impulsivity, sexual compulsivity) than rates of UAI. The three groups differed significantly in PrEP-related risk compensation motivations: sexual pleasure (Gamblers), intimacy (Trusters) and partner pressure (Intimates). These data underscore the importance of focusing the psychological dynamics of risk perception and sexual decision-making.

Understanding structural barriers to accessing HIV testing and prevention services among black men who have sex with men (BMSM) in the United States

Structural-level factors have contributed to the substantial disproportionate rates of HIV among Black men who have sex with men (BMSM) in the United States. Despite insufficient HIV testing patterns, however, there is a void in research investigating the relationship between structural factors and access to HIV testing and prevention services among BMSM. Building on previous scholarly work and incorporating a dynamic social systems conceptual framework, we conducted a comprehensive review of the literature on structural barriers to HIV testing and prevention services among BMSM across four domains: healthcare, stigma and discrimination, incarceration, and poverty. We found that BMSM experience inadequate access to culturally competent services, stigma and discrimination that impede access to services, a deficiency of services in correctional institutions, and limited services in areas where BMSM live. Structural interventions that eliminate barriers to HIV testing and prevention services and provide BMSM with core skills to navigate complex systems are needed.